Radioog Round V otacaps/Rotahaler® (salbutamol sulphate powder for inhalation) ACTION: Bronchodilation through stimulation of beta-2- adrenergic receptors in bronchial smooth muscle, thereby causing relaxation of muscle fibres. INDICATIONS: Symptomatic relief of bronchospasm due to bronchial asthma, chronic bronchits and other chronic bronchopulmonary disorders in which bronchospasm is F. Brandschwei a complicating factor CONTRAINDICATIONS: Hypersensitivity to any of the Dr. Brandschwei is a radiologist in the Department of ingredients and tachyarrhythmias. WARNINGS: The safety of salbutamol in pregnancy has Radiological Sciences and Diagnostic Imaging at the Foothills not been established. Hospital, Calgary, Alberta, and a clinical assistant professor Care should be taken with patents suffering from myocar- dial insufficiency, arrhythmia, hypertension, diabetes in the Department of Radiology at the University of Calgary. mellitus or thyrotoxicosis. Occasional patents have been reported to have developed severe paradoxical airway resistance with repeated excessive use of sympathomimetic inhalation preparations. The cause ofthis refractory state is unknown. It is advisable Supine Abdominal Radiograph from a Patient with Abdominal and that in such instances the use of the preparabon be discon- tinued immediately and altemate therapy insttuted, since Shoulder Pain Following a Colonoscopy. in the reported cases the patients did not respond to other forms of therapy until the drug was withdrawn. Fatalities have been reported following excessive use of aerosol preparations containing sympathomimetic amines, the exact cause of which is unknown. Cardiac arrest was noted in several instances. PRECAUTIONS: 1. Use with caution in patients sensitive to sympathomimetic amines. Other beta-adrenergic drugs, e.g., isoprenaline, should not be given concomitantly.

-.... 2. The application of Ventolin therapy in children should depend on the ability of the individual child to learn the proper use of the Rotahaler. These children should be assisted or supervised by an adult during inhalation. 3. To ensure the proper dosage administration of the drug, the patient should be instructed by a physician or other health professional in the use of the Rotahaler. ADVERSE REACTIONS: Although serious adverse effects are uncommon in association with the recommended doses, increased heart rate, peripheral vasodilation, headache, dizziness, nausea, tremor, and palpitations may occur. SYMPTOMS AND TREATMENT OF OVERDOSE: Over- dosage may cause tachycardia, cardiac arrhythmia, hypertension and in extreme cases, sudden death. In order to antagonize the effect of salbutamol, the use of a beta-adrenergic blocking agent, preferably one of the relatively cardioselective ones (e.g. metoprolol, atenolol), may be considered. DOSAGE AND ADMINISTRATION: A single dose of 200 or 400 mg should be taken for relief of acute broncho- spasm, or before exertion to prevent exercise-induced bronchospasm. For control of chronic asthma a mainte- nance dose of 200 to 400 Mg 3 or 4 times daily may be taken. More than 1600 Mg per day is not recommended. AVAILABILITY: Ventolin Rotacaps contain a mixture of microfine salbutamol sulphate and larger particle lactose in gelatine capsules. Each pale blue Rotacap contains What does this X-ray tell you? 200 MAg, and each dark blue Rotacap contains 400 Mg of salbutamol (as the sulphate). Both are available in polypropylene containers with polypropylene snap caps containing 100 Rotacaps. The contents of the Rotacaps are inhaled using a device called Ventolin Rotahaler which separates the capsule What is your diagnosis? into halves and releases the drug when the patient in- hales, by breath actuation. 1. Smal bowel obstruction The Ventolin Rotahaler is available separately from the Rotacaps in a plastic box held in a carton. 2. Appendicitis Reterences: 1. Orehek J, Gayraud P, Grimaud C, Charpin 3. Adynamic ileus J: Patient error in use of bronchodilator metered aerosols. 4. Pneumopenitoneum Brit Med J 1976; 1:76. 2. Earis JE, Bernstein A: Misuse Anwe of pressurized nebulizers. Brit Med J 1978; 1:1554. 5. Chilaidtonal pagelsyndrome2091.cio 3. Paterson IC, Crompton GK: Use of pressurized aerosols by asthmatic patients. Brit Med J 1976; 1:76. 4. Coady TJ, Stewart CJ, Davies HJ: Synchronization of bronchodilator release. Pract 1976; 217:273-275. 5. Tarlo S M, Broder I, Corey P, Davies G: A one-year study of salbutamol inhaled powder administered by a breath-activated device in asthmatics. Curr Ther Res 1984; 35:566-574.

Product monograph available to health professionals. A &Hg Allen & HIanburys |, A Glaxo Canada L,m,ted Compan PA A B CAN. FAM. PHYSICIAN Vol. 32: OCTOBER 1986 | Toronto Ontario Mon,treal.Onebec (C PP 1- I

Answer to Radiology Rounds (page 2061)

4. Pneumoperitoneum film. These signs include the 2. Inverted V-sign: in the lower This patient developed abdominal and following. abdomen the lateral umbilical shoulder pain following colonoscopy. 1. Rigler's sign (double wall sign): ligaments (containing the umbilical The x-rays show an increase in the intraluminal and extraluminal air artery remnants) are outlined by air. amount of large- and small-bowel gas outline the mucosal and serosal 3. Football or air dome sign: large which was introduced at the time of surfaces of the bowel. (See Figure 1.) collections of air form an eliptical colonoscopy. Evidence of free intraperitoneal air is provided by the "double wall sign (Rigler's sign)" FigurelI and the "triangle sign". (See Figure Close-up View of the Left Upper Quadrant Showing Triangle Sign (single 1.) arrow) and Double Wall Sign (double arrow). In the evaluation of a patient with an acute abdomen, plain radiographs of the abdomen are often obtained. The presence of a pneumoperitoneum is often of great clinical significance, since it may signify rupture of a hollow viscus or intra-abdominal infection with gas-producing organisms. The most common cause of penumoperitoneum is prior surgery. Air introduced into the abdomen at surgery may take up 24 days to disappear. Perforation of a hollow viscus is the second most common cause of free intraperitoneal air and is usually the result of perforation of a gastric or duodenal ulcer. Colonic diverticula result in free intraperitoneal perforation in approximately 25%1 of patients and result in retroperitoneal perforation in approximately 75%1 of patients. Appendiceal and small bowel perforation rarely result in large pneumoperitoneum. Gas produced by gas-producing organisms is usually loculated in an abscess, though free air may be seen. Infection must be considered post-operatively if intraperitoneal air does not resolve in the way anticipated. As little as I cc of free air can be diagnosed on decubitis and upright films. Using these projections, the horizontal X-ray beam passes tangentially to the air collection. Often, however, only a supine abdominal film is obtainable. A number of signs have been described which allow diagnosis of pneumoperitoneum on a single supine CAN. FAM. PHYSICIAN Vol. 32: OCTOBER 1986 2091 configuration over free intraperitoneal 10. Cupola sign: air trapped below the MICTI* fluid. central tendon of the diaphragm. micazole nitrate 4. Falciform ligament sign: the Chilaiditi syndrome refers to Actin falciform ligament is outlined by air distended air-filled bowel lying Miconazole nitrate exhibits brad spectrum jilM fungistatic activity; for example, against species of the genus Candida. Studies with Candida and appears as a linear density between the liver and diaphragm, and ajbicans (strain R.V. 4688) indicate that at low concentrations, miconazole overlying the inferior aspect of the this may simulate free intraperitoneal nitrate acts primarily on the yeast cell membrane resulting in selective inhibition of the uptake of precursors of RIA and DNA (purines) and liver just to the right of the spine. air. (See Figure 2.) mucopolysaccharide (glutamine). 5. Urachus sign: represents the In addition, inLitro antibacterial activity has been reported (Gram-positive bacilli and cocci. intra-abdominal extension of the Conclusions nicatiens and &lbical Use allantois. This may have acute MICATIN is indicated for the topical treatment of dermatophytes and Pneumoperitoneum is an important Candida infections and also lesions caused by mixed infections involving peritoneal reflections and when diagnosis that can often be made, or susceptible organisms. It has been clinically effective in treating tinea air is identified as a pedis athlete's foot), tinea cruris, tinea corporis, and tinea versicolor outlined by at least suggested, on supine caused by density in the midline just below the MICATIN ISdermatophytes.also effective in cutaneous candidiasis. Among the organisms abdominal films. Familiarity with a against which MICAtIN has-been found effecthe are Trichohton rubrum, umbilicus. number of radiologic signs will help Trichmohvton mentaorokhytes (including the variety, interdioitate 6. Perihepatic air: air outlines the the physician to make this diagnosis. niderm oo floccesumIMicrsoswrum canis, Micosoorum uynseum and anterior/inferior surface of the right species of Candida (including C. albicags , and Malassezia Confirmation of this diagnosis often Cutaimdicatius lobe of the liver. lone known. requires upright or decubitis views of Precaltilis 7. Morison's Pouch sign: is seen as a the abdomen. Discontinue medication if sensitization or marked irritation occurs. The triangular air collection over the introduction of MICATIN brand miconazole nitrate cream 2% and lotion 2% into the eyes should be avoided. superior margin of the right kidney. AIdvse Reactins 8. On rare occasions it has been reported that patients treated with MICAJIN Triangle sign: air trapping between experienced mild pruritus, irritation and burning at the site of application. three loops of bowel or between two Symtus aid at of Owdsale lone known. loops of bowel, and the peritoneum Miieninl seen as a triangular collection. (See Reference 1. In VitoIAntimicrobial Activity: Dermatophytes showed high susceptibilitY to miconazole nitrate at a concentration of 10 p.g/ml. Amongst these Figure 1.) 1. Margulis AR, Berhenne, HJ. Ali,mmeti- were Microsforum canis, M. audouini, Ugg mg Trichbohgon 9. Scrotal air sign: air enters the tta,N, tr,a(c(t 1a(dialogay, vol 1. St. Louis, __ta_or_ytes (including the variety, irjitaet, I rubrum, I tonsurans, The 1983: Iverrucosum. L etruaineum, and I violaceum, as well as WLeronIa scrotum through an open saccus MO.: C.V. Mosby Co., onei and [idermo ton floccusum. In most of the dermatophytes vaginalis. 392-4. studied, growth was atso completely inhibited by a 1 ,g/mL concentration of miconazole and marked fungistatic activity was still observed in some species at concentrations of 0.1 ,gIml. Figure 2 Yeasts were also sensitive. High fungistatic effect was observed at concentrations of 10 /mL and 100 pg/mI in all species studied except Erect Chest Film Showing Chilaiditi Sign (single arrow) and Free for Rhodolorua and Candida tronicalis. The fungistatic activity of Subdiaphragmatic Air (double arrow). miconazo nitrate was examined in species of dimorphic fungi, agents of fungal mycetoma Actinomyetales, Phycom etes and various other fungi. Concentrations of 100 4ml. were generalty 100% effective in preventing growth and at concentrations of 10 /mL only a tow species were not completely inhibited in their growth. Sgorothrix So. and Io iumn also proved susceptible to miconazole whereas AsoerigllUs So. and Fusarium were less so. The active bactericidal (bacteriostatic) concentration of miconazole nitrate against all species tested was 10 Wml. Among those tested were Esipelothrix insidiosa, SaDvlococcus hemolyticus, StaDhylocgccus aureus. eococcus pyeesgog Enterococcus, Bacillus suiilis, and Bacillus Bacteriostatic activiq was also found against two strains of penicillin- F~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~...... resistant Stujloeoccus aureus. The rkug was fw devoid of any activit against Gram-negative bacteria. Desa aW Admi tii n Sufficient MICATIN should be applied to cover the infected areas twice daily: morning and evening. The treated area should be massaged gently until the MICATIN disappears. Early clinical improvement (1-2 weeks) has been seen in the treatment of infections caused by dermatophytes and Candida species and in mixed infections, but resistant lesions may take longer to clear. If a patient shows no clinical improvement after 30 days of treatment, the diagnosis should be reconsidered. MICAIN miconazole nitrate 2% is provided in two different dosage forms: MICATIN cream - 30 g tube MICATIN lotion - 30 ml bottle Storage at temperature extremes should be avoided. Product monograph available upon request.

OUTSTANDING SPECTRUM, OUTSTANDING RESULTS.

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