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T4 RATIO IN THYROID DISEASE
1056 ative colitis.6 Further reports on indomethacin-associated colonic lesions in man should bring a new insight into the intestinal action of prostaglandins. We thank Prof. P. Babin, and Mrs F. Peyraut for technical assistance.
Departments of Gastroenterology, Rheumatic Diseases and
Surgery,
University of Poitiers, 86021 Poitiers, France.
Cassegrain
and Mrs M. R.
S. COUTROT D. ROLAND J. BARBIER P. VAN DER MARCQ M. ALCALAY C. MATUCHANSKY
T3/T4 RATIO IN THYROID DISEASE SIR,-Dr Amino and colleagues (Aug. 12, p. 344) proposed that a serum triiodothyronine/thyroxine (TIT 4) ratio value of greater than 20 (ng/g) would be a useful index for differentiating inflammatory thyrotoxicosis from the stimulationinduced hyperthyroidism of Graves’ disease. They refer to our paper’ wherein we reported a post-partum transient thyrotoxicosis syndrome with painless thyroiditis. The T /1’4 ratios available for patients 3, 4, and 5 of our series were greater than 20-i.e., false negative for inflammation-induced thyrotoxicosis according to criterion of Amino et al. The usefulness of this ratio as a test to differentiate between inflammatory and stimulation induced hyperthyroidism in Graves’ disease seems
questionable. The reason for this discrepancy is unclear. Differences in radioimmunoassay technique between laboratories could influence the absolute values and, conceivably, alter the ratio. The time of sampling during the thyrotoxic phase might influence the T /1’4 ratio, higher values being seen earlier and low values later in the course of inflammatory thyrotoxicosis, 2 as noted by Amino et al. and others. Radioactive iodine thyroid uptake was low in all our five cases with post-partum painless thyroiditis’ and therefore seems to be a more specific diagnostic test for recognising thyrotoxicosis induced by inflammatory destruction, once iodine contamination and exogenous thyroid-hormone supplements have been excluded. I suggest that the T 3/f ratio may be subject to error in differentiating the thyrotoxicosis of a painless inflammatory thyroiditis process from Graves’ disease. This ratio, while occasionally helpful, should not be substituted for a radioactive iodine thyroid-uptake study. Research Laboratory and Endocrine Division, Mount Sinai Hospital, Toronto, Ontario M5G 1X5, Canada
Thyroid
PAUL G. WALFISH
RING STERILISATION IN MEN
SIR,-We reported earlier in The Lancet3our preliminary experience with ring sterilisation in man. Follow-up analysis of the sperm after one year showed that in a high percentage of cases the number of spermatozoa increased from low to subnormal values. Reintervention has shown that recanalisation can occur at the base of the ring. Sterilisation with silicone rings is thus not an effective procedure in man. Departments of Urology, Obstetrics and Gynæcology, and Division of Psychosomatic Medicine, Academisch Ziekenhuis St.-Rafaël, 3000 Leuven, Belgium
R. L. VEREECKEN F. A. VAN ASSCHE P. NIJS
6. Gould, S. R., Brash, A. R., Conolly, M. E. Lancet, 1977, ii, 98. 1. Ginsberg, J., Walfish, P. G. Lancet, 1977, i, 1125. 2. Weihl, A. C., Daniels, G. H., Ridgway, E. C., Maloof, F. J. clin. Endocr. Metab. 1977, 44, 1107. 3. Vereecken, R. L., Van Assche, F. A., Nijs, P. Lancet, 1976, ii, 1406.
RIGORS AFTER INTRAVENOUS STREPTOMYCIN AND METHICILLIN
SIR,-Intravenous antibiotics are used routinely in the postoperative period in the cardiothoracic surgical unit of the Royal Adelaide Hospital. For three days after coronary-artery bypass surgery patients receive intravenous bolus doses of streptomycin 500 mg 12-hourly and methicillin 1 g 6-hourly via a subclavian-vein catheter. The streptomycin injection coincides with the alternate doses of methicillin, at which time both drugs are given sequentially over a period of five minutes. The development of rigors after these drugs is rare.’ It was thus of considerable interest when the hospital’s adverse drug reactions reporting programme was alerted to this apparent side-effect of drug administration in postoperative coronary bypass patients. The rigors usually developed within thirty minutes of sequential streptomycin/methicillin therapy and they were very distressing to the patient. They were reported from the unit with a frequency of about three per month during the first six months of this year. A prospective evaluation of intravenous antibiotic administration was undertaken after these reports and it was decided to give the two drugs four hours apart, instead of sequentially. This change was very effective: over the past three months rigors have not been reported after the intravenous administration of these antibiotics. The mechanism for these rigors remains unexnlained.
Department of Clinical Pharmacology, and Pharmacy Department, Royal Adelaide Hospital, Adelaide, South Australia
PETER C. ROBINSON DEREK B. FREWIN JANET ELLERSHAW PATRICIA T. JOLLEY
EPIDEMIC ACUTE DIARRHŒA IN ADULTS ASSOCIATED WITH INFANTILE GASTROENTERITIS VIRUS
SiR,—The xtiological association of infantile gastroenteritis virus (I.G.V.) or rotavirus with acute gastroenteritis in small children has been documented by several reports.1-3 In a few cases i.G.v. has also been found in adult patients with diarrhcea.4-6 We have observed an epidemic of gastroenteritis characterised by frequent findings of i.G.v. in stool samples of acutely ill adult patients. In January, 1977, there was an epidemic of acute gastroenteritis in a small Swedish town. Within 2 weeks, 3172 cases were registered in the local office of the National Health Insurance indicating that at least 30% of the population were afflicted. No spread to the rural districts surrounding the city was observed. There was no epidemic infiuenza during this period. All age groups were represented among the diseased. Schoolchildren and teachers were the first to be reported ill, but within a week the outbreak was general and included practically all ages, from patients on geriatric wards to preschool children. The incidence of gastroenteritis was most pronounced in the school-age group but the distribution of cases did not differ significantly between children and adults. There were no indications of a spread from children to adults. Clinically the epidemic was characterised by diarrhcea, vomiting, headache, muscular pain, and fever up to 39°C. The symptoms disappeared after 1-3 days and in only a few cases did the muscular pain persist for a week. No patient required hospital treatment. Outpatients had leukopenia (3000-4000 white blood-cells/1) and a relative lymphocytosis. About half 1. Can. med. Ass. 1.
Bishop,
R.
J. 1974, 111, 23. F., Davidson, G. P., Holmes, I. H., Ruck, B. J. Lancet, 1973, ii,
1281. 2. Flewett, T. H., Bryden, A. S., Davies, H. ibid. 1497. 3. Kapikian, A. Z., Kim, H. W., Wyatt, R. G., Rodriguez, W. J., Ross, S., Cline, W. L., Parrot, R. H., Chanock, R. M. Science, 1974, 185, 1049. 4. Von Bonsdorff, C. H., Hovi, T., Mäkelä, P., Hovi, L., Tevalvoto-Aarnio, M.
Lancet, 1976, ii, 423. 5. Ørstavik, I., Haüg, K. W., Søvde, A. Scand. J. infect. Dis. 1976, 8, 277. 6. Zissis, G., Lamberg, J. P., Fonteyne, J. Lancet, 1976, i, 96.
Departments of Gastroenterology, Rheumatic Diseases and
Surgery,
University of Poitiers, 86021 Poitiers, France.
Cassegrain
and Mrs M. R.
S. COUTROT D. ROLAND J. BARBIER P. VAN DER MARCQ M. ALCALAY C. MATUCHANSKY
T3/T4 RATIO IN THYROID DISEASE SIR,-Dr Amino and colleagues (Aug. 12, p. 344) proposed that a serum triiodothyronine/thyroxine (TIT 4) ratio value of greater than 20 (ng/g) would be a useful index for differentiating inflammatory thyrotoxicosis from the stimulationinduced hyperthyroidism of Graves’ disease. They refer to our paper’ wherein we reported a post-partum transient thyrotoxicosis syndrome with painless thyroiditis. The T /1’4 ratios available for patients 3, 4, and 5 of our series were greater than 20-i.e., false negative for inflammation-induced thyrotoxicosis according to criterion of Amino et al. The usefulness of this ratio as a test to differentiate between inflammatory and stimulation induced hyperthyroidism in Graves’ disease seems
questionable. The reason for this discrepancy is unclear. Differences in radioimmunoassay technique between laboratories could influence the absolute values and, conceivably, alter the ratio. The time of sampling during the thyrotoxic phase might influence the T /1’4 ratio, higher values being seen earlier and low values later in the course of inflammatory thyrotoxicosis, 2 as noted by Amino et al. and others. Radioactive iodine thyroid uptake was low in all our five cases with post-partum painless thyroiditis’ and therefore seems to be a more specific diagnostic test for recognising thyrotoxicosis induced by inflammatory destruction, once iodine contamination and exogenous thyroid-hormone supplements have been excluded. I suggest that the T 3/f ratio may be subject to error in differentiating the thyrotoxicosis of a painless inflammatory thyroiditis process from Graves’ disease. This ratio, while occasionally helpful, should not be substituted for a radioactive iodine thyroid-uptake study. Research Laboratory and Endocrine Division, Mount Sinai Hospital, Toronto, Ontario M5G 1X5, Canada
Thyroid
PAUL G. WALFISH
RING STERILISATION IN MEN
SIR,-We reported earlier in The Lancet3our preliminary experience with ring sterilisation in man. Follow-up analysis of the sperm after one year showed that in a high percentage of cases the number of spermatozoa increased from low to subnormal values. Reintervention has shown that recanalisation can occur at the base of the ring. Sterilisation with silicone rings is thus not an effective procedure in man. Departments of Urology, Obstetrics and Gynæcology, and Division of Psychosomatic Medicine, Academisch Ziekenhuis St.-Rafaël, 3000 Leuven, Belgium
R. L. VEREECKEN F. A. VAN ASSCHE P. NIJS
6. Gould, S. R., Brash, A. R., Conolly, M. E. Lancet, 1977, ii, 98. 1. Ginsberg, J., Walfish, P. G. Lancet, 1977, i, 1125. 2. Weihl, A. C., Daniels, G. H., Ridgway, E. C., Maloof, F. J. clin. Endocr. Metab. 1977, 44, 1107. 3. Vereecken, R. L., Van Assche, F. A., Nijs, P. Lancet, 1976, ii, 1406.
RIGORS AFTER INTRAVENOUS STREPTOMYCIN AND METHICILLIN
SIR,-Intravenous antibiotics are used routinely in the postoperative period in the cardiothoracic surgical unit of the Royal Adelaide Hospital. For three days after coronary-artery bypass surgery patients receive intravenous bolus doses of streptomycin 500 mg 12-hourly and methicillin 1 g 6-hourly via a subclavian-vein catheter. The streptomycin injection coincides with the alternate doses of methicillin, at which time both drugs are given sequentially over a period of five minutes. The development of rigors after these drugs is rare.’ It was thus of considerable interest when the hospital’s adverse drug reactions reporting programme was alerted to this apparent side-effect of drug administration in postoperative coronary bypass patients. The rigors usually developed within thirty minutes of sequential streptomycin/methicillin therapy and they were very distressing to the patient. They were reported from the unit with a frequency of about three per month during the first six months of this year. A prospective evaluation of intravenous antibiotic administration was undertaken after these reports and it was decided to give the two drugs four hours apart, instead of sequentially. This change was very effective: over the past three months rigors have not been reported after the intravenous administration of these antibiotics. The mechanism for these rigors remains unexnlained.
Department of Clinical Pharmacology, and Pharmacy Department, Royal Adelaide Hospital, Adelaide, South Australia
PETER C. ROBINSON DEREK B. FREWIN JANET ELLERSHAW PATRICIA T. JOLLEY
EPIDEMIC ACUTE DIARRHŒA IN ADULTS ASSOCIATED WITH INFANTILE GASTROENTERITIS VIRUS
SiR,—The xtiological association of infantile gastroenteritis virus (I.G.V.) or rotavirus with acute gastroenteritis in small children has been documented by several reports.1-3 In a few cases i.G.v. has also been found in adult patients with diarrhcea.4-6 We have observed an epidemic of gastroenteritis characterised by frequent findings of i.G.v. in stool samples of acutely ill adult patients. In January, 1977, there was an epidemic of acute gastroenteritis in a small Swedish town. Within 2 weeks, 3172 cases were registered in the local office of the National Health Insurance indicating that at least 30% of the population were afflicted. No spread to the rural districts surrounding the city was observed. There was no epidemic infiuenza during this period. All age groups were represented among the diseased. Schoolchildren and teachers were the first to be reported ill, but within a week the outbreak was general and included practically all ages, from patients on geriatric wards to preschool children. The incidence of gastroenteritis was most pronounced in the school-age group but the distribution of cases did not differ significantly between children and adults. There were no indications of a spread from children to adults. Clinically the epidemic was characterised by diarrhcea, vomiting, headache, muscular pain, and fever up to 39°C. The symptoms disappeared after 1-3 days and in only a few cases did the muscular pain persist for a week. No patient required hospital treatment. Outpatients had leukopenia (3000-4000 white blood-cells/1) and a relative lymphocytosis. About half 1. Can. med. Ass. 1.
Bishop,
R.
J. 1974, 111, 23. F., Davidson, G. P., Holmes, I. H., Ruck, B. J. Lancet, 1973, ii,
1281. 2. Flewett, T. H., Bryden, A. S., Davies, H. ibid. 1497. 3. Kapikian, A. Z., Kim, H. W., Wyatt, R. G., Rodriguez, W. J., Ross, S., Cline, W. L., Parrot, R. H., Chanock, R. M. Science, 1974, 185, 1049. 4. Von Bonsdorff, C. H., Hovi, T., Mäkelä, P., Hovi, L., Tevalvoto-Aarnio, M.
Lancet, 1976, ii, 423. 5. Ørstavik, I., Haüg, K. W., Søvde, A. Scand. J. infect. Dis. 1976, 8, 277. 6. Zissis, G., Lamberg, J. P., Fonteyne, J. Lancet, 1976, i, 96.