Entamoeba cysts were found that could not be identified with certainty as to species. The high percent recovery rates for Ascaris lumbricoides, E. histolytica and Giardia lamblia are not unexpected, for these parasites are dependent on low levels of hygiene for their transmission via food or water. On the other hand, Trichuris trichiura and Endolimax nana, the most common parasites detected by routine stool exT. HANCOCK, MB, BS aminations,2 were found in this series Chipman, NB in remarkably low numbers, even References though they are transmitted by routes similar to those of the others. Also un1. GERRARD JW: Breast milk: a neglected asset (E). Can Med Assoc 1 112: 1281, *1975 usual were the two cases of infection 2. MYRES AW: Obesity: is it preventable in due to Isospora belli. Infection by this infancy and childhood? Can Fam Physician 21 (4): 73, 1975 parasite and the related Isospora hominis is generally considered rare alParasites in orphans from though the parasites are found worldSouth Vietnam wide. The incidence in defined populations may be high,3'4 but difficulties in To the editor: Shortly after the arrival recovering these parasites from stool in Toronto recently of a number of specimens may account for their aporphans from South Vietnam, the To- parent scarcity in the general popularonto parasitology laboratory of the tion.5 While infections by these two Ontario Ministry of Health began re- species of Isospora are generally conceiving stool samples for screening sidered mild and self-limiting, Brandtests. This letter reports the parasites borg, Goldberg and Breidenbach' confound in the first 40 samples (36 pa- cluded that they can cause a variety of tients) to alert physicians and others symptoms, including malabsorption, who may care for these and other damage to and abnormalities of the children before and after adoption. intestinal mucosa, and steatorrhea. Unpreserved stool samples subThese children form a rather homomitted by mail, approximately 1 day geneous group, probably with similar old on arrival, were processed by our backgrounds of institutional living unroutine formalin/ ether concentration der hygienic conditions that were less method and examined by trained, ex- than ideal, so it is not surprising that perienced personnel. Because our dou- the overall rate of recovery of parasites ble-bottle collecting kit, which permits from them is much higher than that greater recovery and diagnostic ac- found in routine examinations in this curacy,' had not been used for this laboratory2 or in immigrants from Farinitial series of samples, simple saline East Asian countries.6 However, the mounts were also examined. rate in this group of children, high as Of the 40 samples (from 36 patients), it is, is probably well below the actual 34 (85%) contained 1 or more para- rate because the method of collecting sites; the total number of parasites re- the samples was less than ideal. As covered was 74 (2.2 per positive sam- shown by Scholten and Yang,' protople). Thirteen different species were zoan trophozoites cannot be recovered identified (Table I). In three instances from "fresh", unpreserved stools unless Mothers will also protest because they are so overwhelmed by advertising that they are unable to see the convenience of breast-feeding and its numerous benefits. Thus, a policy change would have to be accompanied by a massive educational campaign to inform them of the dangers of bottlefeeding and the advantages of breastfeeding.
Table I-Parasites found in Vietnamese orphans according to age Age of orphan (yr) Total Parasite 0-1 1-2 2-3 3-4 4+ Unknown parasites Entamoeba histolytica 1 2 2 5 Entamoeba hartmanni 1 1 3 5 Entamoeba coli 2 1 6 9 Endolimax nana 1 4 5 Iodamoeba buetschlii 1 1 2 Unidentified amebae 1 2 3 Giardia lamblia 1 1 1 2 2 5 12 Chilomastix mesnili 1 1 Isospora belli 1 2 3 Ascaris lumbricoides 1 3 1 3 2 12 22 Trichuris trichiura 1 1 Hookworm 2 2 1 Strongyloides stercoralis 1 2 Hymenolepis nana 1 1 2 None found 3 2 1 Total samples 6 6 3 5 3 = *Percent recovery rate number of parasites/total samples X 100
362 CMA JOURNAL/SEPTEMBER 6, 1975/VOL. 113
17
Recovery rate (%)* 12.5 12.5 22.5 12.5 5.0 7.5 30.0 2.5 7.5 55.0 2.5 5.0 5.0 5.0 15.0
New Tofranil@-SD tablets of
75mg and 150mg one dose lasts from bedtime to bedtime Brief Prescribing Information Tofranli Geigy Antidepressant/Anti-Enuretic Indications Depression: Neurotic or psychotic depressions including: reactive depression, endogenous depression, involutional melancholia, senile depression, the depressive phase of manic-depressive psychosis, depression associated with organic diseases, depression associated with other psychiatric disorders (i.e.: schizophrenia, alcoholism, mental deficiency) Persistentfunctional childhood enuresis
Dowae
The following dosage recommendations should be used as a guide. Depression Except in elderly patients, adolescents or children: one tablet (25 mg) three times daily initially, increased up to six tablets daily, if necessary. Dosage in excess of eight tablets (200 mg) daily is not recommended for office patients. More severe and hospitalized cases may require up to 300 mg daily. In elderly patients and adolescents: 30-40 mg daily, initially, increased by 10 mg daily to a maximum of 100 mg in the elderly. In suitable subjects, the maintenance dose may be administered in a single dose before bedtime.
Enuresis
For persistent, functional enuresis which has not responded to other forms of management, a therapeutic trial with Tofranil may be considered for children between 5 and 15 years old, who are not mentally defective, and in whom organic causes of enuresis have been excluded. The recommended dosage for such a trial is 10-25 mg one hour before bedtime for children 5 years or over. If there is no response, the dosage may be increased up to 50 mg, in children 12-15 years old. The trial period should be 2-4 weeks. If there is a relapse, the treatment can be repeated but the
drug should not be given for more than two months without discontinuing its administration and assessing the need for further drug therapy. Because the margin of safety is lower in children, the recommended dose should not be exceeded and the minimum effective dose should be used at all times. Tofranil is not otherwise recommended in children.
Contraindicatdons
Concurrent use of monoamine oxidase inhibitors is an absolute contraindication. Two weeks should elapse before Tofranil is prescribed for patients who have received MAOI drugs.
Precautions
Utmost caution is recommended when Tofranil is used in patients with corcnary thrombosis, angina pectoris, congestive heart failure, disorders of cardiac rate or rhythm or conduction, prostatic disorders with potential urinary retention, and glaucoma. If any patient develops fever, sore throat, and stomatitis, the drug should be discontinued and a complete differential white cell count performed. As with any drug, Tofranil 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. Side effects Most are related to its anticholinergic action, such as, xerostomia, disturbances of accommodation, tachycardia, constipation and sweating. Some cases of hypotension and changes in atrioventricular conduction time have been reported. Although rare, tremor, skin rashes and blood dyscrasias may occur.
Availability
Each coral sugar-coated round tablet branded * in white, contains 25 mg imipramine HCI Geigy Standard. In boffles of 100 and 1,000. Also supplied in 10 mg triangular and 50 mg round, coral sugar-coated tablets branded 09 in white. Available in bottles of 50 and 100. Also supplied in 75 mg and 150 mg round, coral, sugarcoated tablets branded * in white. Available in bottles of 30 and 500. Full information is available on request.
Geigy Dorval, Quebec H9S 1 Bi
Gt-4091
the sample is examined shortly after defecation or is preserved in a suitable fixative immediately after passage. If this is not done about 20% of E. histolytica and 100% of Dientamoeba fragilis infections, for example, may escape detection. Also, examination of single samples (only 4 of the 40 samples were repeats) may not reveal all infections. Mathur and Kaur7 found that with single samples about 45% of E. histolytica infections are detected; three and six repeat samples were required to reveal 60 and 85%, respectively. The parasites are listed as to single and multiple occurrences in Table II. Assuming that the distribution of parasites in this group of children was random, we calculated the probabilities of the occurrence of each species and of their combinations (Table II, last column). Observed numbers of negative samples did not differ from statistically expected numbers, nor did observed numbers of single and double infections although they tended to be higher than expected. The number of infections with three or more parasites was, however, with two exceptions,
much higher than expected. Similarly, the total number of the various combinations (34) was more than twice that expected (16.2). The basic assumption of random distribution does not, therefore, seem valid. Multiple infections appear to be the rule, not the exception. While the parasite burden of these orphans may be higher than that of the Vietnamese refugees arriving in Canada later, awareness of physicians of the possibility of parasite infection and competent examinations are imperative. Most of the parasites reported here are not restricted to tropical and subtropical regions and, if undetected, could pose a potential health hazard in Canada. It is gratifying that immediate steps were taken in this instance to examine the children and thus safeguard the communities in which they may eventually settle. T. SCHOLTEN, PH D J. PALMER
Parasitology Laboratory Ontario Ministry of Health Toronto. Ont.
References 1. SCHOLTEN T, YANG J: preserved and preserved tection and identification sites. Am J Clin Pathol
Evaluation of unstools for the deof intestinal para62: 563, 1974
Table i--Observed and expected numbers of parasites in single and multiple infections in Vietnamese orphans Number Infection status Observed Expected No parasites found 6 4.7 Single infections 1 Entamoeba histolytica (Eh) 0.7 1 Entamoeba coli (Ec) 1.4 3 Giardia lamblia (GI) 2.0 2 Isospora belli 0.4 1 Chilomastix mesnili 0.1 8 Ascaris lumbricoides (Al) 5.7 16 10.3 Double infections 1 1.7 Ec+ Al 1 Ec+ GI 0.6 5 GI + Al 2.5 1 0.5 Al+ Isospora belli 1 Al + Strongyloides stercoralis (Ss) 0.3 9 5.6 Triple infections 1 Gl + Ec + Trichuris trichiura (TI) 0.01 1 Ec + Endolimax nana (En) + Eh 0.03 1 En + Al + Ec 0.2 1 Gl + Al + Ss 0.1 4 0.34 infections Quadruple Al + Entamoeba hartmanni (Ehart) + 1 Iodamoeba buetschlii (Ib) + Eh 0.006 infections Quintuple 1 Hookworm (Hw) + Al + En + Ehart + Eh 0.0009 1 Eh + Ec + En + Ehart + Hymenolepis nana (Hn) 0.0002 1 Al + Ib + Ec + En + Ehart 0.002 3 0.0031 Sextuple infections 1 Al + Hw + Gl + Ec + Ehart + Hn 0.0003 34 16.2
364 CMA JOURNAL/SEPTEMBER 6, 1975/VOL. 113
2. Idem: Parasite findings at the Toronto Public Health Laboratory over the period 19641974 (abstr). Can J Public Health 66: 50, 1975 3. MANSCHOTr PB, SLEEGERS TM, MEUWISSEN JHET: Een onderzoek naar het voorkomen van Isospora hominis in Nederland. Ned Tijdschr Geneeskd 112: 2038, 1968 4. MEEROVITCH E, GIBBs HC: Intestinal parasitic infections in the inhabitants of Easter Island. Trans R Soc Trop Med Hyg 63: 370, 1969 5. BRANDBORG LL, GOLDBERG SB, BREIDENBACH WC: Human coccidiosis - a possible cause of malabsorption. The lifecycle in small bowel mucosal biopsies as a diagnostic feature. N Engl J Med 283: 1306, 1970 6. YANG J, SCHOLTEN T: Parasite findings in immigrants to Canada during 1972 (abstr). Can J Public Health 66: 50, 1975 7. MATHUR TN, KAuR J: The frequency of excretion of cysts of Entamoeba histolytica in known cases of non-dysenteric amoebic colitis based on 21 stool examinations. Indian J Med Res 61: 330, 1973
Oral agents for diabetes To the editor: On Apr. 12, 1975 the clinical and scientific section of The Canadian Diabetic Association convened a committee of nine experts in diabetes to consider the available results of the UGDP (University Group Diabetes Program) study on tolbutamide in the light of the statistical reevaluation published by the Biometric Society. The committee also considered prospective studies of a similar nature conducted in other countries, particularly in Great Britain, and addressed itself to the question of the usefulness of sulfonylureas in general. The unanimous opinion of the members of the committee was that the data published by the UGDP do not provide sufficient evidence to consider tolbutamide (and by inference other sulfonylureas) harmful if used in proper doses in suitably selected patients. There was also unanimous agreement that sulfonylureas are a useful adjunct in the treatment of diabetes, but they must not be considered as a substitute for proper diet and exercise. The committee is studying the recent publication of the results of the UGDP study on phenformin and a report on this will be submitted in due time. A.M. FIsHER President The Canadian Diabetic Association 1491 Yonge St. Toronto, Ont.
Fund-raising by voluntary agencies To the editor: Believe it, cancer can be beaten! Believe it, cancer can be beaten! Believe it, cancer can be beaten! The meaning of the slogan depends on how you say it. The way the television commercial says it certainly gets the donation money. It also frightens people. In the primary care part of my medical practice I see one new patient with carcinoma every few months, but every day I see several patients who suffer from anxiety about cancer. I have scores of patients who come to me again and again, wasting both my
Table I-Parasites found in Vietnamese orphans according to age Age of orphan (yr) Total Parasite 0-1 1-2 2-3 3-4 4+ Unknown parasites Entamoeba histolytica 1 2 2 5 Entamoeba hartmanni 1 1 3 5 Entamoeba coli 2 1 6 9 Endolimax nana 1 4 5 Iodamoeba buetschlii 1 1 2 Unidentified amebae 1 2 3 Giardia lamblia 1 1 1 2 2 5 12 Chilomastix mesnili 1 1 Isospora belli 1 2 3 Ascaris lumbricoides 1 3 1 3 2 12 22 Trichuris trichiura 1 1 Hookworm 2 2 1 Strongyloides stercoralis 1 2 Hymenolepis nana 1 1 2 None found 3 2 1 Total samples 6 6 3 5 3 = *Percent recovery rate number of parasites/total samples X 100
362 CMA JOURNAL/SEPTEMBER 6, 1975/VOL. 113
17
Recovery rate (%)* 12.5 12.5 22.5 12.5 5.0 7.5 30.0 2.5 7.5 55.0 2.5 5.0 5.0 5.0 15.0
New Tofranil@-SD tablets of
75mg and 150mg one dose lasts from bedtime to bedtime Brief Prescribing Information Tofranli Geigy Antidepressant/Anti-Enuretic Indications Depression: Neurotic or psychotic depressions including: reactive depression, endogenous depression, involutional melancholia, senile depression, the depressive phase of manic-depressive psychosis, depression associated with organic diseases, depression associated with other psychiatric disorders (i.e.: schizophrenia, alcoholism, mental deficiency) Persistentfunctional childhood enuresis
Dowae
The following dosage recommendations should be used as a guide. Depression Except in elderly patients, adolescents or children: one tablet (25 mg) three times daily initially, increased up to six tablets daily, if necessary. Dosage in excess of eight tablets (200 mg) daily is not recommended for office patients. More severe and hospitalized cases may require up to 300 mg daily. In elderly patients and adolescents: 30-40 mg daily, initially, increased by 10 mg daily to a maximum of 100 mg in the elderly. In suitable subjects, the maintenance dose may be administered in a single dose before bedtime.
Enuresis
For persistent, functional enuresis which has not responded to other forms of management, a therapeutic trial with Tofranil may be considered for children between 5 and 15 years old, who are not mentally defective, and in whom organic causes of enuresis have been excluded. The recommended dosage for such a trial is 10-25 mg one hour before bedtime for children 5 years or over. If there is no response, the dosage may be increased up to 50 mg, in children 12-15 years old. The trial period should be 2-4 weeks. If there is a relapse, the treatment can be repeated but the
drug should not be given for more than two months without discontinuing its administration and assessing the need for further drug therapy. Because the margin of safety is lower in children, the recommended dose should not be exceeded and the minimum effective dose should be used at all times. Tofranil is not otherwise recommended in children.
Contraindicatdons
Concurrent use of monoamine oxidase inhibitors is an absolute contraindication. Two weeks should elapse before Tofranil is prescribed for patients who have received MAOI drugs.
Precautions
Utmost caution is recommended when Tofranil is used in patients with corcnary thrombosis, angina pectoris, congestive heart failure, disorders of cardiac rate or rhythm or conduction, prostatic disorders with potential urinary retention, and glaucoma. If any patient develops fever, sore throat, and stomatitis, the drug should be discontinued and a complete differential white cell count performed. As with any drug, Tofranil 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. Side effects Most are related to its anticholinergic action, such as, xerostomia, disturbances of accommodation, tachycardia, constipation and sweating. Some cases of hypotension and changes in atrioventricular conduction time have been reported. Although rare, tremor, skin rashes and blood dyscrasias may occur.
Availability
Each coral sugar-coated round tablet branded * in white, contains 25 mg imipramine HCI Geigy Standard. In boffles of 100 and 1,000. Also supplied in 10 mg triangular and 50 mg round, coral sugar-coated tablets branded 09 in white. Available in bottles of 50 and 100. Also supplied in 75 mg and 150 mg round, coral, sugarcoated tablets branded * in white. Available in bottles of 30 and 500. Full information is available on request.
Geigy Dorval, Quebec H9S 1 Bi
Gt-4091
the sample is examined shortly after defecation or is preserved in a suitable fixative immediately after passage. If this is not done about 20% of E. histolytica and 100% of Dientamoeba fragilis infections, for example, may escape detection. Also, examination of single samples (only 4 of the 40 samples were repeats) may not reveal all infections. Mathur and Kaur7 found that with single samples about 45% of E. histolytica infections are detected; three and six repeat samples were required to reveal 60 and 85%, respectively. The parasites are listed as to single and multiple occurrences in Table II. Assuming that the distribution of parasites in this group of children was random, we calculated the probabilities of the occurrence of each species and of their combinations (Table II, last column). Observed numbers of negative samples did not differ from statistically expected numbers, nor did observed numbers of single and double infections although they tended to be higher than expected. The number of infections with three or more parasites was, however, with two exceptions,
much higher than expected. Similarly, the total number of the various combinations (34) was more than twice that expected (16.2). The basic assumption of random distribution does not, therefore, seem valid. Multiple infections appear to be the rule, not the exception. While the parasite burden of these orphans may be higher than that of the Vietnamese refugees arriving in Canada later, awareness of physicians of the possibility of parasite infection and competent examinations are imperative. Most of the parasites reported here are not restricted to tropical and subtropical regions and, if undetected, could pose a potential health hazard in Canada. It is gratifying that immediate steps were taken in this instance to examine the children and thus safeguard the communities in which they may eventually settle. T. SCHOLTEN, PH D J. PALMER
Parasitology Laboratory Ontario Ministry of Health Toronto. Ont.
References 1. SCHOLTEN T, YANG J: preserved and preserved tection and identification sites. Am J Clin Pathol
Evaluation of unstools for the deof intestinal para62: 563, 1974
Table i--Observed and expected numbers of parasites in single and multiple infections in Vietnamese orphans Number Infection status Observed Expected No parasites found 6 4.7 Single infections 1 Entamoeba histolytica (Eh) 0.7 1 Entamoeba coli (Ec) 1.4 3 Giardia lamblia (GI) 2.0 2 Isospora belli 0.4 1 Chilomastix mesnili 0.1 8 Ascaris lumbricoides (Al) 5.7 16 10.3 Double infections 1 1.7 Ec+ Al 1 Ec+ GI 0.6 5 GI + Al 2.5 1 0.5 Al+ Isospora belli 1 Al + Strongyloides stercoralis (Ss) 0.3 9 5.6 Triple infections 1 Gl + Ec + Trichuris trichiura (TI) 0.01 1 Ec + Endolimax nana (En) + Eh 0.03 1 En + Al + Ec 0.2 1 Gl + Al + Ss 0.1 4 0.34 infections Quadruple Al + Entamoeba hartmanni (Ehart) + 1 Iodamoeba buetschlii (Ib) + Eh 0.006 infections Quintuple 1 Hookworm (Hw) + Al + En + Ehart + Eh 0.0009 1 Eh + Ec + En + Ehart + Hymenolepis nana (Hn) 0.0002 1 Al + Ib + Ec + En + Ehart 0.002 3 0.0031 Sextuple infections 1 Al + Hw + Gl + Ec + Ehart + Hn 0.0003 34 16.2
364 CMA JOURNAL/SEPTEMBER 6, 1975/VOL. 113
2. Idem: Parasite findings at the Toronto Public Health Laboratory over the period 19641974 (abstr). Can J Public Health 66: 50, 1975 3. MANSCHOTr PB, SLEEGERS TM, MEUWISSEN JHET: Een onderzoek naar het voorkomen van Isospora hominis in Nederland. Ned Tijdschr Geneeskd 112: 2038, 1968 4. MEEROVITCH E, GIBBs HC: Intestinal parasitic infections in the inhabitants of Easter Island. Trans R Soc Trop Med Hyg 63: 370, 1969 5. BRANDBORG LL, GOLDBERG SB, BREIDENBACH WC: Human coccidiosis - a possible cause of malabsorption. The lifecycle in small bowel mucosal biopsies as a diagnostic feature. N Engl J Med 283: 1306, 1970 6. YANG J, SCHOLTEN T: Parasite findings in immigrants to Canada during 1972 (abstr). Can J Public Health 66: 50, 1975 7. MATHUR TN, KAuR J: The frequency of excretion of cysts of Entamoeba histolytica in known cases of non-dysenteric amoebic colitis based on 21 stool examinations. Indian J Med Res 61: 330, 1973
Oral agents for diabetes To the editor: On Apr. 12, 1975 the clinical and scientific section of The Canadian Diabetic Association convened a committee of nine experts in diabetes to consider the available results of the UGDP (University Group Diabetes Program) study on tolbutamide in the light of the statistical reevaluation published by the Biometric Society. The committee also considered prospective studies of a similar nature conducted in other countries, particularly in Great Britain, and addressed itself to the question of the usefulness of sulfonylureas in general. The unanimous opinion of the members of the committee was that the data published by the UGDP do not provide sufficient evidence to consider tolbutamide (and by inference other sulfonylureas) harmful if used in proper doses in suitably selected patients. There was also unanimous agreement that sulfonylureas are a useful adjunct in the treatment of diabetes, but they must not be considered as a substitute for proper diet and exercise. The committee is studying the recent publication of the results of the UGDP study on phenformin and a report on this will be submitted in due time. A.M. FIsHER President The Canadian Diabetic Association 1491 Yonge St. Toronto, Ont.
Fund-raising by voluntary agencies To the editor: Believe it, cancer can be beaten! Believe it, cancer can be beaten! Believe it, cancer can be beaten! The meaning of the slogan depends on how you say it. The way the television commercial says it certainly gets the donation money. It also frightens people. In the primary care part of my medical practice I see one new patient with carcinoma every few months, but every day I see several patients who suffer from anxiety about cancer. I have scores of patients who come to me again and again, wasting both my
