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GLUTEN PROVOCATION AND THE XYLOSE TEST IN ADOLESCENTS
381 are better handled in an environment attuned to their needs. The specialty will continue to languish until the Department of Health is seen to provide proper facilities and to substitute action for promises where treatment of the elderly is concerned. It is depressing to hear the reply from a representative of the Department that " other specialties have to put up with poor conditions " in answer to most justified complaints about poor facilities and fears for the future. It suggests a singular lack of the will to do anything and a built-in view that the practice of geriatrics is a second-class activity-not, of course, that the Department is alone in this. Herein lies one of the major causes of the lack of status alluded to by Dr Wright. True status is not to be acquired like a new suit; it results from hard work and a service well performed, but the latter is impossible without the essential tools to do the job.
multiple problems
Department of Geriatrics,
Ipswich Hospital, Heath Road Wing, Ipswich IP4 5PD.
B. MOORE-SMITH.
GLUTEN PROVOCATION AND THE XYLOSE TEST IN ADOLESCENTS
SIR,-In adults with coeliac disease who are well conon a gluten-free diet, a single dose of gluten will
trolled
transient disturbance in small-bowel function. be detected by the xylose test if the results of the two days after gluten challenge are compared with the control value obtained when the patient was on a glutenfree diet.! This observation has been used to assess the toxicity of constituents of wheat gluten. 2,a This test has been performed on 20 adults, aged 22-66, with coeliac disease who have been on a gluten-free diet for
produce This
a
can
GLUTEN PROVOCATION IN FOUR ADOLESCENTS
from 2 months to 14 years. In all cases the administration of 20 g. gluten or gliadin has produced a reduction in xylose excretion in 2 hours of over 20%. By contrast we have challenged 4 adolescents previously shown to have coeliac disease who were admitted to confirm continuing gluten sensitivity. The results are shown in the accompanying table. One patient reacted dramatically to gluten and a second had a borderline result, while the other 2 were unIt is of interest that patients 1 and 2 had both responsive. " a sensitising " dose of gluten some weeks earlier. All these patients later went back to a normal diet or had a prolonged gluten challenge and were then shown to have a flat jejunal biopsy and impaired xylose absorption. All improved on a gluten-free diet. It has been suspected in the past that children with coeliac disease treated with a gluten-free diet may lose or modify their sensitivity to gluten during adolescence.44 Our results indicate that in this age-group the coeliac patient does appear to have a decreased sensitivity to gluten Kendall, M. J., Nutter, S., Hawkins, C. F. Lancet, 1972, i, 667. Kendall, M. J., Schneider, R., Cox, P., Hawkins, C. F. ibid. 1972, ii, 1065. 3. Townley, R. R. W., Bhathal, P. S., Cornell, H. J., Mitchell, J. D. ibid. 1973, i, 1363. 4. Hubble, D. Br. med. J. 1963, ii, 701.
1. 2.
which makes the " xylose gluten provocation test " reliable. However, if these patients are put back on a
unnor-
diet, although there may initially be no dramatic change, a definite relapse will follow in time. The possibility that the use of a pre-sensitising dose of gluten given 4-8 weeks before testing will facilitate the demonstration of gluten " sensitivity " merits further investigation.
mal
"
"
Institute of Child Health, Francis Road, Birmingham 16.
C. J. ROLLES.
Queen Elizabeth Hospital Birmingham B15 2TH.
M. J. KENDALL.
DIETARY POTASSIUM AND DIURETIC THERAPY
SIR,-Potassium depletion is a recognised consequence of chronic therapy with diuretics whose action in the nephron lies proximal to the potassium-hydrogen exchange site. 1, Prevention of a body deficit of potassium has been tackled by the concurrent use of either potassium supplements or one of the potassium-sparing diuretics. 3,4 The evidence on the relative successes of these approaches is conflicting.5.Recent work has highlighted problems concerning the efficacy of potassium supplements. 7-10 Some of the anomalous findings reflect the difficulties inherent in monitoring small changes in body-potassium status using exchangeable 42K or with more sensitive techniques such as the whole-body radiation counter.’-1.12 Many clinicians accept the inevitability of potassium depletion during prolonged diuretic therapy and question the need for any routine attempt at repletion, especially in the absence of symptoms or signs attributable to hypokalxmia.13 With submaximal dosage of thiazides in hypertension or with intermittent use of diuretics in mild congestive cardiac failure, it is often argued that a trend toward potassium depletion can be countered by ensuring an adequate amount of potassium in the diet.14 In particular, patients are often advised to eat fruit or drink fruitjuices as sources of readily available potassium, and this has prompted us to investigate the use of these items in a random selection of patients in this hospital. The strict legal distinction between fruit juices, squashes, and drinks is far from clear in the minds of both patients and doctors. The hospital inpatient tends to have a wide variety of commercial preparations on the bedside locker; most of these have a tenuous connection with their parent fruit.15-17 We have found that only 3 out of 100 ward 1.
Maronde, R. F., Milgrom, M., Dickey, J. M. Am. Heart J. 1969, 78,
16. 2. Lant, A.
F., Wilson, G. M. in Renal Disease (edited by D. A. K. Black); p. 655. Oxford, 1972. 3. Lant, A. F., Smith, A. J., Wilson, G. M. Clin. Pharmac. Ther. 1969, 10, 50. 4. Beevers, D. G., Hamilton, M., Harpur, J. E. Postgrad. med. J. 1971, 47, 639. 5. McKenna, T. J., Donohoe, J. F., Brien, T. G., Healy, J. J., Canning, B. St. J., Muldowney, F. P. Lancet, 1971, ii, 739. 6. Antcliff, A. C., Beevers, D. G., Hamilton, M., Harpur, J. E. Postgrad. med. J. 1971, 47, 644. 7. Edmonds, C. J., Jasani, B. Lancet, 1972, ii, 8. 8. Down, P. F., Polak, A., Roa, R., Mead, J. A. ibid. p. 721. 9. Davidson, C. ibid. p. 882. 10. Muldowney, F. P. ibid. p. 1204. 11. Jones, N. F. Sixth Symposium on Advanced Medicine (edited by J. D. H. Slater); p. 203. London, 1970. 12. Anderson, J., Godfrey, B. E., Hill, D. M., Munro-Faure, A. D., Sheldon, J. Q. Jl Med. 1971, 40, 541. 13. Healy, J. J., McKenna, T. J., Canning, B. St. J., Brien, T. G., Duffy, G. J., Muldowney, F. P. Br. med. J. 1970, i, 716. 14. Hamilton, M., Lant, A. F., Sherlock, S. Diuretics and Potassium. Monograph, Merck Sharp & Dohme Film Library, 1972. 15. Food and Drugs Act. 4 Eliz. 2. ch. 16. H.M. Stationery Office, 1955. 16. Soft Drink Regulations. Statutory Instrument no. 760, p. 1605. H.M. Stationery Office, 1964. 17. Which ?, September 1968, p. 283, Consumers Association, London.
multiple problems
Department of Geriatrics,
Ipswich Hospital, Heath Road Wing, Ipswich IP4 5PD.
B. MOORE-SMITH.
GLUTEN PROVOCATION AND THE XYLOSE TEST IN ADOLESCENTS
SIR,-In adults with coeliac disease who are well conon a gluten-free diet, a single dose of gluten will
trolled
transient disturbance in small-bowel function. be detected by the xylose test if the results of the two days after gluten challenge are compared with the control value obtained when the patient was on a glutenfree diet.! This observation has been used to assess the toxicity of constituents of wheat gluten. 2,a This test has been performed on 20 adults, aged 22-66, with coeliac disease who have been on a gluten-free diet for
produce This
a
can
GLUTEN PROVOCATION IN FOUR ADOLESCENTS
from 2 months to 14 years. In all cases the administration of 20 g. gluten or gliadin has produced a reduction in xylose excretion in 2 hours of over 20%. By contrast we have challenged 4 adolescents previously shown to have coeliac disease who were admitted to confirm continuing gluten sensitivity. The results are shown in the accompanying table. One patient reacted dramatically to gluten and a second had a borderline result, while the other 2 were unIt is of interest that patients 1 and 2 had both responsive. " a sensitising " dose of gluten some weeks earlier. All these patients later went back to a normal diet or had a prolonged gluten challenge and were then shown to have a flat jejunal biopsy and impaired xylose absorption. All improved on a gluten-free diet. It has been suspected in the past that children with coeliac disease treated with a gluten-free diet may lose or modify their sensitivity to gluten during adolescence.44 Our results indicate that in this age-group the coeliac patient does appear to have a decreased sensitivity to gluten Kendall, M. J., Nutter, S., Hawkins, C. F. Lancet, 1972, i, 667. Kendall, M. J., Schneider, R., Cox, P., Hawkins, C. F. ibid. 1972, ii, 1065. 3. Townley, R. R. W., Bhathal, P. S., Cornell, H. J., Mitchell, J. D. ibid. 1973, i, 1363. 4. Hubble, D. Br. med. J. 1963, ii, 701.
1. 2.
which makes the " xylose gluten provocation test " reliable. However, if these patients are put back on a
unnor-
diet, although there may initially be no dramatic change, a definite relapse will follow in time. The possibility that the use of a pre-sensitising dose of gluten given 4-8 weeks before testing will facilitate the demonstration of gluten " sensitivity " merits further investigation.
mal
"
"
Institute of Child Health, Francis Road, Birmingham 16.
C. J. ROLLES.
Queen Elizabeth Hospital Birmingham B15 2TH.
M. J. KENDALL.
DIETARY POTASSIUM AND DIURETIC THERAPY
SIR,-Potassium depletion is a recognised consequence of chronic therapy with diuretics whose action in the nephron lies proximal to the potassium-hydrogen exchange site. 1, Prevention of a body deficit of potassium has been tackled by the concurrent use of either potassium supplements or one of the potassium-sparing diuretics. 3,4 The evidence on the relative successes of these approaches is conflicting.5.Recent work has highlighted problems concerning the efficacy of potassium supplements. 7-10 Some of the anomalous findings reflect the difficulties inherent in monitoring small changes in body-potassium status using exchangeable 42K or with more sensitive techniques such as the whole-body radiation counter.’-1.12 Many clinicians accept the inevitability of potassium depletion during prolonged diuretic therapy and question the need for any routine attempt at repletion, especially in the absence of symptoms or signs attributable to hypokalxmia.13 With submaximal dosage of thiazides in hypertension or with intermittent use of diuretics in mild congestive cardiac failure, it is often argued that a trend toward potassium depletion can be countered by ensuring an adequate amount of potassium in the diet.14 In particular, patients are often advised to eat fruit or drink fruitjuices as sources of readily available potassium, and this has prompted us to investigate the use of these items in a random selection of patients in this hospital. The strict legal distinction between fruit juices, squashes, and drinks is far from clear in the minds of both patients and doctors. The hospital inpatient tends to have a wide variety of commercial preparations on the bedside locker; most of these have a tenuous connection with their parent fruit.15-17 We have found that only 3 out of 100 ward 1.
Maronde, R. F., Milgrom, M., Dickey, J. M. Am. Heart J. 1969, 78,
16. 2. Lant, A.
F., Wilson, G. M. in Renal Disease (edited by D. A. K. Black); p. 655. Oxford, 1972. 3. Lant, A. F., Smith, A. J., Wilson, G. M. Clin. Pharmac. Ther. 1969, 10, 50. 4. Beevers, D. G., Hamilton, M., Harpur, J. E. Postgrad. med. J. 1971, 47, 639. 5. McKenna, T. J., Donohoe, J. F., Brien, T. G., Healy, J. J., Canning, B. St. J., Muldowney, F. P. Lancet, 1971, ii, 739. 6. Antcliff, A. C., Beevers, D. G., Hamilton, M., Harpur, J. E. Postgrad. med. J. 1971, 47, 644. 7. Edmonds, C. J., Jasani, B. Lancet, 1972, ii, 8. 8. Down, P. F., Polak, A., Roa, R., Mead, J. A. ibid. p. 721. 9. Davidson, C. ibid. p. 882. 10. Muldowney, F. P. ibid. p. 1204. 11. Jones, N. F. Sixth Symposium on Advanced Medicine (edited by J. D. H. Slater); p. 203. London, 1970. 12. Anderson, J., Godfrey, B. E., Hill, D. M., Munro-Faure, A. D., Sheldon, J. Q. Jl Med. 1971, 40, 541. 13. Healy, J. J., McKenna, T. J., Canning, B. St. J., Brien, T. G., Duffy, G. J., Muldowney, F. P. Br. med. J. 1970, i, 716. 14. Hamilton, M., Lant, A. F., Sherlock, S. Diuretics and Potassium. Monograph, Merck Sharp & Dohme Film Library, 1972. 15. Food and Drugs Act. 4 Eliz. 2. ch. 16. H.M. Stationery Office, 1955. 16. Soft Drink Regulations. Statutory Instrument no. 760, p. 1605. H.M. Stationery Office, 1964. 17. Which ?, September 1968, p. 283, Consumers Association, London.