Self-medication: an important aspect of primary health care

The main objective of this study was to determine the degree to which individuals practised self-medication in relation to their educational status. Kalutara, a small town in Sri-Lanka is semi-urban and has a good mixture of literates and illiterates. Important findings include the fact that knowledge of drugs was grossly inadequate, literates self-medicated far more than illiterates and a high percentage of the total sample population by-passed other health personnel in preference for Western trained doctors. Self-medication, though desirable, can be dangerous and should be emphasized as a component of primary health care because (i) it is commonly practised even where health professionals are easily accessible, (ii) it encourages self-reliance for curative, preventive, promotive and rehabilitative care and (iii) literacy, which seems to enhance its practice, is increasing worldwide.

Clinical curio: self medication with xylazine

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Phenylpropanolamine-associated hypertension after the use of "over-the-counter" appetite-suppressant products

Eight apparently normotensive Australian women patients developed hypertension after taking appetite-suppressant preparations which contained high doses of phenylpropanolamine. The margin between the maximum dose permitted to be sold in some States of Australia without prescription, and the doses documented as causing hypertension is small. Three patients took twice the recommended dose--a pattern of behaviour which has been described previously. Changes to the regulations governing the availability of phenylpropanolamine may have reduced the risk of this adverse effect, but the use and misuse of preparations still available over-the-counter may not be without danger.

Rhinitis medicamentosa

The diagnosis of rhinitis medicamentosa was made in 130 patients seen over a 10 year period from July 1967 to June 1977. There was an incidence of 1% in our otolaryngological practice. Patients had been taking the causal medication for an average of 21.4 months. There were 73 males and 57 females with the peak incidence in young and middle-age adults. The primary offending medications were decongestant nasal sprays in 85 patients, decongestant drops in 33, and a combination of these drugs in 12 patients. The major reasons for self-medication were 1. deviated nasal septum in 40 patients, 2. an acute upper respiratory infection in 33, 3. allergy in 18, 4. miscellaneous causes in 24 and 5. unknown in 15 patients. The initial management in addition to avoidance of the medication consisted of systemic antibiotics, decongestants, antihistamines, and sedatives depending on the severity of the rhinitis and the presence of secondary infection. Later treatment consisted of correction of the deviated septums, allergic management, and supportive care. Eight patients were considered to have complications of the disease by development of chronic ethmoiditis and nasal polyposis. The pharmacologic properties of the causal agents are thoroughly reviewed as they relate to the pathogenesis of this disease. It is felt that the ready commercial availability and limited clinical value of the topical nasal sprays and drops represents a certain risk to all patients using them.

Diagnosis of self-induced hyperinsulinism in an insulin-dependent diabetic patient by radioimmunoassay of free C-peptide

On the basis of results of simultaneous determinations of plasma free insulin and free c-peptide, episodes of hypoglycemia in an insulin-dependent diabetic were attributed to surreptitious self-administration of insulin. Immunoreactive c-peptide values were falsely increased and diagnostically misleading when measured in unextracted plasma. After preliminary removal of antigen/antibody complexes from the plasma by extraction with polyethylene glycol, the c-peptide values, referred to as "free c-peptide," were suppressed. We suggest that insulin antibodies formed complexes with proinsulin-like material in the plasma of this patient, which accounted for most of the c-peptide immunoreactivity in her unextracted plasma. These complexes must be removed if c-peptide measurements are to be accurate.

[Types of drug side effects and their classification]

The paper discusses side effects of the drugs and presents their classification, based on the principles of a pathogenetic approach. The classification includes side effects related to absolute and relative overdosage; specific effects, apart from the underlying one, related to the chemical structure, pharmacokinetics and pharmacodynamics; nonspecific effects due to individual features of the body.

Vitamin-D poisoning: survey of causes in 21 patients with hypercalcaemia

Hypercalcaemia developed in 21 patients due to vitamin-D poisoning; 2 were poisoned twice and 2 were poisoned three times. All patients had taken milligram doses of vitamin D, which for 5 patients was inappropriate. For the other 16 patients (mainly with hypoparathyroidism) milligram doses of vitamin D were appropriate; the patients were poisoned either early in therapy, trying to correct the plasma-calcium too quickly, or, later, because of failure to follow up patients properly. 2 patients died as a result of their intoxication. Constant vigilance is essential when patients are taking large doses of vitamin D.

[Arnica allergy]

Arnica montana L. (plant family: Compositae) is one of the oldest and most important drug plants. Besides its healing effects it also reveals sensitizing properties. From the literature more than 35 references with more than 100 cases of contact dermatitis could be cited, completed by four own cases. In most cases sensitization was induced by self treatment with tincture of Arnica, whereas occupational contact dermatitis in drug sellers of pharmacists is rare. Chemical and animal experimental investigations corroborated the high sensitizing capacity of Arnica montana L. and near related Arnica species. The low toxic threshold often causes also primary toxic skin reactions. The sesquiterpene lactones helenalin, its acetate and methacrylate have been proved to be the primary sensitizers. As more Arnica-containing drugs are entering the market it is proposed to include Arnica again in the standard test series.

Cutaneous artifactual disease. A review, amplified by personal experience

Cutaneous artifactual disease is part of the general syndrome of contrived disease. While classical examples are easy to recognize, it can present in unusual ways. Difficulties in recognition include the unusual doctor-patient relationship, the doctor's fear of missing organic disease, and the reality of the disease to the patient's family and the family doctor. The diagnosis depends upon finding lesions whose morphology is consistent and an emotionally immature patient, whose personality shows, or has shown, hysterical and masochistic traits. Lesions "arrive" fully developed. Once there they begin to heal, so that a continuous supply of new ones is necessary if the illness is to continue. High intelligence is compatible with the diagnosis, but a mature personality is not. The differential diagnosis is extensive. Investigations prove negative or equivocal; in the latter case, the investigator is led even further into unfamiliar territory. It is suggested that the essence of management is to keep in contact with the patient.

[Bowen carcinoma following many years' use of a "radium cushion" (author's transl)]

A case is reported of a 73-year old female patient in whom precancerous symptoms appeared in the mid-abdominal area of application which for a long time were mistaken for chronic eczema, until after 7 years the development of a skin carcinoma was clinically and histologically confirmed. The case provides a reason to draw attention to the "Radium Cushion" and to restate publicly that they should be delivered to the health authorities. Suspected cases must be thoroughly investigated medically.

Surgical postoperative bleeding associated with aspirin ingestion. Report of two cases

Two patients are reported in whom repeated postoperative hematomas appeared to be secondary to aspirin-induced platelet defect. Routine bleeding and clotting studies will not demonstrate this platelet-induced coagulopathy. A previous history of massive aspirin ingestion makes such a coagulopathy a serious consideration, but the platelet defect may occur with small doses of aspirin. Such aspirin ingestion should be viewed with great concern by the neurosurgeon. The defect is treatable by platelet transfusion.

Self-injected retinal emboli

Twelve patients with bilateral intraretinal talc emboli were examined. Each patient had self-injected large doses of methylphenidate (Ritalin) for one or more years. All fundi showed yellow-white particles in the macular area, and two eyes had reduced vision secondary to retinal vascular occlusion. The clinical syndrome, ophthalmoscopic appearance, and fluorescein angiographic findings of self-injected retinal emboli are presented, and the pathogenesis is discussed.

Factitious hypoglycemia. Diagnosis by measurement of serum C-peptide immunoreactivity and insulin-binding antibodies

In seven patients with factitious hypoglycemia due to the surreptitious injection of insulin, we made the diagnosis by measurements of plasma insulin and C-peptide immunoreactivity (in seven patients), facilitated by the finding of circulating insulin-binding antibodies (in two patients). The simultaneous demonstration of low plasma glucose, high immunoreactive insulin and suppressed C-peptide immunoreactivity represents a triad of results pathognomonic of exogenous insulin administration. Determination of plasma free C-peptide and free insulin permitted patients with high titers of insulin antibodies, including those with a history of insulin-treated diabetes, to be studied and diagnosed in a way similar to that in subjects who had no circulating insulin antibodies.

Epileptic seizures induced by psychotropic drugs

On the basis of information abstracted from case histories, 41 patients who had experienced epileptic seizures thought to be due either to treatment with psychiatric drugs or to withdrawal from sedative drugs were compared with a control group of patients. Those who had experienced seizures were more commonly first born and had a history of post-natal brain damage. During the week preceding the seizure there had been a marked increase in drug prescribing. The implications for drug management are discussed.

Immune haemolytic anaemia and renal failure induced by streptomycin

A case of acute immune haemolytic anaemia and renal failure induced by streptomycin, is reported. The clinical features are similar to those in a case previously reported in which no in vitro proof of antibodies was obtained. In this case, streptomycin-specific IgG antibodies, with both k and lambda light chains, could be demonstrated. The streptomycin bound strongly to the red cell membrane, apparently through chemical groups related to the M antigen and possibly also to the D antigen. Complement-fixation by the drug-specific IgG antibodies, after reaction with the streptomycin-coated red cells, could also be demonstrated. On the basis of these findings, our conclusion is that a complement-fixing hapten-cell mechanism was the main cause of the intravascular haemolytic episode suffered by the patient on exposure to streptomycin. This drug had been prescribed 15 years earlier for pulmonary tuberculosis and he had since injected himself with it whenever he felt "flu" symptoms, without harmful effects, until now.