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Objective To determine whether dietary interventions that increase n-3 fatty acids with and without reduction in n-6 linoleic acid can alter circulating lipid mediators implicated in headache pathogenesis, and decrease headache in adults with migraine. Design Three arm, parallel group, randomized, modified double blind, controlled trial. Setting Ambulatory, academic medical center in the United States over 16 weeks. Participants 182 participants (88% women, mean age 38 years) with migraines on 5-20 days per month (67% met criteria for chronic migraine). Interventions Three diets designed with eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and linoleic acid altered as controlled variables: H3 diet (n=61)—increase EPA+DHA to 1.5 g/day and maintain linoleic acid at around 7% of energy; H3-L6 diet (n=61)—increase n-3 EPA+DHA to 1.5 g/day and decrease linoleic acid to ≤1.8% of energy; control diet (n=60)—maintain EPA+DHA at Main outcome measures The primary endpoints (week 16) were the antinociceptive mediator 17-hydroxydocosahexaenoic acid (17-HDHA) in blood and the headache impact test (HIT-6), a six item questionnaire assessing headache impact on quality of life. Headache frequency was assessed daily with an electronic diary. Results In intention-to-treat analyses (n=182), the H3-L6 and H3 diets increased circulating 17-HDHA (log ng/mL) compared with the control diet (baseline-adjusted mean difference 0.6, 95% confidence interval 0.2 to 0.9; 0.7, 0.4 to 1.1, respectively). The observed improvement in HIT-6 scores in the H3-L6 and H3 groups was not statistically significant (−1.6, −4.2 to 1.0, and −1.5, −4.2 to 1.2, respectively). Compared with the control diet, the H3-L6 and H3 diets decreased total headache hours per day (−1.7, −2.5 to −0.9, and −1.3, −2.1 to −0.5, respectively), moderate to severe headache hours per day (−0.8, −1.2 to −0.4, and −0.7, −1.1 to −0.3, respectively), and headache days per month (−4.0, −5.2 to −2.7, and −2.0, −3.3 to −0.7, respectively). The H3-L6 diet decreased headache days per month more than the H3 diet (−2.0, −3.2 to −0.8), suggesting additional benefit from lowering dietary linoleic acid. The H3-L6 and H3 diets altered n-3 and n-6 fatty acids and several of their nociceptive oxylipin derivatives in plasma, serum, erythrocytes or immune cells, but did not alter classic headache mediators calcitonin gene related peptide and prostaglandin E2. Conclusions The H3-L6 and H3 interventions altered bioactive mediators implicated in headache pathogenesis and decreased frequency and severity of headaches, but did not significantly improve quality of life. Trial registration ClinicalTrials.gov NCT02012790

John Crispin Townsend (“Cris”) was born in Rutland, a special place to him all his life. He started work as a laboratory technician, serving Northampton, but realised his future lay in medicine. As a mature student he entered the 1st MB year at Sheffield University …

OBJECTIVE--To audit the accuracy and impact on the frequency of operation of fine needle aspiration cytology of isolated thyroid swellings. DESIGN--Prospective analysis over six years of cytological predictions compared with histological findings. SETTING--Thyroid clinic serving the Grampian region. PATIENTS--395 Consecutive patients presenting with an isolated thyroid swelling, 307 of whom underwent surgical excision. Analysis was confined to a subgroup of 283 patients with satisfactory aspirates who were operated on. RESULTS--The positive predictive value of aspiration cytology for detecting malignant disease was 100% and the sensitivity 83%. The sensitivity for the detection of neoplasia (frank malignancy together with follicular adenomas) was 76%. The specificity was 58% and the overall accuracy 69%. Recalculation of data in previous papers with strict criteria showed the accuracy of aspiration cytology to be variable and lower than is widely accepted. Since the introduction of aspiration cytology 21% fewer operations for isolated thyroid swellings have been performed. CONCLUSIONS--As a basis of selection for surgical excision of isolated thyroid swellings according to prediction of neoplasia fine needle aspiration cytology is less reliable than is widely accepted. It is an adjunct to management rather than a definitive test, and negative cytological results do not exclude neoplastic disease. Further study should take account of the implications of repeated clinic attendances for review and aspiration as these may culminate in delayed surgical treatment.

disease in an epidemiologic study. AmJ Cardiol 1970;25:325-8. 7 Kreger BE, Cupples LA, Kannel WB. The electrocardiogram in prediction of sudden death: Framingham study experience. Am Heart J 1987;113:377-82. 8 Rabkin SW, Mathewson FAL, T?te RB. The electrocardiogram in apparently healthy men and the risk of sudden death. Br Heart J 1982;47:546-52. 9 Kagan A, Yano K, Reed DM, MacLean CJ. Predictors of sudden cardiac death among Hawaiian-Japanese men. AmJ Epidemiol 1989;130:268-77. 10 Vandenbroucke JP, Matroos AW, Van der Heide-Wessel C, Van der Heide RM. Parental survival, an independent predictor of longevity in middle aged persons. Am J Epidemiol 1984;119:742-50. 11 Miettinen OS. Theoretical epidemiology. Principles of occurrence research in medicine. Chichester: Wiley, 1985. 12 Miettinen OS. Design options in epidemiologic research. An update. ScandJ Work Environ Health 1982; suppl 1:7-14. 13 Miettinen OS. The "case-control" study: valid selection of subjects. J Chrome Dis 1985;38:543-8. 14 van der Heide RF. Resultaten van een geneeskundig onderzoek van 3091 gezonde mannen en vrouwen, 40-65 jaar oud [PhD thesis]. Amsterdam: University of Amsterdam, 1959. 143 pp. 15 Manual of the international statistical classification of diseases, injuries, and causes of death. 9th ?d. Vol 1. Geneva: World Health Organisation, 1977. 16 Greenland S. Adjustment of risk ratios in case-base studies (hybrid epidemio logic designs). StaiMed 1986;5:579-84. 17 Fortuin NJ, Friesinger GC. Exercise-induced ST-segment elevation. Clinical, electrocardiographic and art?riographie studies in twelve patients. AmJMed 1979;49:459-64. 18 Bruce RA, Fisher LD, Pettinger M, Weiner DA, Chaitman BR. ST segment elevation with exercise: a marker for poor ventricular function and poor prognosis. Coronaryartery surgery study (CASS) confirmation of Seattle heart watch results. Circulation 1988;77:897-905. 19 Ellestad MH. Stress testing. Principles and practice. Philadelphia: F Davis, 1980:95-102. 20 Quyyumi AA, Wright C, Fox K. Ambulatory electrocardiographic ST segment changes in healthy volunteers. Br Heart J 1983;50:460-4. 21 Bruce RA, Irving JB. Exercise electrocardiography. In: Hurst W, ed. The heart, arteries and veins. 4th ed. New York: McGraw-Hill, 1978.

Editor—Stewart et al reported that an excess of deaths related to intrapartum care occurred outside office hours.1 In a recent audit done over four months we found that routine neonatal care on our unit was suboptimal at weekends compared with weekdays. Altogether 760 (82.7%) of 919 women had their babies examined by a neonatal senior house officer before they were discharged by their obstetrician during weekdays, compared with only 150 (53.8%) of 279 women at weekends. Forty (14.3%) women had to wait between two and six hours for their babies to be examined at weekends, compared with 77 (8.4%) during the week. Our aim should be to deliver the same standard of neonatal care—both acute and non-acute—at all times. This may require increases in the numbers of senior house officers working in neonatal units at weekends. Alternatively, an extended role for midwives could include performing routine neonatal examinations. This would free neonatal senior house officers for acute neonatal care, especially at weekends.

EDITOR, - K Spencer and colleagues' claims for prenatal detection of trisomy 18 by measurement of maternal serum (alpha) fetoprotein and free β human chorionic gonadotrophin concentrations are impressive.1 Detection of 50% of cases for a false positive rate of only 1% seems to compare favourably with the detection rate for Down's syndrome when similar techniques are used, which is 70% for a false positive rate of 5%. Unfortunately, the authors fail to emphasise the importance of the relative incidence of the two conditions at birth before concluding that screening for trisomy 18 should be introduced. The natural incidence of Down's syndrome at birth is approximately 12.6/10 000 births.2 Among 10 000 pregnant women a 70% sensitivity would result in 8.8 cases being detected at the …

EDITOR, - Susan J McDonald and colleagues conclude that there are “few advantages but several disadvantages for the routine use of oxytocinergometrine when prophylactic active managemant of the third stage of labour is pracyised.” 2 The disadvantages were significantly higher rates of nausea, vomiting and high blood pressure measured in a labour ward. The results suggested, however, if women received oxytocin alone an additional 8-11 women per 1000 would experience a severe postpartum haemorrhage. This is roughly one patient a week in an average hospital with 5000 deliveries a year. Although this increased incidence did not reach significance, it might have done had more women been recruited to the trail, as suggested by the results of meta-analysis2 As the authors point out, postpartum haemorrhage is an important cause of death both in Britain and, more particularly, in the Third World. As it is far more important than the transient side effects that did reach significance, I believe …