Essential fatty acid deficiency in infants receiving parenteral nutrition

The clinical and biochemical features of essential fatty acid deficiency are described in an infant with gastroschisis who required long-term (6 mo) parenteral nutrition. The deficiency responded to therapy with Intralipid, topical sunflower oil, and breast milk. In a prospective study of three infants with gastroschisis, biochemical essential fatty acid deficiency developed in each during the first week of lipid-free parenteral nutrition; clinical signs of the deficiency were absent. The biochemical features were progressive in the one patient followed for 19 days, and were associated with a decrease in weight gain. Both the deficiency and weight gain were corrected by Intralipid. Biochemical essential fatty acid deficiency did not develop in three other gastroschisis infants who were given prophylactic Intralipid (two patients) or topical sunflower oil (one patient). We conclude that all infants on parenteral nutrition should receive a source of linoleic acid to prevent essential fatty acid deficiency.

Hyperparathyroidism after radiotherapy

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Doctor-patient communication in patients with arthritis

Fifty patients with a chronic form of arthritis were given a standard interview concerned with establishing what knowledge they had of their disease and the drugs they were receiving for its treatment. Eighty-six percent of patients overall knew the name of their disease and 74 percent, the names of the drugs which they were receiving. Seventy-three percent of patients receiving non-steroidal anti-inflammatory drugs were unaware that these drugs were likely to have gastro-intestinal side effects even though about half of these patients were receiving either soluble aspirin or indomethacin. Younger patients were more likely to be aware of potential gastro-intestinal side effects (46 percent) than older patients (19 percent). Thirteen patients with rheumatoid arthritis were receiving myocrisin or penicillamine which are more likely to be associated with severe side effects than non-steroidal anti-inflammatory drugs. Four of five younger patients had some knowledge of the likely side effects of these drugs but none of the eight older patients knew this information. Written instructions should be given to older patients receiving these potentially toxic drugs.

Familial medullary thyroid carcinoma

Medullary thyroid carcinoma (M.C.T.) is a tumour of the calcitonin-secreting cells of the thyroid gland; it affects both lobes, has a variable malignant potential, and is often familial. Despite the availability of diagnostic plasma-calcitonin immunoassays, the condition is rarely considered in the initial assessment of a patient with a thyroid mass so that the is often disseminated by the time it is diagnosed, inadequate surgery is performed, and family members are not investigated. We studied 22 members of a family with M.C.T. and gave alcohol to provoke calcitonin secretion. 3 (excluding the index case) had raised basal calcitonin levels and the diagnosis of M.C.T. was confirmed at operation; their calcitonin levels became undetectable after total thyroidectomy. 3 others had detectable levels after alcohol stimulation and are being re-screened at regular intervals.

The confrontation with death and the renewal of life

Several writers have argued that a majority of suicidal acts are "gambles with death". A distinction is made between cases where the gamble with death is merely consequential (i.e., arising from ignorance, apathy, indifference) and cases where it is the very essence of the act. Typically in these latter cases others are excluded from possible intervention. The individual is thus playing a game of "pure" chance. Death is summoned and challenged in order that life may continue. It is argued, from an interactionist perspective, that such acts are desperate efforts to confirm existance in situations of extreme uncertainty and represent a distinct form of what Shneidman has called "egotic" suicide.

Bradshaw lecture, 1976. Thyroid medullary carcinoma

The main characteristics of medullary carcinoma of the thyroid are its non-follicular histological appearance, resulting from its origin from the parafollicular C cells, its secretion of calcitonin, providing a relatively simple diagnostic test, and its equal sex incidence, in contrast to all other diseases of the thyroid. Sporadic cases are seen and it occurs in familial groups, with autosomal dominant inheritance, when it is associated with phaeochromocytoma and parathyroid hyperplasia to form the second type of multiple endocrine adenomatosis (MEA2). These last features make it necessary in every case of medullary carcinoma of the thyroid to examine other members of the family and to investigate the possibility of concomitant adrenal and parathyroid disease. The priorities of treatment when these are present and the indications for total thyroidectomy are discussed.

Methotrexate compared with placebo in lung cancer

Two hundred thirty-nine patients with microscopically proven, inoperable bronchogenic carcinoma were allocated at random to receive twice weekly I.M. injections of either methotrexate at "high dose" of 0.06 mg/kg/dose or methotrexate at "low dose" of 0.2 mg/kg or visually indistinguishable placebo in the same volume of 0.1 ml/kg for four months. Twelve patients were invalidated for procedural reasons. Objective response (greater than or equal to 50% tumor regression) was dose-related with 21% of 48 patients with measurable disease on high -ose, 11% of 37 patients on low dose, and 6% of 32 patients on placebo. Corresponding response rates for epidermoid carcinoma were 35% of 23 patients, 9% of 11 patients, and 0 of 13 patients. Responders in the two treatment groups had a three to four fold increase of median survival (p less than .05). Non-responders on high and low dose methotrexate lived as long as patients on placebo. Leukopenic patients in all three treatment groups lived substantially longer than patients without leukopenia less than 4,500/mm3, irrespective of presence or absence of objective response. All three regimens were well tolerated. None of the patients had life-threatening toxicity. It is concluded that methotrexate at "high dose" is a potentially useful drug for temporary palliation of epidermoid carcinoma of the lung.

Parathyroidectomy: extent of resection and late results

Opinion is divided as to the necessary extent of parathyroid resection in primary hyperparathyroidism. Some surgeons urge that subtotal parathyroidectomy be performed routinely, while others reserve subtotal resections for patients with parathyroid hyperplasia. In a review of 102 patients treated by parathyroidectomy for primary hyperparathyroidism and subsequently followed up for an average of 6 years, there were 73 patients with parathyroid adenoma, 26 with hyperplasia and 3 with carcinoma. The adenoma was not found at the first operation in only 3 cases; in the other 70 after removal of the adenoma no further hypercalcaemia was observed during the follow-up period. Persistent or recurrent hypercalcaemia was a problem in 9 out of the 26 patients with primary hyperplasia who had inadequate resection at the first operation, and also in the 3 patients with carcinoma. Experience shows that peroperative biopsy with frozen section of all the parathyroids is useful in confirming their identity and can be a guide to the type of disease present and the appropriate extent of resection.

Riedel's thyroiditis

Riedel's thyroiditis is a rare chronic inflammatory disease of unknown aetiology and may be one manifestation of multifocal fibrosis. Four patients were seen over a period of 12 years and unusual presentations in 3 of them caused difficulty in diagnosis. The aetiology and methods of treatment are discussed.

Results for serum cholesterol and triglycerides by gas-liquid chromatography, as compared with a continuous-flow technique

We assessed the usefulness of gas-liquid chromatography forthe routine and reference measurement of cholesterol and triglycerides (triacylglycerols). Compared with results obtained by an AutoAnalyzer II method, correlation was good with both serum specimens (triglycerides, r = 0.88; cholesterol, r = 0.90) and lipoprotein fractions isolated by ultracentrifugation (triglycerides, r = 0.98; cholesterol, r = 0.98). However, none of the comparisons was completely free of analytical bias, and in general the AutoAnalyzer method underestimated the cholesterol value and overestimated triglycerides. The obvious advantage of the AutoAnalyzer is its greater analytical speed, but the chromatographic method appeared to be more accurate and precise and to suffer less from interfering substances, and in addition gave information about the cholesterol ester and triglyceride composition. We expect gas-liquid chromatography to be of major importance in the calibration of other analytical methods.

Results for serum cholesterol and triglycerides by gas-liquid chromatography, as compared with a continuous-flow technique

We assessed the usefulness of gas-liquid chromatography forthe routine and reference measurement of cholesterol and triglycerides (triacylglycerols). Compared with results obtained by an AutoAnalyzer II method, correlation was good with both serum specimens (triglycerides, r = 0.88; cholesterol, r = 0.90) and lipoprotein fractions isolated by ultracentrifugation (triglycerides, r = 0.98; cholesterol, r = 0.98). However, none of the comparisons was completely free of analytical bias, and in general the AutoAnalyzer method underestimated the cholesterol value and overestimated triglycerides. The obvious advantage of the AutoAnalyzer is its greater analytical speed, but the chromatographic method appeared to be more accurate and precise and to suffer less from interfering substances, and in addition gave information about the cholesterol ester and triglyceride composition. We expect gas-liquid chromatography to be of major importance in the calibration of other analytical methods.

The rhythm of the normal human heart

The 24-hour cardiac rhythm was studied in 86 subjects (41 male, 45 female) aged 16-65 years, after exclusion of 15 additional volunteers with suspected abnormalities. The electrocardiogram was recorded continuously for two 24-hour periods. In this apparently normal population, 10 subjects (12%) had disturbances of rhythm which are widely believed to be of serious prognostic significance; they included frequent ventricular ectopic beats, R-on-T and multifocal ventricular ectopic beats, bigeminy, and ventricular tachycardia. Supraventricular tachycardia, infrequent ventricular ectopic beats, junctional rhythm, and second-degree heart block were also observed, and if these are included most of the subjects showed some disturbance of rhythm. Bradyarrhythmias and tachyarrhythmias were equally common in waking hours and during sleep. These disturbances were not confined to the older age-groups. Heart-rate but not the number of arrhythmias was significantly higher in smokers.

Hyperparathyroidism: retrospect and prospect

The history of hyperparathyroidism is outlined and the diagnosis and treatment of its various causes reviewed with reference to a series of 153 patients operated on for hyperparathyroidism in the past 20 years. In 119 cases the condition was primary, being due to a tumour or hyperplasia. Future developments in this field are briefly considered.

Radiology in Mendelson's syndrome

Four cases of Mendelson's syndrome (acid pulmonary aspiration) are presented. They all demonstrate an acute diffuse alveolar filling pattern. This appearance is by no means specific. However, in the absence of other causes for this pattern and of evidence of left ventricular failure the radiologist may alert the clinician to the correct diagnosis. Early recognition of this syndrome will result in prompt treatment which differs significantly from that of other causes of this radiographic appearance. The differential diagnosis is discussed.

Occurrence of other endocrine tumours in primary hyperparathyroidism

In a review of a hundred and nineteen patients with primary hyperparathyroidism an unexpectedly high number (17.5%) were found to have evidence of associated endocrine disease and were deemed to have multiple endocrine adenomatosis (M.E.A.). The clinical pattern of hypercalcaemia in no way distinguished these patients from other hyperparathyroid patients. M.E.A. was most commonly found in patients with several diseased parathyroid glands.

Persistent and recurrent hyperparathyroidism

During the past 11 years at Hammersmith Hospital 11 patients have had parathyroid operations following a previous neck exploration. Six had persistent hyperparathyroidism and 5 had recurrent hyperparathyroidism with a “lucid interval” of biochemical normality of from 5 months to 11 years. Sucessful results were obtained in 9 of the 11 patients after a total of 29 operations, 4 of which were combined with sternotomy. The reasons for failure at operation and the medical and surgical management of these patients are reviewed.

Prostatectomy and deep-vein thrombosis

In a study of 50 patients who had undergone prostatectomy the incidence of deep-vein thrombosis was measured, using the 125I-fibrinogen test. Of these, 12 (24 per cent) developed deep-vein thrombosis. This preliminary study showed that in patients who had had a transurethral resection the incidence of deep-vein thrombosis was 6·8 per cent, while in patients who had had a retropubic prostatectomy it was 47·6 per cent.

Thyroid lymphography

A simple method is described for demonstrating the lymphatic architecture and drainage of the thyroid gland, and has been applied to study patients with hyperthroidism, ultinodular goitre, and clinically solitary nodules.