This case is extremely useful as an illustration of the varying
presentations of phaeochromocytomas. The inclusion of the CT and the
details of the differential effects given depending upon the catecholamine
released were helpful.
I might venture a further, perhaps more important, mediator of the
dramatic drop in K+ noted in this patient and other phaeos. There are a
large number of beta ad...
This case is extremely useful as an illustration of the varying
presentations of phaeochromocytomas. The inclusion of the CT and the
details of the differential effects given depending upon the catecholamine
released were helpful.
I might venture a further, perhaps more important, mediator of the
dramatic drop in K+ noted in this patient and other phaeos. There are a
large number of beta adrenoceptors and sympathetic nerves in the renin-
secreting apparatus of the kidney. Stimulation of these should
precipitate, eventually, a raised aldosterone level and thus a drop in K+
(with an increased Na+). Neither Na+ nor any of the components of this
renin-(ACE)-AGII-Aldosterone axis were measured in the article. I wonder
what any relevant tests actually did show? When discussing how beta-
blockers work in hypertension, this is undoubtedly part of the wider
explanation.
Goldhammer et al (1) concluded from their retrospective study of
patients treated with streptokinase that efficacy was higher in the early
evening hours. There are at least two important confounding variables
which may explain these observations. Firstly, it has been previously
found that the time of day has an impact not only on the incidence, but
also on the severity of AMI (2). Hence, the apparent reduction in
effi...
Goldhammer et al (1) concluded from their retrospective study of
patients treated with streptokinase that efficacy was higher in the early
evening hours. There are at least two important confounding variables
which may explain these observations. Firstly, it has been previously
found that the time of day has an impact not only on the incidence, but
also on the severity of AMI (2). Hence, the apparent reduction in
efficacy of streptokinase during early morning hours may be due to a
greater degree of coronary artery obstruction. The authors adjusted for
the location but not the size of the infarct. Secondly, the higher
success rate in the early evenings compared to early mornings may be
confounded by the fact senior clinicians are more likely to be present and
available in the early evenings than in the early morning hours.
Finally, multiple tests were used in determining the statistical
significance of the success rates at different times of the day.
Appropriate adjustments should be made for multiple tests.
Reference
1) Goldhammer E, Kharash L, Abinader EG. Circadian fluctuations in
the efficacy of thrombolysis with streptokinase. Postgrad Med J 1999; 75:
667-671.
2) Hansen O, Johansson BW, Gullberg B. The clinical outcome of acute
myocardial infarction is related to the circadian rhythm of myocardial
infarction onset. Angiology 1993; 44:7, 509-16.
A 39-year diabetic, for six months had primary hypothyroidism three
years ago, normalized with thyroxine. Seventeen months later he was
hyperthyroid, reversed by carbimazole (30 mg/d) and recurred on stopping.
His thyroid microsomal antibody was positive (1:25,600).
Thyroid disorders were present in 6.9% adult diabetics in Edinburgh
(1). Type 2 diabetes was seen in 7.6% patients with Grave’s thyrotoxicosis
in Ja...
A 39-year diabetic, for six months had primary hypothyroidism three
years ago, normalized with thyroxine. Seventeen months later he was
hyperthyroid, reversed by carbimazole (30 mg/d) and recurred on stopping.
His thyroid microsomal antibody was positive (1:25,600).
Thyroid disorders were present in 6.9% adult diabetics in Edinburgh
(1). Type 2 diabetes was seen in 7.6% patients with Grave’s thyrotoxicosis
in Japan (2).
In our database of endocrine diseases, among 8225 diabetics 73 had
thyroid disorders (0.89%): 65 had hypothyroidism (65/73; 89%), and eight
thyrotoxicosis (8/73;11%). Out of 1777 persons with thyroid disorders 31
had diabetes mellitus (1.74%; 16 had hypothyroidism (51.6%), eight
thyrotoxicosis (25.8%) and seven other conditions.)
Consanguinity (2) , increasing age, when thyroid diseases are
common, and some type 2 diabetic patients being slow-onset type 1 diabetic
were implicated (3).
Hypothyroidism going into hyperthyroidism is unusual. It is likely
due to the switch of blocking antibodies replaced by stimulatory
antibodies to TSH and resultant hyperthyroidism (5).
References:
1. Perros P, McCrimmon RJ, Shaw G, Frier BM. Frequency of thyroid
dysfunction in diabetic patients: value of annual screening. .Diabetic Med
1995;12:622-7
2. Komiya I, Takasu N, Yamada T, Ohara N, Ootsuka H, Ota M, Fukushima
H, Sekikawa A, Tominaga M, Sasaki H. Studies on the association of NIDDM
in Japanese patients with hyperthyroid Grave’s disease. Horm Res
1992;38:264-8
3. Jaworski MA, Slater JD, Severini A, Henning KR, Mansour G, Mehta
JG, Jeske R, Schlaut J, Pak CY, Yoon JW. Unusual clustering of diseases in
a Canadian Old Colony (Chortitza) Mennonite kindred and community. CMAJ
1988;138:1017-25
4. McKenzie JM, Zakarija M. Antibodies in autoimmune thyroid disease.
In Braverman LE, Utiger RD (eds). Werner and
The excellent case report on verrucous carcinoma is not only of value
because of being a "first" on tumours of the female breast (1), but also
of focussing attention on this condition.
A myth was unintentionally started by Perez-Meza in 1966 (2)
when they suggested that there may be a possibility that this tumour could
be aggravated by radiation therapy. This started a misconception which is
still widely believed...
The excellent case report on verrucous carcinoma is not only of value
because of being a "first" on tumours of the female breast (1), but also
of focussing attention on this condition.
A myth was unintentionally started by Perez-Meza in 1966 (2)
when they suggested that there may be a possibility that this tumour could
be aggravated by radiation therapy. This started a misconception which is
still widely believed and propagated in the world literature (2).
Whereas surgery still remains the treatment of choice for small
verrucous carcinoma wherever it may occur, radiotherapy is an acceptable
choice of treatment. However, a dose of 50 Gray in fractions of 2 Gray
treating 5 days a week is not enough to control this disease. Despite
being a low grade malignant lesion which rarely if ever metastasizes the
larger dose of 60 Gray is preferred and is in fact mandatory. The disease
will recur if only 50 Gray is given.
References:
1. Munro RA et.al., PMJ 1999;75:674-675
2. Reinecke L & Thornley A L. Review: Radiotherapy as an effective
treatment for vaginal verrucous carcinoma. Brit J Radiol 1993;66:375-374
Dear Sir,
This case is extremely useful as an illustration of the varying presentations of phaeochromocytomas. The inclusion of the CT and the details of the differential effects given depending upon the catecholamine released were helpful.
I might venture a further, perhaps more important, mediator of the dramatic drop in K+ noted in this patient and other phaeos. There are a large number of beta ad...
Goldhammer et al (1) concluded from their retrospective study of patients treated with streptokinase that efficacy was higher in the early evening hours. There are at least two important confounding variables which may explain these observations. Firstly, it has been previously found that the time of day has an impact not only on the incidence, but also on the severity of AMI (2). Hence, the apparent reduction in effi...
A 39-year diabetic, for six months had primary hypothyroidism three years ago, normalized with thyroxine. Seventeen months later he was hyperthyroid, reversed by carbimazole (30 mg/d) and recurred on stopping. His thyroid microsomal antibody was positive (1:25,600).
Thyroid disorders were present in 6.9% adult diabetics in Edinburgh (1). Type 2 diabetes was seen in 7.6% patients with Grave’s thyrotoxicosis in Ja...
The excellent case report on verrucous carcinoma is not only of value because of being a "first" on tumours of the female breast (1), but also of focussing attention on this condition.
A myth was unintentionally started by Perez-Meza in 1966 (2) when they suggested that there may be a possibility that this tumour could be aggravated by radiation therapy. This started a misconception which is still widely believed...
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