Acute hemiplegia in childhood To the editor: Although Tibbles and Brown did not report it in their paper "Acute hemiplegia in childhood" (Can Med Assoc J 113: 309, 1975), migraine can be associated with the sudden onset of hemiplegia.1'2 Hemiplegic migraine is often familial3 and reports of very young children with hemiplegic migraine are common in the literature.4'5 I was involved in the care of such a patient while I was a resident at the Winnipeg Children's Hospital in 1963. A 12-year-old mildly retarded girl with a strong family history of migraine had a left total hemiparesis. The child had suffered from migraine attacks and migraine equivalents for several years. A right cerebral angiogram was reported as normal and an electroencephalogram showed gross abnormalities, especially prominent over the right hemisphere. All other results of investigations were normal. The child recovered completely from the hemiplegia. The definitive statement on migraine has yet to be made. Chao and Davis6 have said that mild or severe hemiplegia accompanies about one third of all cases of migraine in children. We know that seizure disorders and migraine go hand in hand.7-9 Many authors see migraine as a type of convulsive equivalent. The statistics bear this out: 50 to 70% of children with migraine have electroencephalographic abnormalities, while only 15 to 20% of so-called normal children have abnormal electroencephalograms. We do not really understand the migraine syndrome complex, although many attempts have been made to offer intelligent explanations based on physiological principles. It is for this reason that terms such as convulsive equivalent Contributions to the Correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double spaced and should not exceed 1½ pages in length.

syndrome, epileptic equivalent, abdominal epilepsy and autonomic epilepsy8 have come to be used. EARL M. COOPERMAN, MD

356 Woodroffe Ave. Ottawa, ON

References 1. Ross RT: Hemiplegic migraine. Can Med Assoc J 78: 10, 1958 2. BRADSHAW P, PARSONS M: Hemiplegic migraine, a clinical study. Q J Med 34: 65, 1965 3. GLISTA GG, MELLINOER iF, RoolcE ED: Familial hemiplegic migraine. Mayo Clin Proc 50: 307, 1975 4. KREMENITZER M, GOLDEN GS: Hemiplegic migraine: cerebrospinal fluid abnormalities (C). J Pedia:r 85: 139, 1974 5. VERRET S, STEELE JC: Alternating hemiplegia in children. Pediatrics 47: 675, 1971 6. CHAO D, DAVIS SD: Convulsive equivalent syndrome of childhood. I Pedlair 64: 499, 1964 7. Childhood migraine (E). N Engi I Med 276: 56, 1967 8. WHITEHOUSE 0, PAPPAS JA, ESCALA PH, et al: Electroencephalographic changes in children with migraine. Ibid, p 23 9. SUTER C, KLINGMAN WO, AUSTIN H, et al: Migraine and seizure states in children. Dis Nerv Syst 20: 9. 1959

useful epidemiologic tool fell into disrepute because of confusing terminology. Perhaps editors should be encouraging us not to use the word retrospective at all but to speak only of "recordreview" or "case-control" studies. By all means criticize bad research, but to say "the retrospective study is for the birds" is a base canard. T.W. ANDERSON, BM, PH D MJ. ASHLEY, MD, M SC A.E. CLARKE, ME, M SC

Department of preventive medicine and biostatistics Faculty of medicine University of Toronto Toronto, ON

References I. DOLL R, HILL AB: Smoking and carcinoma of the lung: a preliminary report. Br Med J 3: 739, 1950 2. Idem: A study of the aetiology of carcinoma of the lung. Br Med 1 4: 1272, 1952

Cephalosporins in. otitis media The retrospective study To the editor: In the article "The retrospective study: a point of view" (Can Med Assoc J 113: 500, 1975) Dr. Reid has attacked, quite rightly, the mindless assembling of case-note information, but she may have caused some confusion by referring to this type of activity as a retrospective study. The word retrospective can be used in two ways: first, in the nontechnical sense of looking back on things past in this case, hospital records; second, in the technical, epidemiologic sense of working backwards from effect to cause (otherwise known as the casecontrol or "backward" method). As an epidemiologic technique the retrospective study is capable of great elegance and power (see, for example, the classic retrospective studies on lung cancer and cigarette smoking by Doll and Hill1'2) although, as with any other research method, it has to be used properly if it is to yield meaningful results. It would be unfortunate if this very

To the editor: In his report "Four or five drugs for most office practices" (Can Med Assoc J 113: 570, 1975) Eichenwald mentioned the side effects of oral cephalosporins in "high doses". In a study of more than 300 children aged 2 months to 15 years with acute otitis media treated with cephalexin or cephradine, 100 mg/kg ed in four equally divided doses, we found that 88% of the infections caused by Hemophilus influenzae responded well, both bacteriologically and clinically. Cephalosporin concentrations in the serum and middle ear effusion were measured simultaneously. Diarrhea occurred in two patients but subsided spontaneously after 2 days without discontinuance of the drug. None of the patients had nausea, vomiting, muscular discomfort or fever. In a report published in the Oct. 13 issue of JAMA it was stated that no side effects had been encountered in 101 patients treated with cephalosporins. We believe that cephalosporin therapy is efficacious in treating otitis media

CMA JOURNAL/JANUARY 10, 1976/VOL. 114 13

and have found that there are fewer recurrences with it than with ampicillin therapy in groups matched for age, infecting organism and severity of disease. SAMUEL E. MCLINN, MD 2645 North Third St. Harrisburg, PA

Lipid research clinic program To the editor: I am writing to obtain your help in contacting all practising physicians in Toronto, Hamilton and surrounding communities about a vital problem that affects all of us. It concerns the success or failure of the coronary primary prevention trial being conducted at St. Michael's, Toronto General and Hamilton General hospitals, and sponsored by the National Heart & Lung Institute, the Ontario Heart Foundation, the University of Toronto and McMaster University. This prevention program is attempting to answer the important question "Can we prevent first heart attacks and prolong life by lowering the plasma cholesterol concentration in men at high risk for coronary heart disease?" The question is important when one remembers that 30% of all deaths in our population are attributable to heart attacks. This program has been in progress since July 1971. Our budget in Toronto and Hamilton approaches $1 million annually and requires a staff of about 75 persons. Multiply this by the costs and effort of 16 other clinics and control centres of various types in North America and you have a good idea of the total cost. Also you can deduce that the scientific community has a large stake in this program and its outcome. The initial hurdle was to find more than 300 men aged 35 to 59 with plasma cholesterol values consistently greater than 270 mg/dl but without coronary heart disease. We are pleased with the response from our colleagues in allowing us to see their patients and in advising their patients to volunteer for the program. More than 50000 men have been screened so far and some 260 eligible men identified. Although we still need help in finding another 125 suitable men, a different and still higher hurdle confronts us now. This concerns the critical issue of adherence to the treatment program by the participating patients. Nonadherence to the study diet or medication by even a small percentage of the patients who have volunteered could compromise the statistical power of the program and spoil our chances of learning anything about the value of lowering the plasma cholesterol concentration. Again we need the active

collaboration of the medical community to safeguard the coronary prevention program. We want every medical doctor in the province to know that what he says to patients and to the public could seriously affect the outcome of this program. Therefore, we wish to explain our position carefully. We are not claiming that lowering the plasma cholesterol concentration will definitely prevent heart attacks. We merely say that there is a theoretical possibility that this is so. The weight of scientific evidence indicates that a high concentration of plasma cholesterol increases the risk of subsequent development of coronary heart disease. However, we do not know whether lowering the concentration in men with hypercholesterolemia will prevent or delay the onset of ischemic heart disease and this is the reason the coronary prevention program is being conducted. We are asking all doctors to support us in their statements to laymen. The program is designed to be satisfactory both to those doctors who believe that lowering the plasma cholesterol concentration may be beneficial and to those who doubt that it may be beneficial. It should at the end give an honest answer to our basic question. The treatment program is without much risk for the participants. The therapeutic diet, containing up to 400 mg of cholesterol per day and having a ratio of polyunsaturated to saturated fatty acids of 1, is conservative and practical for long-term use. It lowers the plasma cholesterol concentration an average of 5% from baseline in outpatients. Cholestyramine, the study medication prescribed to lower plasma cholesterol concentration, has been used for more than 12 years in our clinics in Toronto and Hamilton without serious toxic side effects. Unlike the other "lipid-lowering" medications it is not absorbed systemically and there have been no large-scale studies of its effectiveness in either primary or secondary prevention of coronary heart disease. The patients in the program are monitored in the lipid research clinics every 2 months; they have minor check-ups every 6 months and complete examinations annually. We are careful not to take the place of the family physician. Indeed, we insist on each participant having a personal physician with whom we can communicate information and discuss problems. We only request the privilege of regulating the cholesterol-lowering diet and medication and of monitoring the results. There is an overall net benefit of this program to the medical community in terms of the information we have provided about the thousands of persons screened for hyperlipoproteinemia and

14 CMA JOURNAL/JANUARY 10, 1976/VOL. 114

COMPOSITION: Each uncoated, scored, light tan tablet contains spironolactone, 25 mg. Aldactone offers an entirely new approach to the treatment of essential hypertension, edema and ascites, including resistant states. Aldactone specifically blocks the effects on the kidneys of mineralocorticoids and antagonizes the sodium retaining and water retaining effects of aldosterone which is important in the production of edema. INDICATIONS: Aldactone is indicated in the treatment of edema and ascites of congestive heart failure, hepatic cirrhosis, the nephrotic syndrome, and idiopathic edema as well as that due to malignant effusions especially if not responding well to conventional diuretics. Aldactone is also indicated for lowering blood pressure in essential hypertension, correcting hypokalemic alkalosis in severe hypertension and in the treatment of myasthenia gravis. DOSAGE: Edema-the initial recommended adult dose is one 25 mg tablet four times daily. Rarely a patient may require up to 300 mg per day and others as little as 75 mg per day. If adequate diuresis with Aldactone is not obtained within five days, Aldactizide should be substituted in its usual dosage to obtain the synergistic effect of the spironolactone and the thiazide components. In an occasional patient with severe, resistant edema, it may be necessary to add a glucocorticoid to this combined therapy. In children a dosage providing 1.5 mg of Aldactone per pound of body weight should be employed. Essential hypertension-One tablet four times a day, treatment should be continued at least two weeks. PRECAUTIONS: Other than acute renal insufficiency there are no known contraindications to Aldactone. It should be used judiciously in patients with hyponatremia or hyperkalemia. SIDE EFFECTS: Side effects are mild and infrequent; drowsiness, mental confusion and maculopapular or erythematous eruptions have occurred rarely, subsiding within forty-eight hours on discontinuation of the drug. Gynecomastia and mild androgenic manifestations have also been reported in a few patients. TOXICITY: No reports of fatal overdosage in man. No adverse effects from high dosage in chronic animal studies. Symptoms of Overdosage-True toxicity has not been reported; drowsiness, mental confusion or a maculopapular or erythematous rash has occurred rarely. These manifestations disappear promptly on discontinuance of medication. Hyperkalemia may be exacerbated. Treatment-No specific antidote. No true toxicity has occurred or is expected. Appearance of effects described above require only discontinuance of the drug. For hyperkalemia, reduce potassium intake, administer potassiu m-excreting diuretics, intravenous glucose with regular insulin or oral ion exchange resins. SUPPLY: Bottles of 100, 1,000 and 2,500 tablets. Complete prescribing information available on request.


the only specific, competitive aldosterone antagonist for gradual, sustained diuresis with minimal possibility of potassium loss.. .especially indicated for the digitalized patient. Searle Pharmaceuticals Oakv,IIe, Ontario

Letter: Cephalosporins in otitis media.

Acute hemiplegia in childhood To the editor: Although Tibbles and Brown did not report it in their paper "Acute hemiplegia in childhood" (Can Med Asso...
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