- Email: [email protected]
ADMISSION TO HOSPITAL
873 paper T.S.H. assay is used as a preliminary confirmation of the significance of an apparently low 1B result. This T.S.H. assay has a lower limit of sensitivity of about 60 microunits/ml. If both the T4 and T.S.H. are abnormal in either the newborn or 4-6-weeks blood-samples, liquid blood is obtained forthwith for further testing. If the T is abnormal, but the T.S.H. is normal on the first blood-sample, no action is taken until the 4-6-weeks specimen is received in the screening laboratory. If the T4 is again abnormal, the patient’s physician is contacted by mail, and the possibilities of pituitary hypo-
thyroidism, thyroid-binding globulin deficiency, or false-positive T4 v. false-negative T.s.H. test results are discussed, and further tests are suggested. Through August, 1975, the laboratory had tested 11 326 newborn specimens and 9903 4-6-weeks specimens. Low T4 values were obtained in 113 newborn and 1254-6-weeks specimens ; of these, 27 were low in T4 in both specimens. 3 of these 27 had abnormally high T.S.H. (100 microunits/ml) on the filter-paper assay, and hypothyroidism has been confirmed by additional tests (T4 T.S.H., 1251 uptake, thyroid scan, &c.). Another baby who had low T4 values on both tests had an apparently normal T.S.H. on a single filter-paper sample, but tests on serum showed a high T.S.H. and hypothyroidism was diagnosed by this and other confirmatory tests. The cause of the persistently low T4 in the remaining 23 babies has not yet been elucidated. None of the 4 had been suspected of being hypothyroid by their doctors, although, armed with the knowledge of the laboratory findings, it was possible to suspect the condition. Each of them had a few of the minor signs, which included sluggishness, pallor, large fontanelles, constipation, slow return of reflexes, prolonged jaundice, umbilical hernia, and large tongue. All the infants have been started on therapy, and we wait to assess the long-term results on their develop-
EARLY DETECTION OF RELAPSE IN HYPERTHYROIDISM
al.l discuss our paper (Marsden et al.); unfortunately given in error* as by Ormston et al.3 We should like to answer some of their points. They state that "serial estimations of thyroid hormones must be done over a prolonged period to distinguish between ... rebound and relapse". Serial evaluation of whatever kind, whether by clinical assessment, serum-T3, T.R.H. test, or otherwise must, we suggest, be undertaken for as long as it is clinically decided to follow the patients and at whatever frequency clinical judgment and local conditions allow. Secondly, we observed "rebound" phenomena only up to twelve weeks after stopping
SIR,-Staub
et
this
was
antithyroid drugs and not for a prolonged period. In our experience the T.R.H. test is an excellent index for the exclusion of hyperthyroidism of any degree, but it is less reliable in distinguishing marginally hyperthyroid patients from euthyroid patients whose thyroid glands are under autonomous stimulation (unsuppressible by exogenous T3). By suggesting the substitution of T.R.H. tests for serum-T3 measurements under these circumstances, Staub et a].’ appear to be employing three hormone estimations in place of one, which appears to us to be "laborious, time-consuming, and expenS1VP’°.
Departments of Medicine and Chemical Pathology, King’s College Hospital Medical School, London SE5, and Clinical Research Centre, Watford Road, Harrow, Middlesex. *This
error was
introduced
by
P. MARSDEN P. J. N. HOWORTH S. CHALKLEY M. ACOSTA
B. LEATHERDALE C. G. MCKERRON
us-ED.L.
ment.
About 1-2% of all bloods tested have had apparent T4 conof 2g/dl whole blood or less. Many of these may be due to inadequate samples or to technical problems in the assay. Supplementary testing for T.s.H. when the T4 is low seems to provide a good discrimination of the false-positive T44 results. This incidence of hypothyroidism of 1/3000 is higher than anticipated from published data. The true figure could be even higher since we do not know whether all the cases have been detected by this programme; but the total number of infants screened to date is still too small to give us an accurate measure of true frequency. Infants with hypoplastic or dysplastic thyroid glands are also detected by this programme and this may explain the figures. Many questions remain unsolved. Will early screening, diagnosis, and therapy materially improve the development of the affected infants? Is there a state of temporary neonatal hypothyroidism (akin to neonatal hypertyrosinaemia); and, if so, does it require therapy? We do not yet know whether infants with partial degrees of hypothyroidism are at risk of mental retardation if untreated. The lessons learned from the atypical forms of hyperphenylalaninaemia should have been well learned!
ABORTION AND MONEY
centrations
Department of Pediatrics, University of Oregon Health Sciences Center,
Portland, Oregon 97201, U.S.A.
NEIL R. M. BUIST
State University of New York at Buffalo
WILLIAM F. MURPHEY
Oregon Public Health Laboratory at Portland
GATLIN R. BRANDON
Children’s Hospital,
Pittsburgh
SIR,-Before you act on Mr Potter’s suggestion (Oct. 11, p. 711) and name miscreants, will you define how large an income from any field of medical practice is so enormous as to be unprofessional? Terrysfield, Downe, Orpington, Kent, BR6 7JT.
ADMISSION TO HOSPITAL
SIR,-It
seems probable that Dr Benjamin Lee composed (Oct. 4, p. 664) in aggravation, after failing to get an "unequivocal promise" from a "far-too-junior, inexperienced and transient hospital doctor" to admit one of his patients. His opening statement is open to some doubt, since
his letter
it is difficult to see how reorganisation of the National Health Service could possibly have altered admission procedures for patients in individual hospitals. Having served as a resident medical officer for some eight years in four large hospitals I do not recall a referring practitioner ever requiring an "unequivocal promise" to admit a patient. When I am able to discuss a patient with a referring doctor-which is extremely difficult when the patient comes via the Emergency Bed Service-in my experience admission or otherwise results from reasoned argument between all parties. Dr Lee can be reassured that R.M.o.s are not a dying breed but are alive and well and one hopes as enthusiastic and informed as they ever were. General Hospital, Steelhouse Lane, Birmingham B4 6NH. 1.
THOMAS P. FOLEY
JR
RHESA L. PENN
G. K. T. HOLMES
Staub, J. J., Barthe, P. L., Werner, I., Girard, J. Lancet, Oct. 4, 1975,
p
661.
Howorth, P. J. N., Chalkley, S., Acosta, M., Leatherdale, B., McKerron, C. G. ibid. 1975, i, 944. 3. Ormston, B. J., Garry, R., Cryer, R. J., Besser, G. M., Hall, R. ibid. 1971, ii, 10.
2. Marsden, P.,
Maternal and Child Health Section Oregon State Board of Health
G. C. R. MORRIS
thyroidism, thyroid-binding globulin deficiency, or false-positive T4 v. false-negative T.s.H. test results are discussed, and further tests are suggested. Through August, 1975, the laboratory had tested 11 326 newborn specimens and 9903 4-6-weeks specimens. Low T4 values were obtained in 113 newborn and 1254-6-weeks specimens ; of these, 27 were low in T4 in both specimens. 3 of these 27 had abnormally high T.S.H. (100 microunits/ml) on the filter-paper assay, and hypothyroidism has been confirmed by additional tests (T4 T.S.H., 1251 uptake, thyroid scan, &c.). Another baby who had low T4 values on both tests had an apparently normal T.S.H. on a single filter-paper sample, but tests on serum showed a high T.S.H. and hypothyroidism was diagnosed by this and other confirmatory tests. The cause of the persistently low T4 in the remaining 23 babies has not yet been elucidated. None of the 4 had been suspected of being hypothyroid by their doctors, although, armed with the knowledge of the laboratory findings, it was possible to suspect the condition. Each of them had a few of the minor signs, which included sluggishness, pallor, large fontanelles, constipation, slow return of reflexes, prolonged jaundice, umbilical hernia, and large tongue. All the infants have been started on therapy, and we wait to assess the long-term results on their develop-
EARLY DETECTION OF RELAPSE IN HYPERTHYROIDISM
al.l discuss our paper (Marsden et al.); unfortunately given in error* as by Ormston et al.3 We should like to answer some of their points. They state that "serial estimations of thyroid hormones must be done over a prolonged period to distinguish between ... rebound and relapse". Serial evaluation of whatever kind, whether by clinical assessment, serum-T3, T.R.H. test, or otherwise must, we suggest, be undertaken for as long as it is clinically decided to follow the patients and at whatever frequency clinical judgment and local conditions allow. Secondly, we observed "rebound" phenomena only up to twelve weeks after stopping
SIR,-Staub
et
this
was
antithyroid drugs and not for a prolonged period. In our experience the T.R.H. test is an excellent index for the exclusion of hyperthyroidism of any degree, but it is less reliable in distinguishing marginally hyperthyroid patients from euthyroid patients whose thyroid glands are under autonomous stimulation (unsuppressible by exogenous T3). By suggesting the substitution of T.R.H. tests for serum-T3 measurements under these circumstances, Staub et a].’ appear to be employing three hormone estimations in place of one, which appears to us to be "laborious, time-consuming, and expenS1VP’°.
Departments of Medicine and Chemical Pathology, King’s College Hospital Medical School, London SE5, and Clinical Research Centre, Watford Road, Harrow, Middlesex. *This
error was
introduced
by
P. MARSDEN P. J. N. HOWORTH S. CHALKLEY M. ACOSTA
B. LEATHERDALE C. G. MCKERRON
us-ED.L.
ment.
About 1-2% of all bloods tested have had apparent T4 conof 2g/dl whole blood or less. Many of these may be due to inadequate samples or to technical problems in the assay. Supplementary testing for T.s.H. when the T4 is low seems to provide a good discrimination of the false-positive T44 results. This incidence of hypothyroidism of 1/3000 is higher than anticipated from published data. The true figure could be even higher since we do not know whether all the cases have been detected by this programme; but the total number of infants screened to date is still too small to give us an accurate measure of true frequency. Infants with hypoplastic or dysplastic thyroid glands are also detected by this programme and this may explain the figures. Many questions remain unsolved. Will early screening, diagnosis, and therapy materially improve the development of the affected infants? Is there a state of temporary neonatal hypothyroidism (akin to neonatal hypertyrosinaemia); and, if so, does it require therapy? We do not yet know whether infants with partial degrees of hypothyroidism are at risk of mental retardation if untreated. The lessons learned from the atypical forms of hyperphenylalaninaemia should have been well learned!
ABORTION AND MONEY
centrations
Department of Pediatrics, University of Oregon Health Sciences Center,
Portland, Oregon 97201, U.S.A.
NEIL R. M. BUIST
State University of New York at Buffalo
WILLIAM F. MURPHEY
Oregon Public Health Laboratory at Portland
GATLIN R. BRANDON
Children’s Hospital,
Pittsburgh
SIR,-Before you act on Mr Potter’s suggestion (Oct. 11, p. 711) and name miscreants, will you define how large an income from any field of medical practice is so enormous as to be unprofessional? Terrysfield, Downe, Orpington, Kent, BR6 7JT.
ADMISSION TO HOSPITAL
SIR,-It
seems probable that Dr Benjamin Lee composed (Oct. 4, p. 664) in aggravation, after failing to get an "unequivocal promise" from a "far-too-junior, inexperienced and transient hospital doctor" to admit one of his patients. His opening statement is open to some doubt, since
his letter
it is difficult to see how reorganisation of the National Health Service could possibly have altered admission procedures for patients in individual hospitals. Having served as a resident medical officer for some eight years in four large hospitals I do not recall a referring practitioner ever requiring an "unequivocal promise" to admit a patient. When I am able to discuss a patient with a referring doctor-which is extremely difficult when the patient comes via the Emergency Bed Service-in my experience admission or otherwise results from reasoned argument between all parties. Dr Lee can be reassured that R.M.o.s are not a dying breed but are alive and well and one hopes as enthusiastic and informed as they ever were. General Hospital, Steelhouse Lane, Birmingham B4 6NH. 1.
THOMAS P. FOLEY
JR
RHESA L. PENN
G. K. T. HOLMES
Staub, J. J., Barthe, P. L., Werner, I., Girard, J. Lancet, Oct. 4, 1975,
p
661.
Howorth, P. J. N., Chalkley, S., Acosta, M., Leatherdale, B., McKerron, C. G. ibid. 1975, i, 944. 3. Ormston, B. J., Garry, R., Cryer, R. J., Besser, G. M., Hall, R. ibid. 1971, ii, 10.
2. Marsden, P.,
Maternal and Child Health Section Oregon State Board of Health
G. C. R. MORRIS