employees in the arenas are less active and perhaps exposed less to carbon monoxide than the skaters, in Winnipeg, and doubtless in many other parts of Canada, the carbon monoxide concentrations in arenas have been much higher than 22.5 ppm, sometimes exceeding 100 ppm for hours at a time. Standards applied to carbon monoxide emission levels vary widely. Acceptable average 1-hour levels can be as high as 100 ppm0 or as low as 13 ppm (unpublished data). All are based on projected carboxyhemoglobin levels resulting from exposure, but, understandably, none are specifically calculated for the activity and exposure of a hockey arena. Because of the significant abatement costs involved, we believed it best to generate criteria that would be specific. Following the lead of the federal Department of the Environment we used the relation described by Larsen and Burke7 to arrive at composite standards for the three exposure groups involved - skaters, spectators and employees - of an average of 25 ppm for 1 hour and 12 ppm for 8 hours. These concentrations would likely produce a carboxyhemoglobin level of 3%, hence obviating documented ill effects. Corrective measures investigated by our group are aimed at improving ventilation and reducing emission levels at the source. Since ventilation equipment is expensive to modify in existing structures, the corrective approach has been aimed primarily at raising exhaust pipes above the Plexiglas® barrier for better dispersal of the exhaust, opening the end doors of the arena during and after flooding, and shunting the exhaust outside with a flexible hose during warm-up of the machine. Reduction of emission levels at the source has led to two basic approaches: catalytic mufflers on gasoline machines and propane conversion. The latter has been attempted in several centres. Although propane conversion has proved adequate in some instances, it has often resulted in temperamental vehicles and problems with handling the propane (H. Monroe: personal communication, 1979). The use of mufflers on vehicles run by gasoline is presently being en-
tertained by Winnipeg at an initial outlay of approximately $1000 per vehicle. Maintenance schedules are demanding, however, and several tune-ups per season are anticipated; thus ongoing costs should be sharply increased over those of previous years. We hope that training courses for operators will standardize the technique and keep resurfacing time to a minimum. Further monitoring to evaluate the success of the program will be carried out this winter. Initial indications are that our criteria can be met. We are grateful for the assistance of the individuals from various jurisdictions across the country who have provided us with information from their experience. If other health professionals have comments or observations we would be very pleased to receive them. D.G. LUCKHURST, MD Deputy medical officer of health Inner City Health Department 510 Main St. Winnipeg, Man. R3B 1B9 W. FRENCH, MD
Executive director Department of Health and Social Development 831 Portage Ave. Winnipeg, Man. R3C 0V8
References 1. JOHNSON CJ, MORAN JC, PAINE SC,
et al: Abatement of toxic levels of carbon monoxide in Seattle ice-skating rinks. Am J Public Health 65: 10, 1975 2. Indoor ice rinks: a public health problem. Mich Occup Health 19: 1, 1973 3. SPENGLER JD, STONE KR, LILLEY FW: High carbon monoxide levels measured in enclosed skating rinks. J Air Pollut Control Assoc 28: 776, 1978 4. MCFARLAND RA: Low level exposure to carbon monoxide and driving
performance. A rcli Environ Health 27: 355, 1973 5. AYRE5 SM, MUELLER HS, GREGORY
JJ, et al: Systemic and myocardial hemodynamic responses to relatively small concentrations of carboxyhemoglobin (COHB). Arch Environ Health 18: 699, 1969 6. Alberta regulation
no 298/72, in
Alberta Gazette, Part if, vol 68, Queen's p 936
Printer,
Edmonton,
1972,
7. LARSEN RI, BURKE HW: Ambient carbon monoxide exposures. Presented at Air Pollution Control Association Meeting, New York City, June 22-26, 1969
1056 CMA JOURNAL/OCTOBER 20, 1979/VOL. 121
Group B streptococcal infection in the newborn To the editor: The commentary on group B streptococcal infection in the newborn by Dr. David Schiff deserves some discussion (Can Med Assoc J 120: 1047, 1979). This is indeed an important problem; however, Dr. Schiff did not discuss several important approaches to therapy and prevention. Therapy for group B streptococcal infection is somewhat controversial; the administration of 200 000 U/kg of penicillin for 10 to 14 days should be undertaken with care. This quantity of penicillin yields extremely high concentrations in the serum and cerebrospinal fluid; such a large dose should not be administered as a bolus injection because of its epileptogenic potential in the newborn. In fact, many prefer the use of conventional doses of penicillin (50 to 100 000 U/kg daily) combined with an aminoglycoside, such as gentamicin; others use ampicillin (100 mg/kg daily) instead of penicillin. This approach is based on evidence that the rate of bacterial killing is enhanced by such combinations.1 They are therefore used in the initial treatment of group B streptococcal infection, and then penicillin administration is continued for a further 10 to 14 days. The prevention of group B streptococcal infection has been under study for some time. Yow and colleagues2 have presented evidence that antibiotics are useful in preventing colonization or infection in the newborn when administered to the mother during early and established labour. Others have noted this effect in an uncontrolled fashion when penicillin was administered to newborn infants.3'4 Antibiotics should not be expected to prevent late onset of the disease. The administration of antibiotics to all mothers and babies perinatally promotes some hazards, such as selection of resistant populations of bacteria, masking of infections due to penicillin-sensitive (or partially sensitive) bacteria, superinfection and toxic effects of drugs. Hence, immunologic approaches to the prevention of group B streptococcal infection in the newborn have received much attention. Some
approaches include the use of active and passive immunization with pneumococcal vaccine,5'8 the administration of leukocytes or antibodies from individuals immune to group B Streptococcus,7 and the development of a group B Streptococcus type 3 vaccine.8 Such approaches, if successful, should allow the identification of an immunologically susceptible maternal population and the selective application of acute or passive immunization, or both, which would be preferable to an antibiotic approach in my opinion. MELVIN I. MARKS, MD
Professor of pediatrics Director of infectious diseases division University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma
References 1. COOPER MD, KEENEY RE, LYONS SF,
et al: Synergistic effects of ampicillin-aminoglycoside combinations on group B streptococci. A utitnicrob Agents Chemother 15: 484, 1979 2. Yow MD, LEEDS U, THOMPSON PK,
et al: Prevention of intrapartum transmission of group B streptococcal infection by intravenous ampicillin. JAMA 241: 1247, 1979 3. LLOYD DJ, BELGAUMKAR TK, Scorr
KE, et al: Prevention of group B streptococcal (GBS) infection in low birth weight (LBW) infants by penicillin (P) administration from birth (abstr). Pediatr Res 12: 495, 1978 4. STEIGMAN AJ, BOTTONE EJ, HANNA
BA: Intramuscular penicillin administration at birth - prevention of early-onset group-B streptococcal disease. Pediatrics 62: 842, 1978 5. FISCHER GW, LOWELL GH, CRUM-
RINE MH, et al: Demonstration of opsonic activity and in vivo protection against group B streptococci type III by Streptococcus pneumoniae type 14 antisera. J Exp Med 148: 776, 1978 6. LOWELL GH, FISCHER GW, WILSON
SR, et al: Serum for adults immunized with pneumococcal vaccine is opsonic in vitro and protective in vivo for group B type III streptococci (abstr). Pediatr Res 13: 463, 1979 7. SHIGEOKA AO, SANTOS JI, HILL HR:
Protection against group B streptococcal infection by administration of leukocytes or antibody containing serum (abstr). Ibid, p 468 8. BAKER
CJ,
EDWARDS
MS.
KASPER
DL: Immunogenicity of polysaccharides from type III, group-B streptococcus. J Clin Invest 61: 1107, 1978
To the editor: Dr. Marks is right when he comments on the promise held by the immunologic approach to the prevention of group B streptococcal infection in the newborn. Indeed, if the present research in this complex area is successful, a more suitable and safer approach to the management of this serious condition in the perinatal period will be achieved. However, to date this is still a serious problem in the perinatal period, and one must strive to make use of what information is presently available on the identification and prevention of this condition in the newborn. Of the many approaches that have been suggested, it seems that that of Yow and colleagues1 holds the most promise. The routine use of penicillin in all newborn infants has been recommended by some investigators2 and is subject to the same criticism expressed by Dr. Marks - that is, many infants not subject to group B streptococcal infection will be exposed to penicillin and its inherent risks. This approach would only deal with mothers in endemic areas or known to be at risk of harbouring the organism. Dr. Marks refers to the dosage of penicillin that has been recommended. There is no question that this is a somewhat controversial area, and indeed in my experience I have found that the conventional daily dose of penicillin, 100000 U/kg, has been as effective as the larger recommended dose. Although the epileptogenic effect of penicillin has been documented, in 15 years' experience in neonatal medicine we have yet to see such a case. D. SCHIFF, MD, PH D, FRcP[c]
Director of newborn nurseries Professor of pediatrics, obstetrics and gynecology University of Alberta Edmonton, Alta.
SUDAFED TABLETS / SYRUP Pseudoephedrine HCI Decongestant
Indications: Relief of nasal congestion associated with allergic rhinitis, acute coryza, vasomotor rhinitis, acute and subacute sinusitis, acute otitis media, asthma, postnasal drip, acute eustachian salpingitis. It may also be used as an adjunct to antibiotics, antihistamines, analgesics and antitussives in the treatment of the aboveconditions. Contraindications: Patients receiving or having received MAO inhibitors in the preceding 3 weeks; known hypersensitivity to pressor amines. Precautions: As pseudoephedrine is a sympathomimetic amine, it should be used with caution in hypertensive and diabetic patients, patients with latent or clinically recognized angle-closure glaucoma, coronary artery disease, congestive heart failure, prostatic hypertrophy, hyperthyroidism, urinary retention. Adverse Effects: As with other sympathomimetic amines, headache, dizziness, insomnia, tremor, confusion, CNS stimulation, muscular weakness, dry mouth, nausea, vomiting, difficulty in micturition, palpitations, tightness in thechest and syncope may beencountered. Overdose: Symptoms: Increase in pulse and respiratory rate, CNS stimulation, disorientation, headache, dry mouth, nausea and vomiting. Treatment: Gastric lavage, repeated if necessary. Acidify the urine and institute general supportive measures. If CNS excitement is prominent, a short-acting barbiturate may be used. Dosage: Adults and children over 6 years: 2 teaspoonfuls of syrup or 1 tablet 3 times daily. Children 4 months to 6 years: ½ adult dose. Infants upto4 months: ½ teaspoonful of syrup 3 times daily. Supplied: Syrup: Each 5 ml of clear purplish-red syrup with a sweet raspberry flavor contains: pseudoephedrine HCI 30 mg. Available in 100 ml and 250 ml bottles. Tablets: Each white, biconvex tablet 8.6 mm in diameterwith code number WELLOOME S7A on same side as diagonal score mark contains: pseudoephedrine HCI 60 mg. Available in cartonsof 18 and bottles of iQOand SOOtablets. Additional prescribing information available on request.
References 1. Yow MD, LEEDS U, THOMPSON PK, et al: Prevention of intrapartum transmission of group B streptococcal in* fection by intravenous ampicillin. JAMA 241: 1247, 1979 2. LLOYD DJ, BELGAUMKAR TK, SCOTT
KE, et al: Prevention of group B streptococcal (GBS) infection in low birth weight (LBW) infants by penicillin (P) administration from birth (abstr). Pediatr Res 12: 495, 1978
Welicome Medcai Division 0u6.Weilcome Ltd. Trade Mark .
CMA JOURNAL/OCTOBER 20, 1979/VOL. 121
W-8004
1057
tertained by Winnipeg at an initial outlay of approximately $1000 per vehicle. Maintenance schedules are demanding, however, and several tune-ups per season are anticipated; thus ongoing costs should be sharply increased over those of previous years. We hope that training courses for operators will standardize the technique and keep resurfacing time to a minimum. Further monitoring to evaluate the success of the program will be carried out this winter. Initial indications are that our criteria can be met. We are grateful for the assistance of the individuals from various jurisdictions across the country who have provided us with information from their experience. If other health professionals have comments or observations we would be very pleased to receive them. D.G. LUCKHURST, MD Deputy medical officer of health Inner City Health Department 510 Main St. Winnipeg, Man. R3B 1B9 W. FRENCH, MD
Executive director Department of Health and Social Development 831 Portage Ave. Winnipeg, Man. R3C 0V8
References 1. JOHNSON CJ, MORAN JC, PAINE SC,
et al: Abatement of toxic levels of carbon monoxide in Seattle ice-skating rinks. Am J Public Health 65: 10, 1975 2. Indoor ice rinks: a public health problem. Mich Occup Health 19: 1, 1973 3. SPENGLER JD, STONE KR, LILLEY FW: High carbon monoxide levels measured in enclosed skating rinks. J Air Pollut Control Assoc 28: 776, 1978 4. MCFARLAND RA: Low level exposure to carbon monoxide and driving
performance. A rcli Environ Health 27: 355, 1973 5. AYRE5 SM, MUELLER HS, GREGORY
JJ, et al: Systemic and myocardial hemodynamic responses to relatively small concentrations of carboxyhemoglobin (COHB). Arch Environ Health 18: 699, 1969 6. Alberta regulation
no 298/72, in
Alberta Gazette, Part if, vol 68, Queen's p 936
Printer,
Edmonton,
1972,
7. LARSEN RI, BURKE HW: Ambient carbon monoxide exposures. Presented at Air Pollution Control Association Meeting, New York City, June 22-26, 1969
1056 CMA JOURNAL/OCTOBER 20, 1979/VOL. 121
Group B streptococcal infection in the newborn To the editor: The commentary on group B streptococcal infection in the newborn by Dr. David Schiff deserves some discussion (Can Med Assoc J 120: 1047, 1979). This is indeed an important problem; however, Dr. Schiff did not discuss several important approaches to therapy and prevention. Therapy for group B streptococcal infection is somewhat controversial; the administration of 200 000 U/kg of penicillin for 10 to 14 days should be undertaken with care. This quantity of penicillin yields extremely high concentrations in the serum and cerebrospinal fluid; such a large dose should not be administered as a bolus injection because of its epileptogenic potential in the newborn. In fact, many prefer the use of conventional doses of penicillin (50 to 100 000 U/kg daily) combined with an aminoglycoside, such as gentamicin; others use ampicillin (100 mg/kg daily) instead of penicillin. This approach is based on evidence that the rate of bacterial killing is enhanced by such combinations.1 They are therefore used in the initial treatment of group B streptococcal infection, and then penicillin administration is continued for a further 10 to 14 days. The prevention of group B streptococcal infection has been under study for some time. Yow and colleagues2 have presented evidence that antibiotics are useful in preventing colonization or infection in the newborn when administered to the mother during early and established labour. Others have noted this effect in an uncontrolled fashion when penicillin was administered to newborn infants.3'4 Antibiotics should not be expected to prevent late onset of the disease. The administration of antibiotics to all mothers and babies perinatally promotes some hazards, such as selection of resistant populations of bacteria, masking of infections due to penicillin-sensitive (or partially sensitive) bacteria, superinfection and toxic effects of drugs. Hence, immunologic approaches to the prevention of group B streptococcal infection in the newborn have received much attention. Some
approaches include the use of active and passive immunization with pneumococcal vaccine,5'8 the administration of leukocytes or antibodies from individuals immune to group B Streptococcus,7 and the development of a group B Streptococcus type 3 vaccine.8 Such approaches, if successful, should allow the identification of an immunologically susceptible maternal population and the selective application of acute or passive immunization, or both, which would be preferable to an antibiotic approach in my opinion. MELVIN I. MARKS, MD
Professor of pediatrics Director of infectious diseases division University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma
References 1. COOPER MD, KEENEY RE, LYONS SF,
et al: Synergistic effects of ampicillin-aminoglycoside combinations on group B streptococci. A utitnicrob Agents Chemother 15: 484, 1979 2. Yow MD, LEEDS U, THOMPSON PK,
et al: Prevention of intrapartum transmission of group B streptococcal infection by intravenous ampicillin. JAMA 241: 1247, 1979 3. LLOYD DJ, BELGAUMKAR TK, Scorr
KE, et al: Prevention of group B streptococcal (GBS) infection in low birth weight (LBW) infants by penicillin (P) administration from birth (abstr). Pediatr Res 12: 495, 1978 4. STEIGMAN AJ, BOTTONE EJ, HANNA
BA: Intramuscular penicillin administration at birth - prevention of early-onset group-B streptococcal disease. Pediatrics 62: 842, 1978 5. FISCHER GW, LOWELL GH, CRUM-
RINE MH, et al: Demonstration of opsonic activity and in vivo protection against group B streptococci type III by Streptococcus pneumoniae type 14 antisera. J Exp Med 148: 776, 1978 6. LOWELL GH, FISCHER GW, WILSON
SR, et al: Serum for adults immunized with pneumococcal vaccine is opsonic in vitro and protective in vivo for group B type III streptococci (abstr). Pediatr Res 13: 463, 1979 7. SHIGEOKA AO, SANTOS JI, HILL HR:
Protection against group B streptococcal infection by administration of leukocytes or antibody containing serum (abstr). Ibid, p 468 8. BAKER
CJ,
EDWARDS
MS.
KASPER
DL: Immunogenicity of polysaccharides from type III, group-B streptococcus. J Clin Invest 61: 1107, 1978
To the editor: Dr. Marks is right when he comments on the promise held by the immunologic approach to the prevention of group B streptococcal infection in the newborn. Indeed, if the present research in this complex area is successful, a more suitable and safer approach to the management of this serious condition in the perinatal period will be achieved. However, to date this is still a serious problem in the perinatal period, and one must strive to make use of what information is presently available on the identification and prevention of this condition in the newborn. Of the many approaches that have been suggested, it seems that that of Yow and colleagues1 holds the most promise. The routine use of penicillin in all newborn infants has been recommended by some investigators2 and is subject to the same criticism expressed by Dr. Marks - that is, many infants not subject to group B streptococcal infection will be exposed to penicillin and its inherent risks. This approach would only deal with mothers in endemic areas or known to be at risk of harbouring the organism. Dr. Marks refers to the dosage of penicillin that has been recommended. There is no question that this is a somewhat controversial area, and indeed in my experience I have found that the conventional daily dose of penicillin, 100000 U/kg, has been as effective as the larger recommended dose. Although the epileptogenic effect of penicillin has been documented, in 15 years' experience in neonatal medicine we have yet to see such a case. D. SCHIFF, MD, PH D, FRcP[c]
Director of newborn nurseries Professor of pediatrics, obstetrics and gynecology University of Alberta Edmonton, Alta.
SUDAFED TABLETS / SYRUP Pseudoephedrine HCI Decongestant
Indications: Relief of nasal congestion associated with allergic rhinitis, acute coryza, vasomotor rhinitis, acute and subacute sinusitis, acute otitis media, asthma, postnasal drip, acute eustachian salpingitis. It may also be used as an adjunct to antibiotics, antihistamines, analgesics and antitussives in the treatment of the aboveconditions. Contraindications: Patients receiving or having received MAO inhibitors in the preceding 3 weeks; known hypersensitivity to pressor amines. Precautions: As pseudoephedrine is a sympathomimetic amine, it should be used with caution in hypertensive and diabetic patients, patients with latent or clinically recognized angle-closure glaucoma, coronary artery disease, congestive heart failure, prostatic hypertrophy, hyperthyroidism, urinary retention. Adverse Effects: As with other sympathomimetic amines, headache, dizziness, insomnia, tremor, confusion, CNS stimulation, muscular weakness, dry mouth, nausea, vomiting, difficulty in micturition, palpitations, tightness in thechest and syncope may beencountered. Overdose: Symptoms: Increase in pulse and respiratory rate, CNS stimulation, disorientation, headache, dry mouth, nausea and vomiting. Treatment: Gastric lavage, repeated if necessary. Acidify the urine and institute general supportive measures. If CNS excitement is prominent, a short-acting barbiturate may be used. Dosage: Adults and children over 6 years: 2 teaspoonfuls of syrup or 1 tablet 3 times daily. Children 4 months to 6 years: ½ adult dose. Infants upto4 months: ½ teaspoonful of syrup 3 times daily. Supplied: Syrup: Each 5 ml of clear purplish-red syrup with a sweet raspberry flavor contains: pseudoephedrine HCI 30 mg. Available in 100 ml and 250 ml bottles. Tablets: Each white, biconvex tablet 8.6 mm in diameterwith code number WELLOOME S7A on same side as diagonal score mark contains: pseudoephedrine HCI 60 mg. Available in cartonsof 18 and bottles of iQOand SOOtablets. Additional prescribing information available on request.
References 1. Yow MD, LEEDS U, THOMPSON PK, et al: Prevention of intrapartum transmission of group B streptococcal in* fection by intravenous ampicillin. JAMA 241: 1247, 1979 2. LLOYD DJ, BELGAUMKAR TK, SCOTT
KE, et al: Prevention of group B streptococcal (GBS) infection in low birth weight (LBW) infants by penicillin (P) administration from birth (abstr). Pediatr Res 12: 495, 1978
Welicome Medcai Division 0u6.Weilcome Ltd. Trade Mark .
CMA JOURNAL/OCTOBER 20, 1979/VOL. 121
W-8004
1057
