1. Rodriguez-Erdmann F, Levitan R: Gastrointestinal and roentgenologic manifestations of Henoch-Schonlein purpura. Gastroenterology

54:260-264, 1968.

2. Spiro HM: Clinical Gastroenterology. New York, Macmillan Co, 1970. 3. Handel J, Schwartz S: Gastrointestinal

manifestations of the Schonlein-Henoch syndrome: Roentgenologic findings. Am J Radiol 78:643-652, 1957. 4. Yentis I: Henoch-Schonlein purpura mimicking acute appendicitis and Crohn's disease. Br J Radiol 46:555-556, 1973.

Nutritional Supplementation in Fibrosis

Cystic

Sir.\p=m-\Thevalue of nutritional supplementation in cystic fibrosis (CF) has been raised in the February issue of

the Journal (129:165, 1975). The results of one year of "complete" dietary supplementation in patients with CF receiving enzyme replacement were described as promising, but "not definitive." When experimental and control groups were compared, the progression of changes in the chest roentgenograms was similar in both groups, and no significant difference was found in the rates of increase of height. Duke Medical Center and the National Institutes of Health have analyzed the maximum achieved heights

of 60 persons with CF 20 years old.1 Both parameters were markedly skewed toward the lower percentile bands (Figure). No significant differences were found among patients whose condition was diagnosed early in life, in those with and

weights

over

more severe

pulmonary

or

gastroin¬

testinal impairment, or among those in whom pancreatic enzyme and/or nutritional supplementation had been employed. Nutritional supplementa¬ tion has yet to be proven a significant long-term influence on the morbidity or mortality of CF. CLIFFORD W. LOBER, MD Department of Medicine Mayo Clinic Rochester, MN 55901 1. Lober CW, Wood RE, di Sant'Agnese PA, et al: Patterns of presentation of cystic fibrosis of the pancreas seen in patients over age 20. Presented at the 40th annual meeting of the American College of Chest Physicians, New Orleans, Nov 5,1974. 2. Vaughan VC III: Growth and development, in Nelson WE, Vaughan VC, McKay RJ (eds): Textbook of Pediatrics. Philadelphia, WB Saunders Co, 1969, p 15. 3. Montoye HJ, Epstein FH, Kjelsberg MO: The measurement of body fatness: A study in total community. Am J Clin Nutr 16:417-427,1965.

In Reply.\p=m-\Loberreported data on 60 persons with cystic fibrosis (CF) over 20 years of age, while our population

Percentile distribution of maximum achieved heights and weights of 60 persons over age 20 with cystic fibrosis. Percentiles determined by comparison with Iowa growth charts up to age 182; extrapolated beyond age 18 by comparison with figures published by Montoye et al.3

MAXIMUM ACHIEVED HEIGHTS AND WEIGHTS

of 63 individuals contained only three who were over 15 years old. The median age of death in patients with CF is 12 years. It is not realistic to compare patients who have survived to adulthood with a younger group. He did not state the type of nutritional supplementation that was of no significance among his patients. Our experience with nutritional supplements other than the amino acid\x=req-\ glucose polymer mixture has been equally poor. The diet of predigested nutrients was given to patients in our clinic whose clinical condition was severe and for whom the prognosis in terms of survival to age 20 was not good. Our data on growth rates were similar to those of Lober in that both heights and weights were skewed toward the lower end, and height was less affected than weight. Increased rates of linear growth were observed in eight of 13 children under 12 years of age at the time the dietary supple¬ ment was begun. These children had failed to grow in height during the previous year. Patients who continue to take the nutritional supplement have not shown further deterioration in pulmonary status. It is not likely that advanced pulmonary changes in patients with severe manifestations of the disease are reversible, but they might be prevented or minimized. Long-term studies of the effects of the predigested dietary supplement, begun early in life, should be under¬ taken to assess its value in decreasing morbidity and mortality in CF. HELEN K. BERRY, MA Institute for Developmental Research Children's Hospital Research Foundation Cincinnati, OH 45229 Lumbar Punctures and

1%

10% 25%

50% 75% 90% 99%

Percentile Band

100%

Meningitis

Sir.\p=m-\Itis hard for me to discern exactly what hypothesis Fischer et al were testing in their recent article, "Lumbar Punctures and Meningitis" (129:590-592, 1975). In their cases 1 through 3 there is no evidence that the lumbar puncture itself contributed in any way to the subsequent manifestation of meningitis in these bacteremic children. It is reasonable to expect that certain microorganisms, after seeding the bloodstream, may infect the meninges. In newborns, essentially every organism\p=m-\ Escherichia coli with capsular anti-

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Letter: Nutritional supplementation in cystic fibrosis.

1. Rodriguez-Erdmann F, Levitan R: Gastrointestinal and roentgenologic manifestations of Henoch-Schonlein purpura. Gastroenterology 54:260-264, 1968...
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