silver straw, at very hot tempera(chimarr\l=a~\o).I think, as do some Brazilian surgeons (G. V. Artigas, MD, F. C. Becker, MD, unpublished data), that the high temperature of the tea and the assiduity of the habit (daily for many years) account, at least in part, for the prevalence of cancer of the esophagus in these a
ture
Selected Characteristics of Black Physicians in the United States, 1972 To the Editor.\p=m-\Anarticle by Theodis Thompson, PhD, in the Sept 23 issue of The Journal (229:1758, 1974) is of some concern to this office. The article, "Selected Characteristics of Black Physicians in the United States, 1972," is based on findings from a survey sponsored by this office. However, we did not see the article prior to its publication. Dr. Thompson states in the article that the findings are based on a sample survey. This statement is wholly inaccurate, and tends to give the findings greater significance than we believe is warranted. A lowerthan-hoped-for response in a pretest led to a decision to mail questionnaires in the final survey to the identifiable universe of about 5,800 black physicians. Usable responses were obtained from only 3,405 physicians who identified themselves as black, so that the findings are subject to considerable overall nonresponse bias, in addition to the serious bias stemming from the lack of response from interns and residents that was men¬ tioned by Dr. Thompson. I think that your readers should be made aware of the limitations of these data so that they may avoid
making
generalizations physicians in the United
erroneous
about black States.
Howard V. Stambler Bureau of Health Resources
Development Department of Health,
the number of physicians by states, for example, should not be considered the actual number of physicians, but the number of physicians responding to the particular survey from a given
state. I agree with Mr. Stambler that the data reported should not be used for
inferences about the characteristics of black physicians in the United States in 1972. However, the data tables used in the study were generated by the programming division of the Bureau of Health Resources Development for the National Medical Association (NMA) Founda¬ tion while I was acting director of the Office of Research and Evaluation. It should also be pointed out that I wrote only the final report for this study. Therefore, I had to rely on ex¬ isting project records and discussions with the former project director, pro¬ grammers, and the then deputy direc¬ tor of the NMA Foundation for an¬ swers to many questions. Mrs. Ruth Crocker of the Resource Analysis Staff, Bureau of Health Resources Development, and Mr. William Wil¬ liams of that division were very help¬ ful in generating data tables. Unfor¬ tunately, I was under the impression from the parties concerned that the NMA Foundation had permission to utilize the data even though the Bu¬ reau of Health Resources Develop¬ ment had the data tapes. Never¬ theless, Mr. Stambler's observations are important in assuring the reduc¬ tion in continuing misinterpretation of statistical data.
making
erroneous
US
Theodis Thompson, PhD
Education, and Welfare
Washington, DC
Bethesda, Md
To the Editor.\p=m-\Theletter by Mr. Stambler points out two observations that I have made in subsequent discussions about my article: (1) The data reported are not generalizable to the universe of black physicians in the United States. (2) The pretest, phase 1, was a stratified sample (p 1758); phase 2, the universe study, (by
definition)
was
not
a
sample study.
The findings reported are based on the responses to 3,405 usable, mailed questionnaires. Moreover, data for Edited
by John D. Archer, MD, Senior Editor.
Etiological
and Environmental
Factors
To the Editor.\p=m-\Aboutthe article by Wynder and Mabuchi, "Etiological and Environmental Factors," concerning esophageal cancer (226:1546, 1973), I would like to report that in some areas of my country, especially in the south states, such as Para\l=n~\\l=a'\, Santa Catarina, and Rio Grande do Sul, some cases of cancer of the esophagus are related with the habit many people have of drinking mat\l=e'\ tea without sugar, in a gourd through
Downloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User on 06/08/2015
people.
Waldomiro Dantas, MD Universidade Federal de
Santa Catarina
Florian\l=o'\polis,Brazil
The Treatment of Graves Disease To the Editor.\p=m-\Ina letter by Caswell and Maier (227:939, 1974) on the treatment of Graves disease, the authors conclude that the advantages of surgical treatment over radioactive iodine therapy and antithyroid drug treatment ensure that it will continue to be the standard by which other treatment methods are measured. They studied 72 patients with previous subtotal thyroidectomy for Graves disease and found a low incidence of postoperative hypothyroidism (10%) as well as a low incidence of recurrent hyperthyroidism (6%).1 In support of this view, Griffiths et al,2 studying 55 thyrotoxic patients fol-
lowing thyroidectomy, recently reported an 11% incidence of hypothyroidism
and
3.5% incidence of Successful treatment with radioactive iodine, on the other hand, is accompanied by an incidence of hypothyroidism of between 30% and 70% by 10 to 20 years of followrecurrence.
up.3
It should be pointed out, however, that all studies are not in agreement with the authors' reported low incidence of postsurgical hypothyroidism. In a series by Michie et al," in which 278 patients with hyperthyroidism treated with partial thyroidectomy were studied prospectively over a seven-year period, the overall inci¬ dence of hypothyroidism was 49%. The occurrence of hypothyroidism de¬ creased significantly as the remnant size left at operation was increased. However, increasing remnant size does not abolish hypothyroidism. Among patients with remnant size of 8 to 10 gm, the incidence of hypothy¬ roidism was 30% and introduced the hazard of thyrotoxic recurrence. Nofal et al5 likewise found an incidence of postoperative hypothyroidism of 43% after ten years of follow-up. Thus it would appear that surgery,
like radioactive iodine and antithyroid drugs, has certain advantages and disadvantages in the treatment of hyperthyroidism and that the ther¬ apy recommended should be tailored to each individual patient. Frank O. Becker, MD Steven G. Economou, MD
Rush-Presbyterian-St. Luke's Medical Center
Chicago 1. Caswell
HT, Maier WP: Results of surgical treatment for hyperthyroidism. Surg Gynecol Obstet 134:218\x=req-\ 220, 1972. 2. Griffiths NJ, Murley RS, Gulin R, et al. Thyroid function following partial thyroidectomy. Br J Surg 61:626-632, 1974. 3. Hagen GA: Treatment of thyrotoxicosis with 131-I and post-therapy hypothyroidism. Med Clin North Am 52:417-421, 1968. 4. Michie W, Pegg CAS, Beirsher PD: Prediction of hypothyroidism after partial thyroidectomy for thyrotoxicosis. Br Med J 1:13-17, 1972. 5. Nofal MM, Bierwaltes WH, Patno ME: Treatment of hyperthyroidism with sodium iodide I 131: A 16-year experience. JAMA 197:605-610, 1966.
Hypothyroidism and Stress To the Editor.\p=m-\Therecent report by
Mataverde et al (230:1014, 1974) is
in pointing out a commonly encountered but not well recognized problem. A less common problem, but one that may have been a factor in the case presented, is the exacerbation of hypothyroidism during periods of stress. An early report1 describes five patients who developed "acute myxedema" following pneumonia. Subsequent work2 has shown that during stress thyroxine (T4) turnover is increased fivefold while plasma T4 levels were maintained within normal limits, thus suggesting an increase in T4 secretory rate. It was thought that the increased turnover was the result of an increase in free T, caused by a decrease in thyroxine-binding prealbumin (TBPA). More recent work3 has confirmed that TBPA does indeed decrease with acute infections, but this was dissociated in time from changes in free T4. It was concluded that the alterations in free T4 with stress (which increased T4 turnover) was due to an inhibition of T4 bind¬
timely
ing. Regardless of its cause, the rapid T4 turnover during stress could have important clinical consequences in the hypothyroid patient whose gland is already secreting maximally.2 The routine prophylactic use of levothyroxine sodium in patients with fixed T4 outputs cannot yet be recommended, and certainly does not approach the addisonian in clinical importance. However, the possibility of an inade¬ quate
response to stress associated
with a worsening hypothyroid state should be kept in mind, especially in the hypothyroid patient who has not
yet begun levothyroxine therapy.
Elliott Eisenbud, MD University of California at Davis 1. Hausmann W, Karlish AJ: Acute myxoedema precipitated by pneumonia. Br Med J 2:1063-1065, 1961. 2. Gregerman RI, Solomon N: Acceleration of thyroxine and triiodothyronine turnover during bacterial pulmonary infections and fever. J Clin Endocrinol Metab
27:93-104, 1967. 3. Lutz JH, Gregerman RI, et al: Thyroxine-binding proteins and thyroxine turnover interrelationships during acute infectious illness in man. J Clin Endocrinol Metab 35:230-249, 1972.
Radionuclide Detection of Metastatic Calcification To the Editor.\p=m-\The article "Radionuclide Detection of Diffuse Interstitial Pulmonary Calcification" (230:992, 1974) was of special interest to me since it coincided with my report of a similar case in the Journal of Nuclear Medicine (15:1057, 1974). My patient, who had hypercalcemia, hyperphosphatemia, and renal failure in association with a poorly differentiated malignancy of the bone marrow showed a dense and diffuse uptake of technetium 99m-labelled polyphosphate throughout the lungs and stomach during the course of a bone scan. Calcification of the stomach and kidneys was proven histologically on tissues removed through simple biopsy procedures but biopsy of the lung (a more formidable procedure) did not seem justified. More recently I have observed another patient, a woman of 33, with
hypercalcemia,
hyperphosphatemia
and renal failure due to vitamin D intoxication. She, too, showed diffuse uptake of 99mTc-labelled polyphosphates throughout the lungs during a bone scan and had histologically proved metastatic calcification of the kidneys. Both of these patients are getting along well with treatment, so there is no immediate prospect of ob¬ taining a sample of lung tissue for microscopic examination. Grames and his colleagues do not say whether the autopsy on their first patient showed metastatic calcifica¬ tion of the stomach. This is a puzzling omission in view of the uptake of pyrophosphate in the stomach, which is so well illustrated in their reproduc¬ tion of the bone scan. Taken together, these cases (and there is reason to believe there are others not yet reported) show that metastatic calcification of the lungs and stomach can now be recognized
Downloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User on 06/08/2015
through scanning after the intra¬ venous injection of a technetiumphosphate complex. Biopsy may no longer be necessary for confirmation. Since the scanning procedure can eas¬ ily be repeated without discomfort to the patient, it may prove to be a use¬ ful guide to the progress of treat¬ ment.
May I utter one tiny objection, di¬ rected as much to the accompanying editorial (230:1018) as to Grames's article? Do we really need the term "diffuse interstitial pulmonary calci¬ fication"? Why not stick with "meta¬ static calcification" and specify the organ involved? "Metastatic calcifica¬ tion" may not be an entirely satisfac¬ tory term but it has been with us for a long time and is simple, versatile, and generally understood. FRCP(C) Royal Jubilee Hospital
A. G. Richards, MD,
Victoria, British Columbia
The American Alcoholic To the Editor.\p=m-\Iwould like to comon Dr. Donald W. Goodwin's review of The American Alcoholic by William Madsen (229:1112, 1974). I believe Dr. Goodwin missed the whole point of the book, which is really an excellent description of Alcoholics Anonymous (AA) and an excellent account of the success of AA in helping to overcome this addiction, particularly in view of the notable failure of psychiatry. I agree that Mr. Madsen does spend considerable time on reference, but I believe he is trying to gather as many ideas and details as possible about the disease in one place. The bibliography is certainly exhaustive, and those of us who are actively engaged in handling alcoholics will find much of the material in this book of great value. ment
G. W. Richmond, MD
San Francisco
Legal Systems
in the
United States
To the Editor.\p=m-\AngelaRoddey Holder (230:1327, 1974) attributed to Charles Dickens a statement made by one of his characters, the beadle, in Oliver Twist, and she cleaned up the grammar a little bit. What the beadle, Mr. Bumble, said was actually "The law is a ass, a idiot." And sometimes it surely is\p=m-\evenif it is, as Ms. Holder shows, "a system, not a collection of traps and snares." Harry L. Arnold, Jr., MD Honolulu
ture
Selected Characteristics of Black Physicians in the United States, 1972 To the Editor.\p=m-\Anarticle by Theodis Thompson, PhD, in the Sept 23 issue of The Journal (229:1758, 1974) is of some concern to this office. The article, "Selected Characteristics of Black Physicians in the United States, 1972," is based on findings from a survey sponsored by this office. However, we did not see the article prior to its publication. Dr. Thompson states in the article that the findings are based on a sample survey. This statement is wholly inaccurate, and tends to give the findings greater significance than we believe is warranted. A lowerthan-hoped-for response in a pretest led to a decision to mail questionnaires in the final survey to the identifiable universe of about 5,800 black physicians. Usable responses were obtained from only 3,405 physicians who identified themselves as black, so that the findings are subject to considerable overall nonresponse bias, in addition to the serious bias stemming from the lack of response from interns and residents that was men¬ tioned by Dr. Thompson. I think that your readers should be made aware of the limitations of these data so that they may avoid
making
generalizations physicians in the United
erroneous
about black States.
Howard V. Stambler Bureau of Health Resources
Development Department of Health,
the number of physicians by states, for example, should not be considered the actual number of physicians, but the number of physicians responding to the particular survey from a given
state. I agree with Mr. Stambler that the data reported should not be used for
inferences about the characteristics of black physicians in the United States in 1972. However, the data tables used in the study were generated by the programming division of the Bureau of Health Resources Development for the National Medical Association (NMA) Founda¬ tion while I was acting director of the Office of Research and Evaluation. It should also be pointed out that I wrote only the final report for this study. Therefore, I had to rely on ex¬ isting project records and discussions with the former project director, pro¬ grammers, and the then deputy direc¬ tor of the NMA Foundation for an¬ swers to many questions. Mrs. Ruth Crocker of the Resource Analysis Staff, Bureau of Health Resources Development, and Mr. William Wil¬ liams of that division were very help¬ ful in generating data tables. Unfor¬ tunately, I was under the impression from the parties concerned that the NMA Foundation had permission to utilize the data even though the Bu¬ reau of Health Resources Develop¬ ment had the data tapes. Never¬ theless, Mr. Stambler's observations are important in assuring the reduc¬ tion in continuing misinterpretation of statistical data.
making
erroneous
US
Theodis Thompson, PhD
Education, and Welfare
Washington, DC
Bethesda, Md
To the Editor.\p=m-\Theletter by Mr. Stambler points out two observations that I have made in subsequent discussions about my article: (1) The data reported are not generalizable to the universe of black physicians in the United States. (2) The pretest, phase 1, was a stratified sample (p 1758); phase 2, the universe study, (by
definition)
was
not
a
sample study.
The findings reported are based on the responses to 3,405 usable, mailed questionnaires. Moreover, data for Edited
by John D. Archer, MD, Senior Editor.
Etiological
and Environmental
Factors
To the Editor.\p=m-\Aboutthe article by Wynder and Mabuchi, "Etiological and Environmental Factors," concerning esophageal cancer (226:1546, 1973), I would like to report that in some areas of my country, especially in the south states, such as Para\l=n~\\l=a'\, Santa Catarina, and Rio Grande do Sul, some cases of cancer of the esophagus are related with the habit many people have of drinking mat\l=e'\ tea without sugar, in a gourd through
Downloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User on 06/08/2015
people.
Waldomiro Dantas, MD Universidade Federal de
Santa Catarina
Florian\l=o'\polis,Brazil
The Treatment of Graves Disease To the Editor.\p=m-\Ina letter by Caswell and Maier (227:939, 1974) on the treatment of Graves disease, the authors conclude that the advantages of surgical treatment over radioactive iodine therapy and antithyroid drug treatment ensure that it will continue to be the standard by which other treatment methods are measured. They studied 72 patients with previous subtotal thyroidectomy for Graves disease and found a low incidence of postoperative hypothyroidism (10%) as well as a low incidence of recurrent hyperthyroidism (6%).1 In support of this view, Griffiths et al,2 studying 55 thyrotoxic patients fol-
lowing thyroidectomy, recently reported an 11% incidence of hypothyroidism
and
3.5% incidence of Successful treatment with radioactive iodine, on the other hand, is accompanied by an incidence of hypothyroidism of between 30% and 70% by 10 to 20 years of followrecurrence.
up.3
It should be pointed out, however, that all studies are not in agreement with the authors' reported low incidence of postsurgical hypothyroidism. In a series by Michie et al," in which 278 patients with hyperthyroidism treated with partial thyroidectomy were studied prospectively over a seven-year period, the overall inci¬ dence of hypothyroidism was 49%. The occurrence of hypothyroidism de¬ creased significantly as the remnant size left at operation was increased. However, increasing remnant size does not abolish hypothyroidism. Among patients with remnant size of 8 to 10 gm, the incidence of hypothy¬ roidism was 30% and introduced the hazard of thyrotoxic recurrence. Nofal et al5 likewise found an incidence of postoperative hypothyroidism of 43% after ten years of follow-up. Thus it would appear that surgery,
like radioactive iodine and antithyroid drugs, has certain advantages and disadvantages in the treatment of hyperthyroidism and that the ther¬ apy recommended should be tailored to each individual patient. Frank O. Becker, MD Steven G. Economou, MD
Rush-Presbyterian-St. Luke's Medical Center
Chicago 1. Caswell
HT, Maier WP: Results of surgical treatment for hyperthyroidism. Surg Gynecol Obstet 134:218\x=req-\ 220, 1972. 2. Griffiths NJ, Murley RS, Gulin R, et al. Thyroid function following partial thyroidectomy. Br J Surg 61:626-632, 1974. 3. Hagen GA: Treatment of thyrotoxicosis with 131-I and post-therapy hypothyroidism. Med Clin North Am 52:417-421, 1968. 4. Michie W, Pegg CAS, Beirsher PD: Prediction of hypothyroidism after partial thyroidectomy for thyrotoxicosis. Br Med J 1:13-17, 1972. 5. Nofal MM, Bierwaltes WH, Patno ME: Treatment of hyperthyroidism with sodium iodide I 131: A 16-year experience. JAMA 197:605-610, 1966.
Hypothyroidism and Stress To the Editor.\p=m-\Therecent report by
Mataverde et al (230:1014, 1974) is
in pointing out a commonly encountered but not well recognized problem. A less common problem, but one that may have been a factor in the case presented, is the exacerbation of hypothyroidism during periods of stress. An early report1 describes five patients who developed "acute myxedema" following pneumonia. Subsequent work2 has shown that during stress thyroxine (T4) turnover is increased fivefold while plasma T4 levels were maintained within normal limits, thus suggesting an increase in T4 secretory rate. It was thought that the increased turnover was the result of an increase in free T, caused by a decrease in thyroxine-binding prealbumin (TBPA). More recent work3 has confirmed that TBPA does indeed decrease with acute infections, but this was dissociated in time from changes in free T4. It was concluded that the alterations in free T4 with stress (which increased T4 turnover) was due to an inhibition of T4 bind¬
timely
ing. Regardless of its cause, the rapid T4 turnover during stress could have important clinical consequences in the hypothyroid patient whose gland is already secreting maximally.2 The routine prophylactic use of levothyroxine sodium in patients with fixed T4 outputs cannot yet be recommended, and certainly does not approach the addisonian in clinical importance. However, the possibility of an inade¬ quate
response to stress associated
with a worsening hypothyroid state should be kept in mind, especially in the hypothyroid patient who has not
yet begun levothyroxine therapy.
Elliott Eisenbud, MD University of California at Davis 1. Hausmann W, Karlish AJ: Acute myxoedema precipitated by pneumonia. Br Med J 2:1063-1065, 1961. 2. Gregerman RI, Solomon N: Acceleration of thyroxine and triiodothyronine turnover during bacterial pulmonary infections and fever. J Clin Endocrinol Metab
27:93-104, 1967. 3. Lutz JH, Gregerman RI, et al: Thyroxine-binding proteins and thyroxine turnover interrelationships during acute infectious illness in man. J Clin Endocrinol Metab 35:230-249, 1972.
Radionuclide Detection of Metastatic Calcification To the Editor.\p=m-\The article "Radionuclide Detection of Diffuse Interstitial Pulmonary Calcification" (230:992, 1974) was of special interest to me since it coincided with my report of a similar case in the Journal of Nuclear Medicine (15:1057, 1974). My patient, who had hypercalcemia, hyperphosphatemia, and renal failure in association with a poorly differentiated malignancy of the bone marrow showed a dense and diffuse uptake of technetium 99m-labelled polyphosphate throughout the lungs and stomach during the course of a bone scan. Calcification of the stomach and kidneys was proven histologically on tissues removed through simple biopsy procedures but biopsy of the lung (a more formidable procedure) did not seem justified. More recently I have observed another patient, a woman of 33, with
hypercalcemia,
hyperphosphatemia
and renal failure due to vitamin D intoxication. She, too, showed diffuse uptake of 99mTc-labelled polyphosphates throughout the lungs during a bone scan and had histologically proved metastatic calcification of the kidneys. Both of these patients are getting along well with treatment, so there is no immediate prospect of ob¬ taining a sample of lung tissue for microscopic examination. Grames and his colleagues do not say whether the autopsy on their first patient showed metastatic calcifica¬ tion of the stomach. This is a puzzling omission in view of the uptake of pyrophosphate in the stomach, which is so well illustrated in their reproduc¬ tion of the bone scan. Taken together, these cases (and there is reason to believe there are others not yet reported) show that metastatic calcification of the lungs and stomach can now be recognized
Downloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User on 06/08/2015
through scanning after the intra¬ venous injection of a technetiumphosphate complex. Biopsy may no longer be necessary for confirmation. Since the scanning procedure can eas¬ ily be repeated without discomfort to the patient, it may prove to be a use¬ ful guide to the progress of treat¬ ment.
May I utter one tiny objection, di¬ rected as much to the accompanying editorial (230:1018) as to Grames's article? Do we really need the term "diffuse interstitial pulmonary calci¬ fication"? Why not stick with "meta¬ static calcification" and specify the organ involved? "Metastatic calcifica¬ tion" may not be an entirely satisfac¬ tory term but it has been with us for a long time and is simple, versatile, and generally understood. FRCP(C) Royal Jubilee Hospital
A. G. Richards, MD,
Victoria, British Columbia
The American Alcoholic To the Editor.\p=m-\Iwould like to comon Dr. Donald W. Goodwin's review of The American Alcoholic by William Madsen (229:1112, 1974). I believe Dr. Goodwin missed the whole point of the book, which is really an excellent description of Alcoholics Anonymous (AA) and an excellent account of the success of AA in helping to overcome this addiction, particularly in view of the notable failure of psychiatry. I agree that Mr. Madsen does spend considerable time on reference, but I believe he is trying to gather as many ideas and details as possible about the disease in one place. The bibliography is certainly exhaustive, and those of us who are actively engaged in handling alcoholics will find much of the material in this book of great value. ment
G. W. Richmond, MD
San Francisco
Legal Systems
in the
United States
To the Editor.\p=m-\AngelaRoddey Holder (230:1327, 1974) attributed to Charles Dickens a statement made by one of his characters, the beadle, in Oliver Twist, and she cleaned up the grammar a little bit. What the beadle, Mr. Bumble, said was actually "The law is a ass, a idiot." And sometimes it surely is\p=m-\evenif it is, as Ms. Holder shows, "a system, not a collection of traps and snares." Harry L. Arnold, Jr., MD Honolulu
