recurred. Therefore, epidural anesthesia is ideal in these Dyazide® To lower blood drainage was continued for another 6 cases. Any operative type of delivery pressure and conserve days. This time the pneumothorax should be reserved for its specific potassium. did not recur after clamping, so the indications. Before prescribing, see complete prescribing information in tube was removed. The patient went Louis BURGENER, MD, FRcs[c] CPS. The following is a brief summary. home the next day and remained JAMES GERALD SOLMES, MD, FRCS[c], FACOG ADULT DOSAGE: Hypertension: Starting dosage is one tablet twice Department of obstetrics and gynecology daily after meals. Dosage can be subseqaently increased or well. St. Michael's decreased according to patients need. If two or more tablets per Hospital day are needed, they should be given in divided doses. Edema: Toronto, Ont. Starting dosage is one tablet twice daily after meals. When dry weight is reached, the patient may be maintained on one tablet Comments References daily. Maximum dosage four tablets daily. INDICATIONS: Mild to moderate hypertension in patients who have In most reported instances pneu- 1. GAss RS, ZEIDRERO LD, HUTCHESON developed hypokalemia and in patients in whom potassium depletion is considered especially dangerous (e.g. digitalized mothorax during pregnancy has oc- RH: Chronic pulmonary histoplas- patients). Medical opinion is not unanimous regarding the inci- mosis complicated by pregnancy and dence and/or clinical significance of hypokalemia occurring among curred around term. In all but two hypertensive patients treated with thiazide-like diuretics alone, and spontaneous pneumothorax. Am Rev concerning the use of potassium-sparing combinations as routine cases labour had not started; in the Tuberc Palm Dis 75: 111, 1957 therapy in hypertension. Edema of congestive heart failure, cirrhosis, nephrotic syndrome, two exceptions 2. Hsu CT, HUANG PW, LIN CT: A steroid-induced edema and idiopathic edema. Dyazide is useful in preceded the pneumothorax.5 Our term delivery complicated by spon- edematous patients whose response to other diuretics is in- taneous pneumothorax. Report of a adequate. case is also an exception since the CONTRAINDICATIONS: Progressive renal dysfunction (including case. Obstet Gynecol 14: 527, 1959 increasing oliguria and azotemia) or increasing hepatic dysfunc- pneumothorax became clinically ob- tins. Hypersensitivity. Elevated serum potassium. Nursing 3. BRANTLEY WM, DEL VALLE RA, mothers. vious after delivery. Only a few pa- SCHOENBUCHER AK: Pneumothorax, WARNINGS: Do not use potassium supplementation or other bilateral, spontaneous, complicating potassium-conserving agents with Dyazide since hyperkalemia tients have had a past history of may result. Hyperkalemia (>5.4 mEq/l) has been reported ranging pregnancy; case report. Am J Obstet in incidence from 4% in patients less than 60 years of age to 120/a in contributory illness such as tuber- Gynecol 81: 42, 1961 patients 60 and older, with an overall incidence of less than 80/a. Rare cases have been associated with cardiac irregularities. Make culosis,' pneumothorax' or histo- 4. PETRENKO VM: Pregnancy and labour periodic serum potassium determinations, particularly in the in a woman with chronic spontaneous elderly, in diabetics, and in suspected or confirmed renal insuffi- plasmosis.1 ciency. If hyperkalemia develops, withdraw Dyazide and substi- pneumothorax. Pediatr A kush Ginekol tute a thiazide alone. The pneumothorax is usually ex- 2: 57, 1962 Hypokalemia is less common than with thiazides alone, but if it tensive and without tension. Half of occurs it may precipitate digitalis intoxication. 5. DAVIDOvA RI: Two cases of spon- PRECAUTIONS: Check laboratory data (e.g. BUN, serum electro- the patients were treated conserva- taneous pneumothorax in pregnancy. lytes) and ECG's periodically, especially in the elderly, in diabetics, in renal insufficiency, and in those who have developed hyper tively, sometimes for long periods. Pediatr Akush Ginekol 3: 62, 1972 kalemia on Dyazide' previously. Electrolyte imbalance may occur, 6. JONAS G: Spontaneous pneumothorax especially where salt-restricted diets or prolonged high-dose Treatment can be limited to about 10 therapy is used. Observe acutely ill cirrhotic patients for early signs at term: report of a case. Obstet of impending coma. Reversible nitrogen retention may be seen. days' drainage (e.g., with needle as- Gynecol 23: 799, 1964 Observe patients regularly for blood dyscrasias, damage or other idiosyncratic reactions: perform appropriate laboratory piration or a chest tube). Failure of 7. VANCE JP: Tension pneumothorax in studies as required. Sensitivity reactions may occur, particularly in labour. Anaesthesia patients with history of allergy or bronchial asthma. Periodic blood the patient to respond to such treat- 23: 94, 1968 studies are recommended in cirrhotics with splenomegaly. Ad(ust 8. NAJAFI JA, GUZMAN LG: Sponta- dosage of other antihypertensive agents given concomitantly. ment renders thoracotomy necessary Antihypertensive effects of Dyazide may be enhanced in the neous pneumothorax in labour. Am J post-sympathectomy patient. Hyperglycemia and glycosuria may for poudrage or decortication. In Obstet Gynecol 129: 463, 1977 occur. Insulin requirement may be altered in diabetics. Hyperuricemia and gout may occur. Thiazides have been reported these cases, congenital cysts or em- 9. BoNic. JJ: Principles and Practice of 10 exacerbate or activate systemic erythematosus. Pathologi- Obstetric Analgesia and A naesthesia, cal changes in the parathyroid glands have been reported with physematous blebs are usually prolonged thiazide therapy. Triamterene may cause a decreasing Davis, Philadelphia, 1971, pp 666-67, alkali reserve, with the possibility of metabolic acidosis. Serum found. ". transaminase elevations sometimes occur with Dyazide'. 998 Thiazides can decrease arterial responsiveness to norepinephrine Hypoxia in the fetus is a definite and increase tubocurarine's paralyzing effect: exercise caution in patients undergoing surgery. Thiazides cross the placental barrier threat. Fortunately, all the infants in Precautionary labelling on and appear in breast milk: this may result in fetal or neonatal hyperbilirubiogmia, , altered carbohydrate the reported cases have done well preparations of retinoic acid metabolism an. possible other adverse reactions that have occurred in the adult. Use in pregnancy only when deemed because of early recognition and To the editor: Further to my reply necessary for the patient's welfare. ADVERSE REACTIONS: The following adverse reactions have been treatment. to Dr. F.W. Danby's letter regarding associated with the use of thiazide diuretics ortriamlerene: Gastrointestinal: dry mouth, anorexia, gastric icritation, nausea, Spontaneous pneumothorax should precautionary labelling on prepara- vomiting, diarrhea, constipation, (aundice (intra-hepatic cholesta- tic) pancreatitis, sialadenitis. Nausea can usually be prevented by be considered in the differential diag- tions of retinoic acid (Can Med As- giving the drug after meals. It should be noted that symptoms of nausea and vomiting can also be indicative of electrolyte imbalance nosis of chest pain and shortness Soc 1 119: 854, 1978), the health (See Precautions) Central nervous system: dizziness, vertigo, paresthesias, of breath during pregnancy, delivery protection branch of Health and Wel- headache, santhopsia. Dermatologic - Hypersensitivity: fever, , anaphylaxis, and the postpartum phase. Conserva- fare Canada is planning a meeting of photosensitivity, rash, urticaria, necrotizing angiitis. Hematologic: leukopenia, thrombocytopenia, agranulocytosis, ap- tive treatment should be given only nongovernmental medical advisers to lastic anemia. Cardiovascular: orthostatic hypotension may occur and may be when the pneumothorax is small and consider this matter further. The potentiated by alcohol, barbiturates, or narcotics. Electrolyte imbalance (See Precautions). steadily decreasing in size, and when members of the committee include Miscellaneous: hyperglycemia, glycosuria, hyperuricemia, muscle no lasting symptoms are present. All Dr. Roy P. Forsey, dermatologist-in- spasm, weakness, restlessness, transient blurred vision. other cases require insertion of a chief and chairman of the department SUPPLY: Scored light orange compressed tablets monogrammed chest tube and continuous under- of dermatology, Montreal General water drainage until the pneumo- Hospital; Dr. F. Clarke Fraser, direc- SKFE93 in bottles of 100, 500, 1,OOOand 2,500. DIN 181528. thorax is resolved. The findings tor of the department of medical should be rechecked after the tube genetics, Montreal General Hospital; Dyazide is clamped and before it is removed. and Dr. Robert Jackson, consultant 25 mg hydrochiorothiazide Thoracotomy should be reserved for dermatologist, Ottawa Civic Hospi- 50 mg tnamterene chronic recurrent pneumothorax and tal. Dr. Danby will be invited to makes sense [..] persistent air leaks. attend the meeting to present his L.SYIJ Low-forceps vaginal delivery with views. . Smith Kfine & French Canada Ltd. S Montreal, Quebec H4M 2L6 20 CMA JOURNAL/JANUARY 6, 1979/VOL. 120 This action is in keeping with our vitch of the institute of parasitology general policy of reviewing regula- of McGill University, and T.A. Dick tory requirements from time to time of the University of Manitoba have in light of accumulated information established in laboratory animals and experience. We much appreciate strains of T. spiralis from previously .292* Dr. Danby's action in bringing this frozen polar bear meat; in one in- problem forward for review at this stance the meat had been frozen for time. 12 months. In 1977 Meerovitch es- tablished in mice T. spiralis from A.B. MORRISON, PH D Tablets Assistant deputy minister larvae in Arctic fox diaphragms col- INDICATIONS: For relief of mild to moderate Health protection branch lected from frozen carcasses stored pain, fever and inflammation as in influenza, Health and Welfare Canada common cold, low back and neck pain, head- Ottawa, Ont. out of doors in Cambridge Bay for ache, trauma, following dental and surgical a period of weeks during which the procedures. DOSAGE: Adults-i tablet two to three times Trichinosis in the Arctic temperature fell to -35 0C at night. daily. Recently I learned from N.N. CONTRAINDICATIONS: Gastrointestinal ulcer- To the editor: For many years it has Ozeretskovskaya that, in Russia, ation and sensitivity to any of the components. been accepted that Trichinella cysts polar bear meat stored frozen for WARNINGS: Salicylates increase the effects of . Caution is necessary when in meat stored at freezing tempera- more than 2 years has yielded living salicylates and anticoagulants are prescribed tures will be rendered nonviable, the Trichinella larvae. concurrently. Also, salicylates may depress the concentration of prothrombin in the plasma. time for "sterilization" varying in- Therefore, it no longer appears Large doses of salicylates may affect insulin versely with the temperature. requirements of diabetics. Salicylates may tenable to advise that meat liable to potentiate sulfonylurea hypoglycemic agents. Legislation in the United States harbour the Arctic strain of T. spi- Analgesic abuse (excessive and prolonged therapy) has been associated with nephropathy. has indicated that the following tem- ralis is rendered safe from trichinosis TO AVOID ACCIDENTAL POISONING perature/time combinations are lethal by freezing at any temperature ACETYLSALICYLIC ACID PREPARATIONS for MUST BE KEPT WELL OUT OF REACH OF to encysted T. spiralis in pork: 50F any length of time. Trichinosis is still CHILDREN. (-150C) for 20 days, -100F a significant problem in the Canadian PRECAUTIONS: Give with caution to patients (-230C) for 10 days, -200F with asthma, other allergic conditions, North and will remain so as long as tendencies, or hypoprothrombinemia. Salicy- (-290C) for 6 days and -360F inadequately cooked meat is lates can produce changes in thyroid function eaten. tests. (-380C) for 2 minutes.1 Whether this apparent resistance to Observe care in use of codeine, although On the basis of these regulations it cold is entirely restricted to Arctic tolerance and addiction are rare. Give codeine was considered for many years in with caution to patients with severe respiratory strains of T. spiralis is unknown but depression. Its depressant effect may be the Northwest Territories that the appears to be a worthwhile field for enhanced by concurrent administration of simple advice not to eat raw meat, investigation. sedatives and tranquilizers. ADVERSE REACTIONS: Acetylsalicylic acid: especially polar bear and walrus, un- Gastrointestinal: dyspepsia, heartburn, nausea, less it had been frozen hard for sev- R.D.P. EATON, PH D, MB, CH B vomiting, diarrhea, gastrointestinal ulceration Northern medical research unit and bleeding. Ear reactions: tinnitus, hearing eral days, was adequate to protect Medical services loss. Hematologic: anemia, leukopenia, Northwest Territories region thrombocytopenia, purpura. Dermatologic and against trichinosis. It was considered Health and Welfare Canada Hypersensitivity: urticaria, angioedema, pointless to specify times and tem- do Charles Camsell Hospital pruritus, various skin eruptions, asthma and Edmonton, Alta. anaphylaxis. Miscellaneous: mental confusion, peratures when no means of record- drowsiness, sweating and thirst. ing the internal temperature of the Codeine: Average or large doses may cause various gastrointestinal symptoms such as sample existed. References nausea, vomiting and constipation. A recent paper by Rowley2 per- 1. KRAYBILL HF: The effect of ionizing Caffeine: May cause nausea, nervousness, petuates this concept: Rowley stated radiation insomnia, headache, vomiting, palpitation, on parasites, or destruction vertigo, muscle tremor, sensory disturbances, that a temperature of - 150C for 20 of Trichina in pork carcasses. mt J excessive diuresis in sensitive patients. Large days destroys Trichinella larvae. Appi Radiat Isot 6: 185, 1959 doses may cause gastric ulceration. Recently the validity FULL INFORMATION AVAILABLE ON of such ad- 2. ROWLEY G: Bernhard Hantzsch: the REQUEST vice has been questioned. I have probable cause of his death in Baffin Island in 1911. Polar Rec 18: 593, HOW SUPPLIED positive assurance from several in- 1977 0292* Tablets-Peach, . marked, scored, vestigators that, in the case of T. engraved 292 on one side. Each tablet contains acetylsalicylic acid 375 mg, caffeine citrate spiralis developing in mammals in 30 mg, codeine phosphate 30 mg. Available the Arctic, freezing cannot be relied "Current Haematology" in bottles of 50 and 500. [correction] upon to destroy the infectivity of the 1. Melmon, K.L., Morelli, H.F. (eds) Clinical encysted larvae. R.L. Rausch, Pharmacology, New York, The MacMillan for- Dr. M. Brazeau has pointed out an Company, 1972, Chap. II, p. 499. merly of the Arctic Health Research error that appeared in this book re- Centre in Alaska, and J.C. Holmes view (Can Med Assoc 1 119: 698, *Trademark 292T-9-394JA of the University of Alberta have 1978). The correct title of the book confirmed the isolation of viable T. is "Clinical Haematology". We apol- spiralis larvae from frozen Arctic ogize to Dr. Brazeau for this over- EED foxes taken from traps. B. Meero- sight. - Ed. CHARLES E. FROSST & Co. KIRKLAND (MONTREAL) CANADA 22 CMA JOURNAL/JANUARY 6, 1979/VOL. 120