Lasix
Indications-Oral: Edema associated with congestive heart failure, cirrhosis of the liver and renal disease including the nephrotic syndrome and other edematous states. Mild to moderate hypertension or with other antihypertensive agents in more severe cases. Parenteral: Acute pulmonary edema, cerebral edema or when oral therapy is precluded. Contraindications: Complete renal shutdown. Discontinue if Increasing azotemia and oliguria occur during treatment of severe progressive renal disease. In hepatic coma, in states of electrolyte depletion, hypovolemia or hypotension, do not institute therapy until the basic condition is improved or corrected. Do not administer to jaundiced newborn infants or to infants suffering from diseases with the potential of causing hyperbilirubinemia and possibly kernicterus. Warnings: Lasix is a potent diuretic requiring careful medical supervision. Dose and dose schedule have to be adjusted to the individual patient's needs. Cases of tinnitus and reversible deafness have been reported. There have also been some reports of cases, the majority in children undergoing renal transplantation, in which permanent deafness has occurred. Hearing impairment is more likely to occur in patients with severely reduced renal function who are given large doses of Lasix parenterally, at a rate exceeding 4 mg/mm or in patients also receiving drugs known to be ototoxic. Do not use in pregnant women unless the benefits outweigh the possible risks to the foetus. Sulfonamide diuretics have been reported to decrease arterial responsiveness to pressor amines and to enhance the effects of tubocurarine. Exercise caution in administering curare or its derivatives during Lasix therapy. Discontinue 1 week prior to elective surgery. Precautions: Excessive diuresis may result in circulatory collapse or vascular thrombosis. It is essential to maintain fluid and electrolyte balance. During long-term therapy a high-potassium diet is recommended. Potassium supplements should be given when high doses are used over prolonged periods. Particular caution with potassium levels is desirable in patients on digitalis glycosides, potassium-depleting steroids, or in infants and children. Potassium supplementation, diminution in dose, or discontinuation of Lasix may be required. Strict restriction in sodium intake is not advisable. Potassium supplements and aldosterone antagonists may be added when treating hepatic cirrhosis with ascites. Sudden alterations of fluid and electrolyte balance in patients with cirrhosis may precipitate hepatic coma. In edematous hypertensives reduce the dosage of other antihypertensives since Lasix potentiates their effects. Monitor urine and blood glucose as decreased glucose tolerance has been observed. Monitor serum calcium levels particularly In children receiving i.v. Lasix, as rare cases of tetany have been reported. Simultaneous administration with cephaloridine is not advisable. Patients receiving high doses of salicylates with Lasix may experience sail cylate toxicity at lower doses. Lasix parenteral in doses up to 100 mg should be injected slowly (1-2 minutes) when the iv. route is used. Adverse reactions: Electrolyte depletion may occur especially with high doses and restricted salt intake; it may manifest Itself by weakness, dizziness, lethargy, leg cramps, anorexia, vomiting and/or mental confusion. Asymptomatic hyperuricemia can occur and gout may rarely be precipitated. Transient elevations of BUN may be seen especially in renal insufficiency. Dermatitis, pruritus, parest heals, blurring of vision, postural hypotension, nausea, vomiting or diarrhea may occur. Anemia, leukopenia, and thrombocytopenia (with purpura) and rare cases of agranulocytosis have occurred. Overdosage-Symptoms: Dehydration, electrolyte depletion and hypotension. Hepatic coma may be precipitated in cirrhotic pat lents. Treatment: Discontinue Lasix and apply corrective treatment. Dosage and administration -Adults: Oral-Edema: Usual initial dosage is 40-80 mg. Adjust according to response. If diuresis has not occurred after 6 hours, increase dosage by increments 20-40 mg. The effective dose can then be repeated 1 to 3 times daily. Maximum daily dose: 200 mg. Maintenance dosage must be adjusted individually. An intermittent dosage schedule of 2-4 consecutive days each week may be utilized. With doses exceeding 120 mg/day, clinical and laboratory observations are advisable. Hypertension: Usual dosage is 20-40 mg twice daily. Individualize therapy and adjust dosage of concomitant antihypertensive therapy. Parenteral: Usual dosage is 20-40 mg given as a single dose, injected in. or iv. The iv. injection should be given slowly (1-2 minutes), and should not be added into the tubing of a running infusion solution. Ordinarily, a prompt diuresis ensues. If diuresis is not satisfactory, succeeding doses may be increased by increments of 20mg 2 hours after the previous dose, until the required diuresis is obtained. Maximum daily dose: 100 mg. Switch to oral therapy as soon as practical. Acute pulmonary edema: Administer 40 mg by slow i.v. injection, followed if necessary by another 40 mg 1-1½ hours later. Pediatric use: Institute therapy under close observation in the hospital. Initial oral or parenteral dose is 0.5-1 mg/kg. The total daily dose should not exceed 2 mg/kg orally or 1 mg/kg parenterally, given in divided doses 6-12 hours apart. In newborn and prematures, the daily dose should not exceed 1 mg/kg. Particular caution with potassium levels is desirable. Adopt an intermittent dosage schedule as soon as possible. Lasix should not be added into the tubing of a running infusion solution. Supply: White, round, 20 mg tablets (Code DLF) in bottles of 30 and 300. Yellow, round, scored 40 mg tablets (Code DLI) in bottles of 50 and 500 and Unit Dose boxes of 100. Amber ampoules of 2 ml (20 mg) in boxes of 5 and 50; 4 ml (40 mg) in boxes of 50. Product monograph on request. 1364/7096 E.
Lasix Special
present health care delivery system and that annual cytologic screening of the cervix is a reasonable safeguard against cancer.
Composition: Each tablet contains 500 mg furosemide. Each 25 ml ampoule contains 250 mg furosemide. indIcatIons-Exclusively for patients with severely impaired renal function. To be used under strict medical supervision within a hospital setting. May be used as an adjuvant treatment of oliguria and of edema in selected patients with acute renal failure or with chronic renal failure or with the nephrotic syn. drome. Contraindlcatlons: Complete renal shutdown and G.F.R. below S mi/mm. In patients whose G.F.R. is above 20 mI/mm. In patients with hepatic cirrhosis or with renal failure due to poisoning with nephrotoxic or hepatotoxic substances, or with renal failure accompanied by hepatic coma. Severe hypokalemia, hypovolemia or hypotension until serum potassium, fluid balance and blood pressure have been restored to normal. Warnings: Cases of tinnitus and reversible deafness have been reported. There have also been some reports of cases, the majority in children undergoing renal transplantation, in which permanent deafness has occurred. Hearing impairment is more likely to occur in patients with severely reduced renal function who are given large doses of Lasix parenterally, at a rate exceeding 4 mg/mm or in patients also receiving drugs known to be ototoxic. Do not use in pregnant women unless the benefits outweigh the ossible risks to the foetus. Sulfonamide diuretics ave been reported to decrease arterial responsiveness to pressor amines and to enhance the effects of tubocurarine. Exercise caution in administering curare or its derivatives during Lasix therapy. Discontinue 1 week prior to elective surgery. Do not administer to jaundiced newborn infants or to infants suffering from diseases with the potential of causing hyperbi irubinemia and possibly kernicterus. PrecautIons: Excessive diuresis may result in circulatory collapse or vascular thrombosis. It is essential to maintain fluid and electrolyte balance. During long-term therapy a high potassium diet is recommended. Potassium supplements should be given when high doses are used over prolonged periods. Particular caution with potassium levels is desirable in patients on digitalis glycosides, potassium-depleting steroids, or in impending hepatic coma. Potassium supplementation, diminution in dose, or discontinuation of Lasix may be required. Strict restriction in sodium intake is not advisable. In edematous hypertensives reduce the dosage of other antihypertensives since Lasix potentiates their effects. Monitor urine and blood glucose as decreased glucose tolerance has been observed. Monitor serum calcium levels as rare cases of tetany have been reported. The simultaneous administration of Lasix and cephaloridine is not advisable. Patients receiving high doses of salicylates with Lasix may experience salicylate toxicity at lower doses. Rate of infusion should not exceed 4 mg/mm. Adverse reactIons: Electrolyte depletion may occur especially with high doses and restricted salt intake; it may manifest itself by weakness, dizziness, lethargy, leg cramps, anorexia, vomiting and/or mental confusion. Asymptomatic hyperuricemia can occur and gout may rarely be precipitated. Transient elevations of BUN may be seen especially in renal insufficiency. Dermatitis, pruritus, paresthesia, blurring of vision, postural hypotension, nausea, vomiting, or diarrhea may occur. Anemia, leukopenia, and thrombocytopenia (with purpura) and rare cases of agranulocytosis have occurred. Over* dosage-Symptoms: Dehydration electrolyte depletion and hypotension. Treatment: Discontinue drug and institute appropriate corrective treatment. Dosage and Admlnlstratlon-ParenteraI: Initial dose of 250mg are mixed with 250 ml of a suitable infusion solution and given by intravenous drip at a rate not exceeding 4 mg/mm. Additional dose of 500 mg should be given if initial dose fails to produce an adequate increase in urinary output after one hour. The effective dose can be repeated every 24 hours. A maximum daily dose of 1000 mg should not be exceeded. Lasix Special 250 mg can be mixed to 250 ml of 5% dextrose in water, isotonic saline or lactated Ringer's injection, immediately before use. Precipitation may occur in solutions with a pH of the mixture less than 5.5. Not to be added into the tubing of a running infusion solution, and not to be mixed with any other drugs in the infusion bottle. If indicated as in case of hypervolemic patients, the i.v. infusion of the undiluted solution must be given with the aid of a motor-driven precision syringe so as to make sure that the upper limit of 4 mg Lasix (0.4 ml) per minute is not exceeded. Oral: Effective intravenous dose is used as the initial dose. Additional dose may be raised by 250 to 500 mg should the initial dose fail to produce an adequate urinary output within 4-6 hours. The maximum daily dose of 1000 mg should not be exceeded. Supply: Yellow round, quarter-scored 500 mg tablets (Code DLX) in bottles of 20. Amber ampoules of 25 ml (250 mg) in a sterile solution at pH of 9.1. Product Monograph on request. 1368/7106 E.
Hoechst
Pharmaceutical Division. Canadian Hoechst Ltd
Montreal
Orro A. SCHMIDT, MD, FRC5[C], FRCOG, FACOG President, Society of Obstetricians and Gynsecologists of Canada Ste. 1102, 233 Kennedy St. Winnipeg, Man.
Continuing medical education To the editor: There must have been an error in either the flag or the heading for J. L. Chouinard's article on the current state of continuing medical education (CME) (Can Med Assoc J 115: 1121, 1976). This dissertation surely belongs in a "Notes from the Past" section. Mr. Chouinard is undoubtedly attempting to be provocative and he has succeeded admirably. There is unquestionably a great need for improvement in CME in Canada; however, many provincial medical associations, governments and medical schools in Canada over the past 20 years have been diligently trying to correct the ancient problems that Mr. Chouinard describes as "current". Teaching and learning in many Canadian CME programs with the best available techniques and the services of well trained educational consultants are being used regularly. Medical school faculties today do not "teach as they were taught". The curricula of most Canadian medical schools have been thoroughly revised in recent years. The undergraduate, graduate and continuing education programs of our universities place great emphasis on small group and individual learning. Lectures play a much smaller but still very important role in our educational programs. Physician-learners are taking an active part in the identification of learning and performance needs and priorities. Their part, however, cannot be a dominant one. Teachers and consultants must take the initiative. The learner provides valuable guidance in setting priorities and deciding upon achievability since he is most familiar with his clientele and the details of locally available resources. It is true that CME courses enjoy "limited popularity". How can it be otherwise when there is little or no incentive to Canadian physicians to participate? In fact, physicians lose hundreds of dollars every time they attend a refresher course and the expenses involved are not income-tax deductible. This clearly is a problem for the profession and the public. We strongly support Mr. Chouinard's view that research into promising approaches to CME is urgently needed. The recruitment for funding for this
CMA JOURNAL/MAY 7, 1977/VOL. 116 975
purpose could be a constructive project References for the Canadian Medical Association. 1. DONNELLY FA, WARE JE, WOLKON GH, Ct al: Evaluation of weekend seminars for physicians. There is substantial evidence that / Med Educ 47: 184, 1972 participation in CME improves not only 2. WILLIAMS 1W, ALEXANDER M, MILLER GE: Continuing education and patient care rethe knowledge and performance of search. JAMA 201: 938. 1967 physicians but also the outcome of pa3. BROWN CR JR, UHL HSM: Mandatory continuing education. Sense or nonsense? JAMA tients. At least 10 good articles1-10 have 213: 1660. appeared during the past 6 years to sup- 4. BROWN CR:1970. Continuing education in community hospitals: a manual for program deport this statement. velopment. N Engi J Med 284 (suppi): 20. The "Brownie point" system, which 1971 HAZLEi-r CB, BAcHYNSKI JE, EMBLETON 1: requires that physicians take 20 to 50 5. Evaluation of on-campus continuing medical education programs in Alberta. Can Med hours of CME annually, is of dubious Assoc J 108: 1282, 1973 value. Reports from our American col6. REID DE, LAPENAS C, ROGERS KD: Continuleagues suggest that the legislation or ing education based on record audit in a community hospital. J Med Educ 48: 1152, adoption of mandatory hours of CME 1973 7. FLEISHER DS, BROWN CR, ZELENIK C, et al: by government or medical associations Mandate project - institutionalizing a system has done little harm. It is, in fact, a relaof patient care quality assurance. Pediatrics 57: 775, 1976 tively inexpensive way of assuring parti8. WILLIAMSON JW: Health accounting: an outcipation in a process that most of us come-based system of quality assurance: illustrative application to hypertension. Bull NY believe contributes to improved quality Acad Med 51: 727, 1975 of patient care. Unfortunately, preoc9. ASHBAUGH DG, McKEAN RS: Continuing medical education: the philosophy and use of cupation with spending hours at courses audit. JAMA 236: 1485, 1976 draws attention away from the more 10. INUI TS, YOURTTE EL, WILLIAMSON JW: Improved outcomes in hypertension after important issues of assured quality paphysician tutorials - a controlled trial. Ann Intern Med 84: 646, 1976 tient care and satisfactory outcomes. Since available time and money for CME is limited, I favour giving the To the editor: Dr. Laxdal, on behalf of highest priority to performance and his professional program-producer coloutcome studies, which will ensure ade- leagues, has taken the bait. Readers quate attention to the most important must decide for themselves the validity of his statements. learning needs. I disagree, however, with one of Dr. The fostering of favourable attitudes towards "life-long learning" is being Laxdal's main themes. He says physiemphasized in Canadian medical cian-learners cannot have a dominant schools. A number of approaches are part in the identification of learning and performance needs and priorities. being made, including the following: 1. Expansion of available elective This attitude, I submit, is a major reason why CME remains largely acclasses. 2. Less emphasis on marks and adop- tivity-oriented instead of goal-directed. tion of pass-fail systems rather than Programs such as those described in the above references, in which the grade-point scoring systems. 3. Introduction of problem- and learner is responsible for determining patient-oriented learning early in the educational needs, and for designing, implementing and participating in a curriculum. 4. Expanded and improved self-in- program directed to resolving these needs and evolving into appropriate structional resources. Many problems of CME could be follow-up of the educational process, solved if its great potential role in the are the most successful. assurance of high-quality patient care J.L. CHOUINARD were acknowledged. Very few univerCoordinator, Council on Medical Education Canadian Medical Association sities allocate more than 2 to 3% of the total medical college budget to CME. With improved staffing, funding and general support, CME offices could The Compendium of contribute at least as much to the gen- Pharmaceuticals and Specialties eral quality of patient care in Canada To the editor: Dr. Warren Bell has quite as undergraduate programs. properly questioned the adequacy of the Directors of CME across Canada "Compendium of Pharmaceuticals and would undoubtedly join me in thanking Specialties" (CPS) (Can Med Assoc J Mr. Chouinard for his bold attempt to 116: 349, 1977). One wishes the opporbe provocative in the field of CME. tunity were available to him to develop He has ably drawn attention to the his arguments more fully so that the considerable need for greater recogni- claim by Mr. J. C. Turnbull of the tion and support for CME. In view of Canadian Pharmaceutical Association the large amount of constructive work (Can Med Assoc J 116: 349, 1977) that that has been done in recent years, CME Dr. Bell's comments lack objectivity cannot be dismissed as a euphemism could be examined critically. Certainly for "courses the rebuttal by Mr. Turnbull does not O.E. LAxJ.L, MD weaken the thrust of Dr. Bell's arguDirector of continuing medical education ments. Dr. Bell suggests that an alternaUniversity of Saskatchewan tive to the CPS is required; it would be Saskatoon, Sask. 976 CMA JOURNAL/MAY 7, 1977/VOL. 116
Cortisporin Otic Drops A leader in the field of otological therap
.Cortisporifl: Otic Drops (Polymyxin B-Neomycin-Hydrocortisone) Sterile
INDICATIONS: External otitis, otitis media with perforated tympanic membrane, infections of mastoidectomy and fenestration cavities. CONTRAINDICATIONS: This product is contraindicated in tuberculous, fungal or viral lesions (herpes simplex, vaccinia and varicella) also inthose individuals who have shown hypersensitivity to any of its components. CAUTiON: This product should be used with care in cases of perforated ear drum and in long-standing cases of chronic otitis media, because of the danger of ototoxicity. As with any antibiotic preparation, prolonged use may result in the overgrowth of non-susceptible organisms, including fungi. Appropriate measures should be taken if this occurs. DOSAGE: 3 or 4 drops in ear 3 to 4 times daily or more frequently in acute conditions if required. SUPPLIED: Each ml contains: polymyxin B sulfate 10,000 units, neomycin sulfate 5 mg, hydrocortisone 10 mg (1%) in sterile aqueous suspension. Available in 7 ml plastic dropper bottles. Also available: CORTISPORIN Ointment 3.5 g tube. Additional product information available on request.
Calmic Limited . Montreal. Toronto
A Welicome Company .Trade Mark
03020
Indications-Oral: Edema associated with congestive heart failure, cirrhosis of the liver and renal disease including the nephrotic syndrome and other edematous states. Mild to moderate hypertension or with other antihypertensive agents in more severe cases. Parenteral: Acute pulmonary edema, cerebral edema or when oral therapy is precluded. Contraindications: Complete renal shutdown. Discontinue if Increasing azotemia and oliguria occur during treatment of severe progressive renal disease. In hepatic coma, in states of electrolyte depletion, hypovolemia or hypotension, do not institute therapy until the basic condition is improved or corrected. Do not administer to jaundiced newborn infants or to infants suffering from diseases with the potential of causing hyperbilirubinemia and possibly kernicterus. Warnings: Lasix is a potent diuretic requiring careful medical supervision. Dose and dose schedule have to be adjusted to the individual patient's needs. Cases of tinnitus and reversible deafness have been reported. There have also been some reports of cases, the majority in children undergoing renal transplantation, in which permanent deafness has occurred. Hearing impairment is more likely to occur in patients with severely reduced renal function who are given large doses of Lasix parenterally, at a rate exceeding 4 mg/mm or in patients also receiving drugs known to be ototoxic. Do not use in pregnant women unless the benefits outweigh the possible risks to the foetus. Sulfonamide diuretics have been reported to decrease arterial responsiveness to pressor amines and to enhance the effects of tubocurarine. Exercise caution in administering curare or its derivatives during Lasix therapy. Discontinue 1 week prior to elective surgery. Precautions: Excessive diuresis may result in circulatory collapse or vascular thrombosis. It is essential to maintain fluid and electrolyte balance. During long-term therapy a high-potassium diet is recommended. Potassium supplements should be given when high doses are used over prolonged periods. Particular caution with potassium levels is desirable in patients on digitalis glycosides, potassium-depleting steroids, or in infants and children. Potassium supplementation, diminution in dose, or discontinuation of Lasix may be required. Strict restriction in sodium intake is not advisable. Potassium supplements and aldosterone antagonists may be added when treating hepatic cirrhosis with ascites. Sudden alterations of fluid and electrolyte balance in patients with cirrhosis may precipitate hepatic coma. In edematous hypertensives reduce the dosage of other antihypertensives since Lasix potentiates their effects. Monitor urine and blood glucose as decreased glucose tolerance has been observed. Monitor serum calcium levels particularly In children receiving i.v. Lasix, as rare cases of tetany have been reported. Simultaneous administration with cephaloridine is not advisable. Patients receiving high doses of salicylates with Lasix may experience sail cylate toxicity at lower doses. Lasix parenteral in doses up to 100 mg should be injected slowly (1-2 minutes) when the iv. route is used. Adverse reactions: Electrolyte depletion may occur especially with high doses and restricted salt intake; it may manifest Itself by weakness, dizziness, lethargy, leg cramps, anorexia, vomiting and/or mental confusion. Asymptomatic hyperuricemia can occur and gout may rarely be precipitated. Transient elevations of BUN may be seen especially in renal insufficiency. Dermatitis, pruritus, parest heals, blurring of vision, postural hypotension, nausea, vomiting or diarrhea may occur. Anemia, leukopenia, and thrombocytopenia (with purpura) and rare cases of agranulocytosis have occurred. Overdosage-Symptoms: Dehydration, electrolyte depletion and hypotension. Hepatic coma may be precipitated in cirrhotic pat lents. Treatment: Discontinue Lasix and apply corrective treatment. Dosage and administration -Adults: Oral-Edema: Usual initial dosage is 40-80 mg. Adjust according to response. If diuresis has not occurred after 6 hours, increase dosage by increments 20-40 mg. The effective dose can then be repeated 1 to 3 times daily. Maximum daily dose: 200 mg. Maintenance dosage must be adjusted individually. An intermittent dosage schedule of 2-4 consecutive days each week may be utilized. With doses exceeding 120 mg/day, clinical and laboratory observations are advisable. Hypertension: Usual dosage is 20-40 mg twice daily. Individualize therapy and adjust dosage of concomitant antihypertensive therapy. Parenteral: Usual dosage is 20-40 mg given as a single dose, injected in. or iv. The iv. injection should be given slowly (1-2 minutes), and should not be added into the tubing of a running infusion solution. Ordinarily, a prompt diuresis ensues. If diuresis is not satisfactory, succeeding doses may be increased by increments of 20mg 2 hours after the previous dose, until the required diuresis is obtained. Maximum daily dose: 100 mg. Switch to oral therapy as soon as practical. Acute pulmonary edema: Administer 40 mg by slow i.v. injection, followed if necessary by another 40 mg 1-1½ hours later. Pediatric use: Institute therapy under close observation in the hospital. Initial oral or parenteral dose is 0.5-1 mg/kg. The total daily dose should not exceed 2 mg/kg orally or 1 mg/kg parenterally, given in divided doses 6-12 hours apart. In newborn and prematures, the daily dose should not exceed 1 mg/kg. Particular caution with potassium levels is desirable. Adopt an intermittent dosage schedule as soon as possible. Lasix should not be added into the tubing of a running infusion solution. Supply: White, round, 20 mg tablets (Code DLF) in bottles of 30 and 300. Yellow, round, scored 40 mg tablets (Code DLI) in bottles of 50 and 500 and Unit Dose boxes of 100. Amber ampoules of 2 ml (20 mg) in boxes of 5 and 50; 4 ml (40 mg) in boxes of 50. Product monograph on request. 1364/7096 E.
Lasix Special
present health care delivery system and that annual cytologic screening of the cervix is a reasonable safeguard against cancer.
Composition: Each tablet contains 500 mg furosemide. Each 25 ml ampoule contains 250 mg furosemide. indIcatIons-Exclusively for patients with severely impaired renal function. To be used under strict medical supervision within a hospital setting. May be used as an adjuvant treatment of oliguria and of edema in selected patients with acute renal failure or with chronic renal failure or with the nephrotic syn. drome. Contraindlcatlons: Complete renal shutdown and G.F.R. below S mi/mm. In patients whose G.F.R. is above 20 mI/mm. In patients with hepatic cirrhosis or with renal failure due to poisoning with nephrotoxic or hepatotoxic substances, or with renal failure accompanied by hepatic coma. Severe hypokalemia, hypovolemia or hypotension until serum potassium, fluid balance and blood pressure have been restored to normal. Warnings: Cases of tinnitus and reversible deafness have been reported. There have also been some reports of cases, the majority in children undergoing renal transplantation, in which permanent deafness has occurred. Hearing impairment is more likely to occur in patients with severely reduced renal function who are given large doses of Lasix parenterally, at a rate exceeding 4 mg/mm or in patients also receiving drugs known to be ototoxic. Do not use in pregnant women unless the benefits outweigh the ossible risks to the foetus. Sulfonamide diuretics ave been reported to decrease arterial responsiveness to pressor amines and to enhance the effects of tubocurarine. Exercise caution in administering curare or its derivatives during Lasix therapy. Discontinue 1 week prior to elective surgery. Do not administer to jaundiced newborn infants or to infants suffering from diseases with the potential of causing hyperbi irubinemia and possibly kernicterus. PrecautIons: Excessive diuresis may result in circulatory collapse or vascular thrombosis. It is essential to maintain fluid and electrolyte balance. During long-term therapy a high potassium diet is recommended. Potassium supplements should be given when high doses are used over prolonged periods. Particular caution with potassium levels is desirable in patients on digitalis glycosides, potassium-depleting steroids, or in impending hepatic coma. Potassium supplementation, diminution in dose, or discontinuation of Lasix may be required. Strict restriction in sodium intake is not advisable. In edematous hypertensives reduce the dosage of other antihypertensives since Lasix potentiates their effects. Monitor urine and blood glucose as decreased glucose tolerance has been observed. Monitor serum calcium levels as rare cases of tetany have been reported. The simultaneous administration of Lasix and cephaloridine is not advisable. Patients receiving high doses of salicylates with Lasix may experience salicylate toxicity at lower doses. Rate of infusion should not exceed 4 mg/mm. Adverse reactIons: Electrolyte depletion may occur especially with high doses and restricted salt intake; it may manifest itself by weakness, dizziness, lethargy, leg cramps, anorexia, vomiting and/or mental confusion. Asymptomatic hyperuricemia can occur and gout may rarely be precipitated. Transient elevations of BUN may be seen especially in renal insufficiency. Dermatitis, pruritus, paresthesia, blurring of vision, postural hypotension, nausea, vomiting, or diarrhea may occur. Anemia, leukopenia, and thrombocytopenia (with purpura) and rare cases of agranulocytosis have occurred. Over* dosage-Symptoms: Dehydration electrolyte depletion and hypotension. Treatment: Discontinue drug and institute appropriate corrective treatment. Dosage and Admlnlstratlon-ParenteraI: Initial dose of 250mg are mixed with 250 ml of a suitable infusion solution and given by intravenous drip at a rate not exceeding 4 mg/mm. Additional dose of 500 mg should be given if initial dose fails to produce an adequate increase in urinary output after one hour. The effective dose can be repeated every 24 hours. A maximum daily dose of 1000 mg should not be exceeded. Lasix Special 250 mg can be mixed to 250 ml of 5% dextrose in water, isotonic saline or lactated Ringer's injection, immediately before use. Precipitation may occur in solutions with a pH of the mixture less than 5.5. Not to be added into the tubing of a running infusion solution, and not to be mixed with any other drugs in the infusion bottle. If indicated as in case of hypervolemic patients, the i.v. infusion of the undiluted solution must be given with the aid of a motor-driven precision syringe so as to make sure that the upper limit of 4 mg Lasix (0.4 ml) per minute is not exceeded. Oral: Effective intravenous dose is used as the initial dose. Additional dose may be raised by 250 to 500 mg should the initial dose fail to produce an adequate urinary output within 4-6 hours. The maximum daily dose of 1000 mg should not be exceeded. Supply: Yellow round, quarter-scored 500 mg tablets (Code DLX) in bottles of 20. Amber ampoules of 25 ml (250 mg) in a sterile solution at pH of 9.1. Product Monograph on request. 1368/7106 E.
Hoechst
Pharmaceutical Division. Canadian Hoechst Ltd
Montreal
Orro A. SCHMIDT, MD, FRC5[C], FRCOG, FACOG President, Society of Obstetricians and Gynsecologists of Canada Ste. 1102, 233 Kennedy St. Winnipeg, Man.
Continuing medical education To the editor: There must have been an error in either the flag or the heading for J. L. Chouinard's article on the current state of continuing medical education (CME) (Can Med Assoc J 115: 1121, 1976). This dissertation surely belongs in a "Notes from the Past" section. Mr. Chouinard is undoubtedly attempting to be provocative and he has succeeded admirably. There is unquestionably a great need for improvement in CME in Canada; however, many provincial medical associations, governments and medical schools in Canada over the past 20 years have been diligently trying to correct the ancient problems that Mr. Chouinard describes as "current". Teaching and learning in many Canadian CME programs with the best available techniques and the services of well trained educational consultants are being used regularly. Medical school faculties today do not "teach as they were taught". The curricula of most Canadian medical schools have been thoroughly revised in recent years. The undergraduate, graduate and continuing education programs of our universities place great emphasis on small group and individual learning. Lectures play a much smaller but still very important role in our educational programs. Physician-learners are taking an active part in the identification of learning and performance needs and priorities. Their part, however, cannot be a dominant one. Teachers and consultants must take the initiative. The learner provides valuable guidance in setting priorities and deciding upon achievability since he is most familiar with his clientele and the details of locally available resources. It is true that CME courses enjoy "limited popularity". How can it be otherwise when there is little or no incentive to Canadian physicians to participate? In fact, physicians lose hundreds of dollars every time they attend a refresher course and the expenses involved are not income-tax deductible. This clearly is a problem for the profession and the public. We strongly support Mr. Chouinard's view that research into promising approaches to CME is urgently needed. The recruitment for funding for this
CMA JOURNAL/MAY 7, 1977/VOL. 116 975
purpose could be a constructive project References for the Canadian Medical Association. 1. DONNELLY FA, WARE JE, WOLKON GH, Ct al: Evaluation of weekend seminars for physicians. There is substantial evidence that / Med Educ 47: 184, 1972 participation in CME improves not only 2. WILLIAMS 1W, ALEXANDER M, MILLER GE: Continuing education and patient care rethe knowledge and performance of search. JAMA 201: 938. 1967 physicians but also the outcome of pa3. BROWN CR JR, UHL HSM: Mandatory continuing education. Sense or nonsense? JAMA tients. At least 10 good articles1-10 have 213: 1660. appeared during the past 6 years to sup- 4. BROWN CR:1970. Continuing education in community hospitals: a manual for program deport this statement. velopment. N Engi J Med 284 (suppi): 20. The "Brownie point" system, which 1971 HAZLEi-r CB, BAcHYNSKI JE, EMBLETON 1: requires that physicians take 20 to 50 5. Evaluation of on-campus continuing medical education programs in Alberta. Can Med hours of CME annually, is of dubious Assoc J 108: 1282, 1973 value. Reports from our American col6. REID DE, LAPENAS C, ROGERS KD: Continuleagues suggest that the legislation or ing education based on record audit in a community hospital. J Med Educ 48: 1152, adoption of mandatory hours of CME 1973 7. FLEISHER DS, BROWN CR, ZELENIK C, et al: by government or medical associations Mandate project - institutionalizing a system has done little harm. It is, in fact, a relaof patient care quality assurance. Pediatrics 57: 775, 1976 tively inexpensive way of assuring parti8. WILLIAMSON JW: Health accounting: an outcipation in a process that most of us come-based system of quality assurance: illustrative application to hypertension. Bull NY believe contributes to improved quality Acad Med 51: 727, 1975 of patient care. Unfortunately, preoc9. ASHBAUGH DG, McKEAN RS: Continuing medical education: the philosophy and use of cupation with spending hours at courses audit. JAMA 236: 1485, 1976 draws attention away from the more 10. INUI TS, YOURTTE EL, WILLIAMSON JW: Improved outcomes in hypertension after important issues of assured quality paphysician tutorials - a controlled trial. Ann Intern Med 84: 646, 1976 tient care and satisfactory outcomes. Since available time and money for CME is limited, I favour giving the To the editor: Dr. Laxdal, on behalf of highest priority to performance and his professional program-producer coloutcome studies, which will ensure ade- leagues, has taken the bait. Readers quate attention to the most important must decide for themselves the validity of his statements. learning needs. I disagree, however, with one of Dr. The fostering of favourable attitudes towards "life-long learning" is being Laxdal's main themes. He says physiemphasized in Canadian medical cian-learners cannot have a dominant schools. A number of approaches are part in the identification of learning and performance needs and priorities. being made, including the following: 1. Expansion of available elective This attitude, I submit, is a major reason why CME remains largely acclasses. 2. Less emphasis on marks and adop- tivity-oriented instead of goal-directed. tion of pass-fail systems rather than Programs such as those described in the above references, in which the grade-point scoring systems. 3. Introduction of problem- and learner is responsible for determining patient-oriented learning early in the educational needs, and for designing, implementing and participating in a curriculum. 4. Expanded and improved self-in- program directed to resolving these needs and evolving into appropriate structional resources. Many problems of CME could be follow-up of the educational process, solved if its great potential role in the are the most successful. assurance of high-quality patient care J.L. CHOUINARD were acknowledged. Very few univerCoordinator, Council on Medical Education Canadian Medical Association sities allocate more than 2 to 3% of the total medical college budget to CME. With improved staffing, funding and general support, CME offices could The Compendium of contribute at least as much to the gen- Pharmaceuticals and Specialties eral quality of patient care in Canada To the editor: Dr. Warren Bell has quite as undergraduate programs. properly questioned the adequacy of the Directors of CME across Canada "Compendium of Pharmaceuticals and would undoubtedly join me in thanking Specialties" (CPS) (Can Med Assoc J Mr. Chouinard for his bold attempt to 116: 349, 1977). One wishes the opporbe provocative in the field of CME. tunity were available to him to develop He has ably drawn attention to the his arguments more fully so that the considerable need for greater recogni- claim by Mr. J. C. Turnbull of the tion and support for CME. In view of Canadian Pharmaceutical Association the large amount of constructive work (Can Med Assoc J 116: 349, 1977) that that has been done in recent years, CME Dr. Bell's comments lack objectivity cannot be dismissed as a euphemism could be examined critically. Certainly for "courses the rebuttal by Mr. Turnbull does not O.E. LAxJ.L, MD weaken the thrust of Dr. Bell's arguDirector of continuing medical education ments. Dr. Bell suggests that an alternaUniversity of Saskatchewan tive to the CPS is required; it would be Saskatoon, Sask. 976 CMA JOURNAL/MAY 7, 1977/VOL. 116
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