THROMBOPHLEBITIS IN INTRAVENOUS NUTRITION

1351 atheroma in some degree but it often remain harmless until complications are severe.33 Primary prevention means changing the habits of the popu lation throughout adult life. We cannot impose such restric tions without evidence from secondary prevention trials whict are at present completely negative. Oliver,3’ who has aban. doned the idea of cholesterol as a cause of C.H.D., points ou that 83% of those with even four "risk factors" in the Fram ingham study were alive after 10 years. After the onset o: angina or an infarct survival for a couple of decades is quitl common and many patients can forget their anxieties. Dieteti< restrictions are burdensome not only to the individual but t( his wife and family. Dairy products are the basis of some oi our most palatable foods and their exclusion can be unpleasant and distressing. Within our profession there are enthusiasts whose faitr triumphs over critical analysis of their inconsistencies. With the aid of uncommitted clinical experts, experimentalists, and pathologists, these matters should be debated. The B.C.S./R.C.P. report should have given a less biased view tc the profession. Like similar publications addressed to the public its views were propaganded by Press and television stressing its over-simplistic dietetic measures. This modern and mar. ginally ethical habit of presenting "research" directly to the public leads to the propagation of half-truths unscreened by professional criticism.35 It is regrettable that learned bodies like the B.C.S. and R.C.P. could lead the public to believe we have an answer to the coronary problem when in fact we have none. In the long run this could be damaging to our profession. We should rather enlist public support and interest in promoting more basic research on arterial disease.

progressive

,

2 North Square, London NW11 7AA

JOHN MCMICHAEL

Serial serum-cholesterol values and body weight in patient with type-n hyperlipidwmia with and without guar gum.

cholesterol test

at

least

as

great

as

that

seen

after the initial 2-week

period.

The patient whose results are shown in the figure had been taking cholestyramine 16 g/day throughout the period of observation but with little effect on the serum-cholesterol. Only one other patient was already on hypocholesteraemic therapy, and here clofibrate 1000 mg/day had brought the cholesterol down to 298 mg/dl, the lowest initial level seen in the group, and guar did not reduce this further. Guar gum is used in small concentrations in a number of manufactured foods, and if it proves possible to increase the concentration without losing palatability such foods could have a therapeutic use. Our results suggest that guar gum will be a useful adjunct

hypocholesterolaemic therapy.

to

We thank Sir Francis

GUAR GUM IN HYPERLIPIDÆMIA

SIR,-Guar gum, a galactomannan storage polysaccharide of the cluster bean, Cyanopsis tetragonoloba, was hypocholesterolaemic in short-term studies in healthy volunteers.36 37 It therefore seemed important to study its effect on hyperlipidsmic individuals. The effect of taking 15 g guar gum

over a 2-week period was patients with type-II hyperlipidaemia (six women, one man; age 56 ±5 years, range 33-71; % ideal body weight, 115 ±6, range 94-148). The gum was taken either in specially prepared soup or as powder mixed with fruit juice or milk, in three divided doses of 5 g at the beginning of each meal. A fasting blood-sample was taken and analysed for cholesterop8 and triglyceride39 at the beginning and end of the 2-week period, and weight was recorded at the same time. Over the 2-week period on guar the mean serum-cholesterol fell from 351 ±17 to 321 ±18 mg/dl and the triglyceride rose from 211 i:43 to 235 +64 mg/dl. Although neither of these changes was significant, the serum-cholesterol in five of the seven patients fell and the remaining two only had increases of 12 ml/dl. Three patients were then placed on guar for a longer period. The cholesterol values of the patient who has been followed for longest are shown in the figure. After the initial 2-week test period on guar this patient has now taken guar for 21-months and a depression of the serum-cholesterol level has been maintained which is similar in magnitude to that seen at the end of the 2-week test period. Similarly the other two patients have achieved a depression of the serum-

studied

on

seven

33. Baroldi, G. 7th Eur. Cardiol. Congr. 1976, abstr. I, 790. 34. Oliver, M. Br. Heart J. 1976, 38, 214. 35. Astrup, P., Crone, C., Lundquist, F., Tygstrup, N. Ugeskr.

Laeger, 1975/6, 138, 28. 36 Fahrenbach, M. J., Riccardi, B. A., Saunders, J. C., Loune, I. M., Heider, J. G. Circulation, 1963, 31/32, suppl. II, p. 1141. 37. Jenkins, D. J. A., Leeds, A. R., Newton, C., Cummings, J. H. Lancet, 1975, i, 1116. 38

Huang,

T.

C , Chen, C. P, Wefler, V., Rafetry, A. Analyt. Chem. 1961, 33,

1405. 39.

Eggstein, M., Kruetz,

F. H. Klin. Wschr. 1966, 44, 267.

Avery Jones and Dr E. N. Rowlands for help and encouragement; and H. J. Heinz & Co. Ltd for provision of soup with and without guar. A. R. L. is in receipt of a Medical Research Council training fellowship. M.R.C. Gastroenterology Unit and Departments of Chemical Pathology and General Medicine, Central Middlesex Hospital and Willesden General Hospital, London NW10

D. J. A. JENKINS A. R. LEEDS BRENDA SLAVIN E. M. JEPSON

THROMBOPHLEBITIS IN INTRAVENOUS NUTRITION

SiR,—We

were

interested in Dr Guest and Mr Leiberman’

(Oct 9, p. 805) of hydropneumothorax and cardiac tamponade related to a rigid catheter used in total parenteral nutrition. We agree that the stiffness and sharp shape of the two

reports

catheters contribute to these dramatic mechanical complications.’ Soft pliable catheters (’Vygon’ silicone, code 18-20) are certainly less traumatic to the veins. The surgical procedure often required to introduce this soft catheter offers the interesting possibility of using a subcutaneous route.2 We do not agree that "when a long line is used for feeding purposes ... the catheter need not be advanced farther than the brachiocephalic vein". In two patients on total parenteral nutrition (one on 30% dextrose and ’Amminosol 100’ [Vitrum], the other on ’Intralipide, Vamin’ [Vitrum] delivered into the subclavian and basilic veins by percutaneous rigid cathetei [vygon ’Stericath’ code 130-20]) a harmful thrombophlebitis with secondary suppuration developed (figs 1 and 2). The clinical course was difficult: basilic phlebectomy and antibiotics were effective in the second patient. We think that these twc incidents of thrombophlebitis at the infusion site were facilitated by hypertonic and acid solutions3 infused in too-peri1.

Bitoun, A., Rambaud, J. C., Bernier, J. J. Archs Mal. App. dig. 1972. 61, 392. 2. Bitoun, A., l’Hirondel, C., Bernier, J. J. in Symposium Vitrum sur la nutrition parentérale; p. 69. Pans, 1973. 3. Elfving, G., Hastbracka, J., Tammisto, T. Am. Heart. J. 1967, 73, 717.

1352 medicine. With this perspective, the medical students are able to assess their own eating habits, to get a taste of therapeutic nutrition, to appreciate the value of seeking the services of a dietitian and to recognise their future leadership responsibih-. ties in the advocacy of dietary management. School of Medicine, Flinders Medical Centre, Bedford Park, South Australia 5042

ALAN STEWART

SUBACUTE SCLEROSING PANENCEPHALITIS IN SOUTH AMERICA

Fig. 1---Phlebogram showing thrombophlebitis of axillary

and

subclavian veins. ArroM indicates site of

perfusion;

catheter introduced in internal

jugular vem.

Fig.2-Phlebogram, showing thrombophlebitis of basilic and. axillary veins. Arrow indicates site of perfusion; catheter introduced in antecubital vein.

phcral veins damaged by free-floating stiff polyethylene catheters.4 Total parenteral nutrition with hypertonic, acid solutions must be delivered to central veins (superior vena cava), though thrombosis may still occur.4 Added heparin, when suitable, may be useful in the prevention of infusion

SIR,-We have published’ the results of an epidemiotogical survey of 31 cases of subacute sclerosing panencephalitis (S.S.P.E.), confirmed by necropsy or biopsy and reported to the Ministry of Health of Colombia during the years 1965-73. The clinical and pathological features of the first 20 cases have been reported elsewhere.3-5 From 1973 to 1975, 32 additional cases of S.S.P.E. were diagnosed in Colombia. Except for the first 4 cases,6 our earlier report, and a previous one of 31 cases from Sao Paulo (Brazil),? s.s.P.E. is practically unknown in Latin America. For this reason, we thought it important to give wider publicity to these findings. Colombia has a population of 22 million, of whom 45% are less than 15 years of age. The presence of 63 cases of S.S.P.E. in the decade 1965-75 represents a much higher incidence than the one obtained by the S.S.P.E. Registry of the U.S.A.’ (1 case per million children in the decade 1960-70). This is also true for the 31 cases of the Province of Sao Paulo in Brazil (1954-67)1 for a population of 17 million people. Measles ranks first as the cause of mortality in the age-group one to four years in Central and South America,9 and 50% of children are exposed to measles before eighteen months of age." Jabbour et a1.8 have emphasised that infection with measles before two years of age could be responsible for the abnormal response of the host to this virus as observed in S.S.P.E. 18 of the 31 patients studied suffered clinical measles, in 7 before two years of age, 10 had contact with measles patients. Of interest was the occurrence of measles prenatally in the mother of 1 patient, clinically diagnosed during a family epidemic, during the third trimester of gestation. In 3 other cases the pregnant women were exposed to measles in the third trimester during an outbreak of measles among the older children. To our knowledge this finding has not been previously published; it requires further attention because the same mechanism is involved in the experimental induction of the chronic form of lymphocytic choriomeningitis (L.C.M.) in the mouse. 1I The remaining epidemiological features of this group of patients closely resemble those described previously in S.S.P.E..78 12 21 cases came from rural areas and 10 from the

thrombophlebitis.s Department

of Gastroenterology,

Saint Lazare

Hospital,

75010-Paris, France

P. MESSING A. BITOUN P. POITRAS J. J. BERNIER

NUTRITION IN MEDICINE p. 743) takes a narrow view of nutrition in a medical curriculum. The of significance ob)ectives are not to make doctors into nutritionists but to increase their awareness of what constitutes sensible dietary choices and of the forces which persuade us to eat what we do. This means that nutrition needs to be presented through the perspective of food choice rather than through biochemistry or

SIR,-Dr Garrow (Oct. 2,

the

4 Ry an, J A. and others, New Engl. J. Med 1974, 290, 757. 5 Daniell, H. W J. Am. med. Ass. 1973, 226, 1317.

1. Navarro de 1973. 2. Navarro de

Román,

L.

M.P.H.

thesis, Universitario Nacional de Colombia,

Román, L., Román, G., Toro, G., Vergara, I. Annoquia méd 1976, 26, 99. 3. López, F., Toro, G., Holgum, J., Uribe, C., Londoño, R. VI Congr. int. Neuropath 1970, p. 1150. 4. López, F., Toro, G., Holquin, J., Uribe, C., Londoño, R. P.E.E.S A.: Estudio de 22 Casos Colombianos. Ministerio de Salud Publica, Colombia, 1971. 5.

Rodriguez, G., Toro, G., Buitrago, B., Sánchez, A. Archos. invest. Méd. 1975, 6, 419. 6. Bogazc, J., and others. Acta neurol. lat. am. 1959, 5, 158. 7. Canelas, J. M., Freitas Juliao, O., Lefevre, A. B., Lamartine de Assis, J, Tognola, W. A., De Jorge, I. B., Fonseca, L. C., Xavier-Lima, A Arq Neuropsychiat. 1962, 25, 255. 8. Jabbour, J. T., Duenas, D. A., Sever, J. L., Krebs, H. M., Horta-Barbosa, L. J. Am. med. Ass. 1972, 220, 959. 9. O.P.S./O.M.S. Las Condiciones de Salud en las Americas. Washington, 1970 10. 11.

Dudgeon, J. A. Br. med. Bull. 1969, 25, 153. Horta-Barbosa, L., Fuccillo,

D.

A., Sever, J. L. J. Am. med. Ass. 1971, 218,

1185. 12 Canal, N , Torck,

P. J. neurol. Sci. 1964, 1,

380.