BRITISH MEDICAL JOURNAL
15
OCTOBER
1021
1977
CORRES PONDENCE Oestrogen treatment and endometrial carcinoma
Role of the hospital in primary paediatric care A J R Waterston, MRCP; R J Brereton, FRCS ................................
Radiation and growth hormone deficiency S M Shalet, MRCP, and others .......... Danger of salt as an emetic W 0 Robertson, MD .................. Cimetidine and gastric carcinoma R S Arnot, FRCSED .................... Perforation of peptic ulcer after withdrawal of cimetidine P V Turkie, MRCP; B D Keighley, MB .... Cimetidine and gastric ulcer healing R J Machell, MRCP, and others .......... MRC treatment trial for mild hypertension W S Peart, FRCP, FRS, and W E Miall, MD. . Care of the elderly sick J G Evans, FRCP ...................... Joint appointments in general and geriatric medicine J C Brocklehurst, FRCSED, and others .... Names of drugs G D J Ball, MB; J W Maltby, FRCS; E T
J Guillebaud, 1021
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Mathews, FFARCS
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The drug bill J F Lowe, FRCGP
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MRCOG
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Exercise-induced asthma J P R Hartley, MRCP, and others; Elizabeth R Miller, MB ........................ 1025 Experimental trial of the tri-cycle pill Elizabeth M Elliott, MB; Nancy B Loudon, MB, and R V Short, FRS, SCD ............ 1025 Painless thyroiditis G A MacGregor, MD .................. 1026 The perilous skateboard A R Rogers, MB ...................... 1026 Late infection after total hip replacement W J Fincham, FIMLS, and Josephine Cook, PHD .. .. . .. .... .. . .. ............1026 Coeliac disease and malignancy Irene M Evans, MRCP .................. 1026 Effects of ethanol-induced hypoglycaemia C Miquel, MD, and J Rubies-Prat, MD .... 1027 1- x-Hydroxycholecalciferol for renal osteodystrophy R Ahmad, MB, and Beryl Large, SRN ...... 1027 Return to work after aortofemoral bypass surgery Felicity C Edwards, DM ................ 1027 Depot tranquillisers for disturbed behaviour M F Green, MRCP .................... 1027
Correspondents are urged to write briefly so that readers may be offered as wide a selection of letters as possible. So many are being received that the omission of some is inevitable. Letters should be signed personally by all their authors.
Role of the hospital in primary paediatric care
SIR,-On a number of points Dr G M Komrower (24 September, p 787) paraphrases the Court Report' in his comments on the role of the general practitioner, the child health practitioner, and the child health visitor; but I fear that his suggestion of a casualty-based primary care service would contribute little to solving the real problems he discusses. Such a system would almost certainly markedly increase the hospital admission rate since no ill child presenting at the door could realistically be returned home, where no care would be available. It would also be hard to ensure continuing support for those families who most need it after the acute episode. Junior paediatric staff encountering a problem family for the first time would be unlikely to make a significant contribution to their welfare. The inclusion of what sound like general practitioner paediatricians in the scheme is interesting: surely they should be treating their own patients in the community and trying to raise the standards there rather than earning large extra sums from casualty sessions. Experience from Sheffield and Gateshead2 shows that home-based schemes involving increased health visitor and nursing supervision of "problem" families can make a real impression on mortality and morbidity, as well as making economic sense. Surely we should be pushing such ideas with their educational
potential rather than reverting to the "disease palace" for the cure of all ills. TONY WATERSTON Department of Child Health, Ninewells Hospital, Dundee
Committee on Child Health Services, Fit for the Fuiture, London, HMSO, 1976. Hally, M R, et al, British MedicalJ7ournal, 1977, 1, 762.
SIR,-The parents of a child born with spina bifida or with Down's syndrome may prevent another pregnancy by contraception and the pregnant mother of such a child may elect to have an affected fetus aborted. Antenatal supervision and investigation and intensive care after delivery may allow a considerable reduction in the damage to the baby during the perinatal period. However, would Dr G M Komrower (24 September, p 787) enlighten me as to how improved antenatal supervision and intensive care after delivery with reduction in damage to the baby in the perinatal period can result in a reduction in the number of children in the community suffering from such disorders as Down's syndrome or spina bifida, as implied in his section on "Children at risk" ? R J BRERETON Alder Hey Children's Hospital,
Liverpool
Bruising in thyrotoxicosis J A Thomson, FRCP .................... Complications of transvenous (transiugular) liver biopsy D Lebrec, MD, and others .............. SI units and acidity M Hamilton, FRCPSYCH ................ Modified jejunoileal bypass for obesity A Cuschieri, FRCS .................... Oxytocin induction and neonatal hyperbilirubinaemia S Singhi, MD, and M Singh, MD ........ Acceptable and unacceptable risks E M Glaser, MRCP .................... Prevention of retained throat pack B S Crawford, FRCS .................... Ulceration of face associated with trigeminal neuropathy A G Freeman, FRCP .................. Study of doctors' career decisions Rosemary Hutt, MA .................. Obdurate politics C M Fletcher, FRCP .................. Attachment of community nurses to general practice J F Fisher, FRCGP .................... Ethics and etiquette of doctor-managers J M Potter, FRS .1030 Training for general practice Anne L Gruneberg, FFARCS ..... .......
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Radiation and growth hormone deficiency SIR,-We were disappointed in your leading article on this subject (27 August, p 536). Firstly, you state that "lack of any dosedependent relationship weakens the case against radiation." This "lack" was corrected in 1976 when we analysed the relationship between the radiation dose delivered to the hypothalamic-pituitary region and the peak growth hormone (GH) response to insulin hypoglycaemia in 39 children irradiated for brain tumours anatomically distant from the hypothalamic-pituitary axis and 17 children with acute leukaemia who received prophylactic central nervous system irradiation.' There was a significant inverse correlation between the radiation dose and the peak GH response (r = -039; P = 0 002). Thirty-six out of the 41 patients who received a radiation dose greater than 2900 rads showed an impaired GH response. The second point concerns the comment that "the normal gland is unlikely to be affected by quite high doses of radiation (5-6000 rads), as used, for example, for treating carcinoma of the nasopharynx." Samaan et a12 studied hypothalamic-pituitary function in 15 patients who received irradiation to that area (dose range 5000-8300 rads) during treatment of carcinoma of the nasopharynx. Twelve patients had evidence of hypothalamic dysfunction. Eleven showed impaired GH responses and six impaired cortisol responses to insulin hypoglycaemia. All 12 had an elevated serum prolactin concentration with no rise after chlorpromazine. Three patients showed subnormal thyroid function in the presence of a normal but delayed rise of serum thyroidstimulating hormone (TSH) after thyro-
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BRITISH MEDICAL JOURNAL
trophin-releasing hormone (TRH). Seven patients showed evidence of primary pituitary deficiency, five of whom showed low thyroid function, while the basal serum TSH level was not elevated and failed to rise after TRH administration. Thus damage to both the normal hypothalamus and the normal pituitary gland may occur following irradiation in the dose range 5000-8300 rads. Further points in the article concern the effects on GH production of neurosurgery and radiation to parts of the brain other than the hypothalamic-pituitary region. We have studied more than 30 children after neurosurgery and before irradiation. No child has shown impaired GH responses to provocative stimuli before irradiation. Furthermore no child whose hypothalamic-pituitary axis totally avoided irradiation has ever shown inadequate GH responses. Much more interesting is the question whether or not irradiation of other parts of the brain may interfere with somatic growth by a non-GH-mediated mechanism. There is some evidence that this occurs in the rat.4 fi Finally, the question is raised at the end of your article about possible growth responses to exogenous GH. We have six children with radiation-induced GH deficiency on GH therapy. The mean growth velocity during the pretreatment year was 3 7 cm and during the first year of GH therapy 7 9 cm. These data have not yet been published,:' but other authors have described similar increases in growth velocity with GH therapy in such children. 8 It is always pleasing to see a leading article in the BMJ related to a topic one is particularly interested in but disheartening when one finds the article so ill-informed as this one. S M SHALET C G BEARDWELL DOROTHY PEARSON P H MORRIS JONES Departments of Medicine, Radiotherapy, and Paediatric Oncology, Christie Hospital and Holt Radium Institute, Manchester Shalet, S M, et al, Clinical Endocrinlology, 1976, 5, 287. Samaan, N A, et al, Annals of Internal Medicine, 1975, 83, 771. 3 Shalet, S M, et al. Submitted for publication. ' Mosier, H D, and Jansons, R A, Growth, 1967, 31, 139. Mosier, H D, and Jansons, R A, Proceeditngs of the Society for Experimental Biology and Medicine, 1968, 128, 23. * Mosier, H D, and Jansons, R A, Radiatiotn Research, 1970, 43, 92. Perry-Keene, D A, et al, Clinical Endocrinology, 1976, 5, 373. 'Richards, G E, et al, 7ournal of Pediatrics, 1976, 89, 553.
***We are glad of the opportunity to apologise to Dr Shalet and his colleagues for missing their "short communication,"' which appeared some time after the paper we discussed and which went some way to remedying its main defect, but in our view the first paper should not have been published without this dosage information (which was presumably readily available) or at the very least without a note to show that the authors appreciated its importance and would be giving the relevant data in a subsequent communication. Unfortunately, there is a further serious omission in this second communication. Nothing is said about why some patients were given a higher dose of radiation than others. No matter how impressive the statistical significance of the inverse correlation found between radiation dose and peak GH response, the possibility
that those patients given a higher dose were in some important way different from those given a lower dose ought to have been looked at and commented on. We look forward to clarification of this point in the unpublished paper mentioned in their letter. With regard to the normal pituitary gland being "unlikely to be affected by quite high doses of radiation" we feel that the context and the references we gave made it clear that we were referring to the fact that long-term follow-up of large numbers of adult patients has provided no evidence of any clinical hypopituitarism in the great majority. This point has again been emphasised recently by Bloom.2 It is important that the risks of radiation should be neither minimised nor exaggerated.-ED, BMJ. Shalet, S M, et al, Cltizzcal Endocrinology, 1976, 5, 287.
2 Bloom, H J G, Proceedintgs of the Royal Society of Medicine, 1977, 70, 319.
Danger of salt as an emetic SIR,-Dr N C Hypher's recent testimonial (16 April, p 1033) championing the use of salt as an emetic is most unfortunate indeed. Your own pages carried the report of a fatality consequent to such use 14 years ago' and again three years ago.2 ' In addition our group and at least three others have documented the danger of such an approach with enormously elevated serium sodium concentrations (for example, 214 mmol(mEq),/l) and death as a direct consequence.'4 Making some conventional assumptions just two tablespoons of salt could lead to a 30 mmol(mEq),l increase in serum sodium." Moreover, in the United States the Consumer Product Safety Commission (Federal Register, 23 June 1977) has proposed a policy calling for the elimination of this archaic and dangerous approach in all first-aid labelling practices and the substitution of syrup of ipecacuanha as the emetic agent of choice. While far from ideal, it is reasonably effective, easily obtainable, and, in the syrup form, totally devoid of any serious toxicity despite its almost routine use in poison centres throughout the United States for more than 10 years. Salt certainly has its place-but not as an emetic. Any recommendation for such use-as a first-aid measure or otherwise -ought to be restricted from publication, incurring as it would potential liability for both author and publisher. WILLIAM 0 ROBERTSON Secretary-Treasurer,
American Association of Poison Control Centers Poison Control Center, Children's Orthopedic Hospital, Seattle, Washington
Ward, D J, British Medical J7ournal, 1963, 2, 432. ' Winter, M, and Taylor, D J E, British Medical J7ournal. 1974, 3, 802. Bird, A, British Medical Journal, 1974, 4, 103. Robertson, W 0, Journal of Pediatrics, 1971, 79, 877. 5De Genaro, F, and Nyhan, W L,J7ournal of Pediatrics, 1971, 78, 1048. Barer, J, et al, American Journal of Diseases of Childreni, 1973, 125, 889. 'Roberts, C J C, and Noakes, M J, Postgraduate Medical Journal, 1974, 50, 513. 'Johnston, J G, and Robertson, W 0, Westerni Medical Jouirnal, 1977, 125, 141.
15 OCTOBER 1977
others (24 September, p 795) suggests that it is almost as effective in promoting the healing of gastric ulcers. While patients with peptic ulcers will undoubtedly benefit from this advance, there is a possibility that as this form of treatment becomes more widespread patients with early gastric carcinoma who present with the same symptoms as those with benign peptic ulceration will be overlooked. It is well established that malignant gastric ulcers will heal and often become symptom-free on careful conservative management, although the cancer continues to proliferate within the stomach wall. If dyspeptic patients can have their symptoms relieved with cimetidine the incidence of missed gastric carcinomas, which is already unacceptably high, will rise even higher. In a recent survey of gastric carcinoma treated at this hospital over the past 13 years only 43",, of patients were operable and of these one-third had palliative resections. The earliest presenting symptom in this series was dyspepsia, which had been present for an average of five months by the time the patient was referred to the hospital, and many patients had been receiving antacid medication from their family practitioner for some months. Patients over the age of 50 with persistent dyspepsia for two months or more should be fully investigated with a barium meal and gastroscopy before conservative treatment is continued. RICHARD S ARNOT Gastro-intestinal Unit, Royal Marsden Hospital, London SV'3
Gray, G R, et al, Lancet, 1977, 1, 4.
Perforation of peptic ulcer after withdrawal of cimetidine SIR,-I am surprised that Mr W A Wallace and his colleagues (1 October, p 865) have implicated cimetidine in perforation of peptic ulcers. They cite no further evidence than that three patients out of 17 who perforated had previously stopped cimetidine abruptly. In view of the popularity of this new drug it seems hardly surprising that some of the patients should have been on cimetidine and that three should have stopped it suddenly. Most patients stop drugs suddenly. This is hardly proof of a causal relationship and on this basis to suggest continuing maintenance for three months irrespective of symptoms seems wrong. Further, to castigate their general practitioners for treating without immediate prior investigation is unrealistic. Two of the patients had had previous barium meals showing ulceration and I do not consider that prescribing cimetidine is, on its own, sufficient reason for reinvestigation as this would deny its benefit to many patients owing to the clogging-up of the various hospital departments for reinvestigation. P V TURKIE Wrexham, Clwyd
SIR,-Dr W A Wallace and others (1 October, p 865) report three cases of peptic ulcer perforation in patients who had undergone recent treatment with cimetidine. They suggest Cimetidine and gastric carcinoma that abrupt cessation of treatment may have SIR,-Cimetidine is now well established as precipitated the perforations. I append details effective in the treatment of duodenal ulcera- of a similar case encountered in this general tion' and the recent report by Dr F Frost and practice.