EXPERIENCE WITH A PRACTICAL FOOD PATTERN TO REDUCE HEART DISEASE

792 trimester may act as an ion trap for many basic compounds from tobacco smoke which the mother has inhaled. High levels of these may be recirculated in the amniotic fluids or stored in the meconium. More research needs to be done to determine the full extent of fetal exposure in utero to combusted tobacco products. Departments of Pharmacology and of Obstetrics and Gynecology, School of Medicine, Ohio State

University.

Columbus, Ohio 43210, U.S.A.

prolonged paralytic

ileus in whom treatment with

a

Cantor tube,

neostigmine, and metoclopramide had not relieved the symptoms. Our experience suggests that CCK can be used in such patients-indeed, CCK might also be tried after ordinary abdominal surgery to prevent

contrast

media,

parenteral

nutrition,

ileus.

BRIAN D. ANDRESEN KWOKEI J. NG JAY D. IAMS JOSEPH R. BIANCHINE

Department of Surgery, Södersjukhuset, S-100 64 Stockholm, Sweden

INGER MAGNUSSON THOMAS IHRE

CHOLECYSTOKININ TO TREAT PARALYTIC ILEUS

SIR,-Cholecystokinin has, among other actions, the power to increase motor activity in the duodenum, small intestine,and distal colon.2 The hormone has been used clinically to relax the-sphincter of Oddi when stones have been retained in the common bileduct after surgery and to initiate small-bowel contractions in X-ray examinations.3 We have used CCK in five patients with prolonged paralytic ileus. Four men and one woman, mean age 54 (range 30-72), with radiologically verified postoperative paralytic ileus, were studied. The operations had been for mechanical intestinal obstruction, intestinal adhesions, gangrenous appendicitis, anal cancer, and bile leakage followed by peritonitis. CCK was given 10-14 days after the operation and when neostigmine (synstigmine), metoclopramide, and intubation with a Cantor tube had failed. Pure natural CCK (Kabi Diagnostica) was given intravenously at a dose of 1 Ivy dog unit per kg body weight to a maximum of 75 units, three times daily for 1 or 2 days. After the injection some patients experienced transient nausea and abdominal cramps. The symptoms subsided within 10 min. No other side-effects were noted. The response is illustrated by the following three cases. Case 1.-A 30-year-old heroin addict was operated on for smallbowel obstruction caused by adhesions after a previous appendicectomy. Postoperatively his abdomen was distended and the stomach was drained by nasogastric tube for an average of 4 litres daily during 2 weeks. Repeated abdominal films showed dilated small-bowel loops with air-fluid levels and gas in the colon. Neither neostigmine 0 -5mg four times daily nor metoclopramide 10 mg three times daily had any effect. 2 weeks after the operation CCK was given for 2 days: on the first day the patient had two minor bowel movements and on the second day four proper bowel evacuations followed by diarrhoea. The patient was sent home on the 4th day after the administration of CCK. Case 2.-A 68-year-old man had paralytic ileus after surgery for gangrenous appendicitis and needed gastric drainage for 2 weeks. Neostigmine and metoclopramide were ineffective but after three injections of CCK on 1 day the patient’s symptoms and gastric stasis disappeared. operation for intestinal adhesions a required gastric drainage and bowel 50-year-old movements were infrequent. Abdominal plain films showed a paralytic intestine. CCK was given for 2 days, and on the second day Case 3.-10

days

woman

after still

an

the bowel

was evacuated and the gastric stasis disappeared. Paralytic ileus is thought to be due to overactivity of the intestinal inhibitory neural system, and treatment with adrenergic a-receptorblocking agents, acetylcholine analogues, and anticholinesterases-has been suggested.4 Postoperative ileus mainly

affects the colon which remains inactive for 48 h

or more

before

5

passage of flatus. The octapeptide of CCK increases colonic motility at lower infusion rates than are necessary to produce its other physiological effects,2 and this prompted us to try CCK in these patients with JG, Chey WY, Dinose VP. Actions of cholecystokinin and secretin on the activity of the small intestine in man. Gastroenterology 1974; 67: 35-41. Snape WJ, Matarazzo SA, Cohen S. Effect of eating and gastro-intestinal hormones on human colonic myoelectrical and motor activity. Gastroenterology 1978; 75:

1 Gutiérrez motor

2.

EXPERIENCE WITH A PRACTICAL FOOD PATTERN TO REDUCE HEART DISEASE

SIR,-In The Lancet of Jan. 23 (p. 217) Jean Marr and Professor Morris ask whether it is possible to devise a diet that "is realistic and still will yield a worthwhile health benefit". They admit to an inability to meet the requirements proposed by Professor Oliver (Nov. 14, p. 1090) with food products available in Britain. Oliver called for 30% of calories as total fat, 10% saturated fatty acids and no increase in polyunsaturated fatty acids. Marr and Morris proposed that saturated fat could be reduced by cutting in half the consumption of foods that provide 90% of the saturated fat. They agree that this is an obviously impracticable solution and suggest less reduction in the saturated fat products along with some increase in the use of polyunsaturated fats. A more realistic and practical solution is based on the removal of as much fat as possible from meats and dairy products and substitution of low saturated table and cooking fats for their saturated counterparts. Two-thirds of the fat in meat can be eliminated by removing the visible fat before cooking and eating.1 Skim milk and defatted milk products can be substituted for customary dairy products. Consequently the nutrient content of these foods, other than fat and calories, is similar to the amounts present in the usual products. The fatty acid content of the resulting diet depends upon the composition of the table and cooking fats used. To meet Oliver’s requirements, these fats would be low in saturated and polyunsaturated fatty acids and high in monounsaturated fatty acids. The foods listed by Marr and Morris would become: skim milk, low-fat cheese, appropriate margarine and oil, meat and meat products low in fat, and biscuits made with the appropriate shortening. All other foodstuffs are very low in, or free from, fat-plain breads, cereals, pasta, and fruits and vegetables of all kinds. Such a food pattern, as fashioned in the United States, provides approximately 12% of calories as fat and 5% saturated fatty acids (ref. 1, table I) yet provides an adequate amount of protein, vitamins, and minerals when the proper proportion of foods is selected. The question is whether a growing child, adolescent, or active adult would obtain sufficient energy on such a low-fat regimen. When low saturated table and cooking fats are added to this basic food pattern to provide 30% of total fat calories, the saturated fatty acid content does not increase appreciably and additional colories are provided. The critical problem is to devise a food pattern that can be easily followed for a long time. No matter how adequate the diet specifications are for reducing heart disease, they are of little value if people cannot meet the food requirements in everyday life. Foods should be readily available, easily prepared, suitable for the entire family, adaptable to different cultural backgrounds, and provide the opportunity to substitute a satisfying food product for an unacceptable one. The food pattern must be nutritious and in large part built on an individual’s own food preferences. These principles were used and refined over the years in many different studies, especially in the National Diet Heart Study2 and

373-78.

JG, Beneventane TC. Acceleration of small bowel contrast study by cholecystokinin. Gastroenterology 1970; 58: 679-83. Meshkinpour H. Intestinal motility: Current concepts. Am J Gastroenterol 1979; 71:

3 Parker 4.

101-06. 5. Woods

JH, Erickson LW, Condon RE, Schulte WJ, Sillin problem? Surgery 1978, 84: 527-32

colonic

LF.

Postoperative

ileus:

a

1. Brown HB.

Availability of suitable foods in the marketplace, B: Animal products for the fat modified food pattern. In: Lauer RM, Shekelle RD, eds. Childhood prevention of atherosclerosis and hypertension. New York. Raven Press, 1980: 410-27. 2. National Diet-Heart Study Research Group. Am Heart Assoc Monogr 18: Circulation 1968; 37: (suppl 1).

793

Multiple Risk Factor Intervention Trial (MRFIT),3 just being completed. In MRFIT, food specifications and their use in the food pattern are developed in more detail than ever before. Papers describing the experience in MRFIT will soon be available. To adapt these principles of food selection for use in Britain, it would be necessary to know the food preferences of the people and the nutrient composition of available foods. in the

Cleveland Clinic Foundation, Cleveland, Ohio 44106, U.S.A.

ALLERGIC SYMPTOMS IN ONE SUBJECT

HELEN B. BROWN

Box 516,

Longwood Avenue, Hyannisport, Massachusetts

IRVINE H. PAGE * 1, no discomfort; 2, mild; 3, mild to moderate; 4, moderate; 5,

tNo data since subject slept for three

CAFFEINE FOR ALLERGIC RHINITIS with allergic rhinitis avoid antihistamines because of their sedative side-effects. Caffeine may provide an alternative. I incidentally noted relief of my allergic symptoms after ingestion of two analgesic tablets containing paracetamol (acetaminophen) 97 mg, salicylamide 130 mg, aspirin 194 mg, and caffeine 65 mg per tablet (’Excedrin’) for a headache and suspected that the effect was due to the caffeine. Xanthines, including and thereby caffeine, inhibit cyclic nucleotide increase intracellular levels of cAMP. This leads to decreased release of histamine2and reduced mast cell degranulation.3 To evaluate the ability of caffeine to relieve allergic rhinitis I did the following experiment on myself. Eight doses of approximately 140 mg caffeine (’NoDoz’), packed into two no. 2 gelatin capsules, and eight doses of placebo (sucrose), similarly packed, were taken in a random double-blind fashion on sixteen consecutive mornings. The capsules were taken upon momentary interruption of sleep one hour before my regular time of awakening so that blood caffeine levels would be greatest for the period from awakening, when my symptoms begin, until leaving home an hour or two later, by which time they have subsided. I recorded the usual symptoms of sneezing, palatal pruritus, and overall discomfort during this period, as well as pruritus at the time of taking the capsules and degree of alertness after awakening. There was a significant difference between caffeine and placebo in the number of sneezes (p<0’05, Wilcoxon two-sample test) and in the overall discomfort (see table) (pG005). Decreased pruritus was noted from the time the capsules were taken until the period after arising, with both caffeine and placebo, but was more marked on the caffeine mornings (not significant; data not shown). Side-effects of caffeine (e.g., increased alertness), which would have invalidated the double-blind format, did not occur. Caffeine’s ability to decrease allergic symptoms more than placebo can be due to the mechanism discussed above, although if such were the case one might have expected a greater effect on pruritus, which is the symptom closely linked to histamine. Despite the theoretical grounds for trying caffeine, its use for allergic rhinitis has not been described, though it has been reported to be useful in the treatment of the related disorder, atopic dermatitis.4Theophylline, another xanthine, is used to treat asthma, which, like allergic rhinitis, is a type I allergy; however, bronchial smooth-muscle relaxation rather than inhibited mediator release is its alleged mechanism of action, and theophylline is not used to treat allergic rhinitis. While this experiment involved only one subject and the mechanism of action is unclear, perhaps caffeine and other

SIR,-Many people

1

Caggiula AW, Christakis G, Farrand M, Hulley SB, Johnson RM, Lasser NL, Stamler J, Widdowson G. (for MRFIT). The Multiple Risk Factor Intervention Trial (MRFIT) IV: Intervention on blood lipids Prev Med1981;10: 443-75. Butcher RW, Sutherland EW. Adenosine 3’, 5’-phosphate in biological materials. J Biol Chem 1962, 237: 1244-50.

2 Lichenstein LM, Margolis S. Histamine release in vitro: Inhibition by catecholamines and methylxanthines. Science 1968; 161: 902-03. 3.Kimura Y, Inoue Y, Honda H. Further studies on rat mast cell degranulation by IgE-

anti-Ige and the inhibitory effect of drugs related to cAMP. Immunology 1974; 26: 983-88. 4.

Kaplan RJ, Daman L, Rosenberg EW, Feigenbaum S. Topical use of caffeine hydrocortisone in the treatment of atopic dermatitis. Arch Dermatol 1978; 60-62.

with 114:

severe.

taking capsules.

xanthines deserve closer scrutiny as possible treatment for rhinitis. After all, is not caffeine’s elation preferable antihistamines’ sedation? Albany Medical College, Albany, N.Y. 12208,U.S.A.

phosphodiesterase

3

hours after

allergic to

the

PHILIP SHAPIRO

DIAGNOSTIC CONTRIBUTION OF ECHOCARDIOGRAPHY

SiR,-While I agree that it is important to take account of medical costs, especially with reference to the introduction of new medical instruments, Dr Grimmer and colleagues’ conclusion (Feb. 20, p. 440) that "echocardiography is rarely useful for the detection of unsuspected disease" deserves closer scrutiny. In 500 patients for whom echocardiography was requested, a clinical diagnosis had been made in only 258 (52%). Only 77% of the 104 patients referred with a specified clinical diagnosis had this diagnosis confirmed by echocardiography and the impression is that in the rest of the patients echocardiography was not helpful. It seems more likely that the clinical diagnosis was wrong. Did the echocardiogram reveal other diagnoses or normal hearts? We are not told. Echocardiography was acknowledged to have been of greater value when used to exclude specific cardiac lesions, which it did in all 55 cases. Thus in all 258 cases where a clinical diagnostic question was raised, it was resolved by echocardiography either by confirmation or by exclusion of the diagnosis. The remaining 242 patients (60% of whom had cardiac murmurs), had ostensibly no clinical diagnosis, or no information was available on the request forms. Table iv is confusing since 81 of these very patients appear in a subgroup "other diagnoses"-e.g., pericardial effusion and atrial This subgroup apart, myxoma. echocardiography demonstrated important and unsuspected cardiac lesions in 18 patients. Grimmer and colleagues’ interpretation is that in patients "with no clinical diagnosis... only 5% had a positive echocardiographic diagnosis". Surely exclusion of a cardiac lesion and establishment of normality is a positive diagnosis which is equally meritorious, and one that is reassuring to patients and their doctors. Since echocardiography simply records whether abnormalities are or are not present, the discordance between clinically anticipated cardiac abnormalities and echocardiographic findings speaks more to the accuracy of the requesting doctors’ diagnoses than to the contribution echocardiography has made to clinical medicine. How, in the absence of any clinical diagnosis, were echocardiograms requested in almost 50% of this series? This is

using echocardiography as a screening procedure, of a technique’s value, and is analogous to assessing the contribution of the chest radiograph in terms of identifying pulmonary lesions in a population of patients with dyspnoea of unknown aetiology. The formulation of a clinical diagnosis, even if no longer an art form, is of paramount importance in clinical decision making and is a cost-effective triage for investigative procedures. The introduction of new medical instruments and technology does not diminish the need for medical

tantamount to

which is

not a true test