1010
Letters to the Editor
tions. 1 Since these are both situations in which binding affinity or capacity is decreased when compared with fresh adult sera, it is reasonable t o assume that the break in the curve is related to changes in binding affinity and capacity rather than to bilirubin concentrations independent of binding. The authors wish to apologize to Dr. Krasner for not having made mention o f his direct bilirubin fluorescence method for binding estimation, w e chose to comment only on those binding methods currently enjoying clinical application. There are, indeed, a number of other methods which have been proposed for estimation of bilirubin binding, and we did not comment on all of them. The development of new concepts for measurement of bilirubin binding, whether clinical or basic scientific application, can only serve to enrich our understanding of bilirubin chemistry and physiology. New knowledge may at first appear to confuse but ultimately it clarifies. We also wish to take issue with the final sentence in Drs. Krasner and Chignell's letter. "Direct" methods are not inherently any more accurate or simple to interprete than "indirect" methods. In fact, modern scientific knowledge in nearly all fields is based, to a very great extent, on the use of "indirect" methods. Lawrence M. Gartner, M.D. Kwang-sun Lee, M.D. Department o f Pediatrics Rose F. Kennedy Research Center Albert Einstein College of Medicine Bronx, N. Y. 10461 REFERENCE
1.
Gartner LM, and Lee KS: Bilirubin binding, free fatty acids and a new concept for the pathogenesis of kernicterus, Proceedings of the International Symposium on Bilirubin Metabolism in the Newborn, Jerusalem, Israel, April, 1974, The National Foundation (in press).
Screening for congenital hypothyroidism To the Editor." There are two minor errors in the "Editor's column," of the May issue of THE JOURNAL OF PEDIATRICS. 1 The first error, in the first paragraph, line 16, I think Dr. D. Fisher meant: " . . . during the early days and weeks of extrauterine life" (and not intrauterine). The second error is on page 823, second paragraph, line 1: "The detection o f T S H deficiency in the immediate post natal p e r i o d . . . " should read: "thyroid deficiency," because the defect is in the thyroid gland and certainly not in the hypothalamus or pituitary .gland.
The Journal of Pediatrics December 1975
The values of TSH concentration are actually very high in congenital hypothyroidism as is shown in Ref. 2 and other reports. Alfredo O. Santesteban. M.D. 2701-17th St. Rock Island, Ill. 61201 REFERENCES
1. Fisher DA: Neonatal detection of hypothyroidism, J P~DIATR 86:822, 1975. 2. Klein A, Agusfin AV, and Foley TP: Successful laboratory screening for congenital hypothyroidism, Lancet 2:77, 1974.
Rep To the Editor: Dr. Santesteban's comments are correct, and I thank him for his letter. Delbert A. Fisher, M.D. UCLA School of Medicine Harbor General Hospital Campus 1000 West Carson St. Torrance, Calif. 90509
Prevention of ulceration of neck by CPAP head box To the Editor: We note with interest the article, "Severe neck ulceration from CPAP head box," by Krauss and Marshall? We have treated 21 babies suffering from hyaline membrane disease in the "Gregory box" make of CPAP head box, and initially used the Velcro strip supplied by the distributors to fasten the plastic hood, but we too found soreness at the nape of the neck developed easily, possibly aggravated by skin edema or even fat necrosis. We found this could be avoided by using an inflated length of Paul's 1-inch colostomy tubing, attached to tapes at each end. (Fig. 1) The length of tubing was approximately 24 cm--according to the size of the infant. This proved more satisfactory than cotton gauze tissue which would become hard when compressed and tended to allow air leakage. The tapes are tied with a single tie anteriorly, which is held in place over the baby's sternum by the ballooned hood overlying it, ie, not constricting the child's neck and thereby risking raised jugular venous pressure and possibly cerebral hemorrhage. We think that the "Gregory box" method of applying CPAP has proved of significant value in treatment of hyaline membrane disease, and it is well worth overcoming such practical difficulties which might otherwise deter the neonatal staff from using it.
Volume 87 Number 6, part 1
Letters to the Editor
1011
necessity of specific countertherapy. If life-threatening anticholinergic manifestations of a cardiovascular nature alone predominate, then a quaternary amine such as neostigmine or pyridostigmine would be indicated, since these do not cross the bloodbrain barrier. If the life-threatening manifestations include the central nervous system, then a tertiary amine such as physostigmine has a place in the therapy, since it will cross the blood-brain barrier. Howard C. Mofenson, M.D. Joseph Greenshei; M.D. Poison Control Center Nassau County Medical Center East Meadow, N. Y. REFERENCES
1. Fig. 1.
Clearly, the safety of such apparatus must always depend on the constant vigilance of skilled nursing staff. Marion Williams, S.R.N., S.E.M., R.S.E.N. John Morgan, M.B., B.Ch., D.C.H., D.Obst. S. A. S. Thompson, M.R.C.P.(Edin), M.B.Ch.B., D.C.H., D.Obst. Maelor General Hospital Wrexham LL13 7TD England REFERENCE
1.
Krauss DR. and Marshall RE: Severe neck ulceration from CPAP head box, J PEDIATR 86:286, 1975.
Physostigmine as an antidote: Use with caution To the Editor: We would like to make several comments on the recent recommendations for the use of physostigmine salicylate as an antidote in accidental intoxications? -~ It is important that physostigmine not be recommended for routine use either in diazepam or even in the more serious tricyclic antidepressant intoxications. Our own experience and a review of the literature fail to reveal a case in which diazepam has caused a fatality, when it was the only drug ingested. Newton ~ has reported convulsions in two patients and severe cholinergic manifestations in two other patients in whom physostigmine was used intravenously. The severity and the type of manifestations caused by the poisonings should be the guide, in each individual case, for the
2. 3.
4.
Di Liberti J, O'Brien ML, and Turner T: The use of physostigmine as an antidote in accidental diazepam intoxication, J PEDIATR 86:106, 1975. Rumack BH: Anticholinergic poisoning: Treatment with physostigmine, Pediatrics 52:449, 1973. Hussey HH: Physostigmine: Value in treatment of central toxic effects of anticholinergic drugs. JAMA 231:1066, 1975. Newton RW: Physostigmine salicylate in the treatment o f tricyclic antidepressant overdose, JAMA 231:941, 1975.
To the Editor: We agree with Drs. Mofenson and Greensher that physostigmine should not be used routinely as an antidote for diazepam intoxication. Further experience is needed before the safety of and need for this therapy is established. The intent of our paper was to report an interesting observation and was n o t a recommendation for routine use. This was pointed out in the text.' The safety and usefulness ofphysostigmine for tricyclic antidepressant intoxication likewise remains to be demonstrated. The nature and severity o f side effects in Newton's ~ small group of patients are puzzling, since Bernards:' has seen no seizures or other significant complications after nearly 5,000 administered doses of physostigmine. Seizures and arrhythmias occur from tricyclic antidepressant intoxication alone. We believe that physostigmine is a relatively safe drug to use for reversal of toxic effects o f diazepam, phenothiazines, anticholinergic drugs, and possibly tricyclic antidepressants. Whether or not such therapy improves morbidity and mortality for these intoxications remains to be demonstrated. Intramuscular injection is probably associated with fewer side effects than intravenous use. Atropine should be available for immediate administration in the event that significant bradycardia or excess salivation occur. John 11. Di Liberti, M.D. Mary Lynn O'Brien, M.D. Pediatric Associates 999 North Curtis Rd Boise, Idaho 83704
Letters to the Editor
tions. 1 Since these are both situations in which binding affinity or capacity is decreased when compared with fresh adult sera, it is reasonable t o assume that the break in the curve is related to changes in binding affinity and capacity rather than to bilirubin concentrations independent of binding. The authors wish to apologize to Dr. Krasner for not having made mention o f his direct bilirubin fluorescence method for binding estimation, w e chose to comment only on those binding methods currently enjoying clinical application. There are, indeed, a number of other methods which have been proposed for estimation of bilirubin binding, and we did not comment on all of them. The development of new concepts for measurement of bilirubin binding, whether clinical or basic scientific application, can only serve to enrich our understanding of bilirubin chemistry and physiology. New knowledge may at first appear to confuse but ultimately it clarifies. We also wish to take issue with the final sentence in Drs. Krasner and Chignell's letter. "Direct" methods are not inherently any more accurate or simple to interprete than "indirect" methods. In fact, modern scientific knowledge in nearly all fields is based, to a very great extent, on the use of "indirect" methods. Lawrence M. Gartner, M.D. Kwang-sun Lee, M.D. Department o f Pediatrics Rose F. Kennedy Research Center Albert Einstein College of Medicine Bronx, N. Y. 10461 REFERENCE
1.
Gartner LM, and Lee KS: Bilirubin binding, free fatty acids and a new concept for the pathogenesis of kernicterus, Proceedings of the International Symposium on Bilirubin Metabolism in the Newborn, Jerusalem, Israel, April, 1974, The National Foundation (in press).
Screening for congenital hypothyroidism To the Editor." There are two minor errors in the "Editor's column," of the May issue of THE JOURNAL OF PEDIATRICS. 1 The first error, in the first paragraph, line 16, I think Dr. D. Fisher meant: " . . . during the early days and weeks of extrauterine life" (and not intrauterine). The second error is on page 823, second paragraph, line 1: "The detection o f T S H deficiency in the immediate post natal p e r i o d . . . " should read: "thyroid deficiency," because the defect is in the thyroid gland and certainly not in the hypothalamus or pituitary .gland.
The Journal of Pediatrics December 1975
The values of TSH concentration are actually very high in congenital hypothyroidism as is shown in Ref. 2 and other reports. Alfredo O. Santesteban. M.D. 2701-17th St. Rock Island, Ill. 61201 REFERENCES
1. Fisher DA: Neonatal detection of hypothyroidism, J P~DIATR 86:822, 1975. 2. Klein A, Agusfin AV, and Foley TP: Successful laboratory screening for congenital hypothyroidism, Lancet 2:77, 1974.
Rep To the Editor: Dr. Santesteban's comments are correct, and I thank him for his letter. Delbert A. Fisher, M.D. UCLA School of Medicine Harbor General Hospital Campus 1000 West Carson St. Torrance, Calif. 90509
Prevention of ulceration of neck by CPAP head box To the Editor: We note with interest the article, "Severe neck ulceration from CPAP head box," by Krauss and Marshall? We have treated 21 babies suffering from hyaline membrane disease in the "Gregory box" make of CPAP head box, and initially used the Velcro strip supplied by the distributors to fasten the plastic hood, but we too found soreness at the nape of the neck developed easily, possibly aggravated by skin edema or even fat necrosis. We found this could be avoided by using an inflated length of Paul's 1-inch colostomy tubing, attached to tapes at each end. (Fig. 1) The length of tubing was approximately 24 cm--according to the size of the infant. This proved more satisfactory than cotton gauze tissue which would become hard when compressed and tended to allow air leakage. The tapes are tied with a single tie anteriorly, which is held in place over the baby's sternum by the ballooned hood overlying it, ie, not constricting the child's neck and thereby risking raised jugular venous pressure and possibly cerebral hemorrhage. We think that the "Gregory box" method of applying CPAP has proved of significant value in treatment of hyaline membrane disease, and it is well worth overcoming such practical difficulties which might otherwise deter the neonatal staff from using it.
Volume 87 Number 6, part 1
Letters to the Editor
1011
necessity of specific countertherapy. If life-threatening anticholinergic manifestations of a cardiovascular nature alone predominate, then a quaternary amine such as neostigmine or pyridostigmine would be indicated, since these do not cross the bloodbrain barrier. If the life-threatening manifestations include the central nervous system, then a tertiary amine such as physostigmine has a place in the therapy, since it will cross the blood-brain barrier. Howard C. Mofenson, M.D. Joseph Greenshei; M.D. Poison Control Center Nassau County Medical Center East Meadow, N. Y. REFERENCES
1. Fig. 1.
Clearly, the safety of such apparatus must always depend on the constant vigilance of skilled nursing staff. Marion Williams, S.R.N., S.E.M., R.S.E.N. John Morgan, M.B., B.Ch., D.C.H., D.Obst. S. A. S. Thompson, M.R.C.P.(Edin), M.B.Ch.B., D.C.H., D.Obst. Maelor General Hospital Wrexham LL13 7TD England REFERENCE
1.
Krauss DR. and Marshall RE: Severe neck ulceration from CPAP head box, J PEDIATR 86:286, 1975.
Physostigmine as an antidote: Use with caution To the Editor: We would like to make several comments on the recent recommendations for the use of physostigmine salicylate as an antidote in accidental intoxications? -~ It is important that physostigmine not be recommended for routine use either in diazepam or even in the more serious tricyclic antidepressant intoxications. Our own experience and a review of the literature fail to reveal a case in which diazepam has caused a fatality, when it was the only drug ingested. Newton ~ has reported convulsions in two patients and severe cholinergic manifestations in two other patients in whom physostigmine was used intravenously. The severity and the type of manifestations caused by the poisonings should be the guide, in each individual case, for the
2. 3.
4.
Di Liberti J, O'Brien ML, and Turner T: The use of physostigmine as an antidote in accidental diazepam intoxication, J PEDIATR 86:106, 1975. Rumack BH: Anticholinergic poisoning: Treatment with physostigmine, Pediatrics 52:449, 1973. Hussey HH: Physostigmine: Value in treatment of central toxic effects of anticholinergic drugs. JAMA 231:1066, 1975. Newton RW: Physostigmine salicylate in the treatment o f tricyclic antidepressant overdose, JAMA 231:941, 1975.
To the Editor: We agree with Drs. Mofenson and Greensher that physostigmine should not be used routinely as an antidote for diazepam intoxication. Further experience is needed before the safety of and need for this therapy is established. The intent of our paper was to report an interesting observation and was n o t a recommendation for routine use. This was pointed out in the text.' The safety and usefulness ofphysostigmine for tricyclic antidepressant intoxication likewise remains to be demonstrated. The nature and severity o f side effects in Newton's ~ small group of patients are puzzling, since Bernards:' has seen no seizures or other significant complications after nearly 5,000 administered doses of physostigmine. Seizures and arrhythmias occur from tricyclic antidepressant intoxication alone. We believe that physostigmine is a relatively safe drug to use for reversal of toxic effects o f diazepam, phenothiazines, anticholinergic drugs, and possibly tricyclic antidepressants. Whether or not such therapy improves morbidity and mortality for these intoxications remains to be demonstrated. Intramuscular injection is probably associated with fewer side effects than intravenous use. Atropine should be available for immediate administration in the event that significant bradycardia or excess salivation occur. John 11. Di Liberti, M.D. Mary Lynn O'Brien, M.D. Pediatric Associates 999 North Curtis Rd Boise, Idaho 83704
