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

M. H.

JOURDAN

***In the paper by Mr Foster and his colleagues the first

sen-

of the second paragraph of the Results should have read: "... and high rates persisted to a surprising degree throughout the operation ..."-ED. L.

tence

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.

ity

Klinisches Institut fur Herzinfarktforschung und Abteilung für Klinische Pharmakologie, Medizinische Universitätsklinik Heidelberg, D-69 Heidelberg, West Germany 1. 2. 3 4

H. KATHER

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

performed.

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

Centre

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.

112 P.M.N. FUNCTION TESTS

ileocxcal area, and undergoing resection, the presence or absence of granulomas in the bowel wall did not affect the recurrence-rate. Whether this is at odds with reports which show such a difference, or whether this reflects a difference between the large and small bowel or, perhaps, other factors, needs further investigation.

*

(or ranges) of: cells/high-power field, t cells ingested by each p.M.N., t% non-viable intra-p.M.N. Candida albicans yeast cells.

Means

followed by tobramycin and, later, carbenicillin, with repeated fresh-frozen plasma infusions, failed to improve the clinical picture or affect the blood cultures. On day 22 the infant received a transfusion of 2x1010 P.M.N.s. A remarkable improvement occurred within a few hours: the lethargic state began to regress, together with the jaundice and other signs of infection. On the following day, for the first time since admission, the patient gained weight, blood cultures became sterile, and peripheral smears reverted to normal. P.M.N. function studies after transfusion were noteworthy in that both chemotactic and killing values surpassed normal ranges (table). The clinical improvement seems to be related not only to the direct microbicidal activity of the transfused cells but also to the immunostimulant effect induced by the same P.M.N.S since transfused P.M.N.s rapidly disappear from the bloodstream. If the efficacy of this therapy is confirmed, P.M.N. transfusion could be considered in the treatment of neonatal sepsis. Department of Pædiatraics, University of Rome, and Transfusion Centre, "Fatebenefratelli" Hosptial, Rome, Italy

F. LAURENTI G. LA GRECA R. FERRO G. BUCCI

GRANULOMAS IN CROHN’S DISEASE

SIR,-Several groups have tried to correlate the pathological findings in Crohn’s disease with the clinical outcome. The sarcoid-like granuloma is an intriguing aspect of this disease because of its possible, yet obscure, relationship to the patient’s immune response. Two reports,I,2 dealing primarily with Crohn’s colitis, indicate a more favourable prognosis in patients with granulomatous disease. As part of a continuing interest in this entity3 we have studied the outcome of 63 patients after resection for primary ileoca’cal Crohn’s disease between 1955 and 1975. Pathological specimens were studied by one of us (G.G.) and classified,

accepted pathological criteria, as possessing or lacking granulomas. Recurrence of Crohn’s disease was defined as the need for a secondary bowel resection to control the disease. Follow-up data were analysed actuarially, and follow-up was considered complete if the patient had recurrence or if his status was known as of 1975. By this definition follow-up was 94% (59/63) complete. 29 of these patients had had granulomas in the bowel wall of the original surgical specimen and on

34 had not. There was virtually no difference in the rate of recurrence, as we have defined it, between these two groups of patients after primary resection. The recurrence-rates for patients having and not having granulomas were 7% and 6%, respectively, at two years, 16% and 16% at five years, and 27% and 25% at eight years. Both groups of patients were comparable in terms of age, sex, and duration of disease before primary resection. Thus, in our patients with Crohn’s disease confined to the 1 Ward, M., Webb, J. M.J. clin. Path. 1977, 30, 126. 2. Glass, R. E., Baker, M. N. W. Gut, 1976, 17, 75. 3. Homan, W. P., Dineen, P. Ann. Surg. 1978, 187, 530.

Departments of Surgery and Pathology, Cornell University Medical College, New York, N.Y. 10021, U.S.A.

WILLIAM P. HOMAN GEORGE F. GRAY, JR. PETER DINEEN

REITER’S SYNDROME COMPLICATING SALMONELLA ENTERITIDIS INFECTION

SIR,-In October, 1977, there was an outbreak of Salmonella enteritidis infection in Stockholm affecting 2800 patients, mainly schoolchildren. Reactive arthropathy was noted in about 2% of the patients. Of these, a 12-year-old boy, had classical Reiter’s syndrome. The boy fell ill on Oct. 9 with enteric symptoms, 3 days after having eaten food contaminated with S. enteritidis. The enteric symptoms faded within a week. On Oct. 16 the boy complained of dysuria and had an inflamed urethral orifice. Urine culture was sterile. On Oct. 17 he had bilateral conjunctivitis and arthralgia which developed into painful swellings of several joints. The conjunctivitis and dysuria cleared rapidly but the arthritis lasted 5 months. Initially the fever was of septic type but a low-grade fever persisted for 3 months. Stool cultures yielded S. enteritidis but urine and blood were sterile several occasions, and so was an aspirate from an inflamed left knee joint. The erythrocyte-sedimentation rate rose to a maximum of 117 mm/h. The peak titre ofO-antibodies specific against S. enteritidis was 1/2070 enzyme-linked immunosorbent assay. Serum-protein electrophoresis showed an intense inflammatory reaction with a relative decrease of C3 and C4 complement. Circulating immune complexes were found in serial serum specimens during the first month of illness. Immune complexes were tested by C1q binding capacity of serum (Dr R. Norberg, National Bacteriological Laboratory, Stockholm). HLA typing was A19, B27, C- (Dr E. Moller, Huddinge Hoson

pital, Stockholm). The cause of Reiter’s syndrome remains unknown, but the syndrome may follow non-specific urethritis with an estimated frequency of 0.8%1 and shigella dysentery (0.2—1.5%2,3). The syndrome seldom seems to follow salmonella infection, but it has been described in children sporadically-i.e., in two cases after enteritis due to S. enteritidis4,5 and one case due to S. typhimurium.6 The Stockholm case occurred in an epidemic afflicting 2800 patients, suggesting a low incidence of Reiter’s syndrome after salmonella infection. Reiter’s syndrome is rare in children, but the incidence of diarrhoea associated with this syndrome seems to be higher in children than adults.’7 HLA B27 has been found in 76% of patients with Reiter’s syndrome,8 as it was in this case. The significance of the circulating immune complexes found during the first month of illness in our patient is uncertain. It may be important to an immunologically susceptible individual when the disease process is triggered by an infectious agent such as S. enteritidis. Hospital for Infectious Diseases, Roslagstulls Hospital, 114 89 Stockholm, Sweden

H. BRIEM B. EVENGÅRD

M. JONSSON

1. Csonka, G. Br. med. J. 1958, i, 1088. 2. Paronen, I. Acta med. scand. 1948, suppl. 212. 3. Noer, H. R. J. Am. med. Ass. 1966, 197, 963. 4. Neiman, N., Pierson, M., Ginsbourger, N. Rev. méd. Nancy, 1959, 84, 302. 5. Iveson, J. M. I., Nanda, B., Hancock, A. H., Ponwall, P. J., Wright, V. Ann.

rheum. Dis. 1975, 34, 364. 6. Jones, R. A. K. Br. med. J. 1977, ii, 1391. 7. Lockie, G. N., Hunder, G. G. Arthr. Rheum. 1971, 14, 767. 8. Brewerton, D. A., Caffrey, M., Nicholls, A., Walters, D., Oates, D. C. O. Lancet, 1973, u, 996.

J. K., James,

Transfusion of polymorphonuclear neutrophils in a premature infant with Klebsiella sepsis.

111 OXPRENOLOL IN THE OPERATING-THEATRE SIR,—Iwas intrigued by the paper from Mr Foster and his colleagues’ on the heart-rates of surgeons whil...
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