THE NOVA SCOTIA MEDICAL BULLETIN

EDITORIAL BOARD

Editor-In-Chief Dr. A.J. Buhr Managing Editor Dr. J.F. O'Connor Dr. J.A.R. Tibbles Mr. D.D. Peacocke Dr. J.P. Welch Associate Editor Dr. W. Putnam Editorial Assistant Dr. A.C. Irwin Dr. T.J. Murray Mrs. T. Clahane

Consensus

"It is important to build within the profession a consensus on what we are and where we are going. Once we have a shared vision, we can start to sell it to others." The words of Dr. Leo-Paul Landry, as he begins his new job of Secretary General of the Canadian Medical Association show an understanding of the problem facing our profession, and give hope for the solution. Consensus though will not be an easy objective to reach, among physicians known to be among the most opinionated individuals in our society. Use of logic and scientific method to reach the truth and justice of issues is not always evident in our considerations or actions. It is surprising that, despite our diversity, the public often views us as a united group, supportive of one another, varying little in our opinions and usually protecting our own interest. If only it were so simple, it would be so much easier to reach the much desired consensus mentioned above. As educated persons, we continue to promote rich intellec tual interaction that fosters learning in all of us. Varying positions and opinions are encouraged and hopefully enrich the profession and improve it. However when political action is necessary it makes solidarity very difficult to achieve, and solidarity, des pite the union-like concept it might suggest is really what we are going to need in the future. The anti-professional attitude so rampant in the past few years will require nothing less, even if we are successful in avoiding confrontations similar to that in Ontario. If in the perception of others, we as physicians promote many different solutions, we will appear only as a group of self-seeking individuals, no different from competing political parties. Most physicians would agree that priorities in health care are best settled by using principles of ethics, good research and thoughtful decision making, rather than by the most effective public relations ca mpaign. However there will always be those issues that of necessity wi ll be settled in the public forum. If we are to be effective, then, in applying our professional ex pertise we must remember that too many opinions often confuse the patient and that unified opinion and action will be necessary if we wish to be heard. At present that unity of the profession is threatened by many issues, withdrawal of services being the most controversial. Income differences among specialty groups maybe the next most devisive issue affecting our unity.

THE NOVA SCOTIA MEDICAL BULLETIN 117 AUGUST 1986 We are being attacked in our very role in the health care sys tem by the nursing association, as well as many other health care professionals. The place of the family practitioner in hospital, in obstetrics and in the emergency room is being debated. The liability crisis is still with us, with increasing differences of premium adding another wedge to our separate specialty groups. Manpower, postgraduate training positions, fiscal res traint to the Maritime Provinces are more poten­ tially devisive issues. Without consensus we will have little to say in the solution of many of them. University and community physicians or town and gown will have to compromise, as will differing specialty groups. Obviously we will have to use our committees, associations and societies more effectively to promote fair discussion and exchange of opinion. If the profession as a whole becomes an ineffective voice then the health ca re sys tem and the patient ultimately will suffer. Dr. Landry sees the problem of co nsensus and it will be up to the physicians of Nova Scotia to be part of the solution. The Secretary General has our bes t wishes as he begins his new position. ].F.O'C. ''The D Asthma Handbook'' Helps You Help Asthma Patients HOUSE CALLS At Investors, we don't keep bankers hours. We keep yours. So ifyou can't come to me. I'll come to you. THE T. LUNG ASSOCIAriON I can help you put ~ together a written, com-l_ ~ \ prehensive financial j I §r v \ "The Asthma Handbook" is a plan that will help you I self-help booklet that answers questions reach your personal I \I I ~~ asthma patients ask-or should ask. finanCial goals. ~~ 1, , "The Asthma Handbook" is 28 Ifyou.need advice. on It J)J"' ) fact-filled pages about asthma, anything from savmg - attractively illustrated, clearly written. taxes to investment "The Asthma Handbook" tells about opportunities,callme ; l ...... :...... asthma triggers, asthma medicines, how today. ./· ... , .. . ~ ·,: . : . : :. ;• ..... 1 to control episodes, how to head off 'to.\\\l.t\lltllllli.t 1°1IU1111LitHhljq 11 tllltjltt•l~h t/(IC\) MURRAYSMIDi oncoming breathlessness. SIMPSONS MAll. HAIJFAX, N.S. "The Asthma Handbook" helps BUS. 423-8294 RES . 835-9983 patients help themselves live better, feel Investors better! Group PROFIT FROM OUR EXPERIENCE ASK YOUR LUNG ASSOCIATION FOR A SAMPLE COPY.

THE NOVA SCOTIA MEDICAL BULLETIN I I8 AUGUST 1986 Insights and Controversies in Pediatric Epilepsy: How Little We Really Know

Peter R. Camfield,* M.D. and CarolS. Camfield,* M.D.,

Halifax, N.S.

INTRODUCTION helpful in improving the prediction of recurrence. In 70% of epilepsy begins in childhood and there are Table I, these three factors are combined to allow more about 900 children with epilepsy in the Province of accurate prediction. For example, a child with a first Nova Scotia. Some of these children outgrow their unprovoked generalized tonic clonic seizure who has epilepsy and for others their disorder is life- long. The a normal neurologica l examination and normal EEG natural history of epilepsy in childhood, the value of has about a 30% chance of recurrence, while a child anticonvulsa nt drug treatment, the role of screening who is neurologically abnormal with an initial partial during anticonvulsant treatment for biochemical complex seizure and epileptiform EEG has a 96% abnormalities and the time when treatment should be chance of recurrence . Seventy-seven percent of stopped, are all areas of current controversy. Close recurrences were within one year of the first seizure coll aboration between families, family physicians and and almost all by two years. the neurology services of the IWK Hospital has offered Strangely enough, in this Nova Scotian series (which some insights into these issues. probably represents the majority of children with a first seizure in the province during the study period), WHO HAS EPILEPSY? the prescription of anticonvulsant medication did not Epilepsy is generally defined as a tendency for seem to alter the.recurrence rate (55% of the 115 treated recurrent seizures and most authorities agree that a had recurrences, 45% of those untreated recurred). This, child should have two unprovoked seizures before the of course, was not a controlled study of medication diagnosis of epilepsy is justified. Nonetheless, all and compliance was not documented, although epilepsy must begin after a first seizure and the compliance in taking anticonvulsant medication is 2 prediction of epilepsy after a first seizure is a matter generally excell ent in Nova Scotian patients. of major concern to both the family and phys ician. Once a child had had two seizures, the recurrence

TABLE I

ESTIMATED PERCENTAGE OF CHILDREN SEIZURE-FREE 24 MONTHS AFTER A FIRST SEIZURE

Seizure EEG non EEG non- EEG epileptiform; EEG epileptiform; Type epileptiform; epileptiform; neurologic neurologic neurologic neurologic examination examination normal abnormal normal abnormal

Generalized Tonic-clonic + secondary generalized 70% 49% 53% 27% Partial Elementary 50% 25% 29% 8% Partial Complex 42% 17% 23% 4%

At the l.W.K. Hospital for Children, we have studied rate was 79% for further seizures and, therefore, a the recurrence rates of 168 children who presented to confident diagnosis of epil epsy rea lly must wait for our EEG laboratory between 1977-81 with a first two seizures. afebrile unprovoked seizure associated with no Our findings were very similar to the NIH Perinatal progressive neurologic disease or acute encephalo­ Study. 3 This study followed 54,000 children from pathy.' The oy,erall recurrence rate was 51%. T he EEG, prenatally to age seven. During this time 435 children neurological examination and seizure type were very had a first seizure and 54.7% had recurrences. Again, the prescription of anticonvulsants did not effect the • Izaak Wal ton Killam Hospita l for Children, Department risk of recurrence but again compliance with of Pediatrics, Dalhousie University, Halifax, N.S. medication was not assessed.

THE NOVA SCOTIA MEDICAL BULLET IN 119 AUGUST 1986 These studies of the initial presentation of childhood that patients took their medication extremely epilepsy raised several important ques tions. Most regularl y. important for the practitioner, is whether or not A comparable study in adults, involving a much . anticonvulsant medica tion should or should not be larger sample size, has co me to similar conclusions prescribed after a first unprovoked seizure. Given the about drug effi cacy.4 Thus, we are far from truly vast amount of information about the effectiveness of excell ent· treatment for a very large number of both anticonvulsants to prevent seizures it would seem children and adults with epilepsy. astonishing if they were without success after a first seizure. In principle, the value of anticonvulsants SCREENING FOR ANTICONVULSANT would be to prevent a second seizure an,d subsequent TOXICITY seizures. The effect of recurrent seizures on children is sti ll unknown, however, following a first seizure Rare but catas trophic idiosyncratic reactions have there is always the possibility that the second seizure occurred with all anticonvulsants. These reactions will cause damage from a fall or result in social appea r to occur in 1/20,000-50,000 patients started on isolation. almost any anticonvulsant drug and include exfoli­ ative dermatitis, nephritis, hepatitis and aplastic Against the use of medication after a first seizure anemia. These serious reactions have led neurologists is the idea that half of such children will be treated and drug manufacturers to recommend routine blood unnecessarily and that the drugs might have signif­ and urine screening during anticonvulsant treatment. icant side effects. Implicit in such a recommendation for screening is To answer these critical issues, we are just beginning the untes ted assumption that serious reactions are a randomized prospective study of carbamazepine preceeded by an asymptomatic phase which can be following a first seizure. Our study will assess the detected by screeniAg and that stopping the drug at efficacy of carbamazepine as well as meas ure possible this stage will prevent or diminish the full-blown cognitive effects of the drug, through detailed reaction. neuropsychological testing. In addition, the attitude We studied 199 children with seizure disorders who of the family and children about being on or off were beginning treatment with an anticonvulsa nt. 5 medica tion will be carefully assessed through The children were followed prospectively with blood questionnaires involving self-esteem and locus of and urine screening before treatment and at I, 3, 6, control. We hope, at the end of this study, to be able 12, 18 and 24 months on medication. Blood tes ts to answer in a practical fashion whether carbamaze­ included routine measures of hematologic, liver and pine is or is not appropriate after a first seizure. This pancreatic function. There were no serious toxic study is to involve 100 children and we welcome reactions to the drugs, however, there were a large prompt referral of any child in Nova Scotia with a number of minor abnormalities in all of the laboratory first unprovoked seizure. tes ts seen equally with all anticonvulsants. These HOW WELL DO ANTICONVULSANT DRUGS CONTROL SEIZURES IN CHILDREN WITH TABLE II EPILEPSY? SYMPTOMS ASSOCIATED WITH SEVERE REACTIONS Carbamazepine is now the most commonly pres­ TO ANTICONVULSANTS cribed anticonvulsant for children with epilepsy in Nova Scotia, followed by phenobarbital, valproic acid Generalized Allergic: and phenytoin. The efficacy of these drugs to Ras h, fever, lymphadenopathy usuall y withi n 2-6 weeks of completely control seizures is not clear cut. We have starting drug (phenobarbital, carbamazepine, phenytoin). prospectively studied 82 children with new ly diag­ nosed, previously untrea ted epilepsy. To our surprise, Bone Marrow Suppression: 41 % had at least one additional seizure on medication SympLOm s from anem ia, unexplained infection s, bruisin g, and 13% had serious medication side effects requiring bl eeding (carba mazep ine, phenytoin, va lproic acid, ethosux im ide). a drug change. This left only 46% with the hoped for result of treatment, namely no further seizures and Nephritis: no significa nt medication side effects. If a child did Hematuria, nephroti c syndrome (carbamazepine, phenytoin). not have seizures during the first six months of treatment, he/ she was very likely to remain seizure Hepatitis: free. I. Somnolence and repeated"vo miting (valproic acid ). 2. j aundice and fatigue (phenytoin , ca rb maze pine, other Children with the best prognosis were those with drugs). generalized seizures who were neurologicall y normal, while those with fo cal epilepsy and neurologic Pancrea titis: impairment had significantly higher rates of drug Abdominal pain and vo miting (valproic acid). failure. Drug levels throughout the study documented

THE NOVA SCOTIA MED ICAL BULLETIN 120 AUGUST 1986 abnormal tes ts, of course, had to be repeated since the free.l Overall, 76% of children remained seizure free. assumption of a presymptomatic phase to severe Children with focal seizures and neurologic impair­ reactions necessitates close attention to any minor ment were found to have a less favourable prognosis. abnormality. Two children had severe abnormalities In this study, an EEG at the time of discontinuing detected by such a screening process, but it turned out medication was not predictive of seizure recurrence. that in neither case was the reaction of any clinical Two more recent studies examined children who signifi cance and in neither case was it secondary to had been four years and two years seizure-free prior the anticonvulsant drug. to discontinuing medication.8 9 These studies found We concluded that routine screening for anticon­ little relationship between recurrence rate and seizure vulsant toxicity has a significant negative impact on type or neurologic status but did find the EEG to be the care of the child with epilepsy with no real hope significantly predictive of further seizures. Thus, it is of benefitting the child. We recommend that routine unclear, once seizure control is es tablished, how long blood and urine screening be discontinued. In its place, anticonvulsa nt drugs should be continued. There we have recommended that children and their parents remains uncertainty whether the EEG or other factors be well informed of the symptoms that accompany about the patient are sufficiently precise predictors of se rious toxic reactions and report these to the phys ician recurrence that they should affect the decision to stop immediately. (Table II) We hope that such an medication. approach will provide a more comprehensive form of screening, which is more acceptable to children and DO ALL CHILDREN WITH EPILEPSY RE­ their families. QUIRE ANTICONVULSANT TREATMENT? Some se izure types in childhood are benign in the THE VALUE OF ANTICONVULSANT BLOOD sense that they are universall y outgrown. The most LEVELS cl ear cut example of this is benign Sylvian seizures T here can be little doubt that anticonvulsant serum or Rolandic epilepsy. This is a specific seizure disorder drug levels document that a patient is taking his usually with its onset before age 10, with most seizures medicati on. The controversy in this area concerns the occurring during sleep. The seizure usually involves so-called therapeutic range for anticonvulsant drugs. the tongue and mouth with or without some spread T here is a wide-spread perception that anticonvulsant to involve the arm and leg. The children are generally drug doses should be adjusted so that the patient's normal and their EEG shows a spike focus over the serum levels fall within an arbitrary "therapeutic" Sylvian fi ss ure. This special seizure disorder accounts ra nge. This assumption has not been direc tl y for approximately 10% of childhood epilepsy and is examined. One very striking study found that leve ls almost always outgrown in the teenage years.IO For are frequently misinterpreted or misused in clincal many children, the seizures are very minor and practice. In our prospective study of 82 children with infrequent and the value of trea tment with anticon­ newly diagnosed epilepsy, we found that the blood vu lsant drugs is not clear cut. levels did not predict recurrence of seizures i. e. higher There is speculation that there may be other benign drug levels were not associated with fewer seizures forms of childhood epilepsy. It may that some of the despite virtually all levels falling within the usual children with generalized tonic clonic seizures may " therapeutic" range.z It would seem unlikely that there have a few se izures only at a critical stage of brain is a serum level below which any anticonvulsant drug maturation. Although there are cl earl y potential is completely ineffec tive and above which side effects consequences from a large number of generalized tonic are routinely seen. The therapeutic range, at best, must clonic seizures, there may well be a group of children be a stati stica l concept with many exceptions. Since who would have 2, 3 or 4 generali zed tonic clonic anti-convulsants may have serious but subtle effects seizures only. If the epileptic tendency is to be so brief, on cognitive function in children with apparently then it seems unlikely that anticonvulsant drugs are " norma l" drug levels there is a real need for needed, provided the public and the families can be psychophysiologic tes ts which could examine the persuaded that the disorder is benign. Given the question of intoxica tion directly. relative ineffi cacy of anticonvulsant drugs and their potential side effects, considerably more work is HOW LONG TO CONTINUE MEDICATION? required to identify the children who reall y benefit An unknown but substantial proportion of children from drug treatment. who develop epilepsy will outgrow their epileptic tendency before reaching adulthood. The ques tion of CONCLUSION how to identify such children and how long to treat The point of this brief review is to indicate tht despite them has been the subj ect of recent controvers y. The our increasing knowledge of pediatric epilepsy there largest study with the longes t follow-up has examined remain large gaps in our understanding of the natural the outcome in 148 children with epilepsy whose history of the disorder, both treated and untreated, and anticonvulsa nts were stopped after four years seizure- major unce rtainties about the most a ppropriate

T HE NOVA SCOTIA MED ICAL BULLETI N I2I AUGUST I986 management. The relative geographic isolation of 4. Ma ttson RH and others. Comparison of carbamazepi ne, Nova Sco tia coupled with its sys tem of centralization phenobarbital, phenytoin and pri midone in partial and of special services for children offers unique oppor­ secondary generalized ton ic-clonic seizures. N Engl 1 Med 1985; 313: 145- 151. tunities for imp roving our understanding and trea tment of epilepsy in children. D 5. Ca mfield CS, Camfie ld PR, Smith E, Tibbles JAR. Asymp­ toma ti c children with epilepsy : Little benefit from screening fo r an,iconvu lsant-ind uced li ver, blood or renal damage. ACKNOWLEDGEMENT S Neurology 1986 (in press). Our thanks to Drs . J.A. R. T ibbles, J.M. Dooley and E.). 6. Beardsley R, Freeman J, Appel F. Anticonvu lsa nt seru m leve ls are usefu l only if the physician appropriately uses them: An Gibson who participated in these studies; Edythe Smith who · assessment of the impact of providing serum level data to provided expert nursing care; lone Anderson.JoF secre tarial phys icia ns. Ep ilepsia 1983; 24: 330-335 . wizardry and the children with epil epsy and their fa milies who have been so patient with our efforts. 7. Thursto n JH, T hursto n DC, Noixon BE, Kell ar AJ Prognosis in chi ldhood epilepsy: add itional followup of 148 children from 15 to 23 years after withdrawa l of anticonvulsa nt therapy. N Engl 1 Med 1982; 306: 831·36. References 8. Emerson R, O'Sou za B, Vi ning E, Holden K, Mell itis D, I. Camfield PR, Camfield CS, Dooley JM, T ib bles JAR, Fung Free ma n J Stopping medication in ch ildren with epilepsy : T, Garn er B. Ep ilepsy after a first unprovoked seizures in Predictors of Outcome. N Engl 1 Med 198 1; 304: 11 25-29. childhood. Neurology 1985; 35: 1657- 1660. 9. Shinnar S, Vi ning P, Mell itis D, D'Souza B, Holden K, 2. Camfield PR, Camfield CS, Smi th E, Tibbles JAR. New treated Baum gardner R, Free ma n J Disconti nuing antiepil ep tic childhood epil epsy: A prospec ti ve study of recurrences and side medi ca ti on in children with epilepsy after 2 years without effects. Neurology 1985; 35: 722-725. seizu res: A prospec ti ve study. N Engl 1 Med 1985; 313: 976· 980. 3. Hirtz DC , Ellenberg JH, Nelson KB. The risk of recurrence of nonfebrile seizures in children. Neurology 1984, 34: 637- 10. Beaussant M, Faou R. Eva luation of Epi lepsy wi th Ro landic 41. parox ys mal foci. Epilepsia 1978; 19:337-342.

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T HE NOVA SCOTIA ME DI CAL BULLETIN 122 AUGUST 1986 Some Management Problems In Adult Epilepsy: A Review

David B. MacDonald,* M.D. and R. Allan Purdy,** M.D. , F.R.C.P. (C).,

Halifax, N.S.

INTRODUCTION until a steady state at maintenance dosage is reached. We have se t out here to review some specific A notable exception is phenytoin which is begun at problems that frequently arise in the management of maintenance dosages or can be given in a large dose the adult epileptic. The principles outlined are general on the first day to " load" the patient. By using blood to adults with se izure disorders and it is important levels at a steady state (reached in 5-7 times the half to individualize therapy for each patient. life) the dose is gradually adjusted to achieve the therapeutic range. Table III lists the half lives of several MONOTHERAPY antiepileptic drugs. The use of several anticonvulsants simultaneously TABLE I has become nearl y standard therapy for many epileptic patients. Although based on a well-intentioned desire SIMPLIFIED INTERNATIONAL CLASSIFICATION OF SEIZURES AND EFFICACY OF to achieve better seizure control, the all too frequent ANTIEPILEPTIC DRUGS (3) and familiar results are complex drug interactions and increasing chronic toxicity, resulting in disappointing Seizure Effective Drugs or even paradoxically deteriorating seizure control. 4 Partial Simple (eg. Jacksonian) CBZ, PHT, PB, PRM Much recent ev idence indicates that the careful and Complex (eg. Psychomotor) CBZ, PHT, PB, PRM, (VAL) patient use of a single anticonvulsant appropriate to Secondary generalized tonic-clonic CBZ, PHT, PB, PRM, VAL the patient's form of epilepsy has much to commend Generalized it.t 2 3 4 5 Polytherapy is much more eas il y prevented Tonic-clon ic (Grand Mal) CBZ, PHT, PB, PRM, VAL than reversed, a process which is difficult, time Myoclonic CLON, VAL consuming, and indeed sometimes impossible. The Absence (Petit Mal) ESM, VAL chief problem is deteriorating se izure control while CllZ=Carbamazepine (Tegretol) VAL=Valproic Ac id (Depakcnc) weaning agents until a steady state is re-es tablished PHT= Phenywin (Dil ant in) CLON=Cionazepam (Cionipin) PB=Phcnobarbital ESM=Ethosuxim ide (Zarontin ) in weeks or months. PRM =Primidone (Myso line) Ideall y then, only one drug should be used with a minimum of toxicity, all owing the patient to carry on his or her activities of daily living without undue res triction. While this outcome is sometimes elusive or impossible, it is well worth striving for in each TABLE II patient. RELATIVE MONTHLY COST OF The bes t approach is first to be certain that epilepsy ANTIEPILEPTIC DRUGS (3) is the condition being trea ted and to accurately identify Drug Cost of Monthly Dose both the seizure type and the underlying etiology (s ti ll Carbamazepine $ 16 most often idiopathic).t-9 When as complete an Phenytoin $ 4 understanding as possible of the problems has been Phenobarbital $ I Primidone $ 12 reached, and therapy is indicated, selec t the drug which Va lproic Acid $ 18 seems most appropriate bearing in mind the seizure Clonazepam $ 10- 15 ty pe and the age, sex and financial situation of the patient (see Tables I and II). Usually this will be Morning drug levels before the first dose are best phenytoin orcarbamazepine in adults. to Sedative drugs to use for this purpose. 2 5 If seizures are inadequately (phenobarbital, clonazepam, primidone) are best controlled, the dose is increased gradually until control avoided if possible.2 Most anticonvulsants are begun is achieved or clinical toxicity develops. Drug leve ls at t/4 to Y3 of the maintenance dose and increased weekly are used only as a guide; the optimal dose for an individual, which achieves the best balance between •Neuro logy Resident, Division of eurology, Department of control and toxicity, may lay outs ide the averaged Medicine, Dalhousie Uni versity. " therapeutic range". Adequate time to achieve a steady .. Ass istant Professor of Medicine, Divisio n o f Neurology, state is given before assessing efficacy; impatience is Department of Medicine, Dalhousie University, Hali fax , N.S. a major pitfalJ.2 5 9

T HE NOVA SCOTIA MED ICA L BULLETIN 123 AUGUST 1986 TABLE III therapy is largely based upon the probability of HALF LIVES OF COMMONLY USED recurrence of seizures . About 5 percent of the ANTIEPILEPTIC DRUGS population have at least one afebrile seizure in thei; Drug Half-Life (hours) lifetime while the prevalence of epilepsy IS much less Usual Range than this.12 Some individuals have only two or three

Ca r bamaz~ p in e• 30 20-40 (acute) se izur e~ in their life. Others have an ongoing 15 5-25 (chronic) disposition requiring life long therapy. Phenobarbital 96 48- 120 Phenytoin 24 6-100 The prognos is of a seizure di sorder may be apparent Primidone•• 16 6-22 after thorough assessment of the problem through Valproic Acid 12 .• 6-20 clinical examination, EEG, CT and other anollary •Carbamazep ine metabolism is autoinduced, so th at it s half life decreases aids. If a brain tumor, arteriovenous malformation or with chroni c use . other space occupying lesion is responsible, seizures .. Primi done is metabolized to Phenobarbital, the half li fe given here is fo r the pareJH co mpound alone. are likely to continue and the prognosis refl ects the underlying pathology. If seizures have occurred secondary to or "symptomatic" of some cute stress If seizures are still inadequately controlled despite or illness extrinsic to but imposed upon the central clinical toxicity, the dose can be reduced slightly to nervous sys tem, such as sleep deprivation, or an acute all ev iate side effects and then a second agent added. metabolic derangement such as hypoglycemia, uremia, Of course, it is essential to be certain that lack of or hyponatremia, then correcting or pr e v e ntin ~ these compliance is not the source of inadequate control, underlying probl ems makes the probab1hty of before adding further medication. The above process recurrence low11 Hence, using temporary anticonvul­ is repea ted for the second agent, again preferrabl y a sant therapy while the provoking factors exist may non-sedating drug (eg. adding carbamazepine to be helpful, long term therapy would not be indicated. phenytoin). If seizures come under control after carefu l adjustment, the first anticonvulsant can be withdrawn Some acute CNS disease such as meningitis, mild very gradually if it was of no benefit, or maintained to moderate head trauma or stroke may ca use acute if it was partiall y successful. If seizures continue despite symptomatic seizures but not necessarily a long term 11 the two drugs, a third is added and adjusted, and the seizure disorder. On the other hand, these same second agent withdrawn. Throughout, an aim for diseases, through scarring and gliosis may give rise monotherapy is maintained, two agents are sometimes to "remote symptomatic seizures" occuring months helpful, three used with great reluctance. or years after the initial event, these epilepsies often being permanent. 11 This occurs in only a minority: One common pitfall in the use of phenytoin 5% of head trauma overall (usually severe) and in 10% specificall y is to increase the dosage to 400 mg daily of strokes. T he presence or absence of acute symp­ 2 after 300 mg has proven inadequate. Toxicity may tomatic seizures is often a poor prognostic indicator res ult, and the drug is then deemed unhelpful. of the future chance of this ocurring and, apart from H owever phenytoin metabolism often becomes head trauma, few good fi gures are available to help sa turated above 300 mg a day leading to increases in predict who will go on to have remote seizures making drug level and toxicity out of proportion to the dosage this particular area somew hat difficult. 11 increment. An empirical but reasonable approach is to treat The so lution is to use the 50 mg pediatric tables an individual who has had significant seizures due which are scored for dividing. By using 50 mg or even to acute CNS disease with anticonvulsants for 1-2 years 25 mg increments, it may then be possible to achieve and then to reassess the situation. Therapy might be a more precisely individualized optimal dosage and very gradually discontinued if no further seizures have 1 successful monotherapy. 2 occurred and if an EEG is not epileptiform. Rein­ When using carbamazepine, dosages of more than stitution of anticonvulsants might be necessary if I 000 mg dail y are often necessary, but sometimes feared remote seizures then occur. beca use of reported serious hematologic or hepati c For the majority of patients whose seizures are 2 toxicity. With increasing experience it appears these "idiopathic" or not associated with progressive CNS 1 2 reports have been over-emphasized and the serious lesions, it ca n be difficult to predict an individual's toxicity was not dose related at any rate. course. Nevertheless, it is prudent to routinely monitor drug About one quarter of epileptics do not respond to levels, CBC, liver function and electrolytes at leas t every initial therapy and many agree that subsequent control three months while taking anticonvulsa nts. In is elusive or unobtainable despite changes or additions particular, when using carbamazepine these studies of anticonvulsa nts.12 Some of these patients may be should be done monthly initially fo r 3-4 months. surgical candidates. Perhaps nowhere is the prognosis more unsettling PROGNOSIS IN EPILEPSY than in the individual presenting with a first seizure. T he decision to begin, continue or discontinue Overall , 25% of patients will have recurrence within T HE NOVA SCOTIA MEDI CA L BULL ETI N 124 AU GUST 1986 three years. II A history of previous neurologic insult of these women will have seizures only during their (stroke, trauma or meningitis for example) increases pregnancy (gestational epilepsy) and not necessarily the ris k to approximately 33%.11 A generalized spike­ in subsequent pregnancies l 2 14 I6 11 wave pattern on EEG increases the risk to approx­ Seizure frequency is unaffected in roughly 50% of ima tely 50%. A family history of epilepsy in a sibling epileptic women during pregnancy. 1 2 About 25% have increases the risk to more than 50%. Without any of improved seizure frequency and in the remaining 25 % these factors, the chance is roughly only 20% of control deteriorates. recurrence. Once a second seizure has occurred, the recurrence rate is at least 75%. 11 Consideration of these The ques tion of anticonvulsant teratogencity is recurrence rates allows one to determine if the benefits complex and emotionally charged and therefore of treatment outweigh the risks and side effects of controversial. There is no doubt that trimethadione anticonvulsant medications. Trea tment must be is highly teratogenic and contraindicated in preg­ individualized for each patient depending on the nancy. 15 I6 Valproic acid is teratogenic in animals and circumstances of the seizure, their lifes tyle, age and there has been concern about neural tube defects, etiology of the seizure. however all the facts are not in yet, and it is perhaps bes t to avoid it if poss ible at prese nt. The situation EEG IN EPILEPSY with other anticonvulsants is much less clear. It is unusual to record an actual seizure on routine What is known is that the risk of anomalies is EEG, which is the only absolutely unequivocal proof increased 2 to 3 fold in epileptic women on treatment, 1 of its epileptic basis. but is still probably less than 10%. 2 s I4 I6 11 Repre­ sentative fi gures for incidence of birth defects are Only about 56% of epileptics have a "positive" first approximately 2.5% in the general population, 4.2% EEG. Additional recordings over time increase the in unmedicated epileptics and 6. 5% in treated chance of "catching" an epileptiform event and epileptics.1 activa tion methods such as hyperventilation and photic stimulation as well as sleep deprived or sleep In general then, if a woman has been seizure-free EEG's may yield positive results in some. for several years, gradual anticonvulsant withdrawal over several weeks can be attempted prior to conception A small minority (8%) of epileptics have consistently otherwise optimized therapy is continued, preferring normal EEG's. A negative EEG does not rule out monotherapy with phenytoin or carbamazepine. 13 epil epsy. Phenobarbital may be used, but most agree that it is Some prognostic information may be provided by not necessary to switch from phenytoin to this drug, EEG. While it is probabl y the case that the pretrea t­ as has been advised. The woman is advised that there ment EEG of a newl y diagnosed epileptic does not is 2-3 fold increased chance of malformations but that help predict seizure controJI 2, it is also true that an the majority of these are mild and that the chance epileptiform EEG after a first unprovoked seizure of good outcome is better than 90%.1 2 16 T he indicates a high chance of recurrence. 11 While importance of compliance and res t are stressed. controversial mos t authorities feel subsequent EEGs Monthly drug levels and visits are recommended. are useful in helping make a decision about discon­ Dosage increments may be necessary and if they are, tinuing therapy in an individual free of seizures for weekly post partum levels are recommended as drug 2-4 years. Continuing epilep tiform EEG activity is felt levels will rise again as drug cl earance returns to to be associated with relapse to some exten t. 13 normal. 1 2 16 Minor non-specific dysrhythmias are just that and MEDICATIONS AND ALCOHOL have no special significance for epilepsy, these findings Although there is a small risk of adversly affecting being seen in 15%o f normal people. seizure control with psychotrophic agen ts, these drugs should not be withheld if indicated. Possible drug EPILEPTIC WOMEN interactions should be assessed by monitoring Hirsutism and coarsening of facial features occur anticonvulsan t levels. 1 in as many as 30-40%o f people trea ted with phenytoin. Phenothiazines are the bes t known epileptogenic Alternative agents, es pecially carbamazepine, are agents, do occasionall y cause seizures, and regularily therefore of special consideration in women, I-3 alter the EEG. High doses or rapid incremen ts are particularly if dark haired and fair skinned. usually invo lved, and brain damaged individuals are Pregnancy is a problem for epileptic women which at greater risk. The mechanism is unknown. After a should be regarded as high-risk and may require single seizure without other explanation, the dose of neurological and obstetrical support to care for the phenothiazine should be reduced and the patient patient. T he aim is to keep the mother seizure-free observed. After a second it may be necessary to protec t with minimal toxicity to her and her fetus. Most are the patient with an anticonvulsant, usually phenytoin, epileptic and under therapy prior to conception. Some if the phenothiazine is truely needed. If the pheno­ experience their first seizure while pregnant and 25% thiazine is subsequently discontinued, the anticonvul-

THE NOVA SCOTIA ME DI CAL BULLETIN 125 AUG UST 1986 sant should be gradually withdrawn. 1 providing the physician is comfortable that the patient Tricyclics are occasionally but infrequently epilep­ is compliant, reliable and not taking alcohol to excess. togenic in the usual doses. The above statements also Someone who has had purely nocturnal seizures for apply to these drugs. Overdosage may cause severe five years may drive, as the chance of a diurnal seizure • seizures among other problems and intravenous is low. An epileptic who has been seizure free for several diazepam and phenytoin may be necessary acutely, but yea rs who then has a seizure during attempted not chronically.1 withdrawitl of anticonvulsants is considered ca pable of driving once the medication is reinstituted. Further Intoxication with monoamine oxidase inhibitors details are available in the guidelines drawn up by may cause seizures, but this is much less common.· the CMA. 1s 0 There is no problem in the usual doses and the EEG is largely unaffected. 1 ACKNOWLEDGEMENTS Benzodiazepine withdrawal may precipitate seizures, We would li ke to thank Dr. L.P. Heffernan who read the bes t treated by reinstitution o f the drug with paper and offered suggestions and Mrs . C. Gill is for her subsequent gradual withdrawal. excellent secretarial ass istance in preparing the manuscript. Alcohol is a frequent problem with epileptics, tending to aggravate their seizures, and should be avoided. In alcoholics withdrawal seizures or "rum References fits " occurs 7-48 hours after stopping drinking, may I. Solomon G E, Hunt H , Plum F. Clinical Management of occur as a flurry of tonic-clonic convulsions, with or Seizures. A Guide for the Physician. 2nd Ed., Philadelphia: without other signs of withdrawal, and are best treated W. B. Saunders Company, 1983. 2. Porter R J Epilepsy. 100 Elementary Principles. In Major with large doses of initially parenteral and then oral Pro blems in Neuro logy, Vol. 12, Sir J. N. Wa lton, ed. benzodiazipines, to which the alcholic is cross-tolerant. Philadelphia: W. B. Saunders Co., 1984. Usuall y chlordiazepoxide is used in large doses and 3. Leppik I E, Drug Treatment of Epilepsy. In Current Therapy gradually withdrawn over weeks. Although frequently in Neurologic Disease. R. T. Johnson, ed. New York: B. C. prescribed, phenytoin is frequently ineffective here and Decker Inc., 1985, pp. 41-45. many authorities feel that chronic therapy of the Reynolds E H, Shorvon S D Monotherapy or Poly-Therapy lor Epil epsy? Epilepsia 198 1; 22: 1-10. alcoholic with this drug may be dangerous because 5. Delgado-Escueta, A V, et al. T he T reatabl e Epi lespsies Pan s associated compliance problems may lead to sudden I and II. New Eng! f Med I982; 308; 1508-1 514 and 1983; 308: anticonvulsant discontinuation combined with 1576-1 584. alcohol withdrawal and produce severe seizures or even 6. Shomer, D L, Partial Epilepsy. New Engl f Med 309: 536- status epilepticus. 1 Abstinence is the only effective if 539. 1983: elusive therapy. 7. Penry J K The Use of Antiepileptic Drugs. Ann lnt Med , 1979; 90: 207-218. LIMITATIONS 8. So E L, Penry J K Epilepsy in Adults. Ann Neural 198 1; 9: The epil eptic's social life is fill ed with restrictions, 3-1 6. 9. Penry J K Current Trends in Antiepil eptic Therapy. American some prejudicial, and some that are reasonable. Academy of Neurology Meeting, April , 1985. Heights, dangerous machinery, piloting airplanes, 10. Mattson R H, et al. Comparison of Carbamazepine, Pheno­ sw imming alone, are examples of activities that are barbital, Phenytoin and Primidone in Partial and Secondaril y dangerous to one who might have a sudden unexpected Generalized Tonic-Clonic Seizures. New Engl f Med 1985; 313: loss of consciousness and would be precluded by 145- 151. common sense, although this does not always prevail. I I. Hauser W A, New ly Identified Seizures in Current Therapy, In Neurologic Disease. R. T. Johnson, ed. B. C. Decker Inc., Jobs involving such activities are reasonably excl uded. 198S. pp. 30-37. Unfortunately, many are refused work for much less 12. Elwes R D C, et al. The Prognosis lor Seizure Control in New ly cl ear reasoning. Diagnosed Epilepsy. New Engl f 1\i/ed 1984; 311 :944-947. Obtaining life, disability and automobil e insurance 13. Pedly T A, The Role of the EEG in the Diagnosis and Differential Diagnosis of Epilepsy. American Academy of can be difficult and expensive. Neurology Meeting, April 1985. Driving is a difficult problem. The automobile is 14. Janz D, Antiepileptic Drugs and Pregnancy: Al tered Utili za tion a sy mbol of freedom and independence and essential Patterns and T eratogenesis. Epilepsia 1982; 23 (S uppl): 553 - 563. to the employment of some people. It seems unfair 15. Nakane Y, et al. Multi-Institutional Study '!n the Teratoge­ to exclude categoricall y epil eptics from driving, so nicity and Fetal Toxicity of Antiepileptic Drugs: A Report guidelines which select those epileptics with a of a Coll aborati ve Study Group in Japan. Epilepsia. 1980; 21: reasonably low chance of difficulty have bee n 663-680. established but may vary from place to place. It is 16. Delers io D j , Seizure Di sorders and Pregnancy. New Engl ] im portant to know yo ur own provincial rulings on Med 1985; 312:359-363. the matter. In general, a person with a solitary seizure 17. Philbert A, Darn M, The Epileptic Mother and Her Child. Epilepsia 1982; 23:85-97. but negative neurologica l examination, EEG and CT, 18. To Drive? Or Not to Drive? The Medical Answer. A Guide is not restricted. An epileptic who has been seizure­ for Ph ysicians in Determining Fitness to Drive a Motor Vehicle. free for one year while on therapy is not restricted, Ottawa: The Canadian Medical Associa ti on, 1981.

THE NOVA SCOTIA MED ICA L BULLETIN 126 AUGUST 1986 A Blood Pressure Survey in a Rural Nova Scotia Community

Pentti M. Rautaharju," M.D. , Ph.D., F.R.C.P.(C), F.A.C.C., Petra Rykers," B.Sc. , Mary B. Baxter," Cathy A. Byrne," B. Ross MacKenzie,"" M.D., F.R.C.P.(C), F.A.C.C. , Ronald D. Gregor,"" M.D., F.R.C.P.(C), and Hermann K. Wolf," Ph.D. ,

Halifax, N.S.

T he purpose of this study was to evaluate the mm Hg of the auscultation method. We made two viability of a mobile research unit for cardiovascular measurements from each subject with an average of survey work and to obtain results on the blood pressure 3 or 4 minutes waiting period between measurements. profile of a volunteer population in a rural Nova The blood pressure was measured on the right arm Scotian community. We used automatic devices for with the subj ect in sitting position. If the automatic blood pressure recording to eliminate the need of a dev ice recorded a diastolic pressure grea ter than 95 quiet environment and make recording in a public mm Hg or a sys tolic press ure grea ter than 160 mm place possible. We found a high degree of cooperation Hg, or if the arm circumference was too large or too among the local population. The blood pressure small for the standard size cuff, an additional set of profile is comparable to that found in other Canadian measurements was made inside the mobile unit with volunteer populations. Only 4% of the participants the doors tightly shut, using a regular mercury were found with elevated blood pressure and all were sphygmomanometer. In addition to blood press ure we aware of their condition; 85% of the persons on co ll ected from each subject information about age, antihypertensive medication had their blood pressure gender, place of res idence, knowledge about previous controlled. elevated blood pressure and whether any medication for cardiac disorders was taken. All measurements were made in the afternoon between 1:00 pm and 6:00 pm. T he organizers of the Whycocomagh Summer At the end of the interview each subject received a Festiva l 1985 had invited the Heart Research Mobile record of her/ his bl ood pressure measurements and Unit of the Department of Physiology and Biophys ics instructions about consultation with their family at Dalhousie University to participate as a stati c physician when an elevated measurement was found. display in the exhibition associated with the Fes tival. T he researchers of Dalhousie used the opportunity to operate a blood p ressure recording station for volunteers during the 3-day event. Cape Breton Island is of particular interes t to cardiovascular epidemiology for its unusuall y high mortality from cardiovascular diseases, es pecially ischemic heart disease. 1 Since elevated bl ood press ure is one of the major risk factors for ischemic heart disease and since its recording is simple to im plement in a fi eld situation, we were very interes ted in conducting such a survey, despite the many shortcomings in the methodology we had to use.

METHODOLOGY T he Heart Research Mobile Unit was stationed together with the other exhibition displays in a large community hall. T he res ulting noise levels made blood Fig. I. Blood pressure recording stati on in front of the mobile press ure measurement by auscultation impractical. We research unit. Automati c blood press ure recorders eliminated the used instead an automatic blood pressure meter (Model need lor using a stethoscope. Digitronic Printing Digital Sphygmomanometer). Two recording stations were se t up in the open hall, RESULTS outside the Mobile Unit. (Fig. I) We had previously Participants. We registered 280 survey participants, verified that its readings were generall y within a few ranging in age fro m 6 to 76 years; 60% of them were wo men. Twenty-nine subjects (10%) identified From the Department of Physiology and Biophys ics• and the themselves as tourists from ou tside the province. For Department of Medicine .. , Dalhousie Unive rsity, Halifax, N.S. 208 persons (75%) the place of residence was a rural Correspondence: Dr. H .K. Wolf, Department Phys iology and area in Nova Scotia, the rest were from an urban Biophys ics, Da lhousie Uni versity, Hali fax , N.S., B3H 4H7. loca tion, 3 did not specify their place of residence.

T HE NOVA SCOTIA MEDI CAL BULLETIN 127 AU GUST 1986 History of blood pressure measurement. Of the 174 not give a true es timate of prevalence in the total Nova Scotian adults (20 years and older), II (6%) community. Nevertheless, some of our findings are claimed they never had their blood pressure recorded; of interes t, especially for the planners of future surveys of those 40 years and older, 2% indicated no previous in Nova Scotia. The major limitation is imposed by blood press ure measurement. the biased population from which we recorded. The History of elevated blood pressure. Forty-three hours of om data coll ecti on were from noon to 6:00 persons had been told by a health care practitioner pm. During this period a large proportion of fes tival on a previous occasion that they had an elevated blood visitors were families with young children. Further­ pressure, 20 of them (47 %) were still taking antihy- more, the Royal Canadian Legion held its own festival pertensive medication. ' nearby which kept many men away from our survey location. Consequently, the ratio of men/ women for Present blood pressure. We chose as the index blood the adult part of our population is 78/ 96, instead of pressure the measurement made with the mercury the expected equal number from both sexes. sphygmomanometer, if it was available. Otherwise, from the two readings with the automatic device we It is significant that only a very small fraction of se lected the one with the lower diastolic pressure. We older participants had no recoll ection of a previous defined as an eleva ted press ure a dias tolic index blood press ure measurement. It indicates that even in pressure above 95 mm Hg or a sys tolic index press ure rural areas of Nova Scotia monitoring of bl ood above 160 mm Hg for persons 40 years or younger pressure by phys icians is being practised. All the or 180 mm Hg for persons older than 40 years. Only persons we found with eleva ted blood pressure had 7 (4%) of our participants met the criteria of elevated previously been made aware of their condition. This press ure and all were aware of their condition, but is quite different from the findings of Handa et af.2 only 3 were taking medication. Of the 20 subjects who and Silverberg et al.3, who reported that 1/3 of their reported being on antihypertensive medication 17 hypertensives were unaware of their status. One can (85%) had a blood pressure within normal limits at only hope that the education campaigns that went the time of the survey. on since the mid-seventies have brought about such a change. The average index blood press ures for 10-year age groups in both sexes is shown in T able I. The small number of participants severely limits the use one can make of the index pressure distribution DISCUSSION in Table I. T ypical standard deviations of blood pressure measurements for 10-year age groups are The primary purpose of this survey exercise was around 10 mm H g. This implies that the 95% to gain experience with the operation of our mobile confidence limits for the mean values shown in T able research unit and to tes t its acceptance by potential I are ±5 mm Hg. Even with this large a range of research subjects. We were very impressed by the high uncertainty the data show the expected increase of degree of cooperation from the people in Whycoco­ pressure with age and the lower values of sy stolic and magh. AI though we do not have any official attendance diastolic pressures for women. The data for the men figure, it is our impression that the majority of persons follow very cl osely the leve ls Handa et al . reported visiting the fes tival while we operated our survey from New Brunswick4 Our data are also compatible station also had their blood pressure recorded. with the data of the Canada Health Survey,5 although Since we did not set out to collect representative the significa nce of the agreement is limited by our population samples of blood press ures, our data do small sample size.

TABLE I

DISTRIBUTION OF SYMBOLIC AND DIASTOLIC BLOOD PRESSURES BY AGE AND SEX, IN A SAMPLE OF NOVA SCOTIANS WHO VISITED THE WHYCOCOMAGH SUMMER FESTIVAL 1985.

AGE GROUP MEN WOMEN No. of No. of subj ects systolic diastolic subj ec ts systolic diastolic 10· 19 22 11 6 60 47 11 8 62 20·29 21 138 68 15 122 66 30·39 13 129 75 35 120 73 40·49 18 131 80 27 124 76 50·59 15 130 81 9 11 5 76 60 II 151 85 10 143 75

Continued on page 130.

THE NOVA SCOT IA MEDI CA L BULLETI N 128 AU GUST 1986 Exercise Tolerance Changes in a Cardiac Rehabiltation Program

Ian M. Fleming and M. Kent Pottle, B.Sc., M.D. ,

Halifax, N.S.

Hea rt disease, because of the cost it exacts in warm-up and walk/ jog sessions per week at the YMCA morbidity and mortality, has commanded grea t interes t or Dalplex, and are encouraged to follow the same in the medical sphere and in the popular press for prescription on their own an additional one to three several decades. In recent years, there has been a times per week. growing awareness of the need for ways to help patients To obtain an obj ective measure of improved regain or improve upon their physical capabilities after functional capacity, participants undergo exercise survivi ng a cardiac event. In response to this need, tolerance tests, using the Bruce treadmill protocol at the Preventive Medicine Centre at the Halifax YM CA designated intervals after admission to the program.t established, in 198 1, the Change of Hea rt Post Cardiac On the basis of symptoms experienced or si gnificant Rehabilita tion Program. ECG changes recorded during the procedures, each T his ongoing program is des igned to help patients tes t is classified as either negative or positive for alter their lifes tyle and reduce certain cardiac risk ischemia; and is ranked according to the New York fa ctors. In regular evening lectures, participants are Heart Association functional cl assification (T able I). informed of such things as the dangers of smoking Furthermore, each performance is quantified in terms and the importance of proper nutrition and stress of metabolic equivalents or METS. This value is a

management. Thro ugh individuall y prescribed measure of V09 and is equivalent to a multiple of exercise, they attempt to control their weight and the basal metabolic rate. Figures corresponding to each improve their activity level. This paper reports the functional cl ass are given in Table I. effectiveness of the program in changing patients exercise tolerance, with conclusions based on a non­ TABLE! controll ed comparison of successive stress test results for each participant. NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION METHODS Potential participants are referred to the program Functional Metabolic by their family physician or their cardiologist. Criteria Classification Equivalents for admiss ion include a clear history of myocardial Pati ents with cardiac disease but no infarction three months to one year prior to appli­ limitation of physical activity. ~ 7. 0 METS cation. Patients are excluded if they demonstrate Ordi nary activity does not cause undue evidence of heart failure, uncontrolled hypertension, fa tigue, palpitations, dyspnea, or angina. unstabl e progressive angina, aneurys m, renal or II Patients with card iac disease causing hepa ti c failure, or an y other severely limiting slight limitation of physica l activity. ~ 4.5 but condition. Comfortable at res t, but ordi nary < 7.. 0 METS acti vity causes sy mptoms listed above. Once admitted, participants are given an initial stress tes t to determine their level of physical capacity. III Marked limitation of phys ical activity. Results of this tes t are used to devise an individualized Comfortable at res t, but less than > 2.0 but exercise prescription, meaning each person is assigned ordinary physica l acti vity causes < 4.5 METS symptoms listed above. a certain distance to walk or jog, a specified time in which to cover that distance, and a targe t heart rate IV Inability to carry on any acti vity to reach in that time. As their conditioning improves without discomfort. Symptoms of cardiac so they can cover the distance in less time and at a insufficiency or of the anginal 1i 2.0 METS syndrome may be present even at lower heart rate, the prescription is altered accordingly. rest. Any phys ical activity increases Participants are ex pec ted to attend two supervised discomfo rt.

From the Hali fax YMCA, Preventive Medicine Centre, Change of RESULTS Heart Program, Hali fax, N.S. Of the 51 patients enrolled as of January I, 1986, Correspondence: Dr. M. Kent Pottle, P.O. Box 3024 , Hali fax South, 38 had undergone more than one stress test. This study Hali fax, N.S. B3H 3]1. group consisted of 37 males and one female; ages

T H E NOVA SCOTIA MED ICAL BULLET IN 129 AUGUST 1986 ranged from 37 to 72 years, with a mean of 55.3 years. th e indica tor, 60.5% showed some improvement. A total of 121 tests was performed; 39 were classified Furthermore, this latter guideline is more sensitive in positive, 38 negative, and 41 non-diagnostic. In 110 showing patients with decreased capability; whereas tests, the patients were receiving heart medication. only two patients worsened in terms of functional class, • Comparing initial and final stress tests, 26 patients four showed a decrease in METS. (68.4%) showed no change in fun ctional class level (25 Following the lead of Dr. Terrance Kavanagh's stayed at cl ass I, one stayed at class II ); 7 (18.4%) group in- Toronto,3 rehabilitation programs are improved; 2 (5.3%) worsened (both from class I to class increasingly common in large Canadian centers. II ); and 3 showed variability (going from I to II to . However, since ethical considerations prevent the use I or the reverse). In terms of METS, however (.see Figure of a contro l group, proper statistical analysis of the 1) 23 patients (60.5%) gained 0.5 to 6.5 METS, 4 (10.5 %) results obtained is impossible. This leaves scant lost 1.0 to 3.0 METS, and 11 (28.9%) demonstrated evidence in the literature to support their effectiveness no change. in terms of improved functiona l class or METS. Even so, the res ults submitted here are encouraging. Eventuall y, such supervised exercise programs co uld Changes in METS as an indicator of gain or loss prove to be an essential component in the management of functional capacity of post-cardiac patients. D

4 References I. Chung EK. Ex ercise Electro cardiography - A Practical z Approach. Baltimore: Williams and Wilkins, 1983. (.!:l ~ z (.!:l 2 2. Ell es tad MD, Cooke BM, Gree nberg PS. Stress tes tin g: clinical ~~ application and predicti ve capacity. Progress ln Cardiovascular 0 CI::I: UJ(/) Diseases, 1979; 21: 43 1-459. co :::;;UJ 3. Kavanagh T. The Hea lthy Heart Program. Toromo: Van ::::>-'zo.. 0 NUMBER OF METS Nostrand Reinhold Ltd., 1980. 0 UJ 2 4 6 7 GAINED OR LOST 0.. (/) (/) g 2

3 A BLOOD PRESSURE SURVEY IN A Figure I RURAL NOVA SCOTIA COMMUNITY Continued from page 128. DISCUSSION Despite all the reservations one has to apply to our One problem encountered in the evaluation of res ults data they crea te quite a positive impress ion with regard was the description of tests as "non-diagnostic". In to hypertension control in rural Nova Scotia. It wi ll many instances, this seemed to indicate the tes t was be interes ting to compare them with data that are nega tive, whi le in others that results were borderline. currently being collected in Halifax County, where To avoid such confusion in the future, it would be the majority of the population lives in an urban useful to classify results as positive, nega tive, or setting. D eq uivoca l. It has been stated that stress tes ts are of no value References when performed on patients with resting abnormal­ 2 I. Health and Welfare Canada, and Statisti cs Canada. Mortality ities when they are receiving cardiac medication. If atlas of Canada. Vo lu me 2: General Mortality. Catalogue No. so, the results of most tests reported here would be H49-6/ 2-1980. questionable. However, it is the belief of the 2. Handa SP, RomaS, and Brewer H. Prevalence of hypertension: administrators of the Change of Heart Program that A screening survey in an adult population. Can 1 Pub/ Health patients should be tested under conditions closely 1980; 71: 171-1 75. resembling normal daily function, which in most cases 3. Si lverberg DS, Smith ESO, Juchli B, et al. l':J se of shopping involves the use of medication. cemres in screening for hypertension . Can Med Assoc 1 1974; lll: 769-774. There is some difficulty inheren t in using functional 4. Handa SP and Wolf HK. Comparison betwee n active and class leve l as the sole measure of cardiac rehabilitation. pa ss ive blood pressure surveys. Can 1 Pub/ Hea lth 1982; 73: In this study, the majority of participants began at 255-258. leve l one (the highes t level ), leaving no room for gain 5. Canada Hea lth Survey, Health and Welfare Ca nada, and in functional class. By this measure, only 18.4%s howed Statistics Canada. The Health of Canadians. Cata logue No. some improvement. However, when using METS as 82-538E.

THE NOVA SCOTIA MEDICAL BULLETIN 130 AUGUST 1986 Malignant Hyperthermia: A Review

J.M. Dooley, M.B. , F.R.C.P.(C)., J.A.R. Tibbles, M.B. , F.R.C.P., F.R.C.P. (C). and C.M. Soder, M.D., F.R.C.P.(C).,*

Halifax, N.S.

INTRODUCTION Muscle rigidity is seen in about 75% of patients and In 1960, Denborough and Lovell rec ognized tends to occur after the onset of the temperature unexplained anesthetic dea ths in several family elevation. Muscle permeability to calcium, potassium, members1 Since the last rev iew of malignant sodium, creatine kinase (CK) and myoglobin increases hyperthermia (MH) in this journal in 1974 many more (Table II ), and myoglobinuria may result in renal affec ted families have been identified. 2 We think that damage. a review of this topic is appropriate as the mortality TABLE II associated with MH ca n be reduced from over 60% LABORATORY ABNORMALITIES DURING MH CRISIS to less than 10% with early recognition and trea tment of the MH crisis. 3 I. Ca ++and K+ (rise early, fa ll late) CLINICAL FEATURES 2. Phosphorous, Magnesium, Glucose (ri se and remain high) 3. pCO? rises, pH falls, lactate ri ses. The clinical features of malignant hyperthermia 4. End·tidal CO? ri ses re fl ect a marked increase in both aerobic metabolism 5. Urine myoglobin positive 6. Clotting fa ctors - elevated PT, PIT (late) with an eleva ted production of hea t, carbon dioxide 7. Eleva ted CK, LDH, SCOT (late) and lactate. The symptoms may be fulminant or 8. Elevated Creatinine and BUN (late) develop more slowly. The syndrome usuall y occurs during anaesthesia but may rarely be present in the The carbon dioxide tension rises above 100 torr and recovery room or without an associated anaesthes ic. the arterial blood pH may be less than 7.0. In patients Early signs include tachycardia and dysrhythmias who are brea thing spontaneously, marked tachypnea (Table I). Masse ter spasm or fasciculations in response may be noted. The skin may appear warm, mottled to suxamethonium may be the initial feature of MH and cyanotic. and should always alert the physician to the possibility Late complica tions ca n include a depletion of of an imminent crisis. 4 platelets , fibrinogen and other clotting factors. Pulmonary edema and myoglobin induced renal TABLE I tubular obstruction have also been described. Autosomal dominant (AD) transmission, is the usual CLIN ICAL SIGNS OF MH CRISIS: mode of inheritance in MH families although sporadic cases ca n occur and may be more common than Tachycardia or Arrhythmias 5 Unstable blood press ure appreciated in the pas t. T he susceptibility to MH may Muscle spasm be increased in patients with other myopathic diseases, Hyperthermia such as central core myopathy.6 Adverse anesthetic Flushing of skin - cyanosis reactions have also been described in patients with Tachypnea Duchenne Muscular Dystrophy but are usually The temperature elevation may be dramatic, rising characterized by bradycardia rather than the more at a rate of approximately I degree Celsius every 5 typical tachycardia of MH.7 minutes. Temperatures up to 43°C have been reported A clinica ll y similar syndrome, the neuroleptic but the hyperthermia may not occur until late in the malignant syndrome, has been described in association course of the crisis. The pea k temperature may occur with major tranquilizers. This syndrome is also graduall y over several hours or may rise abruptly characterized by hyperthermia, muscle rigidity and within 10-1 5 minutes. MH crises may also occur instability of the autonomic nervous system. 8 In without fever, but with the other typical clinica l and contrast to MH, which is due to an intrinsic deficit laboratory fea tures. in the muscle, the neuroleptic mali gnant syndrome is central or presynaptic ·in origin, although its management is simil ar. •Department of Pediatrics and Anesthes ia, Dal housie Uni versi ty and I.W.K. Hospital for Chi ldren, Hali fax, N.S. T he incidence of MH has been estimated to be Correspondence: Dr. j.M. Dooley, Neurology Di vision, I.W.K. 1/ 15,000 anesthetics in children and approximately Hospital for Ch ildren, P.O. Box 3070, Halifax, N.S. B3J 3G9. 1150,000 adult anesthetics.

T HE NOVA SCOTIA MEDICAL BULL ETIN 131 AUGUST 1986 DIAGNOSIS con,tinued orall y for 24 hours following control. Some padents may require IV Dantrolene infusions for many The diagnosis of malignant hyperthermia suscep­ hours or even days following a serious crisis. The tibility (MHS) should be sought through a detailed patient's clinical state and laboratory data should be • history of anes thetic exposures and reactions in at least cl osely monitored in an intensive care unit for several two generations. Causes of death in the family should days after -the attack as late renal and hematologic be detailed and may be si gnificant. The patient's complications may occur. 18 When trea tment was anes thetic history may not be helpful as many patients instituted promptly with Dantrolene the survival rate have their first MH crisis during a second or was 100%.3 Dantrolene has been associa ted with subsequent general anesthetic (GA). hepatotoxicity but this does not occur when the drug The absence of a clinical phenotype makes the is given for less than three weeks. recognition of MH susceptible patients difficul t. The If susceptibility to MH is recognized prior to phys ical examination is usually normal, although anes thes ia the pa ti ent may be treated with oral occasionall y an inconspicuous myopathy may be Dantrolene, 4-8 mg/ Kg/ day for 1-2 days before surgery identified. with the last dose being given 2 hours before the Laboratory inves ti gations should include measure­ anesthesia. 19 Intravenous Da ntrolene should be ments of the serum CK. Normal levels are not clinically continued in the operating room at a dose of 0. 5-1 helpful as at least 30%of MH survivors have CK levels mg/ Kg/ hr, preferably by constant infusion. within normal limits following recovery from their crisis. Conversly an elevation of the serum CK may ETIOLOGY occur in normal individuals following non-specific The details of the pathogenesis of MH remain stimuli such as exercise. In the context of a positive unclear. The acute crisis, however, appears to be due family history of MH, however, an abnormal CK level an excess ively elevated myoplasmic calcium concen­ following a period of rest, usually indicates MHS. tra tio n . The calcium initia tes heat-generating Other biochemical investigations such as abnormal­ mechanisms which include the brea kdown of glyco­ ities in platelet function, have been inconsistently able gen, uncoupling of oxidative phosphorylation and to identify at risk pati entsi 1 13 14 accelerated hydrolysis of ATP by myosin ATPase. The The most reliable test which is currently available, hi gh myoplasmic calcium also produces muscl e is the in-vitro response of skeletal muscle to Halothane contracture. T he rise in muscl e temperature, together and ca ffeine. MH muscl e fib ers contract at a lower with the fall in muscl e ATP concentration perpetuates concentration than normal muscle. The large quantity the contracture. of muscle required for the tes t makes it unacceptable T he defect that underlies the abnormal regulation for use in young children. The test must be performed of intracellular ca lcium is no t known. Several within 5 hours of biopsy and therefore older patients hypotheses have bee n proposes to explain this must travel outside the Maritimes to centers where this biochemical dys function; i) defec tive accumulation of tes t is available. 1s ca lcium by the mitochrondria; ii) abnormal accum­ ul ation of calcium by the sarcoplasmic reticulum; iii) TREATMENT passive diffusion of calcium through a fr agile Anticipatory prevention by the anes thetist must sarcolemma; iv) exaggerated adrenergic metabolism; include EKG and temperature monitoring and the or v) a combination of these factors. Cyclic AM P, which immediate availability of intravenous Dantrolene. is involved in all of these events has recently been 9 End-tidal C02 monitoring provides the most useful shown to be abnormal in MH. The significance of ea rl y warning in at-risk patients, who experi ence a this finding is not yet known. rapid rise in end-tidal C02 early in the course of their T he MH crisis is usuall y precipitated by a general CfiSIS. anes thetic. The list of drugs which can initiate a crisis As soon as the diagnosis is suspected, all anes thesia is ex tensive, although succinylcholine in conjunction should be discontinued. Patients with the fully with an inhalational anes thetic appears to be the most develo ped sy ndrome require prompt treatment, potent stimulus. It is easier to list, and remember, drugs incl uding h yperventila tio n with 100% oxygen , which are relati vely sa fe for use in anes thesia (Table intraveno us bicarbona te, cooling a nd diureti cs. III ). The " safe" drugs include nitrous oxide, Dantrolene is the only specific therapeutic agent and barbiturates, benzodiazepines, narcoti c analgesics and appea rs to have its effect by an indirect action on the droperidol. It is recommended that equipment which sa rcoplas mic reticulumi 6 It should be given as soon has never been ex posed to the contraindicated as the diagnos is is made. T he recommended dose is inhalational agents should be used while administer­ 2. 5 mg/ kg IV over 10-1 5 minutes just prior to induction ing a general anes thetic to a patient who is at risk of anes thesia and the same dose for the initial trea tment for MH . It is still unclear whether " flu shing" the of the MH cri sis.l1 It ca n be repea ted every 5-10 minutes machine with oxygen will remove sufficient drug from to a total dose of I 0 mg/ kg.18 The drug should be the tubing.

THE NOVA SCOTIA MEDI CAL BU LLETIN 132 AUGUST 1986 TABLE III Laboratory investigations should include three measurements of serum CK. If the family is known "SAFE" ANESTHETIC DRUGS FOR MH PATIENTS to contain susceptible individuals, then an elevated CK following a period of rest, should be interpreted I. Local Anesthetics: Proca ine, 2-3 Chloroprocaine, as indicating MH susceptibility. Recently it has been Cocaine, Tetracaine reported that the serum CK is of no value in predicting 20 2. Barbiwrates: All MHS. It may therefore be more appropriate to 3. arcotics: All consider all family members to be MH susceptible. If values for CK are normal, then no conclusion can 4. Sedati ves: Benzodiazepi nes, Amihistamines, be reached. For these patients, the choice is a personal Phenothiaz ines, one regarding the need for confirmation of their MH Butyrophenones status. As noted above, those who wish a muscle biopsy 5. Neuromuscular Blockers: Pancuronium, Atracurium must travel to a centre where such facilities are 6. Ketamine: available. An alternate approach is to assume susceptibility and wear a medical alert bracelet. For 7. Nitrous Oxide: (probably sa fe) these patients, appropriate precautions should be 8. Sympatholyti cs: (eg. Propranolo l) taken for a general anesthesia. In the future, when 9. Parasympathomimeti cs: (eg. Neostigmine, a reliable and less invasive in-vitro test becomes Physostigmine) available, these patients should be reassessed.

SUMMARY C urare may be used with safety for muscle re laxation. Malignant hyperthermia is a potentially fatal condition which is usually precipitated by general Local anesthes ia (LA) with amide anesthetics has anesthesia. Its clinical features include cardiac been contraindicated because of the ability of this dysfunction, hyperthermia, and muscle rigidity. group of drugs to release calcium from the sarcoplas­ Awareness of the syndrome, of the "safe" drugs to use mic reticulum. Ester anes thetics have therefore been and of the appropriate use of Dantrolene can prevent prefered. Adragna has recently questioned the validity a fatal outcome. of this recommendation and states that there are no reported cases of MH caused by Amide LA without D epinephrine.Io

It is known that ca techolamines, generated either References endogenously (e.g. by stress or exercise) or exogenously by drugs (e.g. epinephrine or sympathomimetics) can I. Denborough MA, Lovell RRH. Anaes thetic deaths in a famil y. Lancet 1960; 2: 45. precipitate or aggravate a crisis. It should be remembered that even with the use of safe drugs, these 2. Murray TJ, Si lver I, Tibbles JAR, Purkis IE. Malignant patients remain at an increased risk of MH because hyperthermia. NS Med Bull1974; 130- 13 1. of the stress of surgery. It is essential, therefore, that 3. Kolb ME, Horne ML,Martz R. Dantrolene in human malignant hyperthermia: A multicenter study. Anaesthesio/1982; 56:254- physicians who care for these patients should be 262. prepared to treat them appropriately. Ellis has shown that even nitrous oxide may be a weak inducer of MH 4. Ellis FR, Halsa ll PJ. Suxamethonium spasm, a differential diagnosti c conundrum. Br 1 Anaesth 1984; 56: 38 1-384. crisis.t 1 5. Britt BA, Endrenyi L. Peters PL, et a l. Screening of ma li gnallL hyperthermia susceptible families by creatine phosphokinase COUNSELLING FAMILIES measurement and other clinica l investigations. Can Anaesth For practical purposes, families should be coun­ Soc 1 1976; 23: 263 -284. selled that the disease is inherited in an AD fashion. 6. Frank JP, Harati Y, Butler IJ, et al. Central core disease and malignam hyperthermia syndrome. Ann Neural 1980; 7: I I- There are two main groups of patients who require 17. counselling regarding MH susceptibility. The first are 7. Karpati G, Watters GV. Adverse anaesthetic reactions in re latives of patients with recognized MH while the Duchenne Dystrophy in Muscular Dystrophy research: second group are asymptomatic patients who are Advances and ew Trends. (Imernational Congress Seri es No. fortuitously found to have an elevated serum CK. 527) 1980:206-217. In both groups the physician should take a detailed 8. Gme BH, Baxter LR. Neuroleptic malignant sy ndrome. New Engl 1 Med 1985; 3I3: 163-166. family history for two generations including causes of death, exposure to anesthesia, and unusual reactions 9. Stanec A, Stefano G. Cyclic AMP in normal and malignant hyperpyrexia susceptible and individuals foll owing exercise. during anesthesia. A physical examina tion with Br 1 Anaesth 1984; 56: 1243-1246. primary attention being paid to the musculoskeletal system looking for ev idence of a myopathy may occasionally be helpful. Continued on page 138.

THE NOVA SCOTIA MEDICAL BULLETIN 133 AUGUST 1986 Epstein Barr Virus Serological Testing

Blair O'Neil ! M.D. and Thomas J. Marrie,*·* M.D. , F.R.C.P.(C),

Halifa x, N.S.

Infectious mononucleosis is an illness that usually These tes ts enable the phys ician to cl assify a patient's poses no difficulties in diagnosis. The only laboratory · EBV infection status into one of the foll owing four tests needed to confirm this clinical suspicion are a ca tegories: blood film to look for atypical lymphocy tes and the I. current primary EBV infection; Paul-Bunnell-Davidsohn tes t for heterophile antibo­ 2. a persistent EBV infection as seen m those dies. This tes t is considered positive if the sheep or individuals with chronic infectious horse erythrocy te agglutination titer is > I :40 after nn nonucelosis; absorption with guinea pig kidney. 3. a reactiva tion of EBV infecti on; or Two new developments necessitate tha t most 4. previous EBV infection- not currently active. practitioners know how to interpret the newer Epstein­ Barr virus (EBV) specific serologica l tests. The first 1. Current primary EBV infection is serologically of these is the ready availability of an immuno­ defined as: fluorescent test which can measure IgM and IgG a) early appearance (in a previously seronegative antibodies to the EBV capsid antigen; antibodies to individual) of circulating antiviral capsid antigen diffuse and res tricted components of EBV -earl y (a nti-VCA) lgM and its subsequent decrease to antigen; and antibodies to EBV-nuclear antigen. T he non-detectable levels. second development has been studies which show that infectious mononucleosis can " relapse" and that there b) subsequent increase of anti-VCA IgG antibody, is indeed chronic EBV infection resulting in a chronic which in some cases may continue increasing and fatigue syndrome. persists for life. For these reasons we briefl y revi ew the immunology c) a transient increase in early antigen (EA) - anti­ of EBV infecti ons and give guidelines for the D (diffuse earl y antigen) occurs in 80%. interpretation of the specific serological tests. d) the absence of Epstein-Barr nuclear antibody Epstein-Barr Virus (EBV ) is a member of the herpes (EB NA) during the acute infection, its increase virus family and like other members of this family, weeks to months later and its persistence for life. once it infects a host it remains in a latent state in A majority (>90%) of patients with acute infectious a small number of B lymphocy tes for the life of the mononucleosis develop IgM heterophil agglutin­ individual a nd periodicall y is excreted in the ins of the Paul Bunnell-Davidsohn type - a highly oropharynx. 1 Control of EBV infection is primarily specific marker. a function of cell mediated immunity, in the form of suppressor and cytotoxic T-ce ll activity. Neutral­ izing antibodies play a supportive role by limiting ~ Anti·EBN A viremia and the number of B ce ll s infected initiall y. 2 320 "K(l T hey cannot, however, stop B cell spread of the virus ~ 160 or prevent transformation of EBV-infected B cells into w a: 80 proliferating immunoglobulin-secreting immortal­ >- ;::: 40 1 ized celllines. 2 >- 0 20 0 However, humoral immunity to EBV provides vital ;:::CD 10 z 5 information for diagnosti c and research purposes. T he <[ mid-1960s saw the advent of EBV-specific serological 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 and virologica l tes ting.3 Readily available now are TIME ( weeks ) q ualitati ve and q uanti ta tive methods to detect antibody responses to various structurally and virall y determined EBV antigens. 3 The order of appearance Fig. I. Time course of antibodies to Epstein-Barr virus antigens. of these anti bodies and the duration of their persistence Anti-VCA lgM:- lgM antibody to the viral capsid antigen is shown in the fi gure. Anti-VCA lgG:- lgG antibody to the viral capsid antigen Anti-EBNA - antibody to the Epstein-Barr virus nuclear antigen EA - antibody to early antigen. In uncomplica ted infectious From the Departments of Medicine• and Microbiology.. , Dalhousie mononucl eosis th is is usua ll y a ntibody to the di ff use Uni versity and Vi ctoria General Hospital, Hali fax , N.S. component of the early antigen- see tes t.

T H E NOVA SCOTIA ME DI CAL BULLETIN 134 AUGUST 1986 TABLE! TYPICAL SEROLOGICAL RESPONSES: FOUR CATEGORIES OF EPSTEIN-BARR VIRUS INFECTION

Anti Anti VCA VCA Anti Antibodies to• lgM IgG EBNA Anti D Anti R A. Current Primary 1. >1:5 <1:5 <1:5 EBV infection (positive) (acute infectious) 2,:: 1:5 >1:5•• <1:5 (negative) B. Persistent EBV 1.<1:5 >1:5 >1:5 >1:320 infec tion (negative) (persistently) 2.<1:5 >1:5120 <1:5 (negative) (very high) c. Reactiva tion of <1:5 ?1:3•• >1:5 <1:5.. <1:5 infection (negative) D. Long past EBV <1:5 >1:5 >1:5 infec tion (negative) e.g. 1:160 e.g. 1:80 (inacti ve) and unchanged in the convalescent sample •Currently available only at the National EBV Reference Center •• usually a four fold or grea ter increase between the acute and convalescent samples is demonstrable

2. Persistent EBV infection may be recognized by: The EBV specific serological tests should not be used a) persistence of antibodies to early antigen (EA) as first line diagnostic tests for infectious mononu­ particularly the anti-R (restricted early antigen cleosis, instead they should be used in these situations: component) which tends to appear after the anti­ l. Clinical diagnosis of infectious mononucleosis but D component titres have decreased. 4 Paul-Bunneii-Davidsohn test is negative. b) normal serological progression of anti VCA IgM 2. Diagnosis of infectious mononucleosis in the and IgG. immunocompromised host. c) failure of development of anti-EBNA in those with 3. Evaluation of chronic fatique syndromes. deficient immunity to EBV as those described by 4. Diagnosis of reactivation of infectious Purtillo with the X-linked lymphoproliferative mononucleosis. D disorder (XLP)S or a fall in anti-EBNA titers in patients who become immunologically References compromised.s-1 I. Hanto DW , Fi zzera G, Gajl-Peczalska KJ and Simmons RL. Epstein-Barr virus, immunodefi ciency and B ce ll lymphopro· 3. Reactivation of previous EBV infection is shown liferation. Transplantation 1985; 39: 461·472. by: 2. Tosato G and Blaese MR. Epstein-Barr virus infection and a) absence of anti-VCA IgM immunoregulation in man. Adv Immuno/1985; 17:99-149. b) a fourfold, or greater rise in pre-existing anti VCA 3. Sumaya CV. Serologica l tes ting for Epstein-Barr virus - IgG Developments in interpretation f Infect Dis 1985; 151: 984- 986. c) return of anti EBV-EA IgG titers 4. Joncas ] , Lapointe N, Gervais F, Ley ritz M. Unusual prevalence d) presence of pre-existing anti-EBNA titer of Epstein-Barr virus earl y antigen (EBV -EA) antibody in ataxia telangiectasis. f lmmuno/1977; 119: 1857-1 859. 4. A long-past EBV infection is identified by: 5. Purtillo DT, Sakamoto K, Barnabei V, Seeley T , Bechtold T , Rodgers G, Yetz J , Harada S. Epstein-Barr virus-induced a) absence of anti-VCA IgG titer di sease in boys with the X-linked lymphoproliferative sy ndrome (XLP). Am f M ed 1982; 73: 49-56. b) unchanging anti-VCA IgG titer 6. Henle W and Henle G. Epstein-Barr virus: specific serology c) absence of anti-EA in immunocompromised individuals. Cancer Res 1982; 41: d) presence of an unchanging anti EBNA titer 4222-4225. 7. Henle W and Henle G. Seroepidemiology of the virus. In: Examples of these serological responses are given Epstein MA, Achong BG, eds. The Epstein-Barr Virus. New in Table I. York: Springer-Verlag, 1979:61-78.

THE NOVA SCOTIA MEDICAL BULLETIN 135 .AUGUST 1986 Timing of Obstetric Ultrasonography - Update 1986

B. St.]. Brown," M.B., B.S.,

Halifa x, N.S.

In recent years, obstetric ultrasonography has If the morphometric pattern is aberrant, this will become widely available in Nova Scotia. Although this be a ca use of concern for the health of the fetus. examination is not considered " routine", a large majority of patients will have one or more ultraso­ AT 16 TO 20 WEEKS GESTATION nographic examinations during the course of their Ultrasonographic examination at this stage of pregnancy. development wi ll demonstrate cl early the fetal skull The purpose of this paper is to examine some aspects and brain, spine, limbs, heart, stomach, kidneys, and of optimal timing of ultrasonographic examinations usually the urinary bl adder. Fetal movement, cardiac as a base-line and for specific problems. A fi ve year rate and rhythm can be documented. Some particular survey (1980 to 1984) of 122 pregnancies in Nova Scotia aspects of fetal assessment at this stage can be identified with proven neural tube defects, and review of and certain specific "cavea ts " may apply: experience in the Department of Diagnostic Imaging In the central nervous system: Anencephaly is virtually at the Grace Maternity Hospital from 1974 to 1986 always recognizable at 16 weeks. lniencephaly also form the bas is of many of the recommendations. In should be regularly recognized at 16 weeks. Spina the 122 pregnancies with neural tube defects , 49 bifida may or may not be evident at 16 weeks, but patients (40%) had no prenatal ultrasound examina­ will be shown more reliably at 18 to 20 weeks. 2 ti on. 1 Recently there has been an increasing trend Encephalocele is usually demonstrable at 16 to 18 towards obtaining at least one ultrasound examination weeks. Hydrocephalus is often a progressive condition in most pregnancies. and may not be evident at 16 to 20 weeks unless it Indications for obstetric ultrasonography at certain is early and severe. Dandy-Walker cyst in the posterior stages in gestation can be identified as follows: fo ssa may be identifiable at this stage.

IN EARLY PREGNANCY (first trimester) In the urogenital system: Potter syndrome with an empty urinary bladder, absence of normal kidneys i) Is the patient pregnant? combined with oligohydramnios can be regularly ii) Is the gestation intrauterine or extrauterine, single diagnosed ultrasonographicall y. or multiple? Is the embryo alive? An earl y Conditions which produce fetal oliguria such as pregnancy with bleeding, pain, previous history infantile polycystic disease are less easy to recognize, of ectopic pregnancy or multiple pregnancy, though in this condition the fetal kidneys may triple presence of known abnormality in the uterus, or their size between 20 and 22 weeks gestation. 3 in the pelvis, recurrent miscarriage, presence of an IUD and suspected pregnancy and possible Extreme forms of megacystis, megaureter, and molar pregnancy may warrant ultrasonographic hydronephrosis are usually recognizable at 16 to 18 examination. weeks gestati on . However less severe forms of hydronephrosis may onl y become manifes t later in iii) Uncertain dates: Ultrasonographic measurement pregnancy when there is increasing urinary output. of the embryo in ea rly pregnancy (crown-rump Multicystic kidney is usually recognizable at 16 to 18 length) or of the bi-parietal diameter at approx­ weeks. imately 12 weeks gives an accurate ultrasonogra­ phic dating of gestation, since the standard Hydrometroco1pos and variations, ovarian cyst, and deviations of the mea n measurement are the urinary ascites may be identifiable at 16 to 18 weeks. smallest at this stage compared with any later time in pregnancy. However, after 12 weeks a number Abdominal conditions - Omphalocele has been of specific fetal parts can be identified and repeatedly identified ultrasonographically 1H 16 to 18 measured, hence an aggregate of a number of weeks. The pentalogy of Cantrell with protrusion of morphometric results will provide reliable the heart, and liver, and also true ectopia cordis have evidence for dating purposes in a healthy fetus. been recognized at 16 to 18 weeks. Gastroschisis has been more difficult to identify. Gastro-intestinal obstruction such as duodenal atresia, and small bowel "Director, Department of Radiology, Grace Maternity Hospital, obstruction may not be identifiable at this stage, but Department of Diagnostic Radiology, Dalhousie University, become progressively more manifest later in pregnancy Halifax, N.S. and are often accompanied by polyhydramnios.

THE NOVA SCOTIA MEDICAL BULLETIN 136 AUGUST 1986 In the chest, diaphragmatic hernia, and cys ti c SUMMARY adeno matoid malform ation of the lung have been When obstetric ultrasonography is considered in any identified although these lesions tend to enlarge and individual pregnancy, the follow ing guidelines become more easil y demonstrable later in ges tation. regarding optimal timing of the examination are suggested: Fluid collections, hydrops fetali s, cys ti c hygroma and l. For confirming pregnancy, its loca tion and a live the fea tures of fetal Turner syndrome ca n be identified. Ascites as an iso lated manifes tati on of spec ific embryo; for bleed ing, pain, suspected ectopic preg­ nancy, abortion, molar pregnancy and associated disorders (e.g. storage diseases) has also been identified. gy necol ogic co nditions; for ea rl y dating of the ges tation- exa mination at 6- 12 weeks is optimal. In the musculo-skeletal system: - certain form s of short-limbed dwarfism may be manifes t at 16 to 18 2. Regarding baseline meas urements of the embryo weeks but in large measure, the demonstration of such or fetu s for dating the gestati on, these are bes t obtained li mb and trunk anomalies require adeq uate amounts prior to 18 weeks, since aberrant growth patterns of amniotic fluid to ac t as a bac kground for beco me increasingly common after this stage. If the ul trasonographic visualization. Osteogenes is imper­ examination for baseline assessment is to be restricted fecta Type II, arthrogryposis and joint contractures to one examination only, then at 16- 18 weeks would are potentiall y identifiable. be optimal. 3. Major structural abnormalities ca n be identified Miscellaneous conditions - goiter, and teratoma of at 16 - 18 wee ks. If the patient is at risk for a know n the neck, sacrococcygeal teratoma and multiple gross condition, e.g. neural tube defect, this should be ma lformations may be identifiable at this stage or later. specifica ll y looked for on one or more occasions in this peri od, when consideration for altering the Morphometric assessment: At 16 to 18 weeks, reli able management of the pregnancy may be appropriate. Amniocentes is and other inves ti ga ti ons may be morphometric assessment ca n be made of the fetal indica ted at this stage. head, trunk, and long bones of the ex tremities. Often this is ex tremely valuable as a baseline for management If the examination at 16- 18 weeks shows absence of events later in pregnancy. In particular, baseline of an ex pected finding normall y seen at this stage, morphometric assessment at this stage is most valuable e.g. urine-filled bladder, or revea ls suspicion of in multiple pregnancy, and in intrauterine growth abnormality eg. oligohydramnios, then this aspect retardation from any ca use. should be re-examined within 2 weeks. There is a growing number of instances in which unsuspected Abnormality of the umbilical cord and membranes abnormalities have been detected by ultrasonography (e.g. amniotic bands) may be identifiabl e at this stage. at this stage of ges tation. Both families and physicians are usuall y unprepared for these unexpected findings. This is indeed an unsettling situation and is presently Oligohydramnios, polyhydramnios and their ca uses managed on an individual basis. There is a growing may be identified at this stage of ges tation. body of experi ence in the Prenatal Diagnosis Clinic* whi ch is avail able to all physicia ns in the province. Location of the placenta is easy at this stage although 4. After 22 wee ks: ultrasonography should be it is by no mea ns fin al, since differential growth of performed as indica ted in the individual pregnancy. the myo metrium forming the upper and lower segments may cause the placenta to "migrate" m a 5. At any stage in pregnancy, ultrasonography is an cephalad direction as ges tation adva nces. ex tremely accura te method of documenting a live fetus. Also ultrasonography will demonstrate a normal or AT 22 TO 40 WEEKS GESTATION abnorm al cardiac ra te and rhythm in the second and third trimes ter. This aspect is particularly valuable Ultrasonographic exa mination at this stage of in multiple pregnancy, where oth er meth ods of pregnancy is bes t perform ed for a specific indica tion. monitoring may be less reliable. Such indica ti ons will depend on the individual pregnancy, e.g. suspected intrauterine growth retar­ 6. Special ultrasonographic techniques, e.g. Doppler da ti on, or beca use of a specific problem for which studies are being developed and may revea l new the pati ent may be at risk. When such problems are information in certain disorders. identified, additional techniques such as Doppler stud ies, e.g. for circul atory studies in the fetu s, umbilica l cord , placenta, fetal cardi ac abnormalities, The safety of diagnos tic ultrasonography should be possible twin-to-twin transfusion, and amniocentes is addressed. This form of energy has been in active for chromosome studies may be indica ted. This fi eld of Doppler studies is developing and shows promise. •Telephone (902) 424·649 1

T HE NOVA SCOT IA MEDI CA L BULLETIN 137 AUGUST 1986 clinical use in obstetrics for the last 25 years. The early The guide-lines described are based on the principle embryo is the most sensitive human tissue, but to date that obstetric ultrasonography in Nova Scotia is not no harmful effect in the human fetus, child or adult performed as a routine but as an indicated examination due to exposure to diagnostic ultrasonography in tailored to the individual patient. May it remain • clinical medicine has been reported. This is a so! 0 remarkable safety record. 4 In Nova Scotia, radiologists use equipment with a pulsed ultrasonic beam calibrated to be in accordance with the standards of the American Institute of Ultrasound in Medicine. The References question of long-term biologic effects on populations· exposed to diagnostic levels of pulsed ultrasound I. Winsor EJT, Brown BStJ. Neural tube defects in Nova Sco ti a: cannot yet be answered. In view of their experience Prevalence and Prenatal Diagnosis 1980 · 1984. (unpublished) with ionizing radiation, radiologists are well aware 2. Toms D, Brown BStJ. Prenatal ultrasonographic diagnosis of of possible unforeseen effects of newer forms of energy spina bifida: timing of examination. 1 Can Assoc Radio/1982; in diagnostic medicine. 5 Low-level time-dose energies 33: 276·278. used in diagnostic ultrasonography have shown no 3. Hobbins JC, Winsberg F, Berkowitz RL. Ultrasonography in ill-effects to date; however one generation has not yet Obstetrics and Gynecology, 2nd ed. Balti more: Wi lliams &: Wilkins; 1983, p. 152. passed. 4. Annual Statement of the American Institute of Ultrasound in There is an increasing trend towards obtaining Medicine. Statement on Mammalian in Vi vo Ultrasonic diagnostic ultrasonography in pregnancy, since the BiologicalEffec ts - reaffirmed October 1982. findings at certain stages may provide more informed 5. Brown BStJ. How safe is diagnostic ultrasonography? Can Med management. Assoc 1 1983; 131 Au gust 15: 307·311.

MALIGNANT HYPERTHERMIA: A Review COFFIN NAILS Continued from page 133. It is time for governments to turn smokers into 10. Adragna MG. Medical protocol by habit - the avoidance of pariahs, by making smoking something that has to amide local an es theti cs in malignant hyperthermia susceptib le be done in private. The legislators have only to treat patients. Anesth esio/1985; 62: 99·100. smoking as they treat sex, usually a far healthier II. Ellis FR, Clarke IMC, Appl eyard TN, Dinsdale RCW. pastime. While there are people who will pay to watch Malignant hyperthermia induced by nitrous oxide and treated others indulge in the latter, it seems unlikely that with dexamethason e. Brit Med1 1974; 4: 270·271. anyone will pay to watch tobacco being burnt. 12. Gerrard JM , Duncan PG, Koshyk SA, Glover SM, McCrea JM. Halothane stimulates the aggregation of platelets of both Editorial, New Scientist normal individuals and those susceptible to malignant January 16, 1986 hyperthermia. Br 1 Anaes th 1983; 55: 1249·1 257. 13. Solomons CC, Ma sson NC. Platelet model for halothane - induced effects on nucleotide metabolism applied to ma lignant hyperthermia. Acta Anaes th esia/ Scand 1984; 28: 185·190. 14. Gige r U, Kaplan RF. Malignant hyperthermia: Platelet bioassay - reply. Anaesthesia/ 1984; 60: 266. 15. The Europea n Malignant Hyperpyrexia Group: A protocol for the inves tigation of malignant hyperpyrexia (MH ) susceptibility. Br 1 Anaesth 1984; 56: 1267·1269. 16. Britt BA, Scott E, Frodi s W, Clements MJ, Endrenyi L. Dantrolene - In vitro studies in malignant hyperthermia susceptibility (MHS) and normal skeletal muscle. Can Anaesth Soc 1 1984; 31: 130·1 54. 17. Flewellen EH, Nelson TE. Prophylacti c and Therapeutic Doses of Dantrolene for Malignant Hyperthermia. Anaesthesio/1984; 61: 477. 18. Gronert GA. Malignant hyperthermia. Anaesthesia/ 1980; 53: 395·423. 19. Nelson TE, Fl ewe llen EH. The mali gnant hyperthermia sy ndrome New Eng/ 1 Med 1983; 309: 416·41 8. 20. Paasuke RT, Brownell AKW. Serum Creatinine kinase level as a screening tes t for susceptibility to Malignant Hyperther· mia. 1AMA 1986; 255: 769·771.

THE NOVA SCOTIA MEDICAL BULLETI N 138 AU GUST 1986 The Extramural Hospital

Yvonne M. Lefort,*

Hal ifa x, N.S.

In fo urth year of medical school the option of elective leader and initiates or terminates services as are study allows for an opportunity to pursue a specific required. All departments providing services to a area of interes t. Many choose to visit locations outside particular patient are encouraged to communicate on of Halifax to obtain a new perspective within the area a regular basis with the family physician to bes t assess they wish to study. My choice in December was to continuing care. Extramural services are delivered to visit New Zealand and become acquainted with a home homebound patients and are not meant to substitute ca re sys tem - the Extramural Hospital, in the city for ambulatory care offered in the family physician 's of Auckl and. In cooperation with the University of surgery (ie. offi ce). T his is particularl y emphas ized as Auckl and I became the first overseas elective student EMH services are provided free of charge while visits to work in the E.M. H. to the family physician are only partially subsidized T he phrase 'extramural' (meaning "beyond walls") and require a user-pay charge. The budget for EMH has been applied to an administrative network which is provided by the Auckland Hospital Board which provides hospital and ancilliary care in the homes of entails a maintenance budget of $8.5 million and a 850,000 people within the city of Auckland. Specif­ capital budget of $240,000. icall y, through the existence of EMH, nurses, Over 500 individuals are employed with EMH, the physiotherapists, speech therapists, social workers, greates t proportion of which are nurses. As well, a occupational therapists, podiatrists, dieticians, meals­ large number of people are employed through home on-wheels and home aids, are available to approxi­ aid schemes, that is, provi sion of homemaker aids, mately 6,000 of the city's residents at one time. T hese meals-on-wheels, linen services, long term wheel chair services provide for two purposes - first, to prevent loans and nutritional guidance. There is only one unnecessary acute hospitalization and secondly, to medical doctor employed directly by EMH. Clerical all ow for earl y discharge from acute care beds. staff total 80 with the remainder chiefl y paramedical T he inspirati on for this elaborate sys tem can be staff. traced to 1960 when the New Zealand Board of Health EMH and its administration play an important role iss ued a report on outpatient services. In this report, in many hea lth-related agencies. While an elective hospital boards were encouraged to expand their student I was acquainted with several of these interests. services by reaching into the community . It was felt St. Joseph's unit in Mater Hospital composes 12 acute that by assisting famil y doctors and existing agencies beds for terminally-ill. Sutherl and unit is an eighty­ to become more acti ve in the prevention of disease bed facility for young physically disabled requiring and the maintenance of good health, this would limit acute medical attention. T hese interes ts are maintained the demand for more hospital beds. In 1964 the in order to assure continuity of care to the patients Auckland Hospital Board formally es tablished the upon discharge into the community. I also had the Ex tramural Hospital in res ponse to this suggestion. pleasure of a barbeque supper on December 18 with T he EMH follows the administrative structure of the Auckland Stroke Club - a social gathering of any public hospital in New Zealand- it has a medica l stroke victims and their spouses organized and carried superintendent (a medical doctor), a manager and a out by two speech therapists! principal nurse. Additionally each discipline compos­ I was also able to visit many homes with district ing EMH has its own department head with super­ nurses providing EMH care. Services included: suture visory and research roles therein. Within this city of removal, post-discharge maternity care, dressing 2,000 square miles services are extended through four changes on post- surgical patients, blood glucose unit stati ons offering dail y, weekl y or monthly health monitoring of newly diagnosed diabetics, supportive care maintenance. care to terminally-ill patients and their family and By the nature of its very existence, the hospital's services for the elderl y. structure functions on the team approach. Patients are From the family practitioner's perspec tive, one admitted to EM H through a family phys ician 's person stressed how EMH services had helped him referra l. T his phys ician ass umes the role of the team to expand the sco pe of his practice. He reported that EMH services have allowed him to conduct initial assessment and at times subsequent management of • Fourth Year Medi cal Student, Dalhousie Univers ity Medical ches t pain, stroke or minor injuries in the home, under School, Halifax, N.S. his direction. He believes EMH services have dram-

THE NOVA SCOTIA ME DI CAL BULLETIN 139 AUGUST 1986 aticall y reduced the number of medical hospitaliza­ As a future family physician in Atlantic Canada, tions in his greater-than-average-sized family practice. I cannot help but feel encouraged by the experience Unfortunately, Auckland Hospital Board has not the of this elective. It is my personal and professional compilation of its statistics available to confirm this conviction that the family unit must assume a more fact or EMH's cost effectiveness. However, it was active role in the management of illness in one of calculated that if a petrol (gasoline) strike occurred its members. This requires establishment of priorities the suspension of EMH services would necessitate an in order to ensure the support of allied health additional 700 hospital beds at the end of one week! professionals within the context of the patient's own One aspect of the effect of increased emphasis of home. Whether we speak of the post-surgical or home care, rather than acute hospital admission, can terminally-ill patient the reality is the entire family be recognized on home visitations. People are generally unit is affected by this patient. To remove illness very content to remain at home obtaining medical and completely from the home is not compatible with supportive care rather than go to hospital. Day surgery, recognition of this fact. When w_e anticipate funding for example has grown to a greater magnitude in this restraints and other future projects we must not fail city as has an acceptance of this practice. Maternity to recognize the resources of the home environment. patients rarely exceed two days of hospitalization despite the availability of seven days postpartum care This elective has provided me great food for thought as funded through the New Zealand Health Plan. The and I feel I will be influenced by this experience in home was indeed the place of convalescence. I am well my future practice. I thoroughly enjoyed the hospi­ aware of several services in our own province which tality of the EMH staff and the endless hours of emphasize home care as an alternative to hospitali­ discussion they provided. Specificall y I wish to thank zation. The program that I became involved in offered the Medical Superintendent, Dr. Alec Warren for his this and more and with the full financial back-up of generous cooperation in making this elective possible the Auckland Hospital Board. One quickly recognizes with the full support of Dr. Franklin White, the Hospital Board's Strategic Plan endorses a high Department of Community Health and Epidemiology priority to these services with an expected growth of at Dalhousie University. 20% projected over the next 10 years. D

WORKSHOP: AIDS A PUBLIC HEALTH DILEMMA

The Public Health Association of Nova Scotia wi ll sponsor a one day workshop for professionals and interested individuals who wish to learn about AIDS and its public health implications. "AIDS: A Public Health Dilemma", will be held 111: Yarmouth- October 21, 1986,9:00 a.m.-3:15p.m. at the Yarmouth Regional Hospital. Sydney- October 24, 1986, 9:00a.m.- 3: 15p.m. at the Cape Breton Adu lt Vocational Training Centre. Truro- October 30, 1986, 9:00a.m.- 3:15p.m. at the Best Western-Glengarry Motel. The fee, payable at the door, is $20.00 for PHANS members or $25 .00 for non-members. For more information contact the N.S. Department Health Office in Yarmouth, Sydney, Truro or Janet Braunstein 424-4443.

Share office space in Halifax with General Practitioner. CONSULTANT: MANAGEMENT/FINANCIAL PLANNING' Own office,

share waiting room, 9021429-3479 good location WHITE POINT 804-5885 SPRING GARDEN ROAD 9021354-3696 HALIFAX, N.S. B3H 1Y3 near all hospitals. Call 423-7973 or YOUR GUIDE TO FINANCIAL FREEDOM after regular office hours 429-0520

THE NOVA SCOTIA MEDICAL BULLETIN 140 AUGUST 1986 Medical Ethics and Ethics Committees

Arthur H. Parsons,* B.Sc., M. D.,

Halifax, N.S.

Morality determines whether something is worth profess ion have traditionally been regarded as doing or worthy of being done. Ethics determines how particularl y trustworthy and responsible by the public. something worth doing is to be done right. A code From the profession, therefore, society expects high of ethics must describe a philosophical approach to standards, not only of scien tific education and clinical these difficult problems and define the principles skills, but also for profess ional and humane conduct. which individuals can use to find their own solutions. In the earlies t civilizations medical practitioners In actuality ethics is really a sys tematic attempt to were paid or punished by their results. In Babylon, avoid ta king anyone or anything for granted. In our Hamurabi separated civil from pries tly jurisdiction, society we face the perpetual iss ue of how to and in his "code of laws" (1790 BC) regulated the sim ul ta neously advance the common good and the fees of phys icians who were at that time still pries ts, good of the individual. Our problem revolves around and not yet distinguished from surgeons. For successful the fact that we live in a morally pluristic society and treatments, phys icians were paid in proportion to the wa nt that society to remain democratic. How do we patient's status; but if an operation was fatal, the maintain the coherence of our community when moral physician's hands were cut off . There was a scale concensus on fundamental iss ues is beyond our reach? however, and if the patient was a slave his replacement How do we differentiate right from wrong? Some would suffice. T hese early laws were harsh but they people prefer not to think about the difference but demonstrate how, from the beginning, organized accept the standards of sources outs ide themselves. society has felt the need to regulate the rights and T hey do not trust the idea that those seeking the truth duties of phys icians. Regulation of professional need not appeal to authority. T horoughly lacking standards, not by the state but by the profess ion itself, confidence in the creative moral power of their can be traced to at least as far as the "Hippocratic intelligence to determine right from wrong, these Oath:' (4 th century BC). T his oath was a convenant people turn to the law, convention or custom, p ublic between the physician and his teacher which set ou t opinion, simple spontaneous reactions, or authori t­ an ideal by which he promised to practice. ative statements of either religious, eccles iastic or Greek philosophy provided intellectual foundations professional nature. not only for medicine, but for the church. At the Others, of a quite different ilk, also find little need beginning of the Christian era, when medical opinion for dialogue in ethics. I refer to one-principle persons. was hardened against suicide and abortion, and surgery T hey are usually consistent and very sure of what is was separated from medical practice, the Hippocratic ri ght. Unfortunately, one-principle persons may know Oath gained a ge neral acceptance. In mediaeval little about bridge building. And that is what ethics Christian Europe, the spirit of Pre-Christian medical is - the art of building bridges between the ideal and humanism, with its emphas is on human brotherhood, real worlds, between what should be done and what still provided general guidelines for the conduct of ca n be done. phys icians. Alongs ide these fl ourished the equally ancient traditions of etiquette, medical manners, and T he root o f ethics lies neither in sentences, professional deportment - factors which have always propositions or judgemen ts but in the dynamic helped the phys ician to es tablish his pa tien t's structure of rational se lf consciousness. Ethics is a confidence. function of intelli'gence. Its true essence is not based upon some code or product of human intelligence, Modern medical ethics emerged towards the end of but rather on the sa me process of asking the right the 18th century. The as pirations of the middle classes ques tions that generate good science. When we apply were undermining the aristocratic order, and with it this process to ourselves , to our motives, decisions and came the tripartite es tablishment of phys icians, actions, we are being ra tionally self conscious and are surgeons, and apothecaries. New voluntary hospitals acting res ponsibly. not only raised public expectations but showed how far provision fell short of need, particularly during Because of their specia l knowledge and the epidemics. vunerability of their patients, members of the medical T he British Medical Associationn was formed in 183 2 and appointed a committee on medical ethics •Chair ma n, Comm ittee on Ethics , T he Canadi an Med ica l in 1849. Two years later, following reports by its Association, Ottawa , Ontario. Committee on Quackery, a committee was appointed

T HE NOVA SCOTIA MEDI CAL BULLETIN 141 AUGUST 1986 to frame a code of ethical laws. The present Code of In contrast others have emphasized the importance Ethics of the Canadian Medical Association was of "firm moral rules". Here we are urged to adhere adopted in 1968. It is constantly reviewed and amended to the traditional medical and religious moral by the Committee on Ethics of the Association, as principles. technology and social changes dictate. The committee Additionally, we have the works represented by those consists of five physicians from across the country and who have tried to find a "different language" with has two permanent consultants, an ethicist and a which to talk about ethics and a different way of lawyer plus several observers who take part in the .framing issues. This particular development has had deliberations. two important consequences: an excessive emphasis In the 20th century, wartime experiences have on the language of individual rights, and a blurring marked a certain loss of innocence and idealism, while of the distinction between law and morality. Here we scientific progress has created new moral dilemmas have the development and overuse of the language in medicine and intensified old ones. Contemporary of "rights". This is a language very congenial to the medical ethics, while retaining some of the etiquette courts and to the political process. It focuses for the of an earlier era, is faced with new and evermore most part on individuals, rather than on society as complex problems to which the past offers no a whole or on the welfare of an entire community. solutions. Terms such as "the public interest" or "the common While once the critical controversies in medical good" do not seem to have a political "bite" equal ethics dealt with personal problems faced by patients to that of cl aims to individual entitlement. Perhaps or health professionals, the ethics of medicine must one of the most harmful fruits of a permissive society now be essentially social. The central and controversial dominated by the language of individual rights is that issues involve complex social, political, and economic it is very difficult for a large number of people in relationships and increasing lay involvement in our society to make any sharp distinction between the medical - ethical decision making. Society is groping different demands of law and morality. It is far easier for new mechanisms for making decisions that are now simply to talk about the rights of individuals to make much more complex than those traditionally faced by their own decisions or about the establishment of patients, providers, families, and society as a whole. public procedures to adjudicate among contending values and interests, than it is to talk about what Although ethics has always had a role in the practice individuals ought to do when they make their own of medicine, only in recent years has it become a subject personal moral choices. of intense controversy. This is because of forces both internal and external to medicine. The external causes Many in our society now hopelessly confuse the are: the rise of public concern about the behavior of different demands of law and morality, and it is all professionals; intensified media attention, partic­ imperative that the differences between them be sorted ularily when the media are drawn to situations of out once again. If personal morality comes down to confli ct and controversy; and the sheer size and scope nothing more than the exercise of free choice, with of the health care system heavily supported by public no principles available for moral judgement of the funds. quality of those choices, then law will inevitably be used to fill the res ulting moral vacuum. The internal reasons seem to be no less evident; When there is competition for medical resources or primarily a number of medica l and technologica l conflict between individuals and what they feel is their breakthroughs have created new moral dilemmas. Had right in the medical care system, the medical profession there been no external pressures at all, it is still likely often finds itself ca ught in the middle acting as a referee that the internal pressures resulting from rapid and, in some cases, decision maker. Doctors as a group technological developments would themselves have could represent all the diverse points of view in our created suffi cient impetus for a renewed interest in morally pluristic society and in similar situations biomedical ethics. Although it might casually be different approaches to the same problem may be used. assumed that, for moral purposes the traditional goals There is more to morality however than walking a of medical care can remain unquestioned, this would tight rope between professional codes of ethics and be a naive assumption. Moral problems eventually bills of patients' rights. On one hand it is unrealistic force a confrontation with goals. to suppose that legal and/ or professional· codes of H ow has biomedical ethics progressed and ethics ca n "pinch hit" for personal moral integrity. responded during the las t decade? Some writers have On the other hand if the physician is already a person espoused a radical "situation ethics" or rejection of of high moral integrity, wherein lies the need for fixed moral rules and principles. In deciding if a codification of moral principles at all? defective neonate should be allowed to die, for Rights are social and relational. Individual freedom example, we should be bound by no hard and fast is a social reality. Individual rights are rooted in a rules; context and consequences of each specific case social reality that antedates them and gives them alone should be decisive. meaning. Each of us can exercise rights in a

THE NOVA SCOTIA MEDICAL BULLETIN 142 AUGUST 1986 meaningful way only so long as these rights are in that family. Difficult decisions of all ocations of recognized and respected by others. There are no resources sometimes must be made. There are in fact individual rights outside a social ambiance. This social many imaginable circumstances in which a physician's dimension is not a human creation constituted by duty to the public, to a family, or to a valuable policy choice for the convenience of individuals nor is it could take precedence over obligation to an individual merely an aggregate of individuals. Sociality is a patient. None of this is to deny the value of a patient­ natural, inalienable state of affairs. We are social by centered ethic. But can it always be the inevitably na tu re, not by choice, and rights are a natural extension superior value? Eventuall y, only a deeper analysis of of our society. Any morality that treats individuals the relation between the good of individuals and the as autonomous units is incoherent. Not only are rights good of communities will be helpful. social in origin, it is the institution and roles of social Ethics must be taught in the schools of the health rights that give to individual rights their purpose and professions. For, if prior to confronting situations the co mpleteness. Without our social framework rights are health care professional has been introduced to the empty form alisms, lacking in an historical or political rigors of ethical analysis and has been assisted in meamng. untangling competing and conflicting claims, the T he choice between individual rights and social practitioner will be that much more prepared to deal obligations is not one between conflicting alternatives with the situation when it arises. but between complimentary decisions. Neither makes The doctor has to make ethical decisions in many sense without the other. If the social ethos of rights such situations. We need no longer feel that we must is neglected, moral disputes will continue to be make the decision alone and unaided. Equally, we may antagonistic challenges for individual superiority. no longer substitute our own idiosyncratic sense of Codes of ethics have been adopted by physicians right, if by doing so we offend against that which to co ntrol relationships with other physicians and have the wider society has indicated as its rights. been promulga ted by governments to regulate the Ethics committees should be able to provide a useful re lations of physicians with society at large, but seldom perspective as a resource for physicians, relatives and have these codes articulated major philosophical others. A mu lti-disciplinary approach is recom­ principles or tenets. mended so that the committee will have sufficient Codes such as the CMA Code of Ethics and the expertise to apply and evaluate all pertinent infor­ Hippocratic Oath serve a useful function in ethics mation, and because representation of viewpoints from similar to that of a number of equally useful rules the community is desirable to contribute to better in medical practice such as "treat high fever with decisions. An ethics committee should be large enough aspirin". But, relying solely on such rules without to represent diversity, but not so large as to hinder understanding the nature of its problem in depth is ca ndid discussions and deliberations. like practicing black box medicine; "if the liquid in Ethics committees can study issues and provide the little glass rod moves past 37°C then give the patient guidelines. These guidelines are not slide rules that the pill marked A". It res ults in a superficial treatment make decisions. They are less than that. However they just as relying on ethical codes results in shallow ethics. do allow a communication within a profession and Good medical ethics must be developed slowly. The between different professions. They can serve as a principles of autonomy, dignity, justice and partner­ consciousness-raising stimulus for the individual ship must be found a place. Good medical ethics must member. Perhaps one of the greatest sins of a health provide for a weighing of the interes ts of the group ca re professional is the failure to recognize an ethical as well as and sometimes against the interes ts of the problem that exists. Knowledge is not lost by giving individual. it to someone, as happens with other commodities. The principle of a patient-centered ethic will have The recipient gains and you lose nothing. to be placed in the context of a number of other A common allegation against formal ethical analysis contemporary moral principles and social reality. Is is that little, if any, progress is ever made in the field; it desirable to eleva te any single moral principle to nothing gets decided and disputes are endless. But that a position of overriding importance? It should be as ked allegation makes sense only if one expects a clean­ whether the very idea of a single value mortality can cut, decisive resolution of ethical conflicts here and be adequate for a full y balanced professional ethic. now, with one side accepting the arguments of another In medicine many physicians must now serve side or one view becoming so rationally persuasive legitimate interests and va lues in addition to those that all instantly adopt it. That happens infrequently. of individual patient's welfare. Those in the fi eld of Nevertheless, if the past decade has made anything public hea lth are charged with the welfare of whole clear, it is that a number of ethical disputes have been groups of individuals, as are those who serve in resolved, although in ways that ca n best be seen only administrative roles. Even the physician in private retrospectively. In short, life does not stand still in practice must consider, on occasion, the welfare of the ethics any more than anywhere else. The experience family, and not necessarily only that of a single patient of the pas t decade should indica te that the ques tion

THE NOVA SCOTIA MEDICAL BULLETIN 143 AUGUST I986 is not whether ethical conflicts get resolved or ethical be resistent precisely beca use they wi ll force much more questions answered, but how well they get resolved directly a grappling with theoretical issues of morality and how good the consequential answers are. and medicine, and they will , more than ever, reveal The next round of ethical problems may be far more the shortcomings of the language of "rights", of resis tent to practical consensus than those that individualism, and of merely procedural solutions to captured attention during the past decade. They will problems of deep principle. 0

Current Topics in Community Health

Prepared by: Dr. Frank M.M. White, Department of Community Health and Epideminology Dalhousie University, Halifax, N.S.

PSYCHIATRIC EPIDEMIOLOGY: epidemiological research and its compl exity. The AN IDEA WHOSE TIME HAS COME heterogenous composition of the group was reflected in the comments made during the discussion periods. A workshop held in Halifax April 29 and 30, 1985 Whereas those participants who were primaril y reflects the growing interes t of psychiatrists in involved in research emphasized the increasingly epidemiology. Co-sponsored by the Departments of sophisticated methodology, policy makers while Psychiatry and Community Health and Epidemiology cognizant of the va lue of careful longitudinal study at Dalhousie, its participants included representatives require, in the words of one government epidemiol­ from academia, clinical practice and government, with ogist, "quick and dirty" res ults from studies of service shared interes t in the applicability of epidemiological delivery needs and program evaluation. The need for research to their own endeavors. The workshop was heightened awareness of epidemiology by clinicians envisaged as having three primary goals: to articulate was emphasized by Dr. Alistair Munro, Head of the a development plan for the future application of Department of Psychiatry, Dalhousie. More effective epidemiology to the study of mental illnesses and interchange of information between epidemiologists related services in the Maritimes; to identify ways and and clinicians should result in a better allocation of means of sustaining Dalhousie University as a centre clinician resources. Repeatedl y, past studies have of excellence in Psychiatric Epidemiology; and, in shown that only a small percentage of those people particular, to identify and encourage developments in recognized as having clinically significant mental this fi eld which wi ll be clinicall y and policy relevant illnesses ever see a mental hea lth specialist. for the Maritime Provinces. Epidemiologists may be able to direct clinicians to Organized as a series of presentations punctuated that segment of the ill population most in need of by whole group discussions, the workshop addressed their specialized services. Dr. Munro also commented a wide variety of topics. Overviews on the role of on the potential for developing a resource centre at epidemiology in etiologic studies, health services Dalhousie for epidemi ological inves tiga tion. The research, and clinical epidemiology; the interdiscipli­ At lantic Region offers a relatively stable population nary approach to psychiatric epidemiology; the role for stud y. The type of research conducted by of epidemiology in psychiatric training and practice; epidemiologists is also more suitable to a sma ll er provincial and municipal perspectives on the uses of univers ity centre as it requires people resources more epidemiology, including those epidemiological than it does high tech equipment. • principles and practices of relevance to government Al though the ambitious goals of the workshop were planning; and (not to be ignored), sources of funding not met in their entirety, the level of interes t of the for epidemiological research were among the major participants sugges ted that further efforts were areas of discussion. certainly worthwhile. Clinicians, investiga tors and It was clear by the second day of discussion that administrators all felt that they could benefit from the among the participants, there was widespread establishmen t of an epidemiological resource centre. agreement on the importance of epidem iology but also A recommendation that a steering co mmittee be a growing appreciation of the potential scope of es tablished has been implemented and this group is

THE NOVA SCOTIA MEDICAL BULLETIN 144 AUGUST 1986 currently composing a timetable for further meetings percentage. In contras t to incidence rates, which and seeking submissions from the various interest describe the rate of onset of new cases or events, groups regarding their specific pos itions and needs. prevalence rates are measures of what prevails or exists. An Atlantic inventory of interested persons, their research interests, and publications is being compiled. Incidence and Prevalence Hopefu ll y, this marks the beginning of a major role Incidence and prevalence may be expressed as simple for psychiatric epidemiology in Atlantic Canada. numbers when the required population denominator in order to calculate a rate is not known. Incidence refers to the number of new cases which occur during Source: Dr. Pam Forsythe, Secretary, Atlantic Psychiatric a specified period of time, while prevalence refers to Epidemiology Worki ng Group, Dalhousie the number of cases (old and new) which exist at a University. des ignated point or during a specified period of time. These are less accurate than their respective rates and onl y if the population denominator is not known should they be regarded as useful meas ures. THE USE AND ABUSE OF INCIDENCE AND PREVALENCE RATES

Incidence and prevalence rates are probably the two Source: Dr. Frank White, Dalhousie University. mos t frequently misused epidemiological concepts in medica l and health pub lications and discuss ion. Their correct usage is important if we accept the premise that to communicate accurately and effectively, one ANNOUNCEMENT should use the right term at the right time. These are two quite di stinct terms with their own precise The Canadian Hypertension Society invites all mea nings and should not be used interchangeably. interes ted health professionals to attend a forum on: Accep table definitions are presented below. Community Approaches to High Blood Pressure Prevention and Con trol Sunday, September 21st, 1986, Incidence Rate 1-5 p.m. Harbour Castle Hotel, Toronto. An incidence rate of a disease, disorder or other NO Registration Fee- Preregistration desirable but biological abnormality is a meas ure of the frequency not essential. of new cases or events in a particular population during a specified period of time. This is usuall y To preregister or obtain further information, expressed as the number of cases per population unit contact: per specified period of time, and may be expressed Community Approaches to High Blood Pressure as age- or sex-specific, or as specific for any other Prevention and Control, c/ o Dr. Karen Mann, characteristic of the population. Hypertension Unit, Camp Hill Hospital, 1763 Robie Incidence rates which are calculated for narrowly Street, Halifax, N.S. B3H 3G2, 420-2325. defined populations during short intervals of time, The forum acknowledges the financial support of as in epidemics, are often called attack rates. Attack an educational grant from Frosst, a division of Merck­ rates are usually expressed as a percentage. A secondary Frosst Canada, Inc. attack rate is the incidence of a disease among famil y, The Canadian College of Family Practice has institutional, or other contacts whose population is allocated four (4) credit hours for the forum. 0 definable within the acce pted incubation period following exposure to a primary case, and is used only in refere nce to communicable diseases. The case rate expresses the incidence of clinicall y recognized cases, while injection rate refers to the sum of manifest and inapparent cases. ALFRED J. BELL& GRANT Limited Prevalence Rate INSURAN CE SPE C IALI STS

The prevalence rate of a disease, disorder or other suite 1306, purdy's whorl, 1959 upper water st. biological abnormality is a meas ure of the frequency p.o. box 8, halifax, n. s. , b3j 214 of all current cases of a disease (old and new) within a particular population, either at a specified point or during a specified period of time, hence the terms point prevalence rate and period prevalence rate. This is "INSURANCE- THAT'S ALL!" usuall y ex pressed as the number of cases per population unit, or sometimes more simply as a

THE 1 OVA SCOTIA MED ICAL BULLETIN 145 AUGUST 1986 Appreciations

DR. ELEANORE BERGMANN PORTER hour of the day or night, and continued treating her patients until a week before her death. She was always a champion of freedom and a courageous lady and was so honoured at a banquet in-New York for helping 24 people to escape from Nazi Germany during the war. Help in many cases included sacrificing her own needs to obtain the funds to help others start life in a new country. Eleanore was a rare breed, a warm and generous woman with co mplete dedicati on to her pati ents, family and fri ends. Her vivacious manner, dedication, courage and no nonsense approach to life will continue to be an inspiration to all those who knew her. She is survived by her husband, Lofty and a son, Tony in Edmonton, and a sister, Ruth in New York.

J.K. Little, M.D. Yarmouth, N.S.

With the passing of Dr. Eleanore Bergmann Porter, the medical profession in this province has lost a very loyal supporter. Eleanore passed away at the age of DR. ANGUS EDWARD MURRAY 79 on May 29,1986at the Yarmouth Regional Hospital. She had been in failing health for the past six years, but bore her illness with strength and courage as displayed throughout her life. Dr. Porter was born on May 12, 1907 , in Laupheim, Wurttenberg, Wes t Germany. She graduated in Ulm, as a registered nurse in 1925, and obtained her medical degree in 1933 in Munich. In July 1933, she left Germany to escape Naziism and underwent another year of training in Edinburgh, receiving her British qualifications. Following this, she entered general practice in London which included running a priva te twelve-bed obstetrica l unit with over 3000 deliveries to her credi t. On May 18, 196 1, Eleanore arrived in Yarmouth, and opened a General Practice Office and had the distinction of being the first lady doctor in the area. Over the next 25 years she provided medical services to approximately 3500 fa milies. During that time, she has been an active member of Yarmouth Hospital, a member of the Canadian College of Family T o his colleagues he was "Eddie". Phys icians, and was made an honorary member of this In Nov.-Dec. when I had a minor illness which kept college in 1977. In addition, she was a member of The me at home, Eddie's first house ca ll when he left from Medical Society of Nova Scotia and T he Canadian Armview Ave., was to stop at my home to inquire Medica l Association and became the first lady with the sta te of my health, which in due course fully Senior Membership in T he Medical Society of Nova recovered. Scotia. T hus it was on the morning of Feb. 23rd that I Eleanore was a dedicated physician, and always met him, as frequently happens, in the little corner placed the patient's welfare before her own. She never grocery and with our initial mutual comment "I'm failed to answer a call at the office or house at any fin e", and hav ing discussed world and local affairs,

THE NOVA SCOTIA MED ICAL BULLETIN 146 AUGUST 1986 we took off to our day's work. So my shock and surprise We ex tend our heartfelt sympathy to his wife Olive, when I read in nex t morning's paper that he had died his daughters Olive and An ne, a sister Dr. Anne, a during the night. brother Dr. Foster, and five grandchildren. Dr. Murray was born in Earltown, Pictou County, the son of the late Rev. Robert and Isobel (Sproull) F. Murray Fraser, M.D. Murray. One of a famil y of six - 4 physicians, I Halifax, N.S. clergyman and I teacher - he was educated in the public schools in P.E.I. to which his parents had moved, and Prince of Wales Coll ege: He taught school SURGEON REAR ADMIRAL R.H. ROBERTS in Labrador and then returned to Nova Sco tia and entered Pine Hill Coll ege with the thought in his mind of Theology. There were several medical students in Pi ne Hill residence at that time and after two years Eddie decided that he was not cut out for Theology, but beca me tremendously enthusias tic about Medicine. He graduated from Dalhousie in 1930 and joined Dr. Judson Graham in general practice and surgery. In spi te of a rapidly increasing practice, he acted as Medical Examiner for Halifax and Dartmouth for 29 yea rs and taught Ethics and Med ical Jurisprudence at the Medica l School at Dalhousie. In addition he served as President to the Medical Staff of the Children's Hospital, the Halifax Infirmary, the Halifax Medical Society, the Medico-legal Society; and was a member of the Provincial Medical Board and the Executive of T he Medica l Society of Nova Sco tia. He was made a Senior Member of T he Medical Society of Nova Scotia in 1975. He was a member of St. Matthew's United Church, Armdale Kiwanis Club, Surgeon Rea r Adm iral R.H. Roberts, of the Sa raguay Club, Ashburn Golf and Country Club, the Canadian Armed Forces, died suddenly on March 8 Halifax Wildlife Association and a Life Member of in Ottawa, Canada. the Mayflower Curling Club. Richard Howell Roberts was born in Liverpool in His hob bies, which he pursued with vigor and 191 5 and graduated from Liverpool University in 1938. enthusiasm, were go lf, curling, poker: and he was a After a short residency in orthopaedics at Alder Hey fascinating conversationalist which is rapidly becom­ Childrens ' Hospital, he joined the Roya l Naval ing a los t art. Volunteer Reserve early in the war, serving mainly In his early da ys he developed a very large practice in aircraft carriers and at Fleet Air Arm stations in in the areas of Ketch Harbour, Portuguese Cove and Great Britain and later in India. He served with environs and frequen tl y, at the end of a day's work distinction and was twice mentioned in dispatches. in the city, a ca ll from a patient in the country would Shortly after the end of the war he joined the Royal come in. He thought nothing of driving there at two Canadian Navy and emigrated to Canada in 1948, o'clock in the morning to make that house call, only where he continued in serv ice with the armed forces to find four or fi ve fam ilies patiently waiting for him until reti rement in 1976. His career with the forces at the house. Having treated all present he set off for was distinguished: he became successively command­ the city, for a few hours rest, ready to start again the ing offi cer of the Halifax Naval Hospital, command nex t day. He was always avai labl e, patient and med ica l officer of the National Defence Medical Centre unders tanding. and, fin all y, Surgeon-General of the Canadian forces, The service was held at St. Matthew's, Barrington the first non-Canadian born doctor to hold the post. St. , the Rev. E.P. Thompson officiating. It was simple He took a special interes t in tropical diseases and and beautiful. T he Church was fill ed. There were only was actively involved in research pertaining to the a few of his medical co ll eagues - mostly those in prevention of smallpox, poliomyelitis, cerebrospinal the 65 and over group who knew him well by "Eddie"; meningitis, malaria, amoebiasis and other conditions the rest of the Church was fill ed by his friends from of particular military importance. Among his own the country: great-grandparents, grandparents, parents publications were two of special note: one dea lt with and teenagers. As one elderl y woman her eyes fi lled vira l Coxsackie pericarditis affecting a recru it; the with tears said to me, "He was a blessed man; God other was an epidemiologica l study of a crop of will welcome him with wide open arms." Hepatitis B cases involving a tattoo parlour.

T HE NOVA SCOTIA MEDICAL BULLETIN 147 AUGUST 1986 He was a keen clinician and taught many medical DR. LLEWELLYN THOMPSON STEAD students and resident doctors through his affili ations with Dalhousie Un iversity and Ottawa University, in whose faculties he held the honorary posts of associate professor. I was fortunate to have many associations with Dr. Roberts over a variety of research projects during his tim e of service in both Halifax and Ottawa. During the period when Dr. Roberts was posted to Halifax at H.M .C.S. Stadacona for 17 years.1 I took the opportunity of inviting him to lecture on human parasitology to undergraduate medica l students in the Dalhousie University class of Microbiology. He was an excellent teacher, who could convert a dull topic into an interes ting and exciting one, often re-inforced by his personal experiences gained during the co urse of military operations. In addition to Microbiology, he gave freely of his time to teaching in the Department of Medicine. The Ca nadian Society of Tropical Medicine also flourished under his leadership, and in Nova Sco tia los t a dedica ted physician with the dea th 1964-65 he took part in a scientific and resea rch of Dr. L. T. Stead earlier this year. Ll ew died on March Ca nadian Medica l ex pedition to Eas ter Island , 22, 1986 at the age of 69 while on a holiday in Britain. accompanied by his distinguished pediatrician wife, He was well known for his ever present smile and Dr. Maureen, well known to many in Halifax. sense of humour, his dedica tion to hi s patients and Most recently Dr. Roberts participated in July 1985 his commitment to his work. in the opening ceremonies of the new Dr. A. McCallum He was born in 1916 in Bell Island, New foundland. Hospital at H.M.C.S., Stadacona. After completing his schooling, he worked for several He was married in 1940 to Dr. Maureen McWilliam, years in the Royal Bank. He then joined the 7th who survives him, along with one son and one Antitank Regiment in 1940 and served overseas in Italy daughter. Although he lived in Canada for the las t and North Africa with the Canadian Army, first as 38 years, he maintained a close relationship with a troop officer, then intelligence officer and finall y England, particularly with his class mates fr om as Ca ptain Adjutant of that Regiment. Liverpool University, and he was for many years a After the war he entered Dalhousie University and fell ow of the Roya l Society of Medicine. graduated with his M.D. degree in 1952. He then All his colleagues bemoan his pass ing. Canada has practised Family medicine in Halifax untill966, when lost a great serv ice offi cer, a gentleman, scholar and he began a res id ency in psychiatry. Upon its physician. com pletion in 1970, he joined the staff of the Nova Scotia Hospital, where he practised until his retirement C.E. Van Rooyen, M.D. in 1981. Halifax, N.S. Not one to remain inactive, he began working on a part-time basis at the Pictou County Mental Hea lth Centre in New Glasgow earl y in 1982. He played a vital role in the amalga mation of the Mental Hea lth Centre with the Aberdeen Hospital, and the creation of the hospital Department of Mental Health Services. He remained ac tive there until his death. He was a member of both The Medica l Society of Nova Scotia and of the Canadian Medical Association at the time Rakesh Jain of his dea th. Chartered Accountant He is survived by his wife, the former Jo;n Matthews, three children, Gordon (Dartmouth), Kathryn (M rs. John Sperdakes, Lower Sackville), and Sandra (Mrs. Suite 1205, 1505 Barrington Street Ri chard Capon, Halifax), and five grandchildren and Maritime Centre 429-2220 two sisters. The Medical Society of Nova Scotia ex tends warm sy mpathy to his fam il y. I.M. Slayter, M.D. New Glasgow, N.S. 0

THE NOVA SCOTIA MED ICAL BULLETIN 148 AUGUST 1986 Correspondence Paragraph 48 says that existing agencies (mainly the VO N) should obviously be a major component of the services co ntracted by the Department of Health. While the administration of the VON varies from To the Editor: province to province, it is worth noting that the New Brunswick Extra-M ural Hospital does not use VO N I should like to take this opportunity to applaud nursing services. T he reason appea rs to be that when the report of Brian Hennen's Committee on Home their participation was fi rst discussed, the New Care in Nova Scotia that appeared in yo ur April issue. Brunswick VON wanted a larger say in the admin­ From my point of view (health administration/ health istration of the nursing component of the program economics) the statement appeared we ll thought-out. than the provincial authorities were willing to I too would like to see the Province spend some of concede. While the Nova Scotia VON may have told its scarce health dollars on more and better home care. the Hennen Committee that they were willing to From a dollars-and-cents point of view, I think there provi de the se rvice (see paragraph 70 ), and the is broad agreement on the eventual pay-off from Department of Health may have sa id that they were investment in home care so long as it is a substitute willing to use VON, and both parties were being for more expensive forms of care and not an add-on. completely hones t and above board, the promises may T he problems in actually doing it should be obvious: well evaporate when it comes down to negotiating (I) if money has to be spent before savings are realized the specifics. This is an argument against the Medical without crea ting a defi cit, then some other expenditure Society co mmitting itse lf to any individual agency in will have to be postponed; and (2) the administrative adva nce, because there is a risk it may not work out. considerations have to be thought out as carefully as Paragraph 51 refers to coordination and observes the medical and economic issues. that cooperation between provincial government T he Hennen Committee thoughtfully numbered its departments, and among these, key providers, and paragraphs fro m I to 77, and it is to their credit that municipal governments, does not currently exist in I do not have a word to say about paragraphs 1-44! Nova Scotia. T his is quite true, and deserves further Let's look at the res t now: exploration in a historica l context: Paragraph 45 notes that pay ments by patients for When federal-provincial cost sharing arrangements services that do not clea rl y avoid hospitaliza tion may for hea lth services were first set up, it turned out that be required on a progress ive scale depending on ability some items not allowable fo r cost-sharing as health to pay. T his is fine from the economic point of view services were all owable as social services under the because it puts a penalty on the add-on type of service. Canada Ass istance Plan. A number of prov inces Ad ministratively, this brings up two areas where promptly transferred (or initiated) these activities judgment has to be exercised - determining how under their Departments of Social Services to take mu \= h different people can aff ord to pay, and advantage of federal cost sharing for homes for special determining (w ith periodic review as the state of the care and the like. In Nova Scotia this has led to an art changes) which services clearl y do not avoid added complica tion, since the philosophy of the hos pitalization. T his sort of thing is easy to say, but Department of Hea lth involves the direct purchase of the Department of Hea lth or the Directors of a free ­ services (i.e., by sending cheques to the hos pitals to standing program will have to make a set of specific cover their running expenses and maintaining a staff rules and hire people to apply them. T his cos ts money to supervise them), while the Department of Social too. Services prefers to pay counties and towns to run the services rather than pay directly to the institutions that Paragraph 46 ca lls for stable funding arrangements provide them. Other things being equal, coordination for participating volunteer agencies. It is easy to between two dissimilar sys tems is bound to be difficul t. understand that the agencies want to have their Some provinces have consolidated health and social funding assured if participating in a new home care services in a single department, and in recognition program obliges them to make heavy commitments of the fact that the financial ground rules have (li ke hiring new personnel or buyi ng a fl eet of cars). changed, New Brunswick transferred a good many From the view point of the provincial government, functions back from Social Services to Health a few however, stable funding in the face of unpredictable months ago. Is this a sign that Nova Scotia will do demand makes for an unpredictable call on provincial likew ise? There is really no way to tell. resources. Judging by experience in other countries (e.g. Germany) , if the government insists on a Jumping ahead to paragraph 62, this is the one place predictable quarterl y or annual expenditure at I found myself frankly irritated. The Hennen Commit­ negotiated co ntract rates, the providers must face up tee would have us believe that concern about loss of to the fact that if unexpected peaks in demand occur jobs is not warranted because as hospital positions they will either have to settle for a lower rate per unit are eliminated new jobs outside hos pitals will open of service or else turn away some patients. up. Ad mitting that this may be a true statement, it

T HE NOVA SCOTIA ME DI CA L BULLETIN 149 AUGUST 1986 is nevertheless misleading because we don 't know tures outside the health fi eld. Would the government, whether as many new jobs will open up, whether they for example, be willing to consider the proposed home will be in the sa me localities and require the same ca re program if it mea nt postponing the start of new or similar skills and training, whether they will pay hospital construction in Sydney? Should home care as well as the jobs they replace, and whether people be given priority over institutional facilities for • pas t a certain age will have to retire early or go on ex tended care? There are, after all , home situations welfare because they cannot be retrained or relocated. to which_ no-one in his right mind would want a T he changes can represent a personal catastrophe for patient to be re turned. T here are also old people many even if the numbers manage to balance out. without families who lose their rented room while Paragraph 74 suggests a director of home care they are in hospital and have no place to go on services to be jointly responsible to the-Departments discharge, as well as other appropriate candidates for · of Social Services and Health with an illustrative institutional care. For patients with minimum diagram. The regional hospital affiliation of regional incomes (Canada Pension, Old Age Security, Guaran­ or district offi ces appears in the diagram but is not teed Income Supplement), one should also consider discussed in the text. whether paying for their own food, laundry, and other services at home is necessarily within their means. While the medical profession is taking a praise­ worthy initiative fo r better patient care by making this In a society like ours, the free express ion of interes t proposal, the relation of the doctors to the home care groups is one of the building-blocks of future policy. program is not considered in detail in any of the 77 In this sense, the Hennen Committee has made a numbered paragraphs. In New Brunswick, individual va luable recommendation, and I hope the Medical doctors can apply for admiss ion to the medica l staff Society will give it their enthusias tic backing. Do not of the extra-mural hospital. While in practice most be surprised, however, if other interest groups do not of their contact is by telephone, the home care workers necessarily come down on the sa me side, nor if the can at least identify the pati ent's responsible physician provincial government, while agreeing in principle, and have someone to call when medical problems ari se. cannot find the money for the initial expenditure or This is a distinct advantage over many Canadian home cannot find the agreement among MLAs to give this care programs, and it is to be hoped that a similar project absolute priority over other equally legitimate arrangement can be set up in Nova Scotia. interes ts. Finally, I do not feel that the present government Yours truly, is against the provision of home care through a well­ coordinated program, but wonder whether the A. Peter Ruderman, PhD political will exists to grant this program priority over Professor of other health activities and other provincial expendi- Health Administrati on 0

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Suite 1100 Cogswell Tower 2000 Barrington Street Doane Halifax. Nova Scotia (902) 421-1734 Raymond

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THE NOVA SCOTIA MEDICAL BULLETIN 150 AUGUST 1986 She was a senior member of The Medical Society of Nova Scotia and the Canadian Medical Association. She was an honorary member of the Canadian College of Family Physicians; and the first female doctor at the Yarmouth Regional Hospital. She is survived by her husband and a son. The Bulletin extends sincere sympathy to her family.

Dr. Edward D. MacArthur, (66) of Berwick, N.S. A bes t se ll er, compiled and edited by faculty members died on June 29, 1986. Born in Pictou, he received of Dalhousie Medical School's Family Medicine his medical degree from Dalhousie University in 1952. Centre, is about to run to a second edition in English. He practised in Berwick for 34 years and was Pres ident Family Medicine: A Guidebook to Practitioners of of the medical staff at Western Kings Memorial the Art, written by Dr. David B. Shires, Dr. Brian K. Hospital. He was considered a valued member of the Hennen and Dr. D.I. Rice, has already been translated House during his term as a member of legislature for into a Spanish edition and can be bought in Madrid Kings Wes t from 1960 to 1963. He is survived by his or Buenos Aires. About 20,000 copies of the text book wife, five sons, and two daughters. Our sympathy is have been sold in English and Spanish. A French extended to his family. edition is also under consideration by the publishers, McGraw Hill, New York. In South America, where the eminently readable text book has been widely sold, there has been a massive increase in the teaching of Dr. Robert Mair, (60) of Yarmouth, N.S. died on fam ily medicine programmes in hospitals, universities July 16, 1986. Born in Scotland he received his medical and medical schools. degree from Aberdeen University in 1954 and earned a diploma in psychiatry from Edinburgh University A scant four years ago, there were about 12 such in 1963. He moved to Canada in 1974 and practised teaching programmes. Today, there are more than 180 in various places before moving to Yarmouth in 1982. in Latin American countries from Argentina to He is survived by three sons, a brother and two sisters Mexico, according to co-author Dr. Shires. to whom the Bulletin extends sincere sy mpathy. T he text book provides young family physicians (and even elderly ones) with clear, modern techniques in the continuum of care they give to patients in trea ting their wide ranging diseases from childhood Dr. Olding C. Macintosh, (72) died on August 9, to old age. It also advises on ways of developing the 1986 at Jimtown, N.S. Born in Antigonish, N.S., he subtle art of successful medicine, which is both graduated from Dalhousie Medical School in 1940. He compassionate and competent. served with the Roya l Canadian Air Force during the Second World War, then continued his post graduate training in radiology at the Toronto-Western Hospi­ tal. He practised radiology at St. Martha's, Antigonish OBITUARIES until 1966, then he was appointed head of the Department of Pathology at the Halifax Infirmary and Dr. Laverne E. Cogswell, (79) of Berwick, N.S. died Assistant Professor of Pathology and Micobiology at on May 28, 1986. Born in Kings County he received Dalhousie University retiring in 1969. The Bulletin his medical degree from Dalhousie University in 1932. offers sincere sympathy to his wife and famil y, For many years he was a fam il y physician for the D Berwick area and on staff at the Western Kings Memorial Hospital. He also served as coroner for the County of Kings and medical health officer for the ADVERTISERS' INDEX Town of Berwick. He is survived by his wife, three sons, and three daughters, to whom we extend sincere Bell and Grant Limited ...... 145 sympathy. CompuCroft Associates Ltd ...... •.... 138,150 Classified ...... •...... 140 Doane/ Raymond ...... 150 Investers Syndicate ...... 11 8 Jain, Rakesh C ...... 148 Dr. Eleonore Bergmann-Porter, (79 ) of Yarmouth, Maritime Tel and Tel ...... 122 N.S. died on May 29, 1986. Born in West Germany Med ica l Practice Productivity ...... 122 she received her medical degree in Munich, Germany. Sawyer, Douglas E ...... • ....•...... 140

T HE NOVA SCOTIA ME DI CAL BULLETIN 151 AUGUST 1986 THE MEDICAL SOCIETY OF NOV A SCOTIA NOVA SCOTIA DIVISION OF THE CANADIAN MEDICAL ASSOCIATION

MEMBERS OF EXECUTIVE COMMITTEE

OFFICERS BRANC H SOCIETY REPRESENTATIVES

President . . .. . ].C. Kaz imirski Antigonish-G uysborough .D.P. Cudmore President-Elect ...... W.C. Acker Bedford-Sackville ...... G.L. Mya u Past President (Immediate) .... M.G. Shaw Cape Breton .... P.K. Cadegan & D.P. Hickey Chairman, Executive Committ ee ...... R. Stokes Colchester-East Hants .... F.E. Slipp

Vice-Chairman, Executive Committee . ... . M.E. Lynk Cumberland ...... ·oo - . oooo ••• o oo ••• oo ... .. • ••• W.G. Gill Treasu rer ...... V.P. Audain .Dartmouth ...... I. M. Sha ntz, W.R. Lee

Honorary Secretary ...... ].H. Gold Eastern Shore . . .. oo •••• oo .. • ••• D.P. Sinha Officer-at-large .. W.H. Len co Halifax ...... I. A. Cameron, R.B. Auld & W.G .C. Phi lli ps

Executive Director ..... 0 0 • • •• 00 •• • ••••• D.O. Peacocke Inverness Victoria ...... 00 •• • • 00... • ••••••••••••••••••••••• G. W. Thomas Lunenburg-Queens . .G.H. Nickerso n

Pictou ...... 00 . • •••••• E.R. Sperker Shelb urne...... W.H. Blair

OBSERVERS AN D STt,ff Sydney ...... oo o •• ·oo •• ·oo • • • · oo· • • ·oo •••••••••• P.F. Murphy & G.E. Boyd"

Valley...... 00 • • 00 00 • • 00 00 • • 00 00 • • ••• • JR. MacEachern & R.R. Kimba ll Economics Committee Chairman ...... W.C. Acker Western ...... , ...... P.L. Loveridge Manager, Economics Department .... A.A. Schell inck Student Members ...... B. Carr, G. Ra ymond & D. Jones Director of Communications .. Bil l Martin I.R.A. Rep resentatives ...... Joan Dahmer & Dianne Mosher

OBSERVERS

Editor-in-Chief- The Nova Scotia Medical Bulletin ...... ].F. O'Connor

Representative to Provincial Medical Board ...... , 00 oo · 00 0 . .. • •••••• G. McK. Sau nders

Medical Director M.M.C. Inc ...... · ·· · oo o • ••oo oo • • oo oo • • •••••••••••• H.J. Bla nd

General Manager M.M.C. Inc...... oo ••• oo ••• ·oo· ••••• D.L. McAvoy

C.M.A. Board of Directors ...... ·oo· · · ·oo· · · ·oo· ••• R.D. Saxon

C.M.A. Council on Health Care .. ·oo ••• ·o· .... 00 ••••••••••••••• D.S. Reid

C.M.A. Council on Economics ... . . 00 •••• 0 •• •• 00 •••• 00 •••• 00 •••• 0. .. • •• P. D. Muirhead

C. M.A. Council on Medical Educa tion 00 • • 00 00 •• • 00 ...... J.D.A. Henshaw

M.D. Management Limited ...... oo · ••• 0. • ••• • G.A. Sapp

STANDI NG COMMITTEES BRANCH SOCIETIES

Chai rma n President Secretary

Allied Health Disciplines ..... J.H. Quigley Antigonish-Guysborough.. . .P.J. McKenna ..... T.D. Sm ith Annual Meetings ...... Pres ident Bedford-Sackville...... M.J. Fleming B.C. Canon Archives ...... I. A. Cameron Cape Breton ...... B. j.M. O'Brien .... . ]. A. Stevens

Awards Committee ... ·oo • • •OO oo •••••• P.E. Kin sman Colchester-East Hants ...... C.K. Bridge R.L. Rond ea u

By- Laws ...... o • •• oo o • •••• P.W. Littlejohn Cumberland ...... D.M. Rippey ...... D.P. Kogan Cancer...... A. J. Bodunha Dartmouth ...... G.L. Roy ...... L.B. Marr Child Health ...... G.H. Nickerson Eastern Shore...... W. C. Brown .. D.R. Barnard Community Health... . .M. Kazimirski Hal ifax ...... R.B. Au ld .... S.B. Gibbon Drug & Alco hol A bus e...... E. L. Reid Inverness Victoria ...... ].0. Belen ..... K.R. Murray Editorial ...... J.F. O'Connor Lunenburg- Queen . . E.A. Morse .. J.H. Sul livan

Eth ics ...... K.R. Murray Pictou ...... ·oo ••••••••••• G. E. Farrell ...... C.S. Giffin Finance (Treasurer) . . . . V.P. Audain Shelburne ...... D.H. Wilson .... M.E. Ril ey Hospitals & Emergency Services ...... D.F. Craswe ll Sydney ...... S.M.A. Naq vi ..... J.H. Mac Killop

Maternal & Perinatal Hea lth...... E.R. Luther Vall ey ...... o ... oo o • ... o • ••••••••• R.H. Burnett ...... D.P. Kin g Medical Education ...... G.]. Butler Western...... D.S. Armstrong ...... W.M. Gorman Mem bership Serv ices ...... K.R. Langill e

Nutrition ...... 0 • • M.P. Quigley SECTIONS Occupational Medicine ...... J.D. Prentice Pharmacy ...... J. P. Anderson Anaesthesia. . ... A.C. Walker .... K.R. Hamilton Ph ysical Fitness ...... M. R. Ba nks Emergency Medicine D.M. Maxwell . L. M. Costell o Presidents' Committee...... Pres ident General Practice .... . J.P.T. Graham ..... D.P. Cudmore

W.C.B. Liaison ...... 0 0 0 ••• • ].C. Kazimirski Internal Medicine . . . L.P.M . Hefferman ...... B.J. Cookey In ternes & Residents ...... B. Wr ight .S. Rob inso n Obstetrics and Gynaecology ...... C.A. Maley ..... ~-C. MacLeod Ophthalmology .. . .D.M. Andrews ...... D.M. Kea ting Orthopaedic Surgery ...... ]. C. Hyndman G.H. Rea rdon The Nova Scotia Medical Bulletin Otolaryngology ...... 0...... G. Sh ima ...... F.S. H. Wong 6080 Yo ung Street, Paediatrics ...... A. F. Pysemany ..... A. E. Ha wkins Laboratory Medicine ...... D.A. Taylor ...... A. ]. Wort Suite 305, Psychiatry ...... W.O. McCormick .... R. Morehouse Halifax, N.So B3N IY2 Radiology ...... ].A. Aquino ...... W. F. Barton 902-453-0205 Surgery ...... D.M. Nicholson ...... P.O. Roy Urology...... S.C. Lannon R. W. Norman

Vascular Surgery ...... 00 00 ...... J.A.P. Su ll iva n .. ... R.S. Dun n

T HE NOVA SCOTIA MEDICAL BULLETIN 152 AUGUST 1986