Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Editor's mail Bruce Granovetter, James T. Hamilton, Samuel J. Arnold & Arthur Ginsburg To cite this article: Bruce Granovetter, James T. Hamilton, Samuel J. Arnold & Arthur Ginsburg (1976) Editor's mail, Postgraduate Medicine, 59:4, 24-26, DOI: 10.1080/00325481.1976.11714317 To link to this article: https://doi.org/10.1080/00325481.1976.11714317
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editor's mail UNIVERSITY GROUP DIABETES PROGRAM
To the Editor: The article "Use of Oral Agents in Treating Diabetes Mellitus: A Perspective," published in your January 1976 issue refers to the University Group Diabetes Program (UGDP). 1 would like to point out the following tacts in regard to the UGPD study: • No familial history of cardiovascular disease was reported for patients enrolled in the study, nor was preexisting vascular disease in the patients them selves recorded or taken into consideration. • No evidence was included about duratian of diabetes in the patients studied. • No smoking history was reported for the patients studied, and smoking is a significant factor in the development of vascular complications. • Fixed doses of the oral hypoglycemie and insu lin agents were used, a practice never used in clinical medicine. • Phenformin was included in the study 18 months after tolbutamide, with no acceptable control group. • Only 6 of the 12 participating clinics were included in the phenformin study. • Three times as many patients were on phenformin as on placebo. • lt is weil known that the omission of any data invalidates the multiple logistic statistical method used by UGDP for analysis. 1 hope your readers will take these comments into serious consideration. Bruce Granovetter, MD USV Pharmaceutical Corporation Tuckahoe, New York
TREATING ENURESIS IN CHILDREN
To the Editor: 1 wish to take issue with the investigation and treatment of enuresis outlined in "Understanding and Managing Enuresis in Children" in your November 1975 issue. First, the workup recommended costs $100 to $150 and involves a considerable amount of radiation for a small child. This is usually unnecessary. As for treatment, imipramine has possibly been associated with a slight
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incidence of sudden death. Tome, the risk of such a possibility is too great without first trying safer methods. With my patients, 1recommend the following: wake the child avery night at 11 PM and make him walk to the bathroom and sit on the toilet for two minutes or until he urinates, whichever is first. If the child does not urinate, wake him again at midnight and follow the same procedure. If he does, it may still be necessary to wake him again at 3 or 4 AM. After a week, wake him at 11 :30 PM and follow the same procedure; the following week, wake him at midnight, and so on, until the child can either go ali night without urinating or get up on his own. The parents need to explain avery ti me why they are disturbing the child's sleep. lt may be difficult for a few weeks or months, but it works. James T. Hamilton, MD Madera, California
Dr. Hamilton's comments were sent to the authors of the article on enuresis, whose reply follows. To the Editor: Dr. Hamilton takes issue with our management of enuresis and offers instead a liftwake-walk-talk-pot regimen. Without refuting our data or offering his own, he assumes that enuretic children usually have no organic disease, no diurnal symptoms, and no urinarysexual problems as adults. We feel that these assumptions are unwarranted. As we reported, symptomatic enuretic children, and adults who were enuretic in childhood, often suffer from urinary disturbances; this has been urodynamically confirmed. 1 • 2 We cannat conceive that parents would not gladly spend $100 to $150 and allow their child to be exposed to the necessary radiation (3 to 6 rads) in order to detect and correct disease. If disease is not evident, parents are relieved to learn this. lmipramine (Tofranil) is a safe drug; disasters related to it have generally involved accidentai ingestion of massive doses by children, which can occur with aspirin. ln an extensive survey, Kenneth Anderson, associate diractor, Pharmacy and Drug Information Center, Valley Hospital, Ridgewood, NJ, could notfind
POSTGRADUATE MEDICINE • April1976 • Vol. 59 • No. 4
editor's mail------------------------one reported instance of sudden death of a pediatrie patient due to imipramine used in the prescribed dosage. We have previously expressed our concern about unnecessary or prolonged use of imipramine.3 For asymptomatic enuresis, we recommend leg-raising exercises, lifting, and alarm clocks before we resort to prescribing the drug. We rarely use imipramine for symptomatic enuresis, and when we do, we give the smallest possible amount for the shortest possible time. Parents favor use of imipramine because, unlike alarm systems, it can be carried to camp orto a friend's home, involves no mechanical or electrical problems, and does not disturb the entire household. The lift-wake-walk-talk-pot program, reported 28 years ago, 4 is rarely recommended currently and probably for good reason. Virtually every parent in our large series of cases tried lifting and walking before seeking medical attention. Parents repeatedly describe the extrema difficulty of rousing an enuretic child, and this method is much more demanding on parents than an alarm system.
Other questions should be considered before the lifting and walking regimen is recommended: Does the patient have organic disease which will persist into adult lite? How often do patients suffer recurrences and thus how often do parents have to go through the ordeal of this regimen? What are the psychologie affects of such a program on the entire family? Samuel J. Arnold, MD Arthur Ginsburg, MD Morristown, New Jersey
PS. Please permit us to correct an oversight. ln discussing urologie disease most commonly affecting boys, we neglected to mention bulbomembranous urethral strictures. References
1. Whiteside, CG, Arnold, EP: Persistent primary enuresis: A urodynamic assessment. Br Med J 1 :364-367' 1975 2. Warwick AT: Sorne dinical aspects of detrusor dysfunction. J Urol 113:539-544, 1975 3. Arnold, SJ, Ginsburg, A: Enuresis: Treatment with imipramine. JAMA 228:289-290, 1974 4. Smith, S: The Psychological Origin and Treatment of Enuresis. Seattle, University of Washington Press, 1948.
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POSTGRADUATE MEDICINE • April 1976 • Vol. 59 • No. 4