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The high negative predictive value of LBT in SLE suggests that it is valuable in excluding diseases clinically similar to SLE.

Dexmedetomidine (Precedex), an alpha-2 adrenergic receptor agonist is frequently and safely used as sedative agent during surgical procedures. We report a case of a 76-year-old woman who developed cardiac arrest from the use of dexmedetomidine during pacemaker lead extraction procedure.

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Clinical, radiologic, electrocardiographic and 2-dimensional echocardiographic findings of fifty cases of mitral valve prolapse syndrome attending the Pediatric Cardiology clinic of I.C.H. and Childrens Hospital, Medical College, Kottayam over a period of ten years from 1980-1989 are presented. Mitral valve prolapse syndrome (MVPS) accounted for 2% of cardiac problems attending our pediatric cardiology clinic. Isolated MVPS constituted 64% of the cases. The common causes of secondary MVPS were Marfan Syndrome-18%, Atrial Septal Defect-10% and Rheumatic fever-8%. Associations of MVPS included Pectus excavatum (8%), Isolated arachnodactyly (2%) and Straight back syndrome (2%). 2-D echocardiogram demonstrated prolapse of both leaflets of Mitral valve in 44%, Isolated posterior mitral valve leaflet prolapse in 32% and Isolated anterior mitral valve leaflet prolapse in 24% of cases. No complications were seen during follow up.

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The clinical picture during life and necropsy findings are two sides of the same coin. To look at one without the other is to see only half the picture. Proof of that assertion comes from the known discrepancy between the clinical and necropsy findings-for example, Cameron et al found that 15% of the main diagnoses and 42% of causes of death were not confirmed at necropsy and Hartveit reported that one in five diagnoses thought to be certain were found to be erroneous.1 2In this issue Berlin et al report that only 20% of deaths in the community are followed by necropsies and that three quarters of those are requested by coroners for legal and not for medical reasons (p 1080).3 Why, then, do general practitioners so rarely request necropsies when they sign about one quarter of all death certificates? Berlin et al found that in the main they favour the performance ofnecropsies and want to be sent the reports. They were not asked about their reluctance to request necropsies.During discussion with small groups of general practitioners we have found two main deterrents: a belief that "I only need a postmortem if I don't know the cause of death" and anxiety about the reaction of relatives. Doctors believed that unless the relatives recognised that there are important reasons for a necropsy permission might be difficult to obtain. Indeed, Cameron et al failed to obtain permission in 35% of deaths because of the resistance by relatives or the inadequate approach by medical staff.' They found that female relatives were more likely to give permission than male relatives.Berlin et al argue that more communication between general practitioners and pathologists might help.3 Initial fruitful discussions could review the number of necropsies requested by general practitioners in each hospital area, the availability of the service (which should be universal), and the resource implications. A necropsy costs roughly £200, which would presumably come from fundholding general practitioners and health commissions. If the number of necropsies rose, more staff and facilities might be needed. The next stage would be agreement on firm objectives to satisfy the needs of continuing medical education, audit, and quality control in general practice; again this should come from discussions between general practitioners and pathologists, opening up a climate of investigation and inquiry.One issue raised by Berlin et al could be resolved quickly and easily. At present pathologists and coroners do not always send necropsy reports to general practitioners. In Southampton the coroner permits the routine distribution of these reports to general practitioners, but this is not always the case-indeed, coroners have the power to prevent the dissemination of reports. The questionnaire showed a strong demand from practitioners for these reports, and a distribution scheme organised by the family health services authority could be an important first step toward achieving collaboration between pathologists and general practitioners.For most of us the necro...

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