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VIRUS PARTICLES IN ACUTE GASTROENTERITIS
524 between women with a low hasmatocri tand with a " normal " haematocrit. The data were also examined at still lower haematocrit values. The hmmatocrit was under 40% in 108 men (1-3% of the examined men). 19 of them had died. Their total mortality-rate adjusted for age and follow-up time was 14-7%; that of all the other men was 5-0%. There were 202 clearly anaemic women (haematocrit under 36%). 5 of them had died. Their adjusted total mortality-rate was 3-7%, that of all the other women was 2-2%. The difference was not statistically significant. Our findings also suggest that the association between the total mortality-rate and haematocrit is J-shaped both in men and women. The prognosis appears to be the best " at normal " haematocrit values, around 45-46 in men and 41-42 in women, and the worst at high haematocrit values. According to our data, however, there is no evidence of a protective effect of anxmia with regard to C.H.D. mortality. In this respect the disagreement between our results and those of Dr Elwood and his associates might be, at least in part, due to confounding by age in their results, which are based on crude death-rates in the age-range 21-65. Also the age dependence of the hmmatocrit and the prognosis of anasmia might conceivably be different in British and Finnish women. On the other hand, different certification practices may influence results based on death certificates.
mortality-rate women
Research Institute for Social Security and Division of Epidemiology and Preventive
Medicine, Social Insurance Institution, Helsinki, Finland.
HEIKKI TAKKUNEN ARPO AROMAA.
VIRUS PARTICLES IN ACUTE GASTROENTERITIS
SiR.—Reovirus-like particles have been found in the faeces of children with acute gastroenteritis.1-4 It has been shown that a virus causing acute diarrhoea in newborn calves shares common antigens with the human agent and that both viruses differ from reovirus and orbiviruses morphologically.5 In 1957 Malherbe and Harwin 6 reported the isolation of S.A. 11 virus from gut washings of a vervet monkey, and in 1967 Malherbe and Strickland-Cholmley7 isolated the 0 agent from gut washings of sheep and cattle. Morphological studies 8 on both S.A. 11 and 0 agent showed that these viruses were morphologically identical and that they differed from the blue-tongue type or orbiviruses in their capsid morphology. They are, however, identical in morphology to human agents described in acute gastroenteritis.l,9 The intra-cytoplasmic particle in S.A. 11-infected LLC-MK2 cells closely resembles those in sections of gut biopsy material from children in the acute stage of gastroenteritis. These findings suggest strongly that the human, calf, and simian agents are the same or similar viruses. Consequently, we support the contention that the reovirus-like or orbivirus-like enteritis viruses of children and calves be placed in a group which typifies their structural specificity. Department of Microbiology, University of Pretoria, Pretoria, South Africa. 1.
2. 3. 4. 5. 6. 7. 8. 9.
G. LECATSAS.
Bishop, R. F., Davidson, G. P., Holmes, I. H., Ruck, B. J. Lancet, 1973, ii, 1281. Bishop, R. F., Davidson, G. P., Holmes, I. H., Ruck, B. J. ibid. 1974, i, 149. Flewett, T. H., Bryden, A. S., Davies, H. A. ibid. 1973, ii, 1497. Flewett, T. H., Bryden, A. S., Robertson, M. J., Davies, H. A. J. clin. Path. (in the press). Flewett, T. H., Bryden, A. S., Woode, G. N., Bridgen, J. C., Derrick, J. M. ibid. 1974, ii, 61. Malherbe, H., Harwin, R. Br. J. exp. Path. 1957, 38, 539. Malherbe, H., Strickland-Cholmley, M. Archs ges. Virusforsch. 1967, 22, 235. Els, H. J., Lecatsas, G. J. gen. Virol. 1972, 17, 129. Lecatsas, G. Onderstepoort J. vet. Res. 1972, 39, 133.
SMALL DOSES OF INSULIN IN THE TREATMENT OF DIABETIC "COMA"
SiR,-We were very interested to read the letter of Dr Shaw and others (June 1, p. 1115) who described a case of diabetic coma which failed to show a decrease in bloodglucose after 3 hours’ treatment with small doses of intramuscular insulin (and rejoice with them in the survival of an elderly patient with a cardiac infarct and such severe metabolic upset). Their dissatisfaction with the initial management comes under two heads: the increase in blood-glucose concentration and the initial clinical deterioration. In our paper we wrotez " In hypotensive patients an initial intravenous " pulse of insulin may be advisable, though we also stated that we had not found this necessary, nor have we since, despite some patients as ill metabolically and cerebrally as Dr Shaw’s. The failure of drop in glucose could be due to either an inadequate concentration of plasma-insulin (and it is frustrating that long-term insulin therapy prevented assay of serum-insulin in this patient), or to lack of normal access of glucose to the cells that utilise it because of inadequate peripheral circulation (or to both). This second alternative is inextricably linked with the " question of clinical deterioration ". A fluctuating course is not uncommon in patients admitted with slow nodal rhythm and hypotension who later show evidence of acute myocardial infarction; and it is not easy to discuss further this aspect since we have no details (in the naturally concise report) of changes in heart-rate, blood-pressure, jugular venous pressure, or E.C.G. while 3-5 1. of " normal saline was infused; or indeed of the timing of possible treatments such as atropine or oxygen. The importance in therapy of the passage of time (and perhaps of glucose flux into cells as well as glucose concentration) is illustrated by the return of consciousness after 51 hours when blood-glucose had fallen by only 76 mg. per 100 ml. (or 8%) from its initial value. We were interested, too, in the successful outcome with 1 g. potassium chloride given hourly to a hypotensive " diabetic coma " patient with a relatively short history of symptoms and plasma-potassium concentration on entry of 9-5 meq. per 1. To continue to give intravenous potassium after the first hour on hearing of such initial hyperkalxmia would not be our normal practice, but we strongly believe in general in early sustained potassium replacement and it was certainly associated with success here. " We would question Dr Shaw’s conclusion that " large doses of insulin should be given to severely ill and comatose patients. There have now been other reports 2-4 of the efficacy of small doses (when 2-4-10 units per hour were infused intravenously). We have shown metabolic disadvantages to large doses of insulin, and equal rates of decrease in blood-glucose with circulating insulin concentrations modest beside those achieved by conventional
" large-dose " regimens. We believe the crucial questions raised by this report (a) would larger doses of insulin have produced a substantial decrease in blood-glucose in the presence of such hypotension and bradycardia ?; and (b) what is the optimum range of rates of blood-glucose decrease (or intracellular glucose flux) for recovery ? Finally, we would stress that intended intramuscular injections must indeed be placed deep below the skin, and repeatboth that our summarised plan of treatment
are:
1.
Alberti, K. G. M. M., Hockaday, T. D. R., Turner, R. C. Lancet,
1973, ii, 515. Page, M. McB., Alberti, K. G. M. M., Greenwood, R., Gumaa, K. A., Hockaday, T. D. R., Lowy, C., Nabarro, J. D. N., Pyke. D. A., Sönksen, P. H., Watkins, P. J., West, T. E. T. Br. med.J. 1974, ii, 687. 3. Kidson, W., Casey, J., Kraegen, E., Lazarus, L. ibid. p. 691. 4. Semple, P. F., White, C., Manderson, W. G. ibid. p. 694.
2.
mortality-rate women
Research Institute for Social Security and Division of Epidemiology and Preventive
Medicine, Social Insurance Institution, Helsinki, Finland.
HEIKKI TAKKUNEN ARPO AROMAA.
VIRUS PARTICLES IN ACUTE GASTROENTERITIS
SiR.—Reovirus-like particles have been found in the faeces of children with acute gastroenteritis.1-4 It has been shown that a virus causing acute diarrhoea in newborn calves shares common antigens with the human agent and that both viruses differ from reovirus and orbiviruses morphologically.5 In 1957 Malherbe and Harwin 6 reported the isolation of S.A. 11 virus from gut washings of a vervet monkey, and in 1967 Malherbe and Strickland-Cholmley7 isolated the 0 agent from gut washings of sheep and cattle. Morphological studies 8 on both S.A. 11 and 0 agent showed that these viruses were morphologically identical and that they differed from the blue-tongue type or orbiviruses in their capsid morphology. They are, however, identical in morphology to human agents described in acute gastroenteritis.l,9 The intra-cytoplasmic particle in S.A. 11-infected LLC-MK2 cells closely resembles those in sections of gut biopsy material from children in the acute stage of gastroenteritis. These findings suggest strongly that the human, calf, and simian agents are the same or similar viruses. Consequently, we support the contention that the reovirus-like or orbivirus-like enteritis viruses of children and calves be placed in a group which typifies their structural specificity. Department of Microbiology, University of Pretoria, Pretoria, South Africa. 1.
2. 3. 4. 5. 6. 7. 8. 9.
G. LECATSAS.
Bishop, R. F., Davidson, G. P., Holmes, I. H., Ruck, B. J. Lancet, 1973, ii, 1281. Bishop, R. F., Davidson, G. P., Holmes, I. H., Ruck, B. J. ibid. 1974, i, 149. Flewett, T. H., Bryden, A. S., Davies, H. A. ibid. 1973, ii, 1497. Flewett, T. H., Bryden, A. S., Robertson, M. J., Davies, H. A. J. clin. Path. (in the press). Flewett, T. H., Bryden, A. S., Woode, G. N., Bridgen, J. C., Derrick, J. M. ibid. 1974, ii, 61. Malherbe, H., Harwin, R. Br. J. exp. Path. 1957, 38, 539. Malherbe, H., Strickland-Cholmley, M. Archs ges. Virusforsch. 1967, 22, 235. Els, H. J., Lecatsas, G. J. gen. Virol. 1972, 17, 129. Lecatsas, G. Onderstepoort J. vet. Res. 1972, 39, 133.
SMALL DOSES OF INSULIN IN THE TREATMENT OF DIABETIC "COMA"
SiR,-We were very interested to read the letter of Dr Shaw and others (June 1, p. 1115) who described a case of diabetic coma which failed to show a decrease in bloodglucose after 3 hours’ treatment with small doses of intramuscular insulin (and rejoice with them in the survival of an elderly patient with a cardiac infarct and such severe metabolic upset). Their dissatisfaction with the initial management comes under two heads: the increase in blood-glucose concentration and the initial clinical deterioration. In our paper we wrotez " In hypotensive patients an initial intravenous " pulse of insulin may be advisable, though we also stated that we had not found this necessary, nor have we since, despite some patients as ill metabolically and cerebrally as Dr Shaw’s. The failure of drop in glucose could be due to either an inadequate concentration of plasma-insulin (and it is frustrating that long-term insulin therapy prevented assay of serum-insulin in this patient), or to lack of normal access of glucose to the cells that utilise it because of inadequate peripheral circulation (or to both). This second alternative is inextricably linked with the " question of clinical deterioration ". A fluctuating course is not uncommon in patients admitted with slow nodal rhythm and hypotension who later show evidence of acute myocardial infarction; and it is not easy to discuss further this aspect since we have no details (in the naturally concise report) of changes in heart-rate, blood-pressure, jugular venous pressure, or E.C.G. while 3-5 1. of " normal saline was infused; or indeed of the timing of possible treatments such as atropine or oxygen. The importance in therapy of the passage of time (and perhaps of glucose flux into cells as well as glucose concentration) is illustrated by the return of consciousness after 51 hours when blood-glucose had fallen by only 76 mg. per 100 ml. (or 8%) from its initial value. We were interested, too, in the successful outcome with 1 g. potassium chloride given hourly to a hypotensive " diabetic coma " patient with a relatively short history of symptoms and plasma-potassium concentration on entry of 9-5 meq. per 1. To continue to give intravenous potassium after the first hour on hearing of such initial hyperkalxmia would not be our normal practice, but we strongly believe in general in early sustained potassium replacement and it was certainly associated with success here. " We would question Dr Shaw’s conclusion that " large doses of insulin should be given to severely ill and comatose patients. There have now been other reports 2-4 of the efficacy of small doses (when 2-4-10 units per hour were infused intravenously). We have shown metabolic disadvantages to large doses of insulin, and equal rates of decrease in blood-glucose with circulating insulin concentrations modest beside those achieved by conventional
" large-dose " regimens. We believe the crucial questions raised by this report (a) would larger doses of insulin have produced a substantial decrease in blood-glucose in the presence of such hypotension and bradycardia ?; and (b) what is the optimum range of rates of blood-glucose decrease (or intracellular glucose flux) for recovery ? Finally, we would stress that intended intramuscular injections must indeed be placed deep below the skin, and repeatboth that our summarised plan of treatment
are:
1.
Alberti, K. G. M. M., Hockaday, T. D. R., Turner, R. C. Lancet,
1973, ii, 515. Page, M. McB., Alberti, K. G. M. M., Greenwood, R., Gumaa, K. A., Hockaday, T. D. R., Lowy, C., Nabarro, J. D. N., Pyke. D. A., Sönksen, P. H., Watkins, P. J., West, T. E. T. Br. med.J. 1974, ii, 687. 3. Kidson, W., Casey, J., Kraegen, E., Lazarus, L. ibid. p. 691. 4. Semple, P. F., White, C., Manderson, W. G. ibid. p. 694.
2.