Document OLMQ86JL2q3nnyVGyvdN0amX

FILE NAME Brakes BRK DATE 1981 DOC BRK076 DOCUMENT DESCRIPTION Letters Published in Journal - Asbestos Fibres and the Environment afteyva sie ompeuse of major was quired is conis not ISC We or limiifficient might cy We ils preusculof faecal en as to of palsign of of coninconthin the eir own ppeared " mality clusions referred elevance its could without and his nts they ow their 11 ion that elderly nent is hoed by tatement odified odified in the may be Sithout useful or palpa- HILTON STANTON Urol 1979 valuation Is more a younger cagues 4 seworthy who often nd whose lenge We aspects of findings in ediction of by careful munication consuming frequency in will freurodynamic rhaps avoid T in male and heir inconithough ins shown to patients no made but it evidence of might well profilometry PVEA FF PR EE 4 also does not help in this respect and a pressure flow study of micturition is mandatory The urethral pressure profile is helpful in its indication of the maximum pressure exerted by the urethral sphincter however the results vary widely in both males and females and the two sexes should not be compared as the functional anatomy is completely different The comment in relation to table V p 1103 para 4 that four of the unstable bladders demonstrated a pressure rise to below 13 cm H appears to ignore the basic standards of the International College of Surgeons which accepts a 15 cm H pOressure rise as being necessary prior to a diagnosis of instability The definition of bladder atonicity also seems rathei encompassing Bladders with large capacities may empty effectively Large residuals certainly occur with both high pressure and low pressure outflow obstruction decompensation of the detrusor and in the also with absence of obstruction It is unfortunate that a study of this sort which requires much hard work did not provide guidelines for the prediction of specific features which relate to incontinence in the elderly A short pr^'cisof the approach to the treatment of this difficult clinical problem would have been welcomed PJR SHAH G WHITESIDU individual patients and not volumes and pressures This explains why four patients were put into the their unstable group despite despite not the meeting criteria of the International Continence Society It could be argued that these four should have been in a separate group but there was nothing apart from the pressure of the contraction at incontinence to distinguish them from others in It also pos iblepossible that thethe unstaunstable blegrogurp oup of our patients in the is also also normal possible posible that ththrreee e group were mis- Ocategorised since they had pressure rises at capacity of from 20 to cm H OHowever these patients were not incontinent had normal bladder sensation and did not show any unstable contractions We entely agree that the normal strictly be classed as normal since group cannot they were not selected from individuals with no recent urinary complaint We agree too that the irritable and atonic groups are both clinical and urodynamic diagnoses The cystometric trace 15 usually characteristic in the irritable group and most patients with atonic bladders have large capacities with only small rises in pressure with filling The latter group were almost all referred by the local urologists and so had had outflow obstruction excluded Therapy is based on and yet different for each diagnostic category which must therefore be found as accurately as possible These two groups are particularly responsive to drug treatment details of which will be published later Our statement that incontinence in most elderly patients cerebral is not disease associated with immobility and was based on the results of the Urodynamic Unit mobility assessment mental test scores and Middlesex Hospital clinical examination point being that pre- how to manage the patient How many other invasive hospital investigations can claim this? We remain therefore unrepentent if a little chastened CM CM CASTLEDEN HM HM DUFFIN University Department GeGeneral neral Hospital Leicester LF5 4PW of Medicine 1 the Asbestos fibres fibres and Asbestos environment ~ SIR two articles -1 found the two articles by Daphne V Gloag 14 and 21 February pp 551 and 623 very interesting But I was surprised that she made no reference to dust from brake linings of motor vehicles as a source of atmospheric contamination not at the point of manufacture but from vehicles in motion There must be 1 with quantities enormous quantities of dust loaded with fibres being released daily and this would I expect | monoxide with carbon monoxide and lead a major \ pollutant in traffic jams Furthermore what about the risk to the do- yourself motorist when he renews his brake linings and is intimately exposed to the fine dust which has to be cleaned from the drums Whitchurch Bristol BS14 0HI CP DE FONSEKA Iondon WIN BAA viously incontinence in older patients was thought Farrar DI Warwick Whiteside CG Osborne JL TurnerRI Surg Gynaecol Obster 1975,141 1975,141 875 81 Plate P. Susset 1 J Urol 1980,123 64 74 Abrams PH Urol Chm North Am 1979,6 103 10 We sent these two letters to the authors who reply below -En BMJ While we agree with Drs Shah and Whiteside that the history suggests an urodynamic diagnosis in some elderly incontinent patients in more we find that this is not the case All patients referred to our clinic had been seen by doctors and most had been treated prior to referral without effect to be largely due to immobility and cerebral disease whereas we feel that this reflected the selection of patients for investigation Since a large number of our patients were from geriatric medical wards it would be surprising if these diagnoses were not still relatively common The incidence would drop even more WC suspect in unselected elderly incontinent patients living in the community Immobility itself should not cause incontinence at any age unless the patient is helpless and without help Is the incontinence following an unstable contraction in a patient who has become less mobile due mobile instability to to hihiss immobiimobillity ity or to his bladder Similarly there are many elderly patients with cerebral disease who are not incontinent and many who are but have no cerebral discase feel that the association between incontinence We and *,* Daphne Gloag writes Raised air con- centrations of asbestos roughly proportionate to the number of vehicles passing were found at toll stations where sampling was done in an American linings American American ' survey But although although brabrake kebrake contain a substantial proportion of chrysotile \ most is changed morphologically by the \ friction and the remaining chrysotile fibres are \i mainly short2 so possibly less hazardous 1 Nevertheless even a small proportion of unchanged fibres could be harmful . There 1 in some evidence of asbestosis in vehicle main \ tenance workers and some mesothelioma have been found in garage workers 2 which may have been caused by their occupation though in a recent control study no We can only accept their criticism and that of Dr HD H Eastwood that some of our male patients might have had outflow obstruction We did not do pressure flow studies of micturition except in in whom we thought there was a clinical patients possibility of outflow obstruction In this respect we perhaps underinvestigated our patients Out- flow obstruction was not thought to be present in any of the 22 patients with unstable detrusor contractions and one reason might be that the patients were selected in that they were all referred by other doctors This may also explain the lack of patients with genuine stress incontinence which we always look for cerebral disease in elderly patients is not inevitable as previously suggested In some it is unquestionably connected nevertheless the urodynamic findingfindingss of those in whom it is connected are no different from those in whom it is not There were a great many data on these patients that could not be included because of space We hope to rectify this in the near future and in particular to report on the effects of management We cannot show from our present data however that elderly patients who have had cystometry do better than those who have not We believe that they do certainly none had had this investigation before referral and only 16 the normal group increased risk was evident Thus there seem to be a distinct but small occupational hazard which suggests that yourself car main " tenance would have negligible risks BMJ 1 Bruckman L Rubino RA Journal of the Air Pollutio Control Association 1978,28 1221-6 2 Lorimer WV Rohl AN Miller A. Nicholson W McDonald Selikoff IJ Mt McDonald AD Sinar J Med NY 1876.43 207-1 McDonald JC Cancer 1980.4 Mr Hinton and Mi Stanton have still not answered why why urodynamic assessment is necessary for accurate diagnosis of incontinence in young patients while in the older the algorithmic method is advocated Could not this be applied at any age P We concede that we have overstated our case and agree with their present suggestion that the algorithmic approach is intended for assessment the primary care level where we find it practised and not for specialist urodynamic clinics We also agree that faccal impaction and utinary tract infection can be diagnosed without cystometry and would not now do this examination before successful treatment of these conditions he Mr Hilton and Mr Stanton have slightly misread our urodynamic data No patient in our normal chk group had a capacity of less than 100 ml even though some elderly women are very small in stature For example one woman of 79 years was only 122 cm height and weighed 26 kg As we stated in our paper it is the overall appearance of sont the cystometric trace which enabled us to categorise had achieved continence Finally incontinence like the examining finger on the irregular pulse indicates that something is wrong Given that the clinical history in an elderly incontinent patient is of limited value in establishing the cause of urinary incontinence as Mr. Hilton and Mr Stanton said in their paper if the patient has no demonstrable stress incontinence and no palpable bladder faecal impaction or urinary tract infection and a trial of therapy has been given by a competent doctor is urodynamic investigation not ? indicated Only 22 out of our patients could have avoided such investigation on these clinical grounds The procedure is quick easy and attended by minimal discomfort has a very low complication rate and gives almost 100 accuracy of diagnosis and therefore a clear indication of protein binding Plasma protein binding of drugs SIR would agree with Drs W E Lindi and M C L'E Orme 17 January p 212 th it is difficult to define what is a highly protein drug The concept of prote binding in antibiotic therapy is important as is only the unbound fraction of the drug whic drug can act against bacteria As high protein binding may affect t distribution of drugs in the ussues where t majority of infections occur I was particular interested to study the interrelationship binding and tissue penetration By using Cantharides blister technique which induc a mild inflammatory response one can sam~fi the blister fluid and determine the protein fr fraction of drug Seven lactams were studi fig -Bay k 4999 is an experimental penicill aynei pe e St rape ti