CORRESPON DENCE
SUDAFW TABLETS / SYRUP Pseudoephedrine HCI Decongestant
Surgery and anesthesia in Ontario lated hernias requiring bowel resection. To the editor: For approximately 30 years the staff at Shouldice Hospital has been practising and preaching the use of local infiltration anesthesia with immediate ambulation this alone makes possible - in the management of inguinal herniorrhaphy. In their article analysing the statistics for surgery and anesthesia in Ontario, Vayda, Lyons and Anderson (Can Med Assoc J 116: 1263, 1977) show (Table III) 45 deaths in hospital after 20 576 nonrecurrent inguinal herniorrhaphies performed in 1973. In the same year 4132 such operations were performed at the Shouldice Hospital without a single death. Clearly the mortality for the province would have been even higher if our figures had not been included. The same article cites 12.4 deaths per 1000 herniorrhaphies of patients aged over 65 years (Table IV). From 1967 to 1972 (inclusive) we performed more than 4000 inguinal herniorrhaphies in patients aged over 65 without a single death in hospital;1 according to Vayda and colleagues' figure some 50 deaths might have been expected in this 6-year series. In the over-65-year age group inguinal herniorrhaphy had a higher mortality than hysterectomy (Table IV). Moreover, the mortality for patients of all ages from inguinal herniorrhaphy is shown as 2.2 per 1000 procedures; in the same year - 1973 - the maternal mortality per 1000 livebirths was 0.11. Who would have thought it was 20 times more dangerous to have a hernia repaired than to have a baby? However, the situation is not quite as bad as Vayda and colleagues' article suggests because the code number they use, 3 8.2,2 could include some stranguContributions to the Correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double-spaced and, except for case reports, should be no longer than 1½ manuscript pages.
Though they list nonrecurrent inguinal herniorrhaphy among "discretionary operations", some nondiscretionary procedures must have been included. No doubt a few of the deaths occurred in this small number of emergency operations, from which some deaths are to be expected. It is most unfortunate that emergency herniorrhaphies (with obstruction) are not kept separate statistically,3 but it is improbable that they account for more than a handful of the deaths. It is hard to understand why this sorry state of affairs is tolerated. Unfortunately one can see no chance of improvement in mortality, or in morbidity either - though the latter is harder to define - until the main teaching centres in Ontario adopt local infiltration anesthesia (with immediate ambulation) as the management of choice in what is, after all, the commonest of all abdominal operations. The practice has to start in the teaching centres before it can spread gradually to the rest of the province. J.D.H. ILES, MB, B CH Shouldice Hospital Limited Thornhil, Ont.
References 1. iLES JDH: Geriatric herniorrhaphy: a minor operation. Mod Geriatr no 13, April 1974 2. International Classification of Diseases, Adapted, 8th rev, Geneva, WHO, 1963 3. ILES JDH: Mortality from elective hernia repair. I Abd Surg 11: 87, 1969
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 theaboveconditions. 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. Acidifythe 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 upto 4 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 mIand25Oml bottles. Tablets: Each white, biconvex tablet 8.6 mm in diameter with code number WELLCOME S7A on same side as diagonal score mark contains: pseudoephedrine HCI 60 mg. Available in cartonsof 18 and bottlesof iQOand SOOtablets. Additional prescribing information available on request.
Screening for neural tube defects To the editor: The report of the British collaborative study on a-fetoprotein in relation to neural tube defects1 aroused much interest throughout the world, offering as it did the possibility of detecting fetuses with neural tube defects by screening pregnant women for elevation of serum ct-fetoprotein concentration. In other parts of the world the incidence of neural tube defects may be less than in the areas of Britain where the original study was con-
114 GMA JOURNAL/JANUARY 21, 1978/VOL. 118
. Burroughs Welicome Ltd. LaSalle, 0u6. *Trade Mark
.
W6017
ducted. The feasibility of mass screening for such defects is affected greatly by their incidence in the particular geographic area. We present our assessment of this question in the hope that our data will be of value for other populations. In British Columbia there are approximately 35 000 births per year. The incidence of anencephaly in the province is approximately 0.59 per 1000 births; of open spina bifida, 0.76 per 1000; and of a closed neural tube defect, 0.08 per 1000.2 The report of the collaborative study from Britain' suggested that the optimal time to screen pregnant women for fetal neural tube defects is from the 16th to the 18th week of gestation. All women whose serum a-fetoprotein concentration was greater than two and a half times the median were retested by amniocentesis. From the data we calculate that this figure represents approximately 3.3% of all pregnant women. This means that 33 of every 1000 pregnant women would be tested by ultrasonography or subjected to amniocentesis or both, for British Columbia, approximately 1150 per year. According to the British data approximately 80% of fetuses with open spina bifida and 90% of fetuses with anencephaly would be detected either by ultrasonography or by elevation of the amniotic fluid a-fetoprotein concentration. For British Columbia the numbers of cases would be 21 and 19, respectively, and the cost would be that of investigating, by either of these methods, 1150 pregnancies. For open spina bifida the ratio of "unnecessary" to "necessary" amniocenteses would be approximately 55:1. One would expect to detect the 19 anencephalic fetuses by ultrasonography alone; therefore fewer than 1150 amniocenteses would be needed to discover this anomaly. In this communication we are not addressing the cost/benefit aspect of the problem, though we intend to publish the results of a study on this aspect later, nor are we considering the ethical questions concerned. We are merely estimating, for a population with a relatively small number of neural tube defects, the probable numbers of examinations that would be required to detect a predictable number of such cases. However, there are other practical points to consider. For example, there may be reservations with respect to the practicability of testing pregnant women at exactly 16 to 18 weeks' gestation. Because the a-fetoprotein concentration in maternal serum is strongly dependent on the fetal age, the feasibility of screening all pregnancies for neural tube defects could stand or fall on this issue. Finally, we have
not explored the practicability of screening women who are remote from medical centres. The calculations we present emphasize the need for careful cost! benefit studies before considering a mass screening program to test pregnant women in British Columbia for neural tube defects by sampling maternal blood for a-fetoprotein concentrations. DEREK A. APPLEGARTH, PH D LORNE T. KIRBY, PH D Department of pediatrics University of British Columbia Vancouver, BC R. BRIAN LOWRY, MD, FRCP[C] Division of pediatrics University of Calgary Calgary, Alta.
her psychiatric evaluation she had a serum digoxin value of over 4 ng/mL. With reduction of her digoxin dosage and without further intervention the patient's depression improved in a few days. Monitoring of the serum digoxin concentration, despite its technical difficulties, is in my opinion as mandatory as thorough familiarity with the wide range of possible psychotoxic, neurologic, ophthalmic, gastrointestinal and cardiac symptoms that may arise as a consequence of excessive doses of digitalis. ERWIN K. KORANYT, MD Director, adult psychiatric outpatient department Ottawa General Hospital Ottawa, Ont.
References 1. U.K. COLLABORATIVE STUDY: Maternal serumaipha-fetoprotein measurement in antenatal screening for anencephaly and spina bifida in early pregnancy. Lancet 1: 1323, 1977 2. Registry for Handicapped Children and Adults 1974, spec rep no 143, Victoria, division of vital statistics, Ministry of Health, British Columbia, 1976
Serum digoxin test
Reference 1. SHADER RI (ed): Psychiatric Complications of Medical Drugs, New York, Raven Pr, 1972,
p 35
Classification of degenerative arthritis
To the editor: Drs. N.S. Mitchell and To the editor: Dr. A. Dodek's editorial R.L. Cruess, in their classification of (Can Med Assoc J 117: 994, 1977) is degenerative arthritis, list obesity and a useful and timely reminder for all. occupation as remote causes (Can Med The toxicity of digitalis alkaloids is a Assoc J 117: 763, 1977). In discussing perennial problem that, in its minor the subject they make the observation form, is frequently overlooked. Dodek that "degenerative arthritis is more fredid not elaborate on all aspects, dangers quent in those doing heavy labour." and symptoms of the toxicity. This hypothesis has been brought Just as the ophthalmic signs of digi- forward not infrequently and gives rise talis poisoning do not consist exclu- to the old question, does the back wear sively of typical yellow-green colour out on the job or on the man? This vision, but may include less distinct applies just as aptly to a discussion on scintillations, scotomata and "flashes", joints in general, especially weightlikewise the psychotoxic signs do not bearing joints, and the role of heavy always reach full-blown toxic hallucina- occupational labour in the developtory delirium. Patients whose distur- ment of degenerative arthritic disease. bance is less severe may present with To date I have not seen any studies anxiety, depression, agitation, appre- demonstrating that heavy labour, dehension and similar pseudoneurotic fined as to type, intensity and duration manifestations, which are attributed, of exposure, is the causative factor in often mistakenly, to extraneous and the development of degenerative dicoincidental causes in the patient's en- sease. Furthermore, as Mitchell and vironment. These symptoms do not Cruess may well be aware, studies have respond to anxiolytic or antidepressant shown that in persons in whom demedications or to psychotherapy, just generative disease develops there is no as the digitalis-induced facial neuralgia clear-cut evidence that heavy occupafails to respond to carbamazepine. Psy- tion or labouring types of job tend chotoxic signs of digitalis toxicity are to act as an aggravating factor or to important nevertheless and, quoting give rise to symptoms. If the authors Shader,' "fortunate is he who develops know of any articles that demonstrate gastrointestinal, visual or psychiatric this relation I would be grateful to signs of toxicity before the heart is learn where they have been published affected. Unfortunately, a serious or so that I may evaluate them myself. fatal arrhythmia may be the initial While it is not infrequently stated manifestation of digitalis intoxication." that heavy activity in the workplace Recently a 54-year-old woman with gives rise to arthritic disease, causes long-standing cardiac problems who an acceleration of the disease or gives was taking digoxin was referred to our rise to symptoms from a pre-existing clinic because of depression. There had disease, evidence to support such a been no previous psychiatric problems statement appears still to be lacking. of any magnitude. The depression enW.J. MCCRACKEN, MD, FRCS[C] sued gradually after antidiuretic mediWorkmen's Compensation Board cation was prescribed. At the time of Toronto, Ont.
116 CMA JOURNAL/JANUARY 21, 1978/VOL. 118
SUDAFW TABLETS / SYRUP Pseudoephedrine HCI Decongestant
Surgery and anesthesia in Ontario lated hernias requiring bowel resection. To the editor: For approximately 30 years the staff at Shouldice Hospital has been practising and preaching the use of local infiltration anesthesia with immediate ambulation this alone makes possible - in the management of inguinal herniorrhaphy. In their article analysing the statistics for surgery and anesthesia in Ontario, Vayda, Lyons and Anderson (Can Med Assoc J 116: 1263, 1977) show (Table III) 45 deaths in hospital after 20 576 nonrecurrent inguinal herniorrhaphies performed in 1973. In the same year 4132 such operations were performed at the Shouldice Hospital without a single death. Clearly the mortality for the province would have been even higher if our figures had not been included. The same article cites 12.4 deaths per 1000 herniorrhaphies of patients aged over 65 years (Table IV). From 1967 to 1972 (inclusive) we performed more than 4000 inguinal herniorrhaphies in patients aged over 65 without a single death in hospital;1 according to Vayda and colleagues' figure some 50 deaths might have been expected in this 6-year series. In the over-65-year age group inguinal herniorrhaphy had a higher mortality than hysterectomy (Table IV). Moreover, the mortality for patients of all ages from inguinal herniorrhaphy is shown as 2.2 per 1000 procedures; in the same year - 1973 - the maternal mortality per 1000 livebirths was 0.11. Who would have thought it was 20 times more dangerous to have a hernia repaired than to have a baby? However, the situation is not quite as bad as Vayda and colleagues' article suggests because the code number they use, 3 8.2,2 could include some stranguContributions to the Correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double-spaced and, except for case reports, should be no longer than 1½ manuscript pages.
Though they list nonrecurrent inguinal herniorrhaphy among "discretionary operations", some nondiscretionary procedures must have been included. No doubt a few of the deaths occurred in this small number of emergency operations, from which some deaths are to be expected. It is most unfortunate that emergency herniorrhaphies (with obstruction) are not kept separate statistically,3 but it is improbable that they account for more than a handful of the deaths. It is hard to understand why this sorry state of affairs is tolerated. Unfortunately one can see no chance of improvement in mortality, or in morbidity either - though the latter is harder to define - until the main teaching centres in Ontario adopt local infiltration anesthesia (with immediate ambulation) as the management of choice in what is, after all, the commonest of all abdominal operations. The practice has to start in the teaching centres before it can spread gradually to the rest of the province. J.D.H. ILES, MB, B CH Shouldice Hospital Limited Thornhil, Ont.
References 1. iLES JDH: Geriatric herniorrhaphy: a minor operation. Mod Geriatr no 13, April 1974 2. International Classification of Diseases, Adapted, 8th rev, Geneva, WHO, 1963 3. ILES JDH: Mortality from elective hernia repair. I Abd Surg 11: 87, 1969
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 theaboveconditions. 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. Acidifythe 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 upto 4 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 mIand25Oml bottles. Tablets: Each white, biconvex tablet 8.6 mm in diameter with code number WELLCOME S7A on same side as diagonal score mark contains: pseudoephedrine HCI 60 mg. Available in cartonsof 18 and bottlesof iQOand SOOtablets. Additional prescribing information available on request.
Screening for neural tube defects To the editor: The report of the British collaborative study on a-fetoprotein in relation to neural tube defects1 aroused much interest throughout the world, offering as it did the possibility of detecting fetuses with neural tube defects by screening pregnant women for elevation of serum ct-fetoprotein concentration. In other parts of the world the incidence of neural tube defects may be less than in the areas of Britain where the original study was con-
114 GMA JOURNAL/JANUARY 21, 1978/VOL. 118
. Burroughs Welicome Ltd. LaSalle, 0u6. *Trade Mark
.
W6017
ducted. The feasibility of mass screening for such defects is affected greatly by their incidence in the particular geographic area. We present our assessment of this question in the hope that our data will be of value for other populations. In British Columbia there are approximately 35 000 births per year. The incidence of anencephaly in the province is approximately 0.59 per 1000 births; of open spina bifida, 0.76 per 1000; and of a closed neural tube defect, 0.08 per 1000.2 The report of the collaborative study from Britain' suggested that the optimal time to screen pregnant women for fetal neural tube defects is from the 16th to the 18th week of gestation. All women whose serum a-fetoprotein concentration was greater than two and a half times the median were retested by amniocentesis. From the data we calculate that this figure represents approximately 3.3% of all pregnant women. This means that 33 of every 1000 pregnant women would be tested by ultrasonography or subjected to amniocentesis or both, for British Columbia, approximately 1150 per year. According to the British data approximately 80% of fetuses with open spina bifida and 90% of fetuses with anencephaly would be detected either by ultrasonography or by elevation of the amniotic fluid a-fetoprotein concentration. For British Columbia the numbers of cases would be 21 and 19, respectively, and the cost would be that of investigating, by either of these methods, 1150 pregnancies. For open spina bifida the ratio of "unnecessary" to "necessary" amniocenteses would be approximately 55:1. One would expect to detect the 19 anencephalic fetuses by ultrasonography alone; therefore fewer than 1150 amniocenteses would be needed to discover this anomaly. In this communication we are not addressing the cost/benefit aspect of the problem, though we intend to publish the results of a study on this aspect later, nor are we considering the ethical questions concerned. We are merely estimating, for a population with a relatively small number of neural tube defects, the probable numbers of examinations that would be required to detect a predictable number of such cases. However, there are other practical points to consider. For example, there may be reservations with respect to the practicability of testing pregnant women at exactly 16 to 18 weeks' gestation. Because the a-fetoprotein concentration in maternal serum is strongly dependent on the fetal age, the feasibility of screening all pregnancies for neural tube defects could stand or fall on this issue. Finally, we have
not explored the practicability of screening women who are remote from medical centres. The calculations we present emphasize the need for careful cost! benefit studies before considering a mass screening program to test pregnant women in British Columbia for neural tube defects by sampling maternal blood for a-fetoprotein concentrations. DEREK A. APPLEGARTH, PH D LORNE T. KIRBY, PH D Department of pediatrics University of British Columbia Vancouver, BC R. BRIAN LOWRY, MD, FRCP[C] Division of pediatrics University of Calgary Calgary, Alta.
her psychiatric evaluation she had a serum digoxin value of over 4 ng/mL. With reduction of her digoxin dosage and without further intervention the patient's depression improved in a few days. Monitoring of the serum digoxin concentration, despite its technical difficulties, is in my opinion as mandatory as thorough familiarity with the wide range of possible psychotoxic, neurologic, ophthalmic, gastrointestinal and cardiac symptoms that may arise as a consequence of excessive doses of digitalis. ERWIN K. KORANYT, MD Director, adult psychiatric outpatient department Ottawa General Hospital Ottawa, Ont.
References 1. U.K. COLLABORATIVE STUDY: Maternal serumaipha-fetoprotein measurement in antenatal screening for anencephaly and spina bifida in early pregnancy. Lancet 1: 1323, 1977 2. Registry for Handicapped Children and Adults 1974, spec rep no 143, Victoria, division of vital statistics, Ministry of Health, British Columbia, 1976
Serum digoxin test
Reference 1. SHADER RI (ed): Psychiatric Complications of Medical Drugs, New York, Raven Pr, 1972,
p 35
Classification of degenerative arthritis
To the editor: Drs. N.S. Mitchell and To the editor: Dr. A. Dodek's editorial R.L. Cruess, in their classification of (Can Med Assoc J 117: 994, 1977) is degenerative arthritis, list obesity and a useful and timely reminder for all. occupation as remote causes (Can Med The toxicity of digitalis alkaloids is a Assoc J 117: 763, 1977). In discussing perennial problem that, in its minor the subject they make the observation form, is frequently overlooked. Dodek that "degenerative arthritis is more fredid not elaborate on all aspects, dangers quent in those doing heavy labour." and symptoms of the toxicity. This hypothesis has been brought Just as the ophthalmic signs of digi- forward not infrequently and gives rise talis poisoning do not consist exclu- to the old question, does the back wear sively of typical yellow-green colour out on the job or on the man? This vision, but may include less distinct applies just as aptly to a discussion on scintillations, scotomata and "flashes", joints in general, especially weightlikewise the psychotoxic signs do not bearing joints, and the role of heavy always reach full-blown toxic hallucina- occupational labour in the developtory delirium. Patients whose distur- ment of degenerative arthritic disease. bance is less severe may present with To date I have not seen any studies anxiety, depression, agitation, appre- demonstrating that heavy labour, dehension and similar pseudoneurotic fined as to type, intensity and duration manifestations, which are attributed, of exposure, is the causative factor in often mistakenly, to extraneous and the development of degenerative dicoincidental causes in the patient's en- sease. Furthermore, as Mitchell and vironment. These symptoms do not Cruess may well be aware, studies have respond to anxiolytic or antidepressant shown that in persons in whom demedications or to psychotherapy, just generative disease develops there is no as the digitalis-induced facial neuralgia clear-cut evidence that heavy occupafails to respond to carbamazepine. Psy- tion or labouring types of job tend chotoxic signs of digitalis toxicity are to act as an aggravating factor or to important nevertheless and, quoting give rise to symptoms. If the authors Shader,' "fortunate is he who develops know of any articles that demonstrate gastrointestinal, visual or psychiatric this relation I would be grateful to signs of toxicity before the heart is learn where they have been published affected. Unfortunately, a serious or so that I may evaluate them myself. fatal arrhythmia may be the initial While it is not infrequently stated manifestation of digitalis intoxication." that heavy activity in the workplace Recently a 54-year-old woman with gives rise to arthritic disease, causes long-standing cardiac problems who an acceleration of the disease or gives was taking digoxin was referred to our rise to symptoms from a pre-existing clinic because of depression. There had disease, evidence to support such a been no previous psychiatric problems statement appears still to be lacking. of any magnitude. The depression enW.J. MCCRACKEN, MD, FRCS[C] sued gradually after antidiuretic mediWorkmen's Compensation Board cation was prescribed. At the time of Toronto, Ont.
116 CMA JOURNAL/JANUARY 21, 1978/VOL. 118
