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LYMPHOCYTES IN CHILDREN TREATED WITH PHENYTOIN
1205 LYMPHOCYTES IN CHILDREN TREATED WITH PHENYTOIN
SIR,-Phenytoin has been reported to depress the lymphocyte-count in adults. 1Higashi and others,3 however, found slightly higher counts in phenytoin-treated children than in healthy controls. As part of a larger study, we measured lymphocyte-counts in 17 children (age-range 1 yr 1 mo to 13 yr 9 mo) before and after approximately 6 mo on phenytoin. The mean lymphocyte-count in untreated children was 3070/mm3 (S.E.M.±371) and after treatment was 3235/mm3 (S.E.M.±357). The mean phenytoin level was 6.00 µg/ml. The slight rise in lymphocyteThe mean IgA level fell count was not significant (P>0.05). from 56 to 43 i.u./ml. The only other prospective study4 showed a similar slight rise in lymphocyte-count and a significant fall in serum IgA. IgA-staining B-cells are not depleted in phenytoin-treated IgA-deficient children.5 The difference in lymphocyte-counts in the different series could be due to differences of blood-phenytoin level, since MacKinney and Booker’ found low lymphocyte-counts only in patients whose serum-phenytoin was above the therapeutic range. The other reports did not record drug levels. An alternative explanation is that the epileptics had inherently lower lymphocyte-counts
than the
tional groupings, subcultures, and nations indicate the very small role played by inherited factors. Department of Sociology, College of Sciences and Humanities, Ball State University, Muncie, Indiana 47306, U.S.A.
RICHARD A. BOGG
PORTACAVAL SHUNT FOR HOMOZYGOUS HYPERCHOLESTEROLÆMIA
SIR,-Portacaval shunt operations were done on four homozygous hypercholesterolaemic patients in 1974.1 We report on their status 25-27 months after surgery. The fall in serum-cholesterol has not been impressive (see table). Despite this patients 1, 2, and 4, who had had angina before surgery, now state that this symptom has improved, and patient 2 no longer takes glyceryl trinitrate. Xanthomas have regressed considerably in patients 1, 2, and 4, but there has been little change in patient 3. All the patients feel well, and there have been no occlusive vascular episodes postoperatively. However, in the only patient (no. 2) whose electrocardiogram was abnormal preoperatively, no change has occurred.
(mg/dl)
BEFORE AND AFTER FASTING SERUM-CHOLESTEROL PORTACAVAL SHUNT
healthy subjects.
Cardiff Royal Infirmary, Cardiff CF2 1SZ
J. SEAGER
GENETIC COMPONENT OF OBESITY
SIR,—Dr James and Dr Trayhurn (Oct. 9,, p. 770) argue that the
primary problem in the obese is greater-than-normal efficiency, and that this characteristic may have a genetic component. Such an approach may be appropriate for a small proportion of idiopathic obese, the "hard core" who metabolic
accumulate in metabolic research clinical units and fail to respond even to 1000 kcal diets. But the major factors in obesity must surely be cultural. For example, lower-class women are characteristically heavier than the middle-class women. Two distinctly heavy groups in the U.S. are Black women and White long-distance truck drivers, two groups who find major gratification in food though for different reasons. At Ball State University in Indiana, first-year students report being 3 kg over their personal ideal weight while fourth-year students report being 9 kg overweight. Psychological tension, sedentary living, and a superabundance of high-calorie snack foods are probably more important than inherited defective thermogenic responses in explaining these dramatic increases in collegiate
obesity. U.S.A. youth have become heavier, males in a 1966-70 national sample being 7 kg heavier at age 17 than 17-year-olds in the Iowa Growth Study of the 1950s.67 Compared with Scott’s London County Council data, U.S. males at age 16 are 1 cm taller and 2 kg heavier, but those in the 90th percentile are 5 kg heavier than their London counterparts.8 It would be difficult to make a genetic argument for this greater frequency of obesity. Certainly subject responses to food in clinical settings are highly variable, demonstrating what is well known-that human metabolism is complex and not readily quantified. But the vast differences in obesity between social classes, occupa1. MacKinney, A. A., Booker, H. E. Archs intern. Med. 1972, 129, 988. 2. Brandt, L. , Nilsson, P. G. Lancet, 1976, i, 308. 3. Higashi, A., Ikeda, T., Adaboshi, I., Karashima, S., Miike, T., Matsuda, I. ibid 1976, ii, 44. 4. Sorrell, T. C. , Forbes, I. J. Clin. exp. Immun. 1975, 20, 273. 5. Seager, J., Jamison, D. L., Wilson, J., Hayward, A. R., Soothill, J. F. Lancet, 1975, ii, 632
Height and Weight of Youths 12-17 Years Series ii, no. 124. Washington, D.C., 1973. 7. Nelson, W. E. (editor) Textbook of Pediatrics Philadelphia, 1969. Scott, J. A Report on the Heights and Weights of School Pupils in the County of London in 1959. London, 1959
6 National Center for Health Statistics.
8
We have information on fourteen homozygous hypercholesterolsemic patients who have been given portacaval shunts.1-6 Follow-up has ranged between 12 and 30 months. The fall in total cholesterol has averaged about 30%. Of eight patients known to have had angina before surgery five have improved. Electrocardiographic improvement has been noted in one case.4Angiographic evidence of regression of coronary atheroma was found in another.2 This patient who had had a myocardial infarct with sequelae before her operation died 18 ½ months after surgery, possibly from an acute cardiac arrythmia. So far some improvement in xanthomas has been reported in ten patients. In children growth has been satisfactory. Impairment of liver function and hepatic encephalopathy have been reported. The serious nature of this disease warrants extraordinary measures in those patients in whom dietary and drug treatment is unsatisfactory. Portacaval shunting seems to be one such measure. Plasmapheresis7 and a method based on affinity chromatography8 have been used. These-may be alternative or complementary to the surgical procedure. not
A detailed report
on our
patients
will appear elsewhere.
Lipid Disorders Clinic, Johannesburg General Hospital and Transvaal Memorial Hospital for Children, and D. RUSSELL C. MIENY Department of Chemical Pathology, K. W. HEIMANN M. DINNER School of Pathology of South African S. E. LEVIN B. I. JOFFE Institute for Medical Research D. MENDELSOHN and University of Witwatersrand, A. MEGA DE ANDRADE Johannesburg, South Africa H. C. SEFTEL S. LIEBERTHAL Pettifor, J., Heimann, K. W., Mieny, C., Spitz, L., Saaron, I., Bersohn, I., Dinner, M Lancet, 1975, i, 832. 2. Starzl, T. E., Chase, H. P., Putnam, C. W., Nora, J. J. ibid. 1974, ii, 714. 3. Starzl, T. E., Chase, H. P., Putnam, C. W., Nora, J. J., Fennell, R H., Jr., Porter, K. A ibid. p 1263. 4. Cywes, S., Davies, M R. Q., Louw, J. H., Berger, G. M. B., Bonnici, F , Joffe, H. S. S. Afr. med. J. 1976, 50, 239. 5. Krogh, L., Wickens, J. T. ibid. 1974, 48, 2302. 6. Ahrens. E. H., Jr. Personal communication. 7. Thompson, G. R , Lowenthal, R., Myant, N. B. Lancet, 1975, i, 1208. 8. Lupien, P. J., Moorjani, S. , Awad, J. ibid. 1976, i, 1261. 1. Stein, E. A.,
SIR,-Phenytoin has been reported to depress the lymphocyte-count in adults. 1Higashi and others,3 however, found slightly higher counts in phenytoin-treated children than in healthy controls. As part of a larger study, we measured lymphocyte-counts in 17 children (age-range 1 yr 1 mo to 13 yr 9 mo) before and after approximately 6 mo on phenytoin. The mean lymphocyte-count in untreated children was 3070/mm3 (S.E.M.±371) and after treatment was 3235/mm3 (S.E.M.±357). The mean phenytoin level was 6.00 µg/ml. The slight rise in lymphocyteThe mean IgA level fell count was not significant (P>0.05). from 56 to 43 i.u./ml. The only other prospective study4 showed a similar slight rise in lymphocyte-count and a significant fall in serum IgA. IgA-staining B-cells are not depleted in phenytoin-treated IgA-deficient children.5 The difference in lymphocyte-counts in the different series could be due to differences of blood-phenytoin level, since MacKinney and Booker’ found low lymphocyte-counts only in patients whose serum-phenytoin was above the therapeutic range. The other reports did not record drug levels. An alternative explanation is that the epileptics had inherently lower lymphocyte-counts
than the
tional groupings, subcultures, and nations indicate the very small role played by inherited factors. Department of Sociology, College of Sciences and Humanities, Ball State University, Muncie, Indiana 47306, U.S.A.
RICHARD A. BOGG
PORTACAVAL SHUNT FOR HOMOZYGOUS HYPERCHOLESTEROLÆMIA
SIR,-Portacaval shunt operations were done on four homozygous hypercholesterolaemic patients in 1974.1 We report on their status 25-27 months after surgery. The fall in serum-cholesterol has not been impressive (see table). Despite this patients 1, 2, and 4, who had had angina before surgery, now state that this symptom has improved, and patient 2 no longer takes glyceryl trinitrate. Xanthomas have regressed considerably in patients 1, 2, and 4, but there has been little change in patient 3. All the patients feel well, and there have been no occlusive vascular episodes postoperatively. However, in the only patient (no. 2) whose electrocardiogram was abnormal preoperatively, no change has occurred.
(mg/dl)
BEFORE AND AFTER FASTING SERUM-CHOLESTEROL PORTACAVAL SHUNT
healthy subjects.
Cardiff Royal Infirmary, Cardiff CF2 1SZ
J. SEAGER
GENETIC COMPONENT OF OBESITY
SIR,—Dr James and Dr Trayhurn (Oct. 9,, p. 770) argue that the
primary problem in the obese is greater-than-normal efficiency, and that this characteristic may have a genetic component. Such an approach may be appropriate for a small proportion of idiopathic obese, the "hard core" who metabolic
accumulate in metabolic research clinical units and fail to respond even to 1000 kcal diets. But the major factors in obesity must surely be cultural. For example, lower-class women are characteristically heavier than the middle-class women. Two distinctly heavy groups in the U.S. are Black women and White long-distance truck drivers, two groups who find major gratification in food though for different reasons. At Ball State University in Indiana, first-year students report being 3 kg over their personal ideal weight while fourth-year students report being 9 kg overweight. Psychological tension, sedentary living, and a superabundance of high-calorie snack foods are probably more important than inherited defective thermogenic responses in explaining these dramatic increases in collegiate
obesity. U.S.A. youth have become heavier, males in a 1966-70 national sample being 7 kg heavier at age 17 than 17-year-olds in the Iowa Growth Study of the 1950s.67 Compared with Scott’s London County Council data, U.S. males at age 16 are 1 cm taller and 2 kg heavier, but those in the 90th percentile are 5 kg heavier than their London counterparts.8 It would be difficult to make a genetic argument for this greater frequency of obesity. Certainly subject responses to food in clinical settings are highly variable, demonstrating what is well known-that human metabolism is complex and not readily quantified. But the vast differences in obesity between social classes, occupa1. MacKinney, A. A., Booker, H. E. Archs intern. Med. 1972, 129, 988. 2. Brandt, L. , Nilsson, P. G. Lancet, 1976, i, 308. 3. Higashi, A., Ikeda, T., Adaboshi, I., Karashima, S., Miike, T., Matsuda, I. ibid 1976, ii, 44. 4. Sorrell, T. C. , Forbes, I. J. Clin. exp. Immun. 1975, 20, 273. 5. Seager, J., Jamison, D. L., Wilson, J., Hayward, A. R., Soothill, J. F. Lancet, 1975, ii, 632
Height and Weight of Youths 12-17 Years Series ii, no. 124. Washington, D.C., 1973. 7. Nelson, W. E. (editor) Textbook of Pediatrics Philadelphia, 1969. Scott, J. A Report on the Heights and Weights of School Pupils in the County of London in 1959. London, 1959
6 National Center for Health Statistics.
8
We have information on fourteen homozygous hypercholesterolsemic patients who have been given portacaval shunts.1-6 Follow-up has ranged between 12 and 30 months. The fall in total cholesterol has averaged about 30%. Of eight patients known to have had angina before surgery five have improved. Electrocardiographic improvement has been noted in one case.4Angiographic evidence of regression of coronary atheroma was found in another.2 This patient who had had a myocardial infarct with sequelae before her operation died 18 ½ months after surgery, possibly from an acute cardiac arrythmia. So far some improvement in xanthomas has been reported in ten patients. In children growth has been satisfactory. Impairment of liver function and hepatic encephalopathy have been reported. The serious nature of this disease warrants extraordinary measures in those patients in whom dietary and drug treatment is unsatisfactory. Portacaval shunting seems to be one such measure. Plasmapheresis7 and a method based on affinity chromatography8 have been used. These-may be alternative or complementary to the surgical procedure. not
A detailed report
on our
patients
will appear elsewhere.
Lipid Disorders Clinic, Johannesburg General Hospital and Transvaal Memorial Hospital for Children, and D. RUSSELL C. MIENY Department of Chemical Pathology, K. W. HEIMANN M. DINNER School of Pathology of South African S. E. LEVIN B. I. JOFFE Institute for Medical Research D. MENDELSOHN and University of Witwatersrand, A. MEGA DE ANDRADE Johannesburg, South Africa H. C. SEFTEL S. LIEBERTHAL Pettifor, J., Heimann, K. W., Mieny, C., Spitz, L., Saaron, I., Bersohn, I., Dinner, M Lancet, 1975, i, 832. 2. Starzl, T. E., Chase, H. P., Putnam, C. W., Nora, J. J. ibid. 1974, ii, 714. 3. Starzl, T. E., Chase, H. P., Putnam, C. W., Nora, J. J., Fennell, R H., Jr., Porter, K. A ibid. p 1263. 4. Cywes, S., Davies, M R. Q., Louw, J. H., Berger, G. M. B., Bonnici, F , Joffe, H. S. S. Afr. med. J. 1976, 50, 239. 5. Krogh, L., Wickens, J. T. ibid. 1974, 48, 2302. 6. Ahrens. E. H., Jr. Personal communication. 7. Thompson, G. R , Lowenthal, R., Myant, N. B. Lancet, 1975, i, 1208. 8. Lupien, P. J., Moorjani, S. , Awad, J. ibid. 1976, i, 1261. 1. Stein, E. A.,