1563
smoking on the specific antibody response in pigeon fanciers. Thorax 1988; 43: 798-800. 13. Barton SE, Maddox PH, Jenkins D, Edwards R, Cuzick J, Singer A. Effect of cigarette smoking on cervical epithelial immunity: a mechanism for neoplastic change? Lancet 1988; ii: 652-54. 14. Muller HK, Halliday GM, Knight BA. Carcinogen-induced depletion of cutaneous Langerhans’ cells. Br J Cancer 1985; 52: 81-85. 15. Casolaro MA, Bemaudin J-F, Saltini C, Ferrans VJ, Crystal RG.
Langerhans’ cells on the epithelial surface of the lower respiratory tract in normal subjects in association with cigarette smoking. Am Rev Respir Dis 1988; 137: 406-11. 16. Chollet S, Soler P, Dournovo P, Richard MS, Ferrans VJ, Basset F. Diagnosis of pulmonary histiocytosis X by immunodetection of Langerhans’ cells in the bronchoalveolar lavage fluid. Am J Pathol Accumulation of
1984; 115: 225-32.
HHB, Gatter KC, Sykes G, Casemore V, Mason DY. Langerhans’ cells in human cervical epithelium: effects of wart virus infection and intraepithelial neoplasia. Br J Obstet Gynaecol 1983; 90:
17. Morris
412-20.
KIKUCHI’S DISEASE The histological appearances in the lymph nodes of patients with Kikuchi’s disease (histiocytic necrotising lymphadenitis) are readily recognised, but a recent flurry of case-reportsl-6 suggests that, outside Japan (where the condition was first described in 1972), the clinical manifestations are not widely appreciated. The disease usually affects young women-the female to male ratio is more than four to one-and has been recorded from many countries. However, the predominance of reports from Japan and the fact that many of the patients in Europe and the USA have been of Asian descent may point to a racial or genetic susceptibility. Typically, patients present with a painless but sometimes tender unilateral cervical lymphadenopathy. Occasionally the adenopathy occurs at other sites-isolated involvement of mediastinals or retroperitoneal8 lymph nodes has been described-and in up to 20% of cases it may be generalised. Splenomegaly is Lmcor=on.11,9 Fever is present in about a third of cases and sometimes there is neutropenia or lymphocytosis.9 Abnormal liver function has lately been described as the presenting features and arthralgia, rashes, and epididymitis have also been recorded.9,lO The disease usually resolves spontaneously within three months although it can persist for a year or so and may even recur. 6,8 Within affected lymph nodes the T-cell regions are almost exclusively involved: there is patchy paracortical necrosis consisting of eosinophilic fibrinoid material that contains large quantities of karyorrhectic nuclear debris (nuclear dust). The necrosis is surrounded by a polymorphous cell population of foamy histiocytes, macrophages (some phagocytosing nuclear debris), and reactive T cells.9 Plasma cells are rare and there is a characteristic absence of polymorphonuclear leucocytes. It is still unclear whether the abnormal T cells are cytotoxic/ suppressor or helper/inducer cells, and the proportions of each type may change with the stage of the illness. The proliferation of reactive histiocytes and effacement of normal lymph node architecture may be erroneously
diagnosed as malignant lymphoma or Hodgkin’s disease, z10 but most other causes of fever and lymphadenopathy are readily distinguished by the histological appearance. The aetiology of Kikuchi’s disease is unclear. Kikuchi himself thought it was a form of toxoplasmosis," and occasional cases have been associated with Yersinia enterocolitica infection.5,12 A possible role for human herpesvirus 6 has also been suggestedY Nevertheless, in most cases there is no evidence of recent infection with any
of these organisms. One interpretation is that Kikuchi’s disease is a self-limited systemic-lupus-erythematosus (SLE)-like autoimmune condition induced by infected lymphocytes.14 Some support for this concept comes from the report of patients with Kikuchi’s lymphadenitis, diagnosed by experienced histopathologists, who subsequently manifested frank SLE,9 but such progression may be coincidental. Malignant transformation does not seem to occur and only one fatality (from myocardial damage) has been reported during the acute phase z 1. Bowness
P, Dutoit SH. Kikuchi’s disease as a cause of fever and cervical
lymphadenopathy. J Infect 1988;
16: 310-11.
JKC, Wong K-C, Ng C-S. A fatal case of multicentric Kikuchi’s histiocytic necrotizing lymphadenitis. Cancer 1989; 63: 1856-62. 3. Bailey EM, Klein NC, Cunha BA. Kikuchi’s disease with liver dysfunction presenting as fever of unknown origin. Lancet 1989; ii: 986. 4. Kapadia V, Robinson BA, Angus HB. Kikuchi’s disease presenting as fever of unknown origin. Lancet 1989; ii: 1519. 5. Pearl D, Strauchen JA. Kikuchi’s disease as a cause of fever of unknown origin. N Engl J Med 1989; 320: 1147-48. 6. Nieman RB. Diagnosis of Kikuchi’s disease. Lancet 1990; 335: 295. 2. Chan
7. KikuchiM. Lymphadenitis showing focal reticulum cell hyperplasia with nuclear debris and phagocytes: a clinicopathological study. Nippon Ketsueki Gakkai Zasshi 1972; 35: 379-80 (in Japanese). 8. Rudniki C, Kessler E, Zarfati M, Turani H, Bar-Ziv Y, Zahavi I. Kikuchi’s necrotizing lymphadenitis: a cause of fever of unknown origin and splenomegaly. Acta Haematol (Basel) 1988; 79: 99-102. 9. Dorfman RF, Berry GJ. Kikuchi’s histiocytic necrotizing lymphadenitis: an analysis of 108 cases with emphasis on differential diagnosis. Semin Diagn Pathol 1988; 5: 329-45. 10. Turner RR, Martin J, Dorfman RF. Necrotizing lymphadenitis: a study of 30 cases. Am J Surg Pathol 1983; 7: 115-23. 11. Kikuchi M, Yoshizumi T, Nakamura H. Necrotizing lymphadenitis: possible acute toxoplasmic infection. Virch Arch [A ] 1977; 376: 247-53. 12. Feller AC, Lennert K, Stein H, Bruhn H-D, Wuthe H-H.
Immunohistology and etiology of histiocytic necrotizing lymphadenitis: report of three instructive cases. Histopathology 1983; 7: 825-39. 13. Eizuru Y, Minematsu T, Minamishima Y, et al. Human herpesvirus 6 in lymph nodes. Lancet 1989; i: 40. 14. Imumura M, Ueno H, Matsumura A, et al. An ultrastructural study of subacute necrotizing lymphadenitis. Am J Pathol 1982; 107: 292-99.
PATIENT CARERS The wives of men who have heart attacks merit attention both as carers and as patients in their own right. In a study in Ontario,l most such wives consulted their doctor about their own health in the three months after the husband’s infarction. We do not know what they consulted about or whether these women could be differentiated from those who did not consult a doctor by the Quality of Life Questionnaire for Cardiac Spouses, but there is no doubt that their suffering is reflected in the consultation rates, and that the disability associated with this suffering impaired their effectiveness as the main carers for these cardiac patients. The Canadian work confirms an earlier study in Oxford, in which the psychological reaction of the wives was found to be even greater than that of the patients themselves.2 What can be done to help "cardiac spouses" cope with their own crisis and at the same time enable them to mitigate the frightening disability and anxiety experienced by their husbands? Information leaflets, personal counselling, and self-help groups are among the resources available to these women, who are presented with the problem of having husbands at home before time, possibly behaving like bears with sore heads and without the sanction of normal retirement processes, gold watches, or inscribed silver salvers. Some may even feel guilty about the thought which
1564
dare not speak its name-that the attack might have been fatal and have relieved them of a lifetime of matrimonial servitude. We are inhibited by our perceptual apparatus from seeing other people in two roles at the same time. Just as in the famous ambiguous figure, in which it is impossible to see the beautiful young woman and the old hag in the same picture, so we find it difficult to perceive and treat people simultaneously as carers and as patients. Nevertheless, effort devoted to these lay helpers (who are usually mothers, wives, or daughters) may be more cost-effective than investment in the patients. Even more than cardiac spouses, the wives of accident victims suffer the effects of their husbands’ disabilities. In a study of men with closed head injuries, the wives were found to be under even more strain after five years than after one year.3 In the UK, the charity Headway caters for those with head injuries and their families, but there is no organisation concerned with the victims of accidents and injuries to other parts of the body, who may also have distressing personality changes. A few years ago the pioneers were exploring the psychological reactions of the patient to physical illness;4 now they are exploring the effect of the illness on the spouse. Soon, perhaps, we shall see physical illness and accidents as events affecting and affected by the whole family. LS, Guyatt GH, McCartney M, Oldridge NB. Measuring quality of life in cardiac spouses. J Clin Epidemiol 1990; 43: 481-87. 2. Mayou R, Foster A, Williamson B. The psychological and social effects of myocardial infarction on wives. Br Med J 1978; i: 699-701. 3. Brooks N, Kampsie L, Symington C, Beattie A, McKinlay W. The five year outcome of severe blunt head injury: a relative’s view. J Neurol Neurosurg Psychiatry 1986; 49: 764-70. 4. Lloyd GG. Psychological reactions to physical illness. Br J Hosp Med 1. Ebbesen
1977; 18: 352-58.
THE PERFECT ENEMY: EATING AND IDDM Before the discovery of insulin, diet was the only treatment for insulin deficiency. Subsequently, the balancing of food intake against insulin dose has been the cornerstone of diabetic management. However, attempts to mould the habits of individual patients to conform to a rigid and theoretically ideal diet not only represent a triumph of hope over experience but also may be harmful. Tunbridge,l in 1953, was one of the first to point out that few diabetics adhere rigidly to even the simplest dietary advice. Confirmation of his observations by many other workers led to the iconoclastic view that controlled dietary prescriptions
unnecessary.2,3 Non-compliance with diet should occasion little surprise.
are
In the past instructions varied from clinic to clinic and fashions have changed with time-no wonder that patients are often confused and cynical about this aspect of their management. The recommendations of the Britishand AmericanDiabetic Associations have done much to standardise dietary advice, but still represent counsels of perfection to which few patients can aspire. A middle-aged man with heart disease may be frightened into eating a diet high in slowly absorbed carbohydrate and fibre and low in fat and salt, but a sixteen-year-old who is asked to adopt such a regimen to prevent complications thirty years hence is most unlikely to comply and, if pressed to do so, may adopt defensive strategies that bring him into conflict with parents and professionals alike. More optimistically, McCulloch and colleaguesin a careful study of 178 insulin-dependent patients, showed that good glycaemic control was correlated
with consistency of food intake and some understanding of the carbohydrate value of various foods. They concluded that adherence to dietary advice was more likely if the recommendations were based on the patient’s regular diet before the onset of diabetes, with emphasis on a consistent eating pattern and education in carbohydrate values. In another study of previously badly controlled diabetics, imaginative teaching techniques carried out in small groups were remarkably effective in improving control,7 Tattersall8 has drawn attention to the special difficulties of adolescent patients, in whom excessive pressure for compliance may be self-defeating and add to the strains of growing up; these young people have already been made to feel different from their peer group. Steel and colleagues9 have documented an increased frequency of eating disorders in young diabetic women and they suggest that diabetic management might be a contributory factor. In a survey of 208 patients between the ages of 16 and 25 years, 15 had a clinically apparent eating disorder, including anorexia and bulimia. In a further study of 152 women and 139 men in which non-diabetic siblings or friends of the same age and sex were used as controls, these researchers confirmed the higher frequency of abnormal eating attitudes in young diabetic women.1o Such attitudes were correlated positively with poor glycaemic control and more retinopathy. In all diabetics, but especially in young patients, dietary advice should be part of a sensitive and careful education programme that involves the family and aims to deviate as little as possible from customary habits. Perfection may not be the wisest counsel. 1.
Tunbridge RE. Sociomedical aspects of diabetes mellitus. Lancet 1953; ii:
893-99. 2. Knowles HC. Diabetes mellitus in childhood and adolescence. Med Clin N Am 1971; 55: 975-87.
3. Abraira C, de Bartolo RD, Myscofski JW. Comparison of unmeasured versus exchange diabetic diets in lean adults. Am J Clin Nutr 1980; 33: 1064-70. 4. British Diabetic Association. Dietary recommendations for diabetes for the 1980s—a statement by the British Diabetic Association. Hum Nutr Appl Nutr 1982; 36A: 378-94. 5. American Diabetes Association. Principles of nutrition and dietary recommendations for individuals with diabetes mellitus. Diabetes 1979; 28: 1027. 6. McCulloch DK, Young RJ, Steel JM, Wilson EM, Prescott RJ, Duncan LJP. Effect of dietary compliance in metabolic control in insulindependent diabetes. Hum Nutr Appl Nutr 1983; 37A: 287-92. 7. McCulloch DK, Mitchell RD, Ambler J, Tattersall RB. Influence of imaginative teaching of diet on compliance and metabolic control in insulin-dependent diabetes. Br Med J 1983; 287: 1858-61. 8. Tattersall RB. Psychosocial aspects of diabetes in childhood and adolescence. Pediatr Ann 1987; 16: 58-67. 9. Steel JM, Young RJ, Lloyd GG, et al. Clinically apparent eating disorders in young diabetic women: associations with painful neuropathy and other complications. Br Med J 1987; 294: 859-62. 10. Steel JM, Young RJ, Lloyd GG, Macintyre CCA. Abnormal eating attitudes in young insulin-dependent diabetics. Br J Psychiatry 1989; 155: 515-21.
Publishers’ announcement: Dr Gordon Reeves This is the last issue of The Lancet to be edited by Gordon Reeves. He leaves the journal today after 18 months as its Editor. Dr Reeves’ period of office will be well remembered, not least for the introduction of the new design of The Lancet in January this year and for the start, also in January, of the publication of the North American edition by Williams & Wilkins in Baltimore. We thank Gordon Reeves for much, and we wish him well. His successor will be announced next week.
smoking on the specific antibody response in pigeon fanciers. Thorax 1988; 43: 798-800. 13. Barton SE, Maddox PH, Jenkins D, Edwards R, Cuzick J, Singer A. Effect of cigarette smoking on cervical epithelial immunity: a mechanism for neoplastic change? Lancet 1988; ii: 652-54. 14. Muller HK, Halliday GM, Knight BA. Carcinogen-induced depletion of cutaneous Langerhans’ cells. Br J Cancer 1985; 52: 81-85. 15. Casolaro MA, Bemaudin J-F, Saltini C, Ferrans VJ, Crystal RG.
Langerhans’ cells on the epithelial surface of the lower respiratory tract in normal subjects in association with cigarette smoking. Am Rev Respir Dis 1988; 137: 406-11. 16. Chollet S, Soler P, Dournovo P, Richard MS, Ferrans VJ, Basset F. Diagnosis of pulmonary histiocytosis X by immunodetection of Langerhans’ cells in the bronchoalveolar lavage fluid. Am J Pathol Accumulation of
1984; 115: 225-32.
HHB, Gatter KC, Sykes G, Casemore V, Mason DY. Langerhans’ cells in human cervical epithelium: effects of wart virus infection and intraepithelial neoplasia. Br J Obstet Gynaecol 1983; 90:
17. Morris
412-20.
KIKUCHI’S DISEASE The histological appearances in the lymph nodes of patients with Kikuchi’s disease (histiocytic necrotising lymphadenitis) are readily recognised, but a recent flurry of case-reportsl-6 suggests that, outside Japan (where the condition was first described in 1972), the clinical manifestations are not widely appreciated. The disease usually affects young women-the female to male ratio is more than four to one-and has been recorded from many countries. However, the predominance of reports from Japan and the fact that many of the patients in Europe and the USA have been of Asian descent may point to a racial or genetic susceptibility. Typically, patients present with a painless but sometimes tender unilateral cervical lymphadenopathy. Occasionally the adenopathy occurs at other sites-isolated involvement of mediastinals or retroperitoneal8 lymph nodes has been described-and in up to 20% of cases it may be generalised. Splenomegaly is Lmcor=on.11,9 Fever is present in about a third of cases and sometimes there is neutropenia or lymphocytosis.9 Abnormal liver function has lately been described as the presenting features and arthralgia, rashes, and epididymitis have also been recorded.9,lO The disease usually resolves spontaneously within three months although it can persist for a year or so and may even recur. 6,8 Within affected lymph nodes the T-cell regions are almost exclusively involved: there is patchy paracortical necrosis consisting of eosinophilic fibrinoid material that contains large quantities of karyorrhectic nuclear debris (nuclear dust). The necrosis is surrounded by a polymorphous cell population of foamy histiocytes, macrophages (some phagocytosing nuclear debris), and reactive T cells.9 Plasma cells are rare and there is a characteristic absence of polymorphonuclear leucocytes. It is still unclear whether the abnormal T cells are cytotoxic/ suppressor or helper/inducer cells, and the proportions of each type may change with the stage of the illness. The proliferation of reactive histiocytes and effacement of normal lymph node architecture may be erroneously
diagnosed as malignant lymphoma or Hodgkin’s disease, z10 but most other causes of fever and lymphadenopathy are readily distinguished by the histological appearance. The aetiology of Kikuchi’s disease is unclear. Kikuchi himself thought it was a form of toxoplasmosis," and occasional cases have been associated with Yersinia enterocolitica infection.5,12 A possible role for human herpesvirus 6 has also been suggestedY Nevertheless, in most cases there is no evidence of recent infection with any
of these organisms. One interpretation is that Kikuchi’s disease is a self-limited systemic-lupus-erythematosus (SLE)-like autoimmune condition induced by infected lymphocytes.14 Some support for this concept comes from the report of patients with Kikuchi’s lymphadenitis, diagnosed by experienced histopathologists, who subsequently manifested frank SLE,9 but such progression may be coincidental. Malignant transformation does not seem to occur and only one fatality (from myocardial damage) has been reported during the acute phase z 1. Bowness
P, Dutoit SH. Kikuchi’s disease as a cause of fever and cervical
lymphadenopathy. J Infect 1988;
16: 310-11.
JKC, Wong K-C, Ng C-S. A fatal case of multicentric Kikuchi’s histiocytic necrotizing lymphadenitis. Cancer 1989; 63: 1856-62. 3. Bailey EM, Klein NC, Cunha BA. Kikuchi’s disease with liver dysfunction presenting as fever of unknown origin. Lancet 1989; ii: 986. 4. Kapadia V, Robinson BA, Angus HB. Kikuchi’s disease presenting as fever of unknown origin. Lancet 1989; ii: 1519. 5. Pearl D, Strauchen JA. Kikuchi’s disease as a cause of fever of unknown origin. N Engl J Med 1989; 320: 1147-48. 6. Nieman RB. Diagnosis of Kikuchi’s disease. Lancet 1990; 335: 295. 2. Chan
7. KikuchiM. Lymphadenitis showing focal reticulum cell hyperplasia with nuclear debris and phagocytes: a clinicopathological study. Nippon Ketsueki Gakkai Zasshi 1972; 35: 379-80 (in Japanese). 8. Rudniki C, Kessler E, Zarfati M, Turani H, Bar-Ziv Y, Zahavi I. Kikuchi’s necrotizing lymphadenitis: a cause of fever of unknown origin and splenomegaly. Acta Haematol (Basel) 1988; 79: 99-102. 9. Dorfman RF, Berry GJ. Kikuchi’s histiocytic necrotizing lymphadenitis: an analysis of 108 cases with emphasis on differential diagnosis. Semin Diagn Pathol 1988; 5: 329-45. 10. Turner RR, Martin J, Dorfman RF. Necrotizing lymphadenitis: a study of 30 cases. Am J Surg Pathol 1983; 7: 115-23. 11. Kikuchi M, Yoshizumi T, Nakamura H. Necrotizing lymphadenitis: possible acute toxoplasmic infection. Virch Arch [A ] 1977; 376: 247-53. 12. Feller AC, Lennert K, Stein H, Bruhn H-D, Wuthe H-H.
Immunohistology and etiology of histiocytic necrotizing lymphadenitis: report of three instructive cases. Histopathology 1983; 7: 825-39. 13. Eizuru Y, Minematsu T, Minamishima Y, et al. Human herpesvirus 6 in lymph nodes. Lancet 1989; i: 40. 14. Imumura M, Ueno H, Matsumura A, et al. An ultrastructural study of subacute necrotizing lymphadenitis. Am J Pathol 1982; 107: 292-99.
PATIENT CARERS The wives of men who have heart attacks merit attention both as carers and as patients in their own right. In a study in Ontario,l most such wives consulted their doctor about their own health in the three months after the husband’s infarction. We do not know what they consulted about or whether these women could be differentiated from those who did not consult a doctor by the Quality of Life Questionnaire for Cardiac Spouses, but there is no doubt that their suffering is reflected in the consultation rates, and that the disability associated with this suffering impaired their effectiveness as the main carers for these cardiac patients. The Canadian work confirms an earlier study in Oxford, in which the psychological reaction of the wives was found to be even greater than that of the patients themselves.2 What can be done to help "cardiac spouses" cope with their own crisis and at the same time enable them to mitigate the frightening disability and anxiety experienced by their husbands? Information leaflets, personal counselling, and self-help groups are among the resources available to these women, who are presented with the problem of having husbands at home before time, possibly behaving like bears with sore heads and without the sanction of normal retirement processes, gold watches, or inscribed silver salvers. Some may even feel guilty about the thought which
1564
dare not speak its name-that the attack might have been fatal and have relieved them of a lifetime of matrimonial servitude. We are inhibited by our perceptual apparatus from seeing other people in two roles at the same time. Just as in the famous ambiguous figure, in which it is impossible to see the beautiful young woman and the old hag in the same picture, so we find it difficult to perceive and treat people simultaneously as carers and as patients. Nevertheless, effort devoted to these lay helpers (who are usually mothers, wives, or daughters) may be more cost-effective than investment in the patients. Even more than cardiac spouses, the wives of accident victims suffer the effects of their husbands’ disabilities. In a study of men with closed head injuries, the wives were found to be under even more strain after five years than after one year.3 In the UK, the charity Headway caters for those with head injuries and their families, but there is no organisation concerned with the victims of accidents and injuries to other parts of the body, who may also have distressing personality changes. A few years ago the pioneers were exploring the psychological reactions of the patient to physical illness;4 now they are exploring the effect of the illness on the spouse. Soon, perhaps, we shall see physical illness and accidents as events affecting and affected by the whole family. LS, Guyatt GH, McCartney M, Oldridge NB. Measuring quality of life in cardiac spouses. J Clin Epidemiol 1990; 43: 481-87. 2. Mayou R, Foster A, Williamson B. The psychological and social effects of myocardial infarction on wives. Br Med J 1978; i: 699-701. 3. Brooks N, Kampsie L, Symington C, Beattie A, McKinlay W. The five year outcome of severe blunt head injury: a relative’s view. J Neurol Neurosurg Psychiatry 1986; 49: 764-70. 4. Lloyd GG. Psychological reactions to physical illness. Br J Hosp Med 1. Ebbesen
1977; 18: 352-58.
THE PERFECT ENEMY: EATING AND IDDM Before the discovery of insulin, diet was the only treatment for insulin deficiency. Subsequently, the balancing of food intake against insulin dose has been the cornerstone of diabetic management. However, attempts to mould the habits of individual patients to conform to a rigid and theoretically ideal diet not only represent a triumph of hope over experience but also may be harmful. Tunbridge,l in 1953, was one of the first to point out that few diabetics adhere rigidly to even the simplest dietary advice. Confirmation of his observations by many other workers led to the iconoclastic view that controlled dietary prescriptions
unnecessary.2,3 Non-compliance with diet should occasion little surprise.
are
In the past instructions varied from clinic to clinic and fashions have changed with time-no wonder that patients are often confused and cynical about this aspect of their management. The recommendations of the Britishand AmericanDiabetic Associations have done much to standardise dietary advice, but still represent counsels of perfection to which few patients can aspire. A middle-aged man with heart disease may be frightened into eating a diet high in slowly absorbed carbohydrate and fibre and low in fat and salt, but a sixteen-year-old who is asked to adopt such a regimen to prevent complications thirty years hence is most unlikely to comply and, if pressed to do so, may adopt defensive strategies that bring him into conflict with parents and professionals alike. More optimistically, McCulloch and colleaguesin a careful study of 178 insulin-dependent patients, showed that good glycaemic control was correlated
with consistency of food intake and some understanding of the carbohydrate value of various foods. They concluded that adherence to dietary advice was more likely if the recommendations were based on the patient’s regular diet before the onset of diabetes, with emphasis on a consistent eating pattern and education in carbohydrate values. In another study of previously badly controlled diabetics, imaginative teaching techniques carried out in small groups were remarkably effective in improving control,7 Tattersall8 has drawn attention to the special difficulties of adolescent patients, in whom excessive pressure for compliance may be self-defeating and add to the strains of growing up; these young people have already been made to feel different from their peer group. Steel and colleagues9 have documented an increased frequency of eating disorders in young diabetic women and they suggest that diabetic management might be a contributory factor. In a survey of 208 patients between the ages of 16 and 25 years, 15 had a clinically apparent eating disorder, including anorexia and bulimia. In a further study of 152 women and 139 men in which non-diabetic siblings or friends of the same age and sex were used as controls, these researchers confirmed the higher frequency of abnormal eating attitudes in young diabetic women.1o Such attitudes were correlated positively with poor glycaemic control and more retinopathy. In all diabetics, but especially in young patients, dietary advice should be part of a sensitive and careful education programme that involves the family and aims to deviate as little as possible from customary habits. Perfection may not be the wisest counsel. 1.
Tunbridge RE. Sociomedical aspects of diabetes mellitus. Lancet 1953; ii:
893-99. 2. Knowles HC. Diabetes mellitus in childhood and adolescence. Med Clin N Am 1971; 55: 975-87.
3. Abraira C, de Bartolo RD, Myscofski JW. Comparison of unmeasured versus exchange diabetic diets in lean adults. Am J Clin Nutr 1980; 33: 1064-70. 4. British Diabetic Association. Dietary recommendations for diabetes for the 1980s—a statement by the British Diabetic Association. Hum Nutr Appl Nutr 1982; 36A: 378-94. 5. American Diabetes Association. Principles of nutrition and dietary recommendations for individuals with diabetes mellitus. Diabetes 1979; 28: 1027. 6. McCulloch DK, Young RJ, Steel JM, Wilson EM, Prescott RJ, Duncan LJP. Effect of dietary compliance in metabolic control in insulindependent diabetes. Hum Nutr Appl Nutr 1983; 37A: 287-92. 7. McCulloch DK, Mitchell RD, Ambler J, Tattersall RB. Influence of imaginative teaching of diet on compliance and metabolic control in insulin-dependent diabetes. Br Med J 1983; 287: 1858-61. 8. Tattersall RB. Psychosocial aspects of diabetes in childhood and adolescence. Pediatr Ann 1987; 16: 58-67. 9. Steel JM, Young RJ, Lloyd GG, et al. Clinically apparent eating disorders in young diabetic women: associations with painful neuropathy and other complications. Br Med J 1987; 294: 859-62. 10. Steel JM, Young RJ, Lloyd GG, Macintyre CCA. Abnormal eating attitudes in young insulin-dependent diabetics. Br J Psychiatry 1989; 155: 515-21.
Publishers’ announcement: Dr Gordon Reeves This is the last issue of The Lancet to be edited by Gordon Reeves. He leaves the journal today after 18 months as its Editor. Dr Reeves’ period of office will be well remembered, not least for the introduction of the new design of The Lancet in January this year and for the start, also in January, of the publication of the North American edition by Williams & Wilkins in Baltimore. We thank Gordon Reeves for much, and we wish him well. His successor will be announced next week.
