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THE STERILITY OF EYE MEDICAMENTS
647
constipation, and X-ray examination showed that the colon was still dilated. The Norwegian workers point out that the operation is not as radical as the Duhamel type of resection. In defence of Swenson’s operation it should be said that some pxdiatric surgeons do not make the anastomosis as far distally in the rectum as Swenson recommended. Nevertheless, Eek and Knutrud suggest that Duhamel’s modification of Swenson’s operation has much to commend it. There is general agreement that the smaller amount of dissection of the rectum which Duhamel’s method requires reduces the risk of injury to the
nerve-supply of the bladder and seminal vesicles, but
share their enthusiasm for carrying type of operation on infants Eek and Knutrud maintain that soon after birth. Duhamel’s operation at this time of life avoids a colostomy, which in infancy is well known to be associated with serious complications. The leakage of fxces from the anus amounting to partial incontinence, which occasionally followed Duhamel’s original type of operation, has undoubtedly been reduced by the modification suggested by Grob et al., 29 in which the distal end of the colon is pulled down to the internal sphincter but not through it; the sphincter is thus left at least partly intact, exerting some control over the pulled-down colon. After this operation Eek and Knutrud’s patients have not had any difficulty with control of bowel contents; they have become free of symptoms within a short time, passing spontaneous normal stools daily, and they have not had dilatation of the colon. Moreover, there have been no strictures. not every surgeon would out the Duhamel
THE STERILITY OF EYE MEDICAMENTS
The B.P.C. and the Australian Pharmaceutical Formulary do not insist that eye drops should be prepared by methods that ensure sterility. In the U.S.A. since 1953, the Food and Drug Act has required manufacturers to prepare sterile solutions and to add preservatives, but these regulations do not apply to eye drops or ointments dispensed by local and hospital pharmacists. Crompton 30 makes a forceful plea for new legislation, if the danger of spreading eye infections with contaminated lotions is to be avoided. He points out that Pseudomonas pyocyanea-the most common contaminant-can survive and flourish in aqueous solution, since it needs little substrate except water and a few salts. Moreover, it grows within a range of 4° to 42°C and will live in 4% boric acid.31 Bacillus subtilis is a well-known pathogen in the eye,32 and, because its spores are present in dust everywhere, an autoclave or a pressure cooker is essential for effective sterilisation. Infection is more likely after injuries or operations. Corneal ulceration,33 hypopyon ulcer,32 and postoperative endophthalmitis culminating in blindness 34 have been shown to follow the use of contaminated lotions, and Crompton suggests that these sequelse are not unusual, and lists the safeguards which he regards as essential.
Aqueous solutions should be prepared with water for injection B.P.C. and filtered through sintered glass. They should be packed in 5 ml. screwcap bottles or dropper bottles. Cork stoppers are well known as a source of Ps. pyocyanea, and their use should be prohibited. In hospitals, eye drops should be sterilised in an autoclave, but retail chemists could use a
pressure cooker with a copper sleeve housing a mercury thermometer. One removable 10 lb. vent-weight permits a sterilising temperature of 115°C. A temperature of 100°C is reached when the cooker is steaming without any weight. Physostigmine salts should be steamed at 100‘C for thirty minutes. Antibiotics should be dissolved in a sterile solution and dispensed in previously sterilised containers. Oily eye drops should be prepared under aseptic conditions with previously heat-sterilised oil.
Crompton says that all eye drops should incorporate a bacteriostatic, preferably chlorhexidine, which has been shown to be effective against Ps. pyocyanea in dilutions of 1 in
200,000. Fluorescin and chlorhexidine
should have
34. Allen, H. F. Trans. Amer. ophthal. Soc. 1959, 57, 377.
incom-
an
individual tube.
IDENTIFICATION OF TABLETS AND CAPSULES
IT may be important to identify a preparation that a has taken, but identification is often tedious and sometimes impossible. Collections of labelled tablets and capsules have been used for this purpose in many casualty and outpatient departments, but such collections are almost invariably incomplete and bulky, and need constant maintenance because the specimens deteriorate. The Chemist and Druggist identification charts, first published in 1956, were a great improvement. These charts consist of illustrations which make it possible to identify over 900 preparations, including most coloured capsules and tablets, and white tablets bearing some distinctive mark. But most white tablets kept their anonymity. A more complete scheme for tablet identification was proposed by McArdle and Skew.2 The diameter, colour, markings, and other characteristics of each tablet are recorded on a punch card which is easily accessible. Each card bears the number of the corresponding sample bottle in the reference collection and also contains details of confirmatory tests and of antidotes. As McArdle and Skew say, their system may be suitable for forensic science laboratories, and for large general hospitals, but it is too elaborate for small and casual users. Another method of dealing with the problem would be to imprint all tablets with an identifying code.3 A booklet with the codes could be issued to all who might need it. We must hope that some such a code will be introduced; but even if all manufacturers cooperate fully, it will take time.
patient
An ingenious and immediately practical solution has now been put forward by the American Medical Association.4 A special issue of its Journal is devoted to a comprehensive identification guide, by which over 5000 preparations The principle is similar to that can be identified. used by McArdle, but the properties of each tablet are translated into a ten-figure code number, instead of being punched on cards. In addition several measurements of each tablet are recorded to one-tenth of a millimetre, and any special markings are illustrated. By using all these data even the usually recalcitrant plain white tablets can be identified. The guide deserves careful study in this country. One like it would be very useful here. Meanwhile
29.
Grob, M., Geuton, N., Voutobel, V. Zbl. Chir. 1959, 44, 1781. 30. Crompton, D. O. Aust. J. Pharm. Oct. 30, 1962. 31. Garretson, W. T., Cosgrove, K. W. J. Amer. med. Ass. 1927, 88, 32. Duke-Elder, S. Parsons’ Diseases of the Eye. London, 1959. 33. Stanley, M. M. Amer. J. Med. 1947, 2, 347.
are
patible ; this dye should therefore be used in single-dose sterile eye drops. Lotions, particularly those containing alkaloids, should be stored in a refrigerator. Eye ointments should be sterile when supplied, and each patient
1. Chemist and
2. 3. 4.
simple measure which has been frequently
Druggist Tablet and Capsule Identification Guide, Morgan Brothers. 8s. 6d. McArdle, C., Skew, E. A. Lancet, 1961, ii, 924. Collier, W. A. L. ibid. 1962, i, 473. J. Amer. med. Ass. 1962, 182, 1145. London:
700.
a
1960.
constipation, and X-ray examination showed that the colon was still dilated. The Norwegian workers point out that the operation is not as radical as the Duhamel type of resection. In defence of Swenson’s operation it should be said that some pxdiatric surgeons do not make the anastomosis as far distally in the rectum as Swenson recommended. Nevertheless, Eek and Knutrud suggest that Duhamel’s modification of Swenson’s operation has much to commend it. There is general agreement that the smaller amount of dissection of the rectum which Duhamel’s method requires reduces the risk of injury to the
nerve-supply of the bladder and seminal vesicles, but
share their enthusiasm for carrying type of operation on infants Eek and Knutrud maintain that soon after birth. Duhamel’s operation at this time of life avoids a colostomy, which in infancy is well known to be associated with serious complications. The leakage of fxces from the anus amounting to partial incontinence, which occasionally followed Duhamel’s original type of operation, has undoubtedly been reduced by the modification suggested by Grob et al., 29 in which the distal end of the colon is pulled down to the internal sphincter but not through it; the sphincter is thus left at least partly intact, exerting some control over the pulled-down colon. After this operation Eek and Knutrud’s patients have not had any difficulty with control of bowel contents; they have become free of symptoms within a short time, passing spontaneous normal stools daily, and they have not had dilatation of the colon. Moreover, there have been no strictures. not every surgeon would out the Duhamel
THE STERILITY OF EYE MEDICAMENTS
The B.P.C. and the Australian Pharmaceutical Formulary do not insist that eye drops should be prepared by methods that ensure sterility. In the U.S.A. since 1953, the Food and Drug Act has required manufacturers to prepare sterile solutions and to add preservatives, but these regulations do not apply to eye drops or ointments dispensed by local and hospital pharmacists. Crompton 30 makes a forceful plea for new legislation, if the danger of spreading eye infections with contaminated lotions is to be avoided. He points out that Pseudomonas pyocyanea-the most common contaminant-can survive and flourish in aqueous solution, since it needs little substrate except water and a few salts. Moreover, it grows within a range of 4° to 42°C and will live in 4% boric acid.31 Bacillus subtilis is a well-known pathogen in the eye,32 and, because its spores are present in dust everywhere, an autoclave or a pressure cooker is essential for effective sterilisation. Infection is more likely after injuries or operations. Corneal ulceration,33 hypopyon ulcer,32 and postoperative endophthalmitis culminating in blindness 34 have been shown to follow the use of contaminated lotions, and Crompton suggests that these sequelse are not unusual, and lists the safeguards which he regards as essential.
Aqueous solutions should be prepared with water for injection B.P.C. and filtered through sintered glass. They should be packed in 5 ml. screwcap bottles or dropper bottles. Cork stoppers are well known as a source of Ps. pyocyanea, and their use should be prohibited. In hospitals, eye drops should be sterilised in an autoclave, but retail chemists could use a
pressure cooker with a copper sleeve housing a mercury thermometer. One removable 10 lb. vent-weight permits a sterilising temperature of 115°C. A temperature of 100°C is reached when the cooker is steaming without any weight. Physostigmine salts should be steamed at 100‘C for thirty minutes. Antibiotics should be dissolved in a sterile solution and dispensed in previously sterilised containers. Oily eye drops should be prepared under aseptic conditions with previously heat-sterilised oil.
Crompton says that all eye drops should incorporate a bacteriostatic, preferably chlorhexidine, which has been shown to be effective against Ps. pyocyanea in dilutions of 1 in
200,000. Fluorescin and chlorhexidine
should have
34. Allen, H. F. Trans. Amer. ophthal. Soc. 1959, 57, 377.
incom-
an
individual tube.
IDENTIFICATION OF TABLETS AND CAPSULES
IT may be important to identify a preparation that a has taken, but identification is often tedious and sometimes impossible. Collections of labelled tablets and capsules have been used for this purpose in many casualty and outpatient departments, but such collections are almost invariably incomplete and bulky, and need constant maintenance because the specimens deteriorate. The Chemist and Druggist identification charts, first published in 1956, were a great improvement. These charts consist of illustrations which make it possible to identify over 900 preparations, including most coloured capsules and tablets, and white tablets bearing some distinctive mark. But most white tablets kept their anonymity. A more complete scheme for tablet identification was proposed by McArdle and Skew.2 The diameter, colour, markings, and other characteristics of each tablet are recorded on a punch card which is easily accessible. Each card bears the number of the corresponding sample bottle in the reference collection and also contains details of confirmatory tests and of antidotes. As McArdle and Skew say, their system may be suitable for forensic science laboratories, and for large general hospitals, but it is too elaborate for small and casual users. Another method of dealing with the problem would be to imprint all tablets with an identifying code.3 A booklet with the codes could be issued to all who might need it. We must hope that some such a code will be introduced; but even if all manufacturers cooperate fully, it will take time.
patient
An ingenious and immediately practical solution has now been put forward by the American Medical Association.4 A special issue of its Journal is devoted to a comprehensive identification guide, by which over 5000 preparations The principle is similar to that can be identified. used by McArdle, but the properties of each tablet are translated into a ten-figure code number, instead of being punched on cards. In addition several measurements of each tablet are recorded to one-tenth of a millimetre, and any special markings are illustrated. By using all these data even the usually recalcitrant plain white tablets can be identified. The guide deserves careful study in this country. One like it would be very useful here. Meanwhile
29.
Grob, M., Geuton, N., Voutobel, V. Zbl. Chir. 1959, 44, 1781. 30. Crompton, D. O. Aust. J. Pharm. Oct. 30, 1962. 31. Garretson, W. T., Cosgrove, K. W. J. Amer. med. Ass. 1927, 88, 32. Duke-Elder, S. Parsons’ Diseases of the Eye. London, 1959. 33. Stanley, M. M. Amer. J. Med. 1947, 2, 347.
are
patible ; this dye should therefore be used in single-dose sterile eye drops. Lotions, particularly those containing alkaloids, should be stored in a refrigerator. Eye ointments should be sterile when supplied, and each patient
1. Chemist and
2. 3. 4.
simple measure which has been frequently
Druggist Tablet and Capsule Identification Guide, Morgan Brothers. 8s. 6d. McArdle, C., Skew, E. A. Lancet, 1961, ii, 924. Collier, W. A. L. ibid. 1962, i, 473. J. Amer. med. Ass. 1962, 182, 1145. London:
700.
a
1960.