- Email: [email protected]
THE SOLITARY THYROID NODULE
870
What clinical conclusions can be drawn? Firstly, methionine29 and acety1cysteine30,31 have already been shown to protect against paracetamol-induced hepatotoxicity provided that they are given within 8-10 h of ingestion of the overdose. Secondly, in all animal studies where cimetidine was purported to afford substantial hepatoprotection, it was given either before or soon after the overdose of paracetamol, and even then it was not always effective. This situation is very different from that encountered in clinical practice where a poisoned patient is unlikely to arrive at hospital for treatment within one or two hours of ingestion of an overdose. In fact, the dose of cimetidine required on the basis of animal work would itself represent an overdose. Thus at present there is no reasonable cause to consider the use of cimetidine in the treatment of paracetamol poisoning. Finally, the differential effect of ranitidine on paracetamol glucuronidation and oxidation merits further investigation in man.
THE SOLITARY THYROID NODULE .
THE solitary thyroid nodule raises fear in the patient and the concern of the doctor that the nodule may be malignant, yet most such nodules are benign. They may be due to simple cysts, degenerative changes, colloid nodules, thyroiditis,
benign or malignant tumours, or occasionally lymphomas, granulomas, and infections. Surgical removal of all solitary nodules will provide a definitive diagnosis but thyroid surgery is not without risk of morbidity and is unnecessary in many cases. Clinical investigations are directed to determine the patient’s thyroid status and the likely cause of the nodule in order to select for operation only those with an increased risk of malignant growth. Symptoms and signs are sought to determine whether the patient is thyrotoxic, euthyroid, or hypothyroid. Factors that increase the likelihood of malignancy include a history of external radiation to the neck, increasing age, male sex, a rapid increase in size of the thyroid nodule, and the presence of lymphadenopathy. It can be difficult on clinical examination alone to determine whether the nodule is truly solitary or multiple, cystic or solid. Multiple small nodules and cystic lesions are more likely to be benign than semi-solid or solid nodules. The tools for further investigation include routine biochemical tests of thyroid function and radioisotope scan, ultrasonic scan, fine-needle aspiration cytology or needle biopsy, and ultimately surgical exploration. A radioisotope scan with short-lived iodine-123 or technetium-99 will indicate whether uptake is concentrated in the nodule with partial or complete suppression of uptake in the surrounding gland, a so-called hot nodule. An isotope scan does not, however, indicate whether a cold nodule is cystic or solid and may not reveal small nodules surrounded _
by normal tissue. The main role of the isotope scan is in the thyrotoxic patient to determine whether the overactivity is due to an autonomous hot nodule or diffuse hyperactivity in the whole gland. The autonomous hot nodule is usually deemed to be benign and is equally effectively treated by surgical removal or radioiodine therapy. The choice depends on the age, suitability, and preference of the patient. Malignant change associated with a hot nodule is rare and further investigations are not usually undertaken before treatment unless there are other suspicious factors that might lead either to biopsy or a preference for surgical removal.’ Ultrasonic scan, which is simple, cheap, and convenient for the patient, is used to distinguish cystic from semi-solid or solid lesions. It does not provide histological evidence of the nature of the lesion but a conservative approach is reasonable when the cyst is small, and particularly if there are more than the one initially evident on clinical palpation.2Malignant however, occur in the wall of a presumed Such changes may be detected by analysis of the simple cyst. sediment obtained by aspiration of the fluid or revealed only by histological examination of the cyst removed at operation. A semi-solid or solid lesion should always be regarded with suspicion until proved benign but, if all such lesions are operated upon, malignant change will be found only in a small proportion. Aspiration cytology by fine-needle biopsy shows a good correlation with the histology of tissue removed at changes
operation. 3,4 The technique requires practice in taking samples and making the smear preparations and the skills of an expert cytologist. Technical failures occur in everyone’s experience but these can be cut to about 5%. The procedure can be repeated since it is well tolerated by the patient and is done in the outpatient clinic. The cytologist can determine that an adequate smear contains normal cells only, cells from benign non-tumourous conditions such as lymphocytic or granulomatous thyroiditis, thyroid hyperplasia, or colloid nodules. In the absence of any suspicious clinical factors the patient can then be reassured that operation is not needed. The cytology report that is indeterminate or suspicious of malignant change should be regarded as an indication to proceed to surgical exploration-in the same way as a report of unequivocal malignancy indicating medullary, papillary, or follicular carcinoma. Anaplastic carcinoma seldom presents as a solitary nodule and is rarely suitable for surgical treatment. A false positive report of malignant change is extremely rare but the rate of false negatives-ie, tissue thought to be benign but found to show malignant change at surgery-is 5-10% in most reported series, even in the hands of experienced cytologists.3-6 This is largely because of the difficulty of distinguishing cells from benign adenoma, atypical adenoma, or low grade follicular carcinoma.4,6 The safe policy is thus to regard all such tissue as neoplastic and advise surgical exploration. The few reports comparing the histology of specimens taken by drill biopsy and fine-needle PP, Wang KW, Sinniah R, et al Thyrotoxicosis and thyroid cancer Aust NZ J Med 1982, 12: 589-93. 2 Walker J, Findlay D, Amar SS, Small PG, Wastie ML, Pegg CAS. A prospective study 1 Yeo
of thyroid ultrasound scan in the clinically solitary thyroid nodule. Br 58: 617-19 3
29. Vale JA, Meredith TJ, Goulding R Treatment of acetaminophen poisoning The use of oral methionine. Arch Intern Med 1981, 141: 394-96. 30 Prescott LF, Illingworth RN, Critchley JAJH, Stewart MJ, Adam RD, Proudfoot AT.
Intravenous N-acetylcysteine: the treatment of choice for paracetamol poisoning. Br Med J 1979, ii: 1097-1100 31. Rumack BH, Peterson RC, Koch GG, Amara IA. Acetaminophen overdose: 662 cases with evaluation of oral acetylcysteine treatment Arch Intern Med 1981; 141: 380-85.
may,
4
J Radiol 1985,
Lowhagen T, Granberg P, Lundell G, Skinnari P, Sundeland R, Willem JS Aspiration biopsy cytology (ABC) in nodules of the thyroid gland suspected to be malignant Surg Clin N Am 1979, 59: 3-18 Lowhagen T, Lunsk JA. Aspiration biopsy cytology of the thyroid gland In Lunsk JA, Franzen S, eds Clinical aspiration cytology Philadelphia Lippincott, 1983 61-83
5
Al-Sayer HM, Krukowski ZH, Williams VMM, Matheson NA. Fine needle aspiration cytology in isolated thyroid swellings: a prospective two year evaluation. Br Med J 1985, 290: 1490-92.
871
aspiration cytology with the outcome of surgical exploration indicate that cytology is more effective as well as being simpler and safer than drill biopsy.6,7 Surgical exploration is thus recommended for those patients whose clinical features indicate a high likelihood of malignant change in the nodule and those with positive or equivocal cytological evidence of malignancy. The extent of surgery will depend on the type of malignancy found and evidence of spread beyond the original nodule.8 Such a selective approach has been shown to reduce the number of patients requiring operation by a quarter or more and to increase the proportion of malignant lesions found at operation to more than 50% in some series. 5,9,10 In centres where large numbers of patients with solitary thyroid nodules are seen and the necessary cytological skills are available, fine-needle aspiration cytology is the most useful investigation in conjunction with clinical assessment to determine the patients to be selected for operation and obviates the need for time-consuming and expensive isotope scans. Where patients with solitary nodules are seen only sporadically and there is no expert cytologist, an ultrasonic scan may help to determine selection policy for surgical intervention. When, however, there is any doubt about the nature of a solitary nodule in the thyroid the only way to alleviate continual worry is to remove the lump.
after resection, the capacity of the left ventricular chamber is too small. The decision on whether to operate need not be much influenced by the presence of critical stenoses of the coronary arteries, since grafts can be inserted with negligible extra risk; of more concern are complex derangements of
function following infarction, including acute acquired ventricular septal defect, mitral incompetence, and possibly unstable ventricular arrhythmias, but even in this more precarious group of patients considerable success is possible. Postoperatively they may need the support of inotropic infusions and even intra-aortic balloon pumping. As the Wessex group make clear, these impressive results have been achieved through refinement of the skills of selection, operative techniques, and postoperative care. Now that such success is possible, we must reflect anew on our approach to ventricular aneurysm and be much more prepared to investigate the patient who is doing badly through cardiac failure, with or without angina, mitral incompetence, cardiac arrhythmias, or signs of ventricular septal defect.
PLASMODIUM FALCIPARUM: A MAJOR HEALTH HAZARD TO AFRICANS AND ASIANS RETURNING HOME LEFT VENTRICULAR ANEURYSM PROXIMAL occlusion of a major coronary artery commonly leads to sudden death; but if we survive, destruction of heart muscle and its replacement with scar tissue can lead to formation of a left ventricular aneurysm. The Wessex Regional Cardiothoracic group have now reported the results of operations on 100 patients with such aneurysms. The lesions were anterior apical or lateral in 85 and inferior in the remainder. Coronary angiography revealed a single coronary lesion in just under half. 97 patients had the aneurysm resected and in 3 it was plicated.1 Additional procedures were mitral valve replacement (11) and coronary bypass (40). Early mortality was 7% and actuarial survival at 5 years was 68%. More than three-quarters of the survivors had good exercise ability when fully recovered from the operations. The Wessex group recognise that some patients with left ventricular aneurysm do very well without intervention. The most important message of their paper is that a patient in congestive heart failure, not fully responsive to drug support, may have a surgically correctable condition. When diagnosis ofleft ventricular aneurysm is suspected yet there are no clues from clinical examination or standard chest X-ray, echocardiography is helpful. The definitive investigation, however, is left ventriculography. Not all patients are operable. The contraction of non-aneurysmal muscle must be satisfactory and the aneurysm must not be so extensive that,
ADVICE on malarial prophylaxis is becoming increasingly difficult to give; the disease is increasing in frequency and, more importantly, increasing numbers of Plasmodium falciparum parasites are now resistant (or partly resistant) to chloroquine and other widely used antimalarial agents. A group of people who are especially difficult to advise are members of the minor ethnic groups within the United Kingdom. They arrive with considerable inherent immunity derived from repeated past infection but, by the time they leave for the land of their birth, either permanently or on holiday, that protection has substantially diminished.2 Student populations, and their families, from Africa and Asia (areas where P falciparum is prevalent) are especially vulnerable; after a stay of two or three years, what should they do as protection against this potentially lethal disease? In hyperimmune adults, malarial antibody can remain high for some years. 3,-1 In children, passive immunity derived from partly immune mothers is thought to last for several months,56 but it is difficult to establish exactly how much protection is derived from this maternal source because in a tropical environment recurrent extrinsic antigenic stimulation begins immediately after birth. Lately, Udezue7 has reported an investigation conducted in London on Nigerian mothers and children born to them in the UK. At birth malarial antibody concentrations, measured by an 1. Editorial Chloroquine resistant malaria in Africa Lancet 1985; i: 1487-88 2 Walker E, Brodie C Plasmodium falciparum in Nigerians who live in Britain
6 Boey J, Hsu C, Wong J, Ong GB Fine needle aspiration versus drill-needle biopsy of thyroid nodules: A controlled clinical trial. Surgery 1982; 91: 611-15. 7 Esselstyn CB,Crile G. Needle aspirationand needle biopsy of the thyroid. World J Surg
3.
1978,2: 321-29 8 Block MA
Surgery
of
thyroid
nodules and
malignancy. Curr Probl Surg 1983; 20:
4
133-203. 9
10
1.
Hamberger B,
Gharib H, Melton CJ, Goellner
JR, Zimsmeister AR Fine needle aspiration biopsy of thyroid nodules. Impact on thyroid practice and cost of care Am J Med 1982, 73: 381-84. Walfish PG,Hazani E,StrawbridgeHTG,Miskin M,RosenIB.Combinedultrasound and needle aspiration cytology in the assessment and management of hypofunctioning thyroid nodule Ann Intern Med 1977, 87: 270-74. Keenan DJM, Monro JL, Ross JK, Manners M, Conway N, Johnson AM. Left ventricular aneurysm Br Heart J 1985, 54: 269-72
5 6
Br Med J 1982; 284: 956-57 Fasan PO, Sulzer AJ, Lobel H, Kagan IB. Indirect fluorescent and haemagglutinating antibodies in Nigerian students resident in Washington DC, USA. Afr J Med Sci 1976, 5: 149-53 Draper CC, Sirr SS Serological investigations in retrospective diagnosis of malaria Br
Med J 1980, 280: 1575-76 McGregor IA, et al. Immunofluorescence and the measurement of immune response to hyperendemic malaria Trans R Soc Trop Med Hyg 1965, 59: 395-414 Molineaux L, Cornille-Brogger R, Mathews HM, Storey J. Longitudinal serological study of malaria in infants in the West African savanna Comparisons in infants exposed to, or protected from, transmission from birth Bull WHO 1978, 56: 573-78
7 Udezue EO Persistence of malarial antibody in Nigerian children born in the UK and its
clinical relevance Trans R Soc
Trop Med Hyg 1985, 79: 427-29
What clinical conclusions can be drawn? Firstly, methionine29 and acety1cysteine30,31 have already been shown to protect against paracetamol-induced hepatotoxicity provided that they are given within 8-10 h of ingestion of the overdose. Secondly, in all animal studies where cimetidine was purported to afford substantial hepatoprotection, it was given either before or soon after the overdose of paracetamol, and even then it was not always effective. This situation is very different from that encountered in clinical practice where a poisoned patient is unlikely to arrive at hospital for treatment within one or two hours of ingestion of an overdose. In fact, the dose of cimetidine required on the basis of animal work would itself represent an overdose. Thus at present there is no reasonable cause to consider the use of cimetidine in the treatment of paracetamol poisoning. Finally, the differential effect of ranitidine on paracetamol glucuronidation and oxidation merits further investigation in man.
THE SOLITARY THYROID NODULE .
THE solitary thyroid nodule raises fear in the patient and the concern of the doctor that the nodule may be malignant, yet most such nodules are benign. They may be due to simple cysts, degenerative changes, colloid nodules, thyroiditis,
benign or malignant tumours, or occasionally lymphomas, granulomas, and infections. Surgical removal of all solitary nodules will provide a definitive diagnosis but thyroid surgery is not without risk of morbidity and is unnecessary in many cases. Clinical investigations are directed to determine the patient’s thyroid status and the likely cause of the nodule in order to select for operation only those with an increased risk of malignant growth. Symptoms and signs are sought to determine whether the patient is thyrotoxic, euthyroid, or hypothyroid. Factors that increase the likelihood of malignancy include a history of external radiation to the neck, increasing age, male sex, a rapid increase in size of the thyroid nodule, and the presence of lymphadenopathy. It can be difficult on clinical examination alone to determine whether the nodule is truly solitary or multiple, cystic or solid. Multiple small nodules and cystic lesions are more likely to be benign than semi-solid or solid nodules. The tools for further investigation include routine biochemical tests of thyroid function and radioisotope scan, ultrasonic scan, fine-needle aspiration cytology or needle biopsy, and ultimately surgical exploration. A radioisotope scan with short-lived iodine-123 or technetium-99 will indicate whether uptake is concentrated in the nodule with partial or complete suppression of uptake in the surrounding gland, a so-called hot nodule. An isotope scan does not, however, indicate whether a cold nodule is cystic or solid and may not reveal small nodules surrounded _
by normal tissue. The main role of the isotope scan is in the thyrotoxic patient to determine whether the overactivity is due to an autonomous hot nodule or diffuse hyperactivity in the whole gland. The autonomous hot nodule is usually deemed to be benign and is equally effectively treated by surgical removal or radioiodine therapy. The choice depends on the age, suitability, and preference of the patient. Malignant change associated with a hot nodule is rare and further investigations are not usually undertaken before treatment unless there are other suspicious factors that might lead either to biopsy or a preference for surgical removal.’ Ultrasonic scan, which is simple, cheap, and convenient for the patient, is used to distinguish cystic from semi-solid or solid lesions. It does not provide histological evidence of the nature of the lesion but a conservative approach is reasonable when the cyst is small, and particularly if there are more than the one initially evident on clinical palpation.2Malignant however, occur in the wall of a presumed Such changes may be detected by analysis of the simple cyst. sediment obtained by aspiration of the fluid or revealed only by histological examination of the cyst removed at operation. A semi-solid or solid lesion should always be regarded with suspicion until proved benign but, if all such lesions are operated upon, malignant change will be found only in a small proportion. Aspiration cytology by fine-needle biopsy shows a good correlation with the histology of tissue removed at changes
operation. 3,4 The technique requires practice in taking samples and making the smear preparations and the skills of an expert cytologist. Technical failures occur in everyone’s experience but these can be cut to about 5%. The procedure can be repeated since it is well tolerated by the patient and is done in the outpatient clinic. The cytologist can determine that an adequate smear contains normal cells only, cells from benign non-tumourous conditions such as lymphocytic or granulomatous thyroiditis, thyroid hyperplasia, or colloid nodules. In the absence of any suspicious clinical factors the patient can then be reassured that operation is not needed. The cytology report that is indeterminate or suspicious of malignant change should be regarded as an indication to proceed to surgical exploration-in the same way as a report of unequivocal malignancy indicating medullary, papillary, or follicular carcinoma. Anaplastic carcinoma seldom presents as a solitary nodule and is rarely suitable for surgical treatment. A false positive report of malignant change is extremely rare but the rate of false negatives-ie, tissue thought to be benign but found to show malignant change at surgery-is 5-10% in most reported series, even in the hands of experienced cytologists.3-6 This is largely because of the difficulty of distinguishing cells from benign adenoma, atypical adenoma, or low grade follicular carcinoma.4,6 The safe policy is thus to regard all such tissue as neoplastic and advise surgical exploration. The few reports comparing the histology of specimens taken by drill biopsy and fine-needle PP, Wang KW, Sinniah R, et al Thyrotoxicosis and thyroid cancer Aust NZ J Med 1982, 12: 589-93. 2 Walker J, Findlay D, Amar SS, Small PG, Wastie ML, Pegg CAS. A prospective study 1 Yeo
of thyroid ultrasound scan in the clinically solitary thyroid nodule. Br 58: 617-19 3
29. Vale JA, Meredith TJ, Goulding R Treatment of acetaminophen poisoning The use of oral methionine. Arch Intern Med 1981, 141: 394-96. 30 Prescott LF, Illingworth RN, Critchley JAJH, Stewart MJ, Adam RD, Proudfoot AT.
Intravenous N-acetylcysteine: the treatment of choice for paracetamol poisoning. Br Med J 1979, ii: 1097-1100 31. Rumack BH, Peterson RC, Koch GG, Amara IA. Acetaminophen overdose: 662 cases with evaluation of oral acetylcysteine treatment Arch Intern Med 1981; 141: 380-85.
may,
4
J Radiol 1985,
Lowhagen T, Granberg P, Lundell G, Skinnari P, Sundeland R, Willem JS Aspiration biopsy cytology (ABC) in nodules of the thyroid gland suspected to be malignant Surg Clin N Am 1979, 59: 3-18 Lowhagen T, Lunsk JA. Aspiration biopsy cytology of the thyroid gland In Lunsk JA, Franzen S, eds Clinical aspiration cytology Philadelphia Lippincott, 1983 61-83
5
Al-Sayer HM, Krukowski ZH, Williams VMM, Matheson NA. Fine needle aspiration cytology in isolated thyroid swellings: a prospective two year evaluation. Br Med J 1985, 290: 1490-92.
871
aspiration cytology with the outcome of surgical exploration indicate that cytology is more effective as well as being simpler and safer than drill biopsy.6,7 Surgical exploration is thus recommended for those patients whose clinical features indicate a high likelihood of malignant change in the nodule and those with positive or equivocal cytological evidence of malignancy. The extent of surgery will depend on the type of malignancy found and evidence of spread beyond the original nodule.8 Such a selective approach has been shown to reduce the number of patients requiring operation by a quarter or more and to increase the proportion of malignant lesions found at operation to more than 50% in some series. 5,9,10 In centres where large numbers of patients with solitary thyroid nodules are seen and the necessary cytological skills are available, fine-needle aspiration cytology is the most useful investigation in conjunction with clinical assessment to determine the patients to be selected for operation and obviates the need for time-consuming and expensive isotope scans. Where patients with solitary nodules are seen only sporadically and there is no expert cytologist, an ultrasonic scan may help to determine selection policy for surgical intervention. When, however, there is any doubt about the nature of a solitary nodule in the thyroid the only way to alleviate continual worry is to remove the lump.
after resection, the capacity of the left ventricular chamber is too small. The decision on whether to operate need not be much influenced by the presence of critical stenoses of the coronary arteries, since grafts can be inserted with negligible extra risk; of more concern are complex derangements of
function following infarction, including acute acquired ventricular septal defect, mitral incompetence, and possibly unstable ventricular arrhythmias, but even in this more precarious group of patients considerable success is possible. Postoperatively they may need the support of inotropic infusions and even intra-aortic balloon pumping. As the Wessex group make clear, these impressive results have been achieved through refinement of the skills of selection, operative techniques, and postoperative care. Now that such success is possible, we must reflect anew on our approach to ventricular aneurysm and be much more prepared to investigate the patient who is doing badly through cardiac failure, with or without angina, mitral incompetence, cardiac arrhythmias, or signs of ventricular septal defect.
PLASMODIUM FALCIPARUM: A MAJOR HEALTH HAZARD TO AFRICANS AND ASIANS RETURNING HOME LEFT VENTRICULAR ANEURYSM PROXIMAL occlusion of a major coronary artery commonly leads to sudden death; but if we survive, destruction of heart muscle and its replacement with scar tissue can lead to formation of a left ventricular aneurysm. The Wessex Regional Cardiothoracic group have now reported the results of operations on 100 patients with such aneurysms. The lesions were anterior apical or lateral in 85 and inferior in the remainder. Coronary angiography revealed a single coronary lesion in just under half. 97 patients had the aneurysm resected and in 3 it was plicated.1 Additional procedures were mitral valve replacement (11) and coronary bypass (40). Early mortality was 7% and actuarial survival at 5 years was 68%. More than three-quarters of the survivors had good exercise ability when fully recovered from the operations. The Wessex group recognise that some patients with left ventricular aneurysm do very well without intervention. The most important message of their paper is that a patient in congestive heart failure, not fully responsive to drug support, may have a surgically correctable condition. When diagnosis ofleft ventricular aneurysm is suspected yet there are no clues from clinical examination or standard chest X-ray, echocardiography is helpful. The definitive investigation, however, is left ventriculography. Not all patients are operable. The contraction of non-aneurysmal muscle must be satisfactory and the aneurysm must not be so extensive that,
ADVICE on malarial prophylaxis is becoming increasingly difficult to give; the disease is increasing in frequency and, more importantly, increasing numbers of Plasmodium falciparum parasites are now resistant (or partly resistant) to chloroquine and other widely used antimalarial agents. A group of people who are especially difficult to advise are members of the minor ethnic groups within the United Kingdom. They arrive with considerable inherent immunity derived from repeated past infection but, by the time they leave for the land of their birth, either permanently or on holiday, that protection has substantially diminished.2 Student populations, and their families, from Africa and Asia (areas where P falciparum is prevalent) are especially vulnerable; after a stay of two or three years, what should they do as protection against this potentially lethal disease? In hyperimmune adults, malarial antibody can remain high for some years. 3,-1 In children, passive immunity derived from partly immune mothers is thought to last for several months,56 but it is difficult to establish exactly how much protection is derived from this maternal source because in a tropical environment recurrent extrinsic antigenic stimulation begins immediately after birth. Lately, Udezue7 has reported an investigation conducted in London on Nigerian mothers and children born to them in the UK. At birth malarial antibody concentrations, measured by an 1. Editorial Chloroquine resistant malaria in Africa Lancet 1985; i: 1487-88 2 Walker E, Brodie C Plasmodium falciparum in Nigerians who live in Britain
6 Boey J, Hsu C, Wong J, Ong GB Fine needle aspiration versus drill-needle biopsy of thyroid nodules: A controlled clinical trial. Surgery 1982; 91: 611-15. 7 Esselstyn CB,Crile G. Needle aspirationand needle biopsy of the thyroid. World J Surg
3.
1978,2: 321-29 8 Block MA
Surgery
of
thyroid
nodules and
malignancy. Curr Probl Surg 1983; 20:
4
133-203. 9
10
1.
Hamberger B,
Gharib H, Melton CJ, Goellner
JR, Zimsmeister AR Fine needle aspiration biopsy of thyroid nodules. Impact on thyroid practice and cost of care Am J Med 1982, 73: 381-84. Walfish PG,Hazani E,StrawbridgeHTG,Miskin M,RosenIB.Combinedultrasound and needle aspiration cytology in the assessment and management of hypofunctioning thyroid nodule Ann Intern Med 1977, 87: 270-74. Keenan DJM, Monro JL, Ross JK, Manners M, Conway N, Johnson AM. Left ventricular aneurysm Br Heart J 1985, 54: 269-72
5 6
Br Med J 1982; 284: 956-57 Fasan PO, Sulzer AJ, Lobel H, Kagan IB. Indirect fluorescent and haemagglutinating antibodies in Nigerian students resident in Washington DC, USA. Afr J Med Sci 1976, 5: 149-53 Draper CC, Sirr SS Serological investigations in retrospective diagnosis of malaria Br
Med J 1980, 280: 1575-76 McGregor IA, et al. Immunofluorescence and the measurement of immune response to hyperendemic malaria Trans R Soc Trop Med Hyg 1965, 59: 395-414 Molineaux L, Cornille-Brogger R, Mathews HM, Storey J. Longitudinal serological study of malaria in infants in the West African savanna Comparisons in infants exposed to, or protected from, transmission from birth Bull WHO 1978, 56: 573-78
7 Udezue EO Persistence of malarial antibody in Nigerian children born in the UK and its
clinical relevance Trans R Soc
Trop Med Hyg 1985, 79: 427-29