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SUMMARY Eight stable cirrhotic patients with mild or subclinical portal-systemic encephalopathy (PSE) were studied after shunt surgery when they were off all antiencephalopathic therapy. Equal amounts of mixed proteins were alternated with animal or vegetable protein in a crossover protocol under metabolic conditions for five consecutive, one week periods. The different dietary periods were not associated with either a change in the neurological impairment score or the Trailmaking Tests, which showed a learning effect. The peak frequencies of the computer analysed EEG (CAEEG) were lower during the animal (6.58±0.42 Hz) than the vegetable (7.10±0.44 Hz) diet (p 0.01). Neither arterial ammonia levels nor plasma amino acid ratios changed with the diets, whereas urinary 3-methyl-histidine excretion increased during the animal diet. During the vegetable diet the apparent nitrogen balance tended to be more positive than during either the mixed or animal diets associated with a decrease in the urinary nitrogen excretion. The peak frequency of the CAEEG is the most sensitive test to monitor methods of treatment in portal-systemic encephalopathy. A vegetable protein diet, rather than overall protein restriction, should be considered in the management of this disorder, particularly when the nutritional state is poor.Treatment of mild portal-systemic encephalopathy focuses on prevention of symptoms by protein restriction and, if necessary, by adding lactulose or neomycin. Recently Greenberger1 showed that not only the quantity but also the quality of the dietary protein may be important in the management of the chronic condition. Vegetable derived protein was claimed to be superior to animal protein. Only three patients were studied, however, and two received additional anti-encephalopathic treatment with neomycin, lactulose, or sorbitol. Furthermore, the protocol of the protein administration varied.To investigate the role of dietary protein in portal-systemic encephalopathy we undertook a controlled trial with elimination of all variables apart from the source of protein in the diet. The ' Present address: Karel M de Bruijn, Helpersoon 125, 9722 B7,

The pattern of cardiac arrhythmias and their treatment, by propranolol and chlordiazepoxide, during the first 48 hr of alcohol withdrawal has been studied. Prior to treatment, the incidence of serious and life-threatening arrhythmias was found to be very low and uncorrelated with most biochemical parameters. Propranolol treatment, while efficacious in controlling arrhythmias, was limited due to its association with hallucinations. Chlordiazepoxide was associated with poor early control of arrhythmias. The combination of propranolol and chlordiazepoxide was found to perform best overall with substantial reductions in arrhythmias and the fewest treatment failures.

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