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Summary This study was performed to compare the effect of one month's treatment with hydrochlorothiazide (25 mg) in combination with either amiloride (2.5 mg) or triamterene (50 mg) on plasma sodium levels in elderly people in institutional care. Fifty residents of NHS nursing or social service residential care established on diuretics for congestive cardiac failure and aged 64 years or over were recruited. Forty-one patients were included in the final data analysis. Patients on hydrochlorothiazide/amiloride had a significantly lower plasma sodium (137 vs 139 mmol/l, 95% confidence interval for difference between medians 0-2 mmol/l) than those on hydrochlorthiazide/triamterene (P = 0.01). In equivalent potassium-retaining doses, amiloride is associated with significantly lower plasma sodium levels than triamterene, when given in combination with hydrochlorothiazide in elderly patients with congestive cardiac failure. This finding adds weight to uncontrolled observations implicating thiazide/amiloride diuretic combinations in causing serious hyponatraemia. This danger, although uncommon, should perhaps influence prescribing habits in an at-risk population.

The Effectiveness of Continuing Professional Development. J Grant and F Stanton. (Pp 39; £12 non-members, £10 members.) Association for the Study of Medical Education, 2000. ISBN 0-9044-73260.\**\*|\* This publication saw life initially as a report on continuing professional development (CPD) to the Chief Medical Officer. It gives the background to the nature of CPD, its prevalence, types, aims, the educational approaches, and the factors that influence its provision and the participation in CPD …

Granulomatous muscle disease is most commonly seen in sarcoidosis, but may be seen in association with a wide variety of other disorders or in isolation. Patients with granulomatous myositis usually present with slowly progressive muscle pain and weakness affecting mainly proximal muscles. There are, however, a few reports of granulomatous muscle disease presenting with flexion contractures of the limbs. Two further patients with granulomatous muscle disease and flexion contractures of the limbs, but with no evidence of systemic granulomatous disease, is presented. It is suggested that such patients represent a separate clinical entity that is distinct from idiopathic granulomatous myositis presenting with muscle pain and weakness. The association of contracturing granulomatous myositis with a long-standing vasculitis in one patient suggests that the two conditions may be related.

Summary Two patients with long-standing chronic bronchial suppuration developed antineutrophil cytoplasmic antibody (ANCA) positive Wegener's granulomatosis and microscopic polyarteritis respectively. There is published evidence of an association between previous suppurative respiratory disease and Wegener's granulomatosis. We believe that our cases provide further evidence that chronic lung infection may play an aetiological role in the development of ANCA-positive systemic necrotizing vasculitis in some individuals.

A 28-year-old woman presenting with systemic lupus erythematosus stuck two sewing needles into her pericardium while psychotic from cerebral lupus. We believe this is a unique cause of acute pericarditis as a complication of SLE.

A 42 year old man presented with accelerated hypertension and an abdominal mass that proved to be a primary malignant retroperitoneal germ cell tumour involving renal vessels. The hypertension resolved with chemotherapy. To our knowledge this is the first case of a primary malignant retroperitoneal germ cell tumour to present with accelerated hypertension.

Gastrointestinal complications of Legionnaires' disease are frequently reported. These include diarrhoea, paralytic ileus, acute appendicitis and jaundice. We would like to report the previously unrecorded and life-threatening complication of acalculous cholecystitis.

\**\*|\* The reviewers have been asked to rate these books in terms of four items: readability, how up to date they are, accuracy and reliability, and value for money, using simple four point scales. From their opinions we have derived an overall "star" rating: * = poor, ** = reasonable, \***| = good, \**\*|\* = excellent. This book tells you all you wanted to know and a good deal more that you now need to know about the …

The optic neuritis of systemic lupus erythematosus (S.L.E.) more frequently results in the persistence of a central scotoma or complete blindness after a single attack than demyelinating optic neuritis, although the initial clinical presentations may be identical. A significant number of patients, however, recover normal vision. Optic neuritis may be the presenting symptom of S.L.E. and as myelopathy may also occur in the course of the disease, confusion with multiple sclerosis may result, especially if there are no arthritic, cutaneous nor visceral manifestations. We report a case of lupus optic neuritis associated with anticardiolipin antibodies and a circulating lupus anticoagulant and suggest these may be a marker for vasculitic optic neuritis and play a role in its aetiology.

A 28-year old female is described with a 12-year history of seropositive, erosive rheumatoid arthritis. Subsequently, she developed systemic lupus erythematosus diagnosed both serologically and on renal biopsy. As has previously been emphasised, these two diseases occur rarely in the same patient. HLA typing revealed the patient was HLA - B8 positive and that she had inherited this genetic marker from her mother who is Irish, rather than from her West Indian father. The patient has developed marked atlanto-axial subluxation, a feature not noted in six patients previously described as having both diseases.

A slightly modified Middlesex Hospital Questionnaire was given to 946 patients with hypertension who were receiving treatment at two hospital clinics. The response rate was 90%. Compared with previously published results for the general population the hypertensive patients scored significantly higher for free-floating anxiety, phobic anxiety and depression. Male hypertensive patients, but not female patients, also scored higher for obsession and hysteria. The high scores for hypertensive patients could not be closely correlated with any particular drug therapy with the possible exception of phobic anxiety and propranolol in women but not in men. There was a weak but statistically significant correlation between systolic blood pressure and both somatic complaint rate and phobic anxiety.

Twenty-five of thirty NIDDS who remained hypertensive (diastolic greater than 95 mmHg supine) after 4 weeks on bendrofluazide 2.5 mg daily (B), completed a single-blind, observer-blind randomized crossover study, in which the additional use of atenolol (50 mg daily) (A), slow-release nifedipine (20 mg twice daily) (N), and captopril (25 mg twice daily) (C) was compared. Patients took each drug for 8 weeks with dose doubling at 4 weeks if supine diastolic remained greater than 90 mmHg. All three combinations were more effective than bendrofluazide alone (p less than 0.01). In nine patients studied 2 h after tablets at the end of each treatment period nifedipine was more effective than the other two drugs (B:174/104 mmHg, A:162/95 mmHg, -8%, N:141/88 mmHg, -17%, C:157/94 mmHg, -10%, supine), whereas in 16 patients studied 15 h after their evening dose there was no significant difference. Fasting insulin and HbA1 levels were not significantly different between groups. No drug had a significant adverse effect on creatinine, glomerular filtration rate, overnight urinary albumin excretion or foot transcutaneous oxygen levels (43 degrees C). All three drugs studied were effective without deleterious effects on renal function or peripheral blood flow.

Although the respiratory system is directly involved in a large proportion of cases of systemic lupus erythematosus (S.L.E), little is known of the basic underlying pathological changes (Harvey, Shulman, Tumulty, Conley, and Schoenrich, 1954 ; Larson, 1961). Pleurisy and pleural effusions, which are usually bilateral and small, are well recognized (Winslow, Ploss, and Loitman, 1958). The pulmonary lesions of S.L.E. have been decribed radiologically as patchy pneumonitis, linear atelectasis, and diffuse and micronodular infiltration (Israel, 1953 ; Gould and Daves, 1958 ; Myhre, 1959 ; Alarcon-Segovia and Alarcon 1961). These terms presuppose a pathological basis for which there is remarkably little evidence in post-mortem findings (Purnell, Baggenstoss, and Olsen, 1955 ; Larson, 1961). Several writers have also commented on the occurrence of raised diaphragms, not accounted for by associated pulmonary or pleural involvement, which move slowly over a reduced range (" sluggishly ") (Ellman and Cudkowicz, 1954 ; Harvey et al:, 1954 ; Myhre, 1959). A patient with S.L.E. was seen in whom breathlessness, unexplained by physical and radiological examination, had been a major symptom for many years. Lung-function studies per formed early in her illness showed that she had small stiff lungs.

A double-blind crossover study was carried out to investigate the effects of cyclopenthiazide and oxprenolol on blood lipids in 20 previously untreated patients with mild to moderate hypertension. After a 4-week placebo period, patients received at random either 8-weeks' treatment with the two drugs followed by 8 weeks on cyclopenthiazide alone, or the reversed sequence. Daily doses were 160 mg slow-release oxprenolol and/or 0.25 mg cyclopenthiazide during the first 4 weeks of each treatment period, after which the dosage was doubled. Data from 13 patients who completed the trial showed no significant changes in the blood levels of triglycerides, total cholesterol or LDL and HDL cholesterol fractions. These findings are discussed in relation to published studies on the effects of other beta-blockers on blood lipids.

Two unrelated adult patients were discovered by chance to have a diffuse form of renal cortical nephrocalcinosis, consisting of small nodules of radiologically visible calcification, most marked immediately under the renal capsule. The condition is not associated with urinary abnormalities or renal impairment, and appears to have an excellent prognosis.

SummaryVery few cases of acquired severe copper deficiency have been described. The principal effects are haematological, but the precise abnormalities are uncertain due to the possible association of other deficiencies. A case of isolated severe copper deficiency associated with late onset hypogammaglobulinaemia is reported in which the chief findings were macrocytic anaemia, neutropenia and a decrease in mean platelet volume. All these abnormalities resolved when copper therapy was instituted and recurred when the medication was stopped.

The effect of a six-week course of spironolactone 300 mg/day was examined in 25 unselected patients with essential hypertension. In the blood spironolactone produced a significant rise in urea and potassium concentrations and a fall in sodium and bicarbonate concentrations. In six patients blood pressure was normal at the end of the course, while in five patients there was almost no change. Studies of the effects of spironolactone on various indices usually affected by mineralocorticoids-namely, blood electrolytes, total body potassium, and rectal electrical properties-showed no differences between responding and non-responding patients. Mineralocorticoid excess therefore seems to be rarely responsible for essential hypertension and the influence of spironolactone cannot at present be fully explained.

synopsisTwenty-seven symptoms of 859 treated hypertensive patients were evaluated using a self-administered questionnaire and correlated with the depression (DEP), free-floating anxiety (FFA), phobic anxiety (PHO), obsessionality (OBS) and extraversion (HYS) scores of the Middlesex Hospital Questionnaire. The psychological features were associated with 24 of the 27 symptoms, and the extent to 1which these measurements determined the presence of a symptom was calculated. DEP and FFA were correlated with most of the symptoms, PHO with weak limbs, blurred vision, slow walking pace, nocturia and a lessened interest in sex. HYS was positively associated with the frequency of sexual intercourse in men and negatively with complaints of dyspnoea, tingling in the limbs and a slow walking pace. OBS was only associated with diarrhoea.

Renovascular hypertension is an unusual complication of renal trauma, occurring in approximately 5% of cases. It occurs predominantly in young males following road traffic accidents (RTA) or blunt abdominal trauma. The interval between injury and development of hypertension varies from two days to 14 years but presentation may be acute with hypertensive encephalopathy. Hypertension developing within a few months of injury may be treated conservatively. Conservative treatment more than one year after injury is associated with an increased risk of persistent hypertension. All cases of renal trauma should be followed with regular blood pressure (BP) recording for at least the first year after injury.

Three patients were seen who had sarcoidosis associated with glomerulonephritis. Subsequent review of published reports of cases in which the two conditions occurred simultaneously showed a pattern of histological type of glomerulonephritis different from that seen in patients without associated disease. In sarcoidosis with glomerulonephritis there appeared to be a dearth of minimal-change disease and an excess of membranous glomerulonephritis compared with the prevalence that would be expected if the renal disease was merely a chance occurrence. These findings may provide evidence for an important relation between sarcoidosis and glomerulonephritis.