Rx Summary
HEALTH CARE DELIVERY
Gantanol® (sulfamethoxazole Roche)
Indications Urogenital infections (cystitis, prostatitis, pyelitis and urethritis) and soft tissue infections, due to sulfonamide sensitive organisms. Contraindicatlons Sensitivity to sulfonamides. Severe liver damage; pregnancy at term and during the nursing period or in newborn or premature infants during the first few weeks of life. Precautions Perform blood counts during prolonged therapy; discontinue therapy on signs of headache, nausea, vomiting, urticaria, rash, fever or hematuria With caution in patients with impaired renal or liver function.
Baycrest Centre for Geriatric Care. Part III: Providing integrated services DAVID WOODS The Baycrest Centre for Geriatric He talks about integration of servCare is people-oriented, not medi- ices, continuity of care, the participcine-oriented, says its executive vice ation of Baycrest's residents and president, Sam Ruth. "Our major members, stressing the overall obcontribution is to provide multilevel jective of the centre as stated at care - a continuum of care - so the beginning of this series by medthat people don't get frozen out at ical director Dr. Cyril Gryfe - keepcertain points." ing people at their highest level of Mr. Ruth, who is the senior on- function (See CMAJ 119: 511, the-spot person at Baycrest, is re- 1978). sponsible for policy, planning. and Often, says Sam Ruth, it's not execution of total services at the possible to do that in the community, centre's five integrated elements - where older people may not fit in the Jewish Home for the Aged because, for instance, they're not sick (JHA), the daycare service, Baycrest enough to go to a hospital but at the Hospital, Baycrest Terrace and the same time not quite able to cope in Joseph B. and Minnie Wagman their own homes. What exists at Baycrest is not Centre. Out in the community, he says, unique in its parts, Sam Ruth beolder people can get frozen out: a lieves, but, in putting all those parts nursing home resident who needs together "we.re unique in North acute care, for example, may find it America." difficult to gain readmission to the home when the acute episode is over. Mosaic vs melting pot "The system here," says Ruth, "proBut why the Jewish factor? tects the individual at different levels of needs - social, medical, psycho- Wouldn't Baycrest be more truly inlogical." tegrated if it were more multicultural, Sam Ruth took postgraduate train- more ecumenical? Toronto is, after ing in health administration at the all, among the continent's more cosUniversity of Chicago and came to mopolitan centres. "At one time I had a dream," says Baycrest in 1956. In those days, says the former American, who became Ruth, that places like Villa Columbo a Canadian citizen 8 years ago, (which serves the Italian population "there weren't many administrators and is only 1 km from Baycrest) and around in the field of geriatrics who the Chinese, Japanese, Ukrainian and were trained as such." But that is other unicultural facilities for the changing as the geriatric population aged could be linked. But, he says, grows, he says. many of the residents speak only Like many of those involved in their own language; cultural, religious running the Baycrest Centre, Ruth and linguistic bonds make for a gives the distinct impression this isn't familiar and relaxed atmosphere. simply a job; rather, it's a whole- "Our society as a whole," he adds, "is still not fully integrated; it really hearted commitment. 812 CMA JOURNAL/OCTOBER 7, 1978/VOL. 119
Adverse reactions Discontinue therapy on the appearance of one or more of the following adverse reactions: * Blood dyscrasias: agranulocytosis, aplastic or hemolytic anemia, thrombocytopenia, hypoprothrombinemia, leukopenia, purpura or methemoglobinemia. * Allergic reactions: generalized skin eruptions, urticaria, pruritus, epidermal necrolysis, erythema multiforme, exfoliative dermatitis or other possible allergic reactions. * Gastrointestinal: nausea, vomiting, abdominal pain, diarrhea, anorexia, pancreatitis, stomatitis or hepatitis. * Central nervous system: headache, ataxia, hallucinationC, vertigo, tinnitus. Dosage Adults: 2 g initially, then 1 g every 12 hours. Children: 50 to 60 mg/kg initially, then 25to30 mg/kg every 12 hours. In severe infections, maintenance dose may be given three times daily. Continue therapy for 5 to 7 days or until patient is asymptomatic for 48 hours. Suppiy Pale green, cylindrical, biplane tablet, ROCHE engraved on one face, cross-scored on other with C in upper right and lower left quadrant; contains sulfamethoxazole 500 mg. Bottles of 100 and 500. Cherry flavoured suspension containing sulfamethoxazole - 500 mg/S ml. Bottles of 100 and 400 ml. 'Gantanoi' Dupiex Pack Containing 28 tablets Gantanol and 14 tablets Uro Gantanol'.
Uro Gantanol
(sulfamethoxazole/phenazopyridine HCI Roche') indications Urogenital infections (cystitis, prostatitis, pyelitis and urethritis), particularly those where pain exists. Contraindications Sensitivity to sulfonamides or phenazopyridine. Severe liver damage; pregnancy at term and during the nursing period or in newborn or premature infants during the first few weeks of life. Phenazopyridine is contraindicated in glomerular nephritis, pyelonephritis, uremia and severe hepatitis with gastrointestinal disturbances. Precautions Perform blood counts during prolonged therapy; discontinue therapy on signs of headache, nausea, vomiting, urticaria, rash, fever or hematuria. With caution in patients with impaired renal or liver function. Adverse reactions Discontinue therapy on the appearance of one or more of the following adverse reactions: * Blood dyscrasias: agranulocytosis, aplastic or hemolytic anemia, thrombocytopenia, hypoprothrombinemia, leukopenia, purpura or methemoglobinemia. * Allergic reactions: generalized skin eruptions, urticaria, pruritus, epidermal necrolysis, erythema multiforme, exfoliative dermatitis or other possible allergic reactions. * Gastrointestinal: nausea, vomiting, abdominal pain, diarrhea, anorexia, pancreatitis, stomatitis or hepatitis. *Central nervoussystem: headache, ataxia, hallucinations, vertigo, tinnitus. Dosage Adults: 4 tablets initially, then 2 tablets every 12 hours. Children (up to 36 kg): 2 tablets per 18 kg body weight initially, then 1 tablet per 18 kg body weight every 12 hours. After relief of pain, continued treatment with Gantanol may be considered. Note: Phenazopyridine will colour urine orange-red. Suppiy Red, cylindrical, biconvex, film-coated tablet, engraved Roche II; contains sulfamethoxazole -500 mg, and phenazopyridine HCI -100 mg. Bottles of 100 and 500. Complete prescribing information available on request.
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ann-La Roche Limited Qu4bec J7V 6B3
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is a mosaic and not a melting pot." For this reason he believes the Ontario government has done well to encourage and support these separate facilities, and even though there are at present some tenuous links among them - Villa Columbo residents, for example, use some of Baycrest's services such as audiology testing - forging stronger and closer links can be done naturally without applying a legislative soldering iron. Interviewed in his modest office in the superannuated Baycrest Hospital, overlooking the lawns and trees surrounding the more modern Jewish Home for the Aged building, Sam Ruth acknowledges that everything isn't perfect at the centre, "but we try to understand the residents and their families." There's an urgent need for a new hospital building; government reimbursement is below actual costs; there's a need to undertake more research and teaching and to develop stronger outreach programs to older people living in the surrounding community. Part of the business of being people-oriented at Baycrest involves hiring staff who can show that they're interested. "We look for people who have the potential for commitment and involvement," says Ruth, "who are sensitive, who have initiative, who are not afraid of responsibility." People-orientation also involves admitting only those who will benefit from what the centre has to offer. Determining need is an exercise assigned a good deal of importance, time and money at Baycrest. In fact, says director of intake services Walter Lyons, "we put more money into it than does any comparable place." The service goes beyond being assessment and treatment oriented; participating, functioning and deciding capabilities are sought out and fostered in Baycrest's citizens. Older people, says Lyons, are too often "shipped and sent - that's wrong." If someone's going to move to some place, any place, Lyons observes, they have to contribute to that decision. It's not a question of what they think they ought to need, of what their children want, or even of what Baycrest wants - it's what they themselves need, having thought the problem through with Baycrest's help.
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Scenes from a mosaic: Residents participate in a program recreating Kensington Market circa 1918. In backgrouiid, Baycrest Terrace with 2 storey Wagman Centre
And often that's no quick and simple matter, says Lyons, who is a social worker and former administrator of Baycrest Hospital and who clearly enjoys peeling away the soft outer layer of nuance and semantics that may conceal the real needs of Baycrest applicants. "You can't just say a person can't cope," he points out. "You have to ask why. Is it physical, mental, emotional? Is it lack of family support?" Similarly, the easily affixed label "lonely" must be questioned: "Lonely because they're pulling away from people, or because people are pulling away from them?" "We look at each application," says Lyons, "as a call for help. Our objective: to help the older person and his family to look at the factors, break those factors down and see what can be done - positively. If that can't be done, if people simply want to sit down and give up, they won't get into Baycrest. If they can benefit, they come in."
An MSW with a postgraduate certificate, Elaine Bourke heads a staff of seven social workers at the hospital, which, although part of the Baycrest Centre, serves as the chronic care hospital for northern Toronto. She oversees admissions to the 154-bed hospital. The criteria for admission are medical, and once a decision has been reached to admit someone, she or one of her staff visits the person to talk about what coming to Baycrest Hospital means - about fears, expectations and needs. In an acute care hospital, Bourke explains, people expect to get better and leave; but for many, admission to a chronic hospital may mean that health is irretrievable, there's a kind of failure. The hospital, says Ms Bourke, is non-denominational and admission isn't related to age. Of about 80 patients admitted each month, only about 20 come from Baycrest Terrace or the JHA; many are younger patients with multiple sclerosis; some admissions are for strokes, fractures Social services or for other problems requiring heavy Director of social services at Bay- nursing, catheterization for example. crest Hospital, Elaine Bourke, says About 12% of admissions to Bayshe came to the centre 6 years ago crest Hospital are for terminal care, because she knew that wherever mostly cancer patients. In all cases, Walter Lyons was, there would be says Bourke, "we as social workers a high quality of social work. relate to (patients') strengths, or the
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Aaron and Rose Sadoff have been residents at Baycrest Terrace for 2 years. He is 85, she is 79 and both came to Canada in the early 1920s from Kovno, Lithuania. Like Rebecca Lesk, whom we met in part II of this series, the Sadoffs ascribe their longevity and alertness to keeping occupied and working and having a variety of interests - especially in people. Many people today, they believe - especially young people - aren't as sincere or committed, or as interested in one another or in literature as was the case years ago. "The youth," says Rose Sadoff, "aren't idealistic, sentimental, romantic or compassionate enough; they don't try to find out what makes people tick. There's too much materialism." The Sadoffs value, above all hu-
man qualities, understanding, sensitivity, responsiveness. They admire people who fight for what they believe in; their heroes are Truman, Roosevelt and Kennedy, David BenGurion and Golda Meir, and the Israeli people. Rose, a voracious reader of histories, biographies, novels and detective stories, regards most TV fare as "trash". A former heavy cigarette smoker who developed emphysema and quit on her doctor's advice, she believes that medicine today has become too red tape ridden; there's less time and compassion. Across the lobby, in his similarly bright, neat apartment lives Hyman Bach who will be 88 in December. Mr. Bach, who will shortly marry Becky Canarick, 78, occupies himself in rug weaving and is a member
healthy part; we encourage them to take some responsibility for their own care, to ask questions, to complain if necessary, to be active, not passive. Ms Bourke talks about what she calls a client system at the hospital, a system that includes the patient, his family, friends and neighbours. The social workers try to see as many members of a family as possible, she says, to find out their concerns, to help them help one another. Part of this involves taking them on a tour of the hospital, which, Bourke frankly allows, can be a depressing experience but one that can serve to defuse possible later reaction. The building is relatively old and not purpose-built; there is no airconditioning; TV reception is indifferent. And there are a lot of sick people around.
er," says Elaine Bourke, "individualizes the generalizations of sociology and psychology. We must listen, anticipate, read between the lines."
Holding onto identity The intake social worker refers admitted patients to a floor social worker whose function, says Bourke, is to help them hold onto their identity, to help their families with feelings of helplessness, to allay patients' fears of intellectual impairment, feelings of loss, "to encourage in them as much control over their environment as is possible." "A social work-
of the Terrace's memoirs group whose book is due to be published at the end of the year. He looks 20 years younger than his actual age; again the formula appears to be work. Plus, he says, "I like people; I'm always learning." As befits a man with his surname Mr. Bach loves music; but Johann Sebastian isn't a hero. As a religious man, Mr. Bach says he doesn't make or worship any heroes. But he admires sincerity and truthfulness and he wishes above all else for harmony among nations and individuals. It's difficult to assess how typical of Baycrest's citizens are Rebecca Lesk, Hyman Bach and the Sadoffs, but they certainly epitomize the energy and participation - and the high level of function - that the centre strives to foster.
as Gryfe describes it, is the skill that physician training so often doesn't provide because MDs are taught, above all, "to change states." In a second interview Dr. Gryfe said doctors still lack the training to Lack of training help the elderly; the opportunities to These are the soft science aspects acquire the necessary skills aren't of geriatric care referred to by Bay- being made available. crest Centre's medical director Dr. Gryfe, who sees geriatric care as Gryfe, in the first of these three ar- the responsibility of the primary care ticles. The cultivation of processes, physician (who ought, none the less, to be able to refer patients to geriatrician consultants) is encouraged, though, by the new emphasis on geriatrics now increasingly found within family practice residency programs. But how about this alleged need for a specialist geriatrician? Isn't it true that - just as in fixing a vintage automobile or a modern one where the parts and the workings and the necessary tools are pretty much the same - geriatrics is simply family practice, or internal medicine, for an older population? In a way, yes, says Gryfe; but "the psychosocial dimensions of ageing and disability call for special (medical) talents. The orientation to functional capacity, rather than to cures, is not part of the internist's stock in trade." Dr. Michael Gordon, who directs A corridor in Baycrest Hospital medical services at Baycrest Terrace,
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agrees - "the family doctor should be able to refer to a geriatrician an internist with a special ability." That special ability, he believes, means catching onto the softer symptoms of geriatric patients, noticing lowgrade neurologic problems that the older patient himself might not recognize and not taking a "what do you expect? You're 80" approach to all presented problems. In addition, says Dr. Gryfe, the specialist geriatrician would apply a distinct body of knowledge, provide consultant expertise to the primary physician and identify areas for research in clinical gerontology (especially in thyroid, pulmonary and circulatory functions). Most of the residents at Baycrest Terrace, says Dr. Michael Gordon, need monitoring - what he calls Celebrating the opening of the Wagman Centre poot, March 1977 fine adjustments and occasional intervention for ongoing problems. "Our family physicians (at the Ter- happen in this age group, subtleties "Geriopharmakinetics," says he, race) have specially tuned ears that such as older people taking the right which is about as subtle as you can can pick up the kinds of things that drug but in the wrong amount. get.E '3
Symposium international: Bienfaits et risques du contr6le de Ia fertilite DENISE ROBILLARD
Des conclusions rassurantes touchant l'efficacit6 des m.thodes contraceptives, surtout la pilule et le st.rilet, mais avant tout l'affirmation qu'il faut, dans un climat serein, promouvoir une meilleure connaissance des m.thodes existantes et une approche individua1is.e et circonstanci.e pour en 6valuer les indications, tel est le bilan du symposium international sur l'.valuation du contr6le de la fertilit. qui s'est tenu . Montr6al les 12 et 13 septembre. La rencontre .tait parrain.e par la Soci.t. canadienne de fertilit6 en association avec la National Association of Family Planning Doctors de Grande-Bretagne et le Comit. national fran.ais pour la regulation des naissances. Environ 250 personnes, m.decins surtout, mais aussi infirmi.res, travailleurs sociaux, responsables de services de planning familial, invites sp&iaux en provenance de pays aussi diff.rents que le Maroc, l'Allemagne, la ThaYlande, le Japon et le Liban, ont pu entendre
27 sp.cia1istes Venus d'Australie, du Canada, des Etats-Unis, de la France, de la Grande-Bretagne et de la Su&de. Selon le Dr Jean-Henri Soutoul, pr6sident du Comit. national fran.ais pour la r.gu1ation des naissances, l'objectif de la contraception doit .tre de prot.ger la femme des grossesses non d.sir.es tout en prot.geant son potentiel de fertilit.. Ii pr6ne pour sa part une contraception nuanc.e, adapt.e, soucieuse de favoriser le d& veloppement harmonieux de la femme de fa.on .t pr.venir le recours .i 1'avortement qu'il juge actuellement excessif: "Si l'on veut commander .i la nature, ii faut savoir lui ob6ir". Le Dr Malcolm Potts de Londres, directeur du Programme international de recherche sur la ferti1it., fit lemarquer que si le contr6le de la ferti1it. est maintenant reconnu comme un droit humain fondamental, bien des attitudes restent encore . changer pour que chacun puisse effectivement jouir de cette 1ibert.. La capacit6 de
818 CMA JOURNAL/OCTOBER 7, 1978/VOL. 119
contr6ler sa ferti1it. est de nature . am6liorer la qualit6 de la reproduction humaine puisqu'elle permet . la femme de decider d'une grossesse durant la p.riode de sa vie oii elle comporte le moms de risques. La perspective de 1'.pid.miologiste est diff.rente de celle du biologiste, de I'administrateur ou de la personne concern6e, homme ou femme. Prise isoidment, chacune d'elles est incomplate; on doit tenir compte de chacune si l'on veut parvenir . tine vision plus juste de la r.alit&. Ainsi, trop souvent, fait remarquer le Dr Potts, des ddcisions quant . l'acc.s aux moyens de contr6le de la fertilit6, prises par des administrateurs et des hommes politiques . partir de donn.es .pid6rniologiques et biologiques, se r.v&1ent mal adapt6es aux besoins des personnes concem.es. L'approche .pid.miologique proc&Ie principalement . partir des taux de d.c.s et s'int6resse .t des risques peu nombreux encourus par une large population. Le probl.me est de savoir