9
3. Johanson WG, Pierce AK, Sanford JP, Thomas GD. Nosocomial respiratory infections with gram-negative bacilli. Ann Intern Med 1972; 77: 701-06. 4. Niederman MS, Craven DE, Fein AM, Schultz DE. Pneumonia in the critically ill hospitalized patient. Chest 1990; 97: 170-81. 5. Bartlett JG, O’Keefe P, Tally FP, Louie TJ, Gorbach SL. Bacteriology of hospital-acquired pneumonia. Arch Intern Med 1986; 146: 868-71. 6. Du Moulin GC, Paterson DG, Hedley-Whyte J, Lisbon A. Aspiration of gastric bacteria in antacid-treated patients: a frequent cause of postoperative colonisation of the airway. Lancet 1982; i: 242-45. 7. Vandenbroucke-Grauls CMJE, Vandenbroucke JP. Effect of selective decontamination of the digestive tract on respiratory tract infections and mortality in the intensive care unit. Lancet 1991; 338: 859-62. 8. McCarthy DM. Sucralfate. N Engl J Med 1991; 325: 1017-25.
9. Knaus WA, Draper EA, Douglas P, Wagner P, Zimmennan JE. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13: 818-29. 10. Knaus WA, Draper EA, Wagner DP. Prognosis in acute organ system failure. Ann Surg 1985; 202: 685-90. 11. Baker SP, O’Neill B, Haddon W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974; 14: 187-96. 12. Tran DD, Groeneveld J, Van der Meul J, Nauta JJP, Strack RJM. Age, chronic disease, sepsis, organ system failure, and mortality in a medical intensive care unit. Crit Care Med 1990; 18: 474-79. 13. Stoutenbeek CP, van Saene HKF, Miranda DR, Zandstra DF, Langrehr D. The effect of oropharyngeal decontamination using topical non-absorbable antibiotics on the incidence of nosocomial respiratory tract infection in multiple trauma patients. J Trauma 1987; 27: 357-64. 14. Ledingham IM, Alcock SR, Eastaway AT, McDonald JC, McKay IC, Ramsay G. Triple regimen of selective decontamination of the digestive tract, systemic cefotaxime, and microbiological surveillance for prevention of acquired infection in intensive care. Lancet 1988; i: 785-90. 15. Stoutenbeek CP, Van Saene HKF, Miranda DR, Zandstra DF. The effect of selective decontamination of the digestive tract on colonization and infection rate in multiple trauma patients. Intensive Care Med 1984; 10: 185-92. 16. Ulrich C, Harinck-de w JE, Bakker NC, Jacz K, Doornbos L, De Ridder VA. Selective decontamination of the digestive tract with norfloxacin in the prevention of ICU acquired infections: a prospective randomised study. Intensive Care Med 1989; 15: 424-31.
17. Aerdts SJA, Clasener HAL, Van Dalen R, Van Lier HJJ, Vollaard EJ, Festen J. Prevention of bacterial colonisation of the respiratory tract and stomach of mechanically ventilated patients by a novel regimen of selective decontamination in combination with systemic cefotaxime. J Antimicrob Chemother 1990; 26 (suppl A): 59-76. 18. Unertl K, Ruckdeschel G, Selbmann HK. Prevention of colonisation and respiratory infections in long term ventilated patients by local antimicrobial prophylaxis. Intensive Care Med 1987; 13: 106-13. 19. Kerver
AJH, Rommes JH, Mevissen-V EAE, et al. Prevention of colonization and infection in critically ill patients: a prospective randomized study. Crit Care Med 1988; 26: 1087-93. 20. Konrad F, Schwalbe B, Heidreich T, Schmidts J, Ahnfeld FW. Bacterial colonisation and respiratory tract infections in long term ventilated patients under conventional treatment and selective decontamination of the digestive tract. Intensive Care Med 1988; 14 (suppl): 311. 21. Border J, Bone L, Rodriguez J. The upright chest and the pulmonary failure septic state. In: Cerra F, ed. Perspectives in critical care. St Louis: Quality Medical Publishing, 1988. 22. Stephenson GW, Hall SC, Rudnick S, Seleny FL, Stephenson HC. The effect of anesthetic agents on the human immune response. Anesthesiology 1990; 72: 542-52. 23. Turner J, Potgieter PD, Springhorn H, Briggs S. Patients’ recollection of ICU experience. Crit Care Med 1990; 18: 966-68.
Feeley TW, Du Moulin GC, Hedley-White J, Bushnell LS, Gilbert JP, Feingold DS. Aerosol polymyxin in pneumonia in seriously ill patients. N Engl J Med 1985; 293: 471-75. 25. Brown RB, Kruse JA, Counts GW, Russell JA, Christu NV, Sands ML. Double-blind study of endotracheal Tobramycin in the treatment of gram-negative bacterial pneumonia. Antimicrob Ag Chemother 1990;
24.
34: 269-72. 26. Miranda
DR, Van Saene HKF, Stoutenbeek CP, Zandstra DF. Environment and costs in a surgical ICU. The implication of selective decontamination of the digestive tract (SDD). Acta Anaesthesiol Belg 1983; 34: 223-32. 27. Mandelli M, Mosconi P, Langer M, Cigada M. Prevention of pneumonia in an intensive care unit: a randomized multi-centre clinical trial. Crit Care Med 1989; 17: 501-05. 28. Pugin J, Auckenthaler R, Lew DP. Oropharyngeal decontamination decreases incidence of ventilator associated pneumonia. JAMA 1991; 265: 2704-10.
Long-term thyroxine treatment and bone mineral density
Studies of the effect of thyroxine replacement therapy on bone mineral density have given conflicting results; the reductions in bone mass reported by some have prompted recommendations that prescribed doses of thyroxine should be reduced. We have examined the effect of long-term thyroxine treatment in a large homogeneous group of patients; all had undergone thyroidectomy for differentiated thyroid cancer but had no history of other thyroid disorders. The 49 patients were matched with controls for age, sex, menopausal status, body mass index, smoking history, and calcium intake score; in all subjects bone mineral density at several femoral and vertebral sites was measured by dual-energy X-ray
absorptiometry. Despite long-term thyroxine therapy (mean duration 7·9 [range 1-19] years) at doses (mean 191 [SD 50] µg/day) that resulted in higher serum thyroxine and lower serum thyrotropin concentrations than in the controls, the patients showed no evidence of lower bone mineral density
than the controls at any site. Nor was bone mineral density correlated with dose, duration of therapy, or cumulative intake, or with tests of thyroid function. There was a decrease in bone density with age in both groups. We suggest that thyroxine alone does not have a significant effect on bone mineral density and hence on risk of osteoporotic fractures. Lancet 1992; 340: 9-13.
Introduction The relation between thyroid disease and osteoporosis first recognised 100 years ago. Although effective
was
ADDRESSES: Departments of Medicine (J. A. Franklyn, MD, J. Betteridge, RGN, J. Daykin, RGN, G. D. Oates, FRCS, J. V Parle, MRCGP, D. A. Heath, FRCP, Prof M. C. Sheppard, FRCP), Statistics (R. Holder, PhD), and Nuclear Medicine (J Lilley, MSc), University of Birmingham, and Thyroid Clinic, General Hospital Birmingham, UK. Correspondence to Dr J. A. Franklyn, Department of Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK.
10
TABLE I-CLINICAL DETAILS
*p < 0 05 by paired t test or Wilcoxon signed-rank test. tFrom subject-completed questionnaire: activity score 1 =little, 2= moderate, 3= much; calcium intake Data are mean (SD) except where indicated.
1
=
1000
mg/day.
TABLE II-BIOCHEMICAL RESULTS -
_
_
-
P= alkaline phosphatase; PTH=parathyroid hormone. For differences between cases and controls: *p < 0.05; tp
3. Johanson WG, Pierce AK, Sanford JP, Thomas GD. Nosocomial respiratory infections with gram-negative bacilli. Ann Intern Med 1972; 77: 701-06. 4. Niederman MS, Craven DE, Fein AM, Schultz DE. Pneumonia in the critically ill hospitalized patient. Chest 1990; 97: 170-81. 5. Bartlett JG, O’Keefe P, Tally FP, Louie TJ, Gorbach SL. Bacteriology of hospital-acquired pneumonia. Arch Intern Med 1986; 146: 868-71. 6. Du Moulin GC, Paterson DG, Hedley-Whyte J, Lisbon A. Aspiration of gastric bacteria in antacid-treated patients: a frequent cause of postoperative colonisation of the airway. Lancet 1982; i: 242-45. 7. Vandenbroucke-Grauls CMJE, Vandenbroucke JP. Effect of selective decontamination of the digestive tract on respiratory tract infections and mortality in the intensive care unit. Lancet 1991; 338: 859-62. 8. McCarthy DM. Sucralfate. N Engl J Med 1991; 325: 1017-25.
9. Knaus WA, Draper EA, Douglas P, Wagner P, Zimmennan JE. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13: 818-29. 10. Knaus WA, Draper EA, Wagner DP. Prognosis in acute organ system failure. Ann Surg 1985; 202: 685-90. 11. Baker SP, O’Neill B, Haddon W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974; 14: 187-96. 12. Tran DD, Groeneveld J, Van der Meul J, Nauta JJP, Strack RJM. Age, chronic disease, sepsis, organ system failure, and mortality in a medical intensive care unit. Crit Care Med 1990; 18: 474-79. 13. Stoutenbeek CP, van Saene HKF, Miranda DR, Zandstra DF, Langrehr D. The effect of oropharyngeal decontamination using topical non-absorbable antibiotics on the incidence of nosocomial respiratory tract infection in multiple trauma patients. J Trauma 1987; 27: 357-64. 14. Ledingham IM, Alcock SR, Eastaway AT, McDonald JC, McKay IC, Ramsay G. Triple regimen of selective decontamination of the digestive tract, systemic cefotaxime, and microbiological surveillance for prevention of acquired infection in intensive care. Lancet 1988; i: 785-90. 15. Stoutenbeek CP, Van Saene HKF, Miranda DR, Zandstra DF. The effect of selective decontamination of the digestive tract on colonization and infection rate in multiple trauma patients. Intensive Care Med 1984; 10: 185-92. 16. Ulrich C, Harinck-de w JE, Bakker NC, Jacz K, Doornbos L, De Ridder VA. Selective decontamination of the digestive tract with norfloxacin in the prevention of ICU acquired infections: a prospective randomised study. Intensive Care Med 1989; 15: 424-31.
17. Aerdts SJA, Clasener HAL, Van Dalen R, Van Lier HJJ, Vollaard EJ, Festen J. Prevention of bacterial colonisation of the respiratory tract and stomach of mechanically ventilated patients by a novel regimen of selective decontamination in combination with systemic cefotaxime. J Antimicrob Chemother 1990; 26 (suppl A): 59-76. 18. Unertl K, Ruckdeschel G, Selbmann HK. Prevention of colonisation and respiratory infections in long term ventilated patients by local antimicrobial prophylaxis. Intensive Care Med 1987; 13: 106-13. 19. Kerver
AJH, Rommes JH, Mevissen-V EAE, et al. Prevention of colonization and infection in critically ill patients: a prospective randomized study. Crit Care Med 1988; 26: 1087-93. 20. Konrad F, Schwalbe B, Heidreich T, Schmidts J, Ahnfeld FW. Bacterial colonisation and respiratory tract infections in long term ventilated patients under conventional treatment and selective decontamination of the digestive tract. Intensive Care Med 1988; 14 (suppl): 311. 21. Border J, Bone L, Rodriguez J. The upright chest and the pulmonary failure septic state. In: Cerra F, ed. Perspectives in critical care. St Louis: Quality Medical Publishing, 1988. 22. Stephenson GW, Hall SC, Rudnick S, Seleny FL, Stephenson HC. The effect of anesthetic agents on the human immune response. Anesthesiology 1990; 72: 542-52. 23. Turner J, Potgieter PD, Springhorn H, Briggs S. Patients’ recollection of ICU experience. Crit Care Med 1990; 18: 966-68.
Feeley TW, Du Moulin GC, Hedley-White J, Bushnell LS, Gilbert JP, Feingold DS. Aerosol polymyxin in pneumonia in seriously ill patients. N Engl J Med 1985; 293: 471-75. 25. Brown RB, Kruse JA, Counts GW, Russell JA, Christu NV, Sands ML. Double-blind study of endotracheal Tobramycin in the treatment of gram-negative bacterial pneumonia. Antimicrob Ag Chemother 1990;
24.
34: 269-72. 26. Miranda
DR, Van Saene HKF, Stoutenbeek CP, Zandstra DF. Environment and costs in a surgical ICU. The implication of selective decontamination of the digestive tract (SDD). Acta Anaesthesiol Belg 1983; 34: 223-32. 27. Mandelli M, Mosconi P, Langer M, Cigada M. Prevention of pneumonia in an intensive care unit: a randomized multi-centre clinical trial. Crit Care Med 1989; 17: 501-05. 28. Pugin J, Auckenthaler R, Lew DP. Oropharyngeal decontamination decreases incidence of ventilator associated pneumonia. JAMA 1991; 265: 2704-10.
Long-term thyroxine treatment and bone mineral density
Studies of the effect of thyroxine replacement therapy on bone mineral density have given conflicting results; the reductions in bone mass reported by some have prompted recommendations that prescribed doses of thyroxine should be reduced. We have examined the effect of long-term thyroxine treatment in a large homogeneous group of patients; all had undergone thyroidectomy for differentiated thyroid cancer but had no history of other thyroid disorders. The 49 patients were matched with controls for age, sex, menopausal status, body mass index, smoking history, and calcium intake score; in all subjects bone mineral density at several femoral and vertebral sites was measured by dual-energy X-ray
absorptiometry. Despite long-term thyroxine therapy (mean duration 7·9 [range 1-19] years) at doses (mean 191 [SD 50] µg/day) that resulted in higher serum thyroxine and lower serum thyrotropin concentrations than in the controls, the patients showed no evidence of lower bone mineral density
than the controls at any site. Nor was bone mineral density correlated with dose, duration of therapy, or cumulative intake, or with tests of thyroid function. There was a decrease in bone density with age in both groups. We suggest that thyroxine alone does not have a significant effect on bone mineral density and hence on risk of osteoporotic fractures. Lancet 1992; 340: 9-13.
Introduction The relation between thyroid disease and osteoporosis first recognised 100 years ago. Although effective
was
ADDRESSES: Departments of Medicine (J. A. Franklyn, MD, J. Betteridge, RGN, J. Daykin, RGN, G. D. Oates, FRCS, J. V Parle, MRCGP, D. A. Heath, FRCP, Prof M. C. Sheppard, FRCP), Statistics (R. Holder, PhD), and Nuclear Medicine (J Lilley, MSc), University of Birmingham, and Thyroid Clinic, General Hospital Birmingham, UK. Correspondence to Dr J. A. Franklyn, Department of Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK.
10
TABLE I-CLINICAL DETAILS
*p < 0 05 by paired t test or Wilcoxon signed-rank test. tFrom subject-completed questionnaire: activity score 1 =little, 2= moderate, 3= much; calcium intake Data are mean (SD) except where indicated.
1
=
1000
mg/day.
TABLE II-BIOCHEMICAL RESULTS -
_
_
-
P= alkaline phosphatase; PTH=parathyroid hormone. For differences between cases and controls: *p < 0.05; tp
