syndrome,' and on occasion hypoglycaemia - Europe PMC

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Jan 12, 1985 - Department of Child Health,. Ninewells .... But we nowhere suggest that un- employment is a ... son went on to organ donation after the latter.'.
BRITISH MEDICAL JOURNAL

VOLUME 290

by those writing the articles than by those working in the districts. The best broadsheet I have seen is produced quarterly in Malawi (The Medical Quarterly) and is aimed at all health workers but primarily doctors. It has a combination of short, practical "how to do it" articles, reviews of common problems, and basic research work. An innovative feature is a duplicate "pull out" section on management of conditions such as dehydration or meningitis, which can be posted on the wall of a ward or clinic. The journal's main purpose is educational. A journal of this kind is able to provide much needed information to those working in the districts; it encourages the seeking of knowledge by simple basic research; and it promotes unity among health workers rather than dividing doctors from the rest, as do many existing journals. Cannot more national medical journals follow this example ? TONY WATERSTON Department of Child Health, Ninewells Hospital and Medical School, Dundee DD1 9SY

Hypoglycaemia in acute myelomonoblastic leukaemia SIR,-Dr Mi M Al Hilali and colleagues have drawn attention to the importance of urgent measurement of the blood glucose concentration in anv patient with malignant disease who has sudden onset of confusion or a deterioration in level of consciousness (24 November, p 1443). Recent reviews of tumour hypoglycaemia suggest that most, if not all, types of neoplastic disease can produce this syndrome,' and on occasion hypoglycaemia may be the presenting feature of malignancy. As the authors indicate, several theories have been proposed to explain the development of hvpoglycaemia in patients with ilon-pancreatic tumours, but, despite the development of radioimmunoassay techniques for many hormones and growth factors, the cause of tumour hypoglycaemia has eluded intensive research. It was disappointing, however, that in the two cases described by Dr Al Hilali and his colleagues little attempt had apparently been made to pursue a cause for the hypoglvcaemia, and some fundamental investigations, such as the measurement of plasma insulin concentrations during hypoglycaemia, were not reported. In the second case the hypoglycaemia appears to have been coincidental with the terminal event rather than a feature of the leukaemia per se. Investigation of hypoglvcaemia associated with leukaemia is complicated by the problem of artefactual hypoglvcaemia caused by in vitro glycolysis, which may occur in the leucocvte rich blood sample before laboratory analysis.3 4 While

we would agree with the authors that this phenomenon seems unlikely in their first case, in which the hypoglycaemia was symptomatic and the white cell count was normal, it would not have been difficult to exclude factitious hypoglvcaemia either by assay of the blood sample immediately after venepuncture or by subdivision of the sample into two tubes with separation of serum from one aliquot immediately and from the other after two hours; the absence of a sizable difference between the two glucose values would exclude artefactual hypoglycaemia.5 There is reasonable evidence in certain tumours for the secretion of an insulin like substance causing hypoglvcaemia, but no abnormal secretion was detected in the single case of leukaemia discussed in a review bv Kahn,' in which plasma insulin like activity had been assayed. In the

12 JANUARY 1985

absence of well documented cases it is impossible to attribute hypoglycaemia in patients with leukaemia to the secretion of insulin like substances. One of the striking features of the two cases described by Dr Al Hilali and others was the close temporal relation between the hypoglycaemia and the chemotherapy. Marks et al described two patients who developed hypoglvcaemia shortly after receiving treatment with alkylating agents,6 and it is conceivable that a direct hepatotoxic effect of these drugs may contribute to the hypoglycaemia through disruption of glucose homoeostasis.

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Drs Shapiro and Parry suggest. If it is of causal significance it is almost certainly as a predisposing or vulnerability factor.' Here we refer to a recent study of 95 patients who committed parasuicide admitted also to the regional poisoning treatment centre. Using a full array of life event research techniques the researchers found that 350 had experienced serious unemployment, which was judged to represent a substantial threat or difficulty.3 Similarly, Fruensgaard et al found that unemployment was an important causal factor in their sample of unemployed patients admitted to a psychiatry emergency department, of whom about half were admitted after parasuicide, usually in conjunction with other external factors-for example, interpersonal conflicts, housing problems, and economic difficulties-all of which are, of course, heightened by unemployment.4

The authors are right to promulgate this clinical problem but elucidation of the pathogenesis of tumour induced hypoglycaemia is hampered by the rarity of the syndrome. It is possible that advances in our knowledge Whether or not individuals unemployof factors with insulin like activity (which may ment as being relevant to their see action, outside be a product of the expression of oncogenes) observers and clinicians taking a longer term will clarify the riddle of tumour hypoglycaemia. and more objective viewpoint have certainly seen its importance. established that IAIN C MACDOUGALL there is a very high Having risk of parasuicide asBRIAN M FRIER sociated with long term unemployment, we Division of Medicine, clearly need to elucidate the nature of this Gartnavel General Hospital, relationship. This is an urgent task, but more Glasgow G12 OYN complex than Drs Shapiro and Parry appear 1 Kahn CR. The riddle of tumour hypoglycemia to realise. revisited. Cl/zn Enidocrinol Metab 1980,9:335-60. 2 Marks V, Rose FC, eds. Hypoglycaemia. 2nd ed. STEPHEN PLATT Oxford: Blackw,ell Scientific Publications, 1981: N KREITMAN 246-66.

3 Field JB, Williams HE. Artifactual hypoglycemia associated with leukemia. N Engl/7 Med 1961 ;265: 946-8. 4 Hanrahan JB, Sax SM, Cillo A. Factitious hypoglycemia in patients with leukemia. Am J C/'in

MRC Unit for Epidemiology Studies in Psychiatry, Royal Edinburgh Hospital, Edinburgh EH10 5HF

5 Goodenow TJ, Malarkev WB. Leukocytosis and artifactual hypoglycemia. 3rAMA 1977 ;273:1961-2. 6 Marks LJ, Steinke J, Rolosky S, Egdahl RH. Hypoglycemia associated with neoplasia. Anni NY Acad

1 Platt S. Unemployment and suicidal behaviour: a review of the literature. Soc SciMed 1984;19:93-115. 2 Bancroft J, Skrimshire A, Simkin S. The reasons people give for taking overdoses. Br 7 Psychiatry

Pathol 1963;40:43-5.

Sci 1974;230:147-60.

1976;128 :538-48.

3 Miller PMcC, Salter DP. Is there a short-cut ? An investigation into the life event interview. Acta

Psychiatr Scand 1984;70:417-27.

Is unemployment a cause of parasuicide? SIR,-Drs C M Shapiro and M R Parry (8 December, p 1622) report that only five out of 107 unemployed male parasuicide patients mentioned unemployment as their most important current problem. They conclude that unemployed people committing parasuicide do not see unemployment as relevant to their action, and warn of the danger of interpreting the higher risk of parasuicide among the unemployed (20 October, p 1029) as evidence of a "causal connection." Their findings are in line with other such investigations. In only a small minority of cases is work or non-work cited as a "reason for" or "cause of" the overdose.' However, attempts to elicit from individuals the reasons or motives for their behaviour are fraught with methodological and conceptual problems. Colleagues such as those at the Warneford Hospital, Oxford, sought for many years to develop a valid technique for describing the subject's own perceptions and definitions of his or her overdose and its antecedents.2 The results of their careful studies were by no means unequivocal, and no further research along these lines is planned. Like many others, they came to realise that the concept of a "reason" is extraordinarily complex. If it is to be used at all it requires strict definition, carefully structured questioning, and precise techniques of clarification. The kind of interview method used by Drs Shapiro and Parry would not be very helpful in this context. A second point concerns the interpretation of our epidemiological findings on the relation between unemployment and parasuicide. It is a matter of arithmetic that being unemployed raises the risk of parasuicide by a factor of about 12 and that this risk tends to increase with lengthening durations of unemployment. These are facts, not inferences. But we nowhere suggest that unemployment is a precipitant of parasuicide, and logically it would make no sense to do so, as

4 Fruensgaard K, Benjaminsen S, Joensen S, Helstrup K. Psychosocial characteristics of a group of unemployed patients consecutively admitted to a psychiatry emergency department. Soc Psychiatry 1983; 18:137-44.

Brain stem death SIR,-The debate on persistent vegetative state and brain stem death (8 December, p 1620) is of some personal interest to me. I have not been the relative of a patient in the former state, but two years ago my 20 year old son went on to organ donation after the latter.' The team at the hospital told my wife and me immediately on completion of the second assessment after 24 hours that our son was dead. I was profoundly thankful for this approach for the following reasons. Firstly, the family did not have the agony of a prolonged bedside vigil. Secondly, we were able to say goodbye to him while he looked asleep rather than watch him rattle into cyanosed cardiopulmonary arrest. Thirdly, his body was not subjected to the indignity of futile ventilation. And, fourthly, the nurses were spared the insult of caring for a cadaver. I am concerned lest the arguments of Dr D J Hill and others may so confuse the management of brain stem death that other patients, their families, and the nurses have inflicted on them avoidable mistreatment and distress of the sort that we did not have to endure. Let brain stem death be diagnosed competently, the consequences implemented confidently, and the families informed courageously. MARTIN COLEBROOK Bedford 1 Colebrook M. A son is killed. Br Med J 1983;287: 197 1-2.