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Free fatty acids and arrhythmias
608
TUIi LANGIll'" SIU'Tl1MBHH 11, 197 t
it has become negative. It is also of interest that, of the five patients described with mefenamic-acid-induced hremolytic ansemia, all had taken the drug for at least a year and four also suffered from diarrhcca, Belfast City Hospital, Belfast BT9 7AD.
C. COTTON KENNEDV
J. H. ROBERTSON.
FOLIC-ACID DEFICIENCY AS A CAUSE OF ANGULAR CHEILOSIS Sm,-Mr. J. A. Rose suggests (Aug. 28, p. 453) that folic" acid deficiency may cause angular cheilosis. It is perhaps worth mentioning that serum-folate levels may be influenced by iron status.v-" Folate may be implicated if all other factors in the test subjects and controls were comparable, but only passing reference is made in this paper to routine blood findings or to the iron status of the pnticnts studied. It seems a little premature to invoke folic-acld deficiency as a cause of the lesions before excluding iron deficiency, which is an undisputed cause of angular cheilosis. Heernntology Department, Guy's Hospital, London S,B.L
MICHAn!.
S. Rosn,
SIR,-I read with interest ML·. Rose's article, but his claim that there is "an association between angular cheilosis and low serum-folate" would seem premature, particularly when the mean serum-folate levels for both controls and patients were In the normal range. Angular cheilosis has been a suggested feature of many deficlcnciesriboflavine," nicctinamldc," possibly iron," and pyridoxine q while Ellenberg 7 has emphasised the Importance of malocclusion in the genesis of this sign. Clearly it is important, particularly in patients attending the department of prosthetic dentistry, to have further information on any change in dental state or ability to eat a diet of greater variety before more specific claims are made. Eastern General Hospital, Edinburgh EH6 7LN.
R. MACLEOD.
SATISFACTION AT WORK OR OUTSIDE IT ? SIR,-Dr. Tredgold (Aug. 21, p. 420) describes three needs we have at work which may not be satisfiednamely, the opportunity to be creative, the experiences of social justice, and the chance to have a feeling of personal identity. I suggest a fourth-namely, to be regarded as a man. This is implied in Tredgold's description of the feelings which arise when the need for identity is frustrated, "being trapped 'or pushed about (expressed in more lurid terms by soldiers.") I take it one of the more lurid terms is " buggered ". This expression seems to be a stereotyped form of protest against being treated as the receiver, as the woman, the child, or the animal (these terms being used here of course in their diminishing sense), and not as a man, a doer. While I suggest this assumption of being in a passive libidinal position as a fourth problem, it is also one way of looking at the other problems described by Tredgold, 6 Moray Place, Edinburgh EH3 60S.
W. M.
MCINT'\:'IUl.
Chanarln, I., Rothman, D., Berry, V. BI'. med.:!. 1965, t, 480. Willoughby, M. L. N. BT. J. Hte",at. 1967,13,503. Sebrell, W. H., Butler, R. E. Publ. Hlth Rep., Wash. 1938,53,2282. Spies, T. D., Chinn, A. B., McLester, J. B.J. Am. med, As!. 1937, 108,853. 5. Darby, W. J. ibid, 1946, 130, B30. 6. Smith, S. G., Martin, D. W. Proc, Soc. expo Blol. Med. 1940,43,660. 7. Ellenberg, M., Pollack, H, J. Am. med, Ass. 1942, 119,790.
1. 2. 3. 4.
l'REE FATTY ACIDS AND ARRHYTHMIAS Sm,-Dr. Opic lind his collenguca set out in their paper 1 a number of reasons why they were unable to produce serious ventricular arrhytlunlas with elevation of arterial free fatty acids (F.l'.A.) following the induction of experimental myocardial infarction in dogs, lind why their results lire at variance with ours. n,B To these reasons two more can be added. They infused the ' Intrulipid ' emulsion in 5 'X, glucose. It can be calculated that the amount given would be enough to provide aufliclcnt e-glycerophosphatc for csterlficatlon intraccllularly of 1I11 the F.P.A. obtained from plusmn lipolysis of inttulipid by heparin, In these circumstances" triglyccrklcs lind not F.P.A. would accumulate in ischremlc myocurdiul cells, even though the arterlul levels of l'.P.A. were high. Further, the presence of glucose In the lnluslon mixture would probably atimulate more insulin production lind prornute greater entry of glucose into the cell, und accelerate further the cstecitlcnrlon of It.lI.A. Oplc ct Ill. were upparcntly using a mixture which could reduce the iurruccllulur conccntrurion of II.I'.A. by their convention to triglyceride and possibly reduce, therefore, the chance 0[' producing archythmlna, A second point is the dlflcrcuccs in hcart-rntc between the prepnratious used by us lind by Oplc et Ill. In our experience, elevation of arterial II.II.A. led to less increuse in the frequency of ectopic bents when the heart-rate Will> grcatcr than 150 pel' minute." A number of the dogs in the aeries reported by Opic ct al, had heart-rates greater than 150 pel' minute. The nrrhythruin Induced by elevated F.I1.A. is probably due to a pnrusystollc [ilclis orlginuting in an accelerated" automueic " cell in the Purkln]e system. Such arrythmlaa arc easily affected by varincion« in the rate in supraventricular foci. For n given rnte of n parasystolic focus, more ccropics will be manifest when che sinus rate is slower than when it is Iuater, In their cornparlson of dogs in group 2 (without preloading with intralipid lind heparin) with those in group 3 (with prelouding), Opie et al, concluded that there WIlS no significant increase in the frequency of ectoplcs because the slime percentage frequency of ectoplcs occurred in both these groups of dogs. However, group 2 had a mean sinus rate of 129 per minute, while group 3 had a mean rate of 185 per minute, so that the absolute numbers of ectopics per minute were 38 per minute in group 2 compared with 54 per minute in group 3. Since an increased number of ectopics occurred at the higher sinus rate, the parasystollc focus itself may have become accelerated when F.P.A. were elevated, Departments of Medicine lind Pathology, Unlvcrsity of Edinburgh.
V. A. KUlUEN P. A. YATES
M. F.
OLIVER.
>I< >I< * The Edinburgh workers sent a copy of this letter to Dr. Opie and Dr. Thomas, whose reply follows.-En. L.
SlR,-The composition of' Intralipid ' WIIS unfortunately incorrectly given. Intralipld contains soybean oil and no glucose. We origlnally undertook the cxperlmcnts with infusion of intralipid anticipating that if nrrhyrhmlas were indeed induced by high F.II.A. concentrations, then they might respond to glucose infusion following earerlfication of intracellular P.P.A, as would theoretically he expected. However, no arrythmiaa were produced and tit no stage in these experiments was glucose infused. The lower heart-rate in the Edinburgh experiments as 1. Opic, L. H., Norris, R. M., Thomas, M., Holland, H. A., Owen, B., Van Norden, S. Lancet, 1971, I, 818. 2. Kurlen, V. A., Yates, P. A., Oliver, M. F. ibid, 1969, II, 185. 3. Kurien, V. A., Yates, P. A., Oliver, M. F. EUT.J. clin, Invest, 1971, 1,225.
TUIi LANGIll'" SIU'Tl1MBHH 11, 197 t
it has become negative. It is also of interest that, of the five patients described with mefenamic-acid-induced hremolytic ansemia, all had taken the drug for at least a year and four also suffered from diarrhcca, Belfast City Hospital, Belfast BT9 7AD.
C. COTTON KENNEDV
J. H. ROBERTSON.
FOLIC-ACID DEFICIENCY AS A CAUSE OF ANGULAR CHEILOSIS Sm,-Mr. J. A. Rose suggests (Aug. 28, p. 453) that folic" acid deficiency may cause angular cheilosis. It is perhaps worth mentioning that serum-folate levels may be influenced by iron status.v-" Folate may be implicated if all other factors in the test subjects and controls were comparable, but only passing reference is made in this paper to routine blood findings or to the iron status of the pnticnts studied. It seems a little premature to invoke folic-acld deficiency as a cause of the lesions before excluding iron deficiency, which is an undisputed cause of angular cheilosis. Heernntology Department, Guy's Hospital, London S,B.L
MICHAn!.
S. Rosn,
SIR,-I read with interest ML·. Rose's article, but his claim that there is "an association between angular cheilosis and low serum-folate" would seem premature, particularly when the mean serum-folate levels for both controls and patients were In the normal range. Angular cheilosis has been a suggested feature of many deficlcnciesriboflavine," nicctinamldc," possibly iron," and pyridoxine q while Ellenberg 7 has emphasised the Importance of malocclusion in the genesis of this sign. Clearly it is important, particularly in patients attending the department of prosthetic dentistry, to have further information on any change in dental state or ability to eat a diet of greater variety before more specific claims are made. Eastern General Hospital, Edinburgh EH6 7LN.
R. MACLEOD.
SATISFACTION AT WORK OR OUTSIDE IT ? SIR,-Dr. Tredgold (Aug. 21, p. 420) describes three needs we have at work which may not be satisfiednamely, the opportunity to be creative, the experiences of social justice, and the chance to have a feeling of personal identity. I suggest a fourth-namely, to be regarded as a man. This is implied in Tredgold's description of the feelings which arise when the need for identity is frustrated, "being trapped 'or pushed about (expressed in more lurid terms by soldiers.") I take it one of the more lurid terms is " buggered ". This expression seems to be a stereotyped form of protest against being treated as the receiver, as the woman, the child, or the animal (these terms being used here of course in their diminishing sense), and not as a man, a doer. While I suggest this assumption of being in a passive libidinal position as a fourth problem, it is also one way of looking at the other problems described by Tredgold, 6 Moray Place, Edinburgh EH3 60S.
W. M.
MCINT'\:'IUl.
Chanarln, I., Rothman, D., Berry, V. BI'. med.:!. 1965, t, 480. Willoughby, M. L. N. BT. J. Hte",at. 1967,13,503. Sebrell, W. H., Butler, R. E. Publ. Hlth Rep., Wash. 1938,53,2282. Spies, T. D., Chinn, A. B., McLester, J. B.J. Am. med, As!. 1937, 108,853. 5. Darby, W. J. ibid, 1946, 130, B30. 6. Smith, S. G., Martin, D. W. Proc, Soc. expo Blol. Med. 1940,43,660. 7. Ellenberg, M., Pollack, H, J. Am. med, Ass. 1942, 119,790.
1. 2. 3. 4.
l'REE FATTY ACIDS AND ARRHYTHMIAS Sm,-Dr. Opic lind his collenguca set out in their paper 1 a number of reasons why they were unable to produce serious ventricular arrhytlunlas with elevation of arterial free fatty acids (F.l'.A.) following the induction of experimental myocardial infarction in dogs, lind why their results lire at variance with ours. n,B To these reasons two more can be added. They infused the ' Intrulipid ' emulsion in 5 'X, glucose. It can be calculated that the amount given would be enough to provide aufliclcnt e-glycerophosphatc for csterlficatlon intraccllularly of 1I11 the F.P.A. obtained from plusmn lipolysis of inttulipid by heparin, In these circumstances" triglyccrklcs lind not F.P.A. would accumulate in ischremlc myocurdiul cells, even though the arterlul levels of l'.P.A. were high. Further, the presence of glucose In the lnluslon mixture would probably atimulate more insulin production lind prornute greater entry of glucose into the cell, und accelerate further the cstecitlcnrlon of It.lI.A. Oplc ct Ill. were upparcntly using a mixture which could reduce the iurruccllulur conccntrurion of II.I'.A. by their convention to triglyceride and possibly reduce, therefore, the chance 0[' producing archythmlna, A second point is the dlflcrcuccs in hcart-rntc between the prepnratious used by us lind by Oplc et Ill. In our experience, elevation of arterial II.II.A. led to less increuse in the frequency of ectopic bents when the heart-rate Will> grcatcr than 150 pel' minute." A number of the dogs in the aeries reported by Opic ct al, had heart-rates greater than 150 pel' minute. The nrrhythruin Induced by elevated F.I1.A. is probably due to a pnrusystollc [ilclis orlginuting in an accelerated" automueic " cell in the Purkln]e system. Such arrythmlaa arc easily affected by varincion« in the rate in supraventricular foci. For n given rnte of n parasystolic focus, more ccropics will be manifest when che sinus rate is slower than when it is Iuater, In their cornparlson of dogs in group 2 (without preloading with intralipid lind heparin) with those in group 3 (with prelouding), Opie et al, concluded that there WIlS no significant increase in the frequency of ectoplcs because the slime percentage frequency of ectoplcs occurred in both these groups of dogs. However, group 2 had a mean sinus rate of 129 per minute, while group 3 had a mean rate of 185 per minute, so that the absolute numbers of ectopics per minute were 38 per minute in group 2 compared with 54 per minute in group 3. Since an increased number of ectopics occurred at the higher sinus rate, the parasystollc focus itself may have become accelerated when F.P.A. were elevated, Departments of Medicine lind Pathology, Unlvcrsity of Edinburgh.
V. A. KUlUEN P. A. YATES
M. F.
OLIVER.
>I< >I< * The Edinburgh workers sent a copy of this letter to Dr. Opie and Dr. Thomas, whose reply follows.-En. L.
SlR,-The composition of' Intralipid ' WIIS unfortunately incorrectly given. Intralipld contains soybean oil and no glucose. We origlnally undertook the cxperlmcnts with infusion of intralipid anticipating that if nrrhyrhmlas were indeed induced by high F.II.A. concentrations, then they might respond to glucose infusion following earerlfication of intracellular P.P.A, as would theoretically he expected. However, no arrythmiaa were produced and tit no stage in these experiments was glucose infused. The lower heart-rate in the Edinburgh experiments as 1. Opic, L. H., Norris, R. M., Thomas, M., Holland, H. A., Owen, B., Van Norden, S. Lancet, 1971, I, 818. 2. Kurlen, V. A., Yates, P. A., Oliver, M. F. ibid, 1969, II, 185. 3. Kurien, V. A., Yates, P. A., Oliver, M. F. EUT.J. clin, Invest, 1971, 1,225.