365 I would instead make a plea for research bodies, universities, and appointment committees to pay rather more attention to the intrinsic standard of methodology and non-triviality in papers and not just their numbers. This does mean reading them and often re-reading them rather than just counting them.
Hospital, Uxbridge Road, St. Bernard’s
GERALD SILVERMAN
Southall, Middlesex UB1 3EU
All the patients were given elemental diets for 4-6 months. The nitrogen intake was 12 g/day in the patients with active disease and 10 g/day in the postoperative patients. The highnitrogen preparation of ’Vivonex’ was used, and each g of nitrogen was dissolved in 150 ml of fluid, but the total daily fluid intake was not given as elemental diet. Further studies are required to compare elemental diets with other liquid diets and with normal food in patients with varying degrees of alimentary failure. University Department of Surgery, ANTHONY GOODE Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP. IVAN D. A. JOHNSTON
ELEMENTAL DIETS IN CROHN’S DISEASE
SIR,-We agree with the conclusions of Mr Goode and his colleagues (Jan. 17, p. 122) (which apply to many other clinical situations apart from Crohn’s disease) that (1) adequate nutrition is advantageous and (2) measurement of body-fat, lean body-mass, total body-potassium, and serum-proteins add little to clinical assessment from regular weighing of the patient. However, we question the assumption, implicit in the paper, that in small-bowel disease nitrogen is best absorbed in the form of aminoacids. There seems to be little evidence to support the use of "elemental" diets rather than supplementary feeds containing whole protein. Mathews’ has adduced evidence that nitrogen is absorbed by two different mechanisms: (1) intraluminal digestion of protein to aminoacids which are then absorbed and (2) mucosal uptake of dipeptides and tripeptides which undergo intracellular breakdown with release of aminoacids into the circulation. Adibi et al.1 have suggested that in small-bowel disease aminoacid absorption is impaired, whereas peptide absorption is preserved. Whole protein, unlike aminoacids, is not unpalatable and is a great deal less expensive. At the recommended dose ’Vivonex HN’ costs about 12 per day. The cost of feeding Mr Goode’s 8 patients for 1000 days can readily be calculated. The same amount of nitrogen and more calories could have been supplied in a more palatable form by giving ’Caloreen’ and’Complan’ at a cost of only 1per day. We agree with the final sentence of this paper that "studies comparing elemental diets with other liquid diets in Crohn’s disease are indicated". A. M. J. WOOLFSON M. S. KNAPP S. P. ALLISON
Nottingham City and General Hospitals
ANTIBIOTICS FOR COMMON COLDS?
SIR,-Though I
am
my own
I can state withyears (now aged 62), four days or less, and
"guineapig",
dissimulation that during the past 15
out
I have reduced all my common colds to with no more discharge than clear, watery mucus throughout the attack. This is done from the first dry mucosal inconvenience or mucosal itch, by spray insufflation-two deep sniffs per nostril, and two deep inhalations for laryngotracheal mucosa, half-hourly for three days during waking hourswith the following solution: neomycin sulphate 0 - I%, gramicidin 0.005%, histazylamine 1.00%, and phenylephrine hydrochloride 0-25%. I never consume alimentary (oral) antibiotics. I am convinced, now that I have treated my own nasal, pharyngeal, laryngeal, and tracheal mucosae so many times against the disabling effects of coryza, that these unpleasant and sometimes inconvenient attacks can be aborted by this simple topical application. In other words, the common cold, if anticipated intelligently, would never be a curse to any individual who had this solution. Department of Pathology, Torbay Hospital, Torquay TQ2 7AA.
PETER WARREN
POTASSIUM-INDUCED STRICTURE OF THE SMALL BOWEL
SiR,—Dr Learmonth and Mr Weaver (Jan. 31, p. 251) seem believe that potassium chloride is inevitably present in a slow-release base when it is combined with other drugs. In fact,
to
SIR,-The case reported by Mr Goode and his colleagues (Jan. 17, p. 122) is impressive, but what about the other seven, and the two control patients? I hope you will allow the authors to give some details of these, together with the volumes of the elemental diets ("Vivonex" standard or high-nitrogen?) they received, and how long. Department of Pharmacology and Therapeutics, London Hospital Medical College, Turner Street, London E12AD
’,* This letter has been shown whose reply follows.-ED.L.
to
ANDREW HERXHEIMER
the Newcastle group,
StR,-Our report is part of a detailed evaluation of elemenpatients with severe weight loss and active Crohn’s
tal diets in
disease. The rate of restoration of lean tissue mass in the three patients with active disease was equal and amounted to 10% per month. Six further
patients were studied postoperatively; elemental diet and two received normal given rate of restoration of lean tissue mass was identical m patients (18% per month) but was significantly greater than that in the patients with active disease. four were diets. The
2
potassium chloride in ’Salupres’, cited in two of their
four enteric-coated formulation. Intestinal ulceration caused by enteric-coated potassium-chloride tablets is well documented.1-3 The diuretic/potassium combined preparation ’Hydrosaluric K’ has also been assumed to contain slow-release potassium when, in fact, it contains enteric-coated potassium chloride.4 The requirement for routine potassium supplementation in diuretic-treated hypertensive patients has been questioned, especially in patients not receiving digoxin.’6However, where potassium supplements are definitely required it would seem appropriate to avoid the two preparations mentioned above. The recent evidence of ulcerative reactions and strictures with slow-release potassium preparations, especially where there is delayed intestinal transit,7 means that this form of potassium cases, is present
is
not
as an
completely without danger.
Drug Information Centre, Department of Pharmacy, Southmead Hospital, Bristol, BS10 5NB.
R. A. MOORHOUSE
an
in Peptide Transport in Protein Nutrition (edited by D. M. Mathews and J. W. Payne); p. 61. Amsterdam, 1975. Adibi, S. A., Fogel, M., Agrawal, R. Gastroenterology, 1973, 64, 688.
1. Mathews, D. M.
the
1. Dulake, L. Practitioner, 1966, 196, 289. 2. Wayte, D. M., Helwig, E. Am. J. clin Path. 1968, 49, 26. 3. Delaney, T., Hoxworth, P. Surgery Gynec. Obstet. 1968, 127, 76. 4. Moorhouse, R. A. Br. med. J. 1975, iii, 562. 5. British Medical Journal, 1974, iv, 307. 6. Kosman, M. J. Am. med. Ass. 1974, 230, 743. 7. Farquharson-Roberts, M., Giddings, A., Nunn, A. Br. med. J. 1975,
iii, 206.
Hospital, Uxbridge Road, St. Bernard’s
GERALD SILVERMAN
Southall, Middlesex UB1 3EU
All the patients were given elemental diets for 4-6 months. The nitrogen intake was 12 g/day in the patients with active disease and 10 g/day in the postoperative patients. The highnitrogen preparation of ’Vivonex’ was used, and each g of nitrogen was dissolved in 150 ml of fluid, but the total daily fluid intake was not given as elemental diet. Further studies are required to compare elemental diets with other liquid diets and with normal food in patients with varying degrees of alimentary failure. University Department of Surgery, ANTHONY GOODE Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP. IVAN D. A. JOHNSTON
ELEMENTAL DIETS IN CROHN’S DISEASE
SIR,-We agree with the conclusions of Mr Goode and his colleagues (Jan. 17, p. 122) (which apply to many other clinical situations apart from Crohn’s disease) that (1) adequate nutrition is advantageous and (2) measurement of body-fat, lean body-mass, total body-potassium, and serum-proteins add little to clinical assessment from regular weighing of the patient. However, we question the assumption, implicit in the paper, that in small-bowel disease nitrogen is best absorbed in the form of aminoacids. There seems to be little evidence to support the use of "elemental" diets rather than supplementary feeds containing whole protein. Mathews’ has adduced evidence that nitrogen is absorbed by two different mechanisms: (1) intraluminal digestion of protein to aminoacids which are then absorbed and (2) mucosal uptake of dipeptides and tripeptides which undergo intracellular breakdown with release of aminoacids into the circulation. Adibi et al.1 have suggested that in small-bowel disease aminoacid absorption is impaired, whereas peptide absorption is preserved. Whole protein, unlike aminoacids, is not unpalatable and is a great deal less expensive. At the recommended dose ’Vivonex HN’ costs about 12 per day. The cost of feeding Mr Goode’s 8 patients for 1000 days can readily be calculated. The same amount of nitrogen and more calories could have been supplied in a more palatable form by giving ’Caloreen’ and’Complan’ at a cost of only 1per day. We agree with the final sentence of this paper that "studies comparing elemental diets with other liquid diets in Crohn’s disease are indicated". A. M. J. WOOLFSON M. S. KNAPP S. P. ALLISON
Nottingham City and General Hospitals
ANTIBIOTICS FOR COMMON COLDS?
SIR,-Though I
am
my own
I can state withyears (now aged 62), four days or less, and
"guineapig",
dissimulation that during the past 15
out
I have reduced all my common colds to with no more discharge than clear, watery mucus throughout the attack. This is done from the first dry mucosal inconvenience or mucosal itch, by spray insufflation-two deep sniffs per nostril, and two deep inhalations for laryngotracheal mucosa, half-hourly for three days during waking hourswith the following solution: neomycin sulphate 0 - I%, gramicidin 0.005%, histazylamine 1.00%, and phenylephrine hydrochloride 0-25%. I never consume alimentary (oral) antibiotics. I am convinced, now that I have treated my own nasal, pharyngeal, laryngeal, and tracheal mucosae so many times against the disabling effects of coryza, that these unpleasant and sometimes inconvenient attacks can be aborted by this simple topical application. In other words, the common cold, if anticipated intelligently, would never be a curse to any individual who had this solution. Department of Pathology, Torbay Hospital, Torquay TQ2 7AA.
PETER WARREN
POTASSIUM-INDUCED STRICTURE OF THE SMALL BOWEL
SiR,—Dr Learmonth and Mr Weaver (Jan. 31, p. 251) seem believe that potassium chloride is inevitably present in a slow-release base when it is combined with other drugs. In fact,
to
SIR,-The case reported by Mr Goode and his colleagues (Jan. 17, p. 122) is impressive, but what about the other seven, and the two control patients? I hope you will allow the authors to give some details of these, together with the volumes of the elemental diets ("Vivonex" standard or high-nitrogen?) they received, and how long. Department of Pharmacology and Therapeutics, London Hospital Medical College, Turner Street, London E12AD
’,* This letter has been shown whose reply follows.-ED.L.
to
ANDREW HERXHEIMER
the Newcastle group,
StR,-Our report is part of a detailed evaluation of elemenpatients with severe weight loss and active Crohn’s
tal diets in
disease. The rate of restoration of lean tissue mass in the three patients with active disease was equal and amounted to 10% per month. Six further
patients were studied postoperatively; elemental diet and two received normal given rate of restoration of lean tissue mass was identical m patients (18% per month) but was significantly greater than that in the patients with active disease. four were diets. The
2
potassium chloride in ’Salupres’, cited in two of their
four enteric-coated formulation. Intestinal ulceration caused by enteric-coated potassium-chloride tablets is well documented.1-3 The diuretic/potassium combined preparation ’Hydrosaluric K’ has also been assumed to contain slow-release potassium when, in fact, it contains enteric-coated potassium chloride.4 The requirement for routine potassium supplementation in diuretic-treated hypertensive patients has been questioned, especially in patients not receiving digoxin.’6However, where potassium supplements are definitely required it would seem appropriate to avoid the two preparations mentioned above. The recent evidence of ulcerative reactions and strictures with slow-release potassium preparations, especially where there is delayed intestinal transit,7 means that this form of potassium cases, is present
is
not
as an
completely without danger.
Drug Information Centre, Department of Pharmacy, Southmead Hospital, Bristol, BS10 5NB.
R. A. MOORHOUSE
an
in Peptide Transport in Protein Nutrition (edited by D. M. Mathews and J. W. Payne); p. 61. Amsterdam, 1975. Adibi, S. A., Fogel, M., Agrawal, R. Gastroenterology, 1973, 64, 688.
1. Mathews, D. M.
the
1. Dulake, L. Practitioner, 1966, 196, 289. 2. Wayte, D. M., Helwig, E. Am. J. clin Path. 1968, 49, 26. 3. Delaney, T., Hoxworth, P. Surgery Gynec. Obstet. 1968, 127, 76. 4. Moorhouse, R. A. Br. med. J. 1975, iii, 562. 5. British Medical Journal, 1974, iv, 307. 6. Kosman, M. J. Am. med. Ass. 1974, 230, 743. 7. Farquharson-Roberts, M., Giddings, A., Nunn, A. Br. med. J. 1975,
iii, 206.
