he was taking a minimum of 256 units daily. Thereafter the dosage dropped progressively, but seven weeks later he still needed up to 188 units daily. He was then transferred to Actrapid MC. In three days his insulin requirement fell by 36 % to 102 units daily. He was stabilised on twice daily Actrapid MC in a total dose of 112-124 units daily and remained well controlled, with a mean mid-morning blood sugar level of 6-1 mmol/l (110 mg/ 100 ml). His

The activities of serum aspartate and alanine aminotransferases were measured in protein energy malnutrition (PEM). These enzyme activities were both increased in PEM and fell as recovery was established. There was a marked reduction in the serum albumin level, and an inverse relationship was observed between the serum albumin levels and the enzyme activities. The relationship is discussed in the light of the hepatocellular damage of PEM. The assay of these enzyme activities along with estimation of serum albumin in PEM will prove very useful in the diagnosis of the liver damage that may occur in PEM before clinical manifestations are established.

Aim-To evaluate the clinical usefulness of the thyrotropin releasing hormone (TRH) test and estimation of thyroid autoantibody concentrations in patients with borderline raised thyroid stimulating hormone (TSH). Methods-The records of 34 consecutive patients with persistent borderline increased TSH (4.4-9.9 mU/l) referred to the Medical Investigation Unit were reviewed. MethodsThe records of 34 (30 women and four men) consecutive patients referred over an 18 month period were reviewed. The patients were aged between 23 and 80 years (58+13-9 SEM). All of the patients had borderline raised TSH concentrations (4 4-9-9 mU/l) on at least two occasions three to six months apart.Total thyroxine was measured by radioimmunoassay (Immunodiagnostic Systems Ltd, Tyne and Wear, UK); TSH was measured using a coated tube immunoradiometric assay (Immunodiagnostic Systems Ltd). Interassay precision (coefficient of variation) for the TSH assay was 7% at 3 9 mU/l and 6% at 26-5 mU/l. Thyroglobulin antibodies and thyroid microsomal antibodies were assessed by passive haemagglutination using Serodia kits (Fujirebio Inc., Tokyo, Japan). The TRH test was performed by intravenous administration of200 ,ug TRH and blood samples were collected at zero, 20 and 60 minutes.The indices used in the diagnosis of hypothyroidism were increment of TSH >30 mU/l, 20 minute TSH >35 mU/l or a proportional rise (20 minute TSH/basal TSH >6). ResultsAdministration of TRH was well tolerated by all of the patients and no side effects were reported. The mean total thyroxine concentration in the patients was 92+ 2-7 (SEM) nmol/l (range 60-112 nmol/1). Using linear regression analysis, there was good correlation between the indices used for the diagnosis of hypothyroidism (r. 0-76; p<0 001). Basal TSH alone was poorly correlated with these indices (r<0 145; p.<046)

affected the upper temporal quadrant of the left eye the next day. He described transient pain in his knuckles at the same time that he was aware of blurred vision. Direct questioning established a history of rheumatic fever at the age of 5 years.On examination he was an obese male Caucasian with no jaundice, cyanosis, purpuric rashes, splinter haemorrhages, or digital clubbing. His pulse was 80 and regular, and his blood pressure was 120/90 mm Hg. In addition to normal first and second heart sounds he had a harsh apical systolic murmur. All peripheral pulses were palpable and his chest was clinically clear. The central nervous system was normal. His visual acuity was 6/5 without correction in both eyes and the visual fields were full. Fundus examination showed no features of embolism or retinal ischaemia. Investigations included a chest x ray, electrocardiogram, erythrocyte sedimentation rate, full blood count, lipid profile, serum electrolytes and urea, blood cultures, and thyroid function tests, which were all normal. Urine analysis revealed blood + + + + and protein + + but midstream urine microscopy and culture were negative. Carotid Doppler echography showed a higher than normal peak systolic frequency in the left external carotid artery. His echocardiogram demonstrated a large mobile mass prolapsing through the mitral valve (Fig 1). A pedunculated cylindrical myxoma, 15 cm long, was surgically removed from the left atrium (Fig 2).Two months later the visual acuity remained normal at 6/5 in each eye. Fundus examination revealed several minute superficial retinal haemorrhages just behind the ora serrata in both eyes. A small choroidoretinal scar was identified in the mid-periphery of the retina at the 10 o'clock meridian in the right eye.

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