controlled studies ... have not been published," she goes on to recom- mend that a 50-g oral glucose toler- ance test be performed as a screening test.
consistency in the approach to quinine as stand-by treatment, an issue which is omitted in the text of the article. Quinine remains universally efficacious in vivo against Plasmodium falciparum, and thus plays an important role for stand-by treatment where chloroquine-resistance occurs, especially if accompanied by resistance to
pyrimethamine-sulfadoxine.5 I would suggest that the recommendations therefore explicitly include stand-by treatment with quinine sulfate, 650 mg p.o.q. 8h., for five to seven days. This should certainly be recommended for travel to areas of intense transmission in southeast Asia, and, in circumstances of prolonged exposure, for the Amazon basin and east Africa as well. Robert C. Wittes, MD, CCFP, FRCPC Laboratory Centre for Disease Control Ottawa, Ontario
References 1. Scappatura FP, Lawee D, Gutman E. Malaria prophylaxis problems and recent recommendations. Can Fam Physician 1989; 35:901-6. 2. Wittes R. Adverse reactions to chloroquine and amodiaquine as used for malaria prophylaxis: a review of the literature. Can Fam Physician 1987; 33:2644-9. 3. Bernstein HN. Ophthalmologic considerations and testing in patients receiving long-term antimalarial therapy. Am J Med 1983; 75:25-34. 4. Taylor DN, Pitarangsi CL, Echeverria P, Diniega BM. Campylobacter enteritis during doxycycline prophylaxis for malaria in Thailand. Lancet 1988; ii:578-9. 5. Desjardins RE, Doberstyn EB, Wemsdorfer WH. The treatment and prophylaxis of malaria. In: Wemsdorfer WH, McGregor I, eds. Malaris. principles and practice of malariology. New York: Churchill Livingstone, 1988:827-64.
Inappropriate Diabetes Screening It was with considerable dismay that we read the article by Dr. Levitt on "Screening for Gestational Diabetes."1 It seems we learn nothing from the disasters of inappropriate intervention in the past. Despite her statement that physicians are concerned over the implications of false-positive results, labelling, intense monitoring, and resultant anxiety for both mother and physician, and despite her quotation of the Second International CAN. FAM. PHYSICIAN Vol. 35: JUNE 1989
Workshop-Conference on Gestation- References al Diabetes Mellitus: "randomized controlled studies ... have not been published," she goes on to recommend that a 50-g oral glucose tolerance test be performed as a screening test. In our view, based on the evidence presented in her review, this is dangerous and absurd! This is the same type of reasoning that led to the universal acceptance of continual fetal monitoring in labour, which-when finally studied in randomized controlled trials (RCrS) in low risk pregnancies-was shown to cause considerable increases in operative delivery with no improvement in fetal outcome. Surely a screening test that creates a "disease" in 13% of pregnant women1 should not be accepted until a quality RCr demonstrates a reduction in infant and maternal mortality, especially when patients with a positive test are subjected to dietary restrictions or insulin therapy. Based on the data in Dr. Levitt's review, we offer an alternative recommendation. "Given its potentially significant impact on maternal and physician anxiety, as well as health care costs, the routine screening for gestational diabetics with 50-g glucose tolerance tests cannot be recommended at this time." As there may be potential benefits in terms of fetal or maternal mortality or morbidity, however, it is important that a well run RCr be conducted to assess the possible clinical benefit of this intervention. We will be the first to apply a treatment or other intervention if quality studies prove its benefit, but until then we will stick to "benign neglect" and reassurance of our patients. We also find the statement, "The evidence . . . appears to be overwhelmingly in favour of universal screening, which has been found cost effective."' to be blatantly incorrect. Without an RCT showing improved benefit with interventions resulting from your screening test, there is no convincing evidence of its usefulness. Likewise, cost-effectiveness cannot be assessed. Steve Roedde, MD, CCFP
Janet McLeod, MD, CCFP Thunder Bay, Ont.
1. Levitt C. Screening for gestational diabetes, diagnosis and control: a review. Can Fam Physician 1988; 34:1957-62. 2. MacDonald D, Grant A, SheridanPereira M, Boylan P, Chalmers I. The Dublin randomized controlled trial of intrapartum heart rate monitoring. Am J Obstet Gynecol 1985; 152(5):524-39. 3. Kelso IM, Parsons J, Lawrence G, Shyam S, Edmonds K, Cooke I. An assessment of continuous fetal heart rate monitoring in labour. Am J Obstet Gynecol 1975; 131(5):526-32. 4. Haverkamp AD, Orleans M, Langendoerfer S, McFee J, Murphy J, Thompson H. The controlled trial of the differential effects of intra-partum fetal monitoring. Am J Obstet Gynecol 1979; 134:399-414. 5. Langendoerfer S, Murphy J, Orleans M, Van Doominck W. Pediatric follow up of a randomized controlled trial of intrapartum fetal monitoring techniques. J Pediatr 1986; 97:103-7. 6. Wood C, Renou P, Oats J, Farvell E, Beischer N, Anderson I. A controlled trial of fetal heart rate monitoring in a lowrisk obstetric population. Am J Obstet Gynecol 1981; 141(5):527-34.
Inappropriate Screening: A Response Drs. McLeod and Roedde raise an important concern: do the clinical and epidemiologic studies justify universal screening for gestational diabetes? The primary purpose of screening is to identify patients who have the disease in asymptomatic populations. This is worthwhile only when treatment initiated in the asymptomatic phase can be shown to reduce the risks of the outcome of the untreated or later treated disease effectively. Without universal screening, 50% of cases of gestational diabetes will go undetected. Some of these may be or may become insulin dependent and risk the increased incidence of fetal mortality. The rest (by far the majority) are at risk of fetal morbidity, macrosomia, Caesarean section, shoulder dystocia, and so forth. Singer and his colleagues have recently addressed this issue in depth and have recommended universal
screening.' There are four possible adverse effects of screening in general: the medical complications of the screening test; the false reassurance of a false-negative test result; the psychological stress of a false1235
day of menstrual flow is considered day 1). The first tablet taken is in the "red section", on the corresponding day of the week Following the arrows on the pack, the patient should continue to take one tablet each day, right through to the end of the pack Withdrawal bleeding should usually occur during the last week of tablets. The patient begins her next and all subsequent 28-day courses of tablets on the same day of the week that she began her first course, ("red section"). She continues her next course of 28 tablets immediately after the last course, regardless of whether or not a period of withdrawal bleeding is still in progress. There is no need for the patient to count days between cycles because there are no "off-tablet days". SPECIAL NOTES ON ADMINISTRATlON: ft is recommended that doses be taken at the same time each day, preferably after the evening meal or at bedtime. If Triquilar administration is initiated later than the fifth day of the first menstrual cycle of medication or post-partum, contraceptive reliance should not be placed on Triquibar until after the first 7 consecutive days of administration. The possibility of ovulabon and conception prior to initiation of medication should be considered. In the non-lactatng mother, Triquilar may be prescribed in the post-partum period either rmmediately or at the first post-partum examination, whether or not menstruation has resumed. ft spotting or breakthrough bleeding occurs, the patient is instructed to continue on the same regimen. This type of bleeding usually is transient and without significance, however, if the bleeding is persistent or prolonged, the patient is advised to consuft her physician. The patient should be instructed to take a missed tablet as soon as it is remembered. If 2 consecutive tablets are missed, they should both be taken as soon as remembered. The next tablet should be taken at the usual time. ft breakthrough bleeding occurs following missed tablets it will usually be transient and of no consequence. While there is little likelihodd of ovulabon occurring if only 1 or 2 tablets are missed, the possibility of ovulabon increases with each successive day that scheduled tablets are missed. If 3 consecubve Triquilar tablets are missed, the remainder of the package should be discarded. A new tablet cycle (package) should be started after 7 consecutive days have elapsed without tablets and an aitemate means of contraception should be prescribed during missed pill cycles, until 7 tablets of the new cycle pack have been taken. Although the occurrence of pregnancy is highly unlikely if the tablets are taken according to directions, the possibility of pregnancy should be ruled out before continuing the contraceptive regimen in patients who have missed a period of withdrawal bleeding. A supplementary method of contraception should be employed in the interim. DOSAE FORMS: ballMINltY Triquilar tablets are available: For 21-day regimens in "Triquilar 21". For 28-day regimens in "Triquilar 28". Each pack contains three different combinations in pg of levonorgestrel (d-enantiomorphe of norgestrel) and ethinyl estradiol. 11hqiia 21"-21-ay Packaw Days 1-6. Each light brown tablet contains levonorgestrel 50 jg and ethinyl estradiol 30 pg. Days 7-11. Each white tablet contains levonorgestrel 75 pg and ethinyl estradiol 40 pig. Days 12-21. Each ochreous tablet contains levonorgestrel 125 pg and ethinyl estradiol 30 pg.
"qullar 28"-28-by Packae
Six light brown tablets containing levonorgestrel 50 p1g and ethinyl estradiol 30 pg. Five white tablets containing levonorgestrel 75 pg and ethinyl estradiol 40 pgTen ochreous tablets containing levonorgestrel 125 pg and ethinyl estradiol 30 pg. Seven slightly larger inert white tablets, containing no active ingredients.
Hypertension Detection and Management
PROCEEDINGS NOW AVAILABLE This important symposium took place at the University of Calgary in October 1984. Sponsored by the College of Family Physicians of Canada, the University of Calgary and the Alberta Heritage Foundatdon for Medical Research, it brought together researchers from cardiology, genetics, public health and family practice. The symposium produced three policy statements: a protocol for iniitial assessment of high blood pressure, a protocol for managing hypertension, and a screening policy for the family physician's office. The 60-page proceedings are now available, including all of the policy statements and the full texts of the 12 papers plus the summaries of discussion.
Product monograph available upon request
60 page proceedings: $3 per copy
Discount available for quantity
Order from Canadian Family Physician 1200 Sheppard Ave. E.,#507 Willowdale, Ont. M2K 2S5 Make cheques payable to Canadian Family Physician.
BERLEX CANADA INC.X 2260 32nd Avenue, Lachine, Quebec HOT 3H4
CAN. FAM. PHYSICIAN Vol. 35: JUNE 1989
positive test result; and the medical complications of the intervention in screen-detected cases. Here the screening test (post-glucose phlebotomy) is trivial. Patients with false-negative test results probably do no worse than if they had not been screened. The psychological trauma of false-positive test results is not easily quantified but should be minimized by rapid definitive classification by full glucose tolerance testing. The intervention might lead to important toxic sequelae, such as hypoglycemia, but this risk must be small because diet is the primary therapy for gestational diabetes. Moreover, studies of pregnant patients with type 1 diabetes, where insulin use is universal, have not strongly linked maternal hypoglycemic reactions with adverse effects in the child.2 Universal screening is estimated to add $17 to the cost of prenatal care per pregnant patient ($9.62 for screening and the remainder for treatment).' It would reduce the risk of macrosomia by 2.2 per 1000 and the risk of associated birth trauma by about two in 10 000 patients. The true costs or benefits have, however, not yet been determined, as the costs for all interventions associated with diagnosis of gestational diabetes have not yet been compared with those encountered if the condition is not diagnosed. The real screening advantage is the potential to reduce neonatal deaths by identifying type 1 gestational diabetes.1 Does the intervention of diet and insulin, or diet alone early in the pregnancy, reduce the incidence of fetal and maternal complications? A recent prospective cohort study of 10 500 pregnant women3 evaluated the effectiveness of a universal early screening and intensive management program of gestational diabetes. This study gives strong objective evidence that this program works. Mazze and Langer report that the early identification and treatment of women with gestational diabetes resulted in a decrease from 34% to 15% in the incidence of macrosomia and an impressive Caesarean section rate of only 16% .3 Macrosomia contributed otherwise to a Caesarean section rate of 33% to 69% in women with diabetes, 1237
compared with 20% among nondiabetic mothers.4'5 There are still substantial uncertainties in the field of gestational diabetes screening and control. If current practice is to screen patients who are at risk and manage them with insulin or diet, then there is no doubt that all patients should be screened. At this time, the clinical and epidemiologic studies appear to justify universal screening, indicating that this route has significant benefits. Randomized controlled studies may not be feasible. Further prospective cohort studies with uniform collection would be helpful. I continue to believe that it is prudent to screen all pregnant women and to investigate further those who test positive with an oral glucose tolerance test. C. Levitt, MB, CCFP Montreal, Que.
References 1. Singer DE, Samet JH, Coley CM, Nathan DM. Screening for diabetes mellitus. Ann Intern Med 1988; 109:639-49. 2. Churchill JA, Berendes HW. Intelligence of children whose mothers had acetonuria during pregnancy. In: PAHO Advisory Committee on Medical Research, ed. Perinatal factors affecting human development. Washington, DC: Pan American Health Organization, 1969; scientific publication no. 185:30-5. 3. Mazze RS, Langer 0. Primary, secondary, and tertiary prevention. Program for diabetes in pregnancy. Diabetes Care 1988; 11:263-8. 4. Lavin JP, Lovelace DR, Miodovnik M, Knowles HC, Barden TP. Clinical experience with one hundred seven diabetic pregnancies. Am J Obstet Gynecol 1983; 147:742-52. 5. Kitzmiller JL, Cloherty JP, Younger MD, et al. Diabetic pregnancy and perinatal morbidity. Am J Obstet Gynecol 1978; 131:560-80.
Gull coined the term "anorexia nervosa," and in so doing proved that he did not really understand the condition. There is no reason to believe that bulimia is any less ancient a form of aberrant eating attitudes and behaviour than anorexia nervosa; Bell, in his scholarly work Holy Anorexia,3 cites an example that is somewhat more recognizable as bulimia than Sir Thomas Browne's patient, although it dates from the same period.
Orsola Giuliani was born in central Italy on 27 December 1660 and entered the Capuchin convent of Citta di Castello on 28 October 1677, taking the name Veronica, by which she was later canonized as a saint of the Roman Catholic Church. She led a life of rigourous, compulsive asceticism characterized by repetitive, prolonged fasting. Legend has it that one of her fasts lasted no less than five years, during which she was seen gorging in the
_i.
Ancient Reports of Bulimia I congratulate Dr. Gerald Higgins on his erudite article about bulimia.1 He is quite correct in his diagnosis: Elizabeth Mitchell did not suffer from bulimia as it is known today. I would respectfully disagree, however, with Dr. Higgins' assertion that "eating disorders and bulimia seem to be disorders of modern times," as there is abundant evidence that food refusal has been a maladaptive expression of female assertiveness2 for many centuries before Sir William 1238
WNhen there's pollen in the air, there's rhinitis throughout the land.
For hay fever, it's hard to beat a spray of Beconase Aq Few patients report stinging or irritation with Beconase Aq~It acts topically and it won't cause
drowsiness like most oral antihistamines~ This sneezin' season prescribe Beconase Aq.
CAN. FAM. PHYSICIAN Vol. 35: JUNE 1989
