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5-AMINOSALICYLIC ACID ENEMAS
102 5-AMINOSALICYLIC ACID ENEMAS
SIR,—When we prepared 5-aminosalicylic acid (5-ASA) enemas according to the formula given by Campieri et al.the osmolality was 540 mosmol/1 (not 390) and the pH was 5 - 5 (not 7 - 2). MODIFIED COMPOSITION OF
*
5-ASA ENEMA
Methylparahydroxybenzoate plus propylparahydroxybenzoate 1:3 (w:w).
When we changed the composition of the enema (see table) the solution had an osmolality of 410 mosmol/1 and a pH of 6 0-6 8. Triemli Hospital, 8063 Zurich, Switzerland
*/This
S. MULLER-LISSNER K. WAH M. FREY
letter has been shown
to
the
Bologna
G. MUNST F. PACE A. L. BLUM team, whose
reply
follows.-ED L.
SIR,-The pH (7-2) and osmolality (390 mosmol/1) we gave referred to the basic vehicle, which is a solution, and not to the whole enema. When the active agent (5-ASA or hydrocortisone) and a suspending agent (gum tragacanth) are added the final enema is a suspension and not a solution. We preferred to give information about the basic vehicle common to both preparations; naturally, the pH of each enema varies depending whether 5-ASA (5 - 5) or hydrocortisone (6’5) is added. To maintain 4 g of 5-ASA in suspension a pH of around 5’ 5 was necessary. If the pH is increased above 6, 5-ASA goes into solution, so it is likely that the 5-ASA in the enemas prepared by our Swiss colleagues will be, at least partly, in solution. We preferred a suspension to a solution to get a better spread of the drug in the rectal wall; and most commercial preparations of the steroids and salazopyrine are in this form. We gave the osmolality of the basic solution because measurement of osmolality in a suspension is of doubtful meaning. For several reasons (stability, pH, osmolality, suspension or solution) the best pharmaceutical formula for these enemas has yet to be devised. Our main purpose was to demonstrate the efficacy and
tolerability of high dosage 5-ASA enemas. Medical Clinic I and Pharmacy Service, Policlinico S. Orsola, 40130 Bologna, Italy
A. RAITANO T. MUSSI
S. STECCANELLA S. STRAZZARI
M. CAMPIERI G. A. LANFRANCHI C. BRIGNOLA G. BAZZOCCHI
ULTRASOUND DIAGNOSIS OF CEREBRAL ARTERIOVENOUS MALFORMATION IN THE NEWBORN
SIR,—Cerebral artenovenous malformation with aneurysmal dilatation of the great cerebral vein of Galen is an uncommon cause of heart failure in the newborn. Although clinical suspicion should be aroused bv cyanosis, cardiomegaly, prominent carotid pulsations, and a cranial bruit, the diagnosis may be missed during life3 or madt onlv bv chance when catheterisation studies reveal normal cardiac anatomy but high oxygen saturations in the superior vena cava.’ ’ We report the use ofintracramal contrast ultrasound 1
Campieri M, enemas
et
al Treatment of ulcerative colitis with
high-dose 5-aminosalicylic acid
Lancet 1981, ii: 270-71
2. Holden AM, Fyler DC, Shillito J, Nadas AS Congestive heart failure from intracranial arteriovenous fistula in infancy Pediatrics 1972; 49: 30-39 Watson DG, Smith RR, Brann AW Arteriovenous malformation of the vein of Galen Am JDis Child 1976, 130: 520-25 4 Hope R, Izukawa T Congestive cardiac failure and intracranial arteriovenous : 598-605 communication in infants and children Aust NZ J Med 1973, 3 3
Coronal ultrasound appearances before (upper scan) and after (lower scan) bolus dextrose injection via external jugular vein. LV= lateral ventricle. C:I’= choroid
plexus,
VG =
vein
of Galen
amumns
scanning as a non-invasive means of establishing this diagnosis. This technique has recently been described by Smder et al.5 A term female infant, birthweight 2 - 87 kg, had tachypnoea and feeding difficulty on the 6th day ofltfe, and was referred for cardiac investigation She had mild central cvanosis, a respiratory rate of 80/min, praecordial prominence, and a hyperdynamic cardiac impulse. A triple rhvthm and election systolic murmurvk-erc heard at the left sternal edge. The liver was palpable 5 cm below the costal margin. There were bounding upper limb pulses; the femoral pulses felt normal. Systoltc blood pressure was 80 mm Hg in the right arm, 60 mm Hg in the right leg Head circumference was 34 cm. Right
SIR,—When we prepared 5-aminosalicylic acid (5-ASA) enemas according to the formula given by Campieri et al.the osmolality was 540 mosmol/1 (not 390) and the pH was 5 - 5 (not 7 - 2). MODIFIED COMPOSITION OF
*
5-ASA ENEMA
Methylparahydroxybenzoate plus propylparahydroxybenzoate 1:3 (w:w).
When we changed the composition of the enema (see table) the solution had an osmolality of 410 mosmol/1 and a pH of 6 0-6 8. Triemli Hospital, 8063 Zurich, Switzerland
*/This
S. MULLER-LISSNER K. WAH M. FREY
letter has been shown
to
the
Bologna
G. MUNST F. PACE A. L. BLUM team, whose
reply
follows.-ED L.
SIR,-The pH (7-2) and osmolality (390 mosmol/1) we gave referred to the basic vehicle, which is a solution, and not to the whole enema. When the active agent (5-ASA or hydrocortisone) and a suspending agent (gum tragacanth) are added the final enema is a suspension and not a solution. We preferred to give information about the basic vehicle common to both preparations; naturally, the pH of each enema varies depending whether 5-ASA (5 - 5) or hydrocortisone (6’5) is added. To maintain 4 g of 5-ASA in suspension a pH of around 5’ 5 was necessary. If the pH is increased above 6, 5-ASA goes into solution, so it is likely that the 5-ASA in the enemas prepared by our Swiss colleagues will be, at least partly, in solution. We preferred a suspension to a solution to get a better spread of the drug in the rectal wall; and most commercial preparations of the steroids and salazopyrine are in this form. We gave the osmolality of the basic solution because measurement of osmolality in a suspension is of doubtful meaning. For several reasons (stability, pH, osmolality, suspension or solution) the best pharmaceutical formula for these enemas has yet to be devised. Our main purpose was to demonstrate the efficacy and
tolerability of high dosage 5-ASA enemas. Medical Clinic I and Pharmacy Service, Policlinico S. Orsola, 40130 Bologna, Italy
A. RAITANO T. MUSSI
S. STECCANELLA S. STRAZZARI
M. CAMPIERI G. A. LANFRANCHI C. BRIGNOLA G. BAZZOCCHI
ULTRASOUND DIAGNOSIS OF CEREBRAL ARTERIOVENOUS MALFORMATION IN THE NEWBORN
SIR,—Cerebral artenovenous malformation with aneurysmal dilatation of the great cerebral vein of Galen is an uncommon cause of heart failure in the newborn. Although clinical suspicion should be aroused bv cyanosis, cardiomegaly, prominent carotid pulsations, and a cranial bruit, the diagnosis may be missed during life3 or madt onlv bv chance when catheterisation studies reveal normal cardiac anatomy but high oxygen saturations in the superior vena cava.’ ’ We report the use ofintracramal contrast ultrasound 1
Campieri M, enemas
et
al Treatment of ulcerative colitis with
high-dose 5-aminosalicylic acid
Lancet 1981, ii: 270-71
2. Holden AM, Fyler DC, Shillito J, Nadas AS Congestive heart failure from intracranial arteriovenous fistula in infancy Pediatrics 1972; 49: 30-39 Watson DG, Smith RR, Brann AW Arteriovenous malformation of the vein of Galen Am JDis Child 1976, 130: 520-25 4 Hope R, Izukawa T Congestive cardiac failure and intracranial arteriovenous : 598-605 communication in infants and children Aust NZ J Med 1973, 3 3
Coronal ultrasound appearances before (upper scan) and after (lower scan) bolus dextrose injection via external jugular vein. LV= lateral ventricle. C:I’= choroid
plexus,
VG =
vein
of Galen
amumns
scanning as a non-invasive means of establishing this diagnosis. This technique has recently been described by Smder et al.5 A term female infant, birthweight 2 - 87 kg, had tachypnoea and feeding difficulty on the 6th day ofltfe, and was referred for cardiac investigation She had mild central cvanosis, a respiratory rate of 80/min, praecordial prominence, and a hyperdynamic cardiac impulse. A triple rhvthm and election systolic murmurvk-erc heard at the left sternal edge. The liver was palpable 5 cm below the costal margin. There were bounding upper limb pulses; the femoral pulses felt normal. Systoltc blood pressure was 80 mm Hg in the right arm, 60 mm Hg in the right leg Head circumference was 34 cm. Right