478EDITORIALSANDANNOTATIONSCanadMedAss1Feb271965vol92SeverallargelaboratoriessuchasthosemaintainedbytheHealthDepartmentsoftheProvinceofSaskatchewanandtheStateofMinnesotahavedemonstratedthes ID: 510199
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Canad.Med.Ass.J.Feb.27,1963,vol.92EDITORIALSANDANNOTATIONS477pecte(landunpredictable.Injudiciousandunwar-rantedprescribingofdrugsanddiagnosticpro-cedures,as.vouldbeexpected,resultsinacor-respondingincreaseinuntowardreactions.Al-thoughmostofthesearerelativelybenignandcauselittledisabilityordistress,somegiverisetosevereorprolongeddisabilityandonoccasionmaybefatal.Asthenumberofnewagentsonthemarkethasincreasedsohasthefrequencyofdrugreactions,andthesenowconstituteasignificantcauseofhumanmorbidity.Themagnitudeofthisproblemhasbeencon-vincinglyillustratedinanumberofstudies.Barr,1in1955,estimatedthat5%ofaseriesofhospitalpatientssufferedfrommajortoxicreactionsorac-cidentsresultingfromtheuseoftherapeuticagentsordiagnosticprocedures.Inaneight-monthpros-pectivestudyofmorethan1000personsadmittedtoauniversitymedicalservice,Schimmel2demon-stratedthat20%ofthesepatientsexperiencedoneormoreuntowardreactionstoacceptablethera-peuticordiagnosticprocedurestowhichtheyweresubjectedduringtheirperiodofresidenceinhos-pital.In10%thereactionwasprolongedorunre-solvedatthedateofreporting;itresultedinpro-longationofhospitalizationorwasstillpresentatthetimeofdischargeinmorethanhalfofthepa-tientssoaffected;anditendedfatallyin16cases.Thenumberandvarietyofreactionsencounteredinthisstudywasimpressive.Acarefullydesignedsurveyconductedonthepublicmedicalserviceofanotherteachinghospitalrevealedthatapproxi-mately15%ofthepatientsadmittedoverathree-monthperiodin1963experiencedanadversedrugreactionduringtheirhospitalization.3Asemphasizedbyduff,ThorntonandSeidl,3furtherclarificationofthenatureandextentoftheproblemscreatedbyuntowardreactionstodrugsisnowurgentlyrequired.Themajorityofdrugsgiverisetoreactionsinfrequently.Todetectreactionstoanyparticularpharmaceuticalagentthereforere-quiressurveillanceoflargenumbersofpersonswhoaretakingthatformofmedication.Forthisreason,anefficientreactiondetectionprogramshouldideallycoveralargepopulationofpatientsatrisk,underobservationbyagreatmanyphysi-ciansinmultiplecentres.Meaningfulinterpreta-tionofthedatasoobtainedcanbestbeachievedbyauniformsystemofreportingandacentralizedfacilityforthecollectionandanalysisofthead-versereactionreports.Inrecentyearsvarioussystemshavebeende-visedforthispurpose.Noneoftheseisidealandeachhasitsdisadvantages.Muchremainstobelearnedconcerningtheepidemiologyofdrugre-actionsandthemosteffectivewaysandmeansofacquiringknowledgerelativethereto.Theinescap-ablefactremains,however,thatthevalueofanysystemofreportingwillvaryindirectproportiontotheinterestandextentofparticipationofthephysi-ciansonwhomsuchreportingdepends.Up-to-dateknowledgeofthepotentialhazardsofdiagnosticandtherapeuticagentsisessentialtothejudicioususeofthesesubstancesinthebestinterestsofsoundmedicalpracticeandthepublichealth.Asthemagnitudeoftheproblemscreatedbyadversedrugreactionsassumesincreasingpro-portionstheacquisitionofinformationtoassistintheircontrolandpreventionbecomesincreasinglyimportant.Theprogramforreportingofsuchreactionson.vhichtheFoodandDrugDirectoratehasem-barkedisdesignedtocollectandevaluatesuchinformation.Ifitistobeeffectiveitxvillrequiretheenthusiasticandcontinuingco-operationoftheCanadianmedicalprofessionasawhole.There-sponsibilityforthesuccessofthisimportantpro-jectrestsinnosmallpart.viththeindividualpractitioner.REFERENCES1.BARR,D.P.:.1.A.M.A.,159:1452,1955.2.SCHIMMEL,B.M.Ann.Intern.Med.,60:100.1964.1.CLT-FF,L.K,THORNTON,C.F.ANDSEIDL,L.C.:J..4.ill..4.,188:976,1964.THEVIRUSLABORATORYANDTHECLINICIANACILITIESforrapidandaccuratelaboratory.diagnosisofmanyviralillnessesarerapidlycomingwithinreachofanincreasingproportionofpractisingphysiciansthroughouttheworld.Dr.MorrisSchaeffer,1DirectorofLaboratoriesoftheNe.vYorkCityDepartmentofHealth,hasrecentlyhighlightedsomemeansbywhichviruslaboratoriesmaygreatlyassistclinicians,aswellasepidemi-ologists,inidentifyingtheetiologicalagentsre-sponsibleforsinglecasesorentireoutbreaksofvariousmaladies.TheWorldHealthOrganization'sExpertPanelonViruses,of.vhichDr.Schaefferisamember,iscurrentlypromotingtheextensionofviraldiag-nosticservicesinregionslackingthematpresent.Mostpeople,evenintechnologicallyadvancedcommunities,donothaveavailablelocallybasedlaboratories.Owingtohighcostandscarcityofskilledpersonnel,viruslaboratoriestraditionallyhavebeenconfinedmainlytomedicalcentres,governmentagencies(federal,provincial,stateormunicipal),andthearmedservices.Theperformanceofvirologicalandserologicaltestsappropriatetothepatient'sillnessdependslargelyuponthetypeofclinicalinformationsub-mittedwiththespecimen.Adviceregardingthetypeofspecimenstobeobtained,andinterpreta-tionoflaboratoryresultsinrelationshiptodiag-nosis,treatmentandprognosis,arebestprovidedbyaclinician.vhoiswellversedinvirologicalpro-cedures.Dr.Schaeffer'slaboratoryinNewYorkwillsoonhaveafull-timeconsultantphysiciantopro-videthisadvicetothepractisingprofession. 478EDITORIALSANDANNOTATIONSCanad.Med.Ass..1.Feb.27,1965,vol.92Severallargelaboratories,suchasthosemaintainedbytheHealthDepartmentsoftheProvinceofSaskatchewanandtheStateofMinnesota,havedemonstratedthesubstantialvalueofvirusdiag-nosticservicestopractisingphysiciansandhealthofficersthroughouttheirrespectiveregions.Suchlaboratoryservicesaretheproductofintimateco-operationbetweenafull-timelaboratory-orientedclinicianandahighlyproductiveviruslaboratory.Inmanysmalllaboratorieslocatedwithinteachinghospitals,amedicallyqualifiedvirologistshouldserveasaclinicalconsultantinadditiontobeinganadministratoranddirectoroftechnicalopera-tions.Increasingrapidityofexecutionofviraldiag-nosticteststhroughthewidespreadapplicationofmodemtechniquesincludingtissuecultureandimmunofluorescenc&hasassistedgreatlyindemon-stratingthepracticalvalueofvirologicalstudiesintheclinicalmanagementofmanyvirusillnesses.Forexample,isolationandtypingofpoliovirusfromfecesofapatientwithpoliomyelitis,orofmumpsvirusfromcerebrospinalfluidofapatientwithmeningitis,mayfrequentlybeaccomplishedwithinfourdaysorless.Apresumptivereportmaysome-timesbeissuedwithin48hours.However,inpatientswithsuspectedsmallpox,applicationofthenewerimmunofluorescenttechniqu&forthedetectionofpoxvirusparticlesinscrapingsofvesicleshasre-ducedonlyslightlytheonetotwohoursrequiredtodemonstrateelementaryorinclusionbodiesbythewell-establishedGutsteinorCiemsastains.Inallinstances,isolationandidentificationoftheetiologicalagentassmallpoxvirusbyinoculationofchickembryosrequiresaboutsixdaysforcompletion.3Thetimeintervalrequiredtoestablishadiag-nosisbyserologyisoftensubjecttoadelayoffourtosevendaysafterthepatientfirstreportsformedicalcare,sinceantibodyusuallydoesnotappearintheserumuntilseveraldaysaftertheonsetofsymptoms.However,inthecaseofmumpsmeningitisarisingantihemagglutinintitrehasbeendetectedinseraspacedonlytwotothreedaysapart,4orhighanti-Stitresintheabsenceofanti-Vantibodiesbycomplementfixationtestsonacute-phaseseramayindicateconcurrentinfec-tionbymumpsvirus.5Insuspectedrubellainfec-tionsduringthefirsttrimesterofpregnancy,whereitisimportanttogainexactinformationregardingtheetiologicalagentinviewofthelikelihoodofproductionoffetalabnormalities,6rapiddetectionofantibodyinconvalescent-phasematernalserabyimmunofluorescenttechniquesusingcontinuous-linetissueculturespersistentlyinfectedwithrubellavirus,7mayprovideattendingphysicianswithvitalinformationwhichwillassistinthemanagementofthesepregnancies.Theproblemofattemptingtoprovidelaboratoryconfirmationofillnessessuspectedtobeofviraletiology,onthebasisofantibodiesdetectedinsingleseraobtainedeitherafewdaysorseveralmonthsaftertheonsetofacutefebrileillnesseswithorwithoutsymptomssuchasmyalgiaorabdominalpain,continuestoperplexvirologists.Inspecificinstances,however,thedetectionofneutralizingantibodiestoCoxsackieB5virus,forexample,intheserumofachildwhodevelopedpericarditissomethreeweekspreviously,duringaseasonofhighprevalenceofthisvirus(ithadnotbeenen-counteredpreviouslyduringthelifeofthechild),wouldstronglysuggestanetiologicalrelationshipbetweenpericarditisandCoxsackieB5virus.Shippingofspecimensfromoutlyingareastovirologicallaboratoriesmaypresentproblems;especiallyunderconditionsoftropicalheatwheretheviabilityofvirusesdeclinesrapidlyathightemperatures,orinarcticcoldwherewholebloodmayfreezeandthuscreatedifficultieswithsero-logicalteststhroughtheresultanthemolysis.Undernormalconditionsinthetemperatezones,ho.vever,simplicityinshippingproceduresshouldbestressed1'.inordertoencouragesubmissionofspecimens.Insistenceuponshipmentofallspecimensinvesselscontainingdryiceisunneces-sarywhentransitoccupieslessthan48hours.Satis-factoryratesofisolationofenteroviruseshavefollowedmailingoffecesunrefrigeratedinappro-priatemailingcontainerssuppliedbyProvincialLaboratories.Cerebrospinalfluidspecimens,swabsandthroatwashingsmaybetransmittedsatis-factorilybyairexpresswhenplacedinvacuumjarscontainingiceandwater.Aprimaryaimofvirologistsengagedindiag-nosticservicesshouldbetheimprovementofexist-ingtechniquesandthedevelopmentofnewerandmorerapidproceduresbothforisolationofvirusesandforserologicaltests.Thispresupposesthatanactiveprogramofbasicand/orappliedresearchwillbeexecutedinconjunctionwiththeprovisionoffulldiagnosticfacilities.Institutionofadequatefacilitiesforclinicalconsultation,regardingboththetypeofspecimenstobesecuredattheoptimumstageduringillnessandtheinterpretationofviro-logicalresultsinrelationtoclinicalstates,willstimulateexcellentco-operationbypractisingphy-sicians,inadditiontoprovidingthemwithresultswhichoftenwillbeofconsiderablesignificanceduringmanagementofvirologicalmaladies.REFERENCES1.SCHAEFFER,M.:AntibioticNews,2:January20,1965.2.AmericanPublicHealthAssociation:Diagnosticpro-ceduresforvirusandrickettsialdiseases,editedbyE.H.LennetteandN.J.Schmidt,3rded.,NewYork,1964.3.DUMBELL,K.R.,BEDSON,H.S.ANDRossER,E.:Bull.WHO.,25:73,1961.4.MCLEAN,D.M.etal.:Canad.Med.Ass.J.,90:458,1964.5.HENLE,G.,HARRIS,S.ANDHENLE,W.:J.Bup.Med.,88:133,1948.6.SHERIDAN,M.D.:Brit.Med.,J.,2:536,1964.7.BROWN,0.c.etal.:Science,145:943,1964.8.MCLEAN,D.M.etal.:Canad.J.PublicHealth,51':94,1960.