.[ucophAqrE Metformin Hydrochloride
phasizes the increasing need for continuous vigilance against such occurrences. I thank Dr. 1.0. Stewart of Hamilton for details of the patient's history.
Classification GLUCOPHAGE (Metformin Hydrochloride) is an oral antidiabetic agent of the biguanide family.
T. SCHOLTEN, PH D Head, parasitology laboratory Ontario Ministry of Health P0 Box 9000. Terminal A Toronto, ON
Pharmacology GLUCOPHAGE is rapidly absorbed and excreted. The product is not metabolized and is excreted unchanged in the urine. GLUCOPHAGE lowers glycemia of the diabetic patient but not that of the normal human. Contrary to sulfonylureas hypoglycemia has never been reported at normal doses in diabetic patients treated with GLUCOPHAGE alone. GLUCOPHAGE promotes an increase in the peripheral utilization of glucose and its activity is mediated through insulin. Therefore, GLUCOPHAGE improves the K coefficient of glucose assimilation and the coefficient of insulin efficiency. In the obese diabetic with hyperinsulinemia, GLUCOPHAGE is reported to normalize insulin output. This normalizing effect is concurrent to that of glycemia. During experiments, GLUCOPHAGE was shown to be devoid of any notable action in the body apart from its specific metabolic activity. Contrary to sulfonylureas, GLUCOPHAGE does not stimulate the pancreatic secretion of insulin.
References 1. THEILER G, ROBINSON BN: Ticks in the South African Zoological Survey collection. Part VII. Six lesser known African rhipicephalids. Onderstepoort I Vet Res 26: 93, 1953 2. SCHOLTEN T, HicKs RJ: Myiasis by Cordylobia rodhaini contracted in Africa and diagnosed in Canada. Can I Public Health 64: 488, 1973
Indications 11 Uncomplicated maturity onset diabetes without ketosis which cannot be controlled by dietary measures alone. 21 GLUCOPHAGE is of particular value for the obese diabetic patient; besides its specific action on diabetes it often promotes an important loss of weight in the obese patient. 31 GLUCOPHAGE can also be administered, alone or combined with sulfonylureas, in the case of primary or secondary sulfonylurea failure. Combined therapy of GLUCOPHAGE with a sulfonylurea can also be of considerable value in older diabetics where failure with either drug alone has occurred. This combined treatment can sometimes offer an altemative to insulin. The two compounds possibly act synergistically, the sulfonyluma promoting insulin release from pancreatic Beta cells and metformin potentiating its action on peripheral tissues. 41 Insulin adjuvant: The addition of GLUCOPHAGE to a regimen of insulin dependent patients may be of value, as the dose of insulin can often be reduced, in particular when insulin dosage is very high or when the patient is poorly controlled with insulin alone.
Clinical Use GLUCOPHAGE has been utilized throughout the world since 1957. Many clinical studies have demonstrated that GLUCOPHAGE is characterized as follows: As a sole medication GLUCOPHAGE does not bring about hypoglycemia in the normal human. Contrary to sulfonylureas, GLUCOPHAGE promotes loss of weight in the obese subject. Weight reduction is not related to dosage or to any anorexiant effect of the drug. GLUCOPHAGE maintains its activity during long treatment.
Adverse reactions Metallic taste inthe mouth, epigastric discomfort, nausea and vomiting. Diarrhea and skin rashes have been reported infrequently.
Precautions If vomiting occurs withdraw drug momentarily then resume dosage progressively. GLUCOPHAGE should be used cautiously in patients with Addisons disease and in subjects intolerant to alcohol or sedatives. As with all other oral hypoglycemic agents, it is recommended that complete physical examinations including hepatic tests, blood counts and ophthalmoscopy be performed on a regular basis, in order to prevent or minimize long or short-term complications.
Discontinue treatment in presence of a significant elevation of lactic acid levels in the blood.
Contraindications GLUCOPHAGE, used alone, is contraindicated in the case of ketotic, juvenile, insulin-deficient diabetes. GLUCOPHAGE is contraindicated in severe acidosis, coma and very unstable diabetes. During stress periods, such as severe infections, trauma or surgical procedures, a temporary change to insulin treatment is recommended. GLUCOPHAGE is contraindicated during pregnancies, jaundice, severe liver and renal disorders. GLUCOPHAGE is contraindicated where there are pm-existing complications peculiar to diabetes, for example: retinopathy, neuropathy, and nephropathy, and in latent and pm-diabetes.
Dosage and administration GLUCOPHAGE is administered orally. The usual dosage is 0.5 g three times a day, but it may be increased up to 3to4 gdaily. GLUCOPHAGE is best tolerated with meals. According to the results obtained, it may be required to increase the dose within the given limitsl; the increase should proceed slowly over a period of 10 days to avoid gastro-intestinal discomfort.
Availability Tablets 10.5 gI white, round, convex, scored. Bottles of 100 and 500 tablets. F.) r7z'. fl .
IIkJ .2) LA) 1h5'
HARMACEUTIQUES HARMACEUTICALS LTEE LTD
LavaiQue.
Canada.
Influenza immunization in children To the editor: Extensive publicity about a possible 1976-77 influenza pandemic (due to A/Victoria/75 or A/New Jersey! 76 [swine virus] or both) has renewed interest in routine influenza immunization in children. Although school-aged children have not been the recipients of yearly influenza immunization, they are nevertheless considered primary spreaders of the disease during epidemic years. Routine influenza immunization of healthy individuals is impractical because of the difficulties in manufacturing, testing and distributing large quantities of vaccine each year, which is necessitated by antigenic shifts in the prevalent strains of influenza virus. Another reason healthy children have not been priority targets for immunization is the higher incidence of adverse reactions in them than in adults. While adverse reactions to currently available, zonally purified monovalent and bivalent influenza vaccines are well documented in infants and children less than 2 years of age,1'2 reports of reactogenicity in older children vary.1-7 In a study of adverse reactions in children receiving 1975 bivalent influenza vaccine (A/Port Chalmers/73, A/Scotland/74 and B/Hong Kong/72), approximately 30% of vaccinees had fever or local pain or both.8 However, no convulsions or other serious reactions were encountered and all but one parent indicated they would accept annual influenza immunization for their children. Other investigators, using subunit vaccines, reported no febrile reactions in their vaccinees.'7 Studies of both bivalent and monovalent subunit vaccines have indicated that disruption of the virus particle may decrease reactogenicity.6'7'9 While recent preliminary trials with swine influenza have indicated that the subunit vaccine may be tolerated better, less favourable
immune responses have been achieved with this vaccine.. Varying the dose and route of administration has been proposed to "stretch" limited vaccine supplies in an emergency situation. Studies of these factors have brought about changes in vaccine schedules (a single dose instead of two injections) and have suggested that the intradermal route, which requires only two fifths of the conventional dose, may be as immunogenic as the subcutaneous one.10 Because of the efficacy of the zonally purified bivalent vaccine9 and the relatively minor adverse reactions in children over 3 years old,8 more widespread immunoprophylaxis may be warranted. However, careful consideration must be given to the results of laboratory and field investigations of purity, dose- and route-related immunogenicity, reactogenicity, longterm safety and efficacy.11'11 It is unfortunate that the recent Canadian influenza program appears to have neglected many of these principles, particularly with reference to children. The latest results of worldwide influenza surveillance do not indicate any swine influenza activity, although A/Victoria/75 isolates and clinical disease have been described. This information should be used to formulate new influenza immunization policies for Canadians. Considering the dearth of data available from a variety of sources on swine influenza vaccines intended for Canadian use, and the lessening probability of a swine influenza epidemic, priority should be given for immunization of "high-risk" individuals of all ages against A/Victoria/75 influenza. S. SCHEVILL, B sc M.I. MARKS, MD Departments of microbiology and pediatrics (infectious disease) McGill University-Montreal Children's Hospital Montreal, PQ References 1. MARINE W, STUART-HARRIS C: Reactions and serologic responses in young children and infants after administration of inactivated monovalent influenza A vaccine. I Pedlair 88: 26, 1976 2. WRIGHT PF, SELL SHW, THOMPSOH 3, et al: Clinical reactions and serologic response following inactivated monovalent influenza type B vaccine in young children and infants. I Pedjair 88: 1, 1976 3. SALK JE: Reactions to concentrated influenza virus vaccines. I Immunol 58: 369, 1948 4. QUILLIGAN JJ JR, FRANCIs T sa, MINUsE .E: Reaction to an influenza virus vaccine in infants and children. Am I Dis Child 78:
295, 1949 Active immunization with influenza virus A and B in infants and children. Pediatrics 17: 482, 1956
5. GLAZIER MM, BENENSON AS, WHEELER RE:
6. PHILLIPS CF, PHILLIPS CA, HODGKIN WE, et a.: Killed subunit influehza vaccine in children. Pediatrics 52: 416, 1973 7. WHARBURTON MF, Duxeusw AE: Desozycholate-split influenza virus vaccines in infants and young children. Symp Ser Immuno-
biol Stand 20: 92, 1973
8. SCHEVILL 5, MARKS MI: Adverse reactions to 1975 bivalent influenza vaccine in children (manuscript in prep) 9. Public Health Service Advisory Committee on Immunization Practices: Influenza vaccine-
CMA JOURNAL/SEPTEMBER 18. 1976/VOL. 115 493
supplemental statement. Morbid Mortal Wkly Rep 25: 221, 1976 10. MARKS MI, ELLER JJ: Intradermal influenza immunization. Am Rev Respir Dis 103: 579, 1971 11. BARRY DW, MAYNER RE, STATON E, Ct al: Comparative trial of influenza vaccines: I. Immunogenicity of whole virus and split product vaccines in man. Am I Epidemiol 104: 34, 1976 12. BARRY DW, MAYNER RE, HocHsmIN HD, et al: Comparative trial of influenza vaccines: II. Adverse reactions in children and adults. Am J Epidemiol 104: 47, 1976
Investigation and treatment of allergic asthma To the editor: I read with interest the controversy between Dr. Collins-Williams and Dr. Freedman about the efficacy of detection and treatment of allergies (Can Med Assoc J 114:1086, 1976). I was quite agog as I tried to comprehend a biochemical and immune assessment, but finally gave up because of time and lack of technical knowledge with regard to the abbreviated forms and biochemical terminology. I wish I could have taken time to understand it completely. As a hypnotherapist and one who studies psychobiology I have treated a great number of patients with allergy. With the present treatment system I find it very difficult to do other than totally exhaust the history, the clinical picture and the treatment in two or three sessions. I realize I am referring to psychologically associated allergies, but it is my opinion that they form a large proportion of all allergies. In fact, I have yet to see any patient in the office whose allergy or allergies could not be totally related to psychological sensitization. I obviously have a totally different perspective on allergy. JOHN GEAR, MD Erickson Institute of Medical Hypnosis Ste. 212, Hopedale Mall 1515 Rebecca St. Oakville, ON
To the editor: Drs. Collins-Williams and Freedman seem to be arguing about two different things as far as the radioallergosorbent test (RAST) is concerned. Prick and RAST tests are most reliable with pollen allergens and are least reliable with food allergens. The Rinkel group of allergists in the United States found in a survey (which included subjects with food allergy) and here I quote from memory - a 75% correlation between history and results of prick and RAST tests; their figures seem to be midway between the results quoted by Drs. Collins-Williams and Freedman. Considering again the findings of the Rinkel group, I would say that Dr. Collins-Williams is correct in stating that asthma can be helped. However, with asthma and hay fever the build-up
period for immunization by the filtration technique is kept to an average of six injections. I do not believe in the build-up type of desensitization and use the technique called neutralization, which avoids build-up completely. I agree that desensitization is nowhere near 100% perfect by any method, but it seems to be a lot safer than the use of potent drugs. IvoR L. GLAISHER, MD 900 Midtown Centre Regina, SK
[In the view of the executive committee of the American Academy of Allergy there is no evidence to substantiate the validity of the Rinkel method. Readers who wish to pursue this matter are referred to the following two references: I. GOLBERT TM: A review of controversial diagnostic and therapeutic techniques employed in allergy. / Allergy din Immunol 56: 170, 1975 2. LOWELL FC: Some untested diagnostic and therapeutic procedures in clinical allergy (E). Ibid. p 168
-Ed.]
Diabetic day-care unit To the editor: The authors of the two papers on a diabetic day-care unit (Can Med Assoc J 114: 777, 780; 1976) have performed a distinct service in reporting their evaluation, however optimistic, of the work of their unit. It is to be hoped they will enlarge their series and continue follow-up, as they suggest, since the brief period of observation does not lend a crushing weight of credibility to their initial conclusions. The major weakness in evaluation is the measurement of blood glucose concentration at random times. In a study of this calibre one would have expected a more scientific approach. The "improvement" among 24 insulin-treated diabetics from 13 values over 300 mg at the first visit to 4 at the final visit may have been due simply to a change in the time of day of the measurement. Furthermore, it hardly seems appropriate to calculate the mean of 24 random blood glucose readings and express the statistical significance of the difference of this mean from that of a further 24 random readings an unknown time later. We need to know whether the expenditure of a great deal of effort in training personnel, developing facilities and requiring diabetics to attend clinics to supplement and complement the family physician's task is really as worth while as in theory it ought to be. The subject remains debatable. DAVID RUSSELL AMIES, FRCP(C], FACP 200 Walter Scott Building Moose Jsw SK
494 CMA JOURNAL/SEPTEMBER 18, 1976/VOL. 115
To the editor: Dr. Amies has referred to some limitations of our study describing the development and application of an index to evaluate diabetes control. The results reported, which covered a relatively few weeks of observation for each patient, demonstrated significant improvement in a large number of cases. Undoubtedly more studies with longer periods of observation are required. We agree that the subject of diabetic day-care units is debatable and encourage Dr. Amies and other physicians responsible for the care of diabetic patients to contribute to the debate by applying either the index described or another. The point about random v. fasting plasma glucose determinations is more controversial. Random values undoubtedly vary more than fasting values. On the other hand, one important aim of our study was to develop an index that could be applied to as many circumstances of practice as possible. We chose not to require patients to forego breakfast at home on the day of each visit to the unit. Further, we wished to avoid the need for some patients to visit a laboratory first thing in the morning and keep an appointment at the diabetic unit later in the day. As far as can be determined no bias was introduced by doing determinations randomly. There is no reason to think that patients were seen at the final visit at a time of day that would have resulted in their plasma glucose values being significantly lower than at the initial visit. This being so, the statistical analysis appears appropriate. BERNICE KING, RN, B SC N WILLIAM B. SPAULDING, MD, FRCPICJ, FACP Diabetic day-care unit McMaster University Medical Centre 1200 Main St. Hamilton, ON
Munchausen variant To the editor: We recently encountered a patient with an interesting variant of Munchausen's syndrome. A 24-year-old Black American man came to the emergency department of the Montreal General Hospital with a history of "mitral click syndrome" while taking propranolol. He complained of atypical chest pain. Results of physical examination and electrocardiography were normal. He was referred to the cardiology clinic, where an echocardiogram was ordered. He returned the same day to the emergency department; the physical examination again yielded normal findings. He was noted to have somewhat paranoid ideation and struck the examining physician without provocation. He eventually left this hospital and was admitted to another major Montreal hospital, where results of serial electrocar-
phasizes the increasing need for continuous vigilance against such occurrences. I thank Dr. 1.0. Stewart of Hamilton for details of the patient's history.
Classification GLUCOPHAGE (Metformin Hydrochloride) is an oral antidiabetic agent of the biguanide family.
T. SCHOLTEN, PH D Head, parasitology laboratory Ontario Ministry of Health P0 Box 9000. Terminal A Toronto, ON
Pharmacology GLUCOPHAGE is rapidly absorbed and excreted. The product is not metabolized and is excreted unchanged in the urine. GLUCOPHAGE lowers glycemia of the diabetic patient but not that of the normal human. Contrary to sulfonylureas hypoglycemia has never been reported at normal doses in diabetic patients treated with GLUCOPHAGE alone. GLUCOPHAGE promotes an increase in the peripheral utilization of glucose and its activity is mediated through insulin. Therefore, GLUCOPHAGE improves the K coefficient of glucose assimilation and the coefficient of insulin efficiency. In the obese diabetic with hyperinsulinemia, GLUCOPHAGE is reported to normalize insulin output. This normalizing effect is concurrent to that of glycemia. During experiments, GLUCOPHAGE was shown to be devoid of any notable action in the body apart from its specific metabolic activity. Contrary to sulfonylureas, GLUCOPHAGE does not stimulate the pancreatic secretion of insulin.
References 1. THEILER G, ROBINSON BN: Ticks in the South African Zoological Survey collection. Part VII. Six lesser known African rhipicephalids. Onderstepoort I Vet Res 26: 93, 1953 2. SCHOLTEN T, HicKs RJ: Myiasis by Cordylobia rodhaini contracted in Africa and diagnosed in Canada. Can I Public Health 64: 488, 1973
Indications 11 Uncomplicated maturity onset diabetes without ketosis which cannot be controlled by dietary measures alone. 21 GLUCOPHAGE is of particular value for the obese diabetic patient; besides its specific action on diabetes it often promotes an important loss of weight in the obese patient. 31 GLUCOPHAGE can also be administered, alone or combined with sulfonylureas, in the case of primary or secondary sulfonylurea failure. Combined therapy of GLUCOPHAGE with a sulfonylurea can also be of considerable value in older diabetics where failure with either drug alone has occurred. This combined treatment can sometimes offer an altemative to insulin. The two compounds possibly act synergistically, the sulfonyluma promoting insulin release from pancreatic Beta cells and metformin potentiating its action on peripheral tissues. 41 Insulin adjuvant: The addition of GLUCOPHAGE to a regimen of insulin dependent patients may be of value, as the dose of insulin can often be reduced, in particular when insulin dosage is very high or when the patient is poorly controlled with insulin alone.
Clinical Use GLUCOPHAGE has been utilized throughout the world since 1957. Many clinical studies have demonstrated that GLUCOPHAGE is characterized as follows: As a sole medication GLUCOPHAGE does not bring about hypoglycemia in the normal human. Contrary to sulfonylureas, GLUCOPHAGE promotes loss of weight in the obese subject. Weight reduction is not related to dosage or to any anorexiant effect of the drug. GLUCOPHAGE maintains its activity during long treatment.
Adverse reactions Metallic taste inthe mouth, epigastric discomfort, nausea and vomiting. Diarrhea and skin rashes have been reported infrequently.
Precautions If vomiting occurs withdraw drug momentarily then resume dosage progressively. GLUCOPHAGE should be used cautiously in patients with Addisons disease and in subjects intolerant to alcohol or sedatives. As with all other oral hypoglycemic agents, it is recommended that complete physical examinations including hepatic tests, blood counts and ophthalmoscopy be performed on a regular basis, in order to prevent or minimize long or short-term complications.
Discontinue treatment in presence of a significant elevation of lactic acid levels in the blood.
Contraindications GLUCOPHAGE, used alone, is contraindicated in the case of ketotic, juvenile, insulin-deficient diabetes. GLUCOPHAGE is contraindicated in severe acidosis, coma and very unstable diabetes. During stress periods, such as severe infections, trauma or surgical procedures, a temporary change to insulin treatment is recommended. GLUCOPHAGE is contraindicated during pregnancies, jaundice, severe liver and renal disorders. GLUCOPHAGE is contraindicated where there are pm-existing complications peculiar to diabetes, for example: retinopathy, neuropathy, and nephropathy, and in latent and pm-diabetes.
Dosage and administration GLUCOPHAGE is administered orally. The usual dosage is 0.5 g three times a day, but it may be increased up to 3to4 gdaily. GLUCOPHAGE is best tolerated with meals. According to the results obtained, it may be required to increase the dose within the given limitsl; the increase should proceed slowly over a period of 10 days to avoid gastro-intestinal discomfort.
Availability Tablets 10.5 gI white, round, convex, scored. Bottles of 100 and 500 tablets. F.) r7z'. fl .
IIkJ .2) LA) 1h5'
HARMACEUTIQUES HARMACEUTICALS LTEE LTD
LavaiQue.
Canada.
Influenza immunization in children To the editor: Extensive publicity about a possible 1976-77 influenza pandemic (due to A/Victoria/75 or A/New Jersey! 76 [swine virus] or both) has renewed interest in routine influenza immunization in children. Although school-aged children have not been the recipients of yearly influenza immunization, they are nevertheless considered primary spreaders of the disease during epidemic years. Routine influenza immunization of healthy individuals is impractical because of the difficulties in manufacturing, testing and distributing large quantities of vaccine each year, which is necessitated by antigenic shifts in the prevalent strains of influenza virus. Another reason healthy children have not been priority targets for immunization is the higher incidence of adverse reactions in them than in adults. While adverse reactions to currently available, zonally purified monovalent and bivalent influenza vaccines are well documented in infants and children less than 2 years of age,1'2 reports of reactogenicity in older children vary.1-7 In a study of adverse reactions in children receiving 1975 bivalent influenza vaccine (A/Port Chalmers/73, A/Scotland/74 and B/Hong Kong/72), approximately 30% of vaccinees had fever or local pain or both.8 However, no convulsions or other serious reactions were encountered and all but one parent indicated they would accept annual influenza immunization for their children. Other investigators, using subunit vaccines, reported no febrile reactions in their vaccinees.'7 Studies of both bivalent and monovalent subunit vaccines have indicated that disruption of the virus particle may decrease reactogenicity.6'7'9 While recent preliminary trials with swine influenza have indicated that the subunit vaccine may be tolerated better, less favourable
immune responses have been achieved with this vaccine.. Varying the dose and route of administration has been proposed to "stretch" limited vaccine supplies in an emergency situation. Studies of these factors have brought about changes in vaccine schedules (a single dose instead of two injections) and have suggested that the intradermal route, which requires only two fifths of the conventional dose, may be as immunogenic as the subcutaneous one.10 Because of the efficacy of the zonally purified bivalent vaccine9 and the relatively minor adverse reactions in children over 3 years old,8 more widespread immunoprophylaxis may be warranted. However, careful consideration must be given to the results of laboratory and field investigations of purity, dose- and route-related immunogenicity, reactogenicity, longterm safety and efficacy.11'11 It is unfortunate that the recent Canadian influenza program appears to have neglected many of these principles, particularly with reference to children. The latest results of worldwide influenza surveillance do not indicate any swine influenza activity, although A/Victoria/75 isolates and clinical disease have been described. This information should be used to formulate new influenza immunization policies for Canadians. Considering the dearth of data available from a variety of sources on swine influenza vaccines intended for Canadian use, and the lessening probability of a swine influenza epidemic, priority should be given for immunization of "high-risk" individuals of all ages against A/Victoria/75 influenza. S. SCHEVILL, B sc M.I. MARKS, MD Departments of microbiology and pediatrics (infectious disease) McGill University-Montreal Children's Hospital Montreal, PQ References 1. MARINE W, STUART-HARRIS C: Reactions and serologic responses in young children and infants after administration of inactivated monovalent influenza A vaccine. I Pedlair 88: 26, 1976 2. WRIGHT PF, SELL SHW, THOMPSOH 3, et al: Clinical reactions and serologic response following inactivated monovalent influenza type B vaccine in young children and infants. I Pedjair 88: 1, 1976 3. SALK JE: Reactions to concentrated influenza virus vaccines. I Immunol 58: 369, 1948 4. QUILLIGAN JJ JR, FRANCIs T sa, MINUsE .E: Reaction to an influenza virus vaccine in infants and children. Am I Dis Child 78:
295, 1949 Active immunization with influenza virus A and B in infants and children. Pediatrics 17: 482, 1956
5. GLAZIER MM, BENENSON AS, WHEELER RE:
6. PHILLIPS CF, PHILLIPS CA, HODGKIN WE, et a.: Killed subunit influehza vaccine in children. Pediatrics 52: 416, 1973 7. WHARBURTON MF, Duxeusw AE: Desozycholate-split influenza virus vaccines in infants and young children. Symp Ser Immuno-
biol Stand 20: 92, 1973
8. SCHEVILL 5, MARKS MI: Adverse reactions to 1975 bivalent influenza vaccine in children (manuscript in prep) 9. Public Health Service Advisory Committee on Immunization Practices: Influenza vaccine-
CMA JOURNAL/SEPTEMBER 18. 1976/VOL. 115 493
supplemental statement. Morbid Mortal Wkly Rep 25: 221, 1976 10. MARKS MI, ELLER JJ: Intradermal influenza immunization. Am Rev Respir Dis 103: 579, 1971 11. BARRY DW, MAYNER RE, STATON E, Ct al: Comparative trial of influenza vaccines: I. Immunogenicity of whole virus and split product vaccines in man. Am I Epidemiol 104: 34, 1976 12. BARRY DW, MAYNER RE, HocHsmIN HD, et al: Comparative trial of influenza vaccines: II. Adverse reactions in children and adults. Am J Epidemiol 104: 47, 1976
Investigation and treatment of allergic asthma To the editor: I read with interest the controversy between Dr. Collins-Williams and Dr. Freedman about the efficacy of detection and treatment of allergies (Can Med Assoc J 114:1086, 1976). I was quite agog as I tried to comprehend a biochemical and immune assessment, but finally gave up because of time and lack of technical knowledge with regard to the abbreviated forms and biochemical terminology. I wish I could have taken time to understand it completely. As a hypnotherapist and one who studies psychobiology I have treated a great number of patients with allergy. With the present treatment system I find it very difficult to do other than totally exhaust the history, the clinical picture and the treatment in two or three sessions. I realize I am referring to psychologically associated allergies, but it is my opinion that they form a large proportion of all allergies. In fact, I have yet to see any patient in the office whose allergy or allergies could not be totally related to psychological sensitization. I obviously have a totally different perspective on allergy. JOHN GEAR, MD Erickson Institute of Medical Hypnosis Ste. 212, Hopedale Mall 1515 Rebecca St. Oakville, ON
To the editor: Drs. Collins-Williams and Freedman seem to be arguing about two different things as far as the radioallergosorbent test (RAST) is concerned. Prick and RAST tests are most reliable with pollen allergens and are least reliable with food allergens. The Rinkel group of allergists in the United States found in a survey (which included subjects with food allergy) and here I quote from memory - a 75% correlation between history and results of prick and RAST tests; their figures seem to be midway between the results quoted by Drs. Collins-Williams and Freedman. Considering again the findings of the Rinkel group, I would say that Dr. Collins-Williams is correct in stating that asthma can be helped. However, with asthma and hay fever the build-up
period for immunization by the filtration technique is kept to an average of six injections. I do not believe in the build-up type of desensitization and use the technique called neutralization, which avoids build-up completely. I agree that desensitization is nowhere near 100% perfect by any method, but it seems to be a lot safer than the use of potent drugs. IvoR L. GLAISHER, MD 900 Midtown Centre Regina, SK
[In the view of the executive committee of the American Academy of Allergy there is no evidence to substantiate the validity of the Rinkel method. Readers who wish to pursue this matter are referred to the following two references: I. GOLBERT TM: A review of controversial diagnostic and therapeutic techniques employed in allergy. / Allergy din Immunol 56: 170, 1975 2. LOWELL FC: Some untested diagnostic and therapeutic procedures in clinical allergy (E). Ibid. p 168
-Ed.]
Diabetic day-care unit To the editor: The authors of the two papers on a diabetic day-care unit (Can Med Assoc J 114: 777, 780; 1976) have performed a distinct service in reporting their evaluation, however optimistic, of the work of their unit. It is to be hoped they will enlarge their series and continue follow-up, as they suggest, since the brief period of observation does not lend a crushing weight of credibility to their initial conclusions. The major weakness in evaluation is the measurement of blood glucose concentration at random times. In a study of this calibre one would have expected a more scientific approach. The "improvement" among 24 insulin-treated diabetics from 13 values over 300 mg at the first visit to 4 at the final visit may have been due simply to a change in the time of day of the measurement. Furthermore, it hardly seems appropriate to calculate the mean of 24 random blood glucose readings and express the statistical significance of the difference of this mean from that of a further 24 random readings an unknown time later. We need to know whether the expenditure of a great deal of effort in training personnel, developing facilities and requiring diabetics to attend clinics to supplement and complement the family physician's task is really as worth while as in theory it ought to be. The subject remains debatable. DAVID RUSSELL AMIES, FRCP(C], FACP 200 Walter Scott Building Moose Jsw SK
494 CMA JOURNAL/SEPTEMBER 18, 1976/VOL. 115
To the editor: Dr. Amies has referred to some limitations of our study describing the development and application of an index to evaluate diabetes control. The results reported, which covered a relatively few weeks of observation for each patient, demonstrated significant improvement in a large number of cases. Undoubtedly more studies with longer periods of observation are required. We agree that the subject of diabetic day-care units is debatable and encourage Dr. Amies and other physicians responsible for the care of diabetic patients to contribute to the debate by applying either the index described or another. The point about random v. fasting plasma glucose determinations is more controversial. Random values undoubtedly vary more than fasting values. On the other hand, one important aim of our study was to develop an index that could be applied to as many circumstances of practice as possible. We chose not to require patients to forego breakfast at home on the day of each visit to the unit. Further, we wished to avoid the need for some patients to visit a laboratory first thing in the morning and keep an appointment at the diabetic unit later in the day. As far as can be determined no bias was introduced by doing determinations randomly. There is no reason to think that patients were seen at the final visit at a time of day that would have resulted in their plasma glucose values being significantly lower than at the initial visit. This being so, the statistical analysis appears appropriate. BERNICE KING, RN, B SC N WILLIAM B. SPAULDING, MD, FRCPICJ, FACP Diabetic day-care unit McMaster University Medical Centre 1200 Main St. Hamilton, ON
Munchausen variant To the editor: We recently encountered a patient with an interesting variant of Munchausen's syndrome. A 24-year-old Black American man came to the emergency department of the Montreal General Hospital with a history of "mitral click syndrome" while taking propranolol. He complained of atypical chest pain. Results of physical examination and electrocardiography were normal. He was referred to the cardiology clinic, where an echocardiogram was ordered. He returned the same day to the emergency department; the physical examination again yielded normal findings. He was noted to have somewhat paranoid ideation and struck the examining physician without provocation. He eventually left this hospital and was admitted to another major Montreal hospital, where results of serial electrocar-
