CORRESPONDENCE
Adopted children entering Canada from underdeveloped countries To the editor: In the past 3 or 4 years we have been consulted in the care of children from the Third World entering Canada for adoption. These children, mostly infants (mean age 5 months), suffered from a wide range of medical disorders. Most had several disorders, some of which are not frequently seen in Canada. Therefore, we believed it would be of some assistance to medical practitioners in Canada who are asked to treat these children to summarize our experience (Table I). Table f-Medical problems encountered in
46 children from the ThIrd World enter,ng Canada
Medical problem
% of children
UndernutrIti.nt *5 Chronic 4I.rel,eat Oil Infection Sepal;, meningitIs 6 Pneumonia, bronchlofitls, tuberculosIs 23 Upper respiratory tract Infection, otitle, dhtgnan 36 Parasitic Infection 23 Skin disorder Scables, lice 36 Impetigo, abscesses 13 Candlditals, eczema, seborrhea 40 Metabolic dlsQu*rs HypothermIa, aeldosls, hypoglycende 13 Hyponatrei*, Isypek... lemia, lt.poc.Iciula 36 Iwo thirds$ this group of children also had hypoalbusninemla.1 tAn etlologic agent, bacterial or parasitic, wasidentifledln57%ef th1sgroup. Contributions 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 eports, should be no longer than 1½ manuscript pages.
Of 47 children 93% had acute health problems, including undernutrition (65%), chronic diarrhea (60%), acute infection (74%), skin disorders (55%) and metabolic disorders (40%). We encountered serious management problems in nutritional rehabilitation and the treatment of infections. It is particularly important to consider all the entities listed in Table I when one is assessing these children, since their recovery may be hampered if not all the coexisting conditions are recognized and treated. Malaria was not seen in this group of children. Recently, however, we encountered one child in whom evidence of malaria was sought at the initial assessment but was not found; during nutritional rehabilitation, however, signs and symptoms of malaria appeared and the disease was confirmed hematologically. K.J. MOTIL, MD B.S. KAPLAN, MB, B CH, F.P (sA) P.B. PENCHARZ, MB, CH B, PH D, FRcP[c]
Department of pediatrics Montreal Children's Hospital Montreal, PQ
Reference 1. MCLAREN DS, READ WWC: Weight! length classification of nutritional status. Lance 2: 219, 1975
Accuracy and safety of genetic prenatal diagnosis
To the editor: I wish to communicate my experience with the effects of two environmental agents coffee intake and physical activity - on ultrasonography and amniocentesis. With the increasingly widespread use of ultrasonography and amnio-
centesis, which we at the University Hospital, Saskatoon usually perform consecutively on the same day, several complications are coming to light. Excessive fetal movements during ultrasonography, particularly the B-mode examination, often hamper and occasionally preclude accurate measurements such as the determination of the biparietal diameter of the head of the fetus and hence the gestational age. Coffee intake in women to be examined, presumably by virtue of its caffeine content, appears to precipitate excessive, often jerky, fetal movements and may thus interfere with ultrasonography and vitiate its findings. Furthermore, undue cardiac acceleration and various arrhythmias may also be engendered. On some occasions ultrasonography had to be rescheduled and the patient advised to refrain from drinking coffee or tea at breakfast and during the day until the examination. Satisfactory evaluation was then feasible and accurate results were obtained. Physical effort, both active, such as exercise, and passive, particularly prolonged car rides, has been associated with an increased rate of spontaneous abortion within 24 hours of amniocentesis carried out around 16 weeks' gestation. It also appears that the intake of coffee or other stimulants following the procedure may contribute to this adverse outcome. Therefore, in addition to the usual precautions observed in both ultrasonography and amniocentesis for genetic diagnosis, we now recommend that women undergoing these procedures (a) avoid coffee, tea and other stimulants throughout the day of the test, (b) lie down for half an hour following amniocentesis, (c) sit
CMA JOURNAL/AUGUST 18, 1979/VOL. 121
403
comfortably in hospital for some 2 hours thereafter and (d) avoid exercise and lengthy or bumpy car rides for the remainder of the day. We believe that, even if they are unnecessary in some cases, these precautions are neither unduly onerous to the patient nor demanding of our staff, and cannot be harmful to the mother or the fetus. To better assess the impact of these factors we are currently engaged in an extensive prospective survey of which this is a preliminary communication. I invite others to monitor the potential impact of coffee intake and physical activity, and to record and communicate their observations, particularly regarding the possible adverse effects of excessive physical activity immediately following amniocentesis for genetic diagnosis.
CMA members feel about what happened at the recent presidential election. How can it be possible that someone who did not even stand for election as the representative of the province was sponsored at the election and, indeed, that his proposer was from another province, so that he was elected over the head of the democratically sponsored candidate? I have very good reason to believe that there was "dirty work at the crossroads" or, if one prefers, that this was a "put-up job" engineered by a group who did not like the democratically elected candidate from the province. I fear that if this is the kind of thing that goes on at the CMA, I for one will not remain a member. JOHN F. BOURDILLON, FRcS, FRcs[c]
5780 Cambie St. Vancouver, BC
M.H.K. SHOKEIR, MD, PH 33
Director, division of medical genetics University Hospital Saskatoon, Sask.
CMA presidential election To the editor: I am shocked and outraged at the total disregard of the democratic process exhibited by the members of the General Council of the Canadian Medical Association (CMA) on June 19, 1979 when they elected Dr. W.D.S. Thomas as the CMA president for the 1980-81 term. The General Council completely ignored 2716 members of the British Columbia Medical Association (BCMA) who cast their ballots Mar. 30, 1969 and voted Dr. W. Jory as CMA president nominee, with a substantial majority. I cannot comprehend why these voting members, who have paid their annual dues to both the CMA and the BCMA have been rebuffed. It seems clear that the only correct action available to Dr. Thomas is to resign. Failing this, I wonder how many members of the BCMA will be willing to re-evaluate their membership in such a "democratic" organization. D.E. WATSON, MD
District 4 British Columbia Medical Association 654 Westview Centre North Vancouver, BC
To the editor: I wish to draw attention to the concern that I and many
To the editor: How can an honourable profession behave in such a way as it did in the recent election of the CMA president? A more furtive, unpleasant "set-up" would be hard to find. When "Caesar" was stabbed in the back there was not even one honourable "Brutus" among the voters to excuse their vindictiveness. The repercussions from this malicious action will last at least 2 years, and I cannot see how the annual CMA meeting in Vancouver in 1980 can be other than uncomfortable for our Australian visitors, embarrassing for the CMA executive council and extremely unpleasant for others. CLIVE D. THOMPSON, MD, DRcOG, LRcP, MRCS
12837-.-96th Ave. Surrey, BC [These three letters contain all the points put forward in the four letters the CMA has received regarding the election of the new president of the CMA. Section 1 4.5.1 of The Act of Incorporation and Bylaws of the CMA reads as follows: When the report of the Committee on Nominations has been received by the General Council in session, other nominations may also be received from the floor. *A ballot shall then be taken for each of the offices
404 CMA JOURNAL/AUGUST 18, 1979/VOL. 121
in turn including the Officers, Speaker and Deputy Speaker of the General Council, members of the Committee on Finance, the Committee on Ethics and for the Divisional representatives of the Board of Directors and their alternates. Dr. Jory's name was placed in nomination by the committee on nominations and Dr. Thomas's nomination was received from the floor. Members of the General Council subsequently made their choice by secret ballot. - Ed.]
Diminished libido with cimetidine therapy To the editor: Cimetidine is widely used in the treatment of duodenal ulcers, but it has recently been established that the drug crosses the blood-brain barrier; it can be found in brain tissue and cerebrospinal fluid in humans.1 Seventeen cases of mental confusion have been reported1 and 26 cases of sexual dysfunction in men have been observed in England.2 I report a case of a man in whom libido diminished during withdrawal from cimetidine but reappeared when full-dosage therapy was resumed. A 51-year-old man who was happily married and the father of three children was treated with cimetidine, 800 mg/d, for 6 weeks because of a duodenal ulcer. During this time his wife noticed, but he did not, a decrease in the frequency of their sexual relations from twice a week to once every 2 weeks. Prompted by his wife the man sought medical advice. Cimetidine was discontinued and his libido returned to normal within a week. The patient was asked to try a challenging dose for a month; he agreed and cimetidine, 600 mg/d, was prescribed. Again the result was a decrease in libido. One week after cessation of therapy his libido returned to normal. The patient is presently taking cimetidine, 300 mg/d at bedtime, and his libido is normal. Therefore, the dose threshold for sexual dysfunction in this patient was between 300 and 600 mg/d. No tests for endocrine function were carried out, nor were sperm counts performed. A double-blind experiment with a placebo was not attempted.
Adopted children entering Canada from underdeveloped countries To the editor: In the past 3 or 4 years we have been consulted in the care of children from the Third World entering Canada for adoption. These children, mostly infants (mean age 5 months), suffered from a wide range of medical disorders. Most had several disorders, some of which are not frequently seen in Canada. Therefore, we believed it would be of some assistance to medical practitioners in Canada who are asked to treat these children to summarize our experience (Table I). Table f-Medical problems encountered in
46 children from the ThIrd World enter,ng Canada
Medical problem
% of children
UndernutrIti.nt *5 Chronic 4I.rel,eat Oil Infection Sepal;, meningitIs 6 Pneumonia, bronchlofitls, tuberculosIs 23 Upper respiratory tract Infection, otitle, dhtgnan 36 Parasitic Infection 23 Skin disorder Scables, lice 36 Impetigo, abscesses 13 Candlditals, eczema, seborrhea 40 Metabolic dlsQu*rs HypothermIa, aeldosls, hypoglycende 13 Hyponatrei*, Isypek... lemia, lt.poc.Iciula 36 Iwo thirds$ this group of children also had hypoalbusninemla.1 tAn etlologic agent, bacterial or parasitic, wasidentifledln57%ef th1sgroup. Contributions 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 eports, should be no longer than 1½ manuscript pages.
Of 47 children 93% had acute health problems, including undernutrition (65%), chronic diarrhea (60%), acute infection (74%), skin disorders (55%) and metabolic disorders (40%). We encountered serious management problems in nutritional rehabilitation and the treatment of infections. It is particularly important to consider all the entities listed in Table I when one is assessing these children, since their recovery may be hampered if not all the coexisting conditions are recognized and treated. Malaria was not seen in this group of children. Recently, however, we encountered one child in whom evidence of malaria was sought at the initial assessment but was not found; during nutritional rehabilitation, however, signs and symptoms of malaria appeared and the disease was confirmed hematologically. K.J. MOTIL, MD B.S. KAPLAN, MB, B CH, F.P (sA) P.B. PENCHARZ, MB, CH B, PH D, FRcP[c]
Department of pediatrics Montreal Children's Hospital Montreal, PQ
Reference 1. MCLAREN DS, READ WWC: Weight! length classification of nutritional status. Lance 2: 219, 1975
Accuracy and safety of genetic prenatal diagnosis
To the editor: I wish to communicate my experience with the effects of two environmental agents coffee intake and physical activity - on ultrasonography and amniocentesis. With the increasingly widespread use of ultrasonography and amnio-
centesis, which we at the University Hospital, Saskatoon usually perform consecutively on the same day, several complications are coming to light. Excessive fetal movements during ultrasonography, particularly the B-mode examination, often hamper and occasionally preclude accurate measurements such as the determination of the biparietal diameter of the head of the fetus and hence the gestational age. Coffee intake in women to be examined, presumably by virtue of its caffeine content, appears to precipitate excessive, often jerky, fetal movements and may thus interfere with ultrasonography and vitiate its findings. Furthermore, undue cardiac acceleration and various arrhythmias may also be engendered. On some occasions ultrasonography had to be rescheduled and the patient advised to refrain from drinking coffee or tea at breakfast and during the day until the examination. Satisfactory evaluation was then feasible and accurate results were obtained. Physical effort, both active, such as exercise, and passive, particularly prolonged car rides, has been associated with an increased rate of spontaneous abortion within 24 hours of amniocentesis carried out around 16 weeks' gestation. It also appears that the intake of coffee or other stimulants following the procedure may contribute to this adverse outcome. Therefore, in addition to the usual precautions observed in both ultrasonography and amniocentesis for genetic diagnosis, we now recommend that women undergoing these procedures (a) avoid coffee, tea and other stimulants throughout the day of the test, (b) lie down for half an hour following amniocentesis, (c) sit
CMA JOURNAL/AUGUST 18, 1979/VOL. 121
403
comfortably in hospital for some 2 hours thereafter and (d) avoid exercise and lengthy or bumpy car rides for the remainder of the day. We believe that, even if they are unnecessary in some cases, these precautions are neither unduly onerous to the patient nor demanding of our staff, and cannot be harmful to the mother or the fetus. To better assess the impact of these factors we are currently engaged in an extensive prospective survey of which this is a preliminary communication. I invite others to monitor the potential impact of coffee intake and physical activity, and to record and communicate their observations, particularly regarding the possible adverse effects of excessive physical activity immediately following amniocentesis for genetic diagnosis.
CMA members feel about what happened at the recent presidential election. How can it be possible that someone who did not even stand for election as the representative of the province was sponsored at the election and, indeed, that his proposer was from another province, so that he was elected over the head of the democratically sponsored candidate? I have very good reason to believe that there was "dirty work at the crossroads" or, if one prefers, that this was a "put-up job" engineered by a group who did not like the democratically elected candidate from the province. I fear that if this is the kind of thing that goes on at the CMA, I for one will not remain a member. JOHN F. BOURDILLON, FRcS, FRcs[c]
5780 Cambie St. Vancouver, BC
M.H.K. SHOKEIR, MD, PH 33
Director, division of medical genetics University Hospital Saskatoon, Sask.
CMA presidential election To the editor: I am shocked and outraged at the total disregard of the democratic process exhibited by the members of the General Council of the Canadian Medical Association (CMA) on June 19, 1979 when they elected Dr. W.D.S. Thomas as the CMA president for the 1980-81 term. The General Council completely ignored 2716 members of the British Columbia Medical Association (BCMA) who cast their ballots Mar. 30, 1969 and voted Dr. W. Jory as CMA president nominee, with a substantial majority. I cannot comprehend why these voting members, who have paid their annual dues to both the CMA and the BCMA have been rebuffed. It seems clear that the only correct action available to Dr. Thomas is to resign. Failing this, I wonder how many members of the BCMA will be willing to re-evaluate their membership in such a "democratic" organization. D.E. WATSON, MD
District 4 British Columbia Medical Association 654 Westview Centre North Vancouver, BC
To the editor: I wish to draw attention to the concern that I and many
To the editor: How can an honourable profession behave in such a way as it did in the recent election of the CMA president? A more furtive, unpleasant "set-up" would be hard to find. When "Caesar" was stabbed in the back there was not even one honourable "Brutus" among the voters to excuse their vindictiveness. The repercussions from this malicious action will last at least 2 years, and I cannot see how the annual CMA meeting in Vancouver in 1980 can be other than uncomfortable for our Australian visitors, embarrassing for the CMA executive council and extremely unpleasant for others. CLIVE D. THOMPSON, MD, DRcOG, LRcP, MRCS
12837-.-96th Ave. Surrey, BC [These three letters contain all the points put forward in the four letters the CMA has received regarding the election of the new president of the CMA. Section 1 4.5.1 of The Act of Incorporation and Bylaws of the CMA reads as follows: When the report of the Committee on Nominations has been received by the General Council in session, other nominations may also be received from the floor. *A ballot shall then be taken for each of the offices
404 CMA JOURNAL/AUGUST 18, 1979/VOL. 121
in turn including the Officers, Speaker and Deputy Speaker of the General Council, members of the Committee on Finance, the Committee on Ethics and for the Divisional representatives of the Board of Directors and their alternates. Dr. Jory's name was placed in nomination by the committee on nominations and Dr. Thomas's nomination was received from the floor. Members of the General Council subsequently made their choice by secret ballot. - Ed.]
Diminished libido with cimetidine therapy To the editor: Cimetidine is widely used in the treatment of duodenal ulcers, but it has recently been established that the drug crosses the blood-brain barrier; it can be found in brain tissue and cerebrospinal fluid in humans.1 Seventeen cases of mental confusion have been reported1 and 26 cases of sexual dysfunction in men have been observed in England.2 I report a case of a man in whom libido diminished during withdrawal from cimetidine but reappeared when full-dosage therapy was resumed. A 51-year-old man who was happily married and the father of three children was treated with cimetidine, 800 mg/d, for 6 weeks because of a duodenal ulcer. During this time his wife noticed, but he did not, a decrease in the frequency of their sexual relations from twice a week to once every 2 weeks. Prompted by his wife the man sought medical advice. Cimetidine was discontinued and his libido returned to normal within a week. The patient was asked to try a challenging dose for a month; he agreed and cimetidine, 600 mg/d, was prescribed. Again the result was a decrease in libido. One week after cessation of therapy his libido returned to normal. The patient is presently taking cimetidine, 300 mg/d at bedtime, and his libido is normal. Therefore, the dose threshold for sexual dysfunction in this patient was between 300 and 600 mg/d. No tests for endocrine function were carried out, nor were sperm counts performed. A double-blind experiment with a placebo was not attempted.
