Tandearil® Brief Prescribing Information Dosage In arthritis, extra-articular rheumatism and superficial thrombophlebitis - 400-600 mg per day (4-6 tablets). When improvement is obtained (generally in 2 or 3 days), the dose should be reduced to the lowest effective level. In severe trauma and its sequelae - 400600 mg (4-6 tablets) daily in divided doses for 4 days to a week. For indications in surgery - 400-600 mg (4-6 tablets) daily in divided doses during the 24 hours prior to surgery. As soon as oral medication can be resumed after surgery, maintenance is 300-400 mg daily for 3-4 days. It is suggested that the maintenance level not exceed 400 mg per day. Tandearil should be taken with meals or with a glass of milk. In the absence of a favourable response after a one week trial period, it is recommended that administration of Tandearil be discontinued. Contraindications Tandearil is contraindicated in patients with a history of blood dyscrasia or drug allergy and in those with a history or symptoms of peptic ulcer. In addition, it should not be given to senile patients, to patients with clinical edema or to those with severe renal, hepatic or cardiac disease. Precautions A careful history, physician examination and complete blood count should be done before initiating therapy. Patients receiving this drug should be followed closely and should be warned to discontinue Tandearil and contact their physician immediately should any of the following signs or symptoms appear: fever, sore throat, lesions in the mouth, black or tarry stools, skin reactions or a sudden gain in weight. Patients undergoing long-term therapy should have blood counts done at monthly intervals. Care should be taken when prescribing for the elderly. As with any drug, Tandearil should not be used during the first trimester of pregnancy unless in the opinion of the prescribing physician, the potential benefits outweigh the possible risks. Tandearil may prolong the effect of other drugs taken concomitantly. Special attention should be paid to this fact when anticoagulants are prescribed. Side Effects Nausea, vomiting, abdominal discomfort, formation or activation of peptic ulcer and sodium retention with edema are known to occur. Although rarely observed, hypersensitivity reactions, dermatological reactions and blood dyscrasias have been reported. Availability Tandearil Tablets Each light brown, sugar-coated tablet, branded . in brown, contains 100 mg oxyphenbutazone Geigy Standard. Supplied in bottles of 50 and 500. Full information is available on request.

Geigy Dorval 780, Quebec

G-4063

our statistical findings regarding the observed/expected ratios in Table II. The probabilities shown were based on x2 analyses in which sample sizes are taken into account. Of the six ratios in Table II marked as having a probable significance at the 1% level or less, Dr. Sellers states that very few would be significant even at the 5% level according to his criteria. Perhaps both Dr. Sellers and ourselves have committed the same sin of omission (which we have now corrected with this statement) by failing to specify the statistical test used. We recognize that in any application of statistics one is free to increase or decrease the probability level one personally accepts as convincing. We are impressed by the number of Eskimos with malignant tumours of the lung (particularly women), nasopharynx, salivary gland and uterine cervix, and the relative infrequency of breast cancer. This is why we have published our findings. We are pleased that Dr. Sellers and others have found our paper worthy of comment. 0. SCHAEFER, MD

Northern Medical Research Unit Charles Camsell Hospital Edmonton, Alta.

JA. HILDES, MD

Northern Medical Unit University of Manitoba Winnipeg, Man.

A Canadian institute of child health? To the editor: Over the next few months I shall be engaged in a study of the need for some such organization as an institute of child health to draw attention to the health needs of children. I shall be consulting with parents. physicians, nurses, social workers and other allied health workers, politicians, economists, administrators and members of existing organizations. Many of the problems in child health have been documented. The results of a national nutrition survey caused grave concern about the status of nutrition among Canadian children and teenagers. The Celdic report warned of a crisis situation in learning disabilities. Recent reports indicate an increasing incidence of teenage suicides. Child abuse is now recognized as a national problem. Accidents are the major cause of death between the ages of 2 and 5 years. Venereal disease is reported as having reached epidemic proportions among adolescents. There are many other concerns. It has been suggested that an institute of child health could identify problems and assign priorities; undertake studies to document these problems and propose solutions; secure "action" by stimulating public awareness, the

political process and legislation; act as a resource and information centre; provide liaison and coordination between child-health-related associations and institutions; and develop a national plan for the future health care of children. I would appreciate hearing personally from any physicians who have views on this subject. (MRS.) SHIRLEY POST, RN, MHA

48 Powell Ave. Ottawa, Ont. KIS 2A1

Physical fitness To the editor: In his letter commenting on physical fitness (Can Med Assoc J 113: 92, 1975) Dr. Sheehan concludes "Only when adults become playful will fitness follow and then only because it is not intended." I do not think of fitness as a byproduct of "play" but rather of "exertion", and few will have the energy to exert themselves to the point of perspiration, breathlessness, fatigue and pain from stressed tissues if they are chronically deficient in vitamins and minerals. Nutrition Canada has shown that the dietary intake of vitamin A and of calcium and iron is deficient in 48, 62 and 78%, respectively, of females in the age group 10 to 20 years. I believe that such individuals do not have the will to exert themselves. I believe that one of the basic requirements in the motivation to exert oneself is good nutrition. To ignore this premise is like whipping a starved horse. The best it can do is stand and gaze. CARL J. REICH, MD

205A Medical Centre Calgary, Alta.

"Le Rave Impossible" To the editor: I believe that some of the readers of the Journal will be interested in knowing that my Canadian historical novel "The Three Gifts" is now available in a French edition entitled "Le Rave Impossible". This edition has recently been recommended by the Library Association of Paris for inclusion in 10 of the libraries of that city. It is distributed by Libraire Dussault, 8955 boul. St-Laurent, Montreal, Qua. H2N 1M6. WILFRID PococK, MD

Huntsville, Ont.

Depression after myocardial infarction To the editor: In the paper "Depression after myocardial infarction" (Can Med Assoc J 113: 23, 1975) Kavanagh, Shephard and Tuck suggest that the presence or absence of depression is

QMA JOURNAL/SEPTEMBER 20, 1975/VOL. 113 495

somehow causally related to the occurrence of myocardial infarction. This may or may not be so but they have not provided support for the idea. Their paper does not show that the distribution of depression among patients with myocardial infarction is either unexpected or remarkable. Depression is a very common condition, and by using either the Minnesota Multiphasic Personality Inventory or an ordinary clinical examination it is possible to divide almost any group (e.g., persons with fractured femurs, cabinet ministers, truck drivers, etc.) into a "normal" and a "depressed" group. Even if the authors decided that the prevalence of clinical depression in their group of patients was higher than expected, their own figures suggest two possible reasons: 1. Age. The age groups that are more prone to myocardial infarction are also more prone to depression; the authors' older patients were also the more depressed. This was one of the two significant differences between the groups. 2. Medication for hypertension. The other significant difference between the "depressed", "intermediate" and "normal" groups was that the more depressed groups included more patients with hypertension. It is surprising that the authors did not state how many patients were receiving antihypertensive treatment, since it is well known that many of the drugs most commonly used to treat hypertension (e.g., rauwolfia, guanethidine, methyldopa, propranolol) are also potent causes of clinical *depression. It would be surprising if the prevalence of depression in a group of treated hypertensives were not unusually high. All one can really conclude from the findings presented is that some postinfarction patients are depressed and some are not; that there may or may not be an excess of depressions in a group of postinfarction patients; and that if there is any excess it can probably be accounted for in whole or in part on the basis of age or medication or both. The findings do not justify any more elaborate speculation about possible causal relationships between depression and myocardial infarction. What is important, however, is the effect of hypomania and depression on treatment and rehabilitation, regardless of the subtleties of causal relationships. In some instances the extent of depression was reported to be sufficient to demand psychiatric referral "if encountered in a normal population". Although the qualification is somewhat puzzling, it is clear that patients in the "depressed" group were thought to be genuinely clinically depressed. If, as

seems obvious, mania and depression do interfere with the best management of postinfarction patients, these conditions should be adequately diagnosed and treated. In any case they should be adequately diagnosed and treated in their own right as disabling and potentially fatal medical conditions; and there are more effective treatments for mania and depression than "restraint" and "encouragement". JAMES H. BROWN, MB

Department of psychiatry University of Manitoba Winnipeg, Man.

To the editor: I believe Dr. Brown has missed the point of our article. Without exception the severely depressed patients were also hypochondriacal and hysterical; that is, they had the socalled neurotic triad of symptoms. When hysteria and hypochondriasis were absent depression was also absent. A heart attack (or a broken leg. for that matter) may result in some shortterm depression but rarely, if ever, in long-term neurosis. Therefore it seems reasonable to postulate that the neurosis preceded the acute episode. We had considered the effect of antihypertensive drugs but found that this was not an important factor. The overall use of such medication was low, and similar in both groups. Apparently the degree of hypertension in the depressed group was not considered by the referring physicians to be severe enough clinically to require medication. However, even if this were not the case it would still have been difficult to attribute a neurosis to such pharmaceuticals. The same argument applies to the influence of ageing, which may engender depression but rarely neuro515.

With regard to treatment, we are in accord with Dr. Brown. Expert help is needed for these people if rehabilitation is to be effective. However, in a community postcoronary exercise program the first task is to recognize the two personality types and modify the exercise prescription accordingly. Our centre, the regional rehabilitation centre for Metropolitan Toronto, is fortunate in having a clinical psychologist and a psychiatrist available for our middle-aged postinfarction "jocks"; the average YMCA or commercial fitness institute is less adequately staffed. Even recognition may not be easy, for, as we have noted, the depression is "secret" and without psychotic tendencies. As for "precoronary" care, our previous paper1 describes the "triggering" effect of business and financial stress in a heart attack; it seems not unreasonable to postulate that the depressed neurotic with coronary artery disease will respond adversely to even the or-

498 CMA JOURNAL/SEPTEMBER 20, 1975/VOL. 113

dinary vicissitudes of life. Psychotherapy might, therefore, help to avert the acute episode in such cases. T. KAVANAGH, MD

Toronto Rehabilitation Centre 345 Rumsey Rd. Toronto, Ont.

Reference 1. KAVANAGH T, SHEPHARD RJ: The immediate antecedents of myocardial infarction in active men. Can Med Assoc J 109: 19, 1973

Testicular tumours in brothers-in-law To the editor: Musa (Can Med Assoc I 112: 1201, 1975) and Fetterly (Can Med Assoc 1 113: 92, 1975) describe two instances of malignant testicular tumours occurring in father and son. I would like to report an instance of malignant testicular tumours occurring contemporaneously in brothers-in-law. Since the two men were not consanguineous, environmental factors (oncogenic virus?) may have been important in the development of their neoplasms. In this instance genetic factors can be discounted. The first man, aged 43, had a 6-week history of a seminoma of the testis, which was treated by orchiectomy on June 15, 1965 and by postoperative radiotherapy. He is still alive and well. The second man, aged 36, had an 8-week history of a malignant teratoma of the testis, which was treated by orchiectomy on June 16, 1965 and by postoperative radiotherapy. He died within 6 months with brain metastases. The second man had been married for 15 years to the first man's sister. They met frequently socially. The two men had their orchiectomies on successive days in the same hospital. R.G.C. MACLAREN, MB, FRCS

The Ontario Cancer Foundation Hamilton clinic Hamilton, Ont.

Correction In the editorial "Head and body scanning by computer tomography" by William Feindel (Can Med AsSoc 1 113: 273, 1975) reference 5 should read: FEINDEL W, ETHIER R.

YAMAMOTO YL, et al: Computerized transverse x-ray tomography of the brain. Ann R Coil Phys Surg Can 7: 52, 1974.

Letter: Depression after myocardial infarction.

Tandearil® Brief Prescribing Information Dosage In arthritis, extra-articular rheumatism and superficial thrombophlebitis - 400-600 mg per day (4-6 ta...
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