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SUGAR INTOLERANCE IN ROTAVIRUS GASTROENTERITIS
470 MORTALITY FROM CARCINOMA OF THE CERVIX IN CANADA
sistently present but is usually associated with a low arterial PC02. A rise in arterial Pco2 signifies a late stage of pulmon-
1970-76 ’
ary-gas disturbance and should not be used as
a
criterion for
starting i.P.P.v. In our series duration of shock was judged in absolute terms. During this period we gained the impression that the intensity
of shock lessened in response
to treatment
but this factor
was
objectively measured. As to the possible protective action of glucocorticosteroids in septic shock, almost all of the "large volume of work devoted not
subject" is focused on the acute response. We are not of any firm evidence that these agents prevent the longterm complications of septic shock. Otherwise, Dr Buxton Hopkin’s views on the theories of "endotoxin shock" are known to us and, in the absence of firm facts, he is entitled to speculate on setiological mechanisms. As clinicians involved in the practical management of septic patients we were concerned to examine more immediately available methods of lowering mortality in a "high risk" population. Whether in so doing we contributed little or otherwise to "understanding of the pathophysiology of the condition" we are happy to leave others to judge. to
this
aware
In view of the conflict between the recommendations on the age at which screening should start in the report of the Canadian Task Force on Screening for Cancer of the Cervixs and the recommendations of Spriggs and Husain on behalf of the British Society of Cytology6 and of MacGregor and Teper it is appropriate to review the mortality experience under age 45 from carcinoma of the cervix in Canada over the same time period as considered by Yule. In view of the changes in the Canadian population, rather than presenting number of deaths I present rates per 100 000 per year in 5-year agegroups from 20 to 44. Although, particularly when numbers are small, the rates fluctuate, in general mortality from cancer of the cervix seems to have fallen at all ages. Nevertheless, although the absolute rates are lower, the reduction would seem to be less under age 35. Thus it seems as if Canada-though sharing the changes in sexual activity in the young noted in England and Wales and also seeing in many programmes an increase in pre-cancerous lesions detected on screening in the younger women-is not seeing an increase in mortality from cancer of the cervix at younger ages. It seems reasonable to conclude that the tendency in Canada to concentrate on screening at younger ages and, particularly in well-screened areas, to use the opportunity of a medical contact with a woman indicating sexual activity (antenatal or postnatal visits and prescription of contraceptives for example) on which to tie screening is resulting in a prevention of what might otherwise have occurred-namely, an increase in mortality from cancer of the cervix at younger ages. Accordingly, therefore, and as urged by Yule, it would seem that the recommendations over age of starting screening given in the Canadian Task Force Report are in line with the realities of the disease at the present time. N.C.I.C. Epidemiology Unit, University of Toronto,
A. B. MILLER
Toronto M5S 1A8, Canada
SEPTIC SHOCK
’
SIR,-Dr Buxton Hopkin (July 22, p. 211) raised the question of the indications for instituting intermittent positivepressure ventilation (l.p.p.v.) in patients with septic shock. In general, we have found that the earlier I.P.P.V. is started the less likely is the development of intractable pulmonary problems. Our decision to ventilate, therefore, is based on a mixture of clinical prediction of likely duration of the underlying septic problem and the degree of respiratory embarrassment at the time of referral rather than on absolute values of blood-gas analysis. If the patient is shocked and hyperventilating, and the diagnosis of major sepsis is not in serious doubt, then, in our opinion, i.P.P.v. is indicated. Hypoxaemia is con5. Task Force 6.
appointed by the conference of Deputy Ministers of med. Ass. J. 1976, 114, 2. Spriggs, A. I., Husain, O. A. M. Br. med. J. 1977, i, 1516.
Health. Can.
’
University Department of Surgery, Western Infirmary, Glasgow G116NT
IAIN MCA. LEDINGHAM C. S. MCARDLE
SUGAR INTOLERANCE IN ROTAVIRUS GASTROENTERITIS
SIR,-Dr Sack and colleagues (Aug. 5, p. 280) conclude that children with rotavirus gastroenteritis have defective digestion and absorption of carbohydrate, from their observation that the mean level of stool reducing substances rose after boiling-acid hydrolysis. However, they did not study the stools chromatographically in order to identify the sugars present. Kerry and Townley’ described the technique of boiling-acid hydrolysis of stools for the diagnosis of sucrose malabsorption. Sucrose, a non-reducing sugar, must first be hydrolysed before reducing substances can be identified in sucrose-containing stools unless bacteria have already split malabsorbed sucrose. A rise in the level of stool reducing substances after boilingacid hydrolysis was interpreted as evidence of an excess of stool-sucrose, as in sucrose-isomaltase deficiency. Soeparto et al. also studied the stools chromatographically and doubted whether this interpretation was always correct. They suggested that a false positive result with boiling-acid hydrolysis could result from a colour change reflecting an alteration in the oxidation of the stool bile pigment. The rise in the level of stool reducing substances after boiling-acid hydrolysis in the children given oral sucrose could be interpreted as evidence of sucrose malabsorption. However, a rise after boiling-acid hydrolysis in the level of reducing substances in the stools of children given oral glucose cannot be regarded as evidence of carbohydrate malabsorption without quantitative stool chromatography. Theoretically, this rise is inexplicable and surely must be an artefact because boilingacid hydrolysis of glucose would have no effect on the level of stool reducing substances. We would, however, agree from a practical clinical point of view that a temporary sugar intolerance-most often temporary monosaccharide intolerance-is frequent in infants with rotavirus gastroenteritis, especially those under six months of age. But in only a few infants is this of therapeutic importance, requiring temporary reduction or elimination of dietary monosaccharide. J. A. WALKER-SMITH Department of Child Health, P. MANUEL St. Bartholomew’s Hospital, P. HUTCHINS London EC1A 7BE 1. 2.
Kerry, K. R., Townley, R. R. W. Aust. pæd. J. 1965, 1, 223. Soeparto, P., Stobo, E. A., Walker-Smith, J. A. Archs Dis. 56.
Childh.
1972, 47,
sistently present but is usually associated with a low arterial PC02. A rise in arterial Pco2 signifies a late stage of pulmon-
1970-76 ’
ary-gas disturbance and should not be used as
a
criterion for
starting i.P.P.v. In our series duration of shock was judged in absolute terms. During this period we gained the impression that the intensity
of shock lessened in response
to treatment
but this factor
was
objectively measured. As to the possible protective action of glucocorticosteroids in septic shock, almost all of the "large volume of work devoted not
subject" is focused on the acute response. We are not of any firm evidence that these agents prevent the longterm complications of septic shock. Otherwise, Dr Buxton Hopkin’s views on the theories of "endotoxin shock" are known to us and, in the absence of firm facts, he is entitled to speculate on setiological mechanisms. As clinicians involved in the practical management of septic patients we were concerned to examine more immediately available methods of lowering mortality in a "high risk" population. Whether in so doing we contributed little or otherwise to "understanding of the pathophysiology of the condition" we are happy to leave others to judge. to
this
aware
In view of the conflict between the recommendations on the age at which screening should start in the report of the Canadian Task Force on Screening for Cancer of the Cervixs and the recommendations of Spriggs and Husain on behalf of the British Society of Cytology6 and of MacGregor and Teper it is appropriate to review the mortality experience under age 45 from carcinoma of the cervix in Canada over the same time period as considered by Yule. In view of the changes in the Canadian population, rather than presenting number of deaths I present rates per 100 000 per year in 5-year agegroups from 20 to 44. Although, particularly when numbers are small, the rates fluctuate, in general mortality from cancer of the cervix seems to have fallen at all ages. Nevertheless, although the absolute rates are lower, the reduction would seem to be less under age 35. Thus it seems as if Canada-though sharing the changes in sexual activity in the young noted in England and Wales and also seeing in many programmes an increase in pre-cancerous lesions detected on screening in the younger women-is not seeing an increase in mortality from cancer of the cervix at younger ages. It seems reasonable to conclude that the tendency in Canada to concentrate on screening at younger ages and, particularly in well-screened areas, to use the opportunity of a medical contact with a woman indicating sexual activity (antenatal or postnatal visits and prescription of contraceptives for example) on which to tie screening is resulting in a prevention of what might otherwise have occurred-namely, an increase in mortality from cancer of the cervix at younger ages. Accordingly, therefore, and as urged by Yule, it would seem that the recommendations over age of starting screening given in the Canadian Task Force Report are in line with the realities of the disease at the present time. N.C.I.C. Epidemiology Unit, University of Toronto,
A. B. MILLER
Toronto M5S 1A8, Canada
SEPTIC SHOCK
’
SIR,-Dr Buxton Hopkin (July 22, p. 211) raised the question of the indications for instituting intermittent positivepressure ventilation (l.p.p.v.) in patients with septic shock. In general, we have found that the earlier I.P.P.V. is started the less likely is the development of intractable pulmonary problems. Our decision to ventilate, therefore, is based on a mixture of clinical prediction of likely duration of the underlying septic problem and the degree of respiratory embarrassment at the time of referral rather than on absolute values of blood-gas analysis. If the patient is shocked and hyperventilating, and the diagnosis of major sepsis is not in serious doubt, then, in our opinion, i.P.P.v. is indicated. Hypoxaemia is con5. Task Force 6.
appointed by the conference of Deputy Ministers of med. Ass. J. 1976, 114, 2. Spriggs, A. I., Husain, O. A. M. Br. med. J. 1977, i, 1516.
Health. Can.
’
University Department of Surgery, Western Infirmary, Glasgow G116NT
IAIN MCA. LEDINGHAM C. S. MCARDLE
SUGAR INTOLERANCE IN ROTAVIRUS GASTROENTERITIS
SIR,-Dr Sack and colleagues (Aug. 5, p. 280) conclude that children with rotavirus gastroenteritis have defective digestion and absorption of carbohydrate, from their observation that the mean level of stool reducing substances rose after boiling-acid hydrolysis. However, they did not study the stools chromatographically in order to identify the sugars present. Kerry and Townley’ described the technique of boiling-acid hydrolysis of stools for the diagnosis of sucrose malabsorption. Sucrose, a non-reducing sugar, must first be hydrolysed before reducing substances can be identified in sucrose-containing stools unless bacteria have already split malabsorbed sucrose. A rise in the level of stool reducing substances after boilingacid hydrolysis was interpreted as evidence of an excess of stool-sucrose, as in sucrose-isomaltase deficiency. Soeparto et al. also studied the stools chromatographically and doubted whether this interpretation was always correct. They suggested that a false positive result with boiling-acid hydrolysis could result from a colour change reflecting an alteration in the oxidation of the stool bile pigment. The rise in the level of stool reducing substances after boiling-acid hydrolysis in the children given oral sucrose could be interpreted as evidence of sucrose malabsorption. However, a rise after boiling-acid hydrolysis in the level of reducing substances in the stools of children given oral glucose cannot be regarded as evidence of carbohydrate malabsorption without quantitative stool chromatography. Theoretically, this rise is inexplicable and surely must be an artefact because boilingacid hydrolysis of glucose would have no effect on the level of stool reducing substances. We would, however, agree from a practical clinical point of view that a temporary sugar intolerance-most often temporary monosaccharide intolerance-is frequent in infants with rotavirus gastroenteritis, especially those under six months of age. But in only a few infants is this of therapeutic importance, requiring temporary reduction or elimination of dietary monosaccharide. J. A. WALKER-SMITH Department of Child Health, P. MANUEL St. Bartholomew’s Hospital, P. HUTCHINS London EC1A 7BE 1. 2.
Kerry, K. R., Townley, R. R. W. Aust. pæd. J. 1965, 1, 223. Soeparto, P., Stobo, E. A., Walker-Smith, J. A. Archs Dis. 56.
Childh.
1972, 47,