antibody titres of 1/80 against thyroglobulin and thyroid microsomal antigen, and 1/320 against adrenal antigen. Investigation of thyroid status indicated hypothyroidism and she was treated with levothyroxine. Two years later she presented with a maculopapular eruption on her face and polyarthritis of 2 months' duration. A diagnosis of systemic lupus erythematosus was made on the basis of an antinuclear antibody titre of 1 / 1240 and positive lupus erythematosus cell preparations. The serum concentration of the C3 component of complement was 46 mg/dl (normal 80 to 160 mg/dl). Biopsy of skin and kidney showed immunoglobulin deposition. She was initially treated with prednisone 30 mg/d and the dose was later decreased to 30 mg every other day with satisfactory control of the systemic lupus erythematosus. This necessitated alterations to the dose of insulin. The patient later had two episodes of acute nephritis. The first episode responded to vigorous therapy with prednisone and azathioprine. At the time of admission her diabetes was out of control; the blood glucose concentration was between 300 and 600 mg/dl and the serum creatinine concentration was 292 p.mol/l (3.3 mg/dl). Associated proteinuria (3 g of protein was excreted every 24 hours) and nephritic urinary sediment were noted. She was treated with cyclophosphamide, azathioprine and prednisone. However, after an initial decrease in the serum creatinine concentration, renal function deteriorated and she died 3 weeks after admission to hospital. During the course of the disease histocompatibility antigen testing of lymphocytes revealed HLA antigens A2, Aw24, B8 and B27. Discu.ssion A genetic predisposition to systemic lupus erythematosus has been suggested by HLA tissue-typing studies. HLA-B8 and -Bwl 5 are observed more frequently in patients with this disease than in control subjectsY Similarly, results of studies on patients with diabetes mellitus of juvenile onset have indicated an increased frequency of
the disease in patients with HLAB8, thus providing evidence of a genetic predisposition for the development of the disease.3 Up to 85% of patients with this form of diabetes have been found to have detectable circulating antibody against islet cells at the onset of the disease, which suggests that diabetes of juvenile onset may be considered an autoimmune disease.3 Thus, the reported association with other autoimmune endocrinopathies is not surprising.4'5 Our patient had an autoimmune polyendocrinopathy prior to presentation with systemic lupus erythematosus, as evidenced by the presence of circulating antibodies to thyroid and adrenal antigens. It is reasonable to assume that she may also have had anti-islet-cell antibody formation. A previous report described a patient with transient chemical diabetes after the initiation of prednisone therapy for systemic lupus erythematosus; antibodies directed against cultured insulinoma cells were detected.0 In our patient insulin-dependent diabetes predated systemic lupus erythematosus and was accompanied by autoimmune thyroiditis. Thus, not only did a tissue antigen profile indicate susceptibility to both juvenile insulindependent diabetes mellitus and systemic lupus erythematosus, but also both diseases developed in association with autoantibody formation against at least two other endocrine glands; therefore, our patient had a wide-ranging and ultimately fatal autoimmune disease. In patients with antigens such as B8, in whom autoimmune disease occurs, vigilance is required so that, should other autoimmune states such as systemic lupus erythematosus evolve, they may be readily identified. The silent evolution of this disease in situations in which it was not originally suspected, such as membranous nephropathy,7 suggests that autoantibody formation against nuclear antigens might have been present in our patient at the onset of diabetes and that full clinical expression of the disease did not become apparent for 2 years. It is not unusual to perform serial autoantibody profiles in persons with autoimmune diseases, but our case, as well as that originally de-
scribed,6 in which glucose intolerance improved with control of the patient's lupus state, indicates that such testing may prove fruitful in providing better information for patient management as well as broadening our understanding of the underlying processes in autoimmune disease. SEAN O'REGAN, MD
Department of nephrology H6pital Sainte-Justine Montreal, PQ
References 1. WANEBO HJ, RAWSON RW: Lupus erythematosus complicated by the Chiari-Frommel syndrome and autoimmune thyroiditis. Arch Intern Med 124: 619, 1969 2. DAUSSET J, DEGOS L, HORS J: The association of the HL-A antigens with diseases. Clin Immunol Immunopathol 3: 127, 1974 3. NERUP J, PLATZ P, RYDER LP, et al:
HLA islet cell antibodies, and types of diabetes mellitus. Diabetes 27 (suppi 1): 247, 1978 4. BOTTAZZO GF, FLORIN-CHRISTENSEN
A, DONAICH D: Islet cell antibodies in diabetes mellitus with autoimmune polyendocrine deficiencies. Lancet 2: 1279, 1974 5. MACCUISM AC, BARNES EW, IRVINE
WJ, et al: Antibodies to pancreatic islet cells in insulin-dependent diabetics with coexistent autoimmune disease. Ibid, p 1529 6. FRUMAN LS: Diabetes mellitus, islet cell antibodies and HLA-B8 in a patient with systemic lupus erythematosus. Am J Dis Child 131: 1252, 1977 7. Luwr SA, BURRE B, MICHAEL AF,
et al: Extramembranous glomerulonephritis in childhood: relationship to systemic lupus erythematosus. J Pcdiatr 88: 394, 1976
Music therapy To the editor: I applaud CMAJ for publishing the article on music therapy in palliative care by S. Munro and Dr. B. Mount (Can Med Assoc J 119: 1029, 1978). I wish to report an aspect of music therapy that has received little attention.
The Regional Psychiatric Centre in Abbotsford, BC is a 138-bed prison hospital that was established in 1972 to provide psychiatric treatment to emotionally disturbed or mentally ill federal offenders. In 1975 the centre began a program with a voluntary music appreciation group consisting of inmate patients. Every Tuesday afternoon the group
CMA JOURNAL/NOVEMBER 3, 1979/VOL. 121
1169
gathers in the schoolroom and listens to a piece of classical music for 1 hour. The program started spontaneously and eventually became popular. Every week one member of the group volunteers to choose a composer and selected pieces to be played the following week. After the session there is a general discussion, led by a schoolteacher, about the music and its effect on each member of the group. After 2 years we made some interesting* observations: * Most of the members of the group had no background of classical music. In fact, some of them were not even interested in music. * The group is composed mostly of patients who have committed violent offences. They were selfselected and were not persuaded by treatment teams to join the group. * While listening to a piece of music some of the patients started using visual material, in the form of slide projections on the wall, to augment their appreciation. * The group listened to the music intently without any disruptive behaviour. * When rock music was played the group became disruptive, so much so that the session had to be ended prematurely. * Of all the composers chosen by the group Tchaikowsky seemed to be the most popular, followed by Debussy. * A man who had committed a number of murders and had never been exposed to classical music became obsessed with Debussy's music. All the activities of the group are closely monitored by the department of occupational therapy and training. In the future we may be able to publish some data. However, from the last 2 years' experience it seems clear that classical music has a positive effect on individuals who have shown violence in the past. One wonders whether classical music has a specific effect on the nondominant hemisphere of the brain, which is also closely related to affect. After the publication of Munro and Mount's article I wrote a letter to Yehudi Menuhin asking him to visit our hospital. Mr. Menuhin replied so positively that a date for
his visit was arranged. Unfortunately, he could not come owing to other commitments, but he has confirmed that he will visit our hospital and meet with the group Feb. 8, 1980. Mr. Menuhin was so interested in this aspect of our therapy that I was invited to meet with him following a concert in Vancouver in February 1979. I wrote this letter because I recently observed some criticism of my colleagues on this very important topic. C. Roy, FRCP[C], FRC PSYCH (E)
Secretary general International Council of Prison Medical Services Medical director Regional Psychiatric Centre Abbotsford, BC
Experience with an undergraduate medical bursary program in Ontario To the editor: On Oct. 1, 1969 the Ontario Ministry of Health introduced an undergraduate medical bursary program to attract medical students into family practice in areas of the province designated as underserviced. Ontario residents attending a Canadian medical school were eligible to apply for support. The bursaries provided $3000 per annum in each of the last 3 years of college, and were granted to the students upon their agreement to spend 1 calendar year in family practice in an area designated as underserviced for each year of academic assistance. A total of 220 students received 427 years of bursary assistance. Following graduation the students were permitted up to 3 years' postgraduate training, provided such training was preparing them for family practice. During the last 6 months of internship the bursary recipients were encouraged by the Ontario Ministry of Health to attend an interview, at which they were advised of the various vacancies in the program and given complete information about each. The choice of location in which to practise, made from the list of areas designated as underserviced, was their own. When doctors entered the program they were eligible to apply for the financial support available to any other physician who might join the program.
1170 CMA JOURNAL/NOVEMBER 3, 1979/VOL. 121
At that time such support was in the form of a contract with a guaranteed annual minimum net professional income of $33 000, or an income-tax-free incentive grant of $8000 the first year, $6000 the second year and $3000 in each of the following 2 years. Bursary recipients who do not return the service are responsible for returning the monies plus 10% interest computed from the date of graduation. The following observations were made of the undergraduate medical bursary program: * Of all the bursary recipients 50% returned service and did practise or are practising in underserviced areas. * Half of the 50% who returned service did so in northern Ontario. This was interesting because students were selected for bursaries primarily because they had indicated an interest in practising in the North. * Two thirds of the 50% remained in the underserviced area after their obligation to the Ontario Ministry of Health had been fulfilled. * Students who received undergraduate bursary support for 3 years were more likely to return service than those who received support for only 1 or 2 years. * Fewer than 10% of female students who received bursaries completed the program. * Of the 50% of doctors who failed to fulfill their obligation, about 60% have refunded their monies with interest, and 35% are in the process of returning the funds; collection is a problem with only 5%. * The undergraduate bursary program could be depended upon to provide physicians in areas where primary health care is urgently needed. It was concluded that a small, ongoing undergraduate bursary program would meet the needs of underserviced areas and could be operated at a good cost/benefit ratio. W.J. COPEMAN, MD, DPH, FcFP[c]
Principal program adviser and senior medical consultant Underserviced area program Ontario Ministry of Health Toronto, Ont.
the disease in patients with HLAB8, thus providing evidence of a genetic predisposition for the development of the disease.3 Up to 85% of patients with this form of diabetes have been found to have detectable circulating antibody against islet cells at the onset of the disease, which suggests that diabetes of juvenile onset may be considered an autoimmune disease.3 Thus, the reported association with other autoimmune endocrinopathies is not surprising.4'5 Our patient had an autoimmune polyendocrinopathy prior to presentation with systemic lupus erythematosus, as evidenced by the presence of circulating antibodies to thyroid and adrenal antigens. It is reasonable to assume that she may also have had anti-islet-cell antibody formation. A previous report described a patient with transient chemical diabetes after the initiation of prednisone therapy for systemic lupus erythematosus; antibodies directed against cultured insulinoma cells were detected.0 In our patient insulin-dependent diabetes predated systemic lupus erythematosus and was accompanied by autoimmune thyroiditis. Thus, not only did a tissue antigen profile indicate susceptibility to both juvenile insulindependent diabetes mellitus and systemic lupus erythematosus, but also both diseases developed in association with autoantibody formation against at least two other endocrine glands; therefore, our patient had a wide-ranging and ultimately fatal autoimmune disease. In patients with antigens such as B8, in whom autoimmune disease occurs, vigilance is required so that, should other autoimmune states such as systemic lupus erythematosus evolve, they may be readily identified. The silent evolution of this disease in situations in which it was not originally suspected, such as membranous nephropathy,7 suggests that autoantibody formation against nuclear antigens might have been present in our patient at the onset of diabetes and that full clinical expression of the disease did not become apparent for 2 years. It is not unusual to perform serial autoantibody profiles in persons with autoimmune diseases, but our case, as well as that originally de-
scribed,6 in which glucose intolerance improved with control of the patient's lupus state, indicates that such testing may prove fruitful in providing better information for patient management as well as broadening our understanding of the underlying processes in autoimmune disease. SEAN O'REGAN, MD
Department of nephrology H6pital Sainte-Justine Montreal, PQ
References 1. WANEBO HJ, RAWSON RW: Lupus erythematosus complicated by the Chiari-Frommel syndrome and autoimmune thyroiditis. Arch Intern Med 124: 619, 1969 2. DAUSSET J, DEGOS L, HORS J: The association of the HL-A antigens with diseases. Clin Immunol Immunopathol 3: 127, 1974 3. NERUP J, PLATZ P, RYDER LP, et al:
HLA islet cell antibodies, and types of diabetes mellitus. Diabetes 27 (suppi 1): 247, 1978 4. BOTTAZZO GF, FLORIN-CHRISTENSEN
A, DONAICH D: Islet cell antibodies in diabetes mellitus with autoimmune polyendocrine deficiencies. Lancet 2: 1279, 1974 5. MACCUISM AC, BARNES EW, IRVINE
WJ, et al: Antibodies to pancreatic islet cells in insulin-dependent diabetics with coexistent autoimmune disease. Ibid, p 1529 6. FRUMAN LS: Diabetes mellitus, islet cell antibodies and HLA-B8 in a patient with systemic lupus erythematosus. Am J Dis Child 131: 1252, 1977 7. Luwr SA, BURRE B, MICHAEL AF,
et al: Extramembranous glomerulonephritis in childhood: relationship to systemic lupus erythematosus. J Pcdiatr 88: 394, 1976
Music therapy To the editor: I applaud CMAJ for publishing the article on music therapy in palliative care by S. Munro and Dr. B. Mount (Can Med Assoc J 119: 1029, 1978). I wish to report an aspect of music therapy that has received little attention.
The Regional Psychiatric Centre in Abbotsford, BC is a 138-bed prison hospital that was established in 1972 to provide psychiatric treatment to emotionally disturbed or mentally ill federal offenders. In 1975 the centre began a program with a voluntary music appreciation group consisting of inmate patients. Every Tuesday afternoon the group
CMA JOURNAL/NOVEMBER 3, 1979/VOL. 121
1169
gathers in the schoolroom and listens to a piece of classical music for 1 hour. The program started spontaneously and eventually became popular. Every week one member of the group volunteers to choose a composer and selected pieces to be played the following week. After the session there is a general discussion, led by a schoolteacher, about the music and its effect on each member of the group. After 2 years we made some interesting* observations: * Most of the members of the group had no background of classical music. In fact, some of them were not even interested in music. * The group is composed mostly of patients who have committed violent offences. They were selfselected and were not persuaded by treatment teams to join the group. * While listening to a piece of music some of the patients started using visual material, in the form of slide projections on the wall, to augment their appreciation. * The group listened to the music intently without any disruptive behaviour. * When rock music was played the group became disruptive, so much so that the session had to be ended prematurely. * Of all the composers chosen by the group Tchaikowsky seemed to be the most popular, followed by Debussy. * A man who had committed a number of murders and had never been exposed to classical music became obsessed with Debussy's music. All the activities of the group are closely monitored by the department of occupational therapy and training. In the future we may be able to publish some data. However, from the last 2 years' experience it seems clear that classical music has a positive effect on individuals who have shown violence in the past. One wonders whether classical music has a specific effect on the nondominant hemisphere of the brain, which is also closely related to affect. After the publication of Munro and Mount's article I wrote a letter to Yehudi Menuhin asking him to visit our hospital. Mr. Menuhin replied so positively that a date for
his visit was arranged. Unfortunately, he could not come owing to other commitments, but he has confirmed that he will visit our hospital and meet with the group Feb. 8, 1980. Mr. Menuhin was so interested in this aspect of our therapy that I was invited to meet with him following a concert in Vancouver in February 1979. I wrote this letter because I recently observed some criticism of my colleagues on this very important topic. C. Roy, FRCP[C], FRC PSYCH (E)
Secretary general International Council of Prison Medical Services Medical director Regional Psychiatric Centre Abbotsford, BC
Experience with an undergraduate medical bursary program in Ontario To the editor: On Oct. 1, 1969 the Ontario Ministry of Health introduced an undergraduate medical bursary program to attract medical students into family practice in areas of the province designated as underserviced. Ontario residents attending a Canadian medical school were eligible to apply for support. The bursaries provided $3000 per annum in each of the last 3 years of college, and were granted to the students upon their agreement to spend 1 calendar year in family practice in an area designated as underserviced for each year of academic assistance. A total of 220 students received 427 years of bursary assistance. Following graduation the students were permitted up to 3 years' postgraduate training, provided such training was preparing them for family practice. During the last 6 months of internship the bursary recipients were encouraged by the Ontario Ministry of Health to attend an interview, at which they were advised of the various vacancies in the program and given complete information about each. The choice of location in which to practise, made from the list of areas designated as underserviced, was their own. When doctors entered the program they were eligible to apply for the financial support available to any other physician who might join the program.
1170 CMA JOURNAL/NOVEMBER 3, 1979/VOL. 121
At that time such support was in the form of a contract with a guaranteed annual minimum net professional income of $33 000, or an income-tax-free incentive grant of $8000 the first year, $6000 the second year and $3000 in each of the following 2 years. Bursary recipients who do not return the service are responsible for returning the monies plus 10% interest computed from the date of graduation. The following observations were made of the undergraduate medical bursary program: * Of all the bursary recipients 50% returned service and did practise or are practising in underserviced areas. * Half of the 50% who returned service did so in northern Ontario. This was interesting because students were selected for bursaries primarily because they had indicated an interest in practising in the North. * Two thirds of the 50% remained in the underserviced area after their obligation to the Ontario Ministry of Health had been fulfilled. * Students who received undergraduate bursary support for 3 years were more likely to return service than those who received support for only 1 or 2 years. * Fewer than 10% of female students who received bursaries completed the program. * Of the 50% of doctors who failed to fulfill their obligation, about 60% have refunded their monies with interest, and 35% are in the process of returning the funds; collection is a problem with only 5%. * The undergraduate bursary program could be depended upon to provide physicians in areas where primary health care is urgently needed. It was concluded that a small, ongoing undergraduate bursary program would meet the needs of underserviced areas and could be operated at a good cost/benefit ratio. W.J. COPEMAN, MD, DPH, FcFP[c]
Principal program adviser and senior medical consultant Underserviced area program Ontario Ministry of Health Toronto, Ont.
