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QUININE-INDUCED MYOPATHY
845 ROYAL MEDICAL BENEVOLENT FUND CHRISTMAS APPEAL 1978
SIR,-Last year the R.M.B.F. Christmas appeal yielded the sum of l18 189, and we were able to send a worthwhile gift to every one of our beneficiaries to help them, especially the children, to enjoy a Christmas free from want. The Fund record
doctors for the benefit of docand their dependants. We trust that the medical profession will continue to maintain our help to those in need. Please give is
a
charity supported solely by
tors
generously once more. Contributions may be passed to the treasurer or medical representative of the local guilds of the Royal Medical Benevolent Fund or sent, marked "Christmas Appeal", to the Fund’s head office.
Royal Medical Benevolent Fund, King’s Road, Wimbledon, London SW19 8QN 24
T. HOLMES SELLORS
PERITONEAL DIALYSIS agree with you (Aug. 5, p. 303) that one of the important problems in chronic peritoneal dialysis is peritonitis. During the past seven years we have treated 161 patients in acute and chronic renal failure by peritoneal dialysis, the longest period of treatment being thirty-one months. Peritoneal access was by repetitive puncture,’ Deane prosthesis,2 or Tenckhoff catheter.3,4 Dialysis was done via an open circuit (10 litre tanks of commercial sterile and pyrogen-free solution and a semiautomated Braun machine) or with a closed automated peritoneal dialysis fluid-supply system and sterile pyrogen-free fluid prepared by reverse osmosis (Tenckhoff machineS).
SIR,-We
most
FREQUENCY
OF PERITONITIS COMPLICATING PERITONEAL DIALYSIS
FETAL AND NEONATAL HYPOTHYROIDISM DUE TO ANTITHYROID-DRUG THERAPY
SIR,-Dr Low and colleagues (Aug. 12, p. 370) report
two
of relative hypothyroidism during the neonatal period in infants born to women given antithyroid-drug therapy for thyrotoxicosis during pregnancy. It is difficult to conclude anything about intrauterine thyroid status from observations in the newborn because of the striking change in thyroid physiolI ogy that takes place at birth.l The two infants reported had only slightly raised T3 and T4 values during the first days of life, but these data are difficult to interpret because of the variability of thyroid-hormone concentrations during the neonatal period23 and because total T4 does not reliably reflect thyroid function in the newborn.4 If neonatal hypothyroidism is suspected cord and serum thyroid-stimulating hormone (T.S.H.) should be measured .16 The two infants reported by Low et al. showed a normal increase and decrease in serum-T.s.H., indicating normal thyroid function.7 They had no clinical evidence of hypothyroidism and I conclude that they had been, and were, euthyroid. cases
Department of Obstetrics and Gynæcology, Central Hospital, DK-4800 Nykøbing Falster, Denmark
J. SERUP
V This letter has been shown to Dr Low and his colleagues, whose reply follows.-Ed. L. SIR,-We cannot agree with Dr Serup’s interpretation of the thyroid-function data we presented. The thyroid stimulating hormone (T.S.H.) levels in the cord blood of the two neonates were higher than those observed in 20 normal neonates we have studied so far (mean serum-T.s.H. 6 mU/1, highest 18 mU/1). Since antithyroid drugs cross the placenta freely we believe that the higher cord-blood T.s.H. values observed in the two babies reported are most likely to be due to transplacental passage of antithyroid drugs. Department of Medicine, Gardiner Institute, University of Glasgow, Infirmary, Glasgow G11 6NT; and Radioimmunoassay Unit, Department of Biochemistry, Royal Infirmary, Glasgow.
Western
patient died; in 18 cases (0.38) the peritonitis was so serious that peritoneal dialysis was stopped, but only in 2 cases was surgical drainage of the peritoneum required. *No
L. C. K. Low W. A. RATCLIFFE W. D. ALEXANDER
QUININE-INDUCED MYOPATHY SIR,-Dr Lane and Professor Mastaglia gave a welcome synopsis of drug-induced myopathies, but in neither text nor table
Peritonitis, particularly the most severe forms, has been much less common when a Tenckhoff catheter and closed circuit were used (see table), and we now recommend chronic peritoneal dialysis (closed circuit, Tenckhoff catheter) in the treatment of chronic renal failure. A single treatment by this technique costs 3, compared with 22 for conventional open system and 25 for hxmodialysis.
Nephrology and Dialysis Service, Ospedale di Circolo, 21100 Varese,
Italy
Department of Internal Medicine, Mary’s Hospital,
L. GASTALDI
St.
L. BARATELLI M. CINQUEPALMI M. MARTEGANI E. NASCINBENE L. PIATTI
Reno, Nevada 89503, U S.A.
1 Mion, C Proc. Eur. Dialysis Transplant. Ass. 1975, 12, 140. 2. Jacob, G B., Deane, N. ibid. 1967, 4, 136. 3. Tenckhoff, H., Schechter, H. Trans Am Soc. artif. intern. Org. 1968, 14, 181. 4. Striker, G E., Tenckhoff, H. Surgery, 1971, 69, 70. 5 Tenckhoff, H., Meston, B., Shilipetar, G. Trans. Am. Soc artif. intern. Org.
1972, 18, 436.
are quinine or other cinchona alkaloids mentioned under myasthenic syndromes. It has been known for years that quinine and its isomers (e.g., quinidine) block the neuromuscular junction. Specifically, quinine alters conduction of the muscle action potential9 Cinchona alkaloids are widely used to control cardiac arrhythmias, in muscle cramps, and in tonic water, and these compounds should have been in Lane and Mastaglia’s list.
DAVID A. EDWARDS MICHAEL C. JOHNSON THOMAS J. O’NEILL
1. Fisher, D. A. New Engl. J. Med. 1975, 293, 770. 2. Siersbæk-Nielsen, K., Mølholm Hansen, J. Acta pœdiat. 1967, 56, 141. 3. Malkasian, G. D., Mayberry, W. E. Am. J. Obstet. Gynec. 1970, 108, 1234. 4. Brien, T. G., Fay, J A., Griffin, E. A. Archs Dis. Childh. 1974, 49, 225. 5. Walfish, P. G. Lancet, 1976, i, 1208. 6. Brandt, N. J., Jacobsen, B. B., Andersen, H., Hummer, L., Munkner, T., Sørensen, S. S. Ugeskr. Læg. 1977, 139, 2432. 7. Jacobsen, B. B. ibid. 1977, 139, 2429. 8. Lombardi, G., Panza, N., Cei, S., Cosimato, F , Minozzi, M. Acta endocr.
1978, 87, 70. 9. Goodman, L. S., Gillman, A. The chap. 28. New York, 1965.
Pharmacological
Bases of
Therapeutics,
SIR,-Last year the R.M.B.F. Christmas appeal yielded the sum of l18 189, and we were able to send a worthwhile gift to every one of our beneficiaries to help them, especially the children, to enjoy a Christmas free from want. The Fund record
doctors for the benefit of docand their dependants. We trust that the medical profession will continue to maintain our help to those in need. Please give is
a
charity supported solely by
tors
generously once more. Contributions may be passed to the treasurer or medical representative of the local guilds of the Royal Medical Benevolent Fund or sent, marked "Christmas Appeal", to the Fund’s head office.
Royal Medical Benevolent Fund, King’s Road, Wimbledon, London SW19 8QN 24
T. HOLMES SELLORS
PERITONEAL DIALYSIS agree with you (Aug. 5, p. 303) that one of the important problems in chronic peritoneal dialysis is peritonitis. During the past seven years we have treated 161 patients in acute and chronic renal failure by peritoneal dialysis, the longest period of treatment being thirty-one months. Peritoneal access was by repetitive puncture,’ Deane prosthesis,2 or Tenckhoff catheter.3,4 Dialysis was done via an open circuit (10 litre tanks of commercial sterile and pyrogen-free solution and a semiautomated Braun machine) or with a closed automated peritoneal dialysis fluid-supply system and sterile pyrogen-free fluid prepared by reverse osmosis (Tenckhoff machineS).
SIR,-We
most
FREQUENCY
OF PERITONITIS COMPLICATING PERITONEAL DIALYSIS
FETAL AND NEONATAL HYPOTHYROIDISM DUE TO ANTITHYROID-DRUG THERAPY
SIR,-Dr Low and colleagues (Aug. 12, p. 370) report
two
of relative hypothyroidism during the neonatal period in infants born to women given antithyroid-drug therapy for thyrotoxicosis during pregnancy. It is difficult to conclude anything about intrauterine thyroid status from observations in the newborn because of the striking change in thyroid physiolI ogy that takes place at birth.l The two infants reported had only slightly raised T3 and T4 values during the first days of life, but these data are difficult to interpret because of the variability of thyroid-hormone concentrations during the neonatal period23 and because total T4 does not reliably reflect thyroid function in the newborn.4 If neonatal hypothyroidism is suspected cord and serum thyroid-stimulating hormone (T.S.H.) should be measured .16 The two infants reported by Low et al. showed a normal increase and decrease in serum-T.s.H., indicating normal thyroid function.7 They had no clinical evidence of hypothyroidism and I conclude that they had been, and were, euthyroid. cases
Department of Obstetrics and Gynæcology, Central Hospital, DK-4800 Nykøbing Falster, Denmark
J. SERUP
V This letter has been shown to Dr Low and his colleagues, whose reply follows.-Ed. L. SIR,-We cannot agree with Dr Serup’s interpretation of the thyroid-function data we presented. The thyroid stimulating hormone (T.S.H.) levels in the cord blood of the two neonates were higher than those observed in 20 normal neonates we have studied so far (mean serum-T.s.H. 6 mU/1, highest 18 mU/1). Since antithyroid drugs cross the placenta freely we believe that the higher cord-blood T.s.H. values observed in the two babies reported are most likely to be due to transplacental passage of antithyroid drugs. Department of Medicine, Gardiner Institute, University of Glasgow, Infirmary, Glasgow G11 6NT; and Radioimmunoassay Unit, Department of Biochemistry, Royal Infirmary, Glasgow.
Western
patient died; in 18 cases (0.38) the peritonitis was so serious that peritoneal dialysis was stopped, but only in 2 cases was surgical drainage of the peritoneum required. *No
L. C. K. Low W. A. RATCLIFFE W. D. ALEXANDER
QUININE-INDUCED MYOPATHY SIR,-Dr Lane and Professor Mastaglia gave a welcome synopsis of drug-induced myopathies, but in neither text nor table
Peritonitis, particularly the most severe forms, has been much less common when a Tenckhoff catheter and closed circuit were used (see table), and we now recommend chronic peritoneal dialysis (closed circuit, Tenckhoff catheter) in the treatment of chronic renal failure. A single treatment by this technique costs 3, compared with 22 for conventional open system and 25 for hxmodialysis.
Nephrology and Dialysis Service, Ospedale di Circolo, 21100 Varese,
Italy
Department of Internal Medicine, Mary’s Hospital,
L. GASTALDI
St.
L. BARATELLI M. CINQUEPALMI M. MARTEGANI E. NASCINBENE L. PIATTI
Reno, Nevada 89503, U S.A.
1 Mion, C Proc. Eur. Dialysis Transplant. Ass. 1975, 12, 140. 2. Jacob, G B., Deane, N. ibid. 1967, 4, 136. 3. Tenckhoff, H., Schechter, H. Trans Am Soc. artif. intern. Org. 1968, 14, 181. 4. Striker, G E., Tenckhoff, H. Surgery, 1971, 69, 70. 5 Tenckhoff, H., Meston, B., Shilipetar, G. Trans. Am. Soc artif. intern. Org.
1972, 18, 436.
are quinine or other cinchona alkaloids mentioned under myasthenic syndromes. It has been known for years that quinine and its isomers (e.g., quinidine) block the neuromuscular junction. Specifically, quinine alters conduction of the muscle action potential9 Cinchona alkaloids are widely used to control cardiac arrhythmias, in muscle cramps, and in tonic water, and these compounds should have been in Lane and Mastaglia’s list.
DAVID A. EDWARDS MICHAEL C. JOHNSON THOMAS J. O’NEILL
1. Fisher, D. A. New Engl. J. Med. 1975, 293, 770. 2. Siersbæk-Nielsen, K., Mølholm Hansen, J. Acta pœdiat. 1967, 56, 141. 3. Malkasian, G. D., Mayberry, W. E. Am. J. Obstet. Gynec. 1970, 108, 1234. 4. Brien, T. G., Fay, J A., Griffin, E. A. Archs Dis. Childh. 1974, 49, 225. 5. Walfish, P. G. Lancet, 1976, i, 1208. 6. Brandt, N. J., Jacobsen, B. B., Andersen, H., Hummer, L., Munkner, T., Sørensen, S. S. Ugeskr. Læg. 1977, 139, 2432. 7. Jacobsen, B. B. ibid. 1977, 139, 2429. 8. Lombardi, G., Panza, N., Cei, S., Cosimato, F , Minozzi, M. Acta endocr.
1978, 87, 70. 9. Goodman, L. S., Gillman, A. The chap. 28. New York, 1965.
Pharmacological
Bases of
Therapeutics,