Oct 9, 1991 - varieties which include milkor yoghurt, as does the mild Korma curry. A H HODSON. Coleford Allergy Clinic. The Marshes,. Coleford,.
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Journal of the Royal Society of Medicine Volume 86 February 1993
a week. Primary fibroblast cultures from skin biopsy did not reveal any collagen abnormalities. She had been taking 1.0 g of calcium a day in addition to her diet for the previous 5 years and this was continued. Her serum TSH levels were < 0.1 mU/l with total thyroxine of 220 ng/l, and hence the thyroxine was reduced to 125 tg/day. With this modest reduction, the subsequent TSH levels were between 1 and 2.1 mU/l. The triamsinolone acetamide, which she had been on for 15 years, was reduced and she was gradually, but completely weaned off over the next 2 years. After one year of treatment with calcitonin, parenteral anabolic steroid (decadurabolin 50 mg deep intra-muscular injections given every 3 weeks) was added to the treatment regimen. This was given in a 4 monthly cyclical fashion to minimize the androgenic side effects. In spite of the favourable response to human calcitonin, during the third year of her treatment human calcitonin injections were changed into a nasally administered salmon calcitonin (Miacalcia) 100 IUday due to persistent short-term side effects. Her initial vertebral trabecular bone mineral content (VBMC) measured by quantitative computerized tomography (QCT)3 was only 5 mg/cm3 (normal range 110-220 mg/cm3) which confirmed severe osteoporosis. Figure 1 shows the pre-treatment QCT of 3rd lumbar vertebra of this patient with an age and sex matched control. After one year of therapy VBMC was 16 mg/cm3, end of the second year 22 mg/cm3 and 28 mg/cm3 after 3 years of treatment. QCT was measured using the same software and the same scanner. Furthermore, no new crush fractures occurred since the commencement of treatment for osteoporosis in 1987. More importantly, a marked subjective improvement was seen during this time and she is now able to walk short distances (eg: 400 metres) without assistance and continues her secretarial work.
Letters to the Editor Preference is given to letters commenting on contributions recently published in the JRSM They should not exceed 300 words and should be typed double-spaced.
Inflammatory abdominal aortic aneurysms I read with interest the cases reported by Hennigan et aL (September 1992 JRSM, p 573). They highlight not too infrequent problems encountered in the management of inflnmmatory abdominal aortic aneurysms. Although preoperative steid therapy is now gely accepted as important in achieving symptomatic relief, the rationale for this is still based on a tenuous similarity of the condition to idiopathic retroperitoneal fibrosis'. As the natural history of peri-aortic fibrosis is unknown it is difficult to speculate as to whether the reduction seen following treatment is due to the natural regression of the condition or to therapeutic intervention. Treatment of the obstructed ureter is even more controversial. The statement in the last paragraph suggesting that this should be 'aneurysm repair ... without ureterolysis' is not substantiated in the literature. Whereas the urgent reduction of hydronephrosis by preoperative percutaneous nephrostomy or ureteral
Discussion
There appears to be a causal relationship between ankylosing spondylitis and osteoporosis4. However, her condition was mainly iatrogenic (combination of deep X-ray therapy, antimitotic drugs and long term excessive thyroxine and steroid therapy). Her premature ovarian failure was probably caused by a number of factors, the several courses of radiotherapy and antimitotic drugs given for ankylosing spondylitis combined with a total hysterectomy. Improvements seen in this patient (both subjectively and objectively) are likely to be due to a combination of termination of steroids, reduction of the dose of thyroxine and the initiation of the specific therapies for osteoporosis. Acknowledgment We thank Dr M Pope (Northwick Park Hospital, Harrow) for collagen studies in skin fibroblasts of this patient.
References 1 Conference Report. BMJ 1987;296:914-16 2 MacIntyre I, Stevenson JC, Whitehead MI, Wimalawansa SJ, Banks L, Healy M. Calcitonin for prevention of post-menopausal bone loss. Lancet 1988;ii:900-2 3 Banks LM, Stevenson JC. Modified method of spinal computed tomography for trabecular bone mineral measurements. J Comput Assist Tomogr 1986;10:463-7 4 Resinik D, Niwayama G. Ankylosing Spondylitis. In: Resinik D, Niwayama G, eds. Diagnosis of bone and joint disorders. Philadelphia: WB Saunders, 1988:1104-7
(Accepted 9 October 1991)
stenting is undoubtedly advisable2, several papers also report ureterolysis to be a safe and successful procedure during the course of aneurysm repair3-5. Preservation of renal function is obviously the aim of any procedure on the ureter in this condition and thus, leaving the ureter encased in an inflammatory ma8s, the future progression of which is unknown, would appear to be a situation untenable to the aforementioned principle. A further point of note in the management of the condition is the use of the extraperitoneal approach in the repair of inflammatory abdominal aortic aneurysms. Many surgeons have reported this method to be advantageous in the dissection and control of the aneurysm6. Furthermore, the inflammatory process is least prevalent at the posterolateral aspect of the aorta facilitating access to the neck of the aneurysm without recourse to entering the inflammatory mass7. A K NIGAM Department of Surgery, Rayne Institute University College London, 5 University Street, London WClE 6JJ
References 1 Stotter AT, Grigg MJ, Mansfield AO. The response ofperianeurysmal fibrosis to surgery and steroid therapy. Eur J Vasc Surg 1990;4:201-5 2 Lindblad B, Almgren B, Bergqvist D, et aL Abdominal aortic aneurysms with perianeurysmal fibrosis: experience from 11 Swedish vascular centres. J Vasc Surg 1991; 13:231-7
Journal of the Royal Society of Medicine Volume 86 February 1993 3 Hill J, Charlesworth D. Inflammatory abdinal aortic aneurysms: a report of 37 cases. Ann Vasc Surg 1988;2:352-7 4 Radomski SB, Ameli FM,'Jewett MA. Inflammatory abdominal aortic aneurysms and ureteric obstruction. Can J Surg 1990;33:49-52 l; 5 Boontje AH, Van-den Dungen JJ, Blanksma C. Inflammatory abdominal aortic aneurysms. J Cardiouasc Surg Torino 1990;31:611-16 6 Fiorani P, Faraglia V, Speziale F, et aL Extraperitoneal approach for repair of inflammatory abdominal aortic aneurysm. J Vasc Surg 1991;13:692-7 7 Metcalf RK, Rutherford RB. InflammatQry abdominal aortic aneurysm:: an indication for the retroperitoneal approach. Surgery 1991;109:555-7
Early use of the thermometer Blumenthall in his article concerning the mercury thermometer states that it was first invented by Boulliau in 1659 (September 1992 JRSM, p 553). He suggests that it was 'two centuries later in 1866' that the thermometer was again used by Sir Thomas Ailbut. James Currie MD FRCP(Ein), Fellow of the Royal Society, of Liverpool published 'Medical Reports on the effects of water, cold and warm in fever and febrile diseases' in 1797 (Liverpool, Cadell & Davies). He used a clinical thermometer which he had invented. The medical history section in the Science Museum possesses one of Currie's thermometers. His work became known and Joseph Recamier (1774-1852) advocated Currie's treatment in France. Incidentally, James Currie was the first biographer of Robert Burns. J A Ross Frankby Green, Merseyside L49 1PH
Food sensitivity and epilepsy I was interested to see that the September edition of the Journal contained an editorial as well as articles on the subject of sensitivity to foods (September 1992 JRSMpp 515, 556, 560).. I have beenitrying for oome years to persuade my colleagues that epileptic fits can be induced by certain foods, but this has been met by a profound disinterest. You kindly published a letter from me on the subject of the cause of fits induced by alcohol, in February 1990, and in this I pointed out that organic acids rather than alcohol might -be the cause. The subject studied was my son, whooe epilepsy cannot be controlled by any drug combinations ulnless dietary measures are taken as well. We have found that he is sensitive to all foods containing organic acids such as lemons, apples, totoes, as well as foods which have been exposed to metals in ufacture or processing. For examp, h zed milk (passed through a metal sieve) affects him whereas nonhomogenized milk from,the sesource does not. This suggests that the org acids may act by the now well-established m n ofpromoting absorption of metals. However, he is also sensitive to foods which have apparently been prayed witheinc is. For example, figs bought in hp& hhn, whreas figs eaten straight fromtheltree and unsprayed with chemicals do not affe him. Consequently, he has to take a considerably restricted diet, plus high dose of anti-convulsants to prevent fits. I am sure my son is not unique amongst epileptics.
I have passed on information to another patient with refractory epilepsy, and the same diet has resulted in great reduction in the frequency of his fits. One might think that it would be a simple matter for others to observe the connection between fits and diet, if there was one, but this is. not so. The time interval between food and the fits is some. 1 -24 h, nd this makes it difficult for the connection to be recognized. I feel that it is important that this connection between diet and triggering of fits should be better known to my colleagues. Not only might better control be established in refractory cases, but there might be some clues to better understanding of the condition, and to possible new medication. I therefore hope, you may publish this letter, and-that someone out there might take it seriously and study the subject of diet in relation to epilepsy. 52 Uphill Road G A ROSE Mill Hill, London NW7 4PU
Herbal teas and allergy A publication in The Times on 11 September 1992 about liver damage following the use of herbal remedies coincided with the distribution in September of the Journal of the Royal Society of Medicine in which my discussion paper included herbal 'teas' in the Stone Age Diet (September 1992 JRSM, p 556). Several letters in the Lancet of 12 September 1992 also diuI liver toxicity as a consequence of the use of herbal medicine. The herbal 'teas' as recommended in the Stone Age Diet are in no way comparable with those known to contain active principals which claim to be ofmedical benefit. Herbs have been used for generations as food flavours which simplybecame known from experience mostly by women. They are still used extensively in French traditional cooking. British caterers whose knowledge of flavouring vegetarian dishes seems confined to cheese compare unfavourably. Many herbal flavours are to be found among the weeds which we bestow on our bonfires. They could include plants like Foxglove (Digitalis) but these were not used, presumably from experience. Extensive damage is probably the consequence of selected overuse
possibly enhanced by individual susceptibility. In this clinic patients are advised to try separate herbs and then to make their own mixtures, should they so wish. In this way some patients come up with rare, unexpected reactions. One patient reacted to miut. In4ourast, following removal of masked allergies, tMor coffee are common reactors, but have not beei M-atd to toxicity. A balancebf view is a first essential. Whereas e are reasons to suspect certain herbs which alleged medisl properties, common flavourings hincluding spices seem to be sufficiently safe for me to recommend to my patients occasional Ai curry, subject to the exclusion of Punjabi varieties which include milk or yoghurt, as does the mild Korma curry. A H HODSON Coleford Allergy Clinic The Marshes, Coleford, Glos GL16 8BD
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