1207 work will be necessary to separate the factors involved in this treatment and hence to define the mechanisms leading to
sterilisation tubal pregnancy and hysterectomy with removal of the offending tube for the second.
hypothalamo-pituitary dysfunction.
New Cross
Department of Pædiatrics, Aghia Sophia Children’s Hospital, Athens 608, Greece.
C. DACOU-VOUTETAKIS ST. HAIDAS L. ZANNOS-MARIOLEA
Hospital, Wolverhampton, WV10 0QP.
ALAN M. SMITH
OUR LIVES AND HARD TIMES
TUBAL PREGNANCY AND FAILED STERILISATION am,—raiiure or remale sienusauon
may
result m tUDal
pregnancy.’ This complication poses problems of diagnosis and management, as illustrated in the following two cases. Case1 A woman aged 32 was sterilised by the Oxford technique on the fifth day of the puerperium in 1972. A year later, acute appendicitis was diagnosed but operation revealed a right tubal pregnancy. After salpingectomy, appendicectomy, and a 1100 ml blood-transfusion the patient recovered. The state of the left tube was not recorded. The patient was later readmitted with severe suprapubic pain, a cystic abdominopelvic swelling, and a haemoglobin of 9.33 g/dl. Haemorrhage into an ovarian cyst was provisionally diagnosed. At laparotomy there were old blood clots and a little fresh bleeding from a ruptured left tubal pregnancy. Left salpingo-oophorectomy and hysterectomy were performed with difficulty because of pelvic adhesions. The abdomen requiring drainage but the patient recovered uneventfully. Case 2 This 24-year-old woman was sterilised by laparoscopic tubal diathermy early in 1974. She was admitted to another hospital early in September, 1975, with abdominal pain of 5 days’ duration, associated with constipation. There were 6 weeks of amenorrhoea. The pain settled after an enema, and the patient was referred to the gynaecological department. A pregnancy test was positive. She was readmitted 2 weeks later with uterine bleeding and a haemoglobin of 9.7 g/dl. Curettage was performed because incomplete abortion seemed likely. The endometrium was "non-secretory". When seen later in the clinic the patient complained of pain in the right iliac fossa so that pelvic infection or a urinary-tract disorder was suspected. Only a few days later she was readmitted with very severe pain and peritonism in the right iliac fossa. The haemoglobin was 10’ 7 g/dl, Appendicitis was diagnosed. Laparotomy revealed an old right tubal pregnancy with much organised clot and a little fresh blood. The proximal 3-0 cm of the left tube was replaced by a fibrous strand but the fimbriated end was normal. After right salpingo-oophorectomy and appendicectomy the patient recovered. 3 weeks later she had a small pulmonary infarct requiring another admission to hospital, from which she again recovered. The pregnancy-rate after sterilisation, generally considered to be 3 per 1000, may be higher after laparoscopic tubal coagulation, after which tubal pregnancy may occur.23 Puerperal sterilisation has a bad reputation, but the Oxford technique is normally considered reliable and is potentially reversible.4 The incidence of tubal pregnancy among the failures is not known but must be high. Tubal pregnancy may not be diagnosed after sterilisation and laparotomy may be delayed, with increased morbidity. Ruptured tubal pregnancy is responsible for 9% of all maternal deaths so that awareness of this serious long-term complication becomes more important with the increased incidence of sterilisation.’ This complication was not recorded by Neil et al.6 Bilateral salpingectomy is recommended for the first post1. 2. 3.
Chakravarti, S., Shardlow, J., Br. J. Obstet. Gynœc. 1975, 82, 58. Hughes, G., Liston, W. A., Br. med.J. 1975, 637. Steptoe, P. C.J. Obstet. Gynœc. Br. Commonw. 1969, 76, 1043. 4. Howkins, J., Stallworthy, J. S. Bonney’s Gynaecological Surgery; p. 647. London, 1974. 5. Beral, V. Br. J. Obstet. Gynœc. 1975, 82, 775. 6. Neil, J. R., Noble, A. D., Hammond, G. T., Rushton, L., Letchworth, A. T. Lancet, 1975, ii, 609.
SiR,—Dr Meade (Nov. 29, p. 1053) suggests that the pres-
period of economic stringency should provide us with the incentive and opportunity to divert more of our resources into preventing disease. Unfortunately, the conditions to which he refers in detail are diseases with onset in middle age. The idea that preventing these will ultimately lead to economy in the health-care service is an illusion. Great economies can indeed result from prevention, but the conditions which we must prevent to achieve them are the handicapping conditions with onset in childhood. Man is mortal. Prevention of death from one cause at age 50 merely postpones the terminal illness. The cost of care during the terminal illness may be as great or even greater where the chronic degenerative condition from which the elderly die results in a longer period of dependency than the more acute diseases which kill in middle age. Prevention of disabling congenital conditions such as severe subnormality, spina bifida, and cerebral palsy yields a real saving in the cost of health care and other services. There is already enough evidence of damage to the emotional and mental development of children associated with (and probably caused by) "incubator isolation" in the neonatal period to warrant a campaign to restrict this form of care to the barest minimum. We must attempt to devise better forms of neonatal care. We need to devote resources to research into the causes of mental illness, emotional maladjustment, and social incompetence, conditions which between them place enormous burdens on the taxpayer and on relatives. These are the areas in which real future savings can result from action now and in which it is desirable to invest more money even when other services are having to face cuts. Of course we should also seek to prevent the diseases which cause suffering and hardship in late middle age, but on humanitarian rather than economic grounds. It is only measures which reduce long-term dependency which we could honestly claim to finance out of savings on health care. Reduction in this kind of condition may not be compatible with the aim of further lowering perinatal mortality, but it is the quality of life, not its quantity or duration which really matters.
ent
Scunthorpe Health District, Trent House, Hebden Road, Scunthorpe, Lincolnshire DN15 8DT.
J. S.
ROBERTSON
SIR,-Dr Meade (Nov. 29, p. 1053) touches upon important contemporary issues when he makes a plea for increased investment in the prevention of chronic disease. He recognises that a reduction in expenditure will be needed elsewhere, but the achievement of such reduction is a major problem. Some diseases can be prevented, some cured, some neither. If a disease can be prevented, is all that is possible being done to ensure that the disease does not exist? Some examples are diphtheria, poliomyelitis, and rabies. Any relaxation of control measures could result in epidemics of these conditions in this country. Lung cancer is also preventable, and here the control measures fail to commend themselves to the public. Research is needed to determine why people persis, in killing themselves with cigarettes but are prepared to subscribe to the prevention of the major infectious diseases. Some preventive measures are expensive. Phenylketonuria and neural-tube defects are examples of this. Can we afford to prevent them? What is the cost in terms of money and human suffering if we do not? Many conditions cannot yet be pre-
1208
vented, either because too little is known of their natural history or because, like lung cancer, the control measures are impracticable. Some of these can be cured, and if the cure is relatively harmless and inexpensive, it may be better than prevention. Treatment which does not cure but modifies the disease is also possible in many conditions; squint, cataract, and diabetes mellitus are examples of this. In breast cancer early diagnosis gives a relatively high cure-rate. The management of these conditions is well established in medical practice, and there would seem no case for change at present. There are; however, many conditions which can be neither prevented not cured. Society expects that something should be done, and medicine often responds by attempting a cure which is unlikely to succeed, rather than admitting the true position and ensuring that adequate care is provided. Good care is often expensive and difficult; perhaps for this reason it is not always provided. This is where the shift in priorities has to come. Treatment of self-limiting trivial conditions, drug therapy of chronic diseases, and the surgical treatment of advanced cancer are all expensive, provide little comfort for the patient, and in some cases cause positive harm. In terms of overall benefit, a reduction in ineffective and unnecessary treatment, to allow more investment in the prevention of major health hazards, would be well worth while. Community Health Service, Dudley Area Health Authority, Salford House, 262-264 Castle Street, Dudley, West Midlands DY1 1LW.
J. N. TODD
It would thus seem that at present there is no good objective evidence to suggest that, after several years’ follow-up, the
results of metacarpophalangeal joint arthroplasty are superior using the Swanson prosthetic "spacer" rather than the Calnan-Nicolle encapsulated integral hinge prosthesis. Regional Plastic Surgery Centre, Mount Vernon
Hospital, Northwood, Middlesex.
RICHARD W. GRIFFITHS
BRAN AND BLOOD-LIPIDS
SIR,-A significant lowering of some blood-lipids has been found
by Heaton and Pomarel to follow ingestion of dietary fibre. We have followed a larger number of elderly patients to find out whether or not bran administered for a longer period really did influence different laboratory values. 14 elderly volunteers, aged 56-89 (mean 76) years, were examined. None had liver disease, diabetes mellitus, or hyperlipidaemia and apart from constipation they had no gastrointestinal disorders. Blood-samples were collected for determination of glyceride, glucose, insulin, total protein, iron, calcium (also ionised calcium), and phosphate. The patients were given 20 g bran daily as a supplement to their normal diets in the morning for 6 weeks. They were instructed to continue with their normal diets throughout the whole test period. Serum-cholesterol fell during the investigation (see accompanying table); in contrast, plasma triglycerides, phospholipids, and free fatty acids showed no statistically significant variation. Serum-calcium was unaltered, while serum-iron showed a statistically significant fall.
METACARPOPHALANGEAL JOINT ARTHROPLASTIES out (Nov. 29, p. 1079) that there between deal of difference subjective and objective asgood sessment of the results of metacarpophalangeal joint replacement, as demonstrated by Mannerfelt and Andersson.’ The Swanson prosthesis has probably been the most widely used, but the collective results2 do not compare preoperative and postoperative ranges of joint movement and, until such adequate assessment is done, mainly subjective assessment of’ results will continue and valid comparisons between series will
SIR,-You rightly point
is
a
not prove
(MMOL/L)
()iMOL/L) AFTER
AND SERUM-IRON IN SERUM-CHOLESTEROL ADMINISTRATION OF 20 G BRAN DAILY FOR 6 WEEKS TO
14 PATIFNTS
possible.
You cite Harrison3as not echoing Nicolle’s "happy experience" with the polypropylene hinge prosthesis. Unfortunately, Harrison’s paper was in no way concerned with joint arthroplasty but with interphalangeal joint fixation with the HarrisonNicolle intramedullary polypropylene peg, which at no time has been suggested as an alternative to prosthetic replacement of the metacarpophalangeal joint! The new link chrome/cobalt alloy arthroplasty of Devas and Shah4is an interesting development, and a similar design of prosthesis in polypropylene and clinical-grade stainless steel has been described;’ it will be of great interest to compare late results for both types. The early results of implantation of the encapsulated integral hinge prosthesis were reported in 1972,6 and at that time few problems had been seen. A longer follow-up of these patients has now been published,’ with full objective assessment. Two years after arthroplasty some 50% of patients retained improved hand function and reduced joint pain. Of 31 patients, 2 had hand function at two years which was worse than preoperatively while 7 had more severely deformed joints than before operation. These results are no worse than, and indeed may be viewed as comparable with, those achieved by Mannerfelt and Andersson, since both series compare preoperative and postoperative ranges of movement. 1. Mannerfelt, L., Andersson, K. J. Bone Jt Surg. 1975, 2. Swanson, A. B. Hand, 1972, 4, 119. 3. Harrison, S. H. ibid. 1974, 6, 304. 4. Devas, M., Shah, V.J. Bone Jt Surg. 1975, 57B, 72. 5. Griffiths, R. W., Nicolle, F. V. Hand, 1975, 7, 275. 6. Nicolle, F. V., Galnan, J. S. ibid. 1972, 4, 135.
57A, 484.
*
5% sigmficance level.
t 1 ’t sIgnificance level. Our findings thus accord with those of Heaton and Pomare,’ while they differ from those of others2-6 whose investigations have been marred by religious obstention (Lent), small amount of bran, the selection of young students, or few patients as subjects, or only 2 weeks of investigation. The fall in iron after consuming bran has been demonstrated previously.’ This fall is correlated with the phytin content of bran. In our investigation we have taken the fall in iron as evidence that the patients had taken the bran. Since it has been postulated that the incidence of arterioscleroses might be related to differences in dietary intake of fibre, we find it interesting that a lowering of serum-cholesterol can be demonstrated in elderly patients given a large amount of fibre for a long period. I. PERSSON Medical Department, Department of KN. RABY Clinical Chemistry, Nørre Hospital, P. F¢NNS-BECH and Danish Cooperative Wholesale Society Central Laboratory, Copenhagen, Denmark. E. JENSEN. -
-
Heaton, K. W., Pomare, E. W. Lancet, 1974, i, 49. Eastwood, M. ibid. 1969, ii, 1222. 3. Eastwood, M. A., Kirkpatrick, J. R., Mitchell, W. D., Bone, A., Hamilton, T. Br. med. J. 1973, iv, 392. 4. Connell, A. M., Smith, C. L., Somsel, M. Lancet, 1975, i, 496. 5. Truswell, A. S. ibid. 922. 6. Jenkins, D. J. A., Leeds, A. R., Newton, C., Cummings, J. H. ibid p. 1116. 1. 2.
7.
Bjørn-Rasmussen, E. Nutr. Metabol. 1974, 16, 101.
sterilisation tubal pregnancy and hysterectomy with removal of the offending tube for the second.
hypothalamo-pituitary dysfunction.
New Cross
Department of Pædiatrics, Aghia Sophia Children’s Hospital, Athens 608, Greece.
C. DACOU-VOUTETAKIS ST. HAIDAS L. ZANNOS-MARIOLEA
Hospital, Wolverhampton, WV10 0QP.
ALAN M. SMITH
OUR LIVES AND HARD TIMES
TUBAL PREGNANCY AND FAILED STERILISATION am,—raiiure or remale sienusauon
may
result m tUDal
pregnancy.’ This complication poses problems of diagnosis and management, as illustrated in the following two cases. Case1 A woman aged 32 was sterilised by the Oxford technique on the fifth day of the puerperium in 1972. A year later, acute appendicitis was diagnosed but operation revealed a right tubal pregnancy. After salpingectomy, appendicectomy, and a 1100 ml blood-transfusion the patient recovered. The state of the left tube was not recorded. The patient was later readmitted with severe suprapubic pain, a cystic abdominopelvic swelling, and a haemoglobin of 9.33 g/dl. Haemorrhage into an ovarian cyst was provisionally diagnosed. At laparotomy there were old blood clots and a little fresh bleeding from a ruptured left tubal pregnancy. Left salpingo-oophorectomy and hysterectomy were performed with difficulty because of pelvic adhesions. The abdomen requiring drainage but the patient recovered uneventfully. Case 2 This 24-year-old woman was sterilised by laparoscopic tubal diathermy early in 1974. She was admitted to another hospital early in September, 1975, with abdominal pain of 5 days’ duration, associated with constipation. There were 6 weeks of amenorrhoea. The pain settled after an enema, and the patient was referred to the gynaecological department. A pregnancy test was positive. She was readmitted 2 weeks later with uterine bleeding and a haemoglobin of 9.7 g/dl. Curettage was performed because incomplete abortion seemed likely. The endometrium was "non-secretory". When seen later in the clinic the patient complained of pain in the right iliac fossa so that pelvic infection or a urinary-tract disorder was suspected. Only a few days later she was readmitted with very severe pain and peritonism in the right iliac fossa. The haemoglobin was 10’ 7 g/dl, Appendicitis was diagnosed. Laparotomy revealed an old right tubal pregnancy with much organised clot and a little fresh blood. The proximal 3-0 cm of the left tube was replaced by a fibrous strand but the fimbriated end was normal. After right salpingo-oophorectomy and appendicectomy the patient recovered. 3 weeks later she had a small pulmonary infarct requiring another admission to hospital, from which she again recovered. The pregnancy-rate after sterilisation, generally considered to be 3 per 1000, may be higher after laparoscopic tubal coagulation, after which tubal pregnancy may occur.23 Puerperal sterilisation has a bad reputation, but the Oxford technique is normally considered reliable and is potentially reversible.4 The incidence of tubal pregnancy among the failures is not known but must be high. Tubal pregnancy may not be diagnosed after sterilisation and laparotomy may be delayed, with increased morbidity. Ruptured tubal pregnancy is responsible for 9% of all maternal deaths so that awareness of this serious long-term complication becomes more important with the increased incidence of sterilisation.’ This complication was not recorded by Neil et al.6 Bilateral salpingectomy is recommended for the first post1. 2. 3.
Chakravarti, S., Shardlow, J., Br. J. Obstet. Gynœc. 1975, 82, 58. Hughes, G., Liston, W. A., Br. med.J. 1975, 637. Steptoe, P. C.J. Obstet. Gynœc. Br. Commonw. 1969, 76, 1043. 4. Howkins, J., Stallworthy, J. S. Bonney’s Gynaecological Surgery; p. 647. London, 1974. 5. Beral, V. Br. J. Obstet. Gynœc. 1975, 82, 775. 6. Neil, J. R., Noble, A. D., Hammond, G. T., Rushton, L., Letchworth, A. T. Lancet, 1975, ii, 609.
SiR,—Dr Meade (Nov. 29, p. 1053) suggests that the pres-
period of economic stringency should provide us with the incentive and opportunity to divert more of our resources into preventing disease. Unfortunately, the conditions to which he refers in detail are diseases with onset in middle age. The idea that preventing these will ultimately lead to economy in the health-care service is an illusion. Great economies can indeed result from prevention, but the conditions which we must prevent to achieve them are the handicapping conditions with onset in childhood. Man is mortal. Prevention of death from one cause at age 50 merely postpones the terminal illness. The cost of care during the terminal illness may be as great or even greater where the chronic degenerative condition from which the elderly die results in a longer period of dependency than the more acute diseases which kill in middle age. Prevention of disabling congenital conditions such as severe subnormality, spina bifida, and cerebral palsy yields a real saving in the cost of health care and other services. There is already enough evidence of damage to the emotional and mental development of children associated with (and probably caused by) "incubator isolation" in the neonatal period to warrant a campaign to restrict this form of care to the barest minimum. We must attempt to devise better forms of neonatal care. We need to devote resources to research into the causes of mental illness, emotional maladjustment, and social incompetence, conditions which between them place enormous burdens on the taxpayer and on relatives. These are the areas in which real future savings can result from action now and in which it is desirable to invest more money even when other services are having to face cuts. Of course we should also seek to prevent the diseases which cause suffering and hardship in late middle age, but on humanitarian rather than economic grounds. It is only measures which reduce long-term dependency which we could honestly claim to finance out of savings on health care. Reduction in this kind of condition may not be compatible with the aim of further lowering perinatal mortality, but it is the quality of life, not its quantity or duration which really matters.
ent
Scunthorpe Health District, Trent House, Hebden Road, Scunthorpe, Lincolnshire DN15 8DT.
J. S.
ROBERTSON
SIR,-Dr Meade (Nov. 29, p. 1053) touches upon important contemporary issues when he makes a plea for increased investment in the prevention of chronic disease. He recognises that a reduction in expenditure will be needed elsewhere, but the achievement of such reduction is a major problem. Some diseases can be prevented, some cured, some neither. If a disease can be prevented, is all that is possible being done to ensure that the disease does not exist? Some examples are diphtheria, poliomyelitis, and rabies. Any relaxation of control measures could result in epidemics of these conditions in this country. Lung cancer is also preventable, and here the control measures fail to commend themselves to the public. Research is needed to determine why people persis, in killing themselves with cigarettes but are prepared to subscribe to the prevention of the major infectious diseases. Some preventive measures are expensive. Phenylketonuria and neural-tube defects are examples of this. Can we afford to prevent them? What is the cost in terms of money and human suffering if we do not? Many conditions cannot yet be pre-
1208
vented, either because too little is known of their natural history or because, like lung cancer, the control measures are impracticable. Some of these can be cured, and if the cure is relatively harmless and inexpensive, it may be better than prevention. Treatment which does not cure but modifies the disease is also possible in many conditions; squint, cataract, and diabetes mellitus are examples of this. In breast cancer early diagnosis gives a relatively high cure-rate. The management of these conditions is well established in medical practice, and there would seem no case for change at present. There are; however, many conditions which can be neither prevented not cured. Society expects that something should be done, and medicine often responds by attempting a cure which is unlikely to succeed, rather than admitting the true position and ensuring that adequate care is provided. Good care is often expensive and difficult; perhaps for this reason it is not always provided. This is where the shift in priorities has to come. Treatment of self-limiting trivial conditions, drug therapy of chronic diseases, and the surgical treatment of advanced cancer are all expensive, provide little comfort for the patient, and in some cases cause positive harm. In terms of overall benefit, a reduction in ineffective and unnecessary treatment, to allow more investment in the prevention of major health hazards, would be well worth while. Community Health Service, Dudley Area Health Authority, Salford House, 262-264 Castle Street, Dudley, West Midlands DY1 1LW.
J. N. TODD
It would thus seem that at present there is no good objective evidence to suggest that, after several years’ follow-up, the
results of metacarpophalangeal joint arthroplasty are superior using the Swanson prosthetic "spacer" rather than the Calnan-Nicolle encapsulated integral hinge prosthesis. Regional Plastic Surgery Centre, Mount Vernon
Hospital, Northwood, Middlesex.
RICHARD W. GRIFFITHS
BRAN AND BLOOD-LIPIDS
SIR,-A significant lowering of some blood-lipids has been found
by Heaton and Pomarel to follow ingestion of dietary fibre. We have followed a larger number of elderly patients to find out whether or not bran administered for a longer period really did influence different laboratory values. 14 elderly volunteers, aged 56-89 (mean 76) years, were examined. None had liver disease, diabetes mellitus, or hyperlipidaemia and apart from constipation they had no gastrointestinal disorders. Blood-samples were collected for determination of glyceride, glucose, insulin, total protein, iron, calcium (also ionised calcium), and phosphate. The patients were given 20 g bran daily as a supplement to their normal diets in the morning for 6 weeks. They were instructed to continue with their normal diets throughout the whole test period. Serum-cholesterol fell during the investigation (see accompanying table); in contrast, plasma triglycerides, phospholipids, and free fatty acids showed no statistically significant variation. Serum-calcium was unaltered, while serum-iron showed a statistically significant fall.
METACARPOPHALANGEAL JOINT ARTHROPLASTIES out (Nov. 29, p. 1079) that there between deal of difference subjective and objective asgood sessment of the results of metacarpophalangeal joint replacement, as demonstrated by Mannerfelt and Andersson.’ The Swanson prosthesis has probably been the most widely used, but the collective results2 do not compare preoperative and postoperative ranges of joint movement and, until such adequate assessment is done, mainly subjective assessment of’ results will continue and valid comparisons between series will
SIR,-You rightly point
is
a
not prove
(MMOL/L)
()iMOL/L) AFTER
AND SERUM-IRON IN SERUM-CHOLESTEROL ADMINISTRATION OF 20 G BRAN DAILY FOR 6 WEEKS TO
14 PATIFNTS
possible.
You cite Harrison3as not echoing Nicolle’s "happy experience" with the polypropylene hinge prosthesis. Unfortunately, Harrison’s paper was in no way concerned with joint arthroplasty but with interphalangeal joint fixation with the HarrisonNicolle intramedullary polypropylene peg, which at no time has been suggested as an alternative to prosthetic replacement of the metacarpophalangeal joint! The new link chrome/cobalt alloy arthroplasty of Devas and Shah4is an interesting development, and a similar design of prosthesis in polypropylene and clinical-grade stainless steel has been described;’ it will be of great interest to compare late results for both types. The early results of implantation of the encapsulated integral hinge prosthesis were reported in 1972,6 and at that time few problems had been seen. A longer follow-up of these patients has now been published,’ with full objective assessment. Two years after arthroplasty some 50% of patients retained improved hand function and reduced joint pain. Of 31 patients, 2 had hand function at two years which was worse than preoperatively while 7 had more severely deformed joints than before operation. These results are no worse than, and indeed may be viewed as comparable with, those achieved by Mannerfelt and Andersson, since both series compare preoperative and postoperative ranges of movement. 1. Mannerfelt, L., Andersson, K. J. Bone Jt Surg. 1975, 2. Swanson, A. B. Hand, 1972, 4, 119. 3. Harrison, S. H. ibid. 1974, 6, 304. 4. Devas, M., Shah, V.J. Bone Jt Surg. 1975, 57B, 72. 5. Griffiths, R. W., Nicolle, F. V. Hand, 1975, 7, 275. 6. Nicolle, F. V., Galnan, J. S. ibid. 1972, 4, 135.
57A, 484.
*
5% sigmficance level.
t 1 ’t sIgnificance level. Our findings thus accord with those of Heaton and Pomare,’ while they differ from those of others2-6 whose investigations have been marred by religious obstention (Lent), small amount of bran, the selection of young students, or few patients as subjects, or only 2 weeks of investigation. The fall in iron after consuming bran has been demonstrated previously.’ This fall is correlated with the phytin content of bran. In our investigation we have taken the fall in iron as evidence that the patients had taken the bran. Since it has been postulated that the incidence of arterioscleroses might be related to differences in dietary intake of fibre, we find it interesting that a lowering of serum-cholesterol can be demonstrated in elderly patients given a large amount of fibre for a long period. I. PERSSON Medical Department, Department of KN. RABY Clinical Chemistry, Nørre Hospital, P. F¢NNS-BECH and Danish Cooperative Wholesale Society Central Laboratory, Copenhagen, Denmark. E. JENSEN. -
-
Heaton, K. W., Pomare, E. W. Lancet, 1974, i, 49. Eastwood, M. ibid. 1969, ii, 1222. 3. Eastwood, M. A., Kirkpatrick, J. R., Mitchell, W. D., Bone, A., Hamilton, T. Br. med. J. 1973, iv, 392. 4. Connell, A. M., Smith, C. L., Somsel, M. Lancet, 1975, i, 496. 5. Truswell, A. S. ibid. 922. 6. Jenkins, D. J. A., Leeds, A. R., Newton, C., Cummings, J. H. ibid p. 1116. 1. 2.
7.
Bjørn-Rasmussen, E. Nutr. Metabol. 1974, 16, 101.
