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Robert G. McArthur
1039
Growth Retardation: An Approach to Management
Walter J. Duncan
1047
Childhood Cardiac Murmurs: Innocent or Not?
Howard L. Rudner
1051
Differential Diagnosis of Upper Airway Disease in
Children
Frances Gorzalka, Jay S. Keystone
1055.
Infections in Refugee Children fom Developing
Countries
Walter P. Bobechko
1061
Limp Affecting the Hip and Knee in Children
Barry Shandling
1065
The Unusual but Benign in Pediatric Surgety
Barry Zimmernan, Sasson Lavi, Alex Lozynsky, Elizabeth Weber
1071
Lifestyle 1091
Allergy in Pediatrics
A CFP information section to help healthy patients
stay healthy
Margaret McCaffery
Interview 1100
Donald Ingram Rice: The Man, The Doctor, The
Official
Heather E. Bryant
Report 1109
Miscarriage: How to Help in the Crisis
H. C. Soltan, Z. Pyatt, G. G. Hinton
Family Practice 1119
Case Book
Atypical Severe Muscular Dystrophy in a Male:
Genetic Implications for Female Relatives
Douglas P. Black, Lynn Dunikowski
Academic 1161
Commentary
Videotapes as Continuing Medical Education for
Physicians in Isolated Communities
Cover: Baby boots are like babies: dainty but durable. The boots on the cover are more than 35
years old and still going strong.
Photograph by Bill Woods.
The opinions expressed in articles and claims made in
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are the opinions of the authors and advertisers respectively
and do not imply endorsement by The College of Family
Physicians of Canada.
Published monthly by The College of Family Physicians of
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CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
891
Canadian
Family Physician
Editorial Director
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Consultant Editorial Advisers
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Family Medicine
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89
893
Executive Director's
Donald I. Rice
My Last Hurrah!
MANY MEMBERS of the College
of Family Physicians of Canada
and other readers of CANADIAN FAMILY PHYSICIAN will know that I have
announced my retirement as the College's executive director, effective
June 1, 1985. This will be my last opportunity to communicate with CFP
readers through the Executive Director's Page-my last hurrah!
Many changes have taken place
within the College of Family Physicians of Canada, and within the discipline of general practice/family medicine during the past 21 years. It has
been an exciting and mostly rewarding
experience to have been a part of these
changes. As one might expect, my retirement has prompted numerous interviews by representatives of the medical media. Most have followed a
pattern of reflecting on major changes
that have occurred during my tenure;
satisfactions that I have had; disappointments that I have experienced. In
some instances, I have been invited to
share my thoughts on where I see the
College of Family Physicians and family medicine going in the future.
Certain of these reflections have
been recorded in this issue of CANADIAN FAMILY PHYSICIAN (page 1100);
others in the Canadian Medical Association Journal, Medical Post, and in
other publications.
On the eve of retirement following
21 years as the College's chief executive officer, I am entitled to reflect for
a while on past events and at the same
time, anticipate a degree of immunity
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
from critics should I become unduly
melancholy or preoccupied with the
past. I might even be entitled to a
glimpse into the future.
In this, my final Executive Director's Page, I would like to be somewhat more personal than I have chosen
to be during the several interviews that
I have mentioned.
I was motivated to leave the relative
security of general practice 21 years
ago (August 1964) to assume the office of the College's associate executive director for several very distinct
reasons. I was greatly concerned by
the serious trend away from general
practice by medical students who at
every turn were being encouraged by
their specialist teachers to become specialists, not family doctors. I was concerned that this trend could only continue and worsen as long as there were
no general practitioner teachers in our
medical schools, to participate in the
education of medical students, and to
serve as role models-not to encourage all medical students to become
family doctors, but to provide students
with a proper perspective that would
enable them to make an unbiased selection in their future professional careers.
General practice in the fifties and
sixties represented a major paradox.
Like many of my colleagues, I found
that the demands for my kind of doctor
were so great that I had real difficulty
in coping with these demands, and yet
no attempt was being made to train and
in turn perpetuate this kind of doctor.
Medical schools were preoccupied
with training undifferentiated physicians with the expectation that most
students would take additional residency training and become specialists;
the remainder would enter practice
without the benefit of residency training to become "just a GP". Little
wonder that some general practitioners
of my vintage developed a professional inferiority complex.
A second concem was that few individuals in a position of authority, and
least of all medical educators, acknowledged this need, and were prepared to
do something about it. It became abundantly clear that if change was to take
place, family doctors themselves
would have to assume the major responsibility for influencing this
change. This acknowledgment by the
many concerned and committed
members of the College of Family
Physicians of Canada who have contributed to the evolution of present day
family medicine, and to the relatively
secure position of today's family physician, is an object lesson that we must
always keep before us. The needs as
they concern family physicians may
vary, but the mechanism for response
will remain essentially unchanged. To
a considerable degree, the future destiny of family physicians rests with
family physicians themselves. "If it's
to be-it's up to me."
These earlier events have substantially influenced my own philosophy,
and have encouraged me to impose a
similar philosophy on the policy of the
905
College during the past two decades.
At this stage in my professional career,
people have been most generous in
their acknowledgment of the contribution that I have made to the many
changes that have taken place in family medicine. While I appreciate this
acknowledgment, I would be less than
honest if I did not concede that much
of what has happened has been the result of the College's response to a legitimate and unmet need. It has been
my good fortune to have been in the
right place at the right time to-influence the factors necessary to effect this
balance.
But history has a way of repeating
itself. If one looks critically at the
present climate of family practice, and
in particular at several well established
trends, one gets the distinct feeling
that one has been there before-a different plot and different actors, but the
stage is essentially unchanged. Despite
the substantial improvement in the
status of family medicine, and the position of family physicians in our present health care system, storm clouds
are on the horizon that command early
and appropriate attention. By whom?
Again, by family physicians. Who
else?
The hospital privileges of family
physicians are being eroded, frequently by family physicians themselves, many of whom are disinterested in the hospital care of patients.
An increasing number of family physicians are no longer providing complete
obstetrical care: many have given up
deliveries, others want no part of obstetrical care in any form. The withdrawal of many family physicians
from the episodic care of patients is
giving rise to an increasing number of
episodic care clinics-"docs in the
box". Too many family physicians are
developing a pattern of practice that is
essentially an ambulatory practice limited to an adult population. Others are
developing special interest areas in
emergency medicine, geriatrics and
occupational medicine, at the expense
of, rather than as an integral part of
family practice. And while these voluntary changes in patterns of practice
are taking place, other health professionals (notably the nurse) are standing
in the wings anxious to take over responsibilities in family practice being
vacated by the family physician.
There are certainly reasons for these
changes, but are they legitimate reasons, and do they stand up to critical
scrutiny? Again, the relative strength
of present day family medicine is the
result of concerned family physicians
having acknowledged and responded
to legitimate unmet needs-needs that
have been largely met by improving
the ratio between consulting specialists
and family physicians, and ensuring
that family physicians are properly
trained to provide a broad spectrum of
primary, continuing and comprehensive care; family physicians who are
people oriented as well as disease
oriented; family physicians who are as
interested in keeping people well as in
treating people once they become ill.
From my vantage point, this need
continues to exist. My closing challenge to family physicians is to hold
the line, stand up and be counted, and
resist many of the increasing pressures
on the system that are influencing significant changes in patterns of practice-frequently for the wrong reasons. At the same time, be an integral
part of necessary and appropriate
change and become involved to the degree that is necessary to ensure that
these changes continue to be in the
best interests of patient care, and at the
same time provide the family physician with the essentials that are neces-
sary for professional satisfaction.
And finally, this Executive Director's Page provides me with an opportunity to publicly thank the legions of
College members, specialist colleagues, members of other health professions, representatives of govemment, the pharmaceutical industry,
and the many others with whom I have
been associated during my time as the
executive director of the College of
Family Physicians of Canada. We
have shared both disappointing and
rewarding experiences, and I am
deeply grateful for the support that I
have enjoyed. There have been skirmishes along the way; battles won and
battles lost, but on the average, I am
quite confident that the decisions we
have reached together have been in everyone's mutual interest.
I feel very positive about stepping
down as the College's Executive
Director at this time. I consider myself
singularly fortunate to have been involved in the life of the College during
a period that historians will almost certainly record as one of the most significant periods in the College's history. I
look forward to a change in direction
that will enable me to maintain an interest in selected professional activity,
while at the same time enjoying more
leisure time with my family-an activity that has seemed to elude me for too
many years.
I have great confidence in the future
of family medicine in this country, and
am singularly impressed with the quality of young men and women who
have made a commitment to family
medicine as a professional career. My
message to these younger family physicians is to stand tall; take pride in
being a family doctor, in the knowledge that your future, and that of family medicine is in your own hands.
Goodbye-au revoir.
1----
906
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
capsules
Go
PRESCRIBING
INFORMATION
COMPOSITION:
Each 5 mL (1 tsp)
of GAVISCON liquid
contains sodium alginate, 250 mg; aluminum hydroxide,
100 mg.
Each GAVISCON tablet contains alginic acid, 200 mg;
aluminum hydroxide, 80 mg; magnesium trisillicate,
20 mg.
INDICATIONS: For symptomatic treatment of heartburn
and oesophagitis associated with gastric acid reflux. This
often accompanies ineffective lower oesophageal
sphincter tone as in hiatus hernia, or pregnancy and
nasogastric intubation.
DOSAGE: Adults: 10 to 20 mL (2 to 4 tsp) of GAVISCON
Liquid, or 2 to 4 GAVISCON tablets, 1 to 4 times daily, after
meals and on retiring.
ACTION: GAVISCON liquid or GAVISCON tablets, when
chewed, produce a viscous, demulcent antacid foam
which floats on the stomach contents serving as a
protective barrier for the oesophagus against reflux of
gastric contents. The alkaline foam readily flows into the
oesophagus during reflux, aiding in the neutralization of
refluxed gastric acids. Gaviscon also effectively reduces
the frequency of reflux episodes.
ADMINISTRATION: GAVISCON liquid may be followed by
a sip of water, if desired. GAVISCON tablets must be
chewed thoroughly,and may befollowed bya drinkof water
or milk if desired.
CONTRAINDICATIONS: There are no specific contraindications for GAVISCON LIQUID and GAVISCON FOAMTABS.
See "Precautions' below.
PRECAUTIONS: Each 5 mL of GAVISCON liquid contains
approximately 30 mg and each GAVISCON tablet contains
approximately 22 mg of Na+ which should be noted for
patients on severely restricted sodium diets. The divalent
cations of magnesium. and aluminum interfere with the
absorption of tetracycline, iron and phosphate. In addition,
oral magnesium may accumulate in the plasma of patients
with impaired renal function. Each 5 ml of GAVISCON
liquid contains 20 mg of sodium cyclamate, an artificial
sweetener. Each GAVISCON tablet contains 1.2 g of sucrose
which is equivalent to 4.7 calories.
ADVERSE EFFECTS: Nausea, vomiting, eructation, flatulence.
OVERDOSAGE: Should overdosage occur, gastric distention may result and is best treated conservatively.
PRESENTATION: GAVISCON LIQUID is a light tan-coloured,
pleasantly flavoured suspension supplied in plastic boftles
of 340 mL. GAVISCON FOAMTABS are round creamywhite butterscotch flavoured tablets with the name
'GAVISCON" imprinted on one side and the lefter 'W"
imprinted on the opposite side. Supplied in plastic boftles
of 36 and 100 tablets.
STORAGE PRECAUTIONS: GAVISCON liquid should be
stored in a cool place. GAVISCON tablets should be stored
in a dry place.
REFERENCES:
1. Goodall, J.S., Orwin, J.M. and Imrie, M.J., A Combined pH
and X-Ray Study of a Liquid Alginate/Antacid Formulation
Using a Novel XRay Contrast Medium. Acta Therapeutica
3:141-153, 1977.
2. Beckloff, G.L., M.D., Chapman, J.H., M.D., and
Shiverdecker, P., Objective Evaluation of an Antacid with
Unusual Properties. J. of Clin. Pharm. 12:11-21, 1972.
3. In Vitro experiment, data on file, Winthrop Laboratories,
Aurora, Ontario.
4. Stanciu, C. and Bennet, J.R., Alginate/Antacid in the
Reduction of Gastro-Oesophageal Reflux. Lancet 1:109
111, 1974.
5. McHardy, G. and Balart, L., Reflux Esophagitis in the
Elderly, with Special References to Antacid Therapy. J.
Amer. Ger. Soc. 20:293-304, 1972.
6. Williams, D.L., Haigh, G.G. and Redfern, J.N., The
Symptomatic Treatment of Heartburn and Dyspepsia
with Liquid Gaviscon: A Multicentre General Practitioner
Study. J. Int Med. Res. 7, 551, 1979.
7. McHardy, G., A Multicentric, Randomized Clinical Trial of
Gaviscon in Reflux Esophagitis. Southern Med. J. 71, Supp.
No. 1:16-21, 1978.
8. Chevrel, B., A Comparative Crossover Study on the
Treatment of Heartburn and Epigastric Pain: Liquid
Gaviscon and a Magnesium-Aluminum Antacid Gel. J. Int.
Med. Res. 8:300-302, 1980.
Wminrop Lahoratornes*);
Division of SnerIingDmsgLnd.**
Aurora, Ontarno L4G 3H6
ZRegistered User
Reg, Trade Mark
ItVF[
:PA
tP
The family medicine literature is
wide and varied-and not all to be
found in Index Medicus. On this
page, our librarian Lynn
Dunikowski provides synopses of
articles from the current literature,
full texts of which can be obtained
from the Canadian Library of
Family Medicine, Medical Library,
University of Western Ontario,
London N6A 5C1. Alternatively,
local medical libraries or hospital
libraries may be able to help.
Child Development
Houston HL, Davis RH.
Opportunistic surveillance of child
development in primary care: is it
feasible? J R Coll Gen Pract 1985;
35:77-9.
The authors postulate that effective
developmental surveillance of children, in terms of detecting abnormalities and maternal counselling, can be
done during ordinary consultations to
identify problems and offer advice.
Results presented are part of a more
detailed study in progress to compare
opportunistic methods of health surveillance with the traditional method
of regular age-linked examinations
provided by clinical medical officers.
From a retrospective analysis of the
medical records of 58 one year olds
who had been registered with the study
practice since their birth, the authors
suggest, based upon attendance rates,
that opportunistic assessment of development by a family physician or health
visitor is more likely to encompass
children most at risk than by assessment at clinics.
Cholestasis
Balistreri WF. Neonatal cholestasis.
J Pediatr 1985; 106:171-84.
The heterogeneous nature of diseases that have neonatal cholestasis
(prolonged conjugated hyperbilirubinemia) as the first symptom creates
challenges in evaluation and effective
management. Potential causes of cholestasis in early life are diverse, and it
is important for clinicians to recognize
specific treatable metabolic or infectious entities rapidly in order to begin
early, appropriate, and effective management. In many patients, however,
it is difficult to pinpoint the precise nature of the aberration; this subset has
been termed idiopathic obstructive infantile cholangiopathy; extrahepatic
biliary atresia and neonatal hepatitis
comprise the majority of the cases.
Uncertainty arises because the nosology and diagnostic criteria vary and
there is little information about the
pathophysiologic basis of specific
causes of neonatal cholestasis. This review discusses new concepts about the
genesis of neonatal cholestasis and the
implications of current methods of
evaluation and management.
Continuity of Care
Goldberg HI, Dietrich AJ. The
continuity of care provided to
primary care patients. Med Care
1985; 3:63-73.
The authors compared the continuity of care that family physicians,
general internists, and medical subspecialists gave to their adult primary care
patients. The 40 physicians in the
study came from large, private, multispecialty practices in the San Francisco Bay area. The three types of physicians did not differ significantly in the
degree of continuity provided, measured by the proportion of total visits
to a patient's primary provider, each
type providing about 80% of its primary care patients' visits.
In contrast, the continuity scores of
individual physicians ranged widely,
from 57% to 98%. Proxy measures of
case mix and physician expertise were
found to be associated with differing
scores. Detailed exploration of the
subspecialists revealed that the lowest
levels of continuity were given to patients with high user rates who did not
carry a diagnosis in their primary physician's area of subspecialty expertise.
The "generalist versus subspecialist" debate assumes that a physician' s
training background is a major determinant of quality of primary care. This
was not true in this study for providing
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
one aspect of quality: a high level of lihood of life-threatening intraperitoncontinuity. If factors other than spe- eal hemorrhage and may allow perforcialty or subspecialty designation are mance of more conservative surgery.
generally found to be the important determinants of continuity, isolated Hearing Disorders
changes in the proportion of physi- Wiet RJ, Monsell EM, Hotaling
cians receiving generalist versus sub- AJ. Hearing and balance disorders:
specialty training may have relatively how to recognize, when to refer.
little impact on the level of continuity Postgrad Med 1985; 77:119-30.
given to adult medical patients.
Disorders of hearing and balance
can be devastating to patients and disDysuria
tressing to their families. The primary
Carlson KJ, Mulley AG.
care physician is generally the first to
Management of acute dysuria. Ann examine these patients, and in many
Intern Med 1985; 102:244-9.
cases can provide definitive treatment.
A decision-analysis model was de- The goal of this article is to help physiveloped to estimate the effects and cians recognize hearing and balance
costs of alternative initial management disorders, select the proper treatment,
strategies for women presenting with and determine when referral is approdysuria and pyuria. The authors com- priate.
pared days of morbidity and direct
medical costs of single- and multiple- Hepatitis B
dose regimens of amoxicillin and tri- American Academy of Pediatrics.
methoprim-sulfamethoxazole, and ex- Committee on Infectious Diseases.
amined the cost-effectiveness of an Prevention of hepatitis B virus
initial urine culture.
infections. Pediatrics 1985;
Varying assumptions were used for 75:362-4.
prevalence of etiologic agents, treatInfants born to mothers who are hement efficacy, frequency of side effects, and duration of symptoms. Single-dose regimens were preferable to
multiple-dose regimens of either drug,
and trimethoprim-sulfamethoxazole
was preferable to amoxicillin. Singledose trimethoprim-sulfamethoxazole
therapy resulted in the fewest expected
symptom-days (2.7) and the lowest expected cost ($54). The advantage of
single-dose strategies in minimizing
expected symptom-days resulted
largely from the 75-100% increase in
side effects reported with multipledose therapy. Obtaining initial urine
cultures, in all patients reduced expected symptom-days by about 10%
but increased cost by about 40%.
patitis B surface antigen (HBsAg) positive are frequently infected with hepatitis B virus (HBV). Many of these
newborns will become chronic carriers
of HBV and will subsequently develop
chronic liver disease. Recent studies
have demonstrated that perinatal transmission can be prevented by immunizing the newborn. Recommendations
are presented for managing infants at
risk.
Home Care
Zimmer JG, Groth-Juncker A,
McCusker J. A randomized
controlled study of a home health
care team. Am J Public Health
1985; 75:134-41.
This report describes the findings of
a randomized study of a new team approach to home care for homebound
chronically or terminally ill elderly.
The team includes a physician, nurse
practitioner, and social worker who
deliver primary health care in patients'
homes (including physician house
calls). Weekly team conferences assure coordination of patient care and
Ectopic Pregnancy
Quan MA, Johnson RA, Puffer JC.
The diagnosis of ectopic pregnancy.
Am Fam Physician 1985; 31:201-7
Ectopic pregnancy presents a major
challenge to physicians providing services to women of reproductive age
and is frequently an elusive diagnosis
to make. Recent developments in
pregnancy testing, pelvic ultrasound,
and diagnostic laparoscopy have enabled physicians to make early and accurate diagnosis. Familiarity with
these diagnostic aids is critical since
prompt diagnosis will reduce the likeCAN. FAM. PHYSICIAN Vol. 31: MAY 1985
SHEE
ROUTIN
977
the team is available for emergency
consultation through a 24-hour telephone service. The team physician attends to the patient during hospitalizations. This approach was evaluated in
a randomized experimental design
study measuring its impact on health
care use, functional changes in patients, and patient and caretaker satisfaction.
Team patients had fewer hospitalizations, nursing home admissions,
and outpatient visits than controls.
They were more often able to die at
home, if this was their wish and, as expected, they used more in-home services. Measured in weighted cost figures, overall costs were lower than for
controls, but the difference was not
statistically significant. Their functional abilities were the same as the
controls, but they, and especially their
informal caretakers in the home, expressed significantly higher satisfaction with the care received.
Most texts on malignant melanoma
(MM) have concentrated on descriptions of advance lesions. The inevitable corollary of this approach has been
the very poor prognosis.
Over the past decade, intensive clinicopathologic studies have clearly defined pathological features of prognostic significance, which allow a high
degree of accuracy of prognostication,
not only for groups of patients, but
also for individuals. It is clear that patients with MM diagnosed at a late
stage have five-year survival rates of
about 40%, while those with lesions
diagnosed earlier have a significantly
improved five-year survival of over
85%.
This article describes and illustrates
the early signs of malignant melanoma. As early diagnosis of such
tumors becomes a reality, the goal of
accurately identifying precursor lesions, if they exist, also assumes new
significance. Types of melanocytic
nevi and their natural life history are
described, and the evidence linking soMedical Education
called precursor lesions with malignCurry L, Woodward C. A survey of ant melanoma is presented.
postgraduate training for family
practice. Can Med Assoc J 1985;
Preventive Medicine
132:345-9.
Fowkes FG, Williams T. Preventive
The results of a survey of Canadian medicine during office visits to
primary care physicians for the Cana- family physicians and other
dian Medical Association (CMA's) primary care specialists in the
Task Force on Education for the Provi- United States. Fam Pract Research
sion of Primary Care Services are re- J 1984 Winter; 4:69-78.
ported. Recent Canadian medical
Family physicians frequently note
school graduates in primary care praca special feature of family practice
that
tice reported that the three major trainand
continuity of care is the ability to
ing routes (rotating and mixed internships and family medicine residencies) initiate preventive care at appointprepared them differently for practice. ments made for other purposes. The
Graduates of two-year family medi- extent that family physicians and other
cine residencies were more satisfied primary care specialists in the U.S.
with their preparation than were gradu- acted on this opportunity in 1978 was
ates of the other major training routes. determined from the U.S. National
A two- or three-year family medicine Ambulatory Medical Care Survey.
Two types of consultation were exresidency was preferred by 50% of refor general medical examined:,visits
of
them
33%
spondents, although only
and
visits for certain acute
amination,
had actually taken one of these routes.
where prevenillnesses
self-limiting
There was considerable agreement in
as part
be
care
was
not
to
tive
expected
the
postrespondents' assessments of
graduate education needed for primary of normal doctor-patient interaction.
care practice. Survey results were con- General medical examinations were
sistent with recommendations in the common, with the equivalent of one
annual examination requested per
final report of the CMA's task force.
seven adults in the population. For
visits doctors indicated that they
these
Melanoma
more commonly performed diagnostic
tests and prescribed drugs than carried
MacKie RM. Clinical features of
out "significant" counseling; less than
of
and
the
role
melanoma
cutaneous
one percent of females received family
nevi as precursor lesions. Clin in
planning advice.
Oncol 1984; 3:439-55.
978
The results suggest that high priority
was not given to health promotion and
disease prevention during patient consultations in primary care in the U.S.
in 1978.
Research
Schmitt B. Research design for
family physicians. Fam Pract
Research J 1984; 4:15-26.
With the growth of medical science
and the explosion of medical literature, both practitioners and academics
are continually confronted by practical
issues in research design. Is one treatment more efficacious than another for
a given disease? What is the disease's
prognosis if not treated? How useful is
a diagnostic test for ruling in or ruling
out the disease and in what situations?
These questions routinely arise in clinical practice. However, the pursuit of
valid answers is often frustrated by incomplete, biased, or nongeneralizable
data.
This article acquaints readers with
important aspects of research design
necessary for critiquing medical literature or for planning a research project
and examines major roadblocks to
validity-bias and chance. An overview of research design and individual
design models are described, along
with potential weaknesses making
them vulnerable to bias.
Women Physicians
Mitchell JB. Why do women
physicians work fewer hours than
men physicians? Inquiry 1984;
21:361-8.
Because of the large public investment in medical education, it is important to understand why women
physicians work significantly fewer
hours than men physicians. National
survey data on office-based private
practice physicians were used to estimate hours and weeks worked for
men and women physicians separately.
shorter work weeks for women physicians are not the result of child care responsibilities, nor would higher earnings encourage them to work longer
hours. Instead, results showed significant work reductions among married
women physicians (but not men), implying subordination of careers by
women where combined family incomes are high.
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
Calendar
JUNE
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T
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T
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8
15
22
29
Send all information on courses to Calendar, 1200
Sheppard Ave. E., #507, Willowdale, ON. M2K 2S5,
at least three months before the date of the course.
Readers wishing to register or get further information
on courses should write to the address listed under
'Information', and NOT to CANADIAN FAMILY
PHYSICIAN.
Recommended Courses
3 Peace Arch Hospital Rounds. Peace Arch Hospital, 10-12 Electrocardiogram Interpretation and ArrhythWhite Rock, BC. Information: Dr. Charles D. King,
mia Management. Resorts International, Atlantic City,
2781 Gordon Ave., Crescent Beach, Surrey, BC.
NJ. Information: Margaret A. Kleiger, International
V4A 3J5
Medical Education Corporation, 64 Inverness Drive
3-5 Helping Children Cope with Death. King's College,
East, Englewood, CO. 80112, U.S.A. (13 hours)
London, ON. Information: Dr. J. D. Morgan, King's 10-14 Conference for International Relief Personnel
College, 266 Epworth Ave., London, ON. N6A 2M3
Working with Refugees and Displaced Communities.
(20 hours)
Seneca College of Applied Arts and Technology, Leslie
5 Current Therapeutics. University of British Columbia,
Campus, North York, ON. Information: Mildred G.
Vancouver, BC. Information: Dr. P. Grantham, Dept. of
Jarvis, Seneca College, Leslie Campus, 1255 Sheppard
Ave. E., North York, ON. M2K 1E2 (25 hours)
Family Practice, Mather Bldg., University of British Columbia, Vancouver, BC. V6T 1W5 (4 hours)
13 Update on Thyroid Disease and Diabetes. Mount Sinai
5 Sports Medicine Program. Chedoke Hospital, Hamilton, ON. Information: Program in Continuing Medical
Education, McMaster University Health Sciences
Centre, Room 1M6, 1200 Main St. West, Hamilton,
ON. L8S 4J9
5-9 Ninth Western Canadian Conference on Family
Practice. University of British Columbia, Vancouver,
BC. Information: Alix Hirabayashi, Conference Administrator, School of Social Work, The University of British Columbia, Vancouver, BC. V6T iW5
6-7 Cancer Symposium '85. University Hospital, Saskatoon, SK. Information: Continuing Medical Education
Office, 408 Ellis Hall, University of Saskatchewan, Saskatoon, SK. S7N OWO
6-7 Prediction of Drug Levels and Drug Monitoring.
Madison, WI. Information: Sarah Z. Aslakson, Continuing Medical Education, University of Wisconsin, 465B
WARF Building, 610 Walnut St., Madison, WI. 53705,
U.S.A.
7 Intervention in Child Abuse. The Doctors Hospital,
Toronto, ON. Information: Dr. Jess Goodman, 895
Bloor St. West, Toronto, ON. M6H 1L2 (2 hours)
7 Neurology Update. Inn on the Park, Toronto, ON. Infor.~~~~~~~U.
mation: Organizing Secretary, Neurology Update, Room
E-4623, Sunnybrook Medical Centre, 2075 Bayview
Ave., Toronto, ON. M4N 3M5 (6 hours)
7-8 Advanced Trauma Life Support Course. University
of British Columbia Hospital, Vancouver, BC. Informa(loperamide)
tion: Dr. Norman E. Hamilton, #403-145 East 13th St.,
North Vancouver, BC. V7L 2L4
10 Peace Arch Hospital Rounds. Peace Arch Hospital,
White Rock, BC. Information: Dr. Charles D. King,
PAAB
iJANSSEN
11073E
'Trademark
PHARMACEUTICA
CJanssen 1985
2781 Gordon Ave., Crescent Beach, Surrey, BC.
V4A 3J5
DON'T LEAVE HOME
WITHOUT IT
IMODIUM
For travellers diarrhea
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
981
Hospital, Toronto, ON. Information: Ms. Carol Duncan,
Dept. of Family and Community Medicine, 222 Elm St.,
Suite 101, Toronto, ON. M5G iK5
13-14 Child Abuse-Everyone's Concern. Royal York
Hotel, Toronto, ON. Information: Ingrid Norrish, Program Manager, Professional and Management Development, Humber College, Box 1900, Rexdale, ON.
M9W 5L7
14 Between Therapist and Client: Views of the Therapeutic Relationship. Kitchener-Waterloo Hospital, Kitchener, ON. Information: Dr. D. Barnes, KitchenerWaterloo Hospital, 835 King St., West, Kitchener, ON.
N2G 1G3 (6½/2 hours)
15-21 Seventh Annual Conference on Sexuality: Love,
Sex and Intimacy. University of Guelph, Guelph, ON.
Information: Dr. E. Herold, Family Studies, University
of Guelph, Guelph, ON. NIG 2W1 (11/2 hours)
16-18 New Developments in Child and Adolescent Mental Health: Clinical, Educa,ional, Socio-Legal and
Research Considerations. Westin Hotel, Ottawa, ON.
Information: Dr. C. Stavrakaki, Royal Ottawa Hospital,
1145 Carling Ave., Ottawa, ON. K1Z 7K4 (8 hours)
17 Peace Arch Hospital Rounds. Peace Arch Hospital,
White Rock, BC. Information: Dr. Charles D. King,
2781 Gordon Ave., Crescent Beach, Surrey, BC.
V4A 3J5
19-21 Childbirth Educators' Workshop. McMaster University, Hamilton, ON. Information: Program in Continuing Medical Education, McMaster University Health
Sciences Centre, Room 1M6, 1200 Main St. West, Hamilton, ON. L8S 4J9
21 Disorders of Sleep and Wakefulness. University Hospital, Saskatoon, SK. Information: Continuing Medical
Education Office, 408 Ellis Hall, University of Saskatchewan, Saskatoon, SK. S7N OWO
21 Medicine. York County Hospital, Newmarket, ON. Information: Dr. E. Palermo, 93 Rutledge Ave., Newmarket, ON. L3Y 5T5 (1½/2 hours)
21 Pharmacological Management of Chronic Disease Induced Depression. University of Ottawa, Ottawa, ON.
Information: Education Department, Royal Ottawa Regional Rehabilitation Centre, 505 Smyth Road, Ottawa,
ON. K I H 8M2 (4 hours)
23-24 Pediatric Emergencies for Emergency Physicians.
The Hospital for Sick Children, Toronto, ON. Information: Dr. James C. Fallis, The Hospital for Sick Children, 555 University Ave., Toronto, ON. M5G lX8
(13/2 hours)
23-Jul 18 New Horizons: Professional Development
Seminar. Gabriola Island, BC. Information: Dr. J.
McKeen, PD Seminars, Davis Road, Gabriola Island,
BC. VOR IXO
24 Peace Arch Hospital Rounds. Peace Arch Hospital,
White Rock, BC. Information: Dr. Charles D. King,
2781 Gordon Ave., Crescent Beach, Surrey, BC.
V4A 3J5
26 Inflammatory Bowel Disease. McMaster University,
Hamilton, ON. Information: Program in Continuing
Medical Education, McMaster University Health
Sciences Centre, Room lM6, 1200 Main St. West, Hamilton, ON. L8S 4J9
28-30 Electrocardiogram Interpretation and ArrhythCAN. FAM. PHYSICIAN Vol. 31: MAY 1985
Information: Margaret A. Kleiger, International Medical
Education Corporation, 64 Inverness Drive East, Englewood, CO. 80112, U.S.A. (13 hours)
Other Courses
2-5 Eighty-fifth Annual Meeting of the Canadian Lung
Association and the Annual Scientific Meetings of the
Canadian Nurses' Respiratory Society and the Physiotherapy Section of the Canadian Lung Association.
Skyline Hotel, Ottawa, ON. Information: Mr. A. Les
McDonald, Health Education Coordinator, Canadian
Lung Association, 75 Albert St., Suite 908, Ottawa,
ON. KIP 5E7
5 First National Advanced Life Support Competition.
Westin Hotel, Ottawa, ON. Information: Advanced
Coronary Treatment Foundation, 2625 Queensview
Drive, Ottawa, ON. K2A 3Y4
2-8 Cancer in Children. London, U.K. Information: The
Representative, The British Council, c/o British High
Commission, 80 Elgin St., Ottawa, ON. KIP 5K7
3-7 Ninth Annual Occupational and Safety Workshop
Program for a Better Work Environment. Sydney,
NS. Information: Mr. Sheldon Maclnnes, Program
Coordinator, Chair of Occupational Health and Safety,
University College of Cape Breton, P.O. Box 5300,
Sydney, NS. B1P 6L2
(lopemamide)
For acute diarrhea
I1072E
CJanssen
JANSSEN
1(PHARMACEUTICA
rademark
983
3-8 Health Care of the Geriatric Patient. Charleston, SC.
Kingston, ON. K7L 3N6
Information: Dr. Ben Goodman, Program Coordinator, 20 Critical Care and Medical Management of the
Department of Family Medicine, Medical University of
Cancer Patient. Roswell Park Memorial Institute, BufSouth Carolina, 171 Ashley Ave., Charleston, SC.
falo, NY. Information: Gayle Bersani, RN, Coordinator
29425, U.S.A.
of Continuing Education Programs, Education Depart5 Sexual Abuse of Children. Donald Gordon Centre,
ment, Roswell Park Memorial Institute, 666 Elm St.,
Kingston, ON. Information: Office of Continuing Medical Education, Queen's University, Kingston, ON.
K7L 3N6
5-7 A Practical Course in Emergency Medicine. Montreal General Hospital, Montreal, PQ. Information:
Centre for Continuing Medical Education, McGill University, 1110 Pine Ave. West, Montreal, PQ. H3A 1 A3
6-8 Advanced Trauma Life Support Provider Course.
Sunnybrook Medical Centre, Toronto, ON. Information:
Emergency Department Physicians Management Consultants Ltd., P.O. Box 224, Postal Station Q, Toronto,
ON. M4T 2M1
6-8 Annual Scientific Assembly of the Canadian Association of Emergency Physicians. Westin Hotel, Ottawa,
ON. Information: Dr. Anna Malawski, CAEP Assembly, Emergency Department, Ottawa General Hospital,
501 Smyth Road, Ottawa, ON. K1H 8L6
9-15 Growth Areas in Oncology. London, U.K. Information: The Representative, The British Council, c/o British High Commission, 80 Elgin St., Ottawa, ON.
KlP 5K7
10-15 Family Practice Review. Estes Park, CO. Information: Office of Postgraduate Medical Education, The
University of Colorado School of Medicine, 4200 East
Ninth Ave., Box C-295, Denver, CO. 80262, U.S.A.
11-16 Combined European Congress of General Practice/Family Medicine, 33rd International Congress of
General Practice (SIMG) and 19th German Congress
of General Practice and Family Medicine (DEGAM).
Maritim Park Hotel, Mannheim/Heidelberg, West Germany. Information: Dr. Hans Hamm, President, German
Association of General Practice, D-2100 Hamburg 90,
Alter Postweg 20, West Germany.
14-15 Advanced Trauma Life Support Instructors'
Course. Universite de Sherbrooke, Sherbrooke, PQ. Information: Centre de formation continue, Faculte de
medecine, Universite de Sherbrooke, 3001-12e Avenue
nord, Sherbrooke, PQ. JIH 5N4
14-15 Sexual Dysfunctions. Montreal General Hospital,
Montreal, PQ. Information: Centre for Continuing Medical Education, McGill University, 1110 Pine Ave. West,
Montreal, PQ. H3A 1A3
16-20 International Conference on Oceans-Safety and
Health: Issues Affecting Insurability. Sydney, NS. Information: Prof. Lino Polegato, Director, Division of
Engineering, University College of Cape Breton, P.O.
Box 5300, Sydney, NS. BIP 6L2
17-21 Symposium on the Temporomandibular Joint.
Maui Mariott Hotel, Maui, Hawaii. Information: University of California, San Francisco, CA. 94143,
U.S.A.
17-22 Canadian Summer School in Occupational
Health. Quebec, PQ. Information: Canadian Summer
School in Occupational Health, Faculte de Medecine,
Universite Laval, Sainte-Foy, PQ. GiK 7P4.
19 Important Pediatric Issues in Family Medicine. Hotel
Dieu Hospital, Kingston, ON. Information: Office of
Continuing Medical Education, Queen's University,
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
Buffalo, NY. 14263, U.S.A.
20-22 Advanced Trauma Life Support Provider Course.
Sunnybrook Medical Centre, Toronto, ON. Information:
Emergency Department Physicians Management Consultants Ltd., P.O. Box 224, Postal Station Q, Toronto,
ON. M4T 2M1
21 Bioethics: Daily Implications for Health Care Professionals. Ottawa, ON. Information: Social Work Department, Ottawa Civic Hospital, 1053 Carling Ave., Ottawa, ON. K1Y 4E9
21-23 Advanced Cardiac Life Support Provider Course.
Sunnybrook Medical Centre, Toronto, ON. Information:
Emergency Department Physicians Management Consultants Ltd., P.O. Box 224, Postal Station Q, Toronto,
ON. M4T 2M1
21-23 Third Annual Symposium on Pediatric Nutrition.
Montreal, PQ. Information: Dr. R. K. Chandra, Janeway Child Health Centre, St. John's, NF. AlA 1R8
23-26 Forty-Eighth Annual Meeting of the Canadian
Ophthalmological Society. Harbour Castle Hilton
Hotel, Toronto, ON. Information: Canadian Ophthalmological Society, 1867 Alta Vista Drive, P.O. Box 8844,
Ottawa, ON. K I G 3J2
23-26 Seventeenth Annual Conference of the Canada
Safety Council. Hotel Newfoundland, St. John's, NF.
IMODIUM*
(loperamide)
For diarrhea in children
I11059E
CJanssen 1986
EJANSSEN
PHARMACEUTICA
PAAB
'rdemark
985
Information: Canada Safety Council, 1765 St. Laurent
Blvd., Ottawa, ON. KIG 3V4
23-28 Twenty-First Annual Northern Michigan Summer
Conference: An Update on Common Clinical Concerns. Hilton Shanty Creek, Bellaire, MI. Information:
Dove Margenau, The Office of Continuing Medical Education, The Towsley Centre, Box 057, The University of
Michigan Medical School, Ann Arbor, MI. 48109,
U.S.A.
JULY
Recommended Courses
5-9 Electrocardiogram Interpretation and Arrhythmia
Management. Westin Ilkai, Oahu, Hawaii. Informa1 2 3 4 5 6
tion: Margaret A. Kleiger, International Medical Education Corporation, 64 Inverness Dr. East, Englewood,
7 8 9 10 11 12 13
CO. 80112, U.S.A. (13 hours)
14 15 16 17 18 19 20
8-10 Masters Games Sports Medicine Symposium. Hil21 22 23 24 25 26 27
ton Harbour Castle Hotel, Toronto, ON. Information:
Dr. Robert Brock, Ontario Medical Association, 240 St.
28 29 30 31
George St., Toronto, ON. M5R 2P4 (24 hours)
10-16 Tenth International Congress of Hypnosis and
Psychosomatic Medicine. Harbour Castle Hilton,
Recommended Courses
ON. Information: 10th International Congress
Toronto,
12-14 Electrocardiogram Interpretation and Arrhyth200 St. Clair Ave., West, Suite 402,
Secretariat,
mia Management. Fort Magruder Inn, Williamsburg,
M4V lRl (25 hours)
ON.
Toronto,
VA. Information: Margaret A. Kleiger, International
Workshop
on Stress for Physicians and
23-25
Weekend
Medical Education Corporation, 64 Inverness Drive
Gabriola Island, BC. InforHaven-by-the-Sea,
Spouses.
East, Englewood, CO. 80112, U.S.A. (13 hours)
PD
Seminars, Davis Road,
Dr.
McKeen,
Jock
mation:
15-26 Fundamental Concepts in Addictions. School for
hours)
lXO
(12
VOR
BC.
Island,
Gabriola
Addiction Studies, Toronto, ON. Information: Dr. DonOther
Courses
ald E. Meeks, Director, School for Addiction Studies, 8
4-10 Thirty-Fourth International Congress on AlcoholMay St., Toronto, ON. M4W 2Y1 (22 hours)
ism and Drug Dependency. Calgary, AB. Information:
17-18 Fifth Annual Common Emergency Care ProbTom
Wispinski, Congress Secretariat, #803, 10109-106
lems. Sheraton Inn and Conference Centre, Madison,
AB. T5J 3L7
Edmonton,
St.,
WI. Information: Sarah Z. Aslakson, Continuing MediMedicine. Lake Tahoe, NV. InformaWilderness
12-16
WARF
465b
of
Wisconsin,
cal Education, University
Medical Education, M-017,
Office
of
Continuing
tion:
Bldg., 610 Walnut St., Madison, WI. 53705, U.S.A.
Diego School of Medicine,
California,
San
University
of
( 12 hours)
S
M
T
W
T
F
S
La Jolla, CA. 92093, U.S.A.
14-16
Second International Conference on Illness BeOther Courses
havior.
Roy Thomson Hall, Toronto, ON. Information:
14-19 Twenty-Sixth Annual Institute on Addiction
Behavior Conference, c/o Gut Behaviour
International
Studies. Hamilton, ON. Information: Kathryn Irwin,
Toronto
Western Hospital, 399 Bathurst St.,
Unit,
Alcohol & Drug Concerns, 11 Progress Ave., Suite 200,
M5T
2S8
ON.
Toronto,
MIP
4S7
ON.
Scarborough,
14-26 Progress in Dermatological Therapy. London,
U.K. Information: The Representative, The British
Council, c/o British High Commission, 80 Elgin St., Ottawa, ON. K1P 5K7
15-19 Update Course for Isolated Practitioners. Queensland, Australia. Information: The Secretary, The Royal
Australian College of General Practitioners, Queensland
Faculty, Private Box 3, Eildon Post Office, Windsor
4030, Australia.
26-28 The Second International Congress on Pre- and
Perinatal Psychology. Town and Country Convention
Centre, San Diego, CA. Information: Congress Secretariat, 9091/2 Hayes Ave., San Diego, CA. 92103,
U.S.A.
986
SEPTEMBER
S
M
T
W
T
F
S
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
4 PRESCRIBING INFORMATION >
Recommended Courses
13-15 Marriage and the Stress of the Eighties. Inn on the
Park, Toronto, ON. Information: Dr. Donald M. DenCOMPARATIVE SINGLE DOSE ABSORPTION DATA
mark,
4078 Petrolia St., Petrolia, ON. NON IRO (9
Category/Product
Peak Serum Concentrations of
hours)
Erythromycin Base mcg/mL
Erythromycin Base
19-21 Annual Scientific Assembly and Business Meeting
(Ernapslated Enteric-|
ERY coated
Pellets)
of the Saskatchewan Chapter of The College of FamErythromnycn1
1.15
ily Physicians of Canada, Ramada Renaissance Hotel,
tablets),
Saskatoon, SK. Information: Mrs. Frances Maksymiw,
S|
t>| (Er¶teric-coated tabetS2 J 110.73
Administrative Secretary, Saskatchewan Chapter,
CFPC, Box 217, Rockglen, SK. SOH 3R0
Erythromycin Salt
20 Biomechanical Analysis of the Foot and Ankle.
Toronto East General and Orthopedic Hospital, Toronto,
ON. Information: Susan Johnson, Director, RehabilitaErythromycin Ester
tion Medicine Dept., Toronto East General and OrthopeErythomycvin
dic Hospital, 825 Coxwell Ave., Toronto, ON.
M4C 3E7 (6 hours)
C<0.51
20-24 Annual Scientific Assembly of the British ColumReerereces.
of Hospital Ptharmacy. 1203
Vo. 37, Sept 1980 Aenerican
bia Chapter of The College of Family Physicians of
FraserL
199
2. id
3. Physicsn Desk Reterence.ed 35. Oraddl, New Jersey. Medical Ecoremics Company, a Litton dtotson. 1 981 p. 705.
Canada. Delta Mountain Inn, Whistler, BC. Informa4. bid pp 830.
5. Sande M.A., Mandell G.L. Antimicrobal agents, Giloan A.G., Goodman LS.. and Giknan A. (ofs): Goodmanand Glman's.
The Pharmacolog,al Basis of Therapeutics, ed 6. New York. MacmsllBa Publisheg Co. Inc. 1980. pp 1222-1248.
tion: Ms. Bev Kulyk, Administrator, British Columbia
Chapter, CFPC, 1807 West 10th Ave., Vancouver, BC.
Indications: The treatment of the following infections when caused by susceptible strains of micro-organisms: upper and lower respiratory tract infections; skin
V6J 2A9
and soft tissue infections; gonorrhea; syphilis; Legionnaires' disease; pertussis;
diphtheria; short term prophylaxis of bacterial endocarditis in patients hypersen- 21 International Symposium on the Clinical Aspects of
Immunology. Parkway Inn, Cornwall, ON. Informasitive to penicillin.
tion: Dr. Margaret Macaulay, 125 First St. East, CornContraindicatlons: Known hypersensitivity to erythromycin.
Precautions: The possibility of superinfection caused by overgrowth of nonwall, ON. K6H 1K8 (8 hours)
susceptible bacteria or fungi should be kept in mind during prolonged or repeated
21-22
Pediatrics Update. Pillar and Post Inn, Niagara-ontherapy with ERYC. In such instances, the administration of ERYC should be
discontinued and appropriate treatment instituted if necessary.
the-Lake, ON. Information: Program in Continuing
Erythromycin is excreted principally by the liver. Caution'should be exercised when
Medical Education, McMaster University Health
administering ERYC to patients with impaired hepatic function.
Sciences
Centre, Room 1M6, 1200 Main St. West,
The concomitant administration of erythromycin and high doses of theophylline
may be associated with increased serum theophylline levels and possible
Hamilton, ON. L8S 4J9
theophylline toxicity. The dose of theophylline may require reduction while pa- 22-25 Orthopedic Medicine-Cyriax Techniques: Part
tients are receiving ERYC.
C. Calgary, AB. Information: Catherine McGinley, FacThe safety of ERYC for use in pregnant patients has not been established.
There is placental transfer and excretion of erythromycin in breast milk.
ulty of Continuing Education, The University of CalAdverse Effects: The most frequent side effects are gastrointestinal and are dosegary, 2500 University Drive N.W., Calgary, AB.
related. They include nausea, vomiting, abdominal pain, diarrhea and anorexia.
T2N
1N4(14hours)
Symptoms of hepatic dysfunction and/or abnormal liver function test results may
23-25 Ontario Public Health Association's Annual Meetoccur.
ing-Working Together: Building Coalitions for
Serious allergic reactions have been extremely Infrequent. Mild allergic reactions such as rashes with or without pruritis, urticaria, bullous eruptions
Public Health. Sheraton Centre, Toronto, ON. Informaand eczema have been reported with erythromycin.
tion: Dr. Trevor Hancock, 64 Merton St., Toronto, ON.
Dosage: The most reliable serum levels of erythromycin are achieved when ERYC
l (14 hours)
M4S IA
capsules are taken one hour before meals or in the fasting state.
USP
E RYC*Erythmmycin,
Encapsulated enteric-coated pellets
ER C
[_
J
(Film coted
Estoysucate
1 (Fiim
coatdlablets}
1.
>
Journal
p.
Donald G.
p. 1
in
Adults: The usual dose is 250 mg (one capsule) every 6 hours taken one hour
before meals. If twice-a-day dosage is desired, the recommended dose is 500
mg (two 250 mg capsules) every 12 hours. Twice-a-day dosing is not recommended when doses larger than 1 g daily are administered.
In the treatment of streptococcal infections, a therapeutic dosage of erythromycin
should be administered for at least 10 days. In continuous prophylaxis of streptococcal infections in persons with a history of rheumatic heart disease, the dose
is 250 mg twice-a-day.
For the prevention of bacterial endocarditis due to alpha-hemolytic streptococci
in penicillin-allergic patients with valvular heart disease who are to undergo dental
procedures or surgical procedures of the upper respiratory tract, the recommended dose for adults is 500 mg 1.5 to 2 hours prior to the procedure and then 500
mg every 8 hours for at least 3 days.
Primary syphilis: 2-4 grams per day for a period of 10-15 days.
Intestinal ameblasis: 250 mg four times daily for 10-15 days for adults.
Legionnaire's disease: Although optimum doses have not been established
doses used in reported clinical data were 1 to 4 g daily in divided doses.
How supplied: ERYC capsule is a two-tone clear and orange opaque capsule,
each containing 250 mg erythromycin base as enteric-coated pellets. Available
in bottles of 100.
Store at a room temperature below 30°C. Protect from moisture and light.
Full prescribing information available on request.
PARKE-DAVIS
Parke-Davis Canada Inc., Scarborough, Ontario
0Reg.
988
T.M. Parke, Davis & Company, Parke-Davis Canada Inc., auth. user
"
Other Courses
5-7 Advanced Trauma Life Support Provider Course.
Sunnybrook Medical Centre, Toronto, ON. Information:
Emergency Department Physicians Management Consultants Ltd., P.O. Box 224, Postal Station 'Q",
Toronto, ON. M4T 2M1
8-11 Canadian Pediatric Society Annual Meeting. Hyatt
Regency Hotel, Vancouver, BC. Information: Dr. Joe
Clarke, Director, Genetic & Metabolic Disease Program, Hospital for Sick Children, 555 University Ave.,
Toronto, ON. M5G 1X8
8-12 Fourth International Congress on Medicine and
Law: Hospital Laws-Procedures & Ethics. Israel.
Information: Society of Medicine & Law in Israel,
P.O.B. 394, Tel Aviv 61003, Israel.
9-12 Conjoint Meeting of the Royal College of Physicians and Surgeons and The Canadian Thoracic Society. Vancouver, BC. Information: Mr. A. Les McDonald, Health Education Coordinator, Canadian Lung
Association, 75 Albert St., Suite 908, Ottawa, ON.
K1P SE7
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
9-13 The 1985 National Conference of the Occupational
Medical Association of Canada. Calgary, AB. Information: 1985 Occupational Medical Association of Canada Conference, c/o Margaret-Anne Stroh, Conference
Office, Faculty of Continuing Education, University of
Calgary, 2500 University Dr. N.W., Calgary, AB.
T2N 1N4
16-21 Challenge '85: Joint National Convention Pacific
Regional Conference of WONCA and Annual General Meeting and National Convention of the Royal
Australian College of General Practitioners. Regent
Hotel, Melbourne, Australia. Information: Mrs. Pat
Palmer, Challenge '85, Victoria Faculty, The Royal
Australian College of General Practitioners,
"Trawalla", 22 Lascelles Ave., Toorak, Victoria 3142,
Australia.
16-21 Thirty-Fourth International Congress on General
Practice of the Societas Internationalis Medicinae
Generalis. Klagenfurt, Austria. Information: Mrs.
Sigrid Taupe, Secretariat of the Societas Internationalis
Medicinae Generalis, A-9020 Klagenfurt, Bahnhofstrabe 22, Austria.
19-21 Advanced Trauma Life Support Provider Course.
Sunnybrook Medical Centre, Toronto, ON. Information:
Emergency Department Physicians Management Consultants Ltd., P.O. Box 224, Postal Station "Q",
Toronto, ON. M4T 2M1
19-21 The Challenge of the Lumbar Spine. Amfac Hotel,
Minneapolis, MN. Information: Devora J. Segal, Program Coordinator, The Institute for Low Back Care,
2737 Chicago Ave., Minneapolis, MN. 55407, U.S.A.
20 A Day in Family Medicine. Hotel Dieu Hospital, Kingston, ON. Information: Dr. C. Johnson, Family Medicine Centre, 220 Bagot St., P.O. Bag 8888, Kingston,
ON. K7L 5E9
26-28 Seventh Annual Frontiers in Nutrition. Mariner's
Inn, Hilton Head Island, SC. Information: Division of
Continuing Education, Medical College of Georgia, Augusta, GA. 30912, U.S.A.
16 Annual Day in Obstetrics and Gynecology. Henderson
Hospital, Hamilton, ON. Information: Ms. Laurie Woltman, Program In Continuing Medical Education,
McMaster University H.S.C., 1200 Main St. West,
Room 1M6, Hamilton, ON. L8S 4J9
16-20 Canadian Association of Gerontology Program.
Hamilton, ON. Information: Ms. Laurie Woltman, Program In Continuing Medical Education, McMaster University H.S.C., 1200 Main St. West, Room 1M6,
Hamilton, ON. L8S 4J9
24-26 Annual Scientific Assembly of the Maritime
Chapters of the College of Family Physicians of Canada. Saint John, NB. Information: Mrs. Mavis Alain,
Executive Secretary, New Brunswick Chapter, CFPC,
New Brunswick Medical Society, Suite 209, Priestman
Centre, 565 Priestman St., Fredericton, NB. E3B 5X8
30 Occupational Health Program. Hamilton, ON. Information: Ms. Laurie Woltman, Program In Continuing
Medical Education, McMaster University H.S.C., 1200
Main St. West, Room IM6-,+Iamilton, ON. L8S 4J9
Other Courses
1-4 International Exhibition and the German Congress
for Safety and Medical Care at Work. Dusseldorf,
West Germany. Information: P.R. Charette Inc., 5890
Monkland Ave., Suite 206, Montreal, PQ. H4A 1G2
3-5 Advanced Trauma Life Support Provider Course.
Sunnybrook Medical Centre, Toronto, ON. Information:
Emergency Department Physicians Management Consultants Ltd., P.O. Box 224, Postal Station "Q",
Toronto, ON. M4T 2M1
4-5 Current Psychiatric Issues in Primary Care. The
Marriott Hotel, San Antonio, TX. Information: Medical
School Continuing Education Services, University of
Texas Health Science Centre, 7703 Floyd Curl Dr., San
Antonio, TX. 78284, U.S.A.
7-11 Update Course for General Practitioners. Queensland, Australia. Information: The Secretary, The Royal
Australian College of General Practitioners, Queensland
Faculty, Private Box 3, Eildon Post Office, Windsor
4030, Australia.
17-19 Advanced Trauma Life Support Provider Course.
Sunnybrook Medical Centre, Toronto, ON. Information:
Emergency Department Physicians Management ConT
F
T
S
M
W
S
sultants Ltd., P.O. Box 224, Postal Station "Q",
Toronto, ON. M4T 2M1
1 2 3 4 5
18 Stroke Rehabilitation: Present Trends and Future
6 7 8 9 10 11 12
Directions. Jewish Rehabilitation Hospital, Laval, PQ.
Information: Dr. Henry Coopersmith, 3205 Place Alton
13 14 15 16 17 18 19
Goldbloom, Laval, PQ. H7V 1R2
20 21 22 23 24 25 26
20-Nov 1 Infertility. London, U.K. Information: The Representative, The British Council, c/o British High Com27 28 29 30 31
mission, 80 Elgin St., Ottawa, ON. KIP 5K7
21-22 The Immediate and Long-Term Effects of Separation and Divorce on Parents' Children: New Findings
Recommended Courses
and New Interventions. Westin Hotel, Toronto, ON.
9 Rheumatology Update. Stratford, ON. Information: Ms.
Information: Gilda Ennis, 53 Lisa Cres., Thomhill, ON.
Laurie Woltman, Program In Continuing Medical EduL4J 2N2
cation, McMaster University H.S.C., 1200 Main St.
23-24 The Immediate and Long-Term Effects of SeparaWest, Room 1M6, Hamilton, ON. L8S 4J9
tion and Divorce on Parents' Children: New Findings
12-13 Laboratory Medicine Seminar. Hamilton Convenand New Interventions. Four Seasons Hotel, Montreal,
tion Centre, Hamilton, ON. Information: Ms. Laurie
PQ. Information: Gilda Ennis, 53 Lisa Cres., Thornhill,
Woltman, Program In Continuing Medical Education,
ON. L4J 2N2
McMaster University H.S.C., 1200 Main St. West,
24-25 Living with the Reality of Diabetes: Twelfth AnRoom 1M6, Hamilton, ON. L8S 4J9
OCTOBER
990
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
nual Meeting and Workshop. Hyatt Regency Hotel,
Administrative Director, Ontario Chapter, CFPC, 4000
Montreal, PQ. Information: Ms. Gilda Bastasi, ConferLeslie St., Willowdale, ON. M2K 2R9
ence Chairperson, Montreal General Hospital, 1650
Cedar Ave., Room 200A, Montreal, PQ. H3G 1A4
Other Courses
31-Nov 2 Advanced Trauma Life Support Provider 14-16 Advanced Trauma Life Support Provider Course.
Course. Sunnybrook Medical Centre, Toronto, ON. InSunnybrook Medical Centre, Toronto, ON. Information:
formation: Emergency Department Physicians ManageEmergency Department Physicians Management Conment Consultants Ltd., P.O. Box 224, Postal Station
sultants Ltd., P.O. Box 224, Postal Station "Q',
"Q", Toronto, ON. M4T 2M1
Toronto, ON. M4T 2M1
20-23 REHA 85: The International Fair and Forum on
Rehabilitation Aids for the Disabled. Dusseldorf,
West Germany. Information: P.R. Charette Inc., 5890
Monkland Ave., Suite 206, Montreal, PQ. H4A 1G2
28-30 Advanced Trauma Life Support Provider Course.
Sunnybrook Medical Centre, Toronto, ON. Information:
T
F
S
T
W
M
S
Emergency Department Physicians Management Consultants Ltd., P.O. Box 224, Postal Station "Q",
1 2
Toronto, ON. M4T 2M1
NOVEMBER
3 4 5 6 7 8 9
10 11 12 13 14 15 16
17 18 19 20 21 22 23
24 25 26 27 28 29 30
DECEMBER
Recommended Courses
1 Colorectal Cancer. Hamilton, ON. Information: Ms.
Laurie Woltman, Program In Continuing Medical Education, McMaster University H.S.C., 1200 Main St.
West, Room 1M6, Hamilton, ON. L8S 4J9
2-4 Toronto Rehabilitation Centre's Third International
Symposium on Ischemic Heart Disease, Exercise, and
Related Topics. Royal York Hotel, Toronto, ON. Information: Dr. Terence Kavanagh, 345 Rumsey Road,
Toronto, ON. M4G 1R7 (20 hours)
6 Twelfth Annual Day in Medicine. Royal Connaught
Hotel, Hamilton, ON. Information: Ms. Laurie Woltman, Program In Continuing Medical Education,
McMaster University H.S.C., 1200 Main St. West,
Room 1M6, Hamilton, ON. L8S 4J9
7-8 Saskatchewan Medical Association Annual Meeting.
Saskatoon, SK. Information: Continuing Medical Education Office, 408 Ellis Hall, University of Saskatchewan, Saskatoon, SK. S7N OWO
12-13 Computers in Medicine. Hamilton, ON. Information: Ms. Laurie Woltman, Program In Continuing Medical Education, McMaster University H.S.C., 1200
Main St. West, Room 1M6, Hamilton, ON. L8S 4J9
20 Minor Office Procedures. Hamilton, ON. Information:
Ms. Laurie Woltman, Program In Continuing Medical
Education, McMaster University H.S.C., 1200 Main St.
West, Room 1M6, Hamilton, ON. L8S 4J9
27-30 Twenty-Third Annual Scientific and Business
Meeting of the Ontario Chapter of The College of
Family Physicians of Canada. Hilton Harbour Castle
Hotel, Toronto, ON. Information: Mrs. Marcia Barrett,
2
992
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8
15
22
29
2
9
16
23
30
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3 4 5 6
10 11 12 13
17 18 19 20
24 25 26 27
31
7
14
21
28
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Recommended Courses
5-6 Infectious Diseases '85. University Hospital, Saskatoon, SK. Information: Continuing Medical Education
Office, 408 Ellis Hall, University of Saskatchewan, Saskatoon, SK. S7N OWO
26-30 Allergy, Drugs and Drug Allergies. Royal Lahaina
Resort, Kaanapali, Maui, HI. Information: Joe Harrison,
Symposium Maui, Inc., P.O. Box 10185, Lahaina,
Maui, HI. 96761, U.S.A. (13½/2 hours)
Other Courses
12-14 Advanced Trauma Life Support Provider Course.
Sunnybrook Medical Centre, Toronto, ON. Information:
Emergency Department Physicians Management Consultants Ltd., P.O. Box 224, Postal Station "Q",
Toronto, ON. M4T 2M1
15-19 Fourth International Congress on Medicine and
Law: Drugs and Alcohol. Israel. Information: Society of
Medicine and Law in Israel, P.O.B. 394, Tel Aviv
61003, Israel.
_AN. FAM. PHYI
-V-l. 31: MAY 198
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
PRESCRIBING INFORMATION
floctafenine 200 mg tablets
THERAPEUTIC CLASSIFICATION: Analgesic
ACTION: IDARAC (floctafenine) is an anthranilic acid
derivative which has analgesic and anti-inflammatory
properties. Floctafenine has been shown to inhibit in
vitro biosynthesis of prostaglandins PGE2 and PGF2a.
Gastro-intestinal bleeding determined by daily fecal
blood loss was shown in one clinical trial to be approximately 1.2 ml after 1600 mg/day of floctafenine
compared to 10.4 ml after 2400 mg/day of acetylsalicylic acid.
In normal volunteers, IDARAC was well absorbed
after oral administration and peak plasma levels
were attained 1-2 hours after administration and declined in a biphasic manner with an initial (0 phase)
half-life of approximately 1 hour and a later (fA phase)
half-life of approximately 8 hours. Floctafenine and
its metabolites do not accumulate following oral administration of multiple doses.
After oral and intravenous administration of 14C
labelled IDARAC, urinary excretion accounted for
40% and fecal and biliary excretion accounted for
60% of the recovered radioactivity The main urinary
metabolites are floctafenic acid and its conjugate with
minimal amounts of free floctafenine.
INDICATIONS: IDARAC (floctafenine) is indicated
for short-term use in acute pain of mild and moderate
severity
CONTRAINDICATIONS: IDARAC (floctafenine) is
contraindicated in patients with peptic ulcer or any
other active inflammatory disease of the gastrointestinal tract and in patients who have demonstrated
a hypersensitivity to the drug.
WARNINGS: USE IN PREGNANCY: The use of
IDARAC (floctafenine) in women of childbearing potential requires that the likely benefit of the drug be
weighed against the possible risk to the mother and
fetus. Use of the drug in women who are nursing is
not recommended.
USE IN CHILDREN: The safety and efficacy of IDARAC
in children have not been established and therefore
is not recommended. The safety and efficacy of longterm use of IDARAC have not been established.
PRECAUTIONS: IDARAC (floctafenine) should be
used with caution in patients with impaired renal function. In clinical trials with IDARAC, dysuria without
apparent changes in renal function was reported. It
has not been established whether dysuria is related
to dose and or duration of drug administration.
Patients taking anticoagulant medication may be
given IDARAC with caution. Alterations in prothrombin time have been observed only in clinical trials
where the administration of IDARAC was extended
beyond two weeks. IDARAC should be used with
caution in patients with a history of peptic ulcer or
other gastro-intestinal lesions.
ADVERSE REACTIONS: The most commonly occurring side effects reported during IDARAC
(floctafenine) therapy were:
CENTRAL NERVOUS SYSTEM: Drowsiness, dizziness, headache, insomnia, nervousness, irritability.
GASTRO-INTESTINAL SYSTEM: Nausea, diarrhea,
abdominal pain or discomfort, heartbum, constipation,
abnormal liver function, gastro-intestinal bleeding.
UROGENITAL SYSTEM: Dysuria, burning micturition,
polyuria, strong smelling urine, urethritis and cystitis.
ALLERGIC-TYPE REACTIONS: Maculopapular skin
rash, pruritis, urticaria, redness and itching of the face
and neck.
SYMPTOMS AND TREATMENT OF OVERDOSE:
No cases of overdose have been reported with
IDARAC (floctafenine). In a case of overdose standard
procedures to evacuate gastric contents, maintain
urinary output and provide general supportive care
should be employed.
DOSAGE AND ADMINISTRATION: The usual adult
dose of IDARAC (floctafenine) is 1 to 2 tablets (200 to
400 mg), 3 to 4 times per day as required. The maximum recommended daily dose is 1200 mg. IDARAC
is recommended for short-term management of acute
pain.
The tablets should be taken with a glass of water
IDARAC is not recommended for use in children.
AVAILABILITY: Each tablet of IDARAC contains
200 mg of floctafenine. Tablets are biconvex, cylindrical, yellowish-white, scored on one side with D57
above the breakline and a distinctive logo on the
reverse side.
IDARAC is available in botties of 100 tablets. Store at
room temperature, protected from light.
IDARAC is a Schedule F (prescription) drug.
Product monograph upon request.
VithopterigDus.',
piviio
o
References
1. Valdez-Dapena MA. Sudden infant
death syndrome: a review of the medical
literature 1974-79. Pediatr 1980; 66:597614.
2. Merritt TA. Commentary. In: Proceedings of the 17th Annual Intra-Science Symposium on Sudden Infant Death Syndrome,
1984, Santa Monica. Bethesda, MD., National Institute of Child Health and Human
Development, (in press).
3. Naeye RL. Hypoxia and the sudden infant death syndrome. Science 1974;
186:837.
4. Naeye RL, Fisher R, Ryser M, et al.
Carotid body in the sudden infant death
syndrome. Science 1976; 191:567.
5. Winn K, et al. Medical examiner network for collection of materialfrom infants
who die acutely in an accident. Baltimore,
MD, National Center for the Prevention of
Sudden Infant Death, Altanta, GA, American Sudden Infant Death Institute, 1985.
6. Merritt TA, Krous H, Norris G, ValdezDapena M, Brooks JG. Rebuttal statement
on DPT. Landover, MD, National Sudden
Infant Death Syndrome Foundation, 1985.
7. Bernier RH, Frank JA, Dondero TJ,
Turner P. Diphtheria-tetanus-toxoids-pertussis vaccination and sudden infant death
in Tennessee. J Pediatr 1982; 101:419-
29.
8. National Institute of Child Health and
Human Development multicenter case-control study on SIDS 1980-1985. Bethesda,
MD, National Institute of Health.
9. Segal S, Clogg DK, Fried C, Haworth
J, Krause V, Swyer P, et al. The monitoring of an infant in the home, a commentary
by the Scientific Advisory Committee,
Canadian Foundation for the Study of Infant Deaths, Toronto, ON, 1982.
10. Wasserman AL. A prospective study of
the impact of home monitoring on the family. Pediatr 1984; 74:323-9.
11. Deykin E, Bauman ML, Kelly DH,
Hsieh C-C, Shannon D. Apnea of infancy
and subsequent neurologic, cognitive, and
behavioural status. Pediatr 1984, 73:63845.
12. Pamphlets and various reprints available from The Canadian Foundation for
the Study of Infant Deaths, Box 190, Station R, Toronto, ON. M4G 3Z9.
13. Segal S, Fletcher M, Meekison WG.
Bereaved parents-a retrospective look.
Submitted to Can Med Assoc J 1985.
14. Weinstein SE, ed. Mental health issues
Canadian
Family Physician
Coming Next Month
Oncology
Testis Cancer
R. Brewer Auld
Hodgkin's Disease 1985
Robert E. Myers
Diet and Cancer Prevention
Elizabeth Bright-See
Gastric Cancer in Young People
R. G. Chaytors
Breast Self-Examintion: Available
Programs and Materials
Linda Del Greco
Practical Cancer Chemotherapy:
Venous Access and Extravasation
Malcolm L. Brigden, L. N. Hughes,
J. B. Barnett
Cutaneous Malignant Melanoma
S. T. Norvell, A. J. Bodurtha
Cancer in Canada: An
Epidemiological Perspective
Gerry B. Hill
Hypodermoclysis for Syptom
Control in Terminal Care
Helen Hays
Carcinoma of the Prostate
J. E. DeMaria, W. L. Orovan
Lung Cancer: To Treat or Not To
Treat?
Melvyn Goldberg
Nutritional Considerations for
Cancer Patients
Angela Chen
Multiple Myeloma
Ralph M. Myer
In addition to this comprehensive
look at current trends in cancer
management, CFP's June issue
will also include its regular features
such as Dermacase, Radiology
Rounds, and Medical Digest, as
well as articles on filing reprints,
in grief counselling. Summary of proceed- being a team physician, and
ings, National Conference on Mental selecting practice location
Health Issues Related to Sudden Infant according to training.
Death Syndrome held in Baltimore, MD,
1977. Washington, DC.: Department of
Health and Welfare, 1983.
15. Proceedings of the 17th annual intrascience symposium on sudden infant death
syndrome. 1984, Santa Monica. Bethesda,
MD., National Institute of Child Health
and Human Development, (in press).
defamilie
Medecin
Canadien
doatre
eitrdUe
Aurora,OntanoL4U(3H6 'Kg.IraeMarlK
1030
about SIDS. The recent NICHD survey and some of the newer technology
may open avenues of research leading
to an understanding of the causes and
prevention of SIDS.
CAN. FAM. PHYSICIAN Vol. 31: MAY
1985
arthroscopy or surgery indicated in the
teenager for chondromalacia. In this
age group the symptoms of chondromalacia virtually always vanish spontaneously over a couple of years.
A dislocated patella, which is a distinct full lateral momentary dislocation, may at times be associated with
chondromalacia but here the patient's
apprehension is immediately reproduced by any attempt to slide the patella into the lateral dislocated position. In this condition the patella
should be surgically tightened by tendon transfers to avoid long-term damage to the knee joint by repeated true
dislocation which may occur without
warning and then spontaneously reduce to normal.
Osgood Schlatter's disease typically
occurs in active teenage boys and is
often bilateral. There is diffuse pain
over the soft tissues at the patellar tendon insertion site into the tibial tubercle area. This is point tenderness. Soft
tissue swelling usually occurs adjadent
to the enlarged tibial tubercle area.
There is a minor degree of lifting or
partial avulsion of the epiphyseal projection along the upper tibial shaft.
Here again the epiphyseal plate, like
elsewhere, is weaker than the adjacent
bones, tendon or ligaments. Fortunately the epiphyseal projection of the
tibial tubercle is extra-articular; the
growing athlete can be assured that his
knee will not be ruined by continuing
activity associated with this pain.
Osgood-Schlatter's disease is an extraarticular epiphyseal inflammation:
only rarely is a tensor bandage required around the knee for several
weeks to minimize extremes of flexion
which place the greatest stress, via the
patellar tendon, on the tibial tubercle
epiphysis. If a tensor bandage is used
to limit knee activity, the patient
should be simultaneously taught isometric quadriceps exercises to prevent
otherwise rapid muscular atrophy of
the thigh. The epiphyseal plate heals
quickly but often in a slightly lifted position. At the end of growth, when the
tibial epiphysis is permanently fused to
the tibia, a small painless bump may
be the only remaining evidence of boyhood Osgood Schlatter's disease.
In most childhood knee complaints
the history and diagnosis are easy. The
management is simple-but do not
forget that an X-ray is mandatory.
Canadians have the vivid example of
Terry Fox to remind them of osteogenic sarcoma. i
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
GROUP LIFE AND
DISABILITY
INSURANCE
FOR MEMBERS OF
THE COLLEGE OF
FAMILY PHYSICIANS
OF CANADA
GROUP COVERAGE
FEATURES
* Income Replacement
Plan for Members-provides up to $3,500 per
month when unable to
work due to sickness or
accident.
* Income Replacement
Plan for Employees of
Members-provides up
to $1,500 per month
when unable to work due
to sickness or accident.
. Term Life Insurance
Plans for Members and
Employees of Members-provides a choice
of two plans through
which benefits of up to
$300,000 are available.
* Family Term Life Insurance Option-provides
up to $100,000 in benefits for a spouse of a
member or employee of
a member, and $5,000
for each dependent
child.
For further information
write to:
COLLEGE OF
FAMILY PHYSICIANS
OF CANADA
4000 Leslie St.
Willowdale, ON.
M2K 2R9
NPARAFON
FORTE* C3
PRESCRIBING INFORMATION
THERAPEUTIC CLASSIFICATION: Analgesic Muscle Relaxant.
INDICATIONS: PARAFON FORTE CB tablets with codeine are
indicated as an adjunct to rest and physical therapy for
the symptomatic relief of mild to moderate pain, associated with acute painful musculoskeletal disorders and
cervical and disc syndromes.
CONTRAINDICATIONS: Hypersensitivity to any of the three
components (chlorzoxazone, acetaminophen, codeine).
WARNINGS: Drowsiness can occur with the use of
PARAFON FORTE C8 tablets with codeine and may be
additive to drowsiness from the concomitant use of
alcohol or other central nervous system depressants.
Patients should be cautioned about driving a car or
operating potentially hazardous machinery if they become drowsy or show impaired mental or physical
abilities while taking this medication.
This product contains codeine which can produce drug
dependence of the morphine type and, therefore, has
the potential for being abused.
PARAFON FORTE C8 tablets with codeine are not recommended during pregnancy or lactation, since safety in
pregnant women or nursing mothers has not been
established.
Because safety and effectiveness of PARAFON FORTE C8
tablets with codeine in children have not been established, such use is not recommended.
PRECAUTIONS: Use with caution in patients with known
allergies or with a history of allergic reactions to drugs.
PARAFON FORTE C8 tablets with codeine should be
discontinued if a sensitivity reaction occurs such as
urticaria, redness or itching of the skin.
PARAFON FORTE C8 tablets with codeine are not recommended for patients with liver disease, and should be
discontinued if any signs or symptoms suggestive of
liver dysfunction occur.
AOVERSE EFFECTS: Most frequently observed are central
nervous system effects such as dizziness, lightheadedness, drowsiness, overstimulation, or malaise. These
may be alleviated if the patient lies down.
Occasionally, gastro-intestinal effects such as nausea
and vomiting. Constipation may develop after long-term
use.
Rarely discolouration of the urine may be observed,
resulting from a phenolic metabolite of chlorzoxazone.
This is of no known clinical significance.
Rarely allergic type skin rashes, petechia, ecchymoses.
Angioneurotic edema or anaphylactic reactions are extremely rare.
DRUG INTERACTIONS: None of great clinical significance.
OVERDOSE SYMPTOMS: The manifestation of an overdose
of PARAFON FORTE C8 tablets with codeine are those of
chlorzoxazone and acetaminophen overdose, combined
with an exaggeration of the adverse effects of codeine.
Chlorzoxazone: Initially, gastro-intestinal disturbances,
nausea, vomiting, or diarrhea together with drowsiness,
dizziness, lightheadedness or headache.
Then malaise or sluggishness which may be followed
by loss of muscle tone and voluntary moverTient.
Acetminophen: Early symptoms of acetaminophen overdose overlap the symptoms of codeine overdose and
include gastro-intestinal irritability, nausea, vomiting,
anorexia, diaphoresis and general malaise. Symptoms
of hepatic necrosis may become evident from three to
five days following ingestion.
Codeine: In sufficient overdose, codeine can cause euphoria, dysphoria, miosis, a decrease in respiratory rate,
cyanosis and hypotension. Death due to respiratory
failure may result.
TREATMENT: The stomach should be emptied promptly
by lavage or induction of emesis with syrup of ipecac,
followed by administration of activated charcoal.
The hepatotoxic effect of acetaminophen overdose can
be countered with the antidote N-acetylcysteine. Further information on the clinical course of acetaminophen overdose and its treatment with N-acetylcysteine
is available from McNeil Pharmaceutical (Canada) Ltd.
The respiratory depressant effect of codeine overdose
can be countered with a specific narcotic antagonist
such as naloxone. In the presence of hypoventilation or
apnea, oxygen should be administered and respiration
assisted or controlled. A patent airway must be
maintained.
Hypotension may be counteracted by administration of
norepinephrine.
Cholinergic drugs or analeptic drugs should not be
used.
AOULT DOSAGE:
PAMFON FORTE U8 bblets with codeine: 1 or 2 tablets 4
times a day, not to exceed 8 tablets in a 24-hour period.
DOSAGE FORM:
PARAFON FORTE C8 tablets with codeine: Each tablet imprinted PARAFON FORTE C8 one side and "M" on the
reverse, contains: chlorzoxazone 250 mg, acetaminophen 300 mg, and codeine phosphate 8 mg.
COMbPLETE PRODUCT INFORMA^TION IS AVAILABLE ON
rw
REQUEST.
McNEIL
PHARMACEUTICAL (CANADA) LTD.
Oniario LOH 1LO (4161 640-6900
600 Main Street Went, Stouffville,
Trademark
c 1085 McNEIL-
I
A section of CFP for readers who want to help healthy patients stay healthy
In this issue:
Info section: Proposal to forbid drivers to drink alcohol . .
Smoking habits
Running boots to limit bone stress . . . On
the job noise and hypertension
Stress tests for
middle-aged patients
Ultraviolet B and sore eyes . . .
Newsletter on preventing heart disease
Cushion for low
back pain sufferers
1092
.
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...
...
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CAN.
FAM.
PHYSICIANVol.
31:
MAY1985
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
1091~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~f
~ ~-
1091
mally. The younger two sisters undertook their last three pregnancies only
after genetic counselling. The ten
nephews and nieces of the patient live
in three different parts of Ontario.
Since these relatives whom we have
not seen are reported to be developing
normally by their mothers, it is likely
that the anxiety which might be generated by requests for neurological assessments would surpass any benefit.
Medical Digest
THIS MONTH
* Stomach cancer risk in immunodeficient patients
* Contraindication to gastric restriction surgery * Early 'pill'
use and breast cancer . Heavy lifting in pregnant women
* Diabetic patients' protection from migraine * Effects of
parvovirus infection in pregnancy * Antihypertensive
therapy in pregnancy * Treating split fingernails
* Videotaping consultations * Fetal hazards from airport
Conclusion
screening * Effects of fluoride from toothpaste on the GI tract
The principles followed in the investigations and counselling of this * Toxic shock syndrome and contraceptive sponges
family have general applicability for * Anti-inflammatory drugs and bowel perforations
family practice. Wherever a family * Leukemia risk from long-term chemotherapy
history of suspected genetic disease is * Unemployment a cause of suicide? * Dose dumping of
elicited in a patient or couple who
want to have children, every possible once-a-day theophylline * To treat or not: mildly
effort must be made to arrive quickly hypertensive women . Tips for helping learning disabled
at an accurate and specific diagnosis of children * Susceptibility to infective endocarditis
the relative's condition, whether that * Panic-ridden students
relative is alive or dead. This should
be followed by appropriate genetic
counselling and genetic management
of the problem which, in an increasing
proportion of such cases, involves the Read anything in the overseas
option of prenatal diagnosis or its pos- medical literature that you think is
sibility in the near future.
worth quoting on these pages? Send
a copy along to Medical Digest.
Acknowledgements
This column reviews all
We thank Dr. J. Gilbert for review- non-Canadian English language
ing the patient's 23-year-old muscle medical journals for items of
biopsy slides, Dr. S. A. Stewart for interest to the Canadian family
the EMG studies and Dr. E. G. doctor. Extracts should preferably
Murphy and Dr. A. J. Hudson for the be not more than one column in
information about the neurological length and should be accompanied
status of the patient at ages nine and 25 by the correct Index Medicus
respectively. We are most grateful to reference to the journal.
our deceased patient who cheerfully
cooperated in our studies so that we
could provide genetic counselling to
his sisters and eventually to their children.
immunodeficiency
And Stomach Ca
References
1. Gardner-Medwin D. Clinical features
and classification of the muscular dystrophies. Br Med Bull 1980; 36:109-15.
2. Zatz, M. Diagnosis carrier detection
and genetic c ounselling in the musc ular
dystrophies. Pediatr Clin North Am 1978;
25:557-73.
3. Heych H, Laudahn G. Die progressivedystrophischen myopathien. Berlin:
Springer-Verlag, 1969. '
4. Worton R. Duchenne muscular dystrophy involving translocation of D.M.D.
gene next to ribosomal RNA genes. Science
1984; 224:1447-9.
5. Kingston H, Thomas N, Pearson P, et
al. Genetic linkage between Becker muscular dystrophy and a polymorphic DNA sequence in the short arm of the X-chromosome. J Med Genet 1983; 20.255-8.
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
" (Recent authors) have made a
valuable contribution towards understanding of the role of immunodeficiency in oncogenesis by providing a
denominator which allowed them to
calculate the increased risk of cancer
in patients with common variable immunodeficiency (CVID). Registries of
primary immunodeficiency disorders
such as X-linked lymphoproliferative
syndrome (XLP) offer an opportunity
to estimate the frequency of malignancies in immune-deficient patients:
among the first 100 patients in our registry of XLP, 35% have now had
B-cell lymphomas. The types of malignancies which occur in immune-
deficient patients, such as B-cell lymphoma, Kaposi's sarcoma, cervical
carcinoma, and hepatocellular carcinoma, are probably the result of impaired immunological surveillance of
ubiquitous viruses. Data on the role of
EBV in the induction of malignant Bcell lymphomas in patients with inherited or acquired immunodeficiency
support this hypothesis.
The authors have postulated that the
increased risk of stomach cancer seen
in patients with CVID could be due to
synergistic activity of achlorhydria and
immune impairment. There is no evidence of a virus inducing the gastric
cancers and thus the hypothesis of impaired immune surveillance of virally
infected gastric cells seems unlikely.
An alternative, testable hypothesis is
that immune-deficient patients, such
as those with CVID or ataxiatelangiectasia, have defective immune regulation and recognition capabilities, so
cytotoxic antibodies and other misdirected immune responses arise and
could damage gastric epithelium. This
would lead to cellular proliferation,
which would predispose to the occurrence of genetic error in a proliferating
cell and thereby possibly cancer. Patients with pernicious anemia have
achlorhydria, atrophic gastritis with
gastric cellular proliferation, lymphoid
infiltration of the gastric mucosa, autoantibodies to gastric mucosa, and an
1125
increased risk of stomach cancer. Also
lending support to our hypothesis is
the finding that individuals living in
areas of Venezuela who are at high
risk for stomach cancer are immunodeficient. Our hypothesis requires further
testing. "
Purtilo DT, Merino F. Immunodeficiency and stomach cancer. Lancet
1985; L:751.
Contraindication
For Obesity
Surgery
6 Since 1978, I have performed 160
gastric restriction procedures for
weight loss at Rush-Presbyterian-St
Luke's Medical Center in Chicago.
Patients ranged in age from 12-62
years. All were more than 90% above
their ideal weight, and those who were
less than 100% above the ideal had
significant weight-influenced diseases
*DERMOVATE®
(clobetasol propionate 0.05%)
Indications: Topical therapy of recalcitrant corticosteroidresponsive dermatoses.
Contraindications: Infected skin lesions if no anti-infective
agent is used simultaneously; fungal, viral, and tuberculous
infections of the skin; pregnancy and lactation; hypersensitivity to any of the ingredients.
Warnings: Do not use in the eye. Use Dermovate for brief
periods only and discontinue use after lesion has cleared.
Do not use more than 50 g or mL perweek. Physiciansshould
be advised of prior patient use of corticosteroids.
Precautions: Use with caution on lesionsclosetotheeye.As
adjunctive therapy in bacterial skin infections, discontinue
Dermovate if no response is noted within one week Discontinue use if hypersensitivity reactions.occur. Dermovate
is not recommended under occlusive dressings. Because
the safety and effectiveness of Dermovate has not been
established in children, its use is not recommended.
Adverse Reactions: Local burning, irritation, itching, skin
atrophy, striae, change in pigmentation, secondary infection,
hypertrichosis and adrenal suppression.
Dosage and Administration: Dermovate Cream and
Ointment: Apply thinly to cover the affected area and rub
gently into skin, two to three times daily.
Dermovate Scalp Application: Apply once or twice daily to
the affected areas of the scalp and rub in gently.
Note: As with all alcohol based topical preparations, initial
and transient stinging sensations may occur. Caution
is advised particularly when applying to skin with open
lesions.
Availability: Dermovate Cream and Ointment are available
in 15 g and 50 g tubes and 100 g jars. Dermovate Scalp
Application (an alcohol solution) is available in 60 mL and
20 mL opaque bottles.
Once remission is achieved with Dermovate, prescribe
Eumovate for maintenance therapy.
Product monograph available on request.
Glaxo
Glaxo Laboratories
A Glaxo Canada Limited Company
Montreal, Quebec
Toronto, Ontario
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
[PAiI1
IP
such as diabetes or arthritis. Nine patients had reversal of a jejunoileal bypass done at the same time as the gastric procedure.
During this time, six patients required reversal of their gastric operations (one had her original surgery
elsewhere). Reversal was done for intractable vomiting and was followed
by significant weight regain. All patients who had a takedown of the surgery had at least one rehospitalization
and numerous office visits.
Investigation of these patients during numerous encounters with them
led to an awareness that all had a complete upper dental prosthesis with a
hard plastic portion occluding the hard
palate. A review of the other cases in
the series led to the discovery of three
additional patients who had had more
of a problem with emesis than usual
but who, with perseverance and extreme dietary caution, had managed to
avoid reversal of the procedure. No
patient was found who had extreme
prolonged emesis who did not have a
complete upper dental prosthesis.
These patients had a problem even
with chopped foods such as tuna salad.
During endoscopy on each of these patients, gastritis of the pouch was
noted.
Most gastric restriction procedures
use a small proximal gastric pouch and
a nine to 12-mm stoma between the
pouch and the remainder of the gastrointestinal tract. The pouch retains
food in the region of the gastroesophageal junction. The small stoma delays
emptying to prolong the feeling of
postprandian satiety resulting from a
full pouch. Patients must learn to eat
small amounts of food slowly and to
masticate it to a state close to that of a
puree before swallowing. These procedures may be considered to be a sort of
externally enforced form of behavioral
modification. In theory, patients who
could learn to eat small amounts of
normal food slowly, abstaining from
high-calorie foods, should lose weight
without surgery.
People who have a full upper dental
plate are less able to sense the state of
mastication of the food bolus within
their oral cavity than those who get
sensory feedback from both the tongue
and the hard palate. There have been
many reports of persons with complete
upper dental plates who have inadvertently swallowed bones and other indigestible objects.
Surgeons who are performing these
types of procedures need to become
aware of their patients' state of dentition during the preoperative evaluation. Patients who have full upper dentures should be warned that they could
have serious problems with eating
solid foods after surgery. "
Pomerantz MA. A new contraindication for obesity surgery. JAMA
1985; 253:44.
The Pill And
Breast Cancer
( Two investigations have suggested a relation between oral contraceptive use (OC) and breast cancer in
young women. These studies were
done in areas where OC use was established early and had become extensive. We report here the findings in a
study in another such area, southern
Sweden.
A case-control study was done on
80 consecutive cases of breast cancer
in women bom in 1939 or later and
diagnosed at the age of 45 or earlier.
This number constitutes 40% of all
cases in the health care region of
southern Sweden in 1979-83, Malmo
being excluded because of screening
activities for breast cancer. The cases
were interviewed personally by their
physician. Three healthy women, selected from the population registry,
were individually matched to each
case on birth year and parish. Two
hundred and twenty-five controls remained after losses because some controls declined the interview and others
could not be contacted. The controls
were spoken to over the telephone by a
female questioner.
When the data were analyzed by
conditional logistic regression women
who had started OC use at 20-24 years
of age had three times the risk of developing breast cancer before 46 years
of age compared with non-users.
The relative risk increased with earlier age of OC start. Because an early
age of OC use was highly correlated
with the duration of use, a unique effect of duration could not be found
when starting age was accounted for.
Women who had started OC use after
their first pregnancy had a lower relative risk than others, although the different was not significant.
The risk estimates were adjusted for
age at menarche and age at first fullterm pregnancy. In our investigation
both a low age at menarche and a high
1127
Change of Address
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know well in advance by attacthing the address label fronm youLr
copy of the journial in the space
provided and by filling in your
new address.
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and are not getting y our own
copy of tlle journal, let us know.
Stick old address
label here
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New address
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
age at first full-term pregnancy were
related to increased breast cancer risk
(p=0l12 and p=0-06, respectively).
Different brands of OC were not analyzed.
To investigate the validity of using
two interviewing techniques 17
healthy OC users personally interviewed about their OC use by their
physician in 1980 in connection with
health check-ups were interviewed
again in 1984 by telephone. The reported starting age was, on average,
1 8 years lower when the interview
was by telephone. This quick validity
check indicates that any bias due to
different interviewing techniques
would affect the study in the direction
of underestimation.
Our results accord with those of
Harris et al, Paffenberger et al, Pike et
al and McPherson et al but differ from
those of the Centers for Disease Control Cancer and Steroid Hormone
Study. Another study, by Rosenberg et
al, though reported negative, shows a
significant association between early
OC use and breast cancer risk in the
same age groups.
Our results, taken together with earlier reports linking early OC use with
breast cancer, are a matter of great
concern in respect of OC use by young
women....
Olsson H, Landin Olsson M, Moller
TR, Ranstam J, Holm P. Oral contraceptive use and breast cancer in
young women in Sweden. Lancet
1985; 1:748-9.
Heavy 'Labor' In
Early Pregnancy
(
Q: What advice should be given
to a woman in early pregnancy whose
job requires her to lift boxes regu-
larly?
A: There is no hard and fast advice to
women in early pregnancy undertaking
heavy manual labor: it should depend
on any relevant obstetric history or at
risk factors. For instance, women with
a history of recurrent spontaneous
abortion are best advised against continuing this type of occupation. In general, however, I would suggest that patients inform their employersf. of their
pregnancy and request that they be
given light duties at work. I find thiat
most employers are helpful in these
circumstances.
Lewis GJ. Any questions? Br Med J
1985; 290:53.
1129
Prescribing Information
(RANiTIDINE HC1)
NZANTACO TABLETS (ranitidine hydrochloride)
PHARMACOLOGICAL CLASSIFICATION Histamine H2-receptor antagonist
INDICATIONS AND CLINICAL USE - Zantac Tablets are indicated for the treatment of all
conditions where a controlled reduction of gastric secretion is required for the rapid relief ofpain
and/or ulcer healing. These include duodenal ulcer, benign gastric ulcer and reflux ssophagitis.
CONTRAINDICATIONS - There are no known contraindications to the use of Zantac
(ranitidine).
WARNINGS - Gastric ulcer - Treatment with a histamine H2-antagonist may mask symptoms
associated with carcinoma of the stomach and therefore may delay diagnosis ofthe condition.
Accordingly, where gastric ulcer is suspected the possibility of malignancy should be excluded before
therapy with Zantac Tablets is instituted.
PRECAUTIONS - Use in pregancy and nursing mothers -The safety ofZantac in the
treatment ofconditions where a controlled reduction of gastric secretion is required during pregnancy
has not been established. Reproduction studies performed in rats and rabbits have revealed no evidence
of impaired fertility or harm to the foetus due to Zantac. If the administration of Zantac is considered
to be necessary, its use requires that the potential benefits be weighed against possible hazards to the
patient and to the foetus. Ranitidine is secreted in breast milk in lactating mothers but the clinical
significance of this has not been fully evaluated.
Use in impaired renal fnction - Ranitidine is excreted via the kidney and in the presence of severe
renal impairment, plasma levels of ranitidine are increased and prolonged. Accordingly, in the presence
of severe renal impairment, clinicians may wish to reduce the dose to a half of the usual dose taken
twice daily.
Children - Experience with Zantac Tablets in children is limited and such use has not been fully
evaluated in clinical studies. It has however been used successfully in children aged 8-18 years in doses
up to 150 mg twice daily without adverse effect.
ADVERSE REACTIONS - No serious adverse effects have been reported to date in patients
treated with Zantac. There has been no clinically significant interference with endocrine, gonadal or
liver function, nor has the drug adversely affected the central nervous system even in elderly patients.
The incidence of adverse events among Zantac-treated patients (8.1%) was very little greater than
that among placebo-treated patients (7.7%). Only five adverse events, namely, tiredness (0.38%),
headache (0.90%), dizziness (0.32%), diarrhea (0.52%) and skin rashes (0.52%) had a greater incidence
in the ranitidine treated group than in the control group.
OVERDOSAGE - Zantac is very specific in action and accordingly no particular problems are
expected following overdosage with the drug. Symptomatic and supportive therapy should be given as
appropriate. Ifneed be, the drug may be removed from the plasma by haemodialysis.
DOSAGE AND ADMNISTRATION - Adults: Duodenal ulcer and benign gastric ulcer:
300 mg once daily, at bedtime. It is not necessary to time the dose in relation to meals. In most cases of
duodenal ulcer and benign gastric ulcer, healing will occur in four weeks. In the small number of
patients whose ulcers may not have fully healed, these are likely to respond to a further course of
treatment.
Patients who have responded to this short term therapy, particularly those with a history of
recurrent ulcer, may usefully have extended maintenance treatment at a reduced dosage of one 150 mg
tablet at bedtime.
To help in the management ofreflux cesophagitis, the recommended course of treatment is one
150 mg tablet twice daily for up to 8 weeks.
Experience with Zantac in children is limited and it has not been fully evaluated in clinical
studies-see PRECAUTIONS.
AVAILABILITY - Zantac Tablets are available as white film-coated tablets engraved ZANTAC 150
on one face and GLAXO on the other containing 150 mg ranitidine (as the hydrochloride), in packs of
28 & 56 tablets.
REFERENCES:
1. Ireland A. et al Ranitidine: 150 mg twice daily vs 300 mg nightly in the treatment of duodenal
ulcers. The Lancet, August 4, 1984 pp 274-275.
2. Brogden R.N. et al Ranitidine: A review of its Pharmacology and Therapeutic Use in Peptic Ulcer
Disease and Other Allied Diseases (1982) Drugs 24: 267-303.
3. Product Monograph.
4. Gledhill T. et al (1983): Single nocturnal dose of an H2 receptor antagonist for the treatment of
duodenal ulcer. Gut. 24: 904-908.
5. Dammann H.G. et al: Effects ofhistamine H2 receptor antagonists and other agents on intragastric
acidity and acid secretion in Misiewicz J.J. and Wood J.R., Ranitidine Therapeutic Advances pp
126-139 Excerpta Medica 1984.
6. Colin-Jones D.G.* Comparison of ranitidine, 150 mg twice daily with ranitidine
300 mg in one evening dose, in the treatment ofduodenal ulcer in Misiewicz J.J. and Wood J.R.,
Ranitidine Therapeutic Advances pp 140-153 Excerpta Medica 1984.
*Collaborating physicians listed at the end of the chapter.
7. Dobrilla G. et al. A single nocturnal dose ofranitidine for the short-term treatment ofduodenal
ulcer: interim results of an Italian Multicentre Study in Misiewicz J.J. and Wood J.R., Ranitidine
Therapeutic Advances pp 154-167 Excerpta Medica 1984.
Product monograph available on request.
Glaxo
Glaxo Laboratories
A Glaxo Canada Limited Company
Montreal, Quebec
Toronto, Ontario
Diabetes: No
Headache?
- We have read with considerable
interest the observation of recent authors that the prevalence of migraine in
diabetic patients is less than that in the
normal population. Some of our previous observations may be relevant to
this fact.
We have previously shown that
while cerebral blood flow and its age
related decrease in diabetic patients
and normal subjects is similar, cerebrovascular reactivity in diabetics is
abnormal. For example, cerebral
blood flow increases after carbon dioxide challenge in normal subjects,
whereas in over half of diabetic patients it either falls or does not increase. Carbon dioxide is the most potent dilator of cerebral blood vessels,
and the absence of its dilatory effect on
cerebral vasculature in diabetics indicates a fundamental fault in the ability
of this vasculature to respond to enhanced metabolic requirements. Since
cerebral vasodilatation is an essential
component of the pathogenesis of migraine, the impaired ability of cerebral
vasculature to dilate is probably important to the relative 'protection' of
diabetic patients from developing migraine.
The mechanism underlying the diminished vasodilatory capacity of cerebral vasculature in diabetics is probably very complex. Diminution in the
secretion of prostacyclin (PGI2) in diabetes mellitus may appear to be an obvious contributory mechanism, as suggested by us previously. However,
PGI2 infusion in the human has been
shown to cause a fall in cerebral blood
flow. Whether this PGI2-induced fall
in cerebral blood flow is due to a diffuse vasodilatation which results in a
'steal' from cerebral vasculature or
whether it is the direct result of a paradoxical vasoconstriction of cerebral
vessels requires further elucidation.
Changes in blood glucose concentrations have not hitherto been associated
with altered vascular reactivity, but
fatty acids and other lipids probably do
contribute to alterations in the response of vascular smooth muscle to
vasoactive agents. Fatty acids also inhibit the secretion of PGI2 and accelerate its degradation.
The role of platelets in the pathogenesis of migraine, especially in
terms of the 'protection' offered by
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
diabetes mellitus, is even more perplexing. Activation of platelets, platelet hyperaggregability, and the release
of vasoactive substances from platelets
have all been incriminated in the pathogenesis of migraine. Platelets are
known to be hyperactive and hyperaggregable in diabetes mellitus and release more thromboxane A2, especially when macrovascular disease is
concomitantly present. Yet diabetes
mellitus offers protection from migraine. This would suggest that the answer to the diabetic's 'protection' from
migraine lies not in platelets but in
blood vessels themselves. "
Dandona P, James IM, Beckett AG.
Prevalence of migraine in patients
with diabetes. Br Med J 1985;
ceived rubella revaccination after delivery.
Now that a serological test is available for parvovirus we should like to
encourage our colleagues to consider
this infection in the differential diagnosis of any rash developing during
pregnancy. Only by identifying more
cases can the true importance of parvovirus infection in pregnancy be determined. "
Wright EP, Dyson AJ, Alaily A. Infection with parvovirus during pregnancy. Br Med J 1985; 290:241.
Diuretics in
Pregnancy
with pre-eclampsia in the UK declined
from 4-3 per 1,000 in 1958 (when
most of the studies cited by Dr. Collins
and others would have been in progress) to 0-8 per 1,000 in 1981-2.
Other outcomes such as gestational
age at birth, birth weight, and
mother's time spent in hospital before
delivery should therefore be considered. These outcomes are still important to mothers and their infants, and
the use of such measures may not entail such large numbers as are clearly
necessary to study perinatal mortality.
For these reasons our study was primarily concerned with birth weight.
However, it was obviously necessary
to indicate the numbers of abortions
and stillbirths, together with other
characteristics of birth such as method
of delivery. As indicated above, we
did not expect antihypertensive therapy or its effects on blood pressure to
influence the numbers of deaths. If a
difference had been found our comparison of birth weights might have been
biased and difficult to interpret. Accordingly, although we analyzed and
described birth weight in detail no for-
Perinatal mortality may not
be the best indicator of outcome in
trials of antihypertensive therapy in
pregnancy. At the gestational age
(more than 30 weeks) at which most
cases present the fetus can nearly
always be electively delivered and will
almost certainly survive given the recent advances in perinatal care. For
- (A recent) report describes a sero- example, the fetal loss rates associated
logically proved infection with parvovirus possibly contributing to intrauterine death at birth. Another recent
report provides an association between
intrauterine parvovirus infection and
hydrops fetalis. We should like to describe a case in which a parvovirus infection during pregnancy had a much
happier outcome.
At 14 weeks' gestation a 30-yearold para 1+0 developed a transient
fine macular rash on her limbs followed by swelling, stiffness, and pain
in her fingers, elbows, knees, and
toes. There was no sore throat or occipital lymphadenopathy. Antenatal
sSl|t
clinic screening at ten weeks had
PAIdC&uidpodon
shown the patient to be susceptible to
rubella despite previous rubella vaccination. Serum collected three weeks
after the onset of the rash was compared with the stored antenatal clinic
serum but showed no evidence of recent herpes simplex, varicella zoster,
measles, rubella, or syphilis infection.
The Paul-Bunnell and antistreptolysin
0 screening test were also negative,
occasional conslI*
but the antihuman parvovirus IgM rose
from <0 3 to 21 g/l. The illness
quickly settled and the pregnancy progressed to term, when a healthy girl
weighing 3300 g was delivered. Follow up three months later confirmed a
normal, healthy infant with no apparent abnormalities. The mother re-
290:467-8.
Parvovirus
Infection
in Pregnancy
|'ForGeIO
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
*13
1 133
mal analysis of deaths was presented
and no p values were given. We
merely observed that the groups were
comparable but did not discuss the relevance or importance of this lack of
difference in outcome.
The authors' statement that we concluded that there was no difference in
final fetal outcome because there was
no difference in stillbirth rates in the
treatment group was inappropriate.
Our chief concern was birth weight,
not perinatal mortality. In any case it
was inappropriate to compare our findings with those of Rubin et al (see accompanying letter) since our studies
were quite different in concept. "
De Swiet M, Fayers P. Overview of
randomised trials of diuretics in
pregnancy. Br Med J 1985;
290:788.
Splitting Nails
ii Q: Why does a split fingernail
commonly fail to repair? What treatment is advised?
Agarol*
* PRESCRIBING INFORMATION >
INDICATIONS: Acute functional constipation:
debilitating disorders complicated by inadequate
bowel action; in post-operative cases, hypertensive or chronic cardiac disorders where
forcing a stool must be avoided; in constipation
of pregnancy; in bed-ridden or elderly patients.
CONTRAINDICATIONS: Symptoms of
appendicitis. Idiosyncrasy to phenolphthalein.
PRECAUTIONS: Frequent or prolonged use
of this preparation may result in dependence
on laxatives. If a skin rash develops, discontinue
the use of this or any other phenolphthaleincontaining preparation.
DOSAGE: Adults-2 to 4 teaspoonfuls at
bedtime; if necessary repeat this dosage the
next morning, two hours after breakfast.
Children (three to six years) - Y2 to 1 teaspoonful; (over 6 years)- 1 to 2 teaspoonfuls; (under
three years)- proportionately smaller doses
according to age. May be taken alone or in
milk, water, fruit juice or any miscible food.
SUPPLIED: Each 5 mL of creamy white,
marshmallow-flavoured, calorie-free emulsion
contains: mineral oil-1.60 mL, glycerin200.0 mg, phenolphthalein-65.0 mg. Also
contains agar. Sodium content: 8.3 mg/5 mL.
Available in 250 mL, 500 mL and 750 mL
plastic bottles.
Full information is available on request.
PARKE-DAVIS
Parke-Davis Canada Inc., Scarborough, Ontario
IpAA'B 'Reg. T.M. Warner-Lambert Company
ICCPP
1134
Parke-Davis Canada Inc. auth.
user
Q: A nail may split in various ways
and the cause differs depending on the
type of split. The commonest form of
splitting is splitting into layers, and
this is most pronounced near the tip of
the nail. The condition is common in
housewives and others whose hands
are often in water, especially if the
water is alkaline. Electronmicroscopic
studies show that the nail cells have
lost their adhesion and there may be 30
layers, each one cell in thickness.
There is no satisfactory treatment unless the hands can be kept dry and solvents such as acetone (used to remove
nail varnish) are avoided. Another
form of splitting occurs lengthwise
along ridges that extend from cuticle to
tip. The ridges may result from poor
peripheral circulation or old age and,
less often, lichen planus, which may
play havoc with the nails. In these
cases several nails are likely to be affected and the condition is due to injury to the nail matrix. Similar but less
severe splitting usually near the edge
of one nail is almost certainly due to a
minor injury in the past that was overlooked at the time but which has split
the matrix. The failure to unite is due
to the split matrix, and usually no
treatment is advised except to keep the
nail cut as short as possible. If the split
is particularly troublesome the smaller
part of the nail can be removed surgically. "
Samman PD. Any questions? Br
Med J 1985; 290:775.
Patients On
Camera
- Recent authors are to be congratulated on their interesting paper concerning the reactions of patients to a
video camera in the consulting room.
There is no doubt that a proportion of
patients prefer not to have their consultations recorded, and I suspect that
many who dislike the practice are unwilling to verbalize their disapproval
for fear of jeopardizing their relationship with their general practitioner.
The strength of general practice lies in
trust between doctor and patient in the
consulting room. Personally, if I discovered that my general practitioner
was using a video to record consultations, I would cancel my appointment
and seek advice elsewhere.
There is another objection, more
subtle and more powerful than that of
confidentiality. When a video is used,
both doctor and patient are play-acting. Instead of honest question and answer, straightforward clinical examination restricted to essentials, and
business-like management of treatment, issues tend to be fudged by consideration of what the transaction will
look like to those viewing it later. The
patient may disguise his real objective
in seeking the consultation, and the
doctor may become more concerned
by what his peers will think of his
practice than what is most necessary
and effective in the management of his
patient's problem. An element of artificiality, often amounting to humbug,
is injected into the whole affair.
There are, undoubtedly occasions
when a doctor's personal ambitions are
allowed to take precedence over his
prime duty to protect and foster the interests of his patient. I suggest that all
too often the use of video camera in
the consulting room aids and abets undesirable objectives. "
Hart C. Reactions of patients to a
video camera in the consulting
room. J R Coll Gen Pract 1985;
35:42.
Prenatal
'Screening'
At Airports
- Q: What are the hazards to the
fetus when the mother passes through
the screening gate at airports?
A: The screening gate at airports
works by detecting the disturbances in
a magnetic field induced by metallic
objects being carried through it by passengers. There is no ionizing radiation
such as X and gamma rays. There is no
evidence that exposure to magnetic
fields in this way is harmful to the
fetus. Baggage may be examined by
equipment using X-rays. The exposure
used is very short and the image obtained is maintained on the screen by
electronic means so as to permit detailed inspection. The radiation doses
to the staff using the apparatus and to
passengers in the immediate vicinity
have been monitored and found to be
tiny and insignificant (National Radiological Protection Board, unpublished
data). Rae S. Any questions? Br Med J
1985; 290:227.
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
Tagantet
(ciuefidine, SK&F)
Brief Prescribing Information
for Adult Oral Use
PHARMACOLOGICAL
CLASSIFICATION
Histamine H2-Receptor Antagonist
ACTION
Cimetidine competitively inhibits the
action of histamine at the histamine
H2-receptor. It inhibits daytime and nocturnal basal gastric acid secretion and
also gastric acid secretion stimulated by
food, histamine, pentagastrin, caffeine
and insulin. Total pepsin output is reduced
as a result of the decrease in volume of
gastric juice. Cimetidine has rio effect on
the rate of gastric emptying or lower
esophageal sphincter pressure.
INDICATIONS
* Duodenal ulcer and prophylaxis
of recurrent duodenal ulcer
* Non-malignant gastric ulcer and
prophylaxis
* Gastroesophageal reflux disease
CONTRAINDICATIONS
None known.
PRECAUTIONS
Use in Pregnancy, Nursing Mothers:
Experience in pregnant patients is limited. Animal studies have revealed no
evidence of impaired fertility or harm to
the fetus. TagametX crosses the placental
barrier. It is secreted in human milk.
Anticipated benefits should be weighed
against potential risks. Tagamet, has
been used in clinical trials for the prevention of acid aspiration pneumonitis in
women undergoing cesarean section or
vaginal delivery without harm to the fetus.
In impaired renal function: Dosage
should be reduced - see Product
Monograph
Drug Interactions: Tagamet' may reduce
the hepatic metabolism of warfarin-type
anticoagulants, phenytoin, propranolol,
chlordiazepoxide, lidocaine, diazepam
and theophylline, thereby increasing
blood levels of these drugs. Benzodiazepines metabolized by other systems do
not exhibit this effect. Since clinically
significant effects have been reported
with warfarin anticoagulants, close
monitoring of prothrombin time is recommended, and adjustment of anticoagulant
dose may be necessary.
Use in Gastric Ulcer: Symptomatic
response to Tagamet'k does not preclude
the presence of a gastric malignancy
ADVERSE REACTIONS
Mild and transient diarrhea, tiredness,
dizziness and rash have occurred in a
small number of patients. A few patients
have developed mild, reversible
qynecomastia during prolonged treatment. A few cases of the following have
been reported. decreased white blood
cell counts (including agranulocytosis),
thrombocytopenia, aplastic anemia;
reversible confusional state.s, usually in
elderly and./or severely ill patients with
renal insufficiency or organic brain syndrome, fever; hepatitis; interstitilc1
nephritis; pancreatitis; small increases
in plasma creatinine and serum
tra nsam inases.
OVERDOSAGE
Oral ingestion of up to 20 grams haE
caused no untoward effects. Recovery
has been uneventful.
Treatment: Emesis and/or gastric lavage,
monitoring and supportive therapy.
Assisted respiration may be of value.
DOSAGE AND ADMINISTRATION ADULTS
In clinical studies, Tagamet' has been
used in divided doses of up to 2400 mg
per day.
ACTIVE DUODENAL ULCER
400 mg or 600 mg twice daily (breakfast
and bedtime) or 300 mg four times daily
(with meals and at bedtime) or 2 x 400 mg
(at bedtime) for at least 4 weeks.
NON-MALIGNANT GASTRIC ULCER
400 mg or 600 mg twice daily (breakfast
and bedtime) or 300 mg four times daily
(with meals and at bedtime). Continue
therapy for at least six weeks.
PROPHYLAXIS OF RECURRENT
DUODENAL OR GASTRIC ULCER
400 mg at bedtime or 300 mg twice daily at
breakfast and bedtime. Continue therapy
for at least 6-12 months.
GASTROESOPHAGEAL REFLUX
DISEASE
600 mg twice daily (breakfast and bedtime) or 300 mg four times daily (with
meals and at bedtime). Continue therapy
for 8-12 weeks.
Refer to Product Monograph for information on dosage adjustment for patients
with impaired renal function.
AVAILABILITY:
Tablets: 200, 300, 400 and 600 mg
cimetidine.
PatientPakT: Each PatientPakT contains
Tagamet` in blister-packed strips and
disease-specific patient information in
audiotape cassette and booklet formats.
Tagamett UlcerPak.T: 28 days' supply of
300, 400, or 600 mg cimetidine tablets.
Tagamet' RefluxPakT': 28 days' supply of
300 mg cimetidine tablets. TagametR
PreventPak': 56 days' supply of 400 mg
cimetidine tablets.
Liquid: Cimetidine hydrochloride
equivalent to 300 mg cimetidine per 5 mL.
(Alcohol content 2.85%/ v/v.)
Complete Product Monograph available
to physicians and pharmacists on request.
TagametP
(cilmelidine, SK&F)
NO SUBSTITUTION
SK&F
SmusthKlmnc companuj
a
'1i
c:.l* <
r' .:h} (.c-i.<'.
l.ti .99
1
L(I"
Sodium Fluoride
Gel: GI Hazard?
( Q: A fluoride gel prescribed by
dentists for some patients has 0.4%
stannous fluoride. Patients are advised
to brush the teeth at bedtime, to expectorate after one minute, but not to
rinse; thus, some residual gel may be
inadvertently swallowed during sleep.
Could this be a hazard to persons with
quiescent duodenal ulcer disease and a
of bleeding?
A: Fluoride, when taken orally in
large quantities, can injure the gastrointestinal (GI) tract. The lethal dose
sodium fluoride for an adult is approximately five grams. The amount
of fluoride that could enter the GI tract
after exposure to this particular dental
product is probably quite small. The
likelihood of GI mucosal injury or
duodenal ulcer reactivation as a result
of the use of this product is uncertain,
although I believe it is probably negli-
history
of
gible. "
Feldman M. Sodium fluoride gel.
JAMA 1985; 253:414.
'Sponge Shock'
ii Although toxic shock syndrome
(TSS) is most commonly associated
with the use of vaginal tampons during
menstruation, it has been recognized
in association with many nonmenstrual
conditions. These include surgical incisions, nonsurgical focal infections,
and conditions of postpartum mothers,
ifter spontaneous abortion, vaginal infections, pelvic inflammatory disease,
and diaphragm use.
The Centers for Disease Control has
briefly reported on four cases of TSS
in association with the use of the vaginal contraceptive sponge and has encouraged reporting of other cases.
Currently, 13 confirmed cases of TSS
with this association have been reported. We report such a case in
greater detail.
. . .On the first day of an expected
menstrual period, an 18-year-old
white, nulligravida woman was seen in
the emergency department with a oneday history of yellow-green vaginal
discharge accompanied by fever,
chills, nausea, and severe orthostatic
dizziness. There was no myalgia,
frank vomiting, or diarrhea. The discharge had started shortly after the
1139
rrs TIM ORNGAM
S
OSS
n -
painful removal of a contraceptive
sponge. The sponge had been in place
for 20 hours. A sponge had been used
five days earlier, for several hours,
without difficulty. No vaginal tampons
had been used.
The patient was alert and cooperative. She appeared ill, but not in great
distress. Her oral temperature was
38.8°C with a supine blood pressure of
150/80 mm Hg and pulse rate of 100
beats per minute. There were marked
orthostatic changes on standing. Examination of the head and neck revealed moderate pharyngeal erythema
with a small exudate. There was no
conjunctival erythema. Pelvic examination revealed a small amount of
dark blood and mucus in the vagina
and a slightly erythematous vaginal
mucosa. Two small excoriations were
noted on the cervix and vaginal wall.
Laboratory findings revealed a
white blood cell count of 16,700/cu
mm, with 72% polymorphonuclear
cells and 23% band forms. The hemoglobin level was 15.4 g and the platelet count was estimated normal. Levels
of serum electrolytes were normal, ex-
cept for a bicarbonate value of 16.9
mEq/L. Total bilirubin level was 1.4
mg/dL. Values for alkaline phosphatase were 73 IU/L and for serum glutamicpyruvic transaminase, 23 IU/L.
Urinalysis results were normal. Findings from a screen for 8-subunit of
human chorionic gonadotropin were
negative. Throat culture showed no
growth of staphylococcal or streptococcal organisms. Blood cultures
showed no growth, but cervical culture
showed growth of Staphylococcus
aureus.
The patient was admitted and
treated with intravenous nafcillin.
Within a few hours, her oral temperature rose to 39.2°C and a fine, erythematous, maculopapular rash developed over her limbs and torso. She
was discharged four days later, after a
repeated cervical culture showed no
growth of staphylococcal organisms
and all laboratory study results had returned to normal. Desquamation involving the hands, feet, and small
areas of the thighs occurred after two
weeks.
.. .The cases described by the
Centers for Disease Control all occurred during 1983, among users of a
vaginal contraceptive sponge. All four
patients were white, 20-29 years old,
and met the criteria for diagnosis of
TSS. They also had a vaginal discharge, but none were menstruating.
Vaginal cultures showed growth of S
aureus. Two of these patients left the
sponge in much longer than directed
and another had the sponge fragment
during a difficult removal.
The case presented herein is similar
but has notable differences. The patient was younger, left the sponge in
well under the recommended time of
30 hours, and was menstruating. This
case falls between the previously reported cases involving a vaginal
sponge and the usual case of TSS associated with tampon usage during menstruation.
The vaginal sponge is gaining acceptance as a convenient, effective
contraceptive device with a predicted
low incidence of complications. Evaluation to date indicates an acceptable
risk-benefit ratio, but diligent reporting of further complications is essential. Physicians likely to encounter patients using the vaginal sponge should
be aware of the possibility of
TSS. Dart RC. Toxic shock syndrome associated with the use of the vaginal
contraceptive sponge. JAMA 1985;
253:1877.
Bowel Perforations
From Ingestion of
Anti-infiammatories
f Following a recent report on the
suggested relation between the ingestion of anti-inflammatory drugs and
colonic or small bowel perforation or
hemorrhage we would like to report
our experience of a patient who developed multiple perforations after the ingestion of indomethacin.
A previously fit, 38-year-old man
received indomethacin 50 mg, three
times a day for a painful toe. After one
day he experienced generalized abdominal pain and diarrhea but continued to take the drug. Three days later
his pain had become more severe and
he was admitted to hospital with peritonitis. At laparotomy there was a single perforation in the sigmoid colon
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
and multiple sigmoid diverticulae. A
localized sigmoid colectomy was performed, but after operation he continued to have pain and developed signs
of generalized sepsis and his abdominal wound began discharging feculant
fluid.
He underwent a second laparotomy
13 days later, when extensive peritonitis was found, with pus and feces
throughout the abdomen, and the formation of interloop abscesses. Three
small perforations in the small bowel
were oversewn, but there were also
multiple areas of necrosis and perforation throughout the large bowel. A
total colectomy was performed, the
rectum was oversewn, and an ileostomy created. Four days later a third
laparotomy was required, at which
several small bowel perforations were
again oversewn. After this his nutritional state was so poor that he was
transferred to our unit for parenteral
nutrition.
Unfortunately he continued to drain
small bowel contents from his original
wound and once again developed peritonitis. At his fourth laparotomy several new perforations in the small
bowel were repaired. Apart from the
persistence of an enterocutaneous fistula there were no further abdominal
problems. Following three months of
total parenteral nutrition his fistula
closed, and enteral feeding was reintroduced without any problems.
A multitude of investigations, including histological examination of the
resected bowel, has not provided any
explanation for the spontaneous development of multiple large and small
bowel perforations in this man. We
suggest that ingestion of indomethacin
may have been responsible.
Reports of lower gastrointestinal
tract lesions attributable to nonsteroidal anti-inflammatory agents are
uncommon. The Committee on Safety
of Medicines has recorded 12 cases of
intestinal perforation (with seven
deaths) attributed to indomethacin, as
well as five cases (one death) of intestinal ulceration, and two cases (no
deaths) of intestinal ulceration and perforation since January 1965. There has
also been one report (one death)
of perforated diverticula (personal
communication). It is not known
how many of these cases were due to
conventional formulations of indomethacin and how many were due to
delayed release preparations such as
Osmosin....
Stewart JT, Pennimgton CR, Pringle
R. Anti-inflammatory drugs and
bowel perforations and hemorrhage. Br Med J 1985; 290:787-8.
Leukemia From
Long-term
Chemotherapy
non-malignant conditions. The following case emphasizes the need for accurate assessment of the magnitude of
relative risks.
(A) patient suffered from intractable
pustular psoriasis unresponsive to a
wide range of topical treatments.
Methotrexate produced a modest improvement. The severity of his psoriasis prevented him working or leading
any sort of normal life. A major coronary artery occlusion precluded systemic treatment with retinoids because
of their hypercholesterolemic effects.
Within six months of receiving oral razoxane his skin was almost normal and
his life was transformed.
His life expectancy must be reduced
by his poor coronary history, but how
does this risk relate to the risk of his
developing leukemia from continuing
chemotherapy? I suggest that the decision for or against chemotherapy
should not be confined to whether or
not the condition treated is malignant.
- A (recent) leading article ... on
the risk of leukemia developing in
cancer patients receiving long-term
chemotherapy serves as a timely reminder for us to assess accurately the
risks associated with our treatments
relative to the suffering caused by the
disease we are treating. For most patients with cancer the alternatives are
death or survival. Chemotherapeutic
agents with cell cycle modulating effects are used in several non-malignant
rheumatological conditions and in severe psoriasis. The recent finding of an
increased incidence of acute myelomonocytic leukemia in patients with
psoriasis treated with razoxane has led Griffiths WAD. Risk of leukaemia
many doctors to conclude that this and associated with chemotherapy. Br
similar drugs should never be used in Med J 1985; 290:555.
R:iTt.gt
I0
T r dtla itfr
*
*
S
purpura, thrombocytopenia, neutropenia. Others: Restlessness, fever.
SYMPTOMS AND TREATMENT OF OVERDOSAGE
The most common signs and symptoms to be expected
from overdosage are dehydration and electrolyte imbalance.
Abnormal potassium levels may cause cardiac arrythmias
especially in digitalized patients.
No specific antidote is available. It is not known whether
the drug is dialyzable.
Discontinue MODURET* and observe patient closely.
Treatment is symptomatic and supportive. Suggested
measures include induction of emesis and/or gastric
lavage.
DOSAGE AND ADMINISTRATION
Optimal dosage should be established by the individual
titration of the components.
Maintenance doses may be lower than those required to
initiate diuresis; therefore, attempt reduction in daily
dosage when patient's weight is stabilized.
Hepatc Cirrhosis with Ascites and Edema: Usual maintenance dose: 1 tablet once a day; dosage should not
exceed 4 tablets a day in single or divided doses.
Edema of Cardiac Orign: Usual maintenance dose: 1 or
2 tablets once a day or in divided doses; dosage should
not exceed 4 tablets a day. Therapy may be on an intermittent basis.
Hypertension: Usual maintenance dose: 1 or 2 tablets once
a day or in divided doses; dosage should not exceed
4 tablets a day.
AVAILABILITY
Ca 9626 - Peach-coloured, diamond-shaped compressed
tablets, scored on one side with MSD 917, and tradename
MODURET* on the other, containing 50 mg hydrochlorothiazide and 5 mg amiloride hydrochloride. Available in
bottles of 100 and 1000.
FULL PRODUCT MONOGRAPH AVAILABLE ON REQUEST
1. Multicenter diuretic cooperative study group: Multiclinic
comparison of amiloride, hydrochlorothiazide, and hydrochlorothiazide plus amiloride in essential hypertension,
Arch Intern Med 141:482-486, March 1981.
2. Kaplan, N.M.: Our appropriate concern about hypokalemia, Am J Med 77:1-4, July 1984.
PAAB
MSD
MEMBER
MERCK
PMAC
SH RP
5-115
CANADA
*@Trademark
DORVAL, QUEBEC H9R 4P8
P.O. BOX 1005, POINTE-CLAIRE
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
Unemployment
And Suicide
(
Recent authors report that only
five out of 107 unemployed male parasuicide patients mentioned unemployment as their most important current
problem. They conclude that unemployed people committing parasuicide
do not see unemployment as relevant
to their action, and warn of the danger
of interpreting the higher risk of parasuicide among the unemployed . . . as
evidence of a "causal connection".
Their findings are in line with other
such investigations. In only a small
minority of cases is work or non-work
cited as a "reason for" or "cause of"
the overdose. However, attempts to
elicit from individuals the reasons or
motives for their behavior are fraught
with methodological and conceptual
problems. Colleagues such as those at
the Warneford Hospital, Oxford,
sought for many years to develop a
valid technique for describing the subject's own perceptions and definitions
of his or her overdose and its antecedents. The results of their careful
studies were by no means unequivocal, and no further research along
these lines is planned. Like many
others, they came to realize that the
concept of a "reason" is extraordinarily complex. If it is to be used at all it
requires strict definition, carefully
structured questioning, and precise
techniques of clarification. The kind of
interview method used by (the authors)
would not be very helpful in this context.
A second point concerns the interpretation of our epidemiological findings on the relation between unemployment and parasuicide. It is a
matter of arithmetic that being unemployed raises the risk of parasuicide by
a factor of about 12 and that this risk
tends to increase with lengthening durations of unemployment. These are
facts, not inferences. But we nowhere
suggest that unemployment is a precipitant of parasuicide, and logically it
would make no sense to do so, as (the
authors) suggest. If it is of causal significance it is almost certainly as a predisposing or vulnerability factor. Here
we refer to a recent study of 95 patients who committed parasuicide admitted also to the regional poisoning
treatment centre. Using a full array of
life event research techniques the researchers found that 35% had experi-
'HISMANAL:
rHERAPEUTIC CLASSIFICATION
iistamine Hi-antagonist
kCTION Astemizole is a potent, long-acting and selective
iistamine Hi-antagonist. It produces a dose-related
nhibition of skin reactions to intradermal histamine.
kstemizole inhibits the nose reaction to nasal challenge
vith histamine and allergens. It inhibits the bronchial reiction to inhaled histamine and allergens in asthmatic
atients. Astemizole has extremely weak serotonin anagonism, no anticholinergic properties, no antagonism
f dopamine or other catecholamines. Astemizole has
io effect on the C.N.S. and does not interact with drugs
icting on the C.N.S.
kstemizole is rapidly absorbed after oral administration.
plasma levels are obtained within one hour.
kstemizole is extensively metabolized, and plasma levels
unchanged drug are low.
kstemizole is completely metabolized in the liver and
nainly excreted through the faeces. Two metabolites of
stemizole, desmethylastemizole and norastemizole
ave, orally, the same pharmacological properties as the
compound.
NOICATIONS HISMANAL* astemizole is indicated for
he treatment of seasonal allergic rhinitis, allergic conunctivitis, chronic urticaria and other allergic
'eak
If
larent
:onditions.
:ONTRAINDICATIONS HISMANAL astemizole is conraindicated in patients with a known hypersensitivity to
he drug.
Use In Pregnancy Due to insufficient
lata, HISMANAL astemizole should be used in pregnant
vomen only when, in the opinion of the physician, the
iotential benefits outweigh the possible hazards.
with C.N.S. Depressants HISMANAL astemizole
no potentiating effects with alcohol or other C.N.S.
lepressants in clinical and laboratory studies.
1rug Interaction No drug interaction has been
ound between astemizole and bronchodilators, other
antihistamines, antibiotics, sulfonamides,
estrogens, progestogens, oral conraceptives, diuretics, antihypertensive agents, analgeics and anti-inflammatory agents, tranquillizers and
intidepressants.
REACTIONS The incidence of adverse experinces during astemizole treatment was comparable to
hat during placebo control treatment.
uring chronic treatment, body weight tended to inThis is probably due to an increase in appetite.
tatemizole had no effect on laboratory parameters.
AND TREATMENT OF OVERDOSAGE In
reported to date, involving oral ingestions of up to
100 mg of HISMANAL astemizole, no untoward effects
iave been noted.
)OSAGE AND ADMINISTRATION Adults and children
hlder than 12 years of age: 1 tablet (10 mg) once a day.
between 6 and 12 years of age: 1/2 tablet (5 mg)
nce a day.
under 6 years of age: 2 mg (1 mL suspension)
ier 10 kg/day.
b achieve optimal absorption, astemizole should be
aken on an empty stomach.
'RECAUTIONS
Jse
lad
iystemic
:orticosteroids,
hOVERSE
:rease.
;YMPTOMS
:ases
,hildren
,hildren
iVAILABILITY
ablets Each white, round scored compressed tablet
:ontains 10 mg astemizole. Available in boxes containig 2 blister packs of 10 tablets each.
ouspension Each mL contains 2 mg astemizole.
kvailable in bottles of 30 mL.
IEFERENCES
Sussman, G. L: Today's Ther Trends (in press) 1985. 2. Vanden
lussche, G. et al.: A Review of Woddwide literature HISMANAL
Beerse, Belgium 1983. 3. Holgate, S. T.: THORAX 39
10.9 668-672 1984. 4. Smith, N. T.: SATELITrE SYMPOSIUM, Am
Icad All & Immun, Chicago, 1984. 5. SeppaJa, T.: CurrTher Res 31:
38-44, 1982. 6. Laduron, P. M.: Mol Pharmocol 21: 294-300,
982. 7. Knight, A.: Cdn J Otol 1985.
;YMPOSIUM,
m
JANSSEN
-
st
d
m] M\SSR1£:E
XH;
t,1:.9<.
a. .CNl
(',IY X,^t, '..
1145
enced serious unemployment, which
was judged to represent a substantial
threat or difficulty. Similarly, Fruensgaard et al. found that unemployment
was an important causal factor in their
sample of unemployed patients admitted to a psychiatry emergency department, of whom about half were admitted after parasuicide, usually in
conjunction with other external factors-for example, interpersonal conflicts, housing problems, and economic difficulties-all of which are,
of course, heightened by unemployment.
Whether or not individuals see unemployment as being relevant to their
action, outside observers and clinicians taking a longer term and more
objective viewpoint have certainly
seen its importance. Having established that there is a very high risk of
parasuicide associated with long-term
unemployment, we clearly need to elucidate the nature of this relationship.
This is an urgent task, but more complex than (the authors) realize. -
lif.
Platt S, Kreitman N. Is unemploy- she ate two bowls of 'Cheerios' cereal
ment a cause of parasuicide? Br immediately after taking her theophylMed J 1985; 290:161.
line dose and later that day had a headache and mild nausea. The next morning she ate some candy from her Easter
basket within 15 min of her dose.
Later that day she had a severe headache and projectile vomiting, and was
( An 11-year-old girl had been tak- taken to an emergency room. Her
ing a slow-release theophylline prod- serum concentration, 111/2 hours after
uct ('Theo-Dur') for several months at the dose, was 41-7 ,ug/ml (analyzed
a total daily dose of 700 mg (28 mg/kg twice). She was admitted to intensive
daily) as three doses every eight hours. care and given intravenous anticonvulOn this regimen she had no side- sants prophylactically and activated
effects, and a serum concentration was charcoal every three hours to increase
reported to be 16 ug/ml. All doses the rate of elimination of the drug.
were administered by her mother. Sub- Symptoms of theophylline toxicity dissequently, the theophylline prepara- appeared about six hours after admistion was changed, for increased conve- sion.
This pattern of change in theophylnience, to a once-a-day product
('Theo-24', 'Pulmo-Timelets'). She line concentration is consistent with
took the same dose of 700 mg daily for the results of a study in eight volunseveral weeks at 0700 hours and ate teers, where absorption was slow and
breakfast at 0800 hours without ill- incomplete (71%) when the drug was
effect. On the new regimen, a serum taken fasting, but half the dose was
concentration of 17-3 ug/ml was re- dumped, beginning after six to eight
ported. However, on April 22, 1984, hours when the dose was taken with a
bacon-and-eggs breakfast. The mechanism for the dose-dumping is likely to
be the pH change in the duodenum that
occurs in response to food, since the
coating on the beads rapidly dissolves
atpH7-4. "
Hendeles L, Wubbena P, Weinberger M. Food-induced dose
dumping of once-a-day theophylline. Lancet 1984; 2:1471.
Theophylline Dose
Dumping
For starting therapy: LOPRESOR 50 mg b.i.d.
increased to LOPRESOR 100 mg b.i.d. if necessary
For once-a-day maintenance:
LOPRESOR SR 200 mg
WRITE 'NO SUBSTITUTION'
(metoprolol
tarrrate)
Geigy 1X1
Mississauga, Ontario G-4066
L5N 2W5
1146
Hypertension: Not
A 'Woman's
Problem'?
- (A recent author) concludes "that
no significant benefit of treatment of
hypertension has been found in mildly
hypertensive women". He is mistaken. In 1980 the management committee of the Australian trial undertook
to publish a future paper analyzing the
effect of treatment on the various subgroups, including by sex. This analysis was reported in April 1984 and was
the subject of a leading article in another journal in June. Univariate and
multivariate analysis of trial end points
in women showed the treatment effect
to be significant at the 5% level. The
committee was unable to identify, by
any covariate considered, subjects
under 70 with mild hypertension sustained over a four month period of repeated blood pressure measurement
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
who might be safely spared drug treatment. Indeed, among smokers, the
benefit of drug treatmedt was actually
greater for women with hypertension
than for men.
By way of extra confusion, Dr Silman has chosen to redefine the terms
"mild" and "severe" hypertension.
The Australian trial and the Medical
Research Council trial defined mild
hypertension as a diastolic blood pressure of 95-109 and 90-109 mm Hg respectively. Yet Dr Silman states that
severe hypertension is a diastolic
blood pressure over 105 mm Hg, although the term is normally reserved
for a diastolic blood pressure over 120
mm Hg.
Whatever adjective is used, hypertension in women is a suitable, not
separate, case for treatment....
Bradley N. Hypertension in women.
Br Med J 1985; 290:73-4.
Helping the
Learning Disabled
" While the leaming-disabled student generally fares worse than his or
her normal peers in scholastic achievement and social success, parents may
be able to enhance their child's selfesteem and sense of success in several
ways. They can:
* Give continuing suppoIt and encouragement
* Arrange for private tutoring
* Encourage participation in sports
and other out-of-school activities
* Foster nonacademic skills
* Allow the child to have work experience during junior and senior high
school
So says Harry E. Hartzell, MD,
clinical professor of pediatrics, Stanford University School of Medicine,
Stanford, Calif., and chief of pediatrics, Palo Alto Medical Clinic, Palo
Alto, Calif. In a ten-year follow-up
study of 114 learning-disabled students and their normal siblings, Dr.
Hartzell and Carolyn Compton, PhD,
found in interviews with students and
parents that -such interventions are associated positively with the learningdisabled student's sense of academic
and social success.
Dr. Hartzell emphasizes the need
for continuing support from the family. "The learning problem doesn't go
away. It continues to be a problem all
the way through school. It's something
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
*Cyclomen
danazol capsules U.S.P.
PRESCRIBING INFORMA3nON
THERAPEUTIC CLASSIFICATION:
Pituitary gonadotropin inhibitor.
CLNICALPHARMACOLOGY:
CYCLOMEN suppresses the pituitaryovarian axis by inhibiting the output of
gonadotropins from the pituitary gland. It
has mild androgenic activity. Studies
have established that the drug is neither
estrogenic nor progestational.
Recent evidence suggests a direct inhibitory effect at gonadal sites and a
binding of CYCLOMEN to receptors of
gonadal steroids at target organs.
Generally the pituitary-suppressive
action ofCYCLOMEN is reversible. Ovulation and cyclic bleeding usually return
within 60 to 90 days after CYCLOMEN
therapy is discontinued.
INDICATIONS AND CLINICAL USE
ENDOMETRIOSIS: Cyclomen is indicated
for the treatment ofendometriosis characterized by dysmenorrhea, pelvic pain,
infertility, induration ofthe cul-de-sac,
or dyspareunia.
Cyclomen is not indicated in those
patients where surgery alone is considered
the treatment of choice.
FIBROCYSTIC BREAST DISEASE:
Cyclomen is indicated for the symptomatic
relief of pain and tenderness associated
with fibrocystic disease of the breast. Only
those patients should be selected for
treatment, who are unresponsive to, or intolerant of, other therapeutic measures,
or in whom such measures are otherwise
inadvisable.
CONTRAINDICATIONS: CYCLOMEN
should not be administered in these
conditions:
1. Undiagnosed abnormal genital
bleeding.
2. Markedly impaired hepatic, renal or
cardiac function.
3. Pregnancy.
4. Breast feeding.
PRECAUTIONS: Because CYCLOMEN
may cause some degree offluid retention,
conditions that might be influenced by
this factor, such as epilepsy, migraine, or
cardiac or renal dysfunction, require
careful observation.
ADVERSE REACTIONS: The following
androgenic effects have occurred in patients receiving CYCLOMEN: acne, edema,
mild hirsutism, decrease in breast
size, deepening of the voice, oiliness of
the skin or hair, weight gain, and rarely,
clitoral hypertrophy.
Also hypoestrogenic manifestations
such as flushing, sweating, vaginitis including itching, dryness, burning and
vaginal bleeding, nervousness, and
emotional instability have been reported.
Hepatic dysfunction, as evidenced by
elevated serum enzymes and/or jaundice,
has been reported in patients receiving
adailydosageofCYCLOMEN of400 mgor
more. It is recommended that patients
receiving CYGLOMEN be monitored for
hepatic dysfunction by laboratory tests
and clinical observation. Prolongation of
prothrombin time in patients stabilized
on warfarin has also been reported. Alter-
ations in lipids have also been observed.
Although the following reactions have
also been reported a causal relationship
to the administration of CYCLOMEN has
neither been confirmed nor refuted:
allergic: skin rashes, and rarely, nasal
congestion.
CN'S effects: dizziness, headache, sleep disorders, fatigue, tremor, and rarely, paresthesia in extremities, visual disturbances,
anxiety, depression, changes in appetite
and chills.
gastrointestinal: gastroenteritis, and rarely,
nausea, vomiting, constipation.
musculoskeletal: muscle cramps or
spasms, joint lock-up, joint swelling, and
pain in back, neck or legs.
genitourinary: rarely, hematuria.
other: abnormal glucose tolerance testand
increased insulin requirements in diabetic
patients, loss ofhair, changes in libido,
elevation in blood pressure, and rarely,
pelvic pain.
DOSAGE AND ADMINISTRATION:
Therapy should begin during menstruation. Otherwise, appropriate tests should
be performed to ensure that the patient is
not pregnant while on CYCLOMEN
therapy A non-hormonal method ofcontraception is recommended.
Endometriosis: In moderate to severe
disease, or in patients infertile due to
endometriosis, a starting dose of 800 mg.
given in two divided doses is recommended. For mild cases, an initial daily
dose of 200 to 400 mg given in two
divided doses is recommended and may
be adjusted depending on patient response.
It is essential that therapy continue
uninterrupted for 3 to 6 months but may
be extended to 9 months if necessary.
After termination of therapy, if symptoms
recur, treatment can be reinstituted.
Fibrocystic Breast Disease: The total
daily dosage ofCYCLOMEN for fibrocystic
breast disease ranges from 100 mg to
400 mg given in two divided doses depending upon patient response.
In most cases, breast pain and tenderness are significantly relieved by the first
month and eliminated in 2 to 3 months.
Usually elimination of nodularity requires
4 to 6 months of uninterrupted therapy.
Irregular menstrual patterns may occur.
Clinical studies have demonstrated that
up to 50% of patients may show evidence
of recurrence of symptoms within one
year. In this event, treatment may be
reinstated.
HOW SUPPLIFD: Each capsule contains:
danazol 50 mg (orange and white),
100 mg (yellow), or 200 mg (orange) in
bottles of 100.
Product Monograph available on
request.
References:
1. Aksu, M.F., Tzingounis, V.A., Greenblatt,
R.B.: Treatment of Benign Breast Disease
with Danazol: A Follow-up Report.J. of
Reprod. Med. 21:181-184,1978.
Winthrop Laboratories
Division of Sterling DrugLtd.**
Aurora, Ontario L4G 3H6
SRegistered User
aRe,,. Trade Mark IaP
I[P>]
Answer to Dermacase (page 953)
4. Acne rosacea
Acne rosacea is an idiopathic chronic
eruption of the face. The four clinical
components of the disease are
erythema, telangiectasia, acneform
lesions and rhinophyma. The last of
these elements may cause a bulbous
deformity of the nose, resulting from
hyperplasia with lobulation of the
sebaceous glands. Acne rosacea is
more common in middle-aged women
than men but rhinophyma formation,
when it occurs, is seen almost
exclusively in men. The changes are
most apparent in the middle third of
the face. The earliest manifestation of
the disease is simple intermittent
flushing involving the nose and
cheeks. In time the erythema becomes
fixed, telangiectasia develop, and
acneform lesions may be seen.
Although papules and pustules are
common, comedones are not seen.
Many patients note that alcohol,
that parents need to be aware of as a
cause of frustration about school." Effective family functioning was one of
the two factors the study found to be
most predictive of academic successthe other being high IQ.
Private tutoring proved particularly
helpful, in part because its anonymity
bolstered the child's self-esteem. Involvement in athletics and employment during junior and senior high
school resulted in positive feelings of
worth by offsetting the chronic lack of
academic and social success associated
with a learning disability. While special education classes tailored to the
needs of learning-disabled children
can be vital to academic achievement,
such classes were associated with low
academic and social success, at least in
part because the students with the
greatest disabilities tended to be
enrolled in them.
The children in the study came primarily from upper middle-class families where the breadwinner had a high
occupation level and the mother had
attained a high level of educationboth factors predictive of success in
the child. Additionally, learning-disabled students who had high IQs, relatively minor learning disabilities, or
coffee, tea and spicy foods cause their
disease to flare.
Seborrheic dermatitis produces
redness with scaliness of the face,
especially the eyelids, eyebrow skin,
and nasolabial folds. The absence of
telangiectasia or acneform lesions
helps to differentiate seborrheic
dermatitis from acne rosacea. Lupus
erythematosus may produce redness
with telangiectasia of the face but
acneform lesions and subaceous
hyperplasia of the nose are not
normally seen. Also, most patients
with lupus erythematosus notice that
the sun causes their skin disease to
become worse, which is not usually a
feature of acne rosacea. Acne vulgaris
may be seen in patients this age but
will lack the erythema and
telangiectasia seen in acne rosacea. In
acne vulgaris the lesions arise from
normal rather than erythematous skin.
Acne rosacea is chronic and
to experience greater academic and social success.
At initial evaluation, the students
ranged in age from six to 12 years and
all had primary diagnoses of learning
disability (defined as "a discrepancy
between intellectual ability and academic achievement due to a deficit in
one or more psychological processes
such as attention, memory, or perception"). The researchers excluded mentally retarded children and those with
primary emotional disturbance.
Although learning-disabled students
are often spotted by educators during
the first years of school, it is not uncommon for a learning disability to
present as a medical dysfunction. Dr.
Hartzell suggests giving a child with a
school-related problem-such as vomiting, headache, stomachache, or
anxiety before or after a school day-a
simple reading or math test to help
judge whether the problem might be
linked to a learning disability. He adds
that (physicians) might also find it
worthwhile to seek out and evaluate
services in (their) community geared
toward the learning-disabled child so
(they) can improve (their) effectiveness as a liaison between consultants
positive personalities were more likely and the family. "
1148
indolent. Ocular complications
include blepharitis, conjunctivitis,
iritis and even keratitis. Treatment is
difficult. The avoidance of excessive
exposure to tea, coffee, hot drinks,
alcoholic beverages and spicy foods is
desirable, since these foodstuffs seem
to aggravate acne rosacea.
Hydrocortisone cream may dampen
down some of the redness but has no
effect on the telangiectasia, acneform
lesions, and sebaceous hyperplasia.
Topical fluorinated steroids may
aggravate the telangiectasia and
should be avoided. Tetracycline in
low doses (250-500 mg per day) with
topical antibiotic solutions
(tetracycline, erythromycin or
clindamycin) or benzoyl peroxide
lotions, or gels, will control the
acneform changes. When it is
cosmetically offensive, the
rhinophyma may be treated by
dermabrasion, laser therapy, or
electrosurgery .
Bruni PJ. What added help can I
give my learning disabled child? Patient Care 1985 Mar 15; 19:180-1.
Antibiotic
Prophylaxis For
Electrolysis Patients
CC Recent authors draw attention to
the small but definite risk of infective
ndocarditis associated with insertion
f intrauterine contraceptive devices.
Hair electrolysis is another procedure
that is not generally regarded as causing appreciable bacteremia in patients
at risk of infective endocarditis.
A 40-year-old teacher presented
with mild fever, nausea and vomiting,
in the upper visual fields,
and a throbbing headache of three
days' duration. She had had rheumatic
fever at age 11 and an episode of bacterial endocarditis at age 12. Mitral
regurgitation with paroxysmal atrial
fibrillation had been noted at age 26,
and after increasing episodes of this
she was started on warfarin at age 34.
Five years later she had developed a
right parieto-occipital cerebral hematoma, which was successfully removed, and she had made an excellent
recovery.
Qickering
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
Examination on admission was normal apart from a residual left homonymous hemianopia, mitral regurgitation, atrial fibrillation, and a
temperature of 37 2°C. Blood cultures
were reported the following day as
containing Gram positive cocci in two
out of six specimens. The organism
was identified as Staphylococcus epidermidis and regarded as a probable
contaminant. A computed tomogram
of the brain was normal. Patenteral antibiotics were stopped, and she was allowed home taking oral penicillin on
the fifth day.
Four days after her discharge all six
blood culture specimens had grown S
epidermidis. She was therefore readmitted for a full course of intravenous
antibiotics. Examination on readmission showed numerous splinter hemorrhages in the finger and toe nails. No
new ones appeared after the start of intravenous antibiotics, and she made a
full recovery.
Exhaustive questioning regarding
the source of the bacteremia was initially unhelpful. Later, the patient
volunteered that three weeks before
her admission she had had extensive
hair electrolysis for facial hair and during that period had not received antibiotic prophylaxis. This case suggests
that apparently minor 'external' procedures such as hair electrolysis may expose susceptible individuals to infective endocarditis. "
Daneshmend TK. Need for antibiotic prophylaxis during hair electrolysis? Br Med J 1984; 289:1693.
Examination Panic
prepared and are overconcerned with
THE 8 HOUR NITROGLYCERIN
their work. Some students may have
too great a need to perform well, fearINFORMATION
ing that they will not do themselves PRESCRIBING
Nitroglycerin sustained-release tablets
justice and so fail to obtain that co- Therapeutic classification
veted first class honors degree so nec- Anti-anginal Agent
Indications
essary for a postgraduate research fel- Nitrong
SR Tablets are indicated for the prevention
of attacks of angina pectoris associated with
lowship. Their sense of reality chronic
angina of effort.
becomes distorted, their humor van- Contraindications
ishes, and all they see is doom and Nitrong SR Tablets are contraindicated in patients
severe anemia, increased intraocular presgloom. If such a student is seen just with
sure, increased intracranial pressure and hypotenNitrong SR is also contraindicated in patients
before taking the examination or he sion.
known idiosyncrasy to organic nitrates.
panics in the examination room then with
Warnings
immediate help can often save things. Data on the safe use of Nitrong SR during the early
phase of myocardial infarction (the period during
A quiet room away from the main ex- which
clinical and laboratory findings are unstable)
amination hall is the setting for a firm are insufficient to establish safety.
use of Nitrong SR in patients with congestive
friendly challenge and in most cases a The
heart failure requires careful clinical and/or hemorest, a cup of coffee, and a continuing dynamic monitoring.
Nitrate dependence may occur in patients with
relationship with a sympathetic invigi- chronic
use. To avoid possible withdrawal effects,
lator will enable the student to start, or the administration of Nitrong SR should gradually
be
reduced over 4-6 weeks. In industry workers
restart, the paper and do himself jus- continuously exposed to nitrates, chest pain, acute
tice.
If the potential problem is expected
then deconditioning and relaxation
procedures are of great benefit. Such a
program might consist of writing an
examination question initially under
no pressure and then over some weeks
being steadily forced to do more than
one question until finally examination
papers are done under examination
conditions. This helps to make the actual examination no more than a continuation of a well established procedure. During this period relaxation
techniques can be taught so that as tension occurs the student may deal with
it competently and quickly. It is also
necessary to check that overleaming
and overworking are defused and that
realistic expectations rather than false
hopes are produced by the close involvement of department tutors.
Centres of higher education approach
these problems in various ways but all
would try to offer some help. The
more efficient the service the less need
for medication. I have not found /8
blockers to be of great value and benzodiazepines may lead to sedation and
disaster if taken on the morning of the
examination. Better by far are sympathetic friends and parents, a clearly defined course, approachable tutors and
competent invigilators, and a back up
team of psychologists, nurse, and doctor when needed. "
- Q: What advice and treatment (if
any) should be given to a university
student who suffers from examination
panic?
A: Try to understand why the student is panicking. It is unusual for a
lazy student to seek medical help just
before an examination, but it is possible, and needs to be excluded by
checking that he has done his course
work and prepared adequately. Nearly
all students who suffer from examination panic are diligent, hard working, Dickinson KG. Any questions? Br
conscientious people who have over- Med J 1985; 290:922.
myocardial infarction and even sudden death have
occurred during temporary withdrawal of nitrate
exposure.
Precautions
Headaches or symptoms of hypotension, such as
weakness or dizziness, particularly when arising
suddenly from a recumbent position, may be due
to overdosage. When they occur, the dose should
be reduced or use of Nitrong SR discontinued.
Nitroglycerin is a potent vasodilator and causes a
slight decrease in mean blood pressure (approximately 10-15 mm Hg) in some patients when used
in therapeutic dosages. Caution should be exercised in using the drug in patients who are prone
to, or who might be affected by hypotension.
Nitrong SR Tablets are not intended for immediate
relief of acute attacks of angina pectoris. Sublingual nitroglycerin preparations should be used for
this purpose.
Tolerance to this drug and cross tolerance to other
nitrates or nitrites may occur.
Adverse Effects
Headache is the most common side effect, especially when higher dosages of Nitrong SR are used.
Headache may be treated with concomitant
administration of mild analgesics. If headache is
unresponsive to such treatment, the dose of
Nitrong SR should be reduced or the use of the
product discontinued.
Less frequently, postural hypotension, an increase
in heart rate, faintness, flushing, dizziness, nausea
and vomiting have been reported.
Symptoms and treatment of overdosage
Symptoms of overdosage are primarily related to
vasodilation, including cutaneous flushing,
headache, nausea, dizziness and hypotension.
Methemoglobinemia is also possible.
No specific antidote is available. Treatment should
primarily be symptomatic and supportive.
Dosage and administration
Adult: Recommended initial dosage is 1 tablet 3
times a day before breakfast, late afternoon
before meal and before retiring. Dosage may be
increased progressively up to 2 tablets 3 times
a day.
Availability
Sustairied-Release Tablets of 2.6 mg - Bottles of
100 and 1000.
References:
1. Winsor, T and Berger, H.J., Am. Heart J, Vol. 90,
611-612 (1975)
2. Hirshleifer. I., Curr Ther. Res., 15, 4, 158 (1973)
3. Gensini, G.G., et al., Chest, 60, 522 (1971)
Aw Registered Trademarh
PRHQtNE POULfNC
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
O,Dstribted by Rhone-Pouldenc Pharma Inc
Manufactured by U S. Ethicals.
Long Island City. N Y ., uA |PA
took an ardent stand against the British Medical Association and recommended that all GPs embrace the service and thus "get medicine out of
the market place". Support came
from consultants whose names read
like a role of honor in British medicine. If only he could have lived a little longer and seen what he had forecast-health visitors, district nurses,
and doctors working together in
health centres, and a very strong
Royal College of General Practitioners with an international reputation for sound GP research and clinical audit. Those hectic months are
faithfully and interestingly described
by John Pemberton.
The last quarter of the book catelogues the h-onors coming Pickles'
way as an internationally acclaimed
medical giant whose reputation is assured throughout future generations of
doctors, particularly among those
concerned about moral and ethical
aspects of our profession.
So here is the story of the life of
one of my heroes. Thanks to Pemberton I admire Will even more than before I opened this book.
Reviewed by John Z. Garson. Dr.
Garson, a member of the College, is
a retired medical officer of health,
and is now a health care consultant in
Gabriola, BC.
Will This Book
Get You Out
Of a Pickle?
Title: Epidemiology in Country Practice
Author: William Pickles
Publisher: The Royal College of
General Practitioners, Publications Office, 9 Marlborough Rd.,
Exeter, Devon, U.K.
Publication Date: 1984
Pages: 112
Price: £5.50
This remarkable book is republished
in paperback with the Royal College
of General Practitioners' distinctive
cover, and is a photo reproduction of
the sold-out, limited edition of 1972.
Will Pickles of Wensleydale is
probably the most famous GP researcher, and, with Ryle, a foremost
medical natural historian; if his work
is read with this in mind, his advanced thinking is astounding.
1158
This slim volume begins with a description of the geology and water
supply of the dale; he then discusses
the lines of communication taken by
the infecting germs of communicable
disease and describes his method of
study-enlisting the aid of wife,
daughter, school principal, and medical officer of health. The casual acceptance of the easy partnership and
relationship between the GP and the
MOH highlights the loss to both by
the demise of this essential relationship. Pickles exhorted GPs 50 years
ago to form groups to study the epidemiology of disease, thus presaging the
British Epidemiology Observation
Unit and our own NaReS.
He then goes on to describe the epidemiology of the common communicable diseases. I must have read the
chapters on catarrhal jaundice and epidemic myalgia at least ten times over
the past 12 years, yet at each reading,
I am equally enthralled. I still remember my first case of epidemic
myalgia when I was a house surgeon
some 40 years ago in a London, U.K.
children's hospital. If only I had read
Pickles, it would have saved me from
a worrying night of watching a little
boy sweat with pain.
While it is true that his work was
concerned with common infectious
diseases, Pickles' scrupulous method
and precise observation is still needed
today for unravelling the etiologies of
the myriad of illnesses presenting in
family practice; a casual glance at any
textbook of medicine will show that
we still don't know the etiology of
most illnesses apart from communicable diseases. Certainly family physicians have a role to play in unravelling some of these illnesses, and the
method Pickles describes is still valid,
especially now (with the formation of
NaReS) that we have fulfilled his call
for team work.
Who should read this book? It is
hard to think of any doctor who
would not benefit, but perhaps it is
fair to suggest that all FPs, all medical students, and all family practice
and community medicine residents
should read it. It should be in the library of family practice teaching
units.
Reviewed by John Z. Garson. Dr.
Garson, a member of the College, is
a retired medical officer of health,
and is now a health care consultant in
Gabriola, BC.
Book Received
Borland J, Dacks B: Cast A Thin
Shadow. Toronto, McClelland &
Stewart-Bantam Ltd., 1984. $4.50
Bradbear RA, Campbell CB, Powell
LW: Gastroenterology Revision. New
York, Churchill Livingstone Inc.,
1984. $19.75
Cherniak D: A Book About Sexually
Transmitted Diseases. Montreal, Montreal Press Co., 1983. $2
Epstein E: Regional Dermatology: A
System of Diagnosis. Toronto, Grune
& Stratton, Inc., 1985. $83.50
Feneley RCL, Blannin JP: Incontinence. New York, Churchill Livingstone Inc., 1984. $4.50
Frampton M: Agoraphobia. New
York, Sterling Publishing Co., Inc.,
1985. $8.95
Freudberg F, Emanuel ES: Herpes: A
Complete Guide to Relief and Reassurance. Philadelphia, Running Press,
1982. $10.95
Graedon J: The New People's Pharmacy. New York, Bantam Books, Inc,
1985. $9.95
Gunatilleke G (ed): Intersectoral Linkages and Health Development: Case
Studies in India (Kerala State), Jamaica, Norway, Sri Lanka, and Thailand. Geneva, World Health Organization, 1984. 5 Swiss francs
Hansten PD: Drug Interactions, ed. 5.
Philadelphia, Lea & Febiger, 1985.
$30
Mark Farren (compiler): Infant Mortality and Health In Latin America: An
Annotated Bibliography From the
1979-82 Literature. Ottawa, International Development Research Centre,
1984.
Krauer B, Krauer F, Hytten F: Drug
Prescribing in Pregnancy. New York,
Churchill Livingstone Inc., 1984.
$25.75
Kucera LS, Myvik QN: Fundamentals
of Medical Virology, ed. 2. Philadelphia, Lea & Febiger, 1985.
Lesnoff-Caravaglia G: The World of
the Older Woman: Conflicts and Resolutions. New York, Human Sciences
Press, Inc., 1985. $19.95
Meisel AD, Bullough PG: Atlas of Osteoarthritis. Philadelphia, Lea & Febiger, 1984. $39.25
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985
CHILDREN'S PANADOC
acetminophen
The only alcohol free, sugar free
children's acetaminophen antipyretic
in all dosage forms.
ACTIONS: Acetaminophen is an analgesic and
antipyretic.
INDICATIONS: Panadol* Acetaminophen is indicated for the relief of pain and fever in various
conditions including the symptomatic treatment
of colds.
CONTRAINDICATIONS: Hypersensitivity to
acetaminophen.
ADVERSE EFFECTS: In contrast to salicylates,
gastrointestinal irritation rarely occurs with
acetaminophen. If a rare hypersensitivity reaction
occurs, discontinue the drug. Hypersensitivity is
manifested by rash or urticaria. Regular use of
acetaminophen has shown to produce a slight
increase in prothrombin time in patients receiving
oral anticoagulants, but the clinical significance
of this effect is not clear.
PRECAUTIONS AND TREATMENT OF
OVERDOSE: The majority of patients who have
ingested an overdose large enough to cause
hepatic toxicity have early symptoms. However,
since there are exceptions, in cases of suspected
acetaminophen overdose, begin specific antidotal
therapy as soon as possible. Maintain supportive
treatment throughout management of overdose
as indicated by the results of acetaminophen
plasma levels, liver function tests and other clinical
laboratory tests.
N-acetylcysteine as an antidote for acetaminophen overdose is recommended and is available
in oral and parenteral dosage forms. More detailed
information on the treatment of acetaminophen
overdose with N-acetylcysteine in its oral and
parenteral dosage forms is available from the
manufacturers (Mucomyst, Bristol-Myers Canada
Limited trademark for its brand of oral N-acetylcysteine; Parvolex, Glaxo Canada Ltd. trademark
for its brand of parenteral N-acetylcysteine), or
contact your nearest Poison Control/Information
Centre.
DOSAGE:
Children:
Based on Weight
10-15 mg/kg every 4 to 6 hours, not to exceed
65 mg/kg in 24 hours.
Based on Age
Single Dose
Age
40 mg
Newborn to under 4 months
80 mg
4 months to under 12 months
120 mg
12 months to under 2 years
160 mg
2 and 3 years
4 and 5 years
240 mg
320 mg
6, 7 and 8 years
400 mg
9 and 10 years
480 mg
11 and 12 years
640 mg
13 years and older
Dosage may be repeated 4 to 5 times, not to
exceed 5 doses in 24 hours.
SUPPLIED: Panadol* Drops: Each 0.8 mL contains
80 mg acetaminophen in a deep red liquid vehicle
with a slightly bitter fruit flavoured taste. Available
in amber bottles containing 15 mL t and 25 mL t
and a calibrated dropper.
Panadol* Elixir: Each 5 mL contains 120 mg
acetaminophen in a fruit flavoured red vehicle.
Available in amber bottles containing 100 mL t.
Panadol* Pleasant tasting Chewable Tablets 80 mg:
Each round, pink tablet scored one side and
engraved Panadol* the other side, contains 80 mg
acetaminophen. Available in amber bottles of
24 t tablets.
Sterling Products Division of Sterling Drug Ltd.,
Aurora, Ontario L4G 3H6.
*Trade Mark
REFERENCE:
American Academy of Pediatrics, Committee on
Drugs: Ethanol in Liquid Preparations intended for
FITH COLUMN
Seen any good misprints lately?
Heard any good lines from
patients? We're interested-a laugh
a day keeps the doctor away. Send
items to The Fifth Columnist, 4000
Leslie St., Willowdale M2K 2R9.
Ashes to Ashes
You've probably all read about
"Weedless Wednesday" -the day
when the general public is advised to
"choose to be smoke free" by the
Canadian Council on Smoking and
Health. The Council's publication
"Smoking or Health Update" tells us
about another Wednesday, when a
shop steward successfully brought a
grievance that tobacco smoke violates
the Dangerous Substances Safety Standard for the civil service.
The hearings began on Ash
Wednesday.
state, and "the chancellor of the exchequer is pushing for a benefits
shake-up which will shave billions off
the $38 million cost of social security."
We assume that's a Conservative estimate.
Metamorphosis
Fifth Columnists are to be found in the
most august echelons. A member of
the executive committee for the College's Section of Teachers, visiting
CFP's new offices recently, noted the
flowchart for copy between CFP and
General Printers of Oshawa. One column in particular caught his eye:
"Dummy to GP". "Hmmm", he
mused, "I used to be a dummy, but
now I'm a GP".
At least he didn't say "just a GP".
General Medicine?
The Birds and the Bees
and the Flowers and
the ...
"At the lectern yesterday in the Parklawn Building in Rockville stood the
general-U.S. Surgeon General C.
Everett Koop-resplendent in black
uniform with gold buttons and bars,
-xhorting the corps to fight the good
fight against the- enemies of disease
and illness".
Washington Post
General-a word in your ear about
Sexual taboos evidently don't apply to
the plant kingdom. One Fifth Columnist received a brilliant azalea plant
from a birthday well-wisher with this
ominous warning tucked among the
foliage: "Asexual Reproduction of
enemies . . .
This Plant Without License is Prohibited". Apparently the birds and the
bees have total freedom to cross-polli- You Said It
nate to their hearts' content-and they
don't even need a license! But for a Nice work if you can get it-and a
human to do an innocent cutting with- UBC professor of history's got it. The
out going through the proper chan- Guggenheim Foundation is going to
fund Richard Unger to "write a comnels? Forbidden fruit.
plete history of the brewing industry in
the Netherlands", according to a recent UBC press release.
We've Told You
Is Prof. Unger happy in his work?
A Billion Times
The press release quotes him as sayDon't Exaggerate
ing: "One of the problems of this projis simply digesting the amount of
And it was in the London Sunday
Times, no less. Seems that the U.K. material that's available".
cabinet is trying to reform the welfare
Hic!
:hose
sct
C'hildren. Pediatrics 73: (3) March 1984: 405-407.
1170
CAN. FAM. PHYSICIAN Vol. 31: MAY 1985