- Email: [email protected]
CHILDPROOFING THE MEDICINES BOTTLE
287 PREVENTION OF POSTOPERATIVE DEEP-VENOUS THROMBOSIS VARIOUS REGIMENS OF SUBCUTANEOUS HEPARIN
* D.V.T.
BY
diagnosed by 126I-fibrinogen technique.
wards was also effective but only in cases of benign disease. The figures comparing benign and malignant cases were too small to allow firm conclusions to be drawn, and the attractions of a 3-dose regimen were such that we have since pursued the study in patients with benign conditions only. The 3-dose regimen has now been compared with only one injection of 5000 i.u. of heparin subcutaneously with the premedication, and with a control group in which no injections were given. These three groups have also been compared with the original group of patients with benign disease who received heparin for five days. The results are shown in the accompanying table. It is clear that the incidence of D.V.T. fell progressively with increasing duration of heparin prophylaxis and this trend was significant (P < 0-05). No significant difference in the incidence of complications (e.g., wound haematoma or excessive blood loss at operation) was observed between the groups. A regimen of heparin prophylaxis confined to the immediate perioperative period would have obvious advantages in terms of simplicity, a lower risk of complications, and reduced cost, if it can be shown that such a regimen is effective. The results of this study do suggest that heparin given in one or three doses will reduce postoperative D.v.T. incidence in patients with benign disease, but to a lesser extent than heparin given for five days. We therefore conclude that for subcutaneous heparin prophylaxis to be of maximum benefit, administration should continue for at least five days after operation. Department of Surgical Studies, Middlesex Hospital, London W1N 8AA.
I. GORDON SMITH L. P. LE QUESNE J. F. NEWCOMBE.
CHILDPROOFING THE MEDICINES BOTTLE SiR.—For the benefit of Mr Gartside (June 22, p. 1286) and others who may not be aware of the current status of safety packaging for medicine containers in North America, I would like to bring to their attention two important facts:
(1) There is a plethora of safety packaging for medicines bottles that is child-resistant and withstands wear. Some of the earlier mass-produced items were somewhat deficient. However, the newer ones have corrected this deficiency. Yet, even with the use of packaging that could be compromised with moderate misuse, we have been able to maintain a reduction in childhoodpoisoning rates from oral prescription drugs at our hospital of 88%
over a
7-year period, compared
to our
prior experience.
This despite the fact that two out of three of the failures of the containers that led to the accidental childhood poisoning were due to adult misuse of the container (top left off or left loose, tablets transferred to an unsafe container, tablets loose in the dresser, purse, or on the dinner-plate). Most of the children who opened the closures did so in unconventional ways (e.g. opened with the aid of the teeth, random motion). It was uncommon for a completely worn-out container to be involved in a poisoning. Yet 15-20% of the 2,121,000 safety containers used at Madigan during the past 7 years were refilled one to three times. I might add, however, that the pharmacists at this hospital would replace a defective closure with a new one if it is detected at the time of refill. Most prescriptions in U.S. Army hospitals are written for 7 to 30 days with up to three refills if indicated.
With the use of the newer closures with greater wearability, there may be a further reduction in childhood poisoning. Our biggest problem now is to find ways to encourage a small number of recalcitrant adults to use safety medicine-bottles properly-to close them after use. (2) With the use of " effective " safety packaging for the two major brands of children’s aspirin in the United States, starting in March of 1970, there has been a dramatic decrease in the number of reports of accidental ingestion by children under 5 years of age, to the National Clearing House of Poison Control Centres in the United States-from 14% of all reports in 1969 to 4-2% in 1973-a 70% decrease.
Safety packaging does decrease poisoning of children. must ask and answer the question
However, each society
for itself-is it worth the cost ? Department of Pediatrics, Madigan Army Medical Center, Tacoma, Washington 98431, U.S.A.
ROBERT G. SCHERZ.
MOBILE CORONARY CARE
SIR,-The letters of Mr Orchard (Feb. 16, p. 263, and June 8, p. 1169) and Dr Webb (March 30, p. 559) require Mr Orchard contends that trained ambulance drivers in the Brighton paramedical scheme1 are as effective in the management of acute myocardial infarction as the physician-staffed mobile coronary-care units operating in Belfast and Edinburgh. Mr Orchard cites the Brighton data1 and those from Belfast 2-6and concludes that the paramedical scheme enables patients to get help more quickly and ensures that a higher proportion reach hospital earlier. These conclusions are without validity since they are based on the erroneous assumptions that all patients with myocardial infarction in Brighton bypass their general practitioners and" are dealt with by the ambulance scheme following " 999 calls and that the Belfast schemes do not deal with 999 calls. There is no reason to believe that a paramedical unit will reach the patient more quickly than a medically staffed mobile unit. The Belfast mobile unit’s response-time to a 999 call is similar to that in Brighton. Mr Orchard assumes that, if patients are under intensive care early, it matters not how this is achieved. He appears to be unaware of the evidence that bundling patients into ambulances and rushing them to hospital is likely to be detrimental and may be hazardous. My colleagues and I found that, when patients were seen within three hours and had intensive care before transport, the incidence of shock was 4% and the hospital mortality was 10%.6 When, however, patients were admitted to hospital coronary-care units in the conventional way the mortality was 23% for those seen within three hoursand 19% for those seen within four hours.8 The better outlook for the patient managed early by a medically staffed mobile coronary-care unit presumably results from pain relief, stabilisation of rhythm, and correction of the autonomic disturbance before and during comment.
transport.9,10 An additional advantage of the medically staffed unit relates to the ability of the doctor to differentiate myocardial 1. 2. 3. 4.
5. 6. 7. 8. 9.
White, N. M., Parker, W. S., Binning, R. A., Kimber, E. R., Ead, H. W., Chamberlain, D. A. Br. med. J. 1973, iii, 618. Pantridge, J. F., Geddes, J. S. Lancet, 1966, i, 807. Pantridge, J. F., Geddes, J. S. ibid. 1967, ii, 271. Pantridge, J. F. Chest, 1970, 58, 229. Pantridge, J. F. Hosp. Management, 1970, July/August suppl. Adgey, A. A. J., Allen, J. D., Geddes, J. S., James, R. G G., Webb, S. W., Zaidi, S. A., Pantridge, J. F. Lancet, 1971, ii, 501. Pentecost, B. L., Mayne, N. M. C. Br. med. J. 1968, i, 830. Lawrie, D. M., Greenwood, T. W., Goddard, M., Harvey, A. C., Donald, K. W., Julian, D. G., Oliver, M. F. Lancet, 1967, ii, 109. Webb, S. W., Adgey, A. A. J., Pantridge, J. F. Br. med. J. 1972, iii, 89.
10.
Mulholland,
H.
C., Pantridge, J. F. Lancet, 1974, i,
1244.
* D.V.T.
BY
diagnosed by 126I-fibrinogen technique.
wards was also effective but only in cases of benign disease. The figures comparing benign and malignant cases were too small to allow firm conclusions to be drawn, and the attractions of a 3-dose regimen were such that we have since pursued the study in patients with benign conditions only. The 3-dose regimen has now been compared with only one injection of 5000 i.u. of heparin subcutaneously with the premedication, and with a control group in which no injections were given. These three groups have also been compared with the original group of patients with benign disease who received heparin for five days. The results are shown in the accompanying table. It is clear that the incidence of D.V.T. fell progressively with increasing duration of heparin prophylaxis and this trend was significant (P < 0-05). No significant difference in the incidence of complications (e.g., wound haematoma or excessive blood loss at operation) was observed between the groups. A regimen of heparin prophylaxis confined to the immediate perioperative period would have obvious advantages in terms of simplicity, a lower risk of complications, and reduced cost, if it can be shown that such a regimen is effective. The results of this study do suggest that heparin given in one or three doses will reduce postoperative D.v.T. incidence in patients with benign disease, but to a lesser extent than heparin given for five days. We therefore conclude that for subcutaneous heparin prophylaxis to be of maximum benefit, administration should continue for at least five days after operation. Department of Surgical Studies, Middlesex Hospital, London W1N 8AA.
I. GORDON SMITH L. P. LE QUESNE J. F. NEWCOMBE.
CHILDPROOFING THE MEDICINES BOTTLE SiR.—For the benefit of Mr Gartside (June 22, p. 1286) and others who may not be aware of the current status of safety packaging for medicine containers in North America, I would like to bring to their attention two important facts:
(1) There is a plethora of safety packaging for medicines bottles that is child-resistant and withstands wear. Some of the earlier mass-produced items were somewhat deficient. However, the newer ones have corrected this deficiency. Yet, even with the use of packaging that could be compromised with moderate misuse, we have been able to maintain a reduction in childhoodpoisoning rates from oral prescription drugs at our hospital of 88%
over a
7-year period, compared
to our
prior experience.
This despite the fact that two out of three of the failures of the containers that led to the accidental childhood poisoning were due to adult misuse of the container (top left off or left loose, tablets transferred to an unsafe container, tablets loose in the dresser, purse, or on the dinner-plate). Most of the children who opened the closures did so in unconventional ways (e.g. opened with the aid of the teeth, random motion). It was uncommon for a completely worn-out container to be involved in a poisoning. Yet 15-20% of the 2,121,000 safety containers used at Madigan during the past 7 years were refilled one to three times. I might add, however, that the pharmacists at this hospital would replace a defective closure with a new one if it is detected at the time of refill. Most prescriptions in U.S. Army hospitals are written for 7 to 30 days with up to three refills if indicated.
With the use of the newer closures with greater wearability, there may be a further reduction in childhood poisoning. Our biggest problem now is to find ways to encourage a small number of recalcitrant adults to use safety medicine-bottles properly-to close them after use. (2) With the use of " effective " safety packaging for the two major brands of children’s aspirin in the United States, starting in March of 1970, there has been a dramatic decrease in the number of reports of accidental ingestion by children under 5 years of age, to the National Clearing House of Poison Control Centres in the United States-from 14% of all reports in 1969 to 4-2% in 1973-a 70% decrease.
Safety packaging does decrease poisoning of children. must ask and answer the question
However, each society
for itself-is it worth the cost ? Department of Pediatrics, Madigan Army Medical Center, Tacoma, Washington 98431, U.S.A.
ROBERT G. SCHERZ.
MOBILE CORONARY CARE
SIR,-The letters of Mr Orchard (Feb. 16, p. 263, and June 8, p. 1169) and Dr Webb (March 30, p. 559) require Mr Orchard contends that trained ambulance drivers in the Brighton paramedical scheme1 are as effective in the management of acute myocardial infarction as the physician-staffed mobile coronary-care units operating in Belfast and Edinburgh. Mr Orchard cites the Brighton data1 and those from Belfast 2-6and concludes that the paramedical scheme enables patients to get help more quickly and ensures that a higher proportion reach hospital earlier. These conclusions are without validity since they are based on the erroneous assumptions that all patients with myocardial infarction in Brighton bypass their general practitioners and" are dealt with by the ambulance scheme following " 999 calls and that the Belfast schemes do not deal with 999 calls. There is no reason to believe that a paramedical unit will reach the patient more quickly than a medically staffed mobile unit. The Belfast mobile unit’s response-time to a 999 call is similar to that in Brighton. Mr Orchard assumes that, if patients are under intensive care early, it matters not how this is achieved. He appears to be unaware of the evidence that bundling patients into ambulances and rushing them to hospital is likely to be detrimental and may be hazardous. My colleagues and I found that, when patients were seen within three hours and had intensive care before transport, the incidence of shock was 4% and the hospital mortality was 10%.6 When, however, patients were admitted to hospital coronary-care units in the conventional way the mortality was 23% for those seen within three hoursand 19% for those seen within four hours.8 The better outlook for the patient managed early by a medically staffed mobile coronary-care unit presumably results from pain relief, stabilisation of rhythm, and correction of the autonomic disturbance before and during comment.
transport.9,10 An additional advantage of the medically staffed unit relates to the ability of the doctor to differentiate myocardial 1. 2. 3. 4.
5. 6. 7. 8. 9.
White, N. M., Parker, W. S., Binning, R. A., Kimber, E. R., Ead, H. W., Chamberlain, D. A. Br. med. J. 1973, iii, 618. Pantridge, J. F., Geddes, J. S. Lancet, 1966, i, 807. Pantridge, J. F., Geddes, J. S. ibid. 1967, ii, 271. Pantridge, J. F. Chest, 1970, 58, 229. Pantridge, J. F. Hosp. Management, 1970, July/August suppl. Adgey, A. A. J., Allen, J. D., Geddes, J. S., James, R. G G., Webb, S. W., Zaidi, S. A., Pantridge, J. F. Lancet, 1971, ii, 501. Pentecost, B. L., Mayne, N. M. C. Br. med. J. 1968, i, 830. Lawrie, D. M., Greenwood, T. W., Goddard, M., Harvey, A. C., Donald, K. W., Julian, D. G., Oliver, M. F. Lancet, 1967, ii, 109. Webb, S. W., Adgey, A. A. J., Pantridge, J. F. Br. med. J. 1972, iii, 89.
10.
Mulholland,
H.
C., Pantridge, J. F. Lancet, 1974, i,
1244.