1132
angiography and selective transhepatic pancreatic venous sampling nor at a third operation, at-which a retained antrum had been excluded and total gastrectomy had been attempted. The resection was difficult and a 1 cm cuff of gastric mucosa had been left at the lower end of the oesophagus. Stomal ulceration might still have been a risk because the patient’s serum-gastrin remained very high (300 pmol/1) and might have exerted a trophic effect on the remaining parietal cells.6 We treated him with cimetidine (1 g/day) before considering a further resection. After 1 week of therapy the pH at the site of the anastomosis was measured by an intraluminal electrode positioned fluoroscopically at the junction of the Roux loop and the lower oesophagus. Cimetidine was withheld for 12 h before the test. Continuous pH recording (see figure) indicated a very acidic resting pH with intermittent alkaline waves as small intestinal juice refluxed. The mean pH during the first hour was 3.21. After an intravenous bolus of 400 mg cimetidine intraluminal pH rose to pH 6.8within 60 s and remained stable above pH 6 for the next hour (mean pH 6.30). The patient continued to take oral cimetidine for a further 3 months and, during this time, he gained 2 kg in weight. The pH test was then repeated and the readings were very similar to those of the first test (see figu-e). After he had been 12 h without cimetidine his pH levels fluctuated between pH 1.5 and 4.5with intermittent periods above pH 6. Mean pH during the hour before cimetidine was 4.36. Intravenous cimetidine (400 mg) again caused a rapid decrease in acidity which was maintained for the next hour (mean pH 6 .64). In-situ recording of intraluminal pH is a valuable method of assessing the acidity at the stomal site, a question which standard aspiration tests cannot answer reliably. In this patient cimetidine was very effective in the management of a gastric mucosal remnant with massive hypergastrinaemia when further resection was not feasible, and there was no evidence of "escape" or diminution of cimetidine’s ability to switch off the acid secretion after 3 months’ therapy. Department of Surgery, Royal Postgraduate Medical School and Hammersmith Hospital, London W12 0HS
R. F. McCLOY I. M. MODLIN
THYMOSIN-LIKE ACTIVITY IN FETAL CALF SERUM?
SiR,—The proportion of blood
T lymphocytes, assessed by erythrocytes (E), is one criterion of immunological competence.’ The rosette-forming technique varies considerably from laboratory to laboratory, making it
- fosette-formation with sheep
difficult to compare results. Some workers include2-6 and others oMit7-10 fetal calf serum (F.C.S.) in their test systems. We have shown that F.c.s. can increase the proportion of cells which form rosettes."-’3 We show here that a thymic extract ’Thymosin’ (Hoffman-LaRoche) has similar effects. E-rosette formation by peripheral blood lymphocytes from 364 adults and 64 children was measured, by the method of Byrom et al.," in medium, medium containing 25% F.c.s., and medium containing thymosin. Although F.c.s. and thymosin had little effect on rosette-formation by lymphocytes from normal subjects, five of seven patient groups had an abnormally low proportion of E-rosette-forming cells in medium alone, but a normal proportion when there was F.c.s. or thymosin in the medium. The dependence of the effect of thymosin on its concentration in the medium is described elsewhere." An increase in E-rosette formation after in-vitro incubation in F.c.s. was found previously in cells from patients with Hodgkin’s dis1. 2.
Wybran, J., Fudenberg, H. H. J. clin. Invest. 1973, 52, 1026. Wybran, J., Carr, M. C., Fudenberg, H. H. ibid. 1972, 51, 2537. 3. Wara, D. W., Goldstein, A. L., Doyle, N. E., Ammann, A. J. New Engl. J. Med. 1975, 292, 70. 4. Steel, C. M., Evans, J., Smith, M. A. Nature, 1974, 247, 387. 5. Papamichail, M., Holborow, E. J., Keith, H. I., Currey, H. L. F. Lancet,
1972, ii, 64. 6.
Bourgoin, J. J., Vitris, M., Rifa, J., Geneve, J. Behring Inst. Mitt. 1975, 56,
263. 7. Jondal, M., Holm, G., Wigzell, H. J. exp. Med. 1972, 136, 207. 8. Stimson, W. H., Blackstock, J. C. Behring Inst. Mitt. 1975, 57, 92. 9. Human B and T lymphocytes: a technical report. Scand. J. Immun.
3, 521. 10. Froland, S. S. ibid. 1972, 1, 269. 11. Byrom, N. A., Retsas, S., Dean,
A.
1974,
J., Hobbs, J. R. Clin. Oncol. (in the
press).
Hobbs, J.
R., Malka, S., Byrom, N. A. Proc. XXVth Colloq. Prot. biol, Fluids, 1977 (in the press). 13. Byrom, N. A., Caballero, F., Campbell, M. A., Chooi, M., Hugh-Jones, K., Lane, A. M., Hobbs, J. R. Unpublished. 14. Fuks, Z., Strober, S., King, D. P. J. Immun. (in the press). 15. Fuks, Z., Strober, S., Kaplan, H. S. New Engl. J. Med. 1976, 23, 1273. 12.
CIMETIDINE AND IRON-DEFICIENCY ANÆMIA
SIR,-Achlorhydria alone is an infrequent cause of irondeficiency anaemia but may become more important when iron requirements are increased. The H2-receptor antagonist cimetidine raises the intragastric pH for prolonged periods1 and patients on cimetidine often need iron therapy for iron deficiency anxmia after blood-loss. I have seen three patients (two with gastric ulcers and one with a duodenal ulcer) who were treated with cimetidine (1g daily) and were given ferrous sulphate (600 mg daily) for iron-deficiency anaemia after chronic bleeding. Occult blood disappeared after 2 weeks of combined therapy and after 2 months the ulcers had healed in all three patients. However, anxmia and altered iron metabolism, as shown by serum iron, total iron-binding capacity, and transferrin saturation, persisted almost without change. Cimetidine was reduced to 400 mg daily and ferrous sulphate was maintained at the same dose. The blood picture improved and 30 days later all the laboratory findings were satisfactory. The delay in response to iron therapy may have been caused by the prolonged reduction of gastric acid secretion induced by high doses of cimetidine and it may be necessary to give iron parenterally in such cases if absorption is persistently impaired. Institute of Infectious
University of Milan, 20158 Milan, Italy
EFFECT OF THYMOSIN AND F.C.S. ON E-ROSETTE FORMATION
Diseases,
ROBERTO ESPOSITO
-1
Values for all
I
I
I
groups were compared by Mann-Whitney U test against mean % E-rosettes in medium alone given by control normal subjects (*). p values are in parentheses. N.S.=uot significant.
patient
angiography and selective transhepatic pancreatic venous sampling nor at a third operation, at-which a retained antrum had been excluded and total gastrectomy had been attempted. The resection was difficult and a 1 cm cuff of gastric mucosa had been left at the lower end of the oesophagus. Stomal ulceration might still have been a risk because the patient’s serum-gastrin remained very high (300 pmol/1) and might have exerted a trophic effect on the remaining parietal cells.6 We treated him with cimetidine (1 g/day) before considering a further resection. After 1 week of therapy the pH at the site of the anastomosis was measured by an intraluminal electrode positioned fluoroscopically at the junction of the Roux loop and the lower oesophagus. Cimetidine was withheld for 12 h before the test. Continuous pH recording (see figure) indicated a very acidic resting pH with intermittent alkaline waves as small intestinal juice refluxed. The mean pH during the first hour was 3.21. After an intravenous bolus of 400 mg cimetidine intraluminal pH rose to pH 6.8within 60 s and remained stable above pH 6 for the next hour (mean pH 6.30). The patient continued to take oral cimetidine for a further 3 months and, during this time, he gained 2 kg in weight. The pH test was then repeated and the readings were very similar to those of the first test (see figu-e). After he had been 12 h without cimetidine his pH levels fluctuated between pH 1.5 and 4.5with intermittent periods above pH 6. Mean pH during the hour before cimetidine was 4.36. Intravenous cimetidine (400 mg) again caused a rapid decrease in acidity which was maintained for the next hour (mean pH 6 .64). In-situ recording of intraluminal pH is a valuable method of assessing the acidity at the stomal site, a question which standard aspiration tests cannot answer reliably. In this patient cimetidine was very effective in the management of a gastric mucosal remnant with massive hypergastrinaemia when further resection was not feasible, and there was no evidence of "escape" or diminution of cimetidine’s ability to switch off the acid secretion after 3 months’ therapy. Department of Surgery, Royal Postgraduate Medical School and Hammersmith Hospital, London W12 0HS
R. F. McCLOY I. M. MODLIN
THYMOSIN-LIKE ACTIVITY IN FETAL CALF SERUM?
SiR,—The proportion of blood
T lymphocytes, assessed by erythrocytes (E), is one criterion of immunological competence.’ The rosette-forming technique varies considerably from laboratory to laboratory, making it
- fosette-formation with sheep
difficult to compare results. Some workers include2-6 and others oMit7-10 fetal calf serum (F.C.S.) in their test systems. We have shown that F.c.s. can increase the proportion of cells which form rosettes."-’3 We show here that a thymic extract ’Thymosin’ (Hoffman-LaRoche) has similar effects. E-rosette formation by peripheral blood lymphocytes from 364 adults and 64 children was measured, by the method of Byrom et al.," in medium, medium containing 25% F.c.s., and medium containing thymosin. Although F.c.s. and thymosin had little effect on rosette-formation by lymphocytes from normal subjects, five of seven patient groups had an abnormally low proportion of E-rosette-forming cells in medium alone, but a normal proportion when there was F.c.s. or thymosin in the medium. The dependence of the effect of thymosin on its concentration in the medium is described elsewhere." An increase in E-rosette formation after in-vitro incubation in F.c.s. was found previously in cells from patients with Hodgkin’s dis1. 2.
Wybran, J., Fudenberg, H. H. J. clin. Invest. 1973, 52, 1026. Wybran, J., Carr, M. C., Fudenberg, H. H. ibid. 1972, 51, 2537. 3. Wara, D. W., Goldstein, A. L., Doyle, N. E., Ammann, A. J. New Engl. J. Med. 1975, 292, 70. 4. Steel, C. M., Evans, J., Smith, M. A. Nature, 1974, 247, 387. 5. Papamichail, M., Holborow, E. J., Keith, H. I., Currey, H. L. F. Lancet,
1972, ii, 64. 6.
Bourgoin, J. J., Vitris, M., Rifa, J., Geneve, J. Behring Inst. Mitt. 1975, 56,
263. 7. Jondal, M., Holm, G., Wigzell, H. J. exp. Med. 1972, 136, 207. 8. Stimson, W. H., Blackstock, J. C. Behring Inst. Mitt. 1975, 57, 92. 9. Human B and T lymphocytes: a technical report. Scand. J. Immun.
3, 521. 10. Froland, S. S. ibid. 1972, 1, 269. 11. Byrom, N. A., Retsas, S., Dean,
A.
1974,
J., Hobbs, J. R. Clin. Oncol. (in the
press).
Hobbs, J.
R., Malka, S., Byrom, N. A. Proc. XXVth Colloq. Prot. biol, Fluids, 1977 (in the press). 13. Byrom, N. A., Caballero, F., Campbell, M. A., Chooi, M., Hugh-Jones, K., Lane, A. M., Hobbs, J. R. Unpublished. 14. Fuks, Z., Strober, S., King, D. P. J. Immun. (in the press). 15. Fuks, Z., Strober, S., Kaplan, H. S. New Engl. J. Med. 1976, 23, 1273. 12.
CIMETIDINE AND IRON-DEFICIENCY ANÆMIA
SIR,-Achlorhydria alone is an infrequent cause of irondeficiency anaemia but may become more important when iron requirements are increased. The H2-receptor antagonist cimetidine raises the intragastric pH for prolonged periods1 and patients on cimetidine often need iron therapy for iron deficiency anxmia after blood-loss. I have seen three patients (two with gastric ulcers and one with a duodenal ulcer) who were treated with cimetidine (1g daily) and were given ferrous sulphate (600 mg daily) for iron-deficiency anaemia after chronic bleeding. Occult blood disappeared after 2 weeks of combined therapy and after 2 months the ulcers had healed in all three patients. However, anxmia and altered iron metabolism, as shown by serum iron, total iron-binding capacity, and transferrin saturation, persisted almost without change. Cimetidine was reduced to 400 mg daily and ferrous sulphate was maintained at the same dose. The blood picture improved and 30 days later all the laboratory findings were satisfactory. The delay in response to iron therapy may have been caused by the prolonged reduction of gastric acid secretion induced by high doses of cimetidine and it may be necessary to give iron parenterally in such cases if absorption is persistently impaired. Institute of Infectious
University of Milan, 20158 Milan, Italy
EFFECT OF THYMOSIN AND F.C.S. ON E-ROSETTE FORMATION
Diseases,
ROBERTO ESPOSITO
-1
Values for all
I
I
I
groups were compared by Mann-Whitney U test against mean % E-rosettes in medium alone given by control normal subjects (*). p values are in parentheses. N.S.=uot significant.
patient
