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VITAMINS IN THE ELDERLY
776 While there is now no doubt that many hospital patients would benefit from supplementary vitamin C, more work is needed to establish a suitable dose, since excessive amounts are wasteful and may have undesirable side-effects.12,13
trial of ascorbic acid in patients, particularly children, who receiving long-term corticosteroids.
are
Department of Child Health, Ninewells Hospital, Dundee DD2 1UD.
M.R.C. Unit for Metabolic Studies in
W. R. MCWHIRTER.
Psychiatry,
Middlewood Hospital, P.O. Box 134, Sheffield S6 1TP.
C. R. LEE.
TEACHING TEACHERS
SiR,—Iwas glad to read in the Medical Education section
566) that some teachers of medicine are aware fallibility. One supposes that this material went to press before it was widely known (or acknowledged)
(Sept. 7,
VITAMINS IN THE ELDERLY p.
SIR,—There is a great deal in Dr Taylor’s letter (July 27, 215) with which we disagree, but to set it out in detail
could well involve us later in unconstructive argument on such matters as whether colour photographs can be relied on as evidence of the severity of lesions, and so on. Indeed, our main reason for writing now to express our disagreement is because in his previous letter Dr Taylor seems to imply that unless disagreement is expressed, it should be inferred that it does not exist. That we are not unreasonable in disagreeing with Dr Taylor may be inferred from the following: Dr Taylor in his letter of July 27 writes " those who were seriously ill were excluded " from the samples, yet out of 150 patients 33 (22%) died before. the trial was completed. We wish to give notice that we shall neither continue this unconstructive correspondence nor reopen it.
of their
afford extensions of Parkinson to the all doctors are called upon to give talks Since penultimate. or lectures, and in spite of what has been said many have to rely on self-education (an interesting feedback from medical politics), it would be more appropriate to introduce educational psychology and teaching techniques in the first-year undergraduate course. From a practical point of view most clinical doctors learn most from those immediately above them. Many of the things that really count are learned at night and at weekends: not least self-reliance. It is not the lecture that must go but lecturers who are too busy or too erudite to plan their talks beforehand and to show some empathy.
that Britain
Hospital, Chertsey, Surrey.
E. N. WARDLE.
W. T. C. BERRY.
Norwich.
Department of Health and Social Security, London SE1.
OMENTAL TRANSPOSITION FOR DRAINAGE OF CEREBROSPINAL FLUID
S. J. DARKE.
ASCORBIC ACID AND LONG-TERM STEROIDS et al.14 raised the possibility that at least of the skeletal side-effects of long-term treatment with steroids may be preventable by the administration of ascorbic acid, although clearly further study is required. The probable mechanism of the beneficial effect is the ability of ascorbic acid to reverse the inhibitory action of corticosteroids on the hydroxylation of proline, which is a necessary step in the formation of collagen. These authors are not, however, the first to suggest that the administration of ascorbic acid to patients on ’longterm ’ corticosteroids may be of benefit. Chretien and Garagusi 15 demonstrated that ascorbic acid was capable of correcting the corticosteroid-induced defect of neutrophil function. The increased susceptibility to infections of patients on steroids is, of course, well known, and it has been shown that hydrocortisone suppresses bactericidal activity in neutrophils, probably through its inhibitory effects on N.A.D.H. oxidase 16 and the hexose-monophosphate shunt.l’ This can apparently be corrected by administration of ascorbic acid in large doses to patients who are receiving systemic steroids, presumably because ascorbic acid is able to stimulate the hexose-monophosphate shunt. Thus there appear to be two entirely independent mechanisms by which ascorbic acid may be able to prevent some of the undesirable side-effects of steroid administration. There seems therefore to be a need for a controlled
SIR9 Liakakos
some
Briggs, M. H., Garcin-Webb, P., Davies, P. Lancet, 1973, ii, 201. Schrauzer, G. N., Rhead, W. J. Int. J. Vit. nutr. Res. 1973, 43, 201. Liakakos, D., Ikkos, D. G., Vlachos, P., Ntalles, K., Coulouris, Ch. Archs Dis. Childh. 1974, 49, 400. 15. Chretien, J. H., Garagusi, V. F. J. reticuloendoth. Soc. 1973, 14, 12. 13. 14.
280. 16. 17.
cannot
St. Peter’s
4 Church Farm,
Colney,
p.
own
Chretien, J. H., Garagusi, V. F. ibid. 1972, 11, 358. Cooper, M. R., DeChatelet, L. R., McCall, C. E. Proc. Soc. exp. Biol. Med. 1972, 141, 986.
SIR,-Shipley and Cunninghamreported that the greater omentum plays a role in absorption of fluid from the peritoneal cavity, and surgeons have become aware of the possibilities of using the omentum in, therapy. Goldsmith et allfor example, used omentum transposition for drainage of lymphaedema of the limbs. We wish to draw attention to an experimental procedure3 for cerebrospinal fluid (c.s.F.) drainage by the use of a pedicle graft of the great omentum. The graft was implanted into the lumbosacral subarachnoidal space of animals after laminectomy, and introduced into the spinal canal through the posterior abdominal wall and paravertebral muscles. The omentum was sutured to the dura-arachnoid defect. In rats,4 a rapid uptake of C.S.F. by the omentum graft was demonstrated by the inulin test, even as late as 4-6 months after transposition. In dogs, similar results were demonstrated by cisternography with the gamma camera. The uptake of C.s.F. by omental graft and the further transport of 169Yb-D.T.P.A. (diethylene-triamine-pentaacetic acid) after lumbar subarachnoid injection was evaluated from accumulation in kidneys and bladder. The activity in peripheral blood was also measured and correlated with that in portal blood. Yasargil and others5 reported c.s.F.-absorbing ability of free intracranial transplants of omentum. However, after 3 weeks, they found a thin membrane of connective tissue between the transplant and the surface of the cerebral cortex. In our experiments with omentum implanted in the lumbosacral subarachnoidal space, even the most long-lasting ones of 4 months, microscopical examination showed no evidence of fibrotic degeneration. The surface Shipley, P. C., Cunningham, R. S. Am. J. Physiol. 1916, 40, 75. Goldsmith, H. S., de los Santos, R., Beattie, E. J., Jr. Ann. Surg. 1967, 166, 573. 3. Levander, B. E., Wennerstrand, J. Svenska LäkSällsk. med. Riksst. 1972, p. 292. 4. Wennerstrand, J., Levander, B. E. Acta chir. scand. 1974, 140, 91. 5. Yasargil, M. G., Yonekawa, Y., Denton, J., Piroth, D., Benes, J. J. Neurosurg. 1974, 39, 213. 1. 2.
trial of ascorbic acid in patients, particularly children, who receiving long-term corticosteroids.
are
Department of Child Health, Ninewells Hospital, Dundee DD2 1UD.
M.R.C. Unit for Metabolic Studies in
W. R. MCWHIRTER.
Psychiatry,
Middlewood Hospital, P.O. Box 134, Sheffield S6 1TP.
C. R. LEE.
TEACHING TEACHERS
SiR,—Iwas glad to read in the Medical Education section
566) that some teachers of medicine are aware fallibility. One supposes that this material went to press before it was widely known (or acknowledged)
(Sept. 7,
VITAMINS IN THE ELDERLY p.
SIR,—There is a great deal in Dr Taylor’s letter (July 27, 215) with which we disagree, but to set it out in detail
could well involve us later in unconstructive argument on such matters as whether colour photographs can be relied on as evidence of the severity of lesions, and so on. Indeed, our main reason for writing now to express our disagreement is because in his previous letter Dr Taylor seems to imply that unless disagreement is expressed, it should be inferred that it does not exist. That we are not unreasonable in disagreeing with Dr Taylor may be inferred from the following: Dr Taylor in his letter of July 27 writes " those who were seriously ill were excluded " from the samples, yet out of 150 patients 33 (22%) died before. the trial was completed. We wish to give notice that we shall neither continue this unconstructive correspondence nor reopen it.
of their
afford extensions of Parkinson to the all doctors are called upon to give talks Since penultimate. or lectures, and in spite of what has been said many have to rely on self-education (an interesting feedback from medical politics), it would be more appropriate to introduce educational psychology and teaching techniques in the first-year undergraduate course. From a practical point of view most clinical doctors learn most from those immediately above them. Many of the things that really count are learned at night and at weekends: not least self-reliance. It is not the lecture that must go but lecturers who are too busy or too erudite to plan their talks beforehand and to show some empathy.
that Britain
Hospital, Chertsey, Surrey.
E. N. WARDLE.
W. T. C. BERRY.
Norwich.
Department of Health and Social Security, London SE1.
OMENTAL TRANSPOSITION FOR DRAINAGE OF CEREBROSPINAL FLUID
S. J. DARKE.
ASCORBIC ACID AND LONG-TERM STEROIDS et al.14 raised the possibility that at least of the skeletal side-effects of long-term treatment with steroids may be preventable by the administration of ascorbic acid, although clearly further study is required. The probable mechanism of the beneficial effect is the ability of ascorbic acid to reverse the inhibitory action of corticosteroids on the hydroxylation of proline, which is a necessary step in the formation of collagen. These authors are not, however, the first to suggest that the administration of ascorbic acid to patients on ’longterm ’ corticosteroids may be of benefit. Chretien and Garagusi 15 demonstrated that ascorbic acid was capable of correcting the corticosteroid-induced defect of neutrophil function. The increased susceptibility to infections of patients on steroids is, of course, well known, and it has been shown that hydrocortisone suppresses bactericidal activity in neutrophils, probably through its inhibitory effects on N.A.D.H. oxidase 16 and the hexose-monophosphate shunt.l’ This can apparently be corrected by administration of ascorbic acid in large doses to patients who are receiving systemic steroids, presumably because ascorbic acid is able to stimulate the hexose-monophosphate shunt. Thus there appear to be two entirely independent mechanisms by which ascorbic acid may be able to prevent some of the undesirable side-effects of steroid administration. There seems therefore to be a need for a controlled
SIR9 Liakakos
some
Briggs, M. H., Garcin-Webb, P., Davies, P. Lancet, 1973, ii, 201. Schrauzer, G. N., Rhead, W. J. Int. J. Vit. nutr. Res. 1973, 43, 201. Liakakos, D., Ikkos, D. G., Vlachos, P., Ntalles, K., Coulouris, Ch. Archs Dis. Childh. 1974, 49, 400. 15. Chretien, J. H., Garagusi, V. F. J. reticuloendoth. Soc. 1973, 14, 12. 13. 14.
280. 16. 17.
cannot
St. Peter’s
4 Church Farm,
Colney,
p.
own
Chretien, J. H., Garagusi, V. F. ibid. 1972, 11, 358. Cooper, M. R., DeChatelet, L. R., McCall, C. E. Proc. Soc. exp. Biol. Med. 1972, 141, 986.
SIR,-Shipley and Cunninghamreported that the greater omentum plays a role in absorption of fluid from the peritoneal cavity, and surgeons have become aware of the possibilities of using the omentum in, therapy. Goldsmith et allfor example, used omentum transposition for drainage of lymphaedema of the limbs. We wish to draw attention to an experimental procedure3 for cerebrospinal fluid (c.s.F.) drainage by the use of a pedicle graft of the great omentum. The graft was implanted into the lumbosacral subarachnoidal space of animals after laminectomy, and introduced into the spinal canal through the posterior abdominal wall and paravertebral muscles. The omentum was sutured to the dura-arachnoid defect. In rats,4 a rapid uptake of C.S.F. by the omentum graft was demonstrated by the inulin test, even as late as 4-6 months after transposition. In dogs, similar results were demonstrated by cisternography with the gamma camera. The uptake of C.s.F. by omental graft and the further transport of 169Yb-D.T.P.A. (diethylene-triamine-pentaacetic acid) after lumbar subarachnoid injection was evaluated from accumulation in kidneys and bladder. The activity in peripheral blood was also measured and correlated with that in portal blood. Yasargil and others5 reported c.s.F.-absorbing ability of free intracranial transplants of omentum. However, after 3 weeks, they found a thin membrane of connective tissue between the transplant and the surface of the cerebral cortex. In our experiments with omentum implanted in the lumbosacral subarachnoidal space, even the most long-lasting ones of 4 months, microscopical examination showed no evidence of fibrotic degeneration. The surface Shipley, P. C., Cunningham, R. S. Am. J. Physiol. 1916, 40, 75. Goldsmith, H. S., de los Santos, R., Beattie, E. J., Jr. Ann. Surg. 1967, 166, 573. 3. Levander, B. E., Wennerstrand, J. Svenska LäkSällsk. med. Riksst. 1972, p. 292. 4. Wennerstrand, J., Levander, B. E. Acta chir. scand. 1974, 140, 91. 5. Yasargil, M. G., Yonekawa, Y., Denton, J., Piroth, D., Benes, J. J. Neurosurg. 1974, 39, 213. 1. 2.