BANGLADESH DRUG POLICY
1
1405 Recently, in our hospital, a baby delivered by caesarean section at 24 weeks’ gestation was fed parenterally for 104 days. ’Vamin 9 Glucose’ was used to provide a daily total of 35 g crystalline aminoacids per kg (of this total, 275 mg was phenylalanine). A routine screen for phenylketonuria indicated a borderline result and the serum phenylalanine level was 220 (imot/1. 21 days later the level had increased to 1350 µmo1/1. A daily regimen of ’Synthamin’ at 3-0 g crystalline aminoacids per kg (equivalent to 163 mg phenylalanine) was substituted-the phenylalanine level decreased to 60 µmo1/1 within 5 days. This regimen was continued for the next 34 days with a gradual introduction of an enteral feed. During this time the highest phenylalanine level was 150 µmo1/1. PROPORTION OF PHENYLALANINE IN COMMERCIALLY AVAILABLE PARENTERAL FEEDS* *Strength under each brand’s headmg. The currently available commercial solutions for TPN contain different proportions of phenylalanine (see table). The use of synthamin in newborn babies with TPN-induced hyperphenyl- alaninaemia has the advantage of reducing the phenylalanine load with little effect on the total quantity of aminoacids. It must be remembered, however, that the commercial preparations have different profiles of aminoacid. Until there is evidence to the contrary it would be prudent to monitor the phenylalanine levels of neonates receiving TPN. This may be particularly important in premature babies. It would also be prudent to maintain phenylalanine levels in these babies at 200-500 µmo1/1—ie, the criteria adopted for controlling the hyperphenyl- alaninaemia associated with classical phenylketonuria. Departments of Clinical Biochemistry, Paediatrics, Nutrition and Dietetics, and Pharmacy, General Hospital, Northampton NN7 5BD STANLEY J. EVANS TIM C. J. E. WYNNE-WILLIAMS CHRISTINE A. RUSSELL ADRIAN FAIRBROTHER 1. Smith I, Wolff OH. MRC/DHSS Phenylketonuria Register newsletter 1984, no 9. AMOEBA RESEARCH AND HISTORY SIR,—I would like to recall some of the history of Entamoeba histolytica (Nov 15 editorial) because, as Elsdon-Dew said in his excellent review on the epidemiology of amoebiasis,l "much modem thinking carries a legacy of the misconceptions of the past". In 1913 Kuenen and Swellengrebel2 described the three stages in the cycle of E histolytica (minuta, histolytica, and cyst), crediting others who had worked along the same lines. The concept of commensalism that arose from this work became the line of thought in most of Europe but in the English-speaking world it was strongly opposed. By 1920, several years before Brumpt’s prophecy on harmless amoebic species, two schools of thought could be distinguished-the Swellengrebel school of "commensalists" and the Dobell school of, in the words of Elsdon-Dew, "Prometheans". They differed on the status of the cyst passer; the Prometheans thought that this was a disease state and the commensalists held that this was not necessarily so. According to Elsdon-Dew, Hoare’s conclusion in 1952 that the minuta form represented the essential stage of E histolytica whereas the haematophagous amoebae had no place in its normal life-cycle, came too late "to stem the conflagration initiated by Dobell’s Promethean concept". "The embers still smoulder", he wrote in 1968. I wonder how much Dobell’s concept is still influencing the tendency to treat all carriers; this "good conservative medicine" (your editorial) is probably to a large extent based on that concept. The suggestion that the bacterial flora in the gut lumen may be :" necessary for pathogenicity, made in 1955,4might now be veritred by the work of Mirelman et al (1986),S to which vou refer. It is interesting to see how modem research is confirming an d explaining good old observations. Unit of Tropical Medicine and Infectious Diseases, Academic Medical Centre, University of Amsterdam, 1105 AZ Amsterdam, Netherlands P. A Ka 1 Elsdon-Dew R. The epidemiology of amoebiasis. Adv Parasitol 1968, 6: 1-62 2 Kuenen WA, Swellengrebel NH. Die Entamoben des Menschen und ihre praktis Bedeutung. Zentralbl Bakt Parasitkde 1913; 71: 378-410. 3. Krogstad DJ. Isoenzyme patterns and pathogenicity in amebic infection N Engl J Med 1986; 315: 390-91 4 Phillips BP, Wolfe PA, Rees CW, Gordon HA, Wright WH, Reymiers JA. Studieson the ameba-bacteria relationship in amebiasis: Comparative results of the intrac inoculation of germfree, monocontaminated, and conventional guinea pigs with Entamoeba histolytica. Am J Trop Med Hyg 1955; 4: 675-92. 5 Mrelman D, Bracha R, Chayen A, Aust-Kettis A, Diamond LS Entamoch histolytica: Effect of growth conditions and bacterial associates on isoenzym patterns and virulence. Exp Parasitol 1986; 62: 142-48. NON-ENDOSCOPIC RELIEF OF OESOPHAGEAL OBSTRUCTION SIR,—Dr Myszor and Dr Rees (Oct 11, p 866) describe two patients with sudden and absolute dysphagia due to impaction of food in the oesophagus as a consequence of eating meat with chopsticks. The obstructions were removed endoscopically. In Manchester we have managed such obstructions non-invasively- In the past 6 months two men, aged 32 and 49, presented with absolute dysphagia. Both reported that they had felt a piece of meat obstruct the oesophagus during a meal the previous day, and had been able to swallow nothing since. Physical examination had revealed no abnormality; chest X-rays and soft tissue views of th- neck were normal; and contrast radiology of the oesophagu- revealed a mass obstructing the lower end of the oesophagus. The patients were then given ’Carbex’ effervescent granule (sodium bicarbonate, activated dimethicone, and citric acid) nd fluid, as used in double-contrast barium meal examination. This resulted in the immediate passage of the bolus into the stomach This was confirmed radiologically, and the lower oesophagus was seen to be normal. Both patients have remained symptom-free. We have examined the oesophagus in both cases with a gastroscope, finding no abnormality in the younger man and some slight oesophagitis in the older man. Large boluses of food can obstruct a normal oesophagus but the obstruction may be relieved by carbex, thus avoiding the dangers of endoscopy in the acute episode. Similar success has been reported by Mohammed and Hegediis.1 Departments of Radiology and Surgery, Park Hospital, Manchester M31 3SL N. CAMPBELL P. SYKES 1. Mohammed SH, Hegediis V. Dislodgement of impacted oesophageal foreign bodies with carbonated beverages. Clin Radiol 1986; 37: 589-92. BANGLADESH DRUG POLICY SIR,—Your Round the World correspondent (Nov 1, p 1030) states that the secretary general of the Bangladesh Medical Association (BMA) has claimed that the Association was not consulted in the formation of the country’s drug policy. The Islam committee was made up of experts in Bangladesh chosen on an individual basis. Nonetheless its members did represent broad sections of the medical profession: one was chairman of the scientific :- committee of the Bangladesh Medical Association, another was the president of the Private Practitioners’ Association, and the committee’s chairman was an active member of the Bangladesh Medical Association. A review committee was later constituted, and 1 this committee did consult with the Association. It was only with the review committee that final shape was given to the drug policy Institute of Post-Graduate Medicine and Research, Dacca-2, Bangladesh MOBIN KHAN HARUN-UR-RASHID
Transcript of BANGLADESH DRUG POLICY
1405
Recently, in our hospital, a baby delivered by caesarean section at24 weeks’ gestation was fed parenterally for 104 days. ’Vamin 9Glucose’ was used to provide a daily total of 35 g crystallineaminoacids per kg (of this total, 275 mg was phenylalanine). Aroutine screen for phenylketonuria indicated a borderline result andthe serum phenylalanine level was 220 (imot/1. 21 days later thelevel had increased to 1350 µmo1/1. A daily regimen of ’Synthamin’at 3-0 g crystalline aminoacids per kg (equivalent to 163 mg
phenylalanine) was substituted-the phenylalanine level decreasedto 60 µmo1/1 within 5 days. This regimen was continued for the next34 days with a gradual introduction of an enteral feed. During thistime the highest phenylalanine level was 150 µmo1/1.
PROPORTION OF PHENYLALANINE IN COMMERCIALLY AVAILABLE
PARENTERAL FEEDS*
*Strength under each brand’s headmg.
The currently available commercial solutions for TPN containdifferent proportions of phenylalanine (see table). The use ofsynthamin in newborn babies with TPN-induced hyperphenyl-alaninaemia has the advantage of reducing the phenylalanine loadwith little effect on the total quantity of aminoacids. It must beremembered, however, that the commercial preparations havedifferent profiles of aminoacid.
Until there is evidence to the contrary it would be prudent tomonitor the phenylalanine levels of neonates receiving TPN. Thismay be particularly important in premature babies. It would also beprudent to maintain phenylalanine levels in these babies at 200-500µmo1/1—ie, the criteria adopted for controlling the hyperphenyl-alaninaemia associated with classical phenylketonuria.
Departments of Clinical Biochemistry,Paediatrics, Nutrition and Dietetics,and Pharmacy,
General Hospital,Northampton NN7 5BD
STANLEY J. EVANSTIM C. J. E. WYNNE-WILLIAMSCHRISTINE A. RUSSELLADRIAN FAIRBROTHER
1. Smith I, Wolff OH. MRC/DHSS Phenylketonuria Register newsletter 1984, no 9.
AMOEBA RESEARCH AND HISTORY
SIR,—I would like to recall some of the history of Entamoebahistolytica (Nov 15 editorial) because, as Elsdon-Dew said in hisexcellent review on the epidemiology of amoebiasis,l "muchmodem thinking carries a legacy of the misconceptions of the past".In 1913 Kuenen and Swellengrebel2 described the three stages inthe cycle of E histolytica (minuta, histolytica, and cyst), creditingothers who had worked along the same lines. The concept ofcommensalism that arose from this work became the line of thoughtin most of Europe but in the English-speaking world it was stronglyopposed. By 1920, several years before Brumpt’s prophecy onharmless amoebic species, two schools of thought could bedistinguished-the Swellengrebel school of "commensalists" andthe Dobell school of, in the words of Elsdon-Dew, "Prometheans".They differed on the status of the cyst passer; the Prometheansthought that this was a disease state and the commensalists held thatthis was not necessarily so. According to Elsdon-Dew, Hoare’sconclusion in 1952 that the minuta form represented the essentialstage of E histolytica whereas the haematophagous amoebae had noplace in its normal life-cycle, came too late "to stem the
conflagration initiated by Dobell’s Promethean concept". "Theembers still smoulder", he wrote in 1968. I wonder how muchDobell’s concept is still influencing the tendency to treat all
carriers; this "good conservative medicine" (your editorial) is
probably to a large extent based on that concept.
The suggestion that the bacterial flora in the gut lumen may be:" necessary for pathogenicity, made in 1955,4might now be veritredby the work of Mirelman et al (1986),S to which vou refer.
It is interesting to see how modem research is confirming an dexplaining good old observations.
Unit of Tropical Medicineand Infectious Diseases,
Academic Medical Centre,University of Amsterdam,1105 AZ Amsterdam, Netherlands P. A Ka
1 Elsdon-Dew R. The epidemiology of amoebiasis. Adv Parasitol 1968, 6: 1-622 Kuenen WA, Swellengrebel NH. Die Entamoben des Menschen und ihre praktis
Bedeutung. Zentralbl Bakt Parasitkde 1913; 71: 378-410.3. Krogstad DJ. Isoenzyme patterns and pathogenicity in amebic infection N Engl J
Med 1986; 315: 390-914 Phillips BP, Wolfe PA, Rees CW, Gordon HA, Wright WH, Reymiers JA. Studieson
the ameba-bacteria relationship in amebiasis: Comparative results of the intracinoculation of germfree, monocontaminated, and conventional guinea pigs withEntamoeba histolytica. Am J Trop Med Hyg 1955; 4: 675-92.
5 Mrelman D, Bracha R, Chayen A, Aust-Kettis A, Diamond LS Entamoch
histolytica: Effect of growth conditions and bacterial associates on isoenzympatterns and virulence. Exp Parasitol 1986; 62: 142-48.
NON-ENDOSCOPIC RELIEF OF OESOPHAGEALOBSTRUCTION
SIR,—Dr Myszor and Dr Rees (Oct 11, p 866) describe twopatients with sudden and absolute dysphagia due to impaction offood in the oesophagus as a consequence of eating meat withchopsticks. The obstructions were removed endoscopically. InManchester we have managed such obstructions non-invasively-
In the past 6 months two men, aged 32 and 49, presented withabsolute dysphagia. Both reported that they had felt a piece of meatobstruct the oesophagus during a meal the previous day, and hadbeen able to swallow nothing since. Physical examination hadrevealed no abnormality; chest X-rays and soft tissue views of th-neck were normal; and contrast radiology of the oesophagu-revealed a mass obstructing the lower end of the oesophagus.The patients were then given ’Carbex’ effervescent granule
(sodium bicarbonate, activated dimethicone, and citric acid) ndfluid, as used in double-contrast barium meal examination. Thisresulted in the immediate passage of the bolus into the stomachThis was confirmed radiologically, and the lower oesophagus wasseen to be normal. Both patients have remained symptom-free. Wehave examined the oesophagus in both cases with a gastroscope,finding no abnormality in the younger man and some slightoesophagitis in the older man.
Large boluses of food can obstruct a normal oesophagus but theobstruction may be relieved by carbex, thus avoiding the dangers ofendoscopy in the acute episode. Similar success has been reportedby Mohammed and Hegediis.1
Departments of Radiology and Surgery,Park Hospital,Manchester M31 3SL
N. CAMPBELLP. SYKES
1. Mohammed SH, Hegediis V. Dislodgement of impacted oesophageal foreign bodieswith carbonated beverages. Clin Radiol 1986; 37: 589-92.
BANGLADESH DRUG POLICY
SIR,—Your Round the World correspondent (Nov 1, p 1030)states that the secretary general of the Bangladesh MedicalAssociation (BMA) has claimed that the Association was notconsulted in the formation of the country’s drug policy. The Islamcommittee was made up of experts in Bangladesh chosen on anindividual basis. Nonetheless its members did represent broadsections of the medical profession: one was chairman of the scientific :-
committee of the Bangladesh Medical Association, another was thepresident of the Private Practitioners’ Association, and thecommittee’s chairman was an active member of the BangladeshMedical Association. A review committee was later constituted, and 1this committee did consult with the Association. It was only withthe review committee that final shape was given to the drug policyInstitute of Post-Graduate Medicineand Research,
Dacca-2, Bangladesh MOBIN KHAN HARUN-UR-RASHID
