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
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
