111 OXPRENOLOL IN THE OPERATING-THEATRE
SIR,—Iwas intrigued by the paper from Mr Foster and his colleagues’ on the heart-rates of surgeons whilst operating. I hope the figures obtained do not apply to me, but I shall certainly check to see whether my mean heart-rate during a cholecystectomy is 132/min. However, I wonder if part of the explanation for their findings may not be the speed with which the operations were done. I note that the consultant surgeon was able to perform a York Mason procedure in 50 min and the bottom end of an abdominoperineal in 35 min. Perhaps the solution is not to take exprenolol but to operate more slowly. Department of Surgery, Guy’s Hospital, London SE1 9RT
***In the paper by Mr Foster and his colleagues the first
of the second paragraph of the Results should have read: "... and high rates persisted to a surprising degree throughout the operation ..."-ED. L.
PROSTAGLANDINS AND OBESITY
SIR,—In 1975 Curtis-Prior2 suggested that metabolic obesis caused by overproduction of prostaglandins. He concluded that aspirin, which inhibits prostaglandin synthesis, might protect against hypertensive heart-disease and myocardial infarction by lowering the incidence of overweight. During the German-Austrian Reinfarction Study,3 a representative sample of 40 patients receiving 1.5g aspirin per day for two years was followed up every four weeks for more than twenty-six months for changes in body-weight. The average body-weight was 73. 7:t1.8 kg before therapy and 73-4+2.2 kg after two years of aspirin treatment. No significant changes of body-weight were observed throughout the study in aspirintreated subjects or in controls on placebo. The preliminary results of the study suggest that aspirin can prevent sudden death and myocardial infarction. In the light of the constant body-weight of the patients these beneficial effects are probably due to prevention of clot formation. The effects of prostaglandins on human adipose tissue are far less clear-cut than Curtis-Prior suggested. These C-20 fatty acids not only inhibit the mobilisation of fat from adipose tissue, but also they can stimulate lipolysis in vivo and in vitro.4,5 We have found that E and F prostaglandins are potent activators of the human fat-cell adenylate cyclase, thus mimicking the effects of lipolytic hormones on this key enzyme of hormone-stimulated lipolysis.5 The prostaglandin hypothesis of metabolic obesity is attractive, since it implies that aspirin and other non-steroidal antiinflammatory drugs not only might protect against myocardial infarction but also might be useful in the treatment of obesity. However, in the joint clinical study3 with doses of aspirin at least five times higher than those required for complete inhibition of prostaglandin synthesis in human platelets,’ there was no significant weight loss. The complex effects of prostaglandins in vivo and in vitro are not fully understood and it may be simplistic to assume a fundamental role for them in metabolic obesity, as yet. More needs to be found out about the physiological effects of prostaglandins on human adipose tissue before prostaglandin antagonists or synthetase inhibitors are tried in the obese.
Klinisches Institut fur Herzinfarktforschung und Abteilung für Klinische Pharmakologie, Medizinische Universitätsklinik Heidelberg, D-69 Heidelberg, West Germany 1. 2. 3 4
E. WALTER B. SIMON
Foster. G. E . Evans, D. F., Hardcastle, J. D. Lancet, 1978, i, 1323. Curtis-Prior, P B. Lancet, 1975, i, 897. Breddin. K , Überla, K , Walter, E. Thrombos. Hœmostas 1977, 38, 168. Carlson. L A., Ekelund, L. G., Orö, L., Acta med. scand 1970, 188, 553.
5 Rosenquist, U ibid 1972, 192, 353. 6. Katner, H, Simon, B. J. cycl Nucleotide Res. 7. Burch, J W. Stanford. N., Majerus, P. W
1977, 3, 199. J. clin. Invest. 1978, 61, 314.
HODGKIN’S DISEASE PRESENTING AT THE ELBOW
SIR,—Hodgkin’s disease most often presents with painless progressive enlargement of superficial lymph-nodes, particularly those in the neck, and less often with enlargement of other groups of nodes. Involvement of the supratrochlear nodes is uncommon, even in advanced disease, and it must be very rare as a presenting symptom or sign. Patients receiving "total nodal irradiation" do not usually have these nodes included in the radiation fields. The following case is, therefore, of interest. The patient, a 42-year-old-male, was first seen in March, 1975, with a firm 2 cm swelling at the medial aspect of the left elbow, present for a few months and associated, in his view, with paraathesia in the upper arm and numbness on the dorsum of the hand. There was doubt about the relevance of these symptoms because there were no demonstrable neurological signs. There were no systemic symptoms of lymphoma, and no other abnormalities were found on physical examination. Surgical exploration revealed a fleshy tumour, which was excised. Histological examination of this showed the tumour to consist of a lymph-node, its architecture largely replaced by Hodgkin’s tissue of the nodular sclerotic type. Further investigations, including mediastinal tomography, lymphangiography, and a radioisotope scan of the liver and spleen, revealed no evidence of lymphoma elsewhere. Hasmatological and biochemical tests were all normal. Laparotomy was not
The patient subsequently received a course of high-energy radiation to the left elbow, upper arm and axilla (3750-4000 rad in twenty fractions over 28 days). There were no complications arising from treatment. The patient is a poor attender at the follow-up clinic, but he has been seen intermittently since treatment. He has remained well and without evidence of lymphoma for more than 2 years.
Regional Radiotherapy Cookridge Hospital, Leeds LS16 6QB
L. A. FIRTH
TRANSFUSION OF POLYMORPHONUCLEAR NEUTROPHILS IN A PREMATURE INFANT WITH KLEBSIELLA SEPSIS
SIR,-Polymorphonuclear neutrophils (P.M.N.) can be functionally immature in the newborn,I,2 and in the course of sepsis P.M.N. defects appear more striking: nitroblue-tetrazolium test positivity diminishes3,4 and bacterial killing is imparied.5 We have seen very low values of P.M.N. chemotaxis in the presence of severe sepsis. P.M.N. function in the premature and term infant probably falters in certain pathological conditions,5 and the presence of a normal, or even increased, number of functionally inactive P.M.N. equates a septic newborn to a neutropenic patient. These considerations prompted us to tranfuse concentrated P.M.N.s in a premature infant with klebsiella sepsis unresponsive to antibiotics. This female, born prematurely (30 weeks, 1400 g), was admitted shortly after birth with mild respiratory distress, barely detectable signs of infection (vomiting, brief apnoeic spells, increased band P.M.N.S) rapidly progressing to pallor, lethargy, jaundice, sclerema, abdominal distension, arterial hypotension (systolic 38 mm Hg), metabolic acidosis (base excess mmol/1), and hyperglycaemia. Blood slides revealed P.M.N. vacuolisations, toxic granulations, and megathrombocytes. Blood cultures were positive for klebsiella. Ampicillin and gentamicin 1. Miller, M.E. Pediat. Res. 1971, 5, 487. 2. Klein, R. B , and others Pediatrics, 1977, 60, 467. 3. Cocchi, P., Mori, S., Becattini, A. Acta pædiat. scand. 1971, 60, 475. 4. Wright, W. C., Ank, B., Herbert, J., Stiehm, R. Pediat. Res. 1973, 7, 380. 5. Anderson, D.C., Pickering, L. K., Feigin R. D. J. Pediat. 1974, 85, 420.