1087 THE LAW AND MENTAL DISORDER
SIR,-Your excellent editorial (April 7,
p.
759) clearly pin-
the shortcomings and contradictions in the Government’s white paper. I would suggest that all those interested in mental health who agree with the editorial write to the new Secretary of State for Social Services urging that the whitepaper be amended along the lines suggested by your editorial. The two most retrograde proposals in the white-paper are that informally admitted psychiatric patients should be given a statement of their legal rights on admission to hospital, when this is not done for physical illness, and that political control is being brought into the arena of medical treatment by singling out so-called "hazardous" treatments for lay control as a response to anxieties generated in the lay press. Such anxieties are misinformed because, as your editorial points out, such treatments as E.c.T. and psychosurgery bear a very low risk compared with the risk of most major treatments or with the morbidity of the conditions to which they are applied. Far more important is the precedent of bringing in panels to control individual medical judgments about treatment. This could prove to be the first step in the undermining of the physician’s most precious right to have full responsibility for the therapeutic decisions made for his patients.
points
Department of Psychiatry, Charing Cross Hospital Medical School, London W6 8RF
SMALL STARTING DOSE OF METHIMAZOLE IN THYROTOXICOSIS p. 493) report that thyrotoxic patients small doses of carbimazolc may be as effective as the large ones generally recommended. This accords with our experience with methimazole. However, the main practical problem is how to predict which patients will respond to small doses of antithyroid drugs. When, retrospectively, we reviewed’ the initial response to daily doses of 15-20 mg methimazole (lower than the 30-60 mg usually recommended2) in 57 thyrotoxic patients we found that the best response was in patients in whom a thyroid radioactive iodine uptake (R.A.I.U.) test, done before treatment began, had shown rapid discharge of radioiodine-i.e., 24 h thyroid uptake was
SIR,-Dr Low and colleagues (March 3,
in
some
less than the 6 h value. We have since done test when choosing the
a
prospective study, using the
starting dose of methimazole
R.A.I.U.
for indi-
STEVEN R. HIRSCH
REGULATION OF WHOLE-BODY PROTEIN SYNTHESIS
SIR,-We would like to make two comments on the paper of Dr Sim and his colleagues (Jan. 13, p. 68). First, there is a possible alternative explanation to the reduced rate of nitrogen flux protein synthesis and degradation, when the volunteers were fed intravenously rather than orally. A subject receiving food by the gastrointestinal tract might be expected to dilute out 15N-urea with unlabelled urea arising from dietary aminoacids. This, in turn, would result in a lower isotopic plateau in the urine, and hence, a higher flux-rate than that seen when the aminoacids are administered intravenously. The second issue that we would like to discuss is the 38% reduction in protein synthetic rate when the subjects were receiving aminoacids alone, rather than aminoacids and glucose. Previous investigators have shown in obese adults’ and obese adolescents2 that synthetic rate was unaltered when the subjects were switched from a balanced isocaloric diet to a weight-reduction diet, as long as the level of protein intake was maintained. An important difference between Sim’s study and those in obese adolescents is that the individuals did receive some non-protein energy.intake, albeit limited amounts (about 5-6 kcal/kg/day). When Garlick et al.l switched their subjects from the protein-containing weight-reducing diet to a proteinfree isocaloric diet (500 kcal/day), whole-body protein-synthesis rates were approximately halved. It had been our initial interpretation, based on the data of Garlick’ and Pencharz,22 that rates of whole-body protein synthesis were regulated more by protein intake than by energy intake. However, the paper by Sim et al. suggests that energy intake has an important role to play in the regulation of whole-body protein synthesis. Department of Pædiatrics, Hospital for Sick Children, oronto, Ontario, Canada M5G
P. PENCHARZ
1X8
Department of Medicine, University of Toronto 1
K. JEEJEEBHOY
Garlick, P. J., Klugston, G. A., Waterlow, J. C. Proc. Nutr. Soc. 1978, 37,
22A. 2. Pencharz, P.
26, 864A.
B., Motil,
K.
J., Parsons, H. G., Duffy,
B.
J. Clin. Res. 1978,
T4-RT3 index before and after 4 weeks treatment with methimazole in eleven thyrotoxic iodine after R.A.I.U. tests.
patients
with
rapid discharge of
vidual patients, in an attempt to eliminate unnecessarily large doses of the drug. So far eleven untreated patients (nine women and two men, aged 25-56) with diffuse toxic goitre and a 24 h radioiodine uptake less than the 4 h value have been treated with methimazole at a starting dose of 15 mg daily (5 mg every 8 h). After 4 weeks with this treatment, thyroid status was reassessed both clinically and by measurement ofT4 and T3 status. All but one patient showed both T4 and T3 status within the normal range; eight patients were clinically euthyroid; two showed striking improvement but not complete regression of thyrotoxic symptoms; and the patient with persistently abnormal biochemical tests was still clearly hyperthyroid. Thus good clinical and biochemical control was achieved in ten of eleven thyrotoxic patients, 4 weeks after starting therapy with small doses of methimazole; 4-6 weeks of treatment is generally thought to be necessary to restore a normal metabolic state with conventional doses of thioamides.3.4 These preliminary results seem to indicate the possibility of predicting, with sufficient accuracy and on the basis of a simple test (R.A.I.U.), those patients who will respond promptly and completely to smaller than usual doses of antithyroid drugs. Castiglioni, M., Coli, A., Roni, P., Branchi, R., Riccioni, N. J nucl Biol. Med. 1976, 20, 148 2. Solomon, D. H in The Thyroid: a fundamental and clinical text edited by S.C. Werner and S. H. Ingbar p 917, 1978 3. Ingbar, S. H , Woeber, K. A in Textbook of Endocrinology, edited by R H Williams, p176 1974 4. DeGroot, L. J., Stambury, J. B. The Thyroid and its Diseases; p. 342. 1975. 1.
SIR,-Your excellent editorial (April 7,
p.
759) clearly pin-
the shortcomings and contradictions in the Government’s white paper. I would suggest that all those interested in mental health who agree with the editorial write to the new Secretary of State for Social Services urging that the whitepaper be amended along the lines suggested by your editorial. The two most retrograde proposals in the white-paper are that informally admitted psychiatric patients should be given a statement of their legal rights on admission to hospital, when this is not done for physical illness, and that political control is being brought into the arena of medical treatment by singling out so-called "hazardous" treatments for lay control as a response to anxieties generated in the lay press. Such anxieties are misinformed because, as your editorial points out, such treatments as E.c.T. and psychosurgery bear a very low risk compared with the risk of most major treatments or with the morbidity of the conditions to which they are applied. Far more important is the precedent of bringing in panels to control individual medical judgments about treatment. This could prove to be the first step in the undermining of the physician’s most precious right to have full responsibility for the therapeutic decisions made for his patients.
points
Department of Psychiatry, Charing Cross Hospital Medical School, London W6 8RF
SMALL STARTING DOSE OF METHIMAZOLE IN THYROTOXICOSIS p. 493) report that thyrotoxic patients small doses of carbimazolc may be as effective as the large ones generally recommended. This accords with our experience with methimazole. However, the main practical problem is how to predict which patients will respond to small doses of antithyroid drugs. When, retrospectively, we reviewed’ the initial response to daily doses of 15-20 mg methimazole (lower than the 30-60 mg usually recommended2) in 57 thyrotoxic patients we found that the best response was in patients in whom a thyroid radioactive iodine uptake (R.A.I.U.) test, done before treatment began, had shown rapid discharge of radioiodine-i.e., 24 h thyroid uptake was
SIR,-Dr Low and colleagues (March 3,
in
some
less than the 6 h value. We have since done test when choosing the
a
prospective study, using the
starting dose of methimazole
R.A.I.U.
for indi-
STEVEN R. HIRSCH
REGULATION OF WHOLE-BODY PROTEIN SYNTHESIS
SIR,-We would like to make two comments on the paper of Dr Sim and his colleagues (Jan. 13, p. 68). First, there is a possible alternative explanation to the reduced rate of nitrogen flux protein synthesis and degradation, when the volunteers were fed intravenously rather than orally. A subject receiving food by the gastrointestinal tract might be expected to dilute out 15N-urea with unlabelled urea arising from dietary aminoacids. This, in turn, would result in a lower isotopic plateau in the urine, and hence, a higher flux-rate than that seen when the aminoacids are administered intravenously. The second issue that we would like to discuss is the 38% reduction in protein synthetic rate when the subjects were receiving aminoacids alone, rather than aminoacids and glucose. Previous investigators have shown in obese adults’ and obese adolescents2 that synthetic rate was unaltered when the subjects were switched from a balanced isocaloric diet to a weight-reduction diet, as long as the level of protein intake was maintained. An important difference between Sim’s study and those in obese adolescents is that the individuals did receive some non-protein energy.intake, albeit limited amounts (about 5-6 kcal/kg/day). When Garlick et al.l switched their subjects from the protein-containing weight-reducing diet to a proteinfree isocaloric diet (500 kcal/day), whole-body protein-synthesis rates were approximately halved. It had been our initial interpretation, based on the data of Garlick’ and Pencharz,22 that rates of whole-body protein synthesis were regulated more by protein intake than by energy intake. However, the paper by Sim et al. suggests that energy intake has an important role to play in the regulation of whole-body protein synthesis. Department of Pædiatrics, Hospital for Sick Children, oronto, Ontario, Canada M5G
P. PENCHARZ
1X8
Department of Medicine, University of Toronto 1
K. JEEJEEBHOY
Garlick, P. J., Klugston, G. A., Waterlow, J. C. Proc. Nutr. Soc. 1978, 37,
22A. 2. Pencharz, P.
26, 864A.
B., Motil,
K.
J., Parsons, H. G., Duffy,
B.
J. Clin. Res. 1978,
T4-RT3 index before and after 4 weeks treatment with methimazole in eleven thyrotoxic iodine after R.A.I.U. tests.
patients
with
rapid discharge of
vidual patients, in an attempt to eliminate unnecessarily large doses of the drug. So far eleven untreated patients (nine women and two men, aged 25-56) with diffuse toxic goitre and a 24 h radioiodine uptake less than the 4 h value have been treated with methimazole at a starting dose of 15 mg daily (5 mg every 8 h). After 4 weeks with this treatment, thyroid status was reassessed both clinically and by measurement ofT4 and T3 status. All but one patient showed both T4 and T3 status within the normal range; eight patients were clinically euthyroid; two showed striking improvement but not complete regression of thyrotoxic symptoms; and the patient with persistently abnormal biochemical tests was still clearly hyperthyroid. Thus good clinical and biochemical control was achieved in ten of eleven thyrotoxic patients, 4 weeks after starting therapy with small doses of methimazole; 4-6 weeks of treatment is generally thought to be necessary to restore a normal metabolic state with conventional doses of thioamides.3.4 These preliminary results seem to indicate the possibility of predicting, with sufficient accuracy and on the basis of a simple test (R.A.I.U.), those patients who will respond promptly and completely to smaller than usual doses of antithyroid drugs. Castiglioni, M., Coli, A., Roni, P., Branchi, R., Riccioni, N. J nucl Biol. Med. 1976, 20, 148 2. Solomon, D. H in The Thyroid: a fundamental and clinical text edited by S.C. Werner and S. H. Ingbar p 917, 1978 3. Ingbar, S. H , Woeber, K. A in Textbook of Endocrinology, edited by R H Williams, p176 1974 4. DeGroot, L. J., Stambury, J. B. The Thyroid and its Diseases; p. 342. 1975. 1.
