250
who had declined further therapy (p < 0’02) (data on file, ICN). All these data were submitted to the FDA and all questions raised about the studies reported in 1987 were satisfactorily answered, the company subsequently being granted permission for further clinical trials in the USA. As to the assertion that "the investigators had a financial conflict of interest" there was a single case where one investigator’s wife, unbeknown to him or to ICN Pharmaceuticals, purchased a small amount of company stock. When he learned of this, he asked that the stock be sold. We regret the politicisation of clinical research into anti-HIV therapies, which can only be to the detriment of patient care, and would welcome the setting up of a genuinely independent initiative to study all potentially useful treatments, including ribavirin. Viratek, ICN Plaza, Costa Mesa, California 92626, USA
ROBERTS A. SMITH HUMBERTO FERNANDEZ
1. Snell N. The activity of ribavirin against the human immunodeficiency virus: a review of laboratory and clinical experience. Antiviral Chem Chemother (in press). 2. Johnson K, Hollinger B, Lawrence T, Parks W, Rashed S. IV International Conference on AIDS (Stockholm, 1988); abstr 3571. 3. Crumpacker C, Heagy W, Bubley G, et al. Ribavirin treatment of AIDS and AIDS-related complex. Ann Intern Med 1987; 107: 664-74. 4. Roberts R, Laskin O. Phase I clinical studies of ribavirin in high-risk patients for the acquired immunodeficiency syndrome. In: Smith R, ed. HIV and other highly pathogenic viruses. San Diego: Academic Press, 1988: 95-112. 5. Crumpacker C, Pearlstein G, van der Horst C, et al. A phase I increasing dose trial of oral ribavirin in patients with AIDS and ARC. VI International Conference on AIDS (San Francisco, 1990); abstr SB468. 6. Ruiz Illescas R, Romero M, Collin Fuentes J, et al. Usefulness of ribavirin in the treatment of the patient with acquired immunodeficiency Med Intern Mexico 1988; 4: 128. 7. Roberts R, Hollinger FB, Parks W, et al. A multicenter clinical trial of oral ribavirin in HIV-infected people with lymphadenopathy: virologic observations. J AIDS 1990; 4: 67-72. 8. Spector S, Kennedy C, McCutchan J, et al. The antiviral effect of zidovudine and ribavirin in clinical trials and the use of p24 antigen levels as a virologic marker. J Infect Dis 1989; 159: 822-28. 9. Roberts R, Dickinson G, Heseltine P, et al. A multicenter clinical trial of oral ribavirin in HIV-infected patients with lymphadenopathy. J AIDS 1990; 3: 884-92. 10. Forsythe A, Elashoff J, Dixon W. Statistical consideration of misclassification of patients at baseline in two AIDS clinical trials. V International Conference on AIDS (Montreal, 1989); abstr ThAP 43. 11. Forsythe A. Clinical trial of oral ribavirin. J AIDS 1991; 4: 300-01.
Simultaneous treatment of cytomegalovirus retinitis with ganciclovir and foscarnet SiR,—Over 50% of homosexual men infected with HIV shed cytomegalovirus (CMV) in their body fluids, and over 90% have serological evidence of infection. CMV retinitis develops in 25-30% of AIDS patients, and retinitis is the commonest presentation of CMV in HIV diseased The two drugs available for the treatment of CMV retinitis are foscamet and ganciclovir. After a three week treatment course, maintenance drug administration is recommended to prevent relapse. The use of both drugs concurrently has not been reported, although there is in-vitro evidence of synergism.2,3 A 40-year-old HIV seropositive man, with a previous AIDS diagnosis of Pneumocystis carinii pneumonia had bilateral CMV retinitis diagnosed on ophthalmological examination, after he complained of blurring of vision. The retinitis responded to ganciclovir 10 mg/kg daily for three weeks, followed by a maintenance dose of 5 mg/kg on five consecutive days every week. However, after ten weeks his retinitis relapsed and he was put on foscarnet 200 mg/kg daily followed by a maintenance dose of 100 mg/kg on five consecutive days every week. His retinitis again became quiescent, but five weeks later he relapsed. Foscarnet was given again but ten days later his retinitis was still active and he complained of visual deterioration. This time ganciclovir was started in tandem with foscarnet. After treatment courses of each drug, he remained well with quiescent retinitis on a full maintenance dose of both drugs, until his death from P carinii pneumonia 5 months later. Strains of CMV resistant to ganciclovir have been reported,4 and there has been a recent report in a bone marrow transplant patient of CMV resistant to both ganciclovir and foscamet.5 Our patient,
clinically resistant to treatment with ganciclovir or foscarnet, did respond to dual therapy. In immunocompromised patients with CMV retinitis refractory to treatment with ganciclovir and foscarnet the concurrent use of the two drugs is worth considering. M. R. NELSON G. BARTER D. HAWKINS B. G. GAZZARD
Westminster Hospital, London SW1, UK
Jabs DA, Green WR, Fox R, Polk BF, Barlettt JS. Ocular manifestations of acquired immune deficiency syndrome. Ophthalmology 1989; 96: 1092-99. 2. Manischewitz JF, Quinnan GV Jr, Lane HC, Wittek AE. Synergistic effect of ganciclovir and foscarnet on cytomegalovirus replication in vitro. Antimicrob Agents Chemother 1990; 34: 373-35 3. Freitas VR, Fraser-Smith EB, Matthews TR. Increased efficacy of ganciclovir in combination with foscarnet against cytomegalovirus and herpes simplex virus type 2 in vitro and in vivo. Antivir Res 1989; 12: 205-12. 4. Erice A, Chou S, Biron K, Stanat S, Jordan M. Progressive disease due to ganciclovir resistant cytomegalovirus in immunocompromised patients. N Engl J Med 1989, 1.
320: 289-92. 5. Knox K, Drobyski W, Carrigan D. Cytomegalovirus isolate resistant to ganciclovir and foscarnet from a marrow transplant recipient. Lancet 1991, 337: 1292.
HIV and Romania SIR,-Dr Offerhaus, in his Round the World report on health in Albania (July 6, p 44) suggests that the risk of HIV spread in Albania has been increased by the opening of the border with care
Romania. Albania has borders with Yugoslavia and Greece but not Romania. In the sense that Romania might represent a source for HIV transmission, that applies only to AIDS children in this country and not to HIV seropositivity in adults, which is not
unusually common. Medical University of Bucharest, Blvd Eroilor sanitari 8, Bucharest, Romania
ADRIAN DANESCU
Subacute thyroiditis as consequence of chronic bacterial sinusitis SIR,-Acute thyroiditis is a rare complication of bacterial infection, especially upper-respiratory-tract infection.1,2 Aspiration cytology usually reveals suppuration, though non-suppurative
thyroiditis has been described.12 Subacute thyroiditis (pseudotubercular thyroiditis, giant-cell thyroiditis, de Quervain’s thyroiditis) usually has a viral cause, and the mechanism is rarely immune or idiopathic.l-4 It may present as hyperthyroidism,4,5 In acute
Hashimoto’s disease antibodies will be present in serum,"and patients present with hypothyroidism.4 Organisms causing chronic bacterial infection of the upper respiratory tract can act as antigenic triggers and produce antibodies which are responsible for systemic diseases.6 We describe here subacute thyroiditis in a 43-year-old man with chronic bacterial sinusitis. He presented with a 2-month history of painful throat, nasal discharge, dry cough, and fever. Upper-respiratory-tract infection was diagnosed. Antipyretic, antihistaminic, and antimicrobial drugs were prescribed without a significant response. 15 days after the first symptoms the patient noticed a small nodule on left side of neck followed by a similar painful swelling a week later. The pain radiated to the right side of neck, face, and ear, accompanied by pain in the frontal sinus and the right maxillary sinus. Daily fevers peaking in the evening continued with palpitations and weight loss despite a normal appetite. His resting pulse rate was 104/min regular but there were no other signs of thyroid disease. A nodular 2 x3 cm swelling in the right lobe of thyroid (moving with swallowing) was tender on palpation. Urine and throat swab cultures were negative, as were tests for brucella antigen and a Mantoux test. X-rays revealed haziness of both frontal and right maxillary sinuses. His serum T3 was 306 mg/dl (normal 94-242), T4 22-2 Ilgjdl (5-5-13-5), and thyrotropin 70 )iU/dl; serum antinuclear antibody and anti-DNA antibody were negative. A thyroid scan showed that the gland was poorly defined, with poor uptake. Fine-needle aspiration
251
revealed plentiful red blood cells lymphocytes, histiocytes,
MIDWIVES’ REASONS FOR USE OF WATER SUPPLEMENTATION
polymorphs, multinucleated giant cells, plasma cells, and follicular cells. On right maxillary antral puncture no material was aspirated, and the sinus was irrigated. A mucopurulent nasal discharge was present for 2 days after this procedure, culture revealing coagulasepositive staphylococci. After the antral puncture the patient improved, the fever, palpitations, and painful swollen gland disappeared and he gained weight. In this case, acute thyroiditis secondary to bacterial infection in the upper respiratory tract (sinusitis) seemed to be ruled out by the negative fme-needle aspiration findingS.1,2 Subacute thyroiditis suggested by the low-grade fever and painful thyroid swelling, was confirmed by aspiration. The history of a viral upper-respiratorytract infection before development of subacute thyroiditis suggests that the subacute thyroiditis was viral. Is there a correlation between chronic bacterial sinusitis and subacute thyroiditis-or is this merely a fortuitous finding ? Subacute thyroiditis usually lasts for 2-4 months with gradual improvement, whereas this patient improved within 2 months. Hashimoto’s disease is ruled out because presentation was with hyperthyroidism not hypothyroidism; furthermore the patient improved without treatment and aspiration cytology suggested subacute thyroiditis.
Water supplementation in the urban slum areas of Kumasi is particularly hazardous. Charcoal used as fuel to boil water and sterilise feeding equipment is expensive and is therefore used sparingly. Infective diarrhoea is an important cause of morbidity and mortality in the developing world,! and it has been reported that infants receiving unboiled water have more diarrhoeal episodes than those given boiled water.2 For an education programme to change effectively the ubiquitous practice of water supplementation, it is important to begin with training of the health care professionals, and to understand the cultural beliefs of the community.
Departments of Pathology and Medicine, Swami Ramanand Teerth Rural Medical College,
Department of Paediatric Oncology, Royal Manchester Children’s Hospital, Pendlebury, Manchester M27 1 HA, UK
Ambajogai District, Beed Pin, 431517 Maharashtra, India
S. B. RATHOD S. R. TANKHIWALE A. R. PAZARE
*More than
1. 1. Franssila KO. Thyroid gland. In. Anderson’s pathology, 9th ed. Toronto: Mosby, 1990: 1544-69. 2. Williams Boyd Textbook of pathology, structure and function in diseases, 8th (Indian) ed. Bombay: Vargeese, 1988: 1064-89. 3. Ingbar SH, Woober K. The thyroid gland In: Williams RH, ed. Textbook of endocrinology, 6th ed. Philadelphia: Saunders, 1981: 238-48 4. Valpe RH. Acute (subacute) nonsuppurative thyroiditis In: Wornes SC, Ingbar SH, eds. The thyroid. the fundamental and clinical text, 3rd ed. New York: Harper and
5.
Row, 1962: 853-61. Ingbar SH. Diseases of thyroid. In: Harrison’s principles of internal medicine, 11th ed. New York: McGraw Hill, 1987: 1732-52.
one reason was
given by several
midwives.
ERICA J. MACKIE
Woodruff AW, Suni AE, Kaku M, et al. Infants in Juba, Southern Sudan: the first six
months of life. Lancet 1983; ii: 262-64. 2. Almroth SG. Water requirements of breast-fed infants in Nutr 1978; 31: 1154-57
a
hot climate.
Am J Clin
Sleep apnoea syndrome treated with cyclic medroxyprogesterone
oestradiol and
SIR,-Sleep apnoea syndrome (SAS, more than 5 episodes of apnoea or hypoapnoeas per hour of sleepl) is more frequent among than women.2 In premenopausal women it is unusual, although the prevalence increases after menopause,3suggesting that female hormones have a protective effect. We report a woman with SAS successfully treated with oestradiol and cyclic men
Water supplementation of breast-fed infants in Ghana SIR,-Dr Sachdev and his colleagues (April 20,
929) have
the potentially hazardous practice of water supplementation in breast-fed infants in the tropics is unnecessary. In Ghana, West Africa, water supplementation is encouraged by health workers. The reasons for advocating this practice need to be considered when planning a programme of re-education. A study conducted in Kumasi, Ghana, examined the knowledge and beliefs of 111 midwives, with respect to infant feeding and water supplementation. A semi-structured questionnaire was administered to a random sample of midwives (54 in hospital, 22 final year students, and 35 in the community). This selection was based on those having the most contact with both pregnant women and nursing mothers. All midwives were in favour of breastfeeding as the best method of infant feeding and 94 (85%) believed that breast-milk should be given exclusively, without solids or artificial milk, for at least 3 months (mean 4, range 1-12). However, 79 (71 %) believed that a newborn infant should be offered either glucose (n 36) or water alone (33) before the first breastfeed. The most common explanation for this belief was the risk of hypoglycaemia (25). Others suggested that this water or glucose feed was necessary to check the swallowing reflex and the patency of the gastrointestinal system (13), to prevent a dry mouth (7), and to maintain a correct fluid balance (5). 103 (93%) thought that water supplementation should be given on demand to all infants, beginning on the first day of life and usually within 6 h of birth, and only 7 (6%) stated definitely that water was unnecessary (table). It is a common belief that the tongue must be cleaned after breast-feeding to prevent oral candidiasis, and part of the culture is the notion that water is "essential to life", breast-milk only providing the calories. shown
that
p
=
medroxyprogesterone. A 45-year-old woman with suspected SAS was admitted for sleep study in October, 1989. After two normal pregnancies, she used norethisterone for contraception until amenorrhoea at the age of 35. Intensified snoring, increasing daytime sleepiness, and gastritis occurred after menopause. She would wake up several times during sleep with panic, sweating, and nocturia. She was always tired and could not participate in meetings or attend education classes. She did not use any drugs. Her blood pressure and weight were normal (basal metabolic index 22’6). Polysomnography revealed obstructive SAS. Oxygen desaturation by pulse oximetry was reduced to 84%. Despite a successful test with nasal continuous positive airway pressure (CPAP) she refused home CPAP. In December, 1989, her doctor prescribed oestradiol 2 mg and cyclic medroxyprogesterone 5 mg daily for 10 days every second month for postmenopausal symptoms. Luteinising and follicle stimulating hormones were within the range for postmenopausal women.
In January, 1990, one month after treatment with oestradiol 2 mg daily, her SAS symptoms were much improved. She slept quietly without snoring or arousals and her daytime sleepiness had disappeared. Polysomnography and pulse oximetry in April, 1990, confirmed the improvement. To see if the improvement was due to the hormones, she stopped treatment in June, 1990. The increased tiredness and snoring returned and polysomnography and pulse oximetry in August, 1990, confirmed relapse. She reinstated the hormone treatment and her symptoms improved. In January, 1991, polysomnography again confirmed improvement. During treatment with oestradiol this patient’s symptoms improved and with oestradiol in combination with cyclic medoxyprogesterone SAS was abolished. Clinical trials, mainly in
who had declined further therapy (p < 0’02) (data on file, ICN). All these data were submitted to the FDA and all questions raised about the studies reported in 1987 were satisfactorily answered, the company subsequently being granted permission for further clinical trials in the USA. As to the assertion that "the investigators had a financial conflict of interest" there was a single case where one investigator’s wife, unbeknown to him or to ICN Pharmaceuticals, purchased a small amount of company stock. When he learned of this, he asked that the stock be sold. We regret the politicisation of clinical research into anti-HIV therapies, which can only be to the detriment of patient care, and would welcome the setting up of a genuinely independent initiative to study all potentially useful treatments, including ribavirin. Viratek, ICN Plaza, Costa Mesa, California 92626, USA
ROBERTS A. SMITH HUMBERTO FERNANDEZ
1. Snell N. The activity of ribavirin against the human immunodeficiency virus: a review of laboratory and clinical experience. Antiviral Chem Chemother (in press). 2. Johnson K, Hollinger B, Lawrence T, Parks W, Rashed S. IV International Conference on AIDS (Stockholm, 1988); abstr 3571. 3. Crumpacker C, Heagy W, Bubley G, et al. Ribavirin treatment of AIDS and AIDS-related complex. Ann Intern Med 1987; 107: 664-74. 4. Roberts R, Laskin O. Phase I clinical studies of ribavirin in high-risk patients for the acquired immunodeficiency syndrome. In: Smith R, ed. HIV and other highly pathogenic viruses. San Diego: Academic Press, 1988: 95-112. 5. Crumpacker C, Pearlstein G, van der Horst C, et al. A phase I increasing dose trial of oral ribavirin in patients with AIDS and ARC. VI International Conference on AIDS (San Francisco, 1990); abstr SB468. 6. Ruiz Illescas R, Romero M, Collin Fuentes J, et al. Usefulness of ribavirin in the treatment of the patient with acquired immunodeficiency Med Intern Mexico 1988; 4: 128. 7. Roberts R, Hollinger FB, Parks W, et al. A multicenter clinical trial of oral ribavirin in HIV-infected people with lymphadenopathy: virologic observations. J AIDS 1990; 4: 67-72. 8. Spector S, Kennedy C, McCutchan J, et al. The antiviral effect of zidovudine and ribavirin in clinical trials and the use of p24 antigen levels as a virologic marker. J Infect Dis 1989; 159: 822-28. 9. Roberts R, Dickinson G, Heseltine P, et al. A multicenter clinical trial of oral ribavirin in HIV-infected patients with lymphadenopathy. J AIDS 1990; 3: 884-92. 10. Forsythe A, Elashoff J, Dixon W. Statistical consideration of misclassification of patients at baseline in two AIDS clinical trials. V International Conference on AIDS (Montreal, 1989); abstr ThAP 43. 11. Forsythe A. Clinical trial of oral ribavirin. J AIDS 1991; 4: 300-01.
Simultaneous treatment of cytomegalovirus retinitis with ganciclovir and foscarnet SiR,—Over 50% of homosexual men infected with HIV shed cytomegalovirus (CMV) in their body fluids, and over 90% have serological evidence of infection. CMV retinitis develops in 25-30% of AIDS patients, and retinitis is the commonest presentation of CMV in HIV diseased The two drugs available for the treatment of CMV retinitis are foscamet and ganciclovir. After a three week treatment course, maintenance drug administration is recommended to prevent relapse. The use of both drugs concurrently has not been reported, although there is in-vitro evidence of synergism.2,3 A 40-year-old HIV seropositive man, with a previous AIDS diagnosis of Pneumocystis carinii pneumonia had bilateral CMV retinitis diagnosed on ophthalmological examination, after he complained of blurring of vision. The retinitis responded to ganciclovir 10 mg/kg daily for three weeks, followed by a maintenance dose of 5 mg/kg on five consecutive days every week. However, after ten weeks his retinitis relapsed and he was put on foscarnet 200 mg/kg daily followed by a maintenance dose of 100 mg/kg on five consecutive days every week. His retinitis again became quiescent, but five weeks later he relapsed. Foscarnet was given again but ten days later his retinitis was still active and he complained of visual deterioration. This time ganciclovir was started in tandem with foscarnet. After treatment courses of each drug, he remained well with quiescent retinitis on a full maintenance dose of both drugs, until his death from P carinii pneumonia 5 months later. Strains of CMV resistant to ganciclovir have been reported,4 and there has been a recent report in a bone marrow transplant patient of CMV resistant to both ganciclovir and foscamet.5 Our patient,
clinically resistant to treatment with ganciclovir or foscarnet, did respond to dual therapy. In immunocompromised patients with CMV retinitis refractory to treatment with ganciclovir and foscarnet the concurrent use of the two drugs is worth considering. M. R. NELSON G. BARTER D. HAWKINS B. G. GAZZARD
Westminster Hospital, London SW1, UK
Jabs DA, Green WR, Fox R, Polk BF, Barlettt JS. Ocular manifestations of acquired immune deficiency syndrome. Ophthalmology 1989; 96: 1092-99. 2. Manischewitz JF, Quinnan GV Jr, Lane HC, Wittek AE. Synergistic effect of ganciclovir and foscarnet on cytomegalovirus replication in vitro. Antimicrob Agents Chemother 1990; 34: 373-35 3. Freitas VR, Fraser-Smith EB, Matthews TR. Increased efficacy of ganciclovir in combination with foscarnet against cytomegalovirus and herpes simplex virus type 2 in vitro and in vivo. Antivir Res 1989; 12: 205-12. 4. Erice A, Chou S, Biron K, Stanat S, Jordan M. Progressive disease due to ganciclovir resistant cytomegalovirus in immunocompromised patients. N Engl J Med 1989, 1.
320: 289-92. 5. Knox K, Drobyski W, Carrigan D. Cytomegalovirus isolate resistant to ganciclovir and foscarnet from a marrow transplant recipient. Lancet 1991, 337: 1292.
HIV and Romania SIR,-Dr Offerhaus, in his Round the World report on health in Albania (July 6, p 44) suggests that the risk of HIV spread in Albania has been increased by the opening of the border with care
Romania. Albania has borders with Yugoslavia and Greece but not Romania. In the sense that Romania might represent a source for HIV transmission, that applies only to AIDS children in this country and not to HIV seropositivity in adults, which is not
unusually common. Medical University of Bucharest, Blvd Eroilor sanitari 8, Bucharest, Romania
ADRIAN DANESCU
Subacute thyroiditis as consequence of chronic bacterial sinusitis SIR,-Acute thyroiditis is a rare complication of bacterial infection, especially upper-respiratory-tract infection.1,2 Aspiration cytology usually reveals suppuration, though non-suppurative
thyroiditis has been described.12 Subacute thyroiditis (pseudotubercular thyroiditis, giant-cell thyroiditis, de Quervain’s thyroiditis) usually has a viral cause, and the mechanism is rarely immune or idiopathic.l-4 It may present as hyperthyroidism,4,5 In acute
Hashimoto’s disease antibodies will be present in serum,"and patients present with hypothyroidism.4 Organisms causing chronic bacterial infection of the upper respiratory tract can act as antigenic triggers and produce antibodies which are responsible for systemic diseases.6 We describe here subacute thyroiditis in a 43-year-old man with chronic bacterial sinusitis. He presented with a 2-month history of painful throat, nasal discharge, dry cough, and fever. Upper-respiratory-tract infection was diagnosed. Antipyretic, antihistaminic, and antimicrobial drugs were prescribed without a significant response. 15 days after the first symptoms the patient noticed a small nodule on left side of neck followed by a similar painful swelling a week later. The pain radiated to the right side of neck, face, and ear, accompanied by pain in the frontal sinus and the right maxillary sinus. Daily fevers peaking in the evening continued with palpitations and weight loss despite a normal appetite. His resting pulse rate was 104/min regular but there were no other signs of thyroid disease. A nodular 2 x3 cm swelling in the right lobe of thyroid (moving with swallowing) was tender on palpation. Urine and throat swab cultures were negative, as were tests for brucella antigen and a Mantoux test. X-rays revealed haziness of both frontal and right maxillary sinuses. His serum T3 was 306 mg/dl (normal 94-242), T4 22-2 Ilgjdl (5-5-13-5), and thyrotropin 70 )iU/dl; serum antinuclear antibody and anti-DNA antibody were negative. A thyroid scan showed that the gland was poorly defined, with poor uptake. Fine-needle aspiration
251
revealed plentiful red blood cells lymphocytes, histiocytes,
MIDWIVES’ REASONS FOR USE OF WATER SUPPLEMENTATION
polymorphs, multinucleated giant cells, plasma cells, and follicular cells. On right maxillary antral puncture no material was aspirated, and the sinus was irrigated. A mucopurulent nasal discharge was present for 2 days after this procedure, culture revealing coagulasepositive staphylococci. After the antral puncture the patient improved, the fever, palpitations, and painful swollen gland disappeared and he gained weight. In this case, acute thyroiditis secondary to bacterial infection in the upper respiratory tract (sinusitis) seemed to be ruled out by the negative fme-needle aspiration findingS.1,2 Subacute thyroiditis suggested by the low-grade fever and painful thyroid swelling, was confirmed by aspiration. The history of a viral upper-respiratorytract infection before development of subacute thyroiditis suggests that the subacute thyroiditis was viral. Is there a correlation between chronic bacterial sinusitis and subacute thyroiditis-or is this merely a fortuitous finding ? Subacute thyroiditis usually lasts for 2-4 months with gradual improvement, whereas this patient improved within 2 months. Hashimoto’s disease is ruled out because presentation was with hyperthyroidism not hypothyroidism; furthermore the patient improved without treatment and aspiration cytology suggested subacute thyroiditis.
Water supplementation in the urban slum areas of Kumasi is particularly hazardous. Charcoal used as fuel to boil water and sterilise feeding equipment is expensive and is therefore used sparingly. Infective diarrhoea is an important cause of morbidity and mortality in the developing world,! and it has been reported that infants receiving unboiled water have more diarrhoeal episodes than those given boiled water.2 For an education programme to change effectively the ubiquitous practice of water supplementation, it is important to begin with training of the health care professionals, and to understand the cultural beliefs of the community.
Departments of Pathology and Medicine, Swami Ramanand Teerth Rural Medical College,
Department of Paediatric Oncology, Royal Manchester Children’s Hospital, Pendlebury, Manchester M27 1 HA, UK
Ambajogai District, Beed Pin, 431517 Maharashtra, India
S. B. RATHOD S. R. TANKHIWALE A. R. PAZARE
*More than
1. 1. Franssila KO. Thyroid gland. In. Anderson’s pathology, 9th ed. Toronto: Mosby, 1990: 1544-69. 2. Williams Boyd Textbook of pathology, structure and function in diseases, 8th (Indian) ed. Bombay: Vargeese, 1988: 1064-89. 3. Ingbar SH, Woober K. The thyroid gland In: Williams RH, ed. Textbook of endocrinology, 6th ed. Philadelphia: Saunders, 1981: 238-48 4. Valpe RH. Acute (subacute) nonsuppurative thyroiditis In: Wornes SC, Ingbar SH, eds. The thyroid. the fundamental and clinical text, 3rd ed. New York: Harper and
5.
Row, 1962: 853-61. Ingbar SH. Diseases of thyroid. In: Harrison’s principles of internal medicine, 11th ed. New York: McGraw Hill, 1987: 1732-52.
one reason was
given by several
midwives.
ERICA J. MACKIE
Woodruff AW, Suni AE, Kaku M, et al. Infants in Juba, Southern Sudan: the first six
months of life. Lancet 1983; ii: 262-64. 2. Almroth SG. Water requirements of breast-fed infants in Nutr 1978; 31: 1154-57
a
hot climate.
Am J Clin
Sleep apnoea syndrome treated with cyclic medroxyprogesterone
oestradiol and
SIR,-Sleep apnoea syndrome (SAS, more than 5 episodes of apnoea or hypoapnoeas per hour of sleepl) is more frequent among than women.2 In premenopausal women it is unusual, although the prevalence increases after menopause,3suggesting that female hormones have a protective effect. We report a woman with SAS successfully treated with oestradiol and cyclic men
Water supplementation of breast-fed infants in Ghana SIR,-Dr Sachdev and his colleagues (April 20,
929) have
the potentially hazardous practice of water supplementation in breast-fed infants in the tropics is unnecessary. In Ghana, West Africa, water supplementation is encouraged by health workers. The reasons for advocating this practice need to be considered when planning a programme of re-education. A study conducted in Kumasi, Ghana, examined the knowledge and beliefs of 111 midwives, with respect to infant feeding and water supplementation. A semi-structured questionnaire was administered to a random sample of midwives (54 in hospital, 22 final year students, and 35 in the community). This selection was based on those having the most contact with both pregnant women and nursing mothers. All midwives were in favour of breastfeeding as the best method of infant feeding and 94 (85%) believed that breast-milk should be given exclusively, without solids or artificial milk, for at least 3 months (mean 4, range 1-12). However, 79 (71 %) believed that a newborn infant should be offered either glucose (n 36) or water alone (33) before the first breastfeed. The most common explanation for this belief was the risk of hypoglycaemia (25). Others suggested that this water or glucose feed was necessary to check the swallowing reflex and the patency of the gastrointestinal system (13), to prevent a dry mouth (7), and to maintain a correct fluid balance (5). 103 (93%) thought that water supplementation should be given on demand to all infants, beginning on the first day of life and usually within 6 h of birth, and only 7 (6%) stated definitely that water was unnecessary (table). It is a common belief that the tongue must be cleaned after breast-feeding to prevent oral candidiasis, and part of the culture is the notion that water is "essential to life", breast-milk only providing the calories. shown
that
p
=
medroxyprogesterone. A 45-year-old woman with suspected SAS was admitted for sleep study in October, 1989. After two normal pregnancies, she used norethisterone for contraception until amenorrhoea at the age of 35. Intensified snoring, increasing daytime sleepiness, and gastritis occurred after menopause. She would wake up several times during sleep with panic, sweating, and nocturia. She was always tired and could not participate in meetings or attend education classes. She did not use any drugs. Her blood pressure and weight were normal (basal metabolic index 22’6). Polysomnography revealed obstructive SAS. Oxygen desaturation by pulse oximetry was reduced to 84%. Despite a successful test with nasal continuous positive airway pressure (CPAP) she refused home CPAP. In December, 1989, her doctor prescribed oestradiol 2 mg and cyclic medroxyprogesterone 5 mg daily for 10 days every second month for postmenopausal symptoms. Luteinising and follicle stimulating hormones were within the range for postmenopausal women.
In January, 1990, one month after treatment with oestradiol 2 mg daily, her SAS symptoms were much improved. She slept quietly without snoring or arousals and her daytime sleepiness had disappeared. Polysomnography and pulse oximetry in April, 1990, confirmed the improvement. To see if the improvement was due to the hormones, she stopped treatment in June, 1990. The increased tiredness and snoring returned and polysomnography and pulse oximetry in August, 1990, confirmed relapse. She reinstated the hormone treatment and her symptoms improved. In January, 1991, polysomnography again confirmed improvement. During treatment with oestradiol this patient’s symptoms improved and with oestradiol in combination with cyclic medoxyprogesterone SAS was abolished. Clinical trials, mainly in
