46 the Robertsons.2 The other major British contribution to this inquiry was that of Bowlby,3,4 whose years of clinical and research work established the importance of security to every child. In this district general hospital parents or guardians have been encouraged to help in the induction of anaesthesia for more than a decade, and this has improved our practice and has not adversely affected the conduct of anaesthesia. We make preoperative visits to all patients and tailor premedication and induction methods in the light of our findings. The parent or guardian is present during recovery from anaesthesia, which is made as pain-free as possible. It is to be regretted that these practices and other changes in the development of care (eg, day care, epidural service, pain relief, and palliative care) find opponents in the medical profession despite public support. Perhaps the National Association for the Welfare of Children in Hospital should circulate the names of hospitals where parents and guardians are welcome in the anaesthetic and recovery room. This is more extensively practised than your editorial would have us believe. Departments of Anaesthesia and Paediatrics, Northwick Park Hospital, and Clinical Research Centre, Harrow, Middlesex HA1 3UJ
H. T. DAVENPORT B. VALMAN
1. Ayliffe GAJ, et al. Transfer areas and clean zones in the operating suites. J Hyg (Camb) 1969, 67: 417. 2. Robertson JJ, Roberston J. Young children in bnef separation: Parts I-III Child Development Research Unit, 1967/68. 3. Bowlby J. Attachment and loss I: Attachment. London: Hogarth Press, 1968. 4. Bowlby J. Attachment and loss II: Separation, anxiety and anger. London: Hogarth Press, 1973.
URINARY INCONTINENCE IN ELDERLY PATIENTS :tlR,— i ne last paragraph ot your Dec
6 editorial (p 131 o,) implies
that it is a waste of time employing nurse specialists in incontinence in the absence of "expert medical help" because such nurses become "merely advisors on pads and appliances". This view seriously undervalues the work of continence advisors, whether they are allied to medical departments or not. Certainly there is a central role for urodynamic studies and for the skills and experience of urologists but often the patient needs assistance in the management of incontinence before, during, and after medical intervention-and until the advent of the specialist continence nurse this help was often lacking. Many men have been discharged from hospital still dribbling urine following a prostatectomy. For many elderly women urinary incontinence can be a part of life, caused solely by inappropriate diuretic therapy.1 Advising other nurses about continence aids, however, is only one part of the job. The continence advisor is a specialist whose work is to coordinate and incorporate the skills of teaching, research, and direct patient care2 and impart those to nurses and others working directly with patients. The most important part of an advisor’s clinical work is to assess precisely the client’s incontinence pattern. This means finding out accurately the volume/voiding pattern for at least seven days and throughout the day and night. Whilst this does lead to problems, depending on the locality of the client and the carer, it is the only way to begin a logical management scheme. Even if the nurse has access to admission beds by courtesy of a consultant it is principally the nurse advisor who directs the management scheme. Within geriatric hospitals it is more often nursing routines, constipation, and immobility that present the greater problems in maintaining continence, and the nurse advisor can radically change the attitudes and procedures within these nursing regimens without discussing any pad or appliance, important though these may be. All disciplines have to work well together but it is erroneous to suggest that continence advisors cannot work effectively without access to expert medical help. Frenchay Health Authority, Manor Park Hospital,
ARTHUR F. TURNER,
Bristol BS16 2EW
District continence advisor
1. Norton C
Beaconsfield, Bucks: Beaconsfield Publishers,
1986. 149. 2.
Shepherd AM, Blannin JP. The role of the nurse and
In: Mandelstam D, ed. Incontinence
management, 2nd ed. London: Croom
Helm, 1986: 161.
POTENTIAL SIDE-EFFECTS OF ERYTHROPOIETIN
SIR,-Dr Winearls and colleagues (Nov 22, p 1175) and Dr Zins and co-workers (Dec 6, p 1329) describe the efficacy of erythropoietin in the treatment of anaemia in uraemic patients. Winearls et al note the potential risk of raising blood viscosity in patients at risk of accelerated vascular disease. In an animal experiment we found that treating five-sixths nephrectomised rats (bodyweight 400 g) with erythropoietin (6 IU daily) resulted in an increased mortality in the treatment group. 12 pairs of male Sprague-Dawley rats were matched for body weight, haematocrit, and renal function 3 months after nephrectomy. The treated animals were given 6 IU erythropoietin subcutaneously daily for 4 weeks, while the controls were injected with the buffer solution only. 5 of the 12 of treated animals died from acute renal failure (confirmed by histology and renal function measured before death), while none of the controls died (Fisher’s exact test; p 00186). The packed cell volume in the treatment group increased from 38% (median) to 44%, while in the controls it fell from 38-5 % to 35-5 %. These data demonstrate that erythropoietin is a very efficient drug for the treatment of anaemia caused by chronic renal failure. However, increasing the packed cell volume in patients not yet in terminal renal failure may risk causing acute renal failure due to increased blood viscosity and could affect the heart by causing myocardial infarctions or the brain by causing neurological symptoms. This new drug must be used with great care. =
Klinikum Mannheim, University of Heidelberg, 6800 Mannheim, West Germany
Department of Pathology, University of Heidelberg
N. GRETZ J. J. LASSERRE E. MEISINGER M. STRAUCH
R. WALDHERR K. KRAFT
Department of Anaesthesiology, University of Giessen
BRAIN DEATH AND CEREBRAL BLOOD FLOW
SIR,—Dr Kennett (Dec 6, p 1338) comments on our preliminary (Nov 22, p 1223) on the possible usefulness of HMPAO-
photon emission computed tomography with 99mTc-hexamethylpropyleneamine oxime) in diagnosing the lack of cerebral circulation in suspected brain death when confirmatory investigations are needed. SPECT (single
While it was not our intention to discuss the criteria of brain death in different countries, a few comments seem appropriate. Finland was the first country in which brain death was legally accepted.’ The principles of brain death diagnosis in the UK differ in some respects from those in many other countries, such as Finland and the USA.2 In Finland, as in the UK, it is required that the patient’s condition be due to irremediable structural brain damage, and the diagnosis of a disorder which can lead to brain death has to be fully established. In Finland and many other countries, the diagnosis of brain death can also be made in patients with post cardiac arrest state or metabolic disorders when there is no known cause of increased intracranial pressure. In those cases, confirmatory studies are needed. Aortic arch angiography has been used most extensively. When a known factor of increased intracranial pressure is present, the diagnosis of brain death is confirmed solely by clinical examination emphasising the irreversible cessation of brainstem function, exactly as in the UK. A serious disadvantage of conventional isotope scans in brain death studies has been the difficulty in separating intracranial from extracranial circulation in the head.3 Kennett incorrectly states that HMPAO measures only cortical blood flow. With HMPAOSPECT the whole intracranial circulation down to the foramen magnum can be visualised and clearly separated from extracranial sources.
Departments of Neurology and Nuclear Medicine, Helsinki University Central Hospital, SF-00290 Helsinki, Finland
RISTO O. ROINE JYRKI LAUNES LENA LINDROTH PÄIVI NIKKINEN