583 catheter and

measure

the

opening

graduated column, allowing

pressure

water to

by filling

up the

RISING RATES OF CONGENITAL DISLOCATION OF THE HIP?

flow, and noting the pres-

which the flow stops. This is a very satisfactory method (provided there is a fourth lumen on the Sengstaken tube to suck away any fluid collecting in the oesophagus). Sengstaken tubes are now being made in a variety of new materials, and the inflation pressure will vary greatly with the elasticity of the balloons. If a balloon is resterilised, the rubber may become less rigid and may reach a greater size before reaching the same pressure. We think that the simple catheter method, using an open syringe or central-venous-pressure line rather than a strain-gauge, has fewer inherent dangers than inflating the balloon to an arbitrary pressure which bears no direct relation to the pressure required to stop the bleeding. sure at

Professorial Department of Surgery, Charing Cross Hospital Medical School, London W6 8RF

ALAN G. JOHNSON C. J. C. KIRK

SIR,—Seasonal variation in the incidence of congenital dislocation of the hip (C.D.H.)—i.e., births with C.D.H. occurring

frequently during cold months than during warm reported in studies from Israel.’2 As suggested Cohen3 we by analysed the data from our monitoring programme for the ten-year period 1966-75 and found that rates of births with C.D.H. during the cold months November to January were even lower (65/1000 births or 54out of 8275) than during May to July (12-9/1000 or 99 out of 7649). In addition, more

ones-has been

have not observed any season, or even month, in each of the years under study in which the rates were consistently higher than in others. This finding indicates that the responsible factor(s) for the rising rates of C.D.H. observed in our monitoring programme does not appear to exert its effect more intensively in the winter months than during the hot season: we

Department of Epidemiology, Israel Institute for Biological Research and Tel-Aviv University Sackler School of Medicine MARCUS A. RINA CHEN Ness-Ziona, P.O. Box 19, Israel

BREAST-FEEDING IN HARROW

SIR,—Dr Jepson and his colleagues (Aug. 21, p. 425)

are

alone in finding that a programme of education is associated with an increase in breast-feeding. Over 90% of mothers in the Harrow district (population 230 000) are delivered in this unit, and an education programme, including the making of a film, was started here early in 1974. As the table shows, the proportion of mothers breast-feeding has increased dramatically. Two surveys conducted last year’ showed that breastfeeding is continued for a reasonable length of time. 67% of not

KLINGBERG

Clinical Genetics Unit,

Kaplan Hospital, Rehovot, and Hebrew University-Hadassah Medical School

JUAN CHEMKE

Departments of Pædiatrics A and Pædiatric Research, Kaplan Hospital, Rehovot, and Hebrew University-Hadassah Medical School

STANLEY LEVIN

PARACETAMOL TEST KIT

SIR,—Dr Stewart and Dr Barclay (Aug. 14, p. 362) report

BREAST-FEEDING IN HARROW

on the paracetamol test kit provided by Winthrop Laboratories. Our own experience has been quite different.4 Unlike the samples in the Dundee study, which were prepared artificially, ours were collected from patients who had deliberately taken an overdose of paracetamol. They were analysed initially with the kit by the staff on the ward and were checked in the laboratory by gas liquid chromatography. The findings were as follows:

adversely

103 mothers interviewed just after delivery in August and September intended to breast-feed, and 66% of 217 mothers discharged in April and May were breast-feeding on discharge, the figure having declined to only 41% at one month. Some commentators2-4 have, in our view, been unduly pessimistic in their assessment of the level of breast-feeding that can be achieved. Although the social-class distribution of our population is undoubtedly different from that in Sheffield, standardising for the distribution in the 1970 British Births survey’ only reduced the proportion intending to breast-feed to 6S%. We hope therefore that our experience and that of others6-8 who have achieved rates of 60% and better will encourage more educational programmes to be set up. Northwick Park Hospital and Clinical Research Centre, Harrow Middlesex HA1 3UJ

E. C. COLES H. B. VALMAN

1. Coles, E. C., Cotter, S., Valman, H. B. Lancet, 1975, ii, 978. 2. Eastham, E., Smith, D., Poole, D., Neligan, G. Br. Med. J. 1976, i, 305. 3. Bacon, C. J., Wylie, J. M. ibid. 1976, i, 308. 4. Davies, D. P., Thomas, C. Lancet, 1976, i, 421. 5. National Birthday Trust Fund and Royal College of Obstetricians and Gynæcologists. British Births 1970: vol. I, the First Week of Life. London, 1975 6.

Creery, R. D. Br. med. J. 1973, iv, 299.

7 Levi, J M. B.P.A. Council/M.E.I.U. Joint Meeting, March, 1974. at D.H.S.S. One-day Conference on Breast Feeding,

8. Malvern, J. Paper read

July, 1975.

The only striking discrepancy arose with sample 11, and in this case the tester had used less than the recommended volume of blood. Since this trial the kit has been used routinely in the Guy’s Hospital intensive-care ward, and regular checks by laboratory analyses have continued to demonstrate acceptable agreement. In practice we find that the majority of patients admitted to the hospital allegedly having taken an overdose of paracetamol have, in fact, not ingested anything like a dangerous quantity. We are confident that, with the aid of the kit’, these people can be detected at the outset and, accordingly, no specific treatment will be needed for them. For the minority who show Medalie, J. H., Makin, M., Alkalay, E., Jaffe, J., Cochavi, Z., Erlich, D. Israel J. med. Sci. 1966, 2, 212. 2. Chen, R., Wissman, S. L., Salama, R., Klingberg, M. A. Am. J. Epidem. 1970, 92, 287. 3. Cohen, P. Lancet, 1976, i, 815. 4. Widdop, B. J. int. med. Res. 1976, 4, suppl. 4, p. 89. 1.

584 whether grossly elevated or borderline, the kit alert. Plans can then be made for an antidote regimen, at the same time as more refined (and time-consuming) analyses are carried out in the laboratory. This approach can be very helpful to clinicians in district general hospitals and, probably, no less helpful in many teaching centres. We agree that ward staff should be taught how to use the kit by an experienced laboratory worker. With that proviso, we think it is wrong to say that the results will be substantially misleading and to suggest that there is any danger in handling the kit reagents.

higher levels, will sound

an

Poisons Unit,

Guy’s Hospital, London

from the subjects with ulcerative colitis were distributed differently from other groups, however, and this seemed to be due to a preponderance of subjects with total colonic disease having low M.P.O. activity. Disease activity, distribution in Crohn’s disease and drug therapy seemed to have no influence on results. Since m.p.o. is a haem enzyme, the possibility was considered that low leucocyte M.p.o. might be related to serumiron. In retrospect serum-iron levels were available in seventeen patients (Crohn’s disease and colitis) but only 4 low

B. WIDDOP R. GOULDING

NEUTROPHIL FUNCTION AND MYELOPEROXIDASE ACTIVITY IN INFLAMMATORY BOWEL DISEASE to read of the abnormality of neufunction in Crohn’s disease reported by Segal and Loewi.1 Investigation of this cell is certainly relevant since defective neutrophil function with impaired reduction of nitroblue tetrazolium (N.B.T.) characterises chronic granulomatous disease,2 in which the gastrointestinal features closely resemble those of Crohn’s disease.3 Our own studies of N.B.T. reduction in Crohn’s disease, like those of Segal and Loewi did not show any impaired N.B.T. reduction,4 in fact in most cases N.B.T. reduction was enhanced. Although this may simply be a non-specific marker of inflammatory activity it is of interest, in view of the isolation of viruses in this condition3 that analysis of our results by the technique of Feigin et al.6 showed a tendency for results in Crohn’s disease to cluster in the "viral" area of the nomogram. We have also investigated neutrophil myeloperoxidase M.p.o., E.C. 1.11.1.7) in patients with inflammatory bowel disease because this enzyme is closely involved in intracellular killing of phagocytosed bacteria.7 Sixteen patients with Crohn’s disease, and twenty with ulcerative colitis conforming to the usually accepted diagnostic criteria8 9 were investigated and compared with seventeen healthy controls of similar age and sex distribution. A further group of subjects who had undergone total proctocolectomy for ulcerative colitis between 1 and 18 years previously was also studied. The majority of this group (sixteen) were female and all were in good health at the time of the study. Leucocytes were separated from heparinised blood within 3 h of venepuncture by a modification of the dextran sedimentation technique of Lehrer. 10 Contaminating erythrocytes were removed by differential hypotonic lysis using 0.87% w/v ammonium chloride. After resuspending the cells in lOmmol/1 acetate buffer, pH 3.8, lysis was achieved by homogenising for 60 s in a glass homogeniser with a ’teflon’ pestle followed by freezing and thawing three times in solid carbon dioxide. Debris was removed by centrifuging at 800g for 20 min. Myeloperoxidase activity in the supernatant was assayed by the method of Klebanoff" using o-dianisidine as substrate. Protein concentration was determined by the method of Miller,12 and results, which were expressed as units/µg protein, are shown in the figure. There were no significant differences between controls and any patient group (Kruskal-Wallis test). The results

SIR,—We were interested

trophil

1. Segal, A. W., Loewi, G. Lancet, 1976, ii, 219. 2. Park, B. H., Holmes, B. M., Rodey, G. E., Good, R. A. ibid. 1969, i, 157. 3. Ament, M. E., Ochs, H. D. New Engl. J. Med. 1967, 288, 382. 4. Ward, M., Eastwood, M. A. Digestion, 1976, 14, 179. 5. Gitmck, G. L., Arthur, M. H., Shibata, I. Lancet, 1976, ii, 215. 6. Feigin, R. D., Shackelford, P. G. Choi, S. C., Flake, K. K., Franklin, F A., Eisenberg, C. S. J. Pediat. 1971, 78, 230. 7. Klebanoff, S. J. A. Rev. Med. 1971, 22, 39. 8. Lennard Jones, J. E., Lockhart, Mummery, H. E., Morson, B. C. Gastroenterology, 1968, 54, 1162. 9. Schachter, H., Kirsner, J. B. ibid. 1975, 68, 591. 10. Lehrer, R. I. J. clin Invest., 1971, 50, 2498. 11. Klebanoff, S J. Endocrinology, 1965, 76, 301.

Neutrophil

M.P.O.

activity

in controls and in patients with Crohn’. a group after colectomy for

disease, with ulcerative colitis and in ulcerative coUtis.

enzyme activities were associated with low serum-iron concentrations and no significant linear correlation could be found (r

= 0.13). Since the results in the post-colectomy group do not show the same distribution seen in the ulcerative-colitis patients, this is probably a reflection of the prevailing inflammatory activity rather than any predisposing factor. A phagocyte defect also seems an unlikely primary setiological factor in inflammatory bowel disease in view of the absence of any impaired resistance to infection. However, disorders of neutrophil function have been demonstrated in conditions of known viral" and bacterial14 aetiology, and such defects might well contribute to the persistence of inflammation in gut mucosa damaged by some other primary factor. The combination of a common extrinsic agent such as a virus and a variable defect in neutrophil function might perhaps account for some of the perplexing similarities and differences between ulcerative colitis and Crohn’s disease.15

Department of Pædiatric Biochemistry and Clinical

Chemistry, Royal Hospital for Sick Children, Edinburgh Gastrointestinal Unit, University of Edinburgh, Western General Hospital, Edinburgh EH4 2XU

Department of Pædiatric Biochemistry and Clinical Chemistry, Royal Hospital for Sick Children, Edinburgh

M. RENZ M. WARD M. A. EASTWOOD

R. A. HARKNESS

12. Miller, G. L. Analyt. Chem. 1959, 31, 964. 13. Craft, A. W., Reid, M. M., Low, W. T. Br. med. J. 1976, i, 1570. 14. Ward, P. A., Goralnick, S., Bullock, W. E. J. Lab. clin. Med. 1976, 87, 1025 15. Hywel Jones, J., Lennard Jones, J. E., Morson, B. C., Chapman, M., Sackin, M. J., Sneath, P. H. A., Spicer, C. L., Card, W. I. Q. Jl. Med. 1973, 42, 715.

Letter: Paracetamol test kit.

583 catheter and measure the opening graduated column, allowing pressure water to by filling up the RISING RATES OF CONGENITAL DISLOCATION OF...
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