84
Similarly, the blood concentrations of thyroxine have not varied with the size of the goitre. The statement can only be applicable to those areas where the deficiency is severe. Additional possibilities which may serve to contradict this statement further have been suggested ’*: (a) portions of the goitre may become autonomous and therefore independent of the influence of T.S.H. ; (b) some portions of the goitre may become replaced by non-functional tissue which, however, continues to contribute to the goitre. Makerere University Medical School, P.O. Box 7072, Kampala, Uganda.
long way to the centre, we try to provide a rapid and personal service to compensate for the journey. Our patients have their blood-counts done immediately on arrival, they -are examined and given treatment, and leave within
one to two
hours.
Bone-marrow and other
un-
pleasant examinations are done under anaesthetic,2 and the results are available by lunch-time: the children can leave within three hours. In our experience, patients may spend as long at normal outpatient clinics, and few local hospitals can provide as rapid a service for children with leukaemia.
S. K. KAJUBI.
Royal Manchester Children’s Hospital, Pendlebury, near
MEDICAL CARE OF CHILDHOOD LEUKÆMIA SiR,-Dr McCarthy (May 17, p. 1128) is wrong to suggest from a narrow experience in London that local hospitals throughout the country could provide the same facilities as special centres. The hospitals he chose for his study are hardly representative. One of his special centres treated few children and provided no primary care. At the same time seven of his local hospitals were undergraduate teaching hospitals. This is not the case with leukaemia centres and local hospitals elsewhere. Furthermore, in the Metropolitan regions, the ratio of staff to population is nearly twice the national average in haematology and 20% higher in pxdiatrics.l In the North-West Region, over the years 1954-68, we found that survival-rates for children treated in the two main children’s hospitals of Manchester were consistently better than those for children treated in the paediatric units of general hospitals. As late as 1964-68, results from the regional units were still worse than those achieved in the children’s hospitals five years earlier, between 1959 and 1963 (see accompanying figure). As a result, we
Manchester M27 1HA.
D. I. K. EVANS PATRICIA MORRIS J. K. STEWARD.*
JONES
THYROTOXICOSIS DUE TO " SILENT " THYROIDITIS SiR,—The paper by Dr Papapetrou and Dr Jackson (Feb. 15, p. 361) was of particular interest to me, since I published similar data on four occasions 3-8 between 1971 and 1975. I had chosen to label this entity " occult subacute thyroiditis ".’ In a recent analysis of 100 consecutive patients with subacute thyroiditis, 6 presented with clinical features of thyrotoxicosis without the characteristic pain and tenderness.8 This entity deserves emphasis. The authors might have been more searching in their review of the literature. Northland Thyroid Laboratory, P.C., ’
Northland Medical Building,
20905 Greenfield, Southfield, Michigan 48075, U.S.A.
JOEL I. HAMBURGER.
PIPED MEDICAL-GAS SYSTEMS
SIR,-We congratulate Dr Feeley and his colleagues (June 28, p. 1416) on identifying some omissions from the U.K. guidance document (Hospital Technical Memorandum no. 22). We would however point out that their criticisms are applicable to some extent to nitrous oxide, Entonox’, and medical compressed-air systems as well as to oxygen systems. "
Testing of a high-pressure alarm is described as nearly impossible ". This need not be the case. If the highpressure alarm were connected upstream of the main shut-off valve (see figure in original paper) and an emergency supply-point fitted downstream of this valve (as is the practice in the U.K.) then the alarm could be tested while the main shut-off valve was closed and the gas supply maintained at constant pressure through the emergency
Survival-rates for children with acute leukaemia (all types) treated in psediatric units of regional hospitals (dotted lines) compared with those for children treated in the two main Manchester children’s hospitals (solid lines). at this hospital by 1971 and thus such results, since over 90% of longer compare The results cases from the region are now treated here. have continued to improve, showing that the poor results achieved in the peripheral units was not due to selection of cases. Of the 21 cases of acute lymphoblastic leukaemia presenting in 1970 and treated here, 11 (52%) are still alive and 10 (48%) are in initial remission and off treatment. Although parents may have to bring their children a
centralised the treatment
can no
1. From Hospital Medical Staff Regional W/T Equivalent Tables, as at Sept. 30, 1973. Department of Health and Social Security.
supply-point. This procedure can_also be used to test the pressurerelief valve and the low-pressure alarm which in the U.K. is normally sited upstream of the main shut-off valve. The fact that the gas pressure is not monitored by the alarm system when the emergency supply is in use is not considered to be a dangerous situation because the system will be under manual supervision. The main purpose of the alarms is to monitor an unattended system. Building Services Research Unit, 3 Lilybank Gardens, Glasgow W2.
W. CARSON E. GIBSON.
* Dr Steward died on Tune 20. 2. Evans, D. I. K., Morris Jones, P., Morris, P., Shaw, E. A. Lancet, 1971, i, 751. 3. Hamburger, J. I. Mich. Med. 1971, 70, 1125. 4. Hamburger, J. I. Nontoxic Goiter: Concept and Controversy; p. 94. Springfield, Illinois, 1973. 5. Hamburger, J. I. J. nucl. Med. 1974, 15, 81. 6. Hamburger, J. I. Clinical Thyroidology; p. 174. Southfield, 1974.
Similarly, the blood concentrations of thyroxine have not varied with the size of the goitre. The statement can only be applicable to those areas where the deficiency is severe. Additional possibilities which may serve to contradict this statement further have been suggested ’*: (a) portions of the goitre may become autonomous and therefore independent of the influence of T.S.H. ; (b) some portions of the goitre may become replaced by non-functional tissue which, however, continues to contribute to the goitre. Makerere University Medical School, P.O. Box 7072, Kampala, Uganda.
long way to the centre, we try to provide a rapid and personal service to compensate for the journey. Our patients have their blood-counts done immediately on arrival, they -are examined and given treatment, and leave within
one to two
hours.
Bone-marrow and other
un-
pleasant examinations are done under anaesthetic,2 and the results are available by lunch-time: the children can leave within three hours. In our experience, patients may spend as long at normal outpatient clinics, and few local hospitals can provide as rapid a service for children with leukaemia.
S. K. KAJUBI.
Royal Manchester Children’s Hospital, Pendlebury, near
MEDICAL CARE OF CHILDHOOD LEUKÆMIA SiR,-Dr McCarthy (May 17, p. 1128) is wrong to suggest from a narrow experience in London that local hospitals throughout the country could provide the same facilities as special centres. The hospitals he chose for his study are hardly representative. One of his special centres treated few children and provided no primary care. At the same time seven of his local hospitals were undergraduate teaching hospitals. This is not the case with leukaemia centres and local hospitals elsewhere. Furthermore, in the Metropolitan regions, the ratio of staff to population is nearly twice the national average in haematology and 20% higher in pxdiatrics.l In the North-West Region, over the years 1954-68, we found that survival-rates for children treated in the two main children’s hospitals of Manchester were consistently better than those for children treated in the paediatric units of general hospitals. As late as 1964-68, results from the regional units were still worse than those achieved in the children’s hospitals five years earlier, between 1959 and 1963 (see accompanying figure). As a result, we
Manchester M27 1HA.
D. I. K. EVANS PATRICIA MORRIS J. K. STEWARD.*
JONES
THYROTOXICOSIS DUE TO " SILENT " THYROIDITIS SiR,—The paper by Dr Papapetrou and Dr Jackson (Feb. 15, p. 361) was of particular interest to me, since I published similar data on four occasions 3-8 between 1971 and 1975. I had chosen to label this entity " occult subacute thyroiditis ".’ In a recent analysis of 100 consecutive patients with subacute thyroiditis, 6 presented with clinical features of thyrotoxicosis without the characteristic pain and tenderness.8 This entity deserves emphasis. The authors might have been more searching in their review of the literature. Northland Thyroid Laboratory, P.C., ’
Northland Medical Building,
20905 Greenfield, Southfield, Michigan 48075, U.S.A.
JOEL I. HAMBURGER.
PIPED MEDICAL-GAS SYSTEMS
SIR,-We congratulate Dr Feeley and his colleagues (June 28, p. 1416) on identifying some omissions from the U.K. guidance document (Hospital Technical Memorandum no. 22). We would however point out that their criticisms are applicable to some extent to nitrous oxide, Entonox’, and medical compressed-air systems as well as to oxygen systems. "
Testing of a high-pressure alarm is described as nearly impossible ". This need not be the case. If the highpressure alarm were connected upstream of the main shut-off valve (see figure in original paper) and an emergency supply-point fitted downstream of this valve (as is the practice in the U.K.) then the alarm could be tested while the main shut-off valve was closed and the gas supply maintained at constant pressure through the emergency
Survival-rates for children with acute leukaemia (all types) treated in psediatric units of regional hospitals (dotted lines) compared with those for children treated in the two main Manchester children’s hospitals (solid lines). at this hospital by 1971 and thus such results, since over 90% of longer compare The results cases from the region are now treated here. have continued to improve, showing that the poor results achieved in the peripheral units was not due to selection of cases. Of the 21 cases of acute lymphoblastic leukaemia presenting in 1970 and treated here, 11 (52%) are still alive and 10 (48%) are in initial remission and off treatment. Although parents may have to bring their children a
centralised the treatment
can no
1. From Hospital Medical Staff Regional W/T Equivalent Tables, as at Sept. 30, 1973. Department of Health and Social Security.
supply-point. This procedure can_also be used to test the pressurerelief valve and the low-pressure alarm which in the U.K. is normally sited upstream of the main shut-off valve. The fact that the gas pressure is not monitored by the alarm system when the emergency supply is in use is not considered to be a dangerous situation because the system will be under manual supervision. The main purpose of the alarms is to monitor an unattended system. Building Services Research Unit, 3 Lilybank Gardens, Glasgow W2.
W. CARSON E. GIBSON.
* Dr Steward died on Tune 20. 2. Evans, D. I. K., Morris Jones, P., Morris, P., Shaw, E. A. Lancet, 1971, i, 751. 3. Hamburger, J. I. Mich. Med. 1971, 70, 1125. 4. Hamburger, J. I. Nontoxic Goiter: Concept and Controversy; p. 94. Springfield, Illinois, 1973. 5. Hamburger, J. I. J. nucl. Med. 1974, 15, 81. 6. Hamburger, J. I. Clinical Thyroidology; p. 174. Southfield, 1974.
