his casket gave a date that meant that the saplings that eventually grew into the timber from which these chips came could not have begun to grow until 2 to 3 centuries after his death (according to the accepted date). The results of that test (P-726) were published.4 The layman in archeologic matters may well wonder what all the fuss is about. The answer is that the chronology of the entire ancient East is geared to that of Egypt, so that if Dr. Velikovsky is right, as seems very likely, the history of the cultures of Greece and Crete, the dates of some Assyrian and Babylonian kings, and in fact the history of the entire Middle East will have to be rewritten. The mysterious "Dark Age" of Greece would become a chronologic artefact and simply disappear. If there is agreement beyond any possibility of doubt that the mummy of Nakht belongs to the reign of the predecessor of Ramesses III, it would surely be an ideal subject for 14C dating to help establish which chronology is nearer to the truth, especially when the gap between them is 800 years at this point.. I am told a 14C test costs $100. I am cheerfully prepared to wager this amount that Dr. Velikovsky is right; specifically, that the mummy belongs to the 4th rather than to the 12th century BC. Dr. Velikovsky is always anxious to have his theories put to any fair test, but whether supporters of the conventional view would be willing to take the risk is another question. It looks as if a golden opportunity has so far been allowed to slip by. Is it too late to reconsider? J.D.H. ILES, MB, B CH 44 Fairfield Rd. Toronto, Ont.
References 1. VELIKOVSKY I: Ages In Chaos, New York, Doubleday, 1952
2. Idem: Peoples of the Sea (Ages ii. Chaos series, vol 4), New York, Doubleday, 1977 3. SAVE-SODERBERGH T, OLssoN IU: Proceedings of the 12th Annual Nobel Symposium at Uppsala, 1969 4. STUCKENRATH R JR, RALPH EK: University of Pennsylvania radiocarbon dates VIII. Radio-
carbon 7: 187, 1965
Suppurative conjunctivitis caused by Versinia enterocolitica To the editor: Yersinia enterocolitica infections are being suspected and recognized in Canada with increasing frequency.1'1 Their most common modes of presentation are as gastroenteritis, enterocolitis, terminal ileitis and mesenteric adenitis. The organisms are isolated most commonly from enteric contents, but also from mesenteric glands, cutaneous lesions, abscesses, cerebro-
spinal fluid and the bloodstream. The infection may be associated with nonsuppurative complications such as arthritis, erythema nodosum and Reiter's syndrome and rarely with myocarditis and hepatitis. In view of the increasing importance of the organism as a cause of infection, the Ontario Ministry of Health instituted at the end of 1974 a national reference service for Y. enterc'colitica and Y. pseudotuberculosis infections, both of which have been well reviewed by the Canadian reference centre1'2 and authors in Finland3'4 and Sweden.5'6 I report the following case because of its unusual presentation as suppurative conjunctivitis and adenitis in the absence of any other signs or symptoms that are usually associated with Y. enterocolitica infection.
A 44-year-old man, a railway mechanic, was admitted to St. Paul's Hospital, Vancouver, Nov. 22, 1975. Twelve days earlier he had first noticed redness of his left eye, which was associated with a copious yellow discharge. It became progressively worse in spite of the instillation of gentamicin drops and ampicillin orally. One week after the onset of his illness the area in front of the left ear had become swollen and tender. This became worse and severe frontal headache developed that became so severe as to be intolerable. On admission the patient had severe conjunctivitis and chemosis affecting the left eye, which was almost closed and discharging pus. The left side of his face was swollen owing to tender enlargement of the preauricular node. The right eye was normal. Temperature was 37.5 0C. Physical examination disclosed no other abnormality, and there was no evidence of arthritis or erythema nodosum. There was no history of trauma or of previous eye infection and no family member had a similar condition or any recent history of illness. The family kept a dog that was in good health and there had been no contact with any other animals. The leukocyte count was 12.2 X 109/L (71% neutrophils and 2% staff cells). A gram smear of the conjunctival exudate showed pus cells and gram-negative bacilli; culture produced a pure growth of Y. enterocolitica subsequently defined as biotype 1, serotype 0:4.32. The organisms were found by the Kirby-Bauer method to be sensitive to ampicillin, tetracycline, chloramphenicol and kanamycin. Tests for susceptibility to penicillin were omitted. Treatment was instituted with chloramphenicol, 500 mg q6h orally; penicillin G, 12.5 X 106 U q6h intravenously; and chloramphenicol drops instilled into the conjunctival sac. His temperature rose initially but returned to normal after 2 days. The inflammation subsided quickly. When the patient was discharged 7 days later the left eye was still slightly red but cultures from specimens were sterile. There was no relapse within the following 2 months.
22 CMA JOURNAL/JANUARY 7, 1978/VOL. 118
Dyazide® To lower blood pressure and conserve potassium. Before prescribing, see complete prescribing information in CPS. The following is a brief summary. ADULT DOSAGE: Hypertension: Starting dosage is one tablet twice daily after meals. Dosage can be subsequently increased or decreased according to patient's need. If two or more tablets per day are needed, they should be given in divided doses. Edema: Starting dosage is one tablet twice daily after meals. When dry weight is reached, the patient may be maintained on one tablet daily. Maximum dosage four tablets daily. INDICATIONS: Mild to moderate hypertension in patients who have developed hypokalemia and in patients in whom potassium depletion is considered especially dangerous (e.g. digitalized patients). Medical opinion is not unanimous regarding the incidence and/or clinical significance of hypokalemia occurring among hypertensive patients treated with thiazide-like diuretics alone, and concerning the use of potassium-sparing combinations as routine therapy in hypertension. Edema of congestive heart failure, cirrhosis, nephrotic syndrome, steroid-induced edema and idiopathic edema. Dyazide is useful in edematous patients whose response to other diuretics is inadequate. CONTRAINDICATIONS: Progressive renal dysfunction (including increasing oliguria and azotemia) or increasing hepatic dysfunction. Hypersensitivity. Elevated serum potassium. Nursing mothers. WARNINGS: Do not use potassium supplementation or other potassium-conserving agents with Dyazide since hyperkalemia may result. Hyperkalemia (>5.4 mEq/l) has been reported ranging in incidence from 40/a in patients less than 60 years of age to 1 2o/. in patients 60 and older, with an overall incidence of less than 8./o. Rare cases have been associated with cardiac irregularities. Make periodic serum potassium determinations, particularly in the elderly, in diabetics, and in suspected or confirmed renal insufficiency. If hyperkalemia develops, withdraw Dyazide and substitute a thiazide alone. Hypokalemia is less common than with thiazides alone, but if it occurs it may precipitate digitalis intoxication. PRECAUTIONS: Check laboratory data (e.g. BUN, serum electrolytes) and ECG's periodically, especially in the elderly, in diabetics, in renal insufficiency, and in those who have developed hyper kalemia on Dyazide' previously. Electrolyte imbalance may occur, especially where salt-restricted diets or prolonged high-dose therapy is used. Observe acutely ill cirrhotic patients for early signs of impending coma. Reversible nitrogen retention may be seen. Observe patients regularly for blood dyscrasias, liver damage or other idiosyncratic reactions: perform appropriate laboratory studies as required. Sensitivity reactions may occur, particularly in patients with history of allergy or bronchial asthma. Periodic blood studies are recommended in cirrhotics with splenomegaly. Adjust dosage of other antihypertensive agents given concomitantly. Antihypertensive effects of Dyazide may be enhanced in the post-sympathectomy patient. Hyperglycemia and glycosuria may occur. Insulin requirement may be altered in diabetics. Hyperuricemia and gout may occur. Thiazides have been reported to exacerbate or activate systemic lupus erythematosus. Pathological changes in the parathyroid glands have been reported with prolonged thiazide therapy. Triamlerene may cause a decreasing alkali reserve, with the possibility of metabolic acidosis. Serum transaminase elevations sometimes occur with Dyazide. Thiazides can decrease arterial responsiveness to norepinephrine and increase tubocurarine's paralyzing effect; exercise caution in patients undergoing surgery. Thiazides cross the placental barrier and appear in breast milk; this may result in fetal or neonatal hyperbilirubinemia, thrombocytopenia, altered carbohydrate metabolism and possible other adverse reactions that have occurred in the adult. Use in pregnancy only when deemed necessary for the patient's welfare. ADVERSE REACTIONS: The following adverse reactions have been associated with the use of thiazide diuretics or triamterene: Gastrointestinal: dry mouth, anorexia, gastric irritation, nausea, vomiting, diarrhea, constipation, jaundice (intra-hepatic cholestatic) pancreatitis, sialadenitis. Nausea can usually be prevented by giving the drug after meals. It should be noted that symptoms of nausea and vomiting can also be indicative of electrolyte imbalance (See Precautions). Central nervous system: dizziness, vertigo, paresthesias, headache, xanthopsia. Dermatologic - Hypersensitivity: fever, purpura, anaphylaxis, photosensitivity, rash, urticaria, necrotizing angiitis. Hematologic: leukopenia, thrombocytopenia, agranulocytosis, aplastic anemia. Cardiovascular: orthostatic hypotension may occur and may be potentiated by alcohol, barbiturates, or narcotics. Electrolyte imbalance (See Precautions). Miscellaneous: hyperglycemia, glycosuria, hyperuricemia, muscle spasm, weakness, restlessness, transient blurred vision. SUPPLY: Scored light orange compressed tablets monogrammed SKFE93 in bottles of 100, 500, lOQOand 2,500. DIN 161528.
Dyazide 25 mg hydrochiorothiazide 50 mg triamterene
makes sense
[..]
. Smith Kline & French Canada Ltd. S Montreal, Quebec H4M 2L6
In patients with Y. enterocolitica infection, inflammation of the eye (iritis, episcieritis or conjunctivitis) has been reported in association with arthritis and erythema nodosum. In many cases the diagnosis has been based on serologic evidence. In a review of the ocular complications in 22 of 411 patients with Yersinia infections,7 only 4 patients were discovered for whom the site of origin of positive cultures was not stated and was presumed to have been enteric contents. Suppurative infection of the eye mentioned only in conjunction with meningitis is referred to in connection with Pariaud's oculoglandular syndrome.8 E.P. CRICHTON, MB, CH 11, FRCP[CJ
Department of laboratories St. Paul's )-Iospital Vancouver, BC
References 1. ToMA 5, DesoRicK VR: Incidence of Yersinia enterocolitica and Y. pseudotuberculosis infections in Canada: 1975 semiannual report. Can Med Assoc 1 114: 16, 1976
2. THoNISoN w: Apparent increase in Yersinia
isolations. Can Dis Wkh' Rep 2: 42, 1976 3. AHVONEN P: Human yersiniosis in Finland. 1. Bacteriology and serology. Ann Cliii Res 4: 30, 1972 4. LEINO R, KALLIOMAKS IL: Yersiniosis as an internal disease. Ann Jnterii Med 81: 458, 1974 5. ARVASTON B, DAMGAARD K, wINBLAD 5: Clinical symptoms of infection with Yersinia enterocolitica. Scand I Inject Dis 3: 37, 1971
6. NTLtHN B: Studies of Yersinia enterocolitica.
with special reference to bacterial diagnosis and occurrence in human acute enteric dis-
ease. Acta Pat/sal Microbial Scand 77 (suppl 206): 1969
7. AHVONEN P, DTCKHOFF K: Uveitis, episcleritis and conjunctivitis associated with Yersinia infection. Acta Ophihalmol 123 (suppl): 209, 1974
8. SONNENWIRTH AC: Yersinia enterocolitica. N Engl / Med 283: 1468, 1970
Fluid retention during treatment with carbamazepine To the editor: That carbamazepine possesses vasopressor action has been confirmed recently by Hartmann1 and Uhlich, Leoschke and Eigler2 and Rad6.3 This pharmacologic action has been used in controlling the polyuria of diabetes insipidus but only three cases of abnormal fluid retention induced by carbamazepine have previously been reported in the literature. We report such an occurrence in an epileptic patient. A 42-year-old man suffering from epilepsy and a personality disorder W.IS admitted to the Hamilton Psychiatric Hospital to stabilize his condition with anliconvulsants and improve his behaviour and personality. The patient showed no physical abnormality on examination. His weight was 68.5 kg. Serum concentrations were as follows: sodium, 136 mmol/L; chloride, 102 mrnol/L: and potassium, 4.6 mmol/L. He was mentally alert and well oriented as to time, person and place. Carbamazepine was given for its psychotropic action; the dose was initially 200 mg bid, then was increased gradually to 1 g/d. Phenobarbital was given as well.
After 5 months' treatment the patient complained of headache. dyspnea and confusion. His blood pressure was 130/85 mm Hg. A moderate degree of peripheral edema was evident. His weight was 73.2 kg and the serum values for electrolytes were as follows: sodium, 130 mmol/L: chloride, 94 mmol/L: potassium. 4.4 rnmol/L: and osmolality. 264 mOsm/L. The presence of hydration thereby was confirmed. Carbamazepine was discontinued and furosemide. 40 mg/d. was given for 4 days. The patient's condition started to improve at once and by the 4th day his edema had disappeared completely. In this patient fluid retention occurred during treatment with carbamazepine at a dose lower than the 1.8 g/d reported by Rad64 and for a shorter time. However, there may not be a direct relation between dose and degree of fluid retention since in our patient also the dosage was in the higher range. We have confirmed that carbamazepine has an antidiuretic action but we can offer no explanation. Garcia. Miller and Moses5 suggested that carbamazepine potentiates subthreshold amounts of antidiuretic hormone or enhances its release. The effect can be compared to ehlorpropamide-induced fluid retention, which occurs especially in older patients suffering from diabetes mellitus. A.N. SINGH, B 5C, MB. B5, FRCP[C] Hamilton Psychiatric Hospital Hamilton, Ont.
References 1. HARTMANN G: [Hormone therapy versus chemotherapy in diabetes insipidus]. Schweiz Med Wochen.schr 102: 842, 1972 2. UHLTCH E. LEOSCHKE K. EIGLER J: [Antidiuretic effect of carbamazepine in diabetes insipidos]. Kim Wocheo.schr 50: 1127. 1972 3. RAO6 J P: Clinical use of additive antidiuretic action of carhamazepine and chlorpropamide. form Metab Res 5: 309, 1973 4. RAD6 JP: Water intoxication during carbamazepine treatment. Br Med 1 3: 479, 1973 5. GARCIA M. MtLLER M. Moses AM: Chlorpropamide-induced water retention in patients with diabetes mellitus. Aon Intern Med 75: 549. 1971
Unsolicited advertising To the editor: As a physician I am distressed and angered by the amount of unsolicited advertising I receive from pharmaceutical companies. rangtng from letters and posters to outright bribery in the form of vaginal specula. liote pads, pocket lights and drug samples, to name a few. This method of invading my home is uncouth and distasteful, and reinforces my mistrust and dislike of firms that indulge in this type of advertising. I have sent letters to the drug companies concerned and have demanded that my name be withdrawn from their mailing lists.
24 CMA JOURNAL/JANUARY 7, 1978/VOL. 118
HELGA HoLsT, MD, CCFP London, Ont.
292* Tablets
INDICATIONS: For relief of mild to moderate pain, fever and inflammation as in influenza, common cold, low back and neck pain, headache, trauma, following dental and surgical procedures. DOSAGE: Adults-i tablet two to three times daily. CONTRAINDICATIONS: Gastrointestinal ulceration and sensitivity to any of the components. WARNINGS: Salicylates increase the effects of anticoagulants. Caution is necessary when salicylates and anticoagulants are prescribed concurrently. Also, salicylates may depress the concentration of prothrombin in the plasma. Large doses of salicylates may affect insulin requirements of diabetics. Salicylates may potentiate sulfonylurea hypoglycemic agents. Analgesic abuse (excessive and prolonged therapy) has been associated with nephropathy. TO AVOID ACCIDENTAL POISONING ACETYLSALICYLIC ACID PREPARATIONS MUST BE KEPT WELL OUT OF REACH OF CHILDREN. PRECAUTIONS: Give with caution to patients with asthma, other allergic conditions, bleeding tendencies, or hypoprothrombinemia. Salicylates can produce changes in thyroid function tests. Observe care in use of codeine, although tolerance and addiction are rare. Give codeine with caution to patients with severe respiratory depression. Its depressant effect may be enhanced by concurrent administration of sedatives and tranquilizers. ADVERSE REACTIONS: Acetylsalicylic acid: Gastrointestinal: dyspepsia, heartburn, nausea, vomiting, diarrhea, gastrointestinal ulceration and bleeding. Ear reactions: tinnitus, hearing loss. Hematologic: anemia, leukopenia, thrombocytopenia, purpura. Dermatologic and Hypersensitivity: urticaria, angioedema, pruritus, various skin eruptions, asthma and anaphylaxis. Miscellaneous: mental confusion, drowsiness, sweating and thirst. Codeine: Average or large doses may cause various gastrointestinal symptoms such as nausea, vomiting and constipation. Caffeine: May cause nausea, nervousness, insomnia, headache, vomiting, palpitation, vertigo, muscle tremor, sensory disturbances, excessive diuresis in sensitive patients. Large doses may cause gastric ulceration. FULL INFORMATION AVAILABLE ON REQUEST HOW SUPPLIED 0292* Tablets-Peach, . marked, scored, engraved 292 on one side. Each tablet contains acetylsalicylic acid 375 mg, caffeine citrate 30 mg, codeine phosphate 30 mg. Available in bottles of 50 and 500. 1. Melmon, K.L., Morelli, H.F. (eds) Clinical Pharmacology, New York, The MacMillan Company, 1972, Chap. II, p. 499. *Trademsrk
CHARLES E. FROSST & co. KIRKLAND (MONTREAL) CANADA
292T-7-720-JA
References 1. VELIKOVSKY I: Ages In Chaos, New York, Doubleday, 1952
2. Idem: Peoples of the Sea (Ages ii. Chaos series, vol 4), New York, Doubleday, 1977 3. SAVE-SODERBERGH T, OLssoN IU: Proceedings of the 12th Annual Nobel Symposium at Uppsala, 1969 4. STUCKENRATH R JR, RALPH EK: University of Pennsylvania radiocarbon dates VIII. Radio-
carbon 7: 187, 1965
Suppurative conjunctivitis caused by Versinia enterocolitica To the editor: Yersinia enterocolitica infections are being suspected and recognized in Canada with increasing frequency.1'1 Their most common modes of presentation are as gastroenteritis, enterocolitis, terminal ileitis and mesenteric adenitis. The organisms are isolated most commonly from enteric contents, but also from mesenteric glands, cutaneous lesions, abscesses, cerebro-
spinal fluid and the bloodstream. The infection may be associated with nonsuppurative complications such as arthritis, erythema nodosum and Reiter's syndrome and rarely with myocarditis and hepatitis. In view of the increasing importance of the organism as a cause of infection, the Ontario Ministry of Health instituted at the end of 1974 a national reference service for Y. enterc'colitica and Y. pseudotuberculosis infections, both of which have been well reviewed by the Canadian reference centre1'2 and authors in Finland3'4 and Sweden.5'6 I report the following case because of its unusual presentation as suppurative conjunctivitis and adenitis in the absence of any other signs or symptoms that are usually associated with Y. enterocolitica infection.
A 44-year-old man, a railway mechanic, was admitted to St. Paul's Hospital, Vancouver, Nov. 22, 1975. Twelve days earlier he had first noticed redness of his left eye, which was associated with a copious yellow discharge. It became progressively worse in spite of the instillation of gentamicin drops and ampicillin orally. One week after the onset of his illness the area in front of the left ear had become swollen and tender. This became worse and severe frontal headache developed that became so severe as to be intolerable. On admission the patient had severe conjunctivitis and chemosis affecting the left eye, which was almost closed and discharging pus. The left side of his face was swollen owing to tender enlargement of the preauricular node. The right eye was normal. Temperature was 37.5 0C. Physical examination disclosed no other abnormality, and there was no evidence of arthritis or erythema nodosum. There was no history of trauma or of previous eye infection and no family member had a similar condition or any recent history of illness. The family kept a dog that was in good health and there had been no contact with any other animals. The leukocyte count was 12.2 X 109/L (71% neutrophils and 2% staff cells). A gram smear of the conjunctival exudate showed pus cells and gram-negative bacilli; culture produced a pure growth of Y. enterocolitica subsequently defined as biotype 1, serotype 0:4.32. The organisms were found by the Kirby-Bauer method to be sensitive to ampicillin, tetracycline, chloramphenicol and kanamycin. Tests for susceptibility to penicillin were omitted. Treatment was instituted with chloramphenicol, 500 mg q6h orally; penicillin G, 12.5 X 106 U q6h intravenously; and chloramphenicol drops instilled into the conjunctival sac. His temperature rose initially but returned to normal after 2 days. The inflammation subsided quickly. When the patient was discharged 7 days later the left eye was still slightly red but cultures from specimens were sterile. There was no relapse within the following 2 months.
22 CMA JOURNAL/JANUARY 7, 1978/VOL. 118
Dyazide® To lower blood pressure and conserve potassium. Before prescribing, see complete prescribing information in CPS. The following is a brief summary. ADULT DOSAGE: Hypertension: Starting dosage is one tablet twice daily after meals. Dosage can be subsequently increased or decreased according to patient's need. If two or more tablets per day are needed, they should be given in divided doses. Edema: Starting dosage is one tablet twice daily after meals. When dry weight is reached, the patient may be maintained on one tablet daily. Maximum dosage four tablets daily. INDICATIONS: Mild to moderate hypertension in patients who have developed hypokalemia and in patients in whom potassium depletion is considered especially dangerous (e.g. digitalized patients). Medical opinion is not unanimous regarding the incidence and/or clinical significance of hypokalemia occurring among hypertensive patients treated with thiazide-like diuretics alone, and concerning the use of potassium-sparing combinations as routine therapy in hypertension. Edema of congestive heart failure, cirrhosis, nephrotic syndrome, steroid-induced edema and idiopathic edema. Dyazide is useful in edematous patients whose response to other diuretics is inadequate. CONTRAINDICATIONS: Progressive renal dysfunction (including increasing oliguria and azotemia) or increasing hepatic dysfunction. Hypersensitivity. Elevated serum potassium. Nursing mothers. WARNINGS: Do not use potassium supplementation or other potassium-conserving agents with Dyazide since hyperkalemia may result. Hyperkalemia (>5.4 mEq/l) has been reported ranging in incidence from 40/a in patients less than 60 years of age to 1 2o/. in patients 60 and older, with an overall incidence of less than 8./o. Rare cases have been associated with cardiac irregularities. Make periodic serum potassium determinations, particularly in the elderly, in diabetics, and in suspected or confirmed renal insufficiency. If hyperkalemia develops, withdraw Dyazide and substitute a thiazide alone. Hypokalemia is less common than with thiazides alone, but if it occurs it may precipitate digitalis intoxication. PRECAUTIONS: Check laboratory data (e.g. BUN, serum electrolytes) and ECG's periodically, especially in the elderly, in diabetics, in renal insufficiency, and in those who have developed hyper kalemia on Dyazide' previously. Electrolyte imbalance may occur, especially where salt-restricted diets or prolonged high-dose therapy is used. Observe acutely ill cirrhotic patients for early signs of impending coma. Reversible nitrogen retention may be seen. Observe patients regularly for blood dyscrasias, liver damage or other idiosyncratic reactions: perform appropriate laboratory studies as required. Sensitivity reactions may occur, particularly in patients with history of allergy or bronchial asthma. Periodic blood studies are recommended in cirrhotics with splenomegaly. Adjust dosage of other antihypertensive agents given concomitantly. Antihypertensive effects of Dyazide may be enhanced in the post-sympathectomy patient. Hyperglycemia and glycosuria may occur. Insulin requirement may be altered in diabetics. Hyperuricemia and gout may occur. Thiazides have been reported to exacerbate or activate systemic lupus erythematosus. Pathological changes in the parathyroid glands have been reported with prolonged thiazide therapy. Triamlerene may cause a decreasing alkali reserve, with the possibility of metabolic acidosis. Serum transaminase elevations sometimes occur with Dyazide. Thiazides can decrease arterial responsiveness to norepinephrine and increase tubocurarine's paralyzing effect; exercise caution in patients undergoing surgery. Thiazides cross the placental barrier and appear in breast milk; this may result in fetal or neonatal hyperbilirubinemia, thrombocytopenia, altered carbohydrate metabolism and possible other adverse reactions that have occurred in the adult. Use in pregnancy only when deemed necessary for the patient's welfare. ADVERSE REACTIONS: The following adverse reactions have been associated with the use of thiazide diuretics or triamterene: Gastrointestinal: dry mouth, anorexia, gastric irritation, nausea, vomiting, diarrhea, constipation, jaundice (intra-hepatic cholestatic) pancreatitis, sialadenitis. Nausea can usually be prevented by giving the drug after meals. It should be noted that symptoms of nausea and vomiting can also be indicative of electrolyte imbalance (See Precautions). Central nervous system: dizziness, vertigo, paresthesias, headache, xanthopsia. Dermatologic - Hypersensitivity: fever, purpura, anaphylaxis, photosensitivity, rash, urticaria, necrotizing angiitis. Hematologic: leukopenia, thrombocytopenia, agranulocytosis, aplastic anemia. Cardiovascular: orthostatic hypotension may occur and may be potentiated by alcohol, barbiturates, or narcotics. Electrolyte imbalance (See Precautions). Miscellaneous: hyperglycemia, glycosuria, hyperuricemia, muscle spasm, weakness, restlessness, transient blurred vision. SUPPLY: Scored light orange compressed tablets monogrammed SKFE93 in bottles of 100, 500, lOQOand 2,500. DIN 161528.
Dyazide 25 mg hydrochiorothiazide 50 mg triamterene
makes sense
[..]
. Smith Kline & French Canada Ltd. S Montreal, Quebec H4M 2L6
In patients with Y. enterocolitica infection, inflammation of the eye (iritis, episcieritis or conjunctivitis) has been reported in association with arthritis and erythema nodosum. In many cases the diagnosis has been based on serologic evidence. In a review of the ocular complications in 22 of 411 patients with Yersinia infections,7 only 4 patients were discovered for whom the site of origin of positive cultures was not stated and was presumed to have been enteric contents. Suppurative infection of the eye mentioned only in conjunction with meningitis is referred to in connection with Pariaud's oculoglandular syndrome.8 E.P. CRICHTON, MB, CH 11, FRCP[CJ
Department of laboratories St. Paul's )-Iospital Vancouver, BC
References 1. ToMA 5, DesoRicK VR: Incidence of Yersinia enterocolitica and Y. pseudotuberculosis infections in Canada: 1975 semiannual report. Can Med Assoc 1 114: 16, 1976
2. THoNISoN w: Apparent increase in Yersinia
isolations. Can Dis Wkh' Rep 2: 42, 1976 3. AHVONEN P: Human yersiniosis in Finland. 1. Bacteriology and serology. Ann Cliii Res 4: 30, 1972 4. LEINO R, KALLIOMAKS IL: Yersiniosis as an internal disease. Ann Jnterii Med 81: 458, 1974 5. ARVASTON B, DAMGAARD K, wINBLAD 5: Clinical symptoms of infection with Yersinia enterocolitica. Scand I Inject Dis 3: 37, 1971
6. NTLtHN B: Studies of Yersinia enterocolitica.
with special reference to bacterial diagnosis and occurrence in human acute enteric dis-
ease. Acta Pat/sal Microbial Scand 77 (suppl 206): 1969
7. AHVONEN P, DTCKHOFF K: Uveitis, episcleritis and conjunctivitis associated with Yersinia infection. Acta Ophihalmol 123 (suppl): 209, 1974
8. SONNENWIRTH AC: Yersinia enterocolitica. N Engl / Med 283: 1468, 1970
Fluid retention during treatment with carbamazepine To the editor: That carbamazepine possesses vasopressor action has been confirmed recently by Hartmann1 and Uhlich, Leoschke and Eigler2 and Rad6.3 This pharmacologic action has been used in controlling the polyuria of diabetes insipidus but only three cases of abnormal fluid retention induced by carbamazepine have previously been reported in the literature. We report such an occurrence in an epileptic patient. A 42-year-old man suffering from epilepsy and a personality disorder W.IS admitted to the Hamilton Psychiatric Hospital to stabilize his condition with anliconvulsants and improve his behaviour and personality. The patient showed no physical abnormality on examination. His weight was 68.5 kg. Serum concentrations were as follows: sodium, 136 mmol/L; chloride, 102 mrnol/L: and potassium, 4.6 mmol/L. He was mentally alert and well oriented as to time, person and place. Carbamazepine was given for its psychotropic action; the dose was initially 200 mg bid, then was increased gradually to 1 g/d. Phenobarbital was given as well.
After 5 months' treatment the patient complained of headache. dyspnea and confusion. His blood pressure was 130/85 mm Hg. A moderate degree of peripheral edema was evident. His weight was 73.2 kg and the serum values for electrolytes were as follows: sodium, 130 mmol/L: chloride, 94 mmol/L: potassium. 4.4 rnmol/L: and osmolality. 264 mOsm/L. The presence of hydration thereby was confirmed. Carbamazepine was discontinued and furosemide. 40 mg/d. was given for 4 days. The patient's condition started to improve at once and by the 4th day his edema had disappeared completely. In this patient fluid retention occurred during treatment with carbamazepine at a dose lower than the 1.8 g/d reported by Rad64 and for a shorter time. However, there may not be a direct relation between dose and degree of fluid retention since in our patient also the dosage was in the higher range. We have confirmed that carbamazepine has an antidiuretic action but we can offer no explanation. Garcia. Miller and Moses5 suggested that carbamazepine potentiates subthreshold amounts of antidiuretic hormone or enhances its release. The effect can be compared to ehlorpropamide-induced fluid retention, which occurs especially in older patients suffering from diabetes mellitus. A.N. SINGH, B 5C, MB. B5, FRCP[C] Hamilton Psychiatric Hospital Hamilton, Ont.
References 1. HARTMANN G: [Hormone therapy versus chemotherapy in diabetes insipidus]. Schweiz Med Wochen.schr 102: 842, 1972 2. UHLTCH E. LEOSCHKE K. EIGLER J: [Antidiuretic effect of carbamazepine in diabetes insipidos]. Kim Wocheo.schr 50: 1127. 1972 3. RAO6 J P: Clinical use of additive antidiuretic action of carhamazepine and chlorpropamide. form Metab Res 5: 309, 1973 4. RAD6 JP: Water intoxication during carbamazepine treatment. Br Med 1 3: 479, 1973 5. GARCIA M. MtLLER M. Moses AM: Chlorpropamide-induced water retention in patients with diabetes mellitus. Aon Intern Med 75: 549. 1971
Unsolicited advertising To the editor: As a physician I am distressed and angered by the amount of unsolicited advertising I receive from pharmaceutical companies. rangtng from letters and posters to outright bribery in the form of vaginal specula. liote pads, pocket lights and drug samples, to name a few. This method of invading my home is uncouth and distasteful, and reinforces my mistrust and dislike of firms that indulge in this type of advertising. I have sent letters to the drug companies concerned and have demanded that my name be withdrawn from their mailing lists.
24 CMA JOURNAL/JANUARY 7, 1978/VOL. 118
HELGA HoLsT, MD, CCFP London, Ont.
292* Tablets
INDICATIONS: For relief of mild to moderate pain, fever and inflammation as in influenza, common cold, low back and neck pain, headache, trauma, following dental and surgical procedures. DOSAGE: Adults-i tablet two to three times daily. CONTRAINDICATIONS: Gastrointestinal ulceration and sensitivity to any of the components. WARNINGS: Salicylates increase the effects of anticoagulants. Caution is necessary when salicylates and anticoagulants are prescribed concurrently. Also, salicylates may depress the concentration of prothrombin in the plasma. Large doses of salicylates may affect insulin requirements of diabetics. Salicylates may potentiate sulfonylurea hypoglycemic agents. Analgesic abuse (excessive and prolonged therapy) has been associated with nephropathy. TO AVOID ACCIDENTAL POISONING ACETYLSALICYLIC ACID PREPARATIONS MUST BE KEPT WELL OUT OF REACH OF CHILDREN. PRECAUTIONS: Give with caution to patients with asthma, other allergic conditions, bleeding tendencies, or hypoprothrombinemia. Salicylates can produce changes in thyroid function tests. Observe care in use of codeine, although tolerance and addiction are rare. Give codeine with caution to patients with severe respiratory depression. Its depressant effect may be enhanced by concurrent administration of sedatives and tranquilizers. ADVERSE REACTIONS: Acetylsalicylic acid: Gastrointestinal: dyspepsia, heartburn, nausea, vomiting, diarrhea, gastrointestinal ulceration and bleeding. Ear reactions: tinnitus, hearing loss. Hematologic: anemia, leukopenia, thrombocytopenia, purpura. Dermatologic and Hypersensitivity: urticaria, angioedema, pruritus, various skin eruptions, asthma and anaphylaxis. Miscellaneous: mental confusion, drowsiness, sweating and thirst. Codeine: Average or large doses may cause various gastrointestinal symptoms such as nausea, vomiting and constipation. Caffeine: May cause nausea, nervousness, insomnia, headache, vomiting, palpitation, vertigo, muscle tremor, sensory disturbances, excessive diuresis in sensitive patients. Large doses may cause gastric ulceration. FULL INFORMATION AVAILABLE ON REQUEST HOW SUPPLIED 0292* Tablets-Peach, . marked, scored, engraved 292 on one side. Each tablet contains acetylsalicylic acid 375 mg, caffeine citrate 30 mg, codeine phosphate 30 mg. Available in bottles of 50 and 500. 1. Melmon, K.L., Morelli, H.F. (eds) Clinical Pharmacology, New York, The MacMillan Company, 1972, Chap. II, p. 499. *Trademsrk
CHARLES E. FROSST & co. KIRKLAND (MONTREAL) CANADA
292T-7-720-JA
