230
Miss Hunt and her colleagues have postulated that vitamin D and to a lesser extent outdoor exposure are the two most important factors in the determination of the vitamin D status of Asians. If this is so any difference in the serum 25-OHD3 levels of the five different religious groups should be explicable in terms of these two variables alone. Examination of the variation in serum 25-OHD3 when the concomitant variation in outdoor exposure and vitamin D intake had been taken into account in the model mentioned above revealed that a significant difference in the serum 25-OHD3 levels of the different religious groups still existed (F=9 7; 4,74 DF; P0 05). It would therefore seem essential to include chapatty in any model of vitamin D status in Asians. The amount of variation in serum 25-OHD3 explained by chapatty flour alone (23 040o = 100r2) is greater than the combined contributions of dietary vitamin D and outdoor exposure (19-2"o). These findings strongly support earlier observations which have incriminated chapatty consumption in the aetiology of Asian rickets.35 IRIS ROBERTSON
BRITISH MEDICAL JOURNAL
22 JANUARY 1977
evidence of renal or 8th nerve disease" is standards were returned to an earlier stage of untrue. The initial doses of gentamicin should the committee's proceedings because an preferably be given intravenously by bolus agreement on these standards had not been injection. There are no contraindications to possible. The subject continues to be disthe use of gentamicin since dosage can be cussed. Until these standards can be agreed, tailor-made to the patient's renal function. at least by the delegations from countries in the EEC, it would not appear possible to A M EMMERSON institute an EEC blanket directive to state the presence of gluten. Microbiology Department, Whittington Hospital, However, I support Dr Fielding in the London, N 19 principle that responsible labelling should be C T KEANE sought for the benefit of people who must Microbiology Department, follow a gluten-free diet. The designations of Federated Dublin Voluntary Hospitals, certain ingredients in manufactured foodsDublin for example, cereal binder, starch, rusk, etc**In regard to dosage the essential need is do not convey sufficient information for those to make sure the total daily intake is correct in on a gluten-free diet. relation to the seriousness of the disease, A E PAWAN District Dietitian, sensitivity of the organism, weight, other and Hackney Health District City therapy (such as dialysis) or interacting drugs St Bartholomew's Hospital, (such as ethacrynic acid or cephalosporins), London EC1 and abnormal risks of toxicity on account of 1 Lace, A E, Nutrition, 1971, 99. 25, age, impaired renal function, nervous disease, or pregnancy. All regimens, whether or not designed with the aid of nomograms, must Effect of acute infections on allergic allow for divided doses from ampoules. conditions Nurses ought therefore to regard all doses as novel and check each one against the prescrip- SIR,-A recent contribution to "Any Question and instructions attached to the specific tions ?" (30 October, p 1065) concerned the ampoules by the pharmacist. improvement in hay fever symptoms In the absence of evidence of the relative viral hepatitis. I think the explanationduring Department of Mathematics, may Strathclyde University effectivity and toxicity, or risks of toxicity, be simpler than your expert suggests. A KELMAN of the intravenous and intramuscular routes I had a severe attack of chickenpox during it is still a matter of opinion which is to be which my severe allergic rhinitis disappeared Department of Clinical Physics and Bioengineering, doses. even for preferred loading completely despite increased exposure to the University of Glasgow We accept that the statement about usage M G DUNNIGAN of gentamicin is only partly true. It would causative house-dust mite. When, shortly afterwards, two separate patients commented Department of Medicine, have been better omitted or worded: "In on the improvement in their asthma while Stobhill General Hospital, renal or the function, with patients impaired Glasgow acutely ill I discussed this strange coincidence elderly, the dosage of gentamicin should, of with my colleagues. It was pointed out that Dunnigan, M G, McIntosh, W B, and Ford, J A, course, be suitably adjusted from the start the probable explanation was the high level of Lancet, 1976, 1, 1346. and readjusted according to the serum con- endogenous corticosteroids produced by an 2 Wills, M R, et al, Lancet, 1972, 1, 771. 3 Ford, J A, et al, British Medical yournal, 1972, 3, 446. centration. It is probably best avoided acute illness. It would be interesting to know altogether in pregnancy or with 8th nerve the therapeutic equivalent of the steroid levels disease."-ED, BM7. produced by acute stress of this type. Septic arthritis in rheumatoid disease J PORTER SIR,-In your leading article on this subject Labelling of foodstuffs for patients with Westminster Hospital, London SW1 (6 November, p 1089) reference was made coeliac disease to the use of gentamicin in the treatment of SIR,-The Labelling of Food Regulations in ***Our expert writes: "This suggestion that staphylococcal infections. We fully agree that gentamicin is often Britain do not require the declaration of gluten improvement in allergic conditions such as highly effective in staphylococcal infections in the ingredients panel of a food label. Aware asthma or allergic rhinitis during acute viral which may fall into the group of life- of the potential hazards for coeliacs, the illnesses might be related to increases in threatening situations for which the manufac- Coeliac Society of Great Britain and Northern endogenous steroid levels seems plausible. "It is well recognised that endogenous turers of the drug recommend its use. You Ireland launched the Gluten-free Food Larefer to other workers who use gentamicin in belling Project in 1970-1. A gluten-free symbol cortisol secretion rates and plasma cortisol combination with the penicillins, but the dose was designed and food manufacturers were re- levels increase during acute infections, both regimen cited bears no resemblance to any quested to adopt the symbol when their foods viral and bacterial.' 2 From these studies both recommended scheme of which we are aware. fulfilled the criteria for the designation secretion rate and plasma cortisol levels inAn eight- or six-hourly regimen is advocated "gluten-free."' This was preferred to a state- crease by up to 300O,, but these responses in patients with severe infection when renal ment that gluten features as an ingredient, as vary among subjects. It has been suggested function is normal or slightly impaired. The advocated by Dr J F Fielding (1 January, that the stress response in plasma cortisol interval between doses can be lengthened p 50), the reason being that gluten is a name levels is similar in self-limiting viral infections according to renal function and serum levels often applied to the protein of all starchy seeds to that in severe bacterial infection.2 The of gentamicin. The dose can be based on in the food industry and is therefore not increased steroid production may be related many formulae but a starting dose of 160 mg, exclusive to the gluten protein toxic to to the degree of fever or at least to pyrogen with recurrent doses of 80, 120, or even coeliacs. It is still my hope, as the director of levels, since bacterial pyrogens stimulate 160 mg can be given conveniently. Doses of that specific project six years ago, that the corticotrophin production in rats, probably by 100, 200, or 70 mg, however, are novel and Food Standards Committee will advocate stimulating the pituitary directly.3 Interestwould require complicated dispensing pro- adoption of the symbol. This has already been ingly, the response in rats is potentiated by cedures at ward level during which unaccept- done voluntarily by some food manufac- the addition of salicylate.3 The steroid response to acute infections seems to be similar to, able errors may occur. The Glasgow workers turers. In the meantine the WHO Codex Alimen- though usually slightly less than, that to suggest that gentamicin should be kept in reserve, yet seven out of eight of their patients tarius Commission continues to work to corticotrophin infusions. In therapeutic doses died. You reach the satisfactory conclusion achieve international agreement on the these usually induce increases of 300-7000' that septic arthritis occurring in rheumatoid definition of a gluten-free food, along with in both cortisol secretion rates and plasma other specific requirements for foods for special cortisol levels.4 disease is rare but dangerous to life. "Thus in some individuals the increase in Finally, the statement that "gentamicin dietary uses. At the ninth session of the Codex should not be used in the elderly or those with Committee in September 1975 the draft endogenous steroid production as a result of
Miss Hunt and her colleagues have postulated that vitamin D and to a lesser extent outdoor exposure are the two most important factors in the determination of the vitamin D status of Asians. If this is so any difference in the serum 25-OHD3 levels of the five different religious groups should be explicable in terms of these two variables alone. Examination of the variation in serum 25-OHD3 when the concomitant variation in outdoor exposure and vitamin D intake had been taken into account in the model mentioned above revealed that a significant difference in the serum 25-OHD3 levels of the different religious groups still existed (F=9 7; 4,74 DF; P0 05). It would therefore seem essential to include chapatty in any model of vitamin D status in Asians. The amount of variation in serum 25-OHD3 explained by chapatty flour alone (23 040o = 100r2) is greater than the combined contributions of dietary vitamin D and outdoor exposure (19-2"o). These findings strongly support earlier observations which have incriminated chapatty consumption in the aetiology of Asian rickets.35 IRIS ROBERTSON
BRITISH MEDICAL JOURNAL
22 JANUARY 1977
evidence of renal or 8th nerve disease" is standards were returned to an earlier stage of untrue. The initial doses of gentamicin should the committee's proceedings because an preferably be given intravenously by bolus agreement on these standards had not been injection. There are no contraindications to possible. The subject continues to be disthe use of gentamicin since dosage can be cussed. Until these standards can be agreed, tailor-made to the patient's renal function. at least by the delegations from countries in the EEC, it would not appear possible to A M EMMERSON institute an EEC blanket directive to state the presence of gluten. Microbiology Department, Whittington Hospital, However, I support Dr Fielding in the London, N 19 principle that responsible labelling should be C T KEANE sought for the benefit of people who must Microbiology Department, follow a gluten-free diet. The designations of Federated Dublin Voluntary Hospitals, certain ingredients in manufactured foodsDublin for example, cereal binder, starch, rusk, etc**In regard to dosage the essential need is do not convey sufficient information for those to make sure the total daily intake is correct in on a gluten-free diet. relation to the seriousness of the disease, A E PAWAN District Dietitian, sensitivity of the organism, weight, other and Hackney Health District City therapy (such as dialysis) or interacting drugs St Bartholomew's Hospital, (such as ethacrynic acid or cephalosporins), London EC1 and abnormal risks of toxicity on account of 1 Lace, A E, Nutrition, 1971, 99. 25, age, impaired renal function, nervous disease, or pregnancy. All regimens, whether or not designed with the aid of nomograms, must Effect of acute infections on allergic allow for divided doses from ampoules. conditions Nurses ought therefore to regard all doses as novel and check each one against the prescrip- SIR,-A recent contribution to "Any Question and instructions attached to the specific tions ?" (30 October, p 1065) concerned the ampoules by the pharmacist. improvement in hay fever symptoms In the absence of evidence of the relative viral hepatitis. I think the explanationduring Department of Mathematics, may Strathclyde University effectivity and toxicity, or risks of toxicity, be simpler than your expert suggests. A KELMAN of the intravenous and intramuscular routes I had a severe attack of chickenpox during it is still a matter of opinion which is to be which my severe allergic rhinitis disappeared Department of Clinical Physics and Bioengineering, doses. even for preferred loading completely despite increased exposure to the University of Glasgow We accept that the statement about usage M G DUNNIGAN of gentamicin is only partly true. It would causative house-dust mite. When, shortly afterwards, two separate patients commented Department of Medicine, have been better omitted or worded: "In on the improvement in their asthma while Stobhill General Hospital, renal or the function, with patients impaired Glasgow acutely ill I discussed this strange coincidence elderly, the dosage of gentamicin should, of with my colleagues. It was pointed out that Dunnigan, M G, McIntosh, W B, and Ford, J A, course, be suitably adjusted from the start the probable explanation was the high level of Lancet, 1976, 1, 1346. and readjusted according to the serum con- endogenous corticosteroids produced by an 2 Wills, M R, et al, Lancet, 1972, 1, 771. 3 Ford, J A, et al, British Medical yournal, 1972, 3, 446. centration. It is probably best avoided acute illness. It would be interesting to know altogether in pregnancy or with 8th nerve the therapeutic equivalent of the steroid levels disease."-ED, BM7. produced by acute stress of this type. Septic arthritis in rheumatoid disease J PORTER SIR,-In your leading article on this subject Labelling of foodstuffs for patients with Westminster Hospital, London SW1 (6 November, p 1089) reference was made coeliac disease to the use of gentamicin in the treatment of SIR,-The Labelling of Food Regulations in ***Our expert writes: "This suggestion that staphylococcal infections. We fully agree that gentamicin is often Britain do not require the declaration of gluten improvement in allergic conditions such as highly effective in staphylococcal infections in the ingredients panel of a food label. Aware asthma or allergic rhinitis during acute viral which may fall into the group of life- of the potential hazards for coeliacs, the illnesses might be related to increases in threatening situations for which the manufac- Coeliac Society of Great Britain and Northern endogenous steroid levels seems plausible. "It is well recognised that endogenous turers of the drug recommend its use. You Ireland launched the Gluten-free Food Larefer to other workers who use gentamicin in belling Project in 1970-1. A gluten-free symbol cortisol secretion rates and plasma cortisol combination with the penicillins, but the dose was designed and food manufacturers were re- levels increase during acute infections, both regimen cited bears no resemblance to any quested to adopt the symbol when their foods viral and bacterial.' 2 From these studies both recommended scheme of which we are aware. fulfilled the criteria for the designation secretion rate and plasma cortisol levels inAn eight- or six-hourly regimen is advocated "gluten-free."' This was preferred to a state- crease by up to 300O,, but these responses in patients with severe infection when renal ment that gluten features as an ingredient, as vary among subjects. It has been suggested function is normal or slightly impaired. The advocated by Dr J F Fielding (1 January, that the stress response in plasma cortisol interval between doses can be lengthened p 50), the reason being that gluten is a name levels is similar in self-limiting viral infections according to renal function and serum levels often applied to the protein of all starchy seeds to that in severe bacterial infection.2 The of gentamicin. The dose can be based on in the food industry and is therefore not increased steroid production may be related many formulae but a starting dose of 160 mg, exclusive to the gluten protein toxic to to the degree of fever or at least to pyrogen with recurrent doses of 80, 120, or even coeliacs. It is still my hope, as the director of levels, since bacterial pyrogens stimulate 160 mg can be given conveniently. Doses of that specific project six years ago, that the corticotrophin production in rats, probably by 100, 200, or 70 mg, however, are novel and Food Standards Committee will advocate stimulating the pituitary directly.3 Interestwould require complicated dispensing pro- adoption of the symbol. This has already been ingly, the response in rats is potentiated by cedures at ward level during which unaccept- done voluntarily by some food manufac- the addition of salicylate.3 The steroid response to acute infections seems to be similar to, able errors may occur. The Glasgow workers turers. In the meantine the WHO Codex Alimen- though usually slightly less than, that to suggest that gentamicin should be kept in reserve, yet seven out of eight of their patients tarius Commission continues to work to corticotrophin infusions. In therapeutic doses died. You reach the satisfactory conclusion achieve international agreement on the these usually induce increases of 300-7000' that septic arthritis occurring in rheumatoid definition of a gluten-free food, along with in both cortisol secretion rates and plasma other specific requirements for foods for special cortisol levels.4 disease is rare but dangerous to life. "Thus in some individuals the increase in Finally, the statement that "gentamicin dietary uses. At the ninth session of the Codex should not be used in the elderly or those with Committee in September 1975 the draft endogenous steroid production as a result of
