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DRUG EXPIRY DATES, STORAGE, AND POTENCY
1083
The outbreaks were in summer, 1984 (village A), in autumn, 1985 (B). Children aged 1-15 years were surveyed once in village A in the last 10 days of October, 1984, and three times in village B, in the first month of outbreak, the middle period, and 20 days after the outbreak. Survey rates were 89% (164/184) and 96% (142/148), respectively. The village populations were 651 in A and 578 in B and the respective attack rates for hepatitis A in the whole village were 6.0% and 7-3%, respectively. In A the epidemic lasted 93 days and there was a clear-cut peak while in B the epidemic persisted for 131 days with no peak. Almost all the cases (97-4% and 94-5%, respectively) were in children. The following data relate to children only and for both villages combined:
sodium solution was also used in amidopyrine allergic patients and no reaction in non-allergic patients.2 In many of these subjects, passive transfer according to Prausnitz and Kustner was done.2 The word "hypersensitivity" has always been used for abnormal clinical reactivity with no pathogenetic meaning. By "ex-allergic" we refer to patients who initially had a skin-test and/or RAST positivity and later on became negative. If a patient who never underwent these tests when he was positive is examined only when skin-tests and/or RAST are negative, this subject would be included in the pseudoallergic group. As observed, the patient will show an allergic drug reaction because of immunological memory. caused
Department of Allergology, Catholic University of Rome, 00168 Rome, Italy
G. PATRIARCA
1. De Weck AL, Bundgaard H, eds. Allergic reactions to drugs. Berlin: Springer, 1983. 2. Patriarca G, Venuti A, Bonini W. Allergy to pyramidon (aminopyrine). Ann Allergy
In
village B the clinical:subclinical ratio epidemic:
was
much
1973, 31: 84-86.
higher at the
start of the
DRUG EXPIRY
DATES, STORAGE, AND POTENCY
SIR,-We share Professor Woodruffs concern about the use of time-expired drugs (Oct 1, p 798) and that expiry dates are usually for storage conditions in temperate climates. Certain drugs are heat and light labile than others.1 Thus we are trying to identify the typical temperatures that drugs endure in transport from a manufacturer in a temperate climate to a tropical destination. The temperatures and humidity for a set of regular shipments of drugs from UNICEF Copenhagen to West Africa, East Africa, and the Far East will be automatically recorded every three hours, and drug stability will be analysed. We sympathise with Woodruffsdesire to consume ’HP Sauce’ after its "best before" date and would do the same, but consider that drugs are fundamentally different. Some drugs, such as ergometrine, are potentially life-saving and their correct storage is critical, as we have reported (Aug 13, p 393). set
The ratio of
symptomatic to asymptomatic or clinical in hepatitis A infection has been put at 1:10, 1:20, or even higher, these estimates being based on numbers of anti-HAV-positive people who do not recall an episode of hepatitis.15.6 The ratios in two previous reports from China were 1:302 and 1:1 ’4. Our prospective investigation reveals a reversal of the ratio, with more clinical than subclinical cases being found. This difference is probably related to the setting, for we were looking at a remote, mountainous area with a longer epidemic cycle of hepatitis A, so that the susceptible children were older than is usual. (Young children usually experience a mild, anicteric disease, whereas in older children and adults the illness is generally more severe?) Furthermore the doctors in the villages saw all susceptible children regularly so even very mild cases would have been picked up subclinical
to
cases
eventually. Supported by grants from the Health and Medical Research Council of Hebei Province. We thank Wu Wen-ting, Li Sheng-ping, Wang Zhi-mei, Hao Guo-liang, Zhang Chang-qing, and Liu Zeng-ping for fieldwork, and Gao Shuan-jing, Du Qiu-ping, Chen Shu-fen, Liu Yan-fang, Han Shiu-lan, and others for technical assistance.
more
Action Programme on Essential Drugs, World Health Organisation 1211 Geneva 27, Switzerland
HANS V. HOGERZEIL GODFREY J. A. WALKER
1 Gilman AF, Goodman LS, Gilman A, eds. Goodman and Gilman’s the pharmacological basis of therapeutics 6th ed. New York: Macmillan, 1980.
ACE INHIBITORS Virology Department, Health and Antiepidemic Station of Hebei Province, Baoding, Hebei Province, China; and Health and Antiepidemic Station of Pingshan County, Hebei Province
SUN YONG-DE ZHANG YU-CHENG REN YIN-HAI MENG ZONG-DA
Companson of the epidemiology of hepatitis A and B. In. Deinhardt F, Deinhardt J, eds. Viral hepatitis laboratory and clinical science. New York/Basle Marcel Dekker, 1983; 129-43. 2 Zhuang H, Wang S-Q, Zhang Z-S. Study on subclinical hepatitis A infection Chin J Infect Dis 1986; 4: 191-92. 3 Xu D-Z, Zhuo W-Y, Li Y-Q, et al. An epidemiologic investigation of viral hepatitis A in kindergartens and nurseries. Natl Med J China 1985; 65: 148-50. 4 Yang N-Y, Yu P-H, Mao Z-X, et al. Silent infection by hepatitis A virus. Natl Med J China 1986; 66: 528-30. 5. Szmuness W, Purcell RH, Dienstag JL, et al Antibody to hepatitis A antigen in institutionalized mentally retarded patients. JAMA 1977; 237: 1702-05. 6 Tabor E, Jones R, Gerety RJ, et al. Asymptomatic viral hepatitis types A and B in an adolescent population. Pediatrics 1979; 62: 1026-30 7 Mosley JW The epidemiology of viral hepatitis an overview Am J Med Sci 1975; 270: 253-70 1 Gust ID
CATEGORIES OF DRUG ALLERGY
SIR,-I would like to respond to Dr Kallos and Dr West (Aug 13, p 399). Skin tests were done in our patients with drug solutions (eg, benzylpenicilloylpolylysine and benzylpenicillin) that are commonly used for this kind of diagnosis and with which no "positive" reaction is seen in non-allergic subjects.’ Moreover, in many of these patients, RAST was done (penicillin V, penicillin G). A phenyldimethylpyrazolone methylaminomethansulphonate
are obviously useful in the treatment of and congestive heart failure. Your Oct 15 editorial mentions renal dysfunction problems with these agents but your editorialist should have included a comment on the deleterious effect of ACE inhibitors on the renal function of patients with bilateral renal artery stenosis.’ This condition is thought to be rare, but over 18 months ten patients were referred to our unit with atherosclerotic renovascular disease causing renal failureThe worrying feature was that five of these cases were on ACE inhibitors; the referring physician had not suspected renal artery stenosis. We feel that any patient with renal impairment and peripheral vascular disease who is a smoker should be put on ACE inhibitors only if atherosclerotic renovascular disease has been excluded. The prevalence of atherosclerotic renovascular disease may be higher than previously thought in patients with known atherosclerotic involvement of other arteries, and injudicious use of ACE inhibitors may prove harmful to them.
SiR,—ACE inhibitors
hypertension
Renal Unit, Royal Free Hospital, London NW3 2QG
J. E. SCOBLE P. SWENY J. F. MOORHEAD
DE, Browning PJ, Kopelman R, Goomo WE, Madias NE, Dzan VJ Captopril-induced functional renal insufficiency in patients with bilateral renal artery stenosis or renal artery stenosis in a solitary kidney N Engl J Med 1983; 308:
1.Hrick
373. 2.
Scoble JE, Maher ER, Hamilton G, Dick R, Sweny P, Moorhead JF. Atherosclerotic renovascular disease causing renal impairment Renal Association, Belfast, 1988 abstr
The outbreaks were in summer, 1984 (village A), in autumn, 1985 (B). Children aged 1-15 years were surveyed once in village A in the last 10 days of October, 1984, and three times in village B, in the first month of outbreak, the middle period, and 20 days after the outbreak. Survey rates were 89% (164/184) and 96% (142/148), respectively. The village populations were 651 in A and 578 in B and the respective attack rates for hepatitis A in the whole village were 6.0% and 7-3%, respectively. In A the epidemic lasted 93 days and there was a clear-cut peak while in B the epidemic persisted for 131 days with no peak. Almost all the cases (97-4% and 94-5%, respectively) were in children. The following data relate to children only and for both villages combined:
sodium solution was also used in amidopyrine allergic patients and no reaction in non-allergic patients.2 In many of these subjects, passive transfer according to Prausnitz and Kustner was done.2 The word "hypersensitivity" has always been used for abnormal clinical reactivity with no pathogenetic meaning. By "ex-allergic" we refer to patients who initially had a skin-test and/or RAST positivity and later on became negative. If a patient who never underwent these tests when he was positive is examined only when skin-tests and/or RAST are negative, this subject would be included in the pseudoallergic group. As observed, the patient will show an allergic drug reaction because of immunological memory. caused
Department of Allergology, Catholic University of Rome, 00168 Rome, Italy
G. PATRIARCA
1. De Weck AL, Bundgaard H, eds. Allergic reactions to drugs. Berlin: Springer, 1983. 2. Patriarca G, Venuti A, Bonini W. Allergy to pyramidon (aminopyrine). Ann Allergy
In
village B the clinical:subclinical ratio epidemic:
was
much
1973, 31: 84-86.
higher at the
start of the
DRUG EXPIRY
DATES, STORAGE, AND POTENCY
SIR,-We share Professor Woodruffs concern about the use of time-expired drugs (Oct 1, p 798) and that expiry dates are usually for storage conditions in temperate climates. Certain drugs are heat and light labile than others.1 Thus we are trying to identify the typical temperatures that drugs endure in transport from a manufacturer in a temperate climate to a tropical destination. The temperatures and humidity for a set of regular shipments of drugs from UNICEF Copenhagen to West Africa, East Africa, and the Far East will be automatically recorded every three hours, and drug stability will be analysed. We sympathise with Woodruffsdesire to consume ’HP Sauce’ after its "best before" date and would do the same, but consider that drugs are fundamentally different. Some drugs, such as ergometrine, are potentially life-saving and their correct storage is critical, as we have reported (Aug 13, p 393). set
The ratio of
symptomatic to asymptomatic or clinical in hepatitis A infection has been put at 1:10, 1:20, or even higher, these estimates being based on numbers of anti-HAV-positive people who do not recall an episode of hepatitis.15.6 The ratios in two previous reports from China were 1:302 and 1:1 ’4. Our prospective investigation reveals a reversal of the ratio, with more clinical than subclinical cases being found. This difference is probably related to the setting, for we were looking at a remote, mountainous area with a longer epidemic cycle of hepatitis A, so that the susceptible children were older than is usual. (Young children usually experience a mild, anicteric disease, whereas in older children and adults the illness is generally more severe?) Furthermore the doctors in the villages saw all susceptible children regularly so even very mild cases would have been picked up subclinical
to
cases
eventually. Supported by grants from the Health and Medical Research Council of Hebei Province. We thank Wu Wen-ting, Li Sheng-ping, Wang Zhi-mei, Hao Guo-liang, Zhang Chang-qing, and Liu Zeng-ping for fieldwork, and Gao Shuan-jing, Du Qiu-ping, Chen Shu-fen, Liu Yan-fang, Han Shiu-lan, and others for technical assistance.
more
Action Programme on Essential Drugs, World Health Organisation 1211 Geneva 27, Switzerland
HANS V. HOGERZEIL GODFREY J. A. WALKER
1 Gilman AF, Goodman LS, Gilman A, eds. Goodman and Gilman’s the pharmacological basis of therapeutics 6th ed. New York: Macmillan, 1980.
ACE INHIBITORS Virology Department, Health and Antiepidemic Station of Hebei Province, Baoding, Hebei Province, China; and Health and Antiepidemic Station of Pingshan County, Hebei Province
SUN YONG-DE ZHANG YU-CHENG REN YIN-HAI MENG ZONG-DA
Companson of the epidemiology of hepatitis A and B. In. Deinhardt F, Deinhardt J, eds. Viral hepatitis laboratory and clinical science. New York/Basle Marcel Dekker, 1983; 129-43. 2 Zhuang H, Wang S-Q, Zhang Z-S. Study on subclinical hepatitis A infection Chin J Infect Dis 1986; 4: 191-92. 3 Xu D-Z, Zhuo W-Y, Li Y-Q, et al. An epidemiologic investigation of viral hepatitis A in kindergartens and nurseries. Natl Med J China 1985; 65: 148-50. 4 Yang N-Y, Yu P-H, Mao Z-X, et al. Silent infection by hepatitis A virus. Natl Med J China 1986; 66: 528-30. 5. Szmuness W, Purcell RH, Dienstag JL, et al Antibody to hepatitis A antigen in institutionalized mentally retarded patients. JAMA 1977; 237: 1702-05. 6 Tabor E, Jones R, Gerety RJ, et al. Asymptomatic viral hepatitis types A and B in an adolescent population. Pediatrics 1979; 62: 1026-30 7 Mosley JW The epidemiology of viral hepatitis an overview Am J Med Sci 1975; 270: 253-70 1 Gust ID
CATEGORIES OF DRUG ALLERGY
SIR,-I would like to respond to Dr Kallos and Dr West (Aug 13, p 399). Skin tests were done in our patients with drug solutions (eg, benzylpenicilloylpolylysine and benzylpenicillin) that are commonly used for this kind of diagnosis and with which no "positive" reaction is seen in non-allergic subjects.’ Moreover, in many of these patients, RAST was done (penicillin V, penicillin G). A phenyldimethylpyrazolone methylaminomethansulphonate
are obviously useful in the treatment of and congestive heart failure. Your Oct 15 editorial mentions renal dysfunction problems with these agents but your editorialist should have included a comment on the deleterious effect of ACE inhibitors on the renal function of patients with bilateral renal artery stenosis.’ This condition is thought to be rare, but over 18 months ten patients were referred to our unit with atherosclerotic renovascular disease causing renal failureThe worrying feature was that five of these cases were on ACE inhibitors; the referring physician had not suspected renal artery stenosis. We feel that any patient with renal impairment and peripheral vascular disease who is a smoker should be put on ACE inhibitors only if atherosclerotic renovascular disease has been excluded. The prevalence of atherosclerotic renovascular disease may be higher than previously thought in patients with known atherosclerotic involvement of other arteries, and injudicious use of ACE inhibitors may prove harmful to them.
SiR,—ACE inhibitors
hypertension
Renal Unit, Royal Free Hospital, London NW3 2QG
J. E. SCOBLE P. SWENY J. F. MOORHEAD
DE, Browning PJ, Kopelman R, Goomo WE, Madias NE, Dzan VJ Captopril-induced functional renal insufficiency in patients with bilateral renal artery stenosis or renal artery stenosis in a solitary kidney N Engl J Med 1983; 308:
1.Hrick
373. 2.
Scoble JE, Maher ER, Hamilton G, Dick R, Sweny P, Moorhead JF. Atherosclerotic renovascular disease causing renal impairment Renal Association, Belfast, 1988 abstr