1
807 Hepatoma and germ cell tumour are the two conditions most likely to produce serum AFP values above 1000 ng/ml. Although rare in a young woman in the United States, hepatoma is more -frequent than germ cell tumour. ],2 Other conditions associated with an increased serum AFP in adults include certain non-malignant liver diseases, liver metastases, and primary tumours of the gastro- intestinal tract, all of which characteristically have serum AFP values less than 1000 ng/ml. 3-5 Foundation for Blood Research, Scarborough, Maine 04074, U.S.A JAMES E. HADDOW DONNA K. THOMPSON EDWARD M. KLOZA NEURAL TUBE DEFECTS IN SIBS OF CHILDREN WITH TRACHEO-ŒSOPHAGEAL DYSRAPHISM SIR,-Two studies of the family distribution ofoesophageal atresia with or without tracheo-cesophageal fistula (hereafter referred to as tracheo-aesophageal dysraphism) have reported an increased frequency of neural tube defects (NTD) in the first degree relatives of probands. In view of the implications for prenatal diagnosis, we have measured the frequency of NTD in the sibs of another series, obtained from family history charts of 57 probands with tracheo- cesophageal dysraphism referred to the department of medical genetics of the Montreal Children’s Hospital. These included detailed pedigrees and information about the prenatal history. 3 of the probands were twins. None of the co-twins was affected. 1 of 141 sibs had a myelomeningocele with club foot. There were 7 other sibs with malformations: 2 congenital heart disease, 1 club foot, I Down syndrome, 1 polydactyly, 1 pyloric stenosis, umbilical hernia, and 1 tracheo-eesophageal fistula. The occurrence of tracheo-oesophageal dysraphism in 1/140 sibs confirms previous observations that the average recurrence risk for sibs is less than 1%. For this and previous studiesl,2 the combined figure is 3/510 sibs, or 0 - 6%. The excess of twin probands is consis- tent with the association of oesophageal atresia and twinning noted by David and O’Callaghan. I I case ofNTD in 141 sibs is higher than the population frequency of about 3 per 1000 live births, though not significantly so with the present small sample size. Combining this figure with those of the previously cited reports gives a frequency of 9/635 or 1 -6±0-5% cases of NTD among the sibs of children with tracheo-cesophageal dysplasia. This is within the range generally accepted as justifying referral for prenatal diagnosis in subsequent pregnancies. These findings are consistent with the hypothesis that one or more environmental factors predisposing to the occurrence of tracheo-cesophageal dysplasia may also increase the probability of NTD in genetically predisposed embryos. It would be useful to know whether other series show the same phenomenon. We are aware that a call for other reports may lead to a "me too" bias, since those who find a positive result are more likely to report it than those who do not. We would therefore encourage those with suitable data on the frequency ofNTD in sibs of children with tracheo-cesophageal dysraphism to publish their findings, positive or negative, or to send them to us for inclusion in a collaborative report. Department of Medical Genetics, Montreal Children’s Hospital, Montreal, Quebec H3H 1P3, Canada F. C. FRASER E. NUSSBAUM 1. Kurman RJ, Norris HJ. Endodermal sinus tumor ofthe ovary. Cancer 1976; 38: 2404. 2. Kurman RJ, Norris HJ. Embryological carcinoma of the ovary. Cancer 1976; 38: 2420. 3. Alpert E Alpha-1-fetoprotein Clins Gastroenterol 1976; 5: 639. 4. Bloomer JR, Waldmann TA, McIntire KR, Klatskin G. Alpha-fetoprotein in non- neoplastic hepatic disorders. JAMA 1975; 273: 38. 5 Waldmann T, McIntire KR. The use of a radioimmunoassay for alpha-fetoprotein in the diagnosis of malignancy. Cancer 1974, 34: 1510. 1. David TJ, O’Callaghan SE. Oesophageal atresia in the South West of England J Med Genet 1975, 12: 1-11 2 Warren J, Evans K, Carter CO. Offspring of patients with tracheo-œsophageal fistula. J Med Genet 1979, 16: 338-40. 3 Horowitz I, McDonald AD. Anencephaly and spina bifida in the Province of Quebec Can Med Assoc J 1969, 100: 748-55 FRENCH BEDS IN A CHILDREN’S WARD SIR,-A year ago we moved into the children’s ward in the new John Radcliffe Hospital, Oxford. The area was not specifically de- signed as a children’s ward, but during the years of evolution of the architect’s plans and the period of commissioning it had to be adapted to meet children’s needs. As a result, there is insufficient accommodation on the children’s ward for parents to stay with their sick children. This is a problem common to many new hospital buildings and indicates that, despite the Hospital Building Note published by the Ministry of Health in 1964,1 the needs of children in hospital have not been given sufficient recognition. To overcome this difficulty, we have substituted "French beds" (Rest Assured Ltd, Northamption) in the children’s ward in place of armchairs. These beds serve both as compact armchairs by day and comfortable single beds at night. A large number of parents of the younger patients have chosen to sleep at the bedside and they report that the experience has been comfortable. For example, in one 25 bed acute medical/surgical ward over the six month period from October, 1979,433 relatives stayed overnight in the hospital, 246 in one of the two bedrooms available on the children’s ward and 187 on French beds. Providing a bed is not, in itself, a total solution to the problem of accommodating parents on a children’s ward; there are also the serious problems (uncatered for in our hospital) of facilities for washing and relaxation and the cost of meals for the parent. Nevertheless, provision of French beds has provided a workable and acceptable solution to at least the physical accommodation of some parents on the children’s ward, which we look upon as a matter of the highest priority. 2 Department of Pædiatrics, John Radcliffe Hospital, Oxford OX3 9DU J. D. BAUM J. WYLE MARY LINDSAY ACETAZOLAMIDE IN HIGH ALTITUDE ACCLIMATISATION SIR,-Encouraged by the findings of Hackett et al. j and by recent research by the Birmingham Medical Research Expedition Society, four experienced male climbers used acetazolamide, 500 mg in a sustained release preparation, for the first fortnight of mountain climbing in the Peruvian Andes at heights of up to 6200 m. All had extensive experience of high altitude climbing and their subjective view was that acclimatisation at these heights was quicker and easier than on previous attempts when not taking acetazolamide. Disadvantages included an increased diuresis of up to 1-2 litres extra daily and often disturbing at night (acetazolamide was taken nightly). Taking acetazolamide in the morning helped here. There was also much increased wakefulness at night. Painful peripheral parxsthesix were common. I met many parties in the Andes who were taking acetazolamide regularly. However, this is not by any means a panacea for acclimatisation.’ I helped treat one young male climber with severe cerebral oedema at 6000 m and his companion who had early pulmonary oedema. Both had taken ten days to acclimatise to this height and were taking acetazolamide daily over the same time. Acetazolamide, therefore, does seem to help in high altitude acclimatisation but its use does not obviate the need for slowness in exposure to great heights, and the drug has some drawbacks. I thank Dr P. G. Brock, Lederle Laboratories, for supplies of acetazolamide (’Dlamox Sustets’). East Hens Hospital Hertford SG13 7HU A. PINES 1. Ministry of Health, Children’s ward: Hospital building note 23. London: HMSO, 1964. 2. MacCarthy D, Lindsay M, Morris I. Children in hospital with mothers. Lancet 1962; i: 603-08. 3. Hackett PH, Rennie D, Levine HD. The incidence, importance, and prophylaxis of acute mountain sickness. Lancet 1976, ii:1149-55.

ACETAZOLAMIDE IN HIGH ALTITUDE ACCLIMATISATION

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807

Hepatoma and germ cell tumour are the two conditions mostlikely to produce serum AFP values above 1000 ng/ml. Althoughrare in a young woman in the United States, hepatoma is more-frequent than germ cell tumour. ],2 Other conditions associated withan increased serum AFP in adults include certain non-malignantliver diseases, liver metastases, and primary tumours of the gastro-intestinal tract, all of which characteristically have serum AFPvalues less than 1000 ng/ml. 3-5

Foundation for Blood Research,Scarborough, Maine 04074, U.S.A

JAMES E. HADDOWDONNA K. THOMPSONEDWARD M. KLOZA

NEURAL TUBE DEFECTS IN SIBS OF CHILDRENWITH TRACHEO-ŒSOPHAGEAL DYSRAPHISM

SIR,-Two studies of the family distribution ofoesophageal atresiawith or without tracheo-cesophageal fistula (hereafter referred to astracheo-aesophageal dysraphism) have reported an increased

frequency of neural tube defects (NTD) in the first degree relativesof probands. In view of the implications for prenatal diagnosis, wehave measured the frequency of NTD in the sibs of another series,obtained from family history charts of 57 probands with tracheo-cesophageal dysraphism referred to the department of medicalgenetics of the Montreal Children’s Hospital. These includeddetailed pedigrees and information about the prenatal history.

3 of the probands were twins. None of the co-twins was affected. 1of 141 sibs had a myelomeningocele with club foot. There were 7other sibs with malformations: 2 congenital heart disease, 1 club

foot, I Down syndrome, 1 polydactyly, 1 pyloric stenosis, umbilicalhernia, and 1 tracheo-eesophageal fistula.The occurrence of tracheo-oesophageal dysraphism in 1/140 sibs

confirms previous observations that the average recurrence risk forsibs is less than 1%. For this and previous studiesl,2 the combinedfigure is 3/510 sibs, or 0 - 6%. The excess of twin probands is consis-tent with the association of oesophageal atresia and twinning notedby David and O’Callaghan. I

I case ofNTD in 141 sibs is higher than the population frequencyof about 3 per 1000 live births, though not significantly so with thepresent small sample size. Combining this figure with those of thepreviously cited reports gives a frequency of 9/635 or 1 -6±0-5%cases of NTD among the sibs of children with tracheo-cesophagealdysplasia. This is within the range generally accepted as justifyingreferral for prenatal diagnosis in subsequent pregnancies.These findings are consistent with the hypothesis that one or

more environmental factors predisposing to the occurrence oftracheo-cesophageal dysplasia may also increase the probability ofNTD in genetically predisposed embryos.

It would be useful to know whether other series show the same

phenomenon. We are aware that a call for other reports may lead to a"me too" bias, since those who find a positive result are more likelyto report it than those who do not. We would therefore encouragethose with suitable data on the frequency ofNTD in sibs of childrenwith tracheo-cesophageal dysraphism to publish their findings,positive or negative, or to send them to us for inclusion in acollaborative report.

Department of Medical Genetics,Montreal Children’s Hospital,Montreal, Quebec H3H 1P3, Canada

F. C. FRASERE. NUSSBAUM

1. Kurman RJ, Norris HJ. Endodermal sinus tumor ofthe ovary. Cancer 1976; 38: 2404.2. Kurman RJ, Norris HJ. Embryological carcinoma of the ovary. Cancer 1976; 38: 2420.3. Alpert E Alpha-1-fetoprotein Clins Gastroenterol 1976; 5: 639.4. Bloomer JR, Waldmann TA, McIntire KR, Klatskin G. Alpha-fetoprotein in non-

neoplastic hepatic disorders. JAMA 1975; 273: 38.5 Waldmann T, McIntire KR. The use of a radioimmunoassay for alpha-fetoprotein in

the diagnosis of malignancy. Cancer 1974, 34: 1510.1. David TJ, O’Callaghan SE. Oesophageal atresia in the South West of England J Med

Genet 1975, 12: 1-112 Warren J, Evans K, Carter CO. Offspring of patients with tracheo-œsophageal fistula.

J Med Genet 1979, 16: 338-40.3 Horowitz I, McDonald AD. Anencephaly and spina bifida in the Province of Quebec

Can Med Assoc J 1969, 100: 748-55

FRENCH BEDS IN A CHILDREN’S WARD

SIR,-A year ago we moved into the children’s ward in the newJohn Radcliffe Hospital, Oxford. The area was not specifically de-signed as a children’s ward, but during the years of evolution of thearchitect’s plans and the period of commissioning it had to be

adapted to meet children’s needs. As a result, there is insufficientaccommodation on the children’s ward for parents to stay with theirsick children. This is a problem common to many new hospitalbuildings and indicates that, despite the Hospital Building Notepublished by the Ministry of Health in 1964,1 the needs of childrenin hospital have not been given sufficient recognition.To overcome this difficulty, we have substituted "French beds"

(Rest Assured Ltd, Northamption) in the children’s ward in place ofarmchairs. These beds serve both as compact armchairs by day andcomfortable single beds at night. A large number of parents of theyounger patients have chosen to sleep at the bedside and they reportthat the experience has been comfortable. For example, in one 25bed acute medical/surgical ward over the six month period fromOctober, 1979,433 relatives stayed overnight in the hospital, 246 inone of the two bedrooms available on the children’s ward and 187 onFrench beds. Providing a bed is not, in itself, a total solution to theproblem of accommodating parents on a children’s ward; there arealso the serious problems (uncatered for in our hospital) of facilitiesfor washing and relaxation and the cost of meals for the parent.Nevertheless, provision of French beds has provided a workable andacceptable solution to at least the physical accommodation of someparents on the children’s ward, which we look upon as a matter ofthe highest priority. 2

Department of Pædiatrics,John Radcliffe Hospital,Oxford OX3 9DU

J. D. BAUMJ. WYLEMARY LINDSAY

ACETAZOLAMIDE IN HIGH ALTITUDEACCLIMATISATION

SIR,-Encouraged by the findings of Hackett et al. j and by recentresearch by the Birmingham Medical Research Expedition Society,four experienced male climbers used acetazolamide, 500 mg in asustained release preparation, for the first fortnight of mountainclimbing in the Peruvian Andes at heights of up to 6200 m. All hadextensive experience of high altitude climbing and their subjectiveview was that acclimatisation at these heights was quicker and easierthan on previous attempts when not taking acetazolamide.

Disadvantages included an increased diuresis of up to 1-2 litresextra daily and often disturbing at night (acetazolamide was takennightly). Taking acetazolamide in the morning helped here. Therewas also much increased wakefulness at night. Painful peripheralparxsthesix were common. I met many parties in the Andes whowere taking acetazolamide regularly. However, this is not by anymeans a panacea for acclimatisation.’ I helped treat one youngmale climber with severe cerebral oedema at 6000 m and his

companion who had early pulmonary oedema. Both had taken tendays to acclimatise to this height and were taking acetazolamidedaily over the same time. Acetazolamide, therefore, does seem tohelp in high altitude acclimatisation but its use does not obviate theneed for slowness in exposure to great heights, and the drug hassome drawbacks.

I thank Dr P. G. Brock, Lederle Laboratories, for supplies of acetazolamide(’Dlamox Sustets’).

East Hens HospitalHertford SG13 7HU A. PINES

1. Ministry of Health, Children’s ward: Hospital building note 23. London: HMSO,1964.

2. MacCarthy D, Lindsay M, Morris I. Children in hospital with mothers. Lancet 1962; i:603-08.

3. Hackett PH, Rennie D, Levine HD. The incidence, importance, and prophylaxis ofacute mountain sickness. Lancet 1976, ii:1149-55.