1157 the administration of zinc in doubtful cases in syndrome is incomplete. BENJAMIN PORTNOY The Skin Hospital, MOHAMED MOLOKHIA Quay Street, Manchester M3 3HL.
URINE
not prevent
which the
ELEMENTAL DIETS
SIR,—Mr Thornton Holmes (Nov. 1, p. 874) criticises us for blurring the distinction between elemental and other liquid diets (Sept. 13, p. 507). The first, of course, contains nitrogen in the form of aminoacids,
that the gut is relieved of the in other liquid diets. We contend that there is little evidence for the advantage of elemental diets save in certain bowel disorders so
necessity for digesting the protein which is present
and possibly for patients under intensive care. Mr Thornton Holmes is wrong to suggest that a homogenised normal ward diet is cheaper, better, or easier to manage in hospitals lacking specialised support. Our costing figures suggest that the ’Caloreen/’Complan’ feed is considerably less expensive than food from the hospital kitchen. We administer tube feeds by constant drip throughout the 24 hours. A work study carried out by two of us (B.P. and S.M.H.) has shown a saving of one hour of nurse/dietitian time per patient per day, when this method is used, compared wih the old-fashioned method of syringing food down a Ryle’s tube. The use of 1-litre standard Winchester bottles with a special drip feed giving-set made for us by Avon Plastics has further reduced the nursing time involved in tube-feed administration. Homogenised ordinary food is too viscid to be given satisfactorily by constant drip and its administration is therefore wasteful of nursing time. In cases where balance data are important, the known electrolyte and mineral content of artificial liquid diets provides an additional advantage. Although, in our hospitals, the feeds are usually prepared by the diet-kitchen cook and then sent to the ward in bottles, the nurses on busy general wards have shown themselves quite capable of preparing these feeds themselves.
Nottingham City and General Hospitals.
A. M. WOOLFSON B. POLLARD S. M. HARDY S. P. ALLISON
Na+/K+
RATIOS IN SAMPLES TAKEN
3
HOURS AFTER
ADMINISTRATION OF WATER OR ETHANOL TO PREHYDRATED RATS
The administered volume was 30 ml/kg body-weight, and made 3 hours previously with water 30 ml/kg body-weight.
prehydrauon
was
system in a dose-dependent manner. There was an increase of over 100% in plasma-renin activity in volunteers after the ingestion of 1-5-2-3g ethanol per kg body-weight during 3 hours (Linkola et al., unpublished), but a clear decrease at 45 minutes when 0-75 g was ingested per kg body-weight, during half an hour (M. M. Nieminen et al., unpublished). Apparently, small amounts of ethanol do not trigger the release of aldosterone via the renin-angiotensin system as do large amounts. Thus, in addition to the mechanisms discussed elsewhere,1 the renin-angiotensin-aldosterone system should be regarded as an important factor when the reasons for electrolyte disturbances in beer drinkers are investigated.
giotensin-aldosterone
Research Laboratories of the State
Alcohol
Monopoly (Alko),
Box 350, SF-00101 Helsinki 10, and Minerva Institute for Medical Research, P.O.B. 819, SF-00101 Helsinki 10,
Finland.
J. LINKOLA
INFANTILE GASTROENTERITIS Dr J. A. WALKER-SMITH and his colleagues write: "Unforwe omitted in our article (Nov. 29, p. 1082) to give due acknowledgement to Mr K. N. Tsiquaye, Mrs Linda Fath-
tunately
alla, and other members of the Department of Microbiology
at
the London School of Hygiene, without whose valuable participation this survey could not have been carried out. Our apologies to these our colleagues."
Parliament NATRIURESIS AFTER DILUTED ETHANOL SOLUTIONS
SIR,—The commonly accepted belief that ethanol decreases Na+ and K+ excretion should be reconsidered for several reasons. Many reports support my suggestion that the hydration state needs elucidating when the excretion of Na+ and K+ is measured during ethanol intoxication.’ Another factor is surely the amount of ethanol administered. My findings (see accompanying table) show that, when water or different amounts of ethanol are given to prehydrated rats in the same volume, the Na+/K+ ratio of the urine collected during 3 hours varies greatly. It is high with small amounts of ethanol and low with large amounts. Dr Hilden and Dr Svensen (Aug. 9, p. 245), Demanet et al.,2 Daugharty,3 and Gwinup et al.4 have described electrolyte disturbances in beer drinkers. The mechanisms postulated as producing hyponatrxmia and hypokalsemia (I have discussed them in part in another context’) seem to be essentially the same in all these investigations. We have recently observed that ethanol affects the renin-an1. Linkola, J. Acta physiol. scand. 2 Demamet, J. C., Bonnyns, M.,
1974, 92, 212. Bleiberg, H., Stevens-Rockmans, C. Lancet.
1971, ii, 1115. 3. Daugharty, T. M. Calif. Med. 1972, 116, 77. 4. Gwinup, G., Chelvam, R., Jabola, R., Meister, L. ibid. p 78.
QUESTION TIME Firework
Safety
New measures aimed at reducing the hazard of fireworks were announced in a written answer in the House of Commons on Nov. 25. Mr ALAN WILLIAMS, Minister of State for Prices and Consumer Protection, said that, following careful consideration of all the views submitted in response to the consultative document on firework safety issued in April, and discussions with the principal bodies concerned, the Government had decided to strengthen existing controls. Legislation would be introduced to raise from 13 to 16 the apparent age of people to whom it was permitted to sell fireworks, and to increase from C20 to 200 the maximum penalties for the offence of selling fireworks to children below the specified age and of throwing or discharging fireworks in the street. An order would be laid under the Local Government Act 1974 to remove the statutory maximum from the fee charged for registering premises where fireworks could be kept, and to empower local authorities to determine the charge in their own areas. Other measures would be achieved by voluntary agreement with the manufacturers and with the retailers’ and wholesalers’ associations. Flyabout or helicopter types of fireworks would be phased out of production and cease to be available; the production of bangers, which were the fireworks most li-
URINE
not prevent
which the
ELEMENTAL DIETS
SIR,—Mr Thornton Holmes (Nov. 1, p. 874) criticises us for blurring the distinction between elemental and other liquid diets (Sept. 13, p. 507). The first, of course, contains nitrogen in the form of aminoacids,
that the gut is relieved of the in other liquid diets. We contend that there is little evidence for the advantage of elemental diets save in certain bowel disorders so
necessity for digesting the protein which is present
and possibly for patients under intensive care. Mr Thornton Holmes is wrong to suggest that a homogenised normal ward diet is cheaper, better, or easier to manage in hospitals lacking specialised support. Our costing figures suggest that the ’Caloreen/’Complan’ feed is considerably less expensive than food from the hospital kitchen. We administer tube feeds by constant drip throughout the 24 hours. A work study carried out by two of us (B.P. and S.M.H.) has shown a saving of one hour of nurse/dietitian time per patient per day, when this method is used, compared wih the old-fashioned method of syringing food down a Ryle’s tube. The use of 1-litre standard Winchester bottles with a special drip feed giving-set made for us by Avon Plastics has further reduced the nursing time involved in tube-feed administration. Homogenised ordinary food is too viscid to be given satisfactorily by constant drip and its administration is therefore wasteful of nursing time. In cases where balance data are important, the known electrolyte and mineral content of artificial liquid diets provides an additional advantage. Although, in our hospitals, the feeds are usually prepared by the diet-kitchen cook and then sent to the ward in bottles, the nurses on busy general wards have shown themselves quite capable of preparing these feeds themselves.
Nottingham City and General Hospitals.
A. M. WOOLFSON B. POLLARD S. M. HARDY S. P. ALLISON
Na+/K+
RATIOS IN SAMPLES TAKEN
3
HOURS AFTER
ADMINISTRATION OF WATER OR ETHANOL TO PREHYDRATED RATS
The administered volume was 30 ml/kg body-weight, and made 3 hours previously with water 30 ml/kg body-weight.
prehydrauon
was
system in a dose-dependent manner. There was an increase of over 100% in plasma-renin activity in volunteers after the ingestion of 1-5-2-3g ethanol per kg body-weight during 3 hours (Linkola et al., unpublished), but a clear decrease at 45 minutes when 0-75 g was ingested per kg body-weight, during half an hour (M. M. Nieminen et al., unpublished). Apparently, small amounts of ethanol do not trigger the release of aldosterone via the renin-angiotensin system as do large amounts. Thus, in addition to the mechanisms discussed elsewhere,1 the renin-angiotensin-aldosterone system should be regarded as an important factor when the reasons for electrolyte disturbances in beer drinkers are investigated.
giotensin-aldosterone
Research Laboratories of the State
Alcohol
Monopoly (Alko),
Box 350, SF-00101 Helsinki 10, and Minerva Institute for Medical Research, P.O.B. 819, SF-00101 Helsinki 10,
Finland.
J. LINKOLA
INFANTILE GASTROENTERITIS Dr J. A. WALKER-SMITH and his colleagues write: "Unforwe omitted in our article (Nov. 29, p. 1082) to give due acknowledgement to Mr K. N. Tsiquaye, Mrs Linda Fath-
tunately
alla, and other members of the Department of Microbiology
at
the London School of Hygiene, without whose valuable participation this survey could not have been carried out. Our apologies to these our colleagues."
Parliament NATRIURESIS AFTER DILUTED ETHANOL SOLUTIONS
SIR,—The commonly accepted belief that ethanol decreases Na+ and K+ excretion should be reconsidered for several reasons. Many reports support my suggestion that the hydration state needs elucidating when the excretion of Na+ and K+ is measured during ethanol intoxication.’ Another factor is surely the amount of ethanol administered. My findings (see accompanying table) show that, when water or different amounts of ethanol are given to prehydrated rats in the same volume, the Na+/K+ ratio of the urine collected during 3 hours varies greatly. It is high with small amounts of ethanol and low with large amounts. Dr Hilden and Dr Svensen (Aug. 9, p. 245), Demanet et al.,2 Daugharty,3 and Gwinup et al.4 have described electrolyte disturbances in beer drinkers. The mechanisms postulated as producing hyponatrxmia and hypokalsemia (I have discussed them in part in another context’) seem to be essentially the same in all these investigations. We have recently observed that ethanol affects the renin-an1. Linkola, J. Acta physiol. scand. 2 Demamet, J. C., Bonnyns, M.,
1974, 92, 212. Bleiberg, H., Stevens-Rockmans, C. Lancet.
1971, ii, 1115. 3. Daugharty, T. M. Calif. Med. 1972, 116, 77. 4. Gwinup, G., Chelvam, R., Jabola, R., Meister, L. ibid. p 78.
QUESTION TIME Firework
Safety
New measures aimed at reducing the hazard of fireworks were announced in a written answer in the House of Commons on Nov. 25. Mr ALAN WILLIAMS, Minister of State for Prices and Consumer Protection, said that, following careful consideration of all the views submitted in response to the consultative document on firework safety issued in April, and discussions with the principal bodies concerned, the Government had decided to strengthen existing controls. Legislation would be introduced to raise from 13 to 16 the apparent age of people to whom it was permitted to sell fireworks, and to increase from C20 to 200 the maximum penalties for the offence of selling fireworks to children below the specified age and of throwing or discharging fireworks in the street. An order would be laid under the Local Government Act 1974 to remove the statutory maximum from the fee charged for registering premises where fireworks could be kept, and to empower local authorities to determine the charge in their own areas. Other measures would be achieved by voluntary agreement with the manufacturers and with the retailers’ and wholesalers’ associations. Flyabout or helicopter types of fireworks would be phased out of production and cease to be available; the production of bangers, which were the fireworks most li-
