- Email: [email protected]
CONFUSION OVER LOPERAMIDE
483
1:160). Serum reacted with smooth brucella April 14, agglutination test 1:40, complement fixation 1:16, and direct fluorescent antibody test 1:100; these tests were negative on May 12. Antibiotic treatment (nalidixic acid and colimycin) was started on April 4 because we were worried about bacterasmia (fever and shivering). When the fever persisted cefoxitin was added and the fever stopped. The patient was progressively weaned off parenteral nutrition. On April 27 the patient’s temperature was normal and the erythema nodosum had gone. A
CAPILLARIES IN THE FETAL SCALP
Mollaret; normal<
antigens:
on
repeat barium
enema was
normal apart from
some
ulcerations
slightly rigid left colon, but the diarrhaea persisted. On April 27 there were no signs of hyperthyroidism and the
on a
T3 was normal; however, her T4 was in the upper part of the normal range (table). There were no antibodies against smooth muscle or thyroid antigens. Her HLA type was A29, Aw33, B14, Bw37. Scintigraphy showed a medium sized symmetrical, and non-homogeneous goitre. On June 7, T4 and T3 values were increased; TRH test showed no hypophyseal response. Carbimazole was prescribed. Any stress or infection may change a euthyroid goitre-or even a normal thyroid-into a hyperthyroid goitre, and the development of hyperthyroidism one month after acute yersinia enterocolitis may be fortuitous. However, bearing in mind the immunological evidence so far available, there may be a more specific link.
SIR,-Dr O’Connor and co-workers (Nov. 3, p. 947) raise an
old argument
over
whether values in fetal
scalp
blood
are
representative of the acid-base and blood gas status of the fetus. This is an important question in view of the interest in continuous measurement of tissue pH and transcutaneous P02 for fetal monitoring. O’Connor et al. suggest from their studies with the Huch TcP02 electrode that "the fetal scalp in labour provides a totally unrepresentative capillary bed in which stasis and local hypoxia is commonplace" and that compression on the fetal head as it descends the birth canal has a "tonsure-like" effect, compressing the capillary circulation and inducing circulatory stasis. Two types of study have been used to validate the fetal scalp as a sampling site. Animal studies apart, the early investigations on normal fetuses’-3 were longitudinal in design with serial samples taken during labour. Any "tonsure" effect
J. L. LEGOUX Department of Internal Medicine, Hôpital du Bocage, 21034-Dijon, France
D. SPIELMANN H. PORTIER A. LEGOUX P. CORTET
CONFUSION OVER LOPERAMIDE
SiR,—Dr Heap (Dec. 15, p. 1299) cites six reierences which "much evidence" for the efficacy of loperamide in
provide
children with acute, subacute, and chronic diarrhoeal states of various aetiologies. Five of these studies were uncontrolled and three do not refer to acute infective diarrhoea, the subject of Heap’s letter. In the one study (uncontrolled) of children with acute diarrhoea in which an attempt was made to determine the xtiology, 5 of 17 patients with Salmonella or enteropathogenic Escherichia coli were not improved following 72 h treatment.’I In our earlier letter (Sept. 27, p. 689) we demonstrated that loperamide has potent antisecretory properties, and our observations may, in part, explain the drug’s efficacy in certain diarrhoeal states. Besides this antisecretory action, however, loperamide affects gut motility and since there is experimental evidence that the antiperistaltic action of opiates interferes with the normal defence mechanisms against bacterial colonisation of the upper small intestine,2 it could be argued that the administration of such drugs might facilitate and prolong colonisation of the gut in acute bacterial diarrhoea. We reported a clear-cut observation on the pharmacological properties of loperamide, and were careful not to make any therapeutic recommendations. We agree with Dr Cutting and Dr Marshall (Nov. 10, p. 1022) that loperamide should not be used in-the management of acute infective diarrhoea in childhood. If controlled clinical trials with bacteriological and virological studies demonstrate unequivocally that loperamide is an effective and safe drug in such children, then there would be a basis for formulating recommendations.
B. SANDHU Department of Child Health, Institute of Child Health, London WC IN 1EH 1. Dubru
J. H. TRIPP D. C. A. CANDY J. T. HARRIES
JM, Lambrechts A. Le R 18 553 dans le traitement des diarrhées
aigues du jeune enfant. Revue Méd Liege 1974; 29: 579-81. TH, et al. Acute enteritis due to Salmonella typhimurium in treated guinea pigs. Arch Pathol 1966; 81: 501-08.
2. Kent
opium-
pH values in paired samples of fetal scalp blood taken within 30 min of delivery and umbilical arterial blood. n=39; r=O.82; pG0 001). should have led to acidaemia developing as labour progressed, and the fact that scalp blood acid-base and blood gas values remained fairly constant until shortly before delivery is indirect evidence against such an effect. In the second type of study values in fetal scalp blood collected 15 min or less before delivery and in cord blood were compared. We know of six such studies and all showed good agreement between the sampling sites--e.g., correlation (r) values of 0.79,3 0.82and 0-89/ were recorded for three comparisons of fetal scalp and umbilical arterial blood. O’Connor et al. analyse our data3and find that the correlation between scalp values (taken with the head on the perineum) and umbilical venous values is not significant. This is to be expected because the random error of measurement with such a small number of paired values over a narrow range would obscure any correlation. The accompanying figure shows further data, distributed over a wider range, and a good correlation between fetal scalp blood pH, taken within 30 min of delivery, and umbilical artery blood
pH. 1.
Saling E. Die Blutgas verhaltnisse und der Saure-Basen-Haunshalt des Feten
bei ungestorten Geburtsablauf. Z Geburth Gynœkol 1964; 161: 262-92. 2. Kubli FW. Fetale Gefahrenzustande und ihre Diagnose. Thieme: Stuttgart, 1966. 3. Bowe ET, Beard RW, Finster M, et al. Reliability of fetal blood sampling. Am J Obstet Gynecol 1970; 107: 279-87. 4. Boenisch H, Saling E. The reliability of pH-values in fetal blood samples. A study of the second stage. J Perinat Med 1976; 4: 45-50. 5. Teramo K. The validity of foetal capillary blood samples during labour.
Gynœcologia 1969; 167: 511-21.
1:160). Serum reacted with smooth brucella April 14, agglutination test 1:40, complement fixation 1:16, and direct fluorescent antibody test 1:100; these tests were negative on May 12. Antibiotic treatment (nalidixic acid and colimycin) was started on April 4 because we were worried about bacterasmia (fever and shivering). When the fever persisted cefoxitin was added and the fever stopped. The patient was progressively weaned off parenteral nutrition. On April 27 the patient’s temperature was normal and the erythema nodosum had gone. A
CAPILLARIES IN THE FETAL SCALP
Mollaret; normal<
antigens:
on
repeat barium
enema was
normal apart from
some
ulcerations
slightly rigid left colon, but the diarrhaea persisted. On April 27 there were no signs of hyperthyroidism and the
on a
T3 was normal; however, her T4 was in the upper part of the normal range (table). There were no antibodies against smooth muscle or thyroid antigens. Her HLA type was A29, Aw33, B14, Bw37. Scintigraphy showed a medium sized symmetrical, and non-homogeneous goitre. On June 7, T4 and T3 values were increased; TRH test showed no hypophyseal response. Carbimazole was prescribed. Any stress or infection may change a euthyroid goitre-or even a normal thyroid-into a hyperthyroid goitre, and the development of hyperthyroidism one month after acute yersinia enterocolitis may be fortuitous. However, bearing in mind the immunological evidence so far available, there may be a more specific link.
SIR,-Dr O’Connor and co-workers (Nov. 3, p. 947) raise an
old argument
over
whether values in fetal
scalp
blood
are
representative of the acid-base and blood gas status of the fetus. This is an important question in view of the interest in continuous measurement of tissue pH and transcutaneous P02 for fetal monitoring. O’Connor et al. suggest from their studies with the Huch TcP02 electrode that "the fetal scalp in labour provides a totally unrepresentative capillary bed in which stasis and local hypoxia is commonplace" and that compression on the fetal head as it descends the birth canal has a "tonsure-like" effect, compressing the capillary circulation and inducing circulatory stasis. Two types of study have been used to validate the fetal scalp as a sampling site. Animal studies apart, the early investigations on normal fetuses’-3 were longitudinal in design with serial samples taken during labour. Any "tonsure" effect
J. L. LEGOUX Department of Internal Medicine, Hôpital du Bocage, 21034-Dijon, France
D. SPIELMANN H. PORTIER A. LEGOUX P. CORTET
CONFUSION OVER LOPERAMIDE
SiR,—Dr Heap (Dec. 15, p. 1299) cites six reierences which "much evidence" for the efficacy of loperamide in
provide
children with acute, subacute, and chronic diarrhoeal states of various aetiologies. Five of these studies were uncontrolled and three do not refer to acute infective diarrhoea, the subject of Heap’s letter. In the one study (uncontrolled) of children with acute diarrhoea in which an attempt was made to determine the xtiology, 5 of 17 patients with Salmonella or enteropathogenic Escherichia coli were not improved following 72 h treatment.’I In our earlier letter (Sept. 27, p. 689) we demonstrated that loperamide has potent antisecretory properties, and our observations may, in part, explain the drug’s efficacy in certain diarrhoeal states. Besides this antisecretory action, however, loperamide affects gut motility and since there is experimental evidence that the antiperistaltic action of opiates interferes with the normal defence mechanisms against bacterial colonisation of the upper small intestine,2 it could be argued that the administration of such drugs might facilitate and prolong colonisation of the gut in acute bacterial diarrhoea. We reported a clear-cut observation on the pharmacological properties of loperamide, and were careful not to make any therapeutic recommendations. We agree with Dr Cutting and Dr Marshall (Nov. 10, p. 1022) that loperamide should not be used in-the management of acute infective diarrhoea in childhood. If controlled clinical trials with bacteriological and virological studies demonstrate unequivocally that loperamide is an effective and safe drug in such children, then there would be a basis for formulating recommendations.
B. SANDHU Department of Child Health, Institute of Child Health, London WC IN 1EH 1. Dubru
J. H. TRIPP D. C. A. CANDY J. T. HARRIES
JM, Lambrechts A. Le R 18 553 dans le traitement des diarrhées
aigues du jeune enfant. Revue Méd Liege 1974; 29: 579-81. TH, et al. Acute enteritis due to Salmonella typhimurium in treated guinea pigs. Arch Pathol 1966; 81: 501-08.
2. Kent
opium-
pH values in paired samples of fetal scalp blood taken within 30 min of delivery and umbilical arterial blood. n=39; r=O.82; pG0 001). should have led to acidaemia developing as labour progressed, and the fact that scalp blood acid-base and blood gas values remained fairly constant until shortly before delivery is indirect evidence against such an effect. In the second type of study values in fetal scalp blood collected 15 min or less before delivery and in cord blood were compared. We know of six such studies and all showed good agreement between the sampling sites--e.g., correlation (r) values of 0.79,3 0.82and 0-89/ were recorded for three comparisons of fetal scalp and umbilical arterial blood. O’Connor et al. analyse our data3and find that the correlation between scalp values (taken with the head on the perineum) and umbilical venous values is not significant. This is to be expected because the random error of measurement with such a small number of paired values over a narrow range would obscure any correlation. The accompanying figure shows further data, distributed over a wider range, and a good correlation between fetal scalp blood pH, taken within 30 min of delivery, and umbilical artery blood
pH. 1.
Saling E. Die Blutgas verhaltnisse und der Saure-Basen-Haunshalt des Feten
bei ungestorten Geburtsablauf. Z Geburth Gynœkol 1964; 161: 262-92. 2. Kubli FW. Fetale Gefahrenzustande und ihre Diagnose. Thieme: Stuttgart, 1966. 3. Bowe ET, Beard RW, Finster M, et al. Reliability of fetal blood sampling. Am J Obstet Gynecol 1970; 107: 279-87. 4. Boenisch H, Saling E. The reliability of pH-values in fetal blood samples. A study of the second stage. J Perinat Med 1976; 4: 45-50. 5. Teramo K. The validity of foetal capillary blood samples during labour.
Gynœcologia 1969; 167: 511-21.