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SERUM INSULIN AND ANTIBODY LEVELS IN PATIENTS ON INSULIN
931 Her temperature remained her sedimentation-rate fell to 40 mm. in the lst hour. The marrow biopsy was sterile. 15 months after discharge the patient was readmitted because of high temperature, fatigue, lack of appetite, and pains in the joints and muscles. Laboratory results were similar to those during the first admission except that a muscle-biopsy specimen showed that she had dermatomyositis. Treatment with prednisone and indomethacin
rifampicin for four more weeks. normal, she gained weight, and
was
Novo Research Institute,
Copenhagen, Denmark.
SCHLICHTKRULL AA. HEIN CHRISTIANSEN L. G. HEDING.
J.
successful.
In view of this diagnosis, it is hard to explain the prompt drop in temperature and remission of symptoms previously obtained with rifampicin. We suggest that the remission was due to an immunosuppressant property of rifampicin. Infection Clinic of Medical Faculty, University in Ljubljana MAROLT-GOMIŠČEK MARIJA. Japljeva 2, Yugoslavia.
ABSENCE OF R.D.S. IN CHILDREN OF HEROIN-ADDICTED MOTHERS
SIR,-Dr. Glass and his associates (Sept. 25, p. 685) do give probability values for the likelihood of their observations representing random phenomena. May I offer the probability values that I feel should have been included in that paper? Based on the data of Dr. Glass and his associates, the probability that an infant of 32-33 weeks gestational age will not have respiratory distress syndrome (R.D.S.) is 12/26. The probability that each of not
6 infants in this age-group will not have R.D.s. is therefore (12/26)6=0.00985. Of the 39 infants of gestational age 34-35 weeks, 31 did not have R.D.S. The probability that each of 9 infants in this age-group will not have R.D.S. is (31/39)9= 0.125. Children’s Hospital Medical Center, Boston, Mass. 02115, U.S.A.
ALAN LEVITON.
SERUM INSULIN AND ANTIBODY LEVELS IN PATIENTS ON INSULIN
SIR,-Further to the letter of Dr. Quickel and Dr. Feld(July 24, p. 212) and the letter of Dr. Reeves (Aug. 28, p. 490), our results may serve to elucidate some points at issue. In the insulin-treated diabetic, the serum-immunoreactive-insulin (I.R.I) can stay within normal limits even after years of treatment-e.g., when non-immunogenic insulin preparations are used for therapy and no antibodies are formed. Along with the development of insulin antiman
bodies in the
course
of treatment with conventional insulin
preparations there is a rise in total (i.e., acid/ethanolextractable) serum insulin, which may reach levels of several thousand (iu per ml. These high amounts of insulin are partly " bound " and partly " free ".1 The "free" insulin is, however, not free in the sense that it is present in the same state as before the development of antibodies; most of it is bound to serum-proteins that are not immunoglobulins.2 These proteins may be albumin, a2-macroglobulin, and &bgr;-lipoprotein.3The question is open whether or not the very high levels of such " free " insulin, and, for that matter, also the antibody-bound insulin, may exert an effect in the walls of the blood-vessels and perhaps in the liver without having any noticeable blood-sugarlowering effect. The induction of antibodies and unphysiological levels of serum-insulin can be considered as undesirable side-effects. To the best of our knowledge, it has never been demonstrated that a change of insulin dose 1. 2.
would cause a change in the antibody level. The only means at present to keep the serum-insulin in a normal state and at normal levels (by avoiding insulin antibodies) is the use of non-immunogenic insulin preparations-the socalled monocomDonent insulin.4
Heding, L. G. Horm. Metab. Res. 1969, 1, 145. Heding, L. G. Unpublished. 3. Christiansen, Aa. H., Volund, Aa. Paper read at the 7th Annual Meeting of European Association for the Study of Diabetes, Southampton, 1971.
CONTINUOUS ASSESSMENT SIR,-It is easy to understand the irritation engendered by your editorial, College Capers (Sept. 11, p. 587). That perhaps it contained some good advice cannot be denied, but in writing it you have shown, besides a lack of objectivity, a penchant for gratuitous admonition. I should like to call to question several of your " ex cathedra " pronouncements. Firstly, that in which you maintain, " Nowadays most medical educators, even in the United Kingdom, concede that formal examinations as steps towards specialist appointments are on the way out ". The tenor of this statement implies that medical educators in the United Kingdom are far more reactionary than their counterparts elsewhere. This is far from the truth. Just where in the world are formal examinations on the way out ? Certainly not in the U.S.A. or Canada, where specialty boards with formal examinations are being spawned at the same rate as children in China. Here, if present trends continue, we shall have distinct large and small bowel specialty boards. For your information, the examinations for specialty boards in the U.S.A. are taken after completion of a required period of training-not before-and in this I agree they could learn from the Royal College of Physicians. Secondly, the choice of the term " medical educator " is rather unfortunate, since in the U.S.A. " medical educators " are looked upon as a bit of a joke. The term here is reserved for those physicians who lead a peripatetic life, flitting from one convention to another and speaking in a jargon that virtually no one else understands. It is easy to understand why they are not known as teachers, since this is the one activity in which they are not engaged. Perhaps this pest has taken hold in Britain as well. Next, your general denunciation of examinations is to be deplored. They still remain the only way of objectively assessing knowledge and proficiency. A good examination pits a candidate against accepted standards of knowledge; moreover, it is objective and impartial. The alternative to formal examinations is " continuous course (coarse might be more descriptive) assessment ". It is this system that prevails in undergraduate education in America, and let me assure you that it is fertile breeding ground of prejudice and partiality; conformity and mediocrity become the criteria for success; originality and independence are suffocated. Those of us who have experienced both routines would prefer to be objectively assessed by an examination rather than left to the mercy of the whims and peculiarities of one’s superior. That examinations have in the past often been lacking in objectivity none can deny, but surely this is a reason for reform, not euthanasia. The " connew Royal College would be ill advised to rely on Or do you believe that tinuous course assessment". psychiatrists should be exempt from demonstrating their proficiency ? Surely the general public is entitled to some
safeguards. Finally, you would imply that every word of the Todd Report is sacrosanct. In this context, it is salutary to recall the errors of an earlier Government-sponsored report which, shortly after the war, recommended either holding 4.
Schlichtkrull, J. Paper read
at
the 7th Annual Meeting of the
European Association for the Study of Diabetes, Southampton, 1971.
rifampicin for four more weeks. normal, she gained weight, and
was
Novo Research Institute,
Copenhagen, Denmark.
SCHLICHTKRULL AA. HEIN CHRISTIANSEN L. G. HEDING.
J.
successful.
In view of this diagnosis, it is hard to explain the prompt drop in temperature and remission of symptoms previously obtained with rifampicin. We suggest that the remission was due to an immunosuppressant property of rifampicin. Infection Clinic of Medical Faculty, University in Ljubljana MAROLT-GOMIŠČEK MARIJA. Japljeva 2, Yugoslavia.
ABSENCE OF R.D.S. IN CHILDREN OF HEROIN-ADDICTED MOTHERS
SIR,-Dr. Glass and his associates (Sept. 25, p. 685) do give probability values for the likelihood of their observations representing random phenomena. May I offer the probability values that I feel should have been included in that paper? Based on the data of Dr. Glass and his associates, the probability that an infant of 32-33 weeks gestational age will not have respiratory distress syndrome (R.D.S.) is 12/26. The probability that each of not
6 infants in this age-group will not have R.D.s. is therefore (12/26)6=0.00985. Of the 39 infants of gestational age 34-35 weeks, 31 did not have R.D.S. The probability that each of 9 infants in this age-group will not have R.D.S. is (31/39)9= 0.125. Children’s Hospital Medical Center, Boston, Mass. 02115, U.S.A.
ALAN LEVITON.
SERUM INSULIN AND ANTIBODY LEVELS IN PATIENTS ON INSULIN
SIR,-Further to the letter of Dr. Quickel and Dr. Feld(July 24, p. 212) and the letter of Dr. Reeves (Aug. 28, p. 490), our results may serve to elucidate some points at issue. In the insulin-treated diabetic, the serum-immunoreactive-insulin (I.R.I) can stay within normal limits even after years of treatment-e.g., when non-immunogenic insulin preparations are used for therapy and no antibodies are formed. Along with the development of insulin antiman
bodies in the
course
of treatment with conventional insulin
preparations there is a rise in total (i.e., acid/ethanolextractable) serum insulin, which may reach levels of several thousand (iu per ml. These high amounts of insulin are partly " bound " and partly " free ".1 The "free" insulin is, however, not free in the sense that it is present in the same state as before the development of antibodies; most of it is bound to serum-proteins that are not immunoglobulins.2 These proteins may be albumin, a2-macroglobulin, and &bgr;-lipoprotein.3The question is open whether or not the very high levels of such " free " insulin, and, for that matter, also the antibody-bound insulin, may exert an effect in the walls of the blood-vessels and perhaps in the liver without having any noticeable blood-sugarlowering effect. The induction of antibodies and unphysiological levels of serum-insulin can be considered as undesirable side-effects. To the best of our knowledge, it has never been demonstrated that a change of insulin dose 1. 2.
would cause a change in the antibody level. The only means at present to keep the serum-insulin in a normal state and at normal levels (by avoiding insulin antibodies) is the use of non-immunogenic insulin preparations-the socalled monocomDonent insulin.4
Heding, L. G. Horm. Metab. Res. 1969, 1, 145. Heding, L. G. Unpublished. 3. Christiansen, Aa. H., Volund, Aa. Paper read at the 7th Annual Meeting of European Association for the Study of Diabetes, Southampton, 1971.
CONTINUOUS ASSESSMENT SIR,-It is easy to understand the irritation engendered by your editorial, College Capers (Sept. 11, p. 587). That perhaps it contained some good advice cannot be denied, but in writing it you have shown, besides a lack of objectivity, a penchant for gratuitous admonition. I should like to call to question several of your " ex cathedra " pronouncements. Firstly, that in which you maintain, " Nowadays most medical educators, even in the United Kingdom, concede that formal examinations as steps towards specialist appointments are on the way out ". The tenor of this statement implies that medical educators in the United Kingdom are far more reactionary than their counterparts elsewhere. This is far from the truth. Just where in the world are formal examinations on the way out ? Certainly not in the U.S.A. or Canada, where specialty boards with formal examinations are being spawned at the same rate as children in China. Here, if present trends continue, we shall have distinct large and small bowel specialty boards. For your information, the examinations for specialty boards in the U.S.A. are taken after completion of a required period of training-not before-and in this I agree they could learn from the Royal College of Physicians. Secondly, the choice of the term " medical educator " is rather unfortunate, since in the U.S.A. " medical educators " are looked upon as a bit of a joke. The term here is reserved for those physicians who lead a peripatetic life, flitting from one convention to another and speaking in a jargon that virtually no one else understands. It is easy to understand why they are not known as teachers, since this is the one activity in which they are not engaged. Perhaps this pest has taken hold in Britain as well. Next, your general denunciation of examinations is to be deplored. They still remain the only way of objectively assessing knowledge and proficiency. A good examination pits a candidate against accepted standards of knowledge; moreover, it is objective and impartial. The alternative to formal examinations is " continuous course (coarse might be more descriptive) assessment ". It is this system that prevails in undergraduate education in America, and let me assure you that it is fertile breeding ground of prejudice and partiality; conformity and mediocrity become the criteria for success; originality and independence are suffocated. Those of us who have experienced both routines would prefer to be objectively assessed by an examination rather than left to the mercy of the whims and peculiarities of one’s superior. That examinations have in the past often been lacking in objectivity none can deny, but surely this is a reason for reform, not euthanasia. The " connew Royal College would be ill advised to rely on Or do you believe that tinuous course assessment". psychiatrists should be exempt from demonstrating their proficiency ? Surely the general public is entitled to some
safeguards. Finally, you would imply that every word of the Todd Report is sacrosanct. In this context, it is salutary to recall the errors of an earlier Government-sponsored report which, shortly after the war, recommended either holding 4.
Schlichtkrull, J. Paper read
at
the 7th Annual Meeting of the
European Association for the Study of Diabetes, Southampton, 1971.