present, whereas all but one of the patients using less than 50 g/wk showed no suppression. Healthy volunteers applied various amounts of Dermovate to either 50% or 90% of the body surface, again without occlusion. Rapid suppression in all but one subject was produced with the use of 90 g/wk, but not with the use of 45 g/wk. As a result we recommended the maximum "safe" weekly dose of Dermovate to be 50 g, a figure Glaxo Laboratories accepted.2 Considering that a single application of cream to widespread psoriasis may require 20 to 30 g, this is not an excessive amount. Since the use of Dermovate in Canada is increasing rapidly it is an appropriate time to remind physicians of the dangers of this highly potent corticosteroid that is extremely useful as a topical agent. While it usually clears psoriasis, the condition often relapses on cessation of treatment, sometimes in a more active, even pustular, form. I believe that Dermovate should be reserved for use in limited areas or specifically selected cases of psoriasis since indiscriminate use of this agent in the treatment of psoriasis may do more harm than good. J. ALASTAIR CARRUTHERS, MD
Division of dermatology University of British Columbia Vancouver, BC
References 1. CARRUTHERS JA, AUGUST PJ, STAUGH-
TON RCD: Observations on the systemic effect of topical clobetasol propionate (Dermovate). Br Med J 4: 203, 1975 2. Dermovate Product Monograph, Glaxo Canada Ltd, Toronto, June 25, 1976, p2
Cervicofacial emphysema To the editor: Drs. D.B. Clement and L.G. Lommel, in their report oii cervicofacial emphysema in an endurance runner (Can Med Assoc J 118: 1539, 1978), mention Box's1 statement that small lacerations of the buccal mucosa may constitute the portal of air entry. Soon after World War II in some parts of the Middle East an epidemic of gross cervicofacial emphysema afflicted the members of the British army. Officers and sergeants were never affected and corporals were seldom affected. The medical of-
DJLANTIN/ZARONTIN BRIEF PRESCRIBING INFORMATION
INDICATIONS (DILANTIN): DILANTIN is indicated for the control of grand mal epilepsy, psychomotor seizures, and certain other convulsive disorders. Parenteral DILANTIN is indicated for the treatment of status epilepticus and the prophylactic control of seizures in neurosuigery. PRECAUTIONS AND CONTRAINDICATIONS (DILANTIN): Periodic examination of the blood is advisable since hematologic disorders in association with DILANTIN administration have been reported. Nystagmus in combination with diplopia and ataxia indicates dosage should be reduced. When DILANTIN with PHENOBARBITAL or PHELANTIN are used, it should be borne in mind that phenobarbital may cause drowsiness, and may be habit-forming. PHELANTIN, because of the methamphetamine content, should be given cautiously to patients with hypertension. PHELANTIN iscontraindicated in patients hypersensitive to ephedrine-like compounds; in those showing anxiety or undue excitability; and in patients with cardiac or coronary disease not likely to tolerate vasoconstrictors. The possibility of toxic effects of DILANTIN during pregnancy has not been explored. ADVERSE REACTIONS (DILANTIN): Once proper dosage has been determined, toxic effects of Dl..lN are infrequent. Minor side effects which may occur during the initial stages of therapy include gastric distress, nausea, weight loss, transient nervousness, sleeplessness, and a feeling of unsteadiness, all of which usually subside with continued use. Allergic phenomena such as polyarthropathy, fever, and skin eruptions may occur. Acute generalised morbilliform eruptions with or without a temperature elevation, may occur about two weeks after treatment is begun. The dermatitis may in some instances go on to exfoliation and hepatitis may occur, contraindicating further therapy with DILANTIN. Eruptions usually subsid6 when therapy is discontinued. Gingival hyperirophy, hirsutism, and excessive motor activity are occasionally encountered, especially in children, adolescents, and young adults. Only occasionally is it necessary to discontinue DlLANTIN because of these manifestations. Gingival hypertrophy can be greatiy minimized by scrupulous dally care of gums and prophylactic dental care. Megaloblastic anemia and macrocytosis have been reported but have responded to antianemic therapy. Leukopenia, granulocytopenia, thrombocytopenia, pancytopenia, aplastic anemia, and agranulocytosis have also been reported. Usually these patients were simultaneously receiving other drugs. Lupus erythematosus and erythema muitiforme have occurred in patients receiving DILANTIN. DOSAGE AND ADMINISTRATION (DILANTIN): In all cases, optimal dosage of DILANTIN must be determined by trial. Dosage in excess of the minimum required to prevent convulsions is not recommended. For most patients, DILANTIN CAPSULES, 100mg or DILANTIN CAPSULES, 30mg are suitable for administration. FORMS AVAILABLE: In order to provide versatile therapy, DILANTIN is supplied in the following convenient product forms: DILANTIN* CAPSULES, 100 mg (Cap 362). Each white capsule with orange cap contains phenytoin sodium 100 mg. DILANTIN* CAPSULES, 30 mg (Cap 365). Each white capsule with pale pink cap contalns phenytoin sodium 30mg. DILANTIN* INFATABS, 50 mg. Each triangular shaped, grooved tablet, contalns 50mg phenytoin. INFATABS are palatably flavoured tablets, intended primarily for pediatric use. DILANTIN-125 SUSPENSION. Each 5 ml contalns 125 mg phenytoin. DILANTIN-30 SUSPENSION. Each S ml contains 30mg phenytoin. These are pleasantly flavoured suspensions of DILANTIN, especially adapted for pediatric use, but suitableforadolescents and aduits who preferliquid medication. . DILANTIN* with 15 mg PHENOBARBITAL CAPSULES, (Cap. 375). Each white capsule with garnet cap contalna 100mg phenytoin sodium and 15mg phenobarbital.
564 CMA JOURNAL/SEPTEMBER 23, 1978/VOL. 119
DILANTIN with 30mg PHENOBARBITAL CAPSULES (Cap. 531). Each white capsule with black cap contains 100mg phenytoin sodium and 30mg phenobarbital. These combinations of DILANTIN with PHENOBARBITAL are supplied for the convenient and economical use of those patients who require combined DILANTIN and PHENOBARBITAL therapy. .> PHELANTIN CAPSULES*, (Cap. 394). Each yellow capsule contains phenytoin sodium, 100 mg; phenobarbital. 30mg; and methamphetamine hydrochloride, 2.5 mg. Combining these agents takes advantage of the clinically proved anticonvulsant actions of DILANTIN and phenobarbital, while the methamphetamine counteracts the sedative effects of phenobarbital. DILANTIN. AMPOULES, 100 mg (Amp. 1488). Each 2 ml ampoule contains 100 mg (50 mg/mI) phenytoin sodium ready-mixed. DILANTIN* AMPOULES, 250 mg (Amp. 1475). Each 5 ml ampoule contains 250mg (50 mg/mI) of phenytoin sodium ready-mixed. INDICATIONS (ZARONTIN): ZARONTIN is indicated for the control of petit mal epilepsy. PRECAUTIONS (ZARONTIN): The physician should be alert to any symptoms indicative of the following conditions which have been reported in association with the use of ZARONTIN: aplastic anemia, agranulocytosis, dermatitis, leukopenia. Periodic blood counts should be performed. The drug should be used with caution in patients with known liver or renal disease or dysfunction. Routine urinalyses and frequent liverfunction tests are advised. Safe use of this drug in pregnancy has not been established. Because of the possibility of drug-induced drowsiness, operation of motor vehicles or other machinery by patients on ethosuximide therapy is not advised. ZARONTIN when used alone in mixed types of epilepey may increase the frequency of grand mal attacks in some patients. ADVERSE REACTIONS (ZARONTIN): In 727 patients gastrointestinal side effects occurred in 12.5%, central nervous system symptoms in 6.7%, blood changes in 0.4%, and miscellaneous side effects in 1.2%. Side effects are usually mild and transient and usually subside with continued therapy. Anorexia, gastric distress, nausea, emesis, drowsiness, headache, dizziness, euphoria, and singultus have been reported. Psychiatric or peychologic aberrations, including insomnia, night terrors, inability to concentrate, motor unrest, agitation, and aggressiveness thought to be drug-induced or exacerbated by anticonvulsant medication, were noted in a few patients who had previouslyshown emotional instability. Leukopenia, agranulocytosis, and severe pancytopenia with fatal outcome, have been reported in association with ethosuximide. In most cases of leukopenia, the condition cleared either on reduction of dosage or discontinuation of the dru9. Other reactions in which the extent of ethosuximide implication is not yet determined include myopia, rash, vaginal bleeding, swelling of the tongue, and hirsutism. One instance of temporarily elevated (3-plus) cephalin flocculation test has been reported; patient showed normal values as medication continued. DOSAGE AND ADMINISTRATION (ZARONTIN): The initial dose for children under six years of age is 250 mg (1 capsule or 5 ml of syrup) per day; for patients six years of age and older, 500mg (2 capsules or 10 ml of syrup) per day. The dose thereafter must be individualized according to the patient's response. FORMS AVAILABLE: ZARONTIN* CAPSULES, 250 mg (Cap. 237). Each soluble gelatin capsule contains 250 mg ethosuximide. ZARONTIN* SYRUP: Each 5 ml contalns 250 mg ethosuximide. Full prescribing information available on request.
PARKE-DAVIS .
Parke, Davis & Company, Ltd. carborough, Ont. MiK 5C5
L..?.J
i.ORELCa PROBUCOL ANTIHYPERCHOLESIEROLEMIC AGENT INDICATIONS: LORELCO is indicated as an adjunct to diet for the treat ment of hypercholesterolemia associated with elevated low density lipoproteins, and may he useful in loweringelevated chotesferol levels in patients with mined hyperfipidemia (hypercholesterolemia and hypertrigtyceridemial, where the hypercholesterolemia is the moiety of most concern. .ONTRAINDICATIONS: LORELCO is contraindicated in patients known to he hypersensitive to the drug. The safety of LORELCO has not been established in pregnancy and therefore, it should not be used in these circumstances, neither should it he used in nursing mothers since animal studies have shown that the drug is excreted in milk. WARNINGS: Strict birth control procedures must beesercised hy women of child-bearing potential. In the event LORELCO is discontinued, such procedures should be followed for at least the suhsequent sin months. In the eventa marked and sustained elevation in the serum triglyceride level occurs that is not related to diet, consideration should be given to discontinuing treatment with LORELCO. (See PRECAUTIONS). PRECAUTIONS: Before instituting therapy with LORELCO (probucol) an attempt should be made to control serum cholesterol by appropriate dietary regimens, weight reduction, and the treatment of any underlying disorder which might be the cause of the hypercholesterolemia. Because LORELCO is intended furlong term administration, adequate baseline studies should be performed to determine that the patient has elevated serum cholesterol levels. Serum cholesterol levels should be determined frequently during the first few months of treatment and periodically thereafter. A favorable trend in cholesterol reduction should be evident during the first two months of LORELCO administration. This regimen should befollowed as longasthetrend continuesand a decision should be made by thefourtb month asto whetheran adequate reduction is being maintained. A baseline for serum triglycerides should also be established and serum triglyceride levels should be determined periodically. If a marked sustained rise in serum triglycerides is observed during probucol therapy: consideration should be given to improved diet compliance. alcohol abstinence, further calorie restriction or adjustment of carbohydrate intake. Probucol should not be continued if this hyper triglyceridemia persists. Limited experience from clinical studies indicates that an increase in serum triglyceride levels can sometimes occur without necessarily an additive effect being apparent on the serum cholesterol, when LORELCO is used concomitantly with clofibrafe. The combination of LORELCO and clofibrate is, therefore, not recommended. The safety and effectiveness of LORELCO has not been established in children. ADVERSE REACTIONS: The adverse reactions associated with LORELCO (probucol) are generally mild to moderate and of short duration. The most commonly affected system is the gastrointestinal tract. Diarrhea occurs in about one in 10 patients. Other adverse gastrointestinal reactions in descending order of frequency are flatulence, abdominal pain, nausea and vomiting. These reactions are usuallytransient and seldom require the drug to be discontinued. Duringthe clinical studies, LORELCO was discontinued in about 2% of the patients because of adverse gastrointestinal reactions. Less frequent adverse reactions are: hyperhidrosis, fetid sweat and angloneurotic edema occurring in less than one in 500 subjects. An idiosyncratic reaction characterized by dizziness, palpitations, syncope, nausea, vomiting and chest pain has been reperted. Other events, where the relationship to LORELCO has not been established include: headache, dizziness, paresthesia and eusinophilia, observed in about one in 5fsabjects; consistently low hemoglobin and! or hematocrit values, observed in about one in 100 patients; rash, pruritus, impotency, insomnia, conjunctivitis, tearing, blurred vision, tinnitus, diminished sense of taste and smell, enlargement of a multinodular goiter, anorexia, heartburn, indigestion, vomiting, gaslrointesfinal bleeding, ecchymosis and petechiae, thrombocytopenia, nocturia, and peripheral neuritis, observed with a frequency of about onefo six per thousand subjects. Elevations of the serum transaminases (glufamic-oxalacetic and glotamic-pyruvic), bilirubin, alkaline phosphatase, creative phosphokinase, uric acid, blood urea nitrogen and blood glucose abovethe normal range were observed on one or more occasions in various patientstreated with LORELCO (probucol). Most often these were transient and/or could have been related to the patient's clinical state or other modes of therapy. Although the basis for the relationship between probucol and theseabuormalities is not firm, the possibilifythat some ofthesearedrug related cannot be excluded. In the controlled trials the incidence of abnormal laboratory values was not higher in the patients treated with probucol than in the patients who received placebo. DOSAGE AND ADMINISTRATION: The recommended adult dose is 500 ag (two 250 mg tablets), twice daily, with morning and evening meals. AVAILABILITY: LORELCO is a white, film-coated tablet, containing 250 mg probucol, available in bottles 01120 tablets. Product monograph available upon request.
DOW PHARMACEUTICALS Dow Chemical of Canada, Limited 380 Elgin Mills Road East, Richmond Hill, Ontario Twadelnaff of She 5ow Chem,cal comoany
.
ficers, alarmed at the grotesque ap- to victims. The successive mortality pearance of an acute ailment in their rates for choking (suffocation from trusty warriors, excused them from ingestion of food or an object) from duty and often packed them off to 1971 through 1976 in the United hospital - much to the delight of States were 2877, 2830, 3013, 2991, 3106 and (estimated) 2900.2 the sufferers. I believe that research methods Soldiers far from hearth and home have repeatedly exploited the limit- must be developed to determine the less possibilities for malingering. In effectiveness of such unproven meththese instances, by nicking the inside ods as back-slapping and the selfof the cheek with a razor blade, applied Heimlich maneuver in the pinching the nose, shutting the mouth hope that an effective and easy-toand expelling a few quick forced remember technique will result. breaths, they created a new tropical Opening the mouth widely and forcing the tongue out might be found disease. to allow a sufficient opening so that IAN MIDDLEMASS, MD Department of radiology a victim could continue to breathe Royal Inland Hospital or even expel an obstruction. Also Kamloops, BC to be considered is that, in normal males, maximum forced expiration Reference produces an average pulmonary pres1. Box HK: Oxygen Insufflation in Perio- sure of 114 mm Hg,' a pressure more dontal Diseases, CC Thomas, Springthan three times that produced by field, Ill, 1955, p 88 the Heimlich maneuver. Because a To the editor: The article by Clement million lives will be at stake over the and Lommell brings to mind two next 20 years, this subject demands cases I have seen in which the cause a more systematic approach than it of cervicofacial emphysema was has been given in the past. other than dental surgery. In the JOHN SPRINGFIELD, MA Middle East during World War II a Cancer research laboratory young serviceman was admitted to Veterans Administration Hospital Minneapolis, Minnesota the psychiatric unit with cervicofacial emphysema. I would not have thought this remarkable, but shortly References afterwards a second person from the 1. HEIMLICH HJ: Food asphyxiation (C). Can Med Assoc J 112: 1383, 1975 same unit was admitted. As these servicemen were homosexual part- 2. National Safety Council: Accident Chicago, 1975-77 ners, one would have thought there 3. Facts, RAHN H, Oris AB, CHADWICK LE, et was a connection, but where? al: The pressure volume diagram of Eventually the truth came out. the thorax and lung. Am J Physiol 146: 161, 1946 The emphysema was self-induced: the men used the pricker of a Primus stove to prick the buccal mucosa, Cesarean section: what is held the nose, and then, with the an acceptable rate? (correction) mouth closed, blew hard. They hoped to get a medical discharge, F. Toll, manager of the management but it was on grounds of homo- information section of the Manitoba sexuality that they left the service. Health Services Commission, has brought the attention of the Journal MYRE SIM, MD, FRCP (ErnN), FRC PSYCH, and Dr. T.F. Baskett to some disFRCP[C], DPM Professor of psychiatry crepancies in the data cited in his University of Ottawa Ottawa, Ont. editorial (118: 1019, 1978). The second sentence of the second paragraph, with italics indicating the corrected figures, should read: "In MaThe Heimlich maneuver nitoba the overall rate had doubled To the editor: The Heimlich man- since 1971, reaching 9.8% in 1976, euver, first publicized in 1974, has and varied from 12.7% to 16.2% been reported to be very effective in (average 14.2%) in teaching hospiexpelling boluses by pressurizing the tals, 6.1% to 13.1% (average 9.6%) lungs to an average of 31 mm Hg.1 in community hospitals served by However, as judged from the un- specialists in obstetrics and other abated mortality, competent assist- fields, and 0% to 15.4% (average ance of this type is seldom available 5.5%) in rural hospitals.. .". - Ed.
568 CMA JOURNAL/SEPTEMBER 23, 1978/VOL. 119
Division of dermatology University of British Columbia Vancouver, BC
References 1. CARRUTHERS JA, AUGUST PJ, STAUGH-
TON RCD: Observations on the systemic effect of topical clobetasol propionate (Dermovate). Br Med J 4: 203, 1975 2. Dermovate Product Monograph, Glaxo Canada Ltd, Toronto, June 25, 1976, p2
Cervicofacial emphysema To the editor: Drs. D.B. Clement and L.G. Lommel, in their report oii cervicofacial emphysema in an endurance runner (Can Med Assoc J 118: 1539, 1978), mention Box's1 statement that small lacerations of the buccal mucosa may constitute the portal of air entry. Soon after World War II in some parts of the Middle East an epidemic of gross cervicofacial emphysema afflicted the members of the British army. Officers and sergeants were never affected and corporals were seldom affected. The medical of-
DJLANTIN/ZARONTIN BRIEF PRESCRIBING INFORMATION
INDICATIONS (DILANTIN): DILANTIN is indicated for the control of grand mal epilepsy, psychomotor seizures, and certain other convulsive disorders. Parenteral DILANTIN is indicated for the treatment of status epilepticus and the prophylactic control of seizures in neurosuigery. PRECAUTIONS AND CONTRAINDICATIONS (DILANTIN): Periodic examination of the blood is advisable since hematologic disorders in association with DILANTIN administration have been reported. Nystagmus in combination with diplopia and ataxia indicates dosage should be reduced. When DILANTIN with PHENOBARBITAL or PHELANTIN are used, it should be borne in mind that phenobarbital may cause drowsiness, and may be habit-forming. PHELANTIN, because of the methamphetamine content, should be given cautiously to patients with hypertension. PHELANTIN iscontraindicated in patients hypersensitive to ephedrine-like compounds; in those showing anxiety or undue excitability; and in patients with cardiac or coronary disease not likely to tolerate vasoconstrictors. The possibility of toxic effects of DILANTIN during pregnancy has not been explored. ADVERSE REACTIONS (DILANTIN): Once proper dosage has been determined, toxic effects of Dl..lN are infrequent. Minor side effects which may occur during the initial stages of therapy include gastric distress, nausea, weight loss, transient nervousness, sleeplessness, and a feeling of unsteadiness, all of which usually subside with continued use. Allergic phenomena such as polyarthropathy, fever, and skin eruptions may occur. Acute generalised morbilliform eruptions with or without a temperature elevation, may occur about two weeks after treatment is begun. The dermatitis may in some instances go on to exfoliation and hepatitis may occur, contraindicating further therapy with DILANTIN. Eruptions usually subsid6 when therapy is discontinued. Gingival hyperirophy, hirsutism, and excessive motor activity are occasionally encountered, especially in children, adolescents, and young adults. Only occasionally is it necessary to discontinue DlLANTIN because of these manifestations. Gingival hypertrophy can be greatiy minimized by scrupulous dally care of gums and prophylactic dental care. Megaloblastic anemia and macrocytosis have been reported but have responded to antianemic therapy. Leukopenia, granulocytopenia, thrombocytopenia, pancytopenia, aplastic anemia, and agranulocytosis have also been reported. Usually these patients were simultaneously receiving other drugs. Lupus erythematosus and erythema muitiforme have occurred in patients receiving DILANTIN. DOSAGE AND ADMINISTRATION (DILANTIN): In all cases, optimal dosage of DILANTIN must be determined by trial. Dosage in excess of the minimum required to prevent convulsions is not recommended. For most patients, DILANTIN CAPSULES, 100mg or DILANTIN CAPSULES, 30mg are suitable for administration. FORMS AVAILABLE: In order to provide versatile therapy, DILANTIN is supplied in the following convenient product forms: DILANTIN* CAPSULES, 100 mg (Cap 362). Each white capsule with orange cap contains phenytoin sodium 100 mg. DILANTIN* CAPSULES, 30 mg (Cap 365). Each white capsule with pale pink cap contalns phenytoin sodium 30mg. DILANTIN* INFATABS, 50 mg. Each triangular shaped, grooved tablet, contalns 50mg phenytoin. INFATABS are palatably flavoured tablets, intended primarily for pediatric use. DILANTIN-125 SUSPENSION. Each 5 ml contalns 125 mg phenytoin. DILANTIN-30 SUSPENSION. Each S ml contains 30mg phenytoin. These are pleasantly flavoured suspensions of DILANTIN, especially adapted for pediatric use, but suitableforadolescents and aduits who preferliquid medication. . DILANTIN* with 15 mg PHENOBARBITAL CAPSULES, (Cap. 375). Each white capsule with garnet cap contalna 100mg phenytoin sodium and 15mg phenobarbital.
564 CMA JOURNAL/SEPTEMBER 23, 1978/VOL. 119
DILANTIN with 30mg PHENOBARBITAL CAPSULES (Cap. 531). Each white capsule with black cap contains 100mg phenytoin sodium and 30mg phenobarbital. These combinations of DILANTIN with PHENOBARBITAL are supplied for the convenient and economical use of those patients who require combined DILANTIN and PHENOBARBITAL therapy. .> PHELANTIN CAPSULES*, (Cap. 394). Each yellow capsule contains phenytoin sodium, 100 mg; phenobarbital. 30mg; and methamphetamine hydrochloride, 2.5 mg. Combining these agents takes advantage of the clinically proved anticonvulsant actions of DILANTIN and phenobarbital, while the methamphetamine counteracts the sedative effects of phenobarbital. DILANTIN. AMPOULES, 100 mg (Amp. 1488). Each 2 ml ampoule contains 100 mg (50 mg/mI) phenytoin sodium ready-mixed. DILANTIN* AMPOULES, 250 mg (Amp. 1475). Each 5 ml ampoule contains 250mg (50 mg/mI) of phenytoin sodium ready-mixed. INDICATIONS (ZARONTIN): ZARONTIN is indicated for the control of petit mal epilepsy. PRECAUTIONS (ZARONTIN): The physician should be alert to any symptoms indicative of the following conditions which have been reported in association with the use of ZARONTIN: aplastic anemia, agranulocytosis, dermatitis, leukopenia. Periodic blood counts should be performed. The drug should be used with caution in patients with known liver or renal disease or dysfunction. Routine urinalyses and frequent liverfunction tests are advised. Safe use of this drug in pregnancy has not been established. Because of the possibility of drug-induced drowsiness, operation of motor vehicles or other machinery by patients on ethosuximide therapy is not advised. ZARONTIN when used alone in mixed types of epilepey may increase the frequency of grand mal attacks in some patients. ADVERSE REACTIONS (ZARONTIN): In 727 patients gastrointestinal side effects occurred in 12.5%, central nervous system symptoms in 6.7%, blood changes in 0.4%, and miscellaneous side effects in 1.2%. Side effects are usually mild and transient and usually subside with continued therapy. Anorexia, gastric distress, nausea, emesis, drowsiness, headache, dizziness, euphoria, and singultus have been reported. Psychiatric or peychologic aberrations, including insomnia, night terrors, inability to concentrate, motor unrest, agitation, and aggressiveness thought to be drug-induced or exacerbated by anticonvulsant medication, were noted in a few patients who had previouslyshown emotional instability. Leukopenia, agranulocytosis, and severe pancytopenia with fatal outcome, have been reported in association with ethosuximide. In most cases of leukopenia, the condition cleared either on reduction of dosage or discontinuation of the dru9. Other reactions in which the extent of ethosuximide implication is not yet determined include myopia, rash, vaginal bleeding, swelling of the tongue, and hirsutism. One instance of temporarily elevated (3-plus) cephalin flocculation test has been reported; patient showed normal values as medication continued. DOSAGE AND ADMINISTRATION (ZARONTIN): The initial dose for children under six years of age is 250 mg (1 capsule or 5 ml of syrup) per day; for patients six years of age and older, 500mg (2 capsules or 10 ml of syrup) per day. The dose thereafter must be individualized according to the patient's response. FORMS AVAILABLE: ZARONTIN* CAPSULES, 250 mg (Cap. 237). Each soluble gelatin capsule contains 250 mg ethosuximide. ZARONTIN* SYRUP: Each 5 ml contalns 250 mg ethosuximide. Full prescribing information available on request.
PARKE-DAVIS .
Parke, Davis & Company, Ltd. carborough, Ont. MiK 5C5
L..?.J
i.ORELCa PROBUCOL ANTIHYPERCHOLESIEROLEMIC AGENT INDICATIONS: LORELCO is indicated as an adjunct to diet for the treat ment of hypercholesterolemia associated with elevated low density lipoproteins, and may he useful in loweringelevated chotesferol levels in patients with mined hyperfipidemia (hypercholesterolemia and hypertrigtyceridemial, where the hypercholesterolemia is the moiety of most concern. .ONTRAINDICATIONS: LORELCO is contraindicated in patients known to he hypersensitive to the drug. The safety of LORELCO has not been established in pregnancy and therefore, it should not be used in these circumstances, neither should it he used in nursing mothers since animal studies have shown that the drug is excreted in milk. WARNINGS: Strict birth control procedures must beesercised hy women of child-bearing potential. In the event LORELCO is discontinued, such procedures should be followed for at least the suhsequent sin months. In the eventa marked and sustained elevation in the serum triglyceride level occurs that is not related to diet, consideration should be given to discontinuing treatment with LORELCO. (See PRECAUTIONS). PRECAUTIONS: Before instituting therapy with LORELCO (probucol) an attempt should be made to control serum cholesterol by appropriate dietary regimens, weight reduction, and the treatment of any underlying disorder which might be the cause of the hypercholesterolemia. Because LORELCO is intended furlong term administration, adequate baseline studies should be performed to determine that the patient has elevated serum cholesterol levels. Serum cholesterol levels should be determined frequently during the first few months of treatment and periodically thereafter. A favorable trend in cholesterol reduction should be evident during the first two months of LORELCO administration. This regimen should befollowed as longasthetrend continuesand a decision should be made by thefourtb month asto whetheran adequate reduction is being maintained. A baseline for serum triglycerides should also be established and serum triglyceride levels should be determined periodically. If a marked sustained rise in serum triglycerides is observed during probucol therapy: consideration should be given to improved diet compliance. alcohol abstinence, further calorie restriction or adjustment of carbohydrate intake. Probucol should not be continued if this hyper triglyceridemia persists. Limited experience from clinical studies indicates that an increase in serum triglyceride levels can sometimes occur without necessarily an additive effect being apparent on the serum cholesterol, when LORELCO is used concomitantly with clofibrafe. The combination of LORELCO and clofibrate is, therefore, not recommended. The safety and effectiveness of LORELCO has not been established in children. ADVERSE REACTIONS: The adverse reactions associated with LORELCO (probucol) are generally mild to moderate and of short duration. The most commonly affected system is the gastrointestinal tract. Diarrhea occurs in about one in 10 patients. Other adverse gastrointestinal reactions in descending order of frequency are flatulence, abdominal pain, nausea and vomiting. These reactions are usuallytransient and seldom require the drug to be discontinued. Duringthe clinical studies, LORELCO was discontinued in about 2% of the patients because of adverse gastrointestinal reactions. Less frequent adverse reactions are: hyperhidrosis, fetid sweat and angloneurotic edema occurring in less than one in 500 subjects. An idiosyncratic reaction characterized by dizziness, palpitations, syncope, nausea, vomiting and chest pain has been reperted. Other events, where the relationship to LORELCO has not been established include: headache, dizziness, paresthesia and eusinophilia, observed in about one in 5fsabjects; consistently low hemoglobin and! or hematocrit values, observed in about one in 100 patients; rash, pruritus, impotency, insomnia, conjunctivitis, tearing, blurred vision, tinnitus, diminished sense of taste and smell, enlargement of a multinodular goiter, anorexia, heartburn, indigestion, vomiting, gaslrointesfinal bleeding, ecchymosis and petechiae, thrombocytopenia, nocturia, and peripheral neuritis, observed with a frequency of about onefo six per thousand subjects. Elevations of the serum transaminases (glufamic-oxalacetic and glotamic-pyruvic), bilirubin, alkaline phosphatase, creative phosphokinase, uric acid, blood urea nitrogen and blood glucose abovethe normal range were observed on one or more occasions in various patientstreated with LORELCO (probucol). Most often these were transient and/or could have been related to the patient's clinical state or other modes of therapy. Although the basis for the relationship between probucol and theseabuormalities is not firm, the possibilifythat some ofthesearedrug related cannot be excluded. In the controlled trials the incidence of abnormal laboratory values was not higher in the patients treated with probucol than in the patients who received placebo. DOSAGE AND ADMINISTRATION: The recommended adult dose is 500 ag (two 250 mg tablets), twice daily, with morning and evening meals. AVAILABILITY: LORELCO is a white, film-coated tablet, containing 250 mg probucol, available in bottles 01120 tablets. Product monograph available upon request.
DOW PHARMACEUTICALS Dow Chemical of Canada, Limited 380 Elgin Mills Road East, Richmond Hill, Ontario Twadelnaff of She 5ow Chem,cal comoany
.
ficers, alarmed at the grotesque ap- to victims. The successive mortality pearance of an acute ailment in their rates for choking (suffocation from trusty warriors, excused them from ingestion of food or an object) from duty and often packed them off to 1971 through 1976 in the United hospital - much to the delight of States were 2877, 2830, 3013, 2991, 3106 and (estimated) 2900.2 the sufferers. I believe that research methods Soldiers far from hearth and home have repeatedly exploited the limit- must be developed to determine the less possibilities for malingering. In effectiveness of such unproven meththese instances, by nicking the inside ods as back-slapping and the selfof the cheek with a razor blade, applied Heimlich maneuver in the pinching the nose, shutting the mouth hope that an effective and easy-toand expelling a few quick forced remember technique will result. breaths, they created a new tropical Opening the mouth widely and forcing the tongue out might be found disease. to allow a sufficient opening so that IAN MIDDLEMASS, MD Department of radiology a victim could continue to breathe Royal Inland Hospital or even expel an obstruction. Also Kamloops, BC to be considered is that, in normal males, maximum forced expiration Reference produces an average pulmonary pres1. Box HK: Oxygen Insufflation in Perio- sure of 114 mm Hg,' a pressure more dontal Diseases, CC Thomas, Springthan three times that produced by field, Ill, 1955, p 88 the Heimlich maneuver. Because a To the editor: The article by Clement million lives will be at stake over the and Lommell brings to mind two next 20 years, this subject demands cases I have seen in which the cause a more systematic approach than it of cervicofacial emphysema was has been given in the past. other than dental surgery. In the JOHN SPRINGFIELD, MA Middle East during World War II a Cancer research laboratory young serviceman was admitted to Veterans Administration Hospital Minneapolis, Minnesota the psychiatric unit with cervicofacial emphysema. I would not have thought this remarkable, but shortly References afterwards a second person from the 1. HEIMLICH HJ: Food asphyxiation (C). Can Med Assoc J 112: 1383, 1975 same unit was admitted. As these servicemen were homosexual part- 2. National Safety Council: Accident Chicago, 1975-77 ners, one would have thought there 3. Facts, RAHN H, Oris AB, CHADWICK LE, et was a connection, but where? al: The pressure volume diagram of Eventually the truth came out. the thorax and lung. Am J Physiol 146: 161, 1946 The emphysema was self-induced: the men used the pricker of a Primus stove to prick the buccal mucosa, Cesarean section: what is held the nose, and then, with the an acceptable rate? (correction) mouth closed, blew hard. They hoped to get a medical discharge, F. Toll, manager of the management but it was on grounds of homo- information section of the Manitoba sexuality that they left the service. Health Services Commission, has brought the attention of the Journal MYRE SIM, MD, FRCP (ErnN), FRC PSYCH, and Dr. T.F. Baskett to some disFRCP[C], DPM Professor of psychiatry crepancies in the data cited in his University of Ottawa Ottawa, Ont. editorial (118: 1019, 1978). The second sentence of the second paragraph, with italics indicating the corrected figures, should read: "In MaThe Heimlich maneuver nitoba the overall rate had doubled To the editor: The Heimlich man- since 1971, reaching 9.8% in 1976, euver, first publicized in 1974, has and varied from 12.7% to 16.2% been reported to be very effective in (average 14.2%) in teaching hospiexpelling boluses by pressurizing the tals, 6.1% to 13.1% (average 9.6%) lungs to an average of 31 mm Hg.1 in community hospitals served by However, as judged from the un- specialists in obstetrics and other abated mortality, competent assist- fields, and 0% to 15.4% (average ance of this type is seldom available 5.5%) in rural hospitals.. .". - Ed.
568 CMA JOURNAL/SEPTEMBER 23, 1978/VOL. 119
