Beclo vent
CPHA annual meeting: ambitious program despite transport troubles
Additional prescribing information INDICATIONS
Treatment of steroid-reOPOt5lVC bronchial asthma: but (1) In patients who in the pent hove not been on steroids the severity of their condition warranto noch treatment. oral (21 In oteroid.depetdett patients so replace or redoce systemic medication through gradoal withdrawal of steroldo. CONTRAINDICATIONS or unActive or quiescent untreated puiwonary tuberculosis, children treated fungal, bacterial and viral islectioss, and in onder sic. Statos asthmat:cus, and in patients with moderate to severe broschlectasis.
WARNINGS
in patients previously on high doses of systemic steroids, transfer to BECLOVENT Inhaler may cause withdrawal sympIn toms soch as tiredness, aches and pains, and depression. several cases, acute adrenal insufficiency may occur necessitating the temporary resumption of systemic steroids. is The development of pharyngeal and laryngeal candidiasis the cause of concern because the en tent of its penetration oftreatrespiratory tract is unknown. If cendidiasis develops thetherapy ment should be discontinutd and appropriate antifungal Initiated. The incidence of candidiasis can generally be held to a minimum by having patients rinse their mouth with water after each inhalation.
PRECAUTIONS I.
2. 3.
4.
5. e. 7.
It is essential that patients be informed that BECLOVENT Inhaler is a preventive agent must be taken at regular attach. intervals, and is not to be used during an anthroatic The replacement of a systemic steroid with BECLOVENT by the Inhaler has to be gradual and carefully supervised AdmInistration physician the guidelines under Dosage and should be followed In each case triunnecessary administratIOn of drugs during the first may mester of pregnancy Is undesirable. CorticosterOids way mask some signs of infection and new infections has appear. A decreased resistance to localized stection longbeen observed during cornicosceroid therapy. During term therapy, pituitary-adrenal function and hematolosital status should be periodIcally assessed. Fluorocarbon propellasts may be hazardous if they are of deliberately abused. Inhalation of high concentrations efaerosol sprays has brought about cardiovascular toult of fects and even death. asp.ially under conditions hypoula. However, evidence attests to the relative safety of aerosols when used properly and with adequate ventilation. There is an enhanced effect of cornicosteroids on patients with hypothyroidism and in those with cirrhosis. Atetylsallcyllc acid should be used cautiously in conjunction with corsicosteroids in hypoprothromhinenlia. Patients should be advised to luform subsequent physicians of the prior use of corticosteroids.
ADVERSE REACTIONS
No major side-effects attributable to the use of recommended doses of SECLOVENT Inhaler have been reported. No systemic below effects have been observed when the daily dose was plasma 1 mg (twenty puffs). Above this dose, reduction of occur. cortisol Indicating adrenocortical suppression. may albia did Can of the appearance Therapeutic doses may cause cane in the mouth and throat. The replacement of systemic steroids with SECLOVENT Inhaler may unmask symptons of allergies which were preas viously suppressed by the systemic drug. Conditions such allergic rhinitis and eczema may thus become apperent during SECLDVENT therapy after the withdrawal of systewit corticosteroids. SYMPTOMS AND TREATMENT OP OVERDOSAGE Overdosage way cause systemic steroid effects such as adrenal suppression and hypercortltlsnt. Decreasing the dose will abolish these side-effects.
DOSAGE AND ADMINISTRATION The optimal dosage of BECLOVENT may vary widely and must be individually determined, but the total dully dose should not euceed mg of beclomethasone dipropionate 120 puffs). Adults: times The usual dose is two inhalations 11110 mcgl three to four initially. daily. If this dose is not sufficient, It can be doubled As a maintenance dose, many patients do well on two inhalaclose daily. ChIldren:in use for Issufficient information is available to warrant the safedose children under siu years of age. The average ofdaily body weight. children over siu years of age is S mug/hg
IMPORTANT: As a steroid aerosol, Seclovest inhaler is for maintenance end therapy. It Is out intended to give immediate relief, proper technique effectiveness depends both on regular use and of inhalation. Patients must be instructed to tahe the inhaleaerobronchodilator due at regular intervals and not, as with symptoms sole, when they feel a need for relief of They should also he instructed in the correct method of use, which is to gohale completely, then place the lips tightly as the around the mouthpiece. The aerosol should be actuatedmaximum patient brealheu Is deeply and ulowir. This ensuresbe held as breath should penetration into the lungs, and the long as possible following each InhalatIon. The patients attention should be drawn to the Instruction Sheet, enclosed In each Seclovent pack. In the presence of eucessive mucus secretion, the drug may fail to reach the bronchioles. Therefore, if an obvious be response is not obtained after ten days, attempts should and/or with a made to remove the mucus with eupectorants short course of systemic corticosteroid treatment. previously Careful attention must he given to patients treated for prolonged periods with systemic corticosteroids. the when transferred to SECLOVENT. Initially BECLOVENT anddose systemic steroid must he given concomitantly while the withof the latter is gradually decreased. The usual rateof of2.5 ma is the equivalent drawal of the systemic corticoid of prednisone every four days if the patient is under close oheervatios. If continuous supervision is not feasible, the withdrawal of the systemic steroid should be slower, approximately 2.5 mg of prednisone (or equivalent) every ten days. If withdrawal symptoms appear, the previous dose of the systemic is drug atdecrease disabeold be resumed for a week before further tempted. There are some patients who cannot completely a minimum continue the oral corticosteroid. In these cases, SECLOVENT to in addition be given should dose maintenance Inhaler. SUPPLIED 50 BECLOVENT inhaler is a metered-dose aerosol delivering micrograms of beclomethasose dipropionate with each depres5105 of the valve. There are two hundred doses in a container.
Official product monograph on request.
EE. Allen & Hanburys
/44 Toronto, Canada a Glaxo Canada Limited Company
DAVID WOODS Despite the air strike, more than 350 delegates managed to show up for the 67th annual meeting of the Canadian Public Health Association in Moncton, June 22 to 25. Greater numbers of delegates had been expected, and it's ironic that a bilingual meeting in a bilingual city was affected by a bilingual issue. One Montreal registrant, arriving at 1:00 am, enquired "Est-ce qu'il y a un chariot pour mes bagages?" The hotel clerk replied "I don't speak French". Even to this essentially unilingual reporter, it was clear the man wanted a chariot for his baggage. Whatever the merits of the bilingualism issue in the air, this one on the ground in Frenchspeaking New Brunswick was clear-cut. "You should speak French", said the Montrealer without malice, and quite correctly. In any event, the meeting itself seemed worth the heroic efforts made by many delegates to get there, even if several scheduled speakers were unable to show up, and even if the ambitious program, featuring such promising session titles as 'Is current knowledge about health being applied?' often failed to address that or other similarly broad questions. The opening keynote address was presented by Dr. Kerr L. White who spoke on 'Evaluation of health care how can nations cope?' Dr. White, a professor of medicine at Johns Hopkins University, said that Canada is the only country that has produced such a "startling statistical analysis" as health minister Marc Lalonde's "A new perspective on the health of Canadians". While this isn't the last word on the topic (of evaluating health care), said Dr. White, it's a beginning, and its message is clear: "The vast bulk of funds invested in health goes to the provision of curative medical care, the component that contributes least to the health status of society. Biological and genetic factors, environmental factors, behaviour and lifestyle", said White, "are the major determinants of health and health status, not curative medical care." Dr. White saw four major areas that those interested in the public's health need to rethink, especially if there's going to be any counterweight to what he sees as the "increasing mystification
176 CMA JOURNAL/JULY 17, 1976/VOL. 115
of medicine as an arcane, technologically-based science... The first is health information and statistics; here, said White, we need an epidemiological approach to assess health status, needs, demands, use and satisfaction; further, he said, we need uniform classification and terminology for ambulatory, hospital and long-term care. "The rules for coding associated with the International Classification of Diseases", said Dr. White, "do not focus on determining the reasons why patients seek help of a nurse or physician in the first place, or on the reasons for the patient's being hospitalized. It is this kind of information that is essential for managing patients' health problems, managing health care institutions, allocating resources, setting priorities and evaluating the outcomes of care." Second, Dr. White turned to the matter of health benefits, noting that we've reached a point where it's no longer ethical to prescribe or use any form of medical intervention that has not had its efficacy, toxicity, utility and impact fully assessed. Collective responsibility Third, on health education, White stressed that what's important is not teaching but learning - learning that all of us are collectively responsible for most of the factors that influence our own health and well-being. Taking a Jesuitical approach, Dr. White said that early instruction in human biology and behaviour, and in sex and ecology, would establish a much firmer basis for learning healthy patterns of living than do the traditional courses in hygiene and nutrition still taught in many schools. And anyway, he asked, have we even used what we already know about the learning process in the interests of improving health? Finally, on the subject of health manpower, Dr. White suggested that our societies, especially the industrialized ones, "will insist on having someone they can call 'doctor' as their principal source of care. This doctor", he said, "will be a compassionate, caring counsellor, thoroughly and appropriately trained in behavioural and biomedical sciences to help with the recognition, management or resolution of 90% of the general health problems presented by general populations."
Jean Lupien, federal deputy minister of health, was introduced as "being likely" to discuss the subject of government and the increasing costs of health care; instead, however, M. Lupien opened with a couple of smokescreen issues having to do with noncommunication among different professionals in the health field and the "pressing problem and priority" of Canada's indigenous population where health is
concerned. Important issues, certainly, but perhaps not ones to be raised and left hanging, however articulately. But Lupien did get around to costs, noting that health consumes 7% of GNP in Canada and that this isn't an unduly large amount, particularly when one considers that the United States, without a government health insurance plan, devotes about 8 % of its GNP to health care. The scare that costs would run wild under medicare was unfounded, said M. Lupien; however, now that the "curative infrastructure" has been built, he said, it may be time to deploy funds differently. It may well be, he allowed, that total health care dollars are inefficiently allocated, that expenditures are reaching a point of diminishing returns, and that there should be a new emphasis on lifestyle and environmental factors in the health care delivery process. That process, said M. Lupien, should aim at meshing curative and preventive medicine and should be conducted as close to the people as possible; it might embrace such elements as home care, nursing care and ambulatory services and, above all, it should place the patient, not the health care professional, at the focal point. Whose business? In the somewhat desultory debate that followed, a member of the audience asked the speaker if he wasn't recommending "areas of change that we don't know enough about"; is it possible, he asked, to get people to lose weight or stop smoking? And, more important, is it any of the government's business? M. Lupien agreed that the question of intervention in people's lifestyles is a difficult one, but felt that government should certainly inform the public not proscribe or dictate - on the issues involved, a commendable viewpoint, but one on which Lupien may find himself at odds with his boss, Marc Lalonde, whose plans for the liquor industry were being unveiled at the time of the Moncton meeting. The core of this meeting consisted of 18 sessions held in concurrent batches;
Lupien: inform not dictate
their main themes were: assessment of existing programs, new roles and new members in community health, changing modes of delivery and changes required in outlook. In one of the sessions, titled 'Is current knowledge about health care being applied?', the panellist who came closest to answering this question said No. He said that our best resources, both of personnel and technology, are being directed towards treatment of acute illness; those in the field of prevention, he said, are controlled by bureaucrats and are paid less. The reason the public doesn't respond to health information, the panellist suggested, is because it's constantly assailed with messages of one kind or another and tends to select only those that have some immediate application. This speaker, a dentist, noted that government attempts to encourage preventive measures are hampered by the fact that expenditures on items that give quick results, and are more visible, make more sense politically; he cited the Nova Scotia government's axeing of preventive aspects of that province's dental plan and urged health professionals to apply the techniques of the media in getting across the message about preventive medicine.
Eroding services In a session on the effect that rationing health care dollars has on standards, Dr. D.R. Kinloch, special adviser on health policy and programs to Quebec's
deputy minister, said that budget cuts are eroding services, but for different reasons than those generally advanced. Dr. Kinloch said that health care is overfinanced as a result of overmedication, unnecessary surgery and "diagnostic and therapeutic overkill". There's also, he suggested, an overuse of technology, one example of which is the radiation hazard inherent in mass screening programs for breast cancer. He said that the 80 000 surgical procedures done annually in Quebec account for 300 000 hospital days and that much of this represents a misuse of acute hospital beds in that many of these procedures could have been done on a day-surgery basis. Restraints that are imposed, said Kinloch, are often done simplistically by using percentages. Administrators say they have to cut back on ambulatory care while leaving coronary bypass operations on the schedule. There's a need to look at alternative methods of financing, he said, and at payments to doctors; money shouldn't be wasted on services that are clinically worthless. We must ask, said Kinloch, if there's a specific need, a proven efficacy or superior alternatives. Looking at the question of whether present day providers of health care are standard-bearers or obstructionists, panellist Dr. R.W. Sutherland, associate professor in the University of Ottawa's school of health administration, said that the health professionals have obstructed patients enjoyment of their basic rights as well as attempts to examine what they themselves do. MDs, said Sutherland, perpetuate the theory that only they can diagnose and treat and have obstructed the entry of nonmedical administrators and attempts at manpower planning. Among the standard-bearers, Sutherland singled out public health nurses and gerontologists, while noting that most other standard-bearing is associated with building empires. Responding to a speaker from the audience who said that existing fee schedules don't encourage standardbearing (at least onto the field of preventive medicine), Sutherland said that since MDs control that schedule, why don't they revise it to place lower value on a tonsillectomy and higher value on, say, a period of thorough prenatal care. Involvement Retiring CPHA president Dr. E.A. Watkinson said in his valedictory address: "No matter what developments take place in health care delivery or in what direction it grows, public health authorities become completely involved sooner or later;" he said he couldn't recall a time when the association had
CMA JOURNAL/JULY 17, 1976/VOL. 115 177
been more involved in the mainstream of national activities and thought dealing with public health and the delivery of health care. His successor is Dr. Kenneth I.G. Benson of Vancouver, and next year's CPHA meeting will be held in that city. The Moncton meeting concluded
with the approval of resolutions on compulsory seat-belt legislation in provinces where there is none, on field trials for swine 'flu vaccines, on opposition to financial cutbacks in such areas as home care and community geriatric programs, and on recruitment of native peoples into the public health field and the CPHA.E
APPOINTMENT SYSTEM continued from page 161 Remember, people do not mind waiting if they know beforehand how much time may be involved. Another basic rule is that the doctor should be prepared to modify his system. One of the advantages of the front-end load system is that it lends itself to modification. When problems arise, the doctor or receptionist should note the time when the delay occurs. By this means, the pattern of the difficulty can be established and the system changed accordingly. In one case where the system was used, the mornings ran smoothly; however, the doctor fell behind every day in the afternoon. During discussions with the doctor and his staff it was mentioned that he tended to slow down after lunch each day. His activity curve dropped for the first hour and a half after lunch and then picked up to surpass his morning rate. The solution was to schedule two fewer patients during the first part of the afternoon and one more per hour for the remainder of the afternoon. The fifth basic rule in establishing an appointment system is that the scheduler should have autonomy. One of a medical secretary's duties is to schedule appointments, and providing the ground rules are explicit (for instance, complete physical examinations on
Wednesdays, Thursday afternoons off) only this person should keep the appointment record. This means that the physician should not book appointments. It is always interesting to look objectively at any communications transaction. It quite often happens that what the speaker said, what he meant, and what was interpreted are three different things. For example, when a doctor after examining a patient decides that a follow-up visit is required, he should not say "Mrs. Jones, I would like to see you again in about 2 days' time" because the patient may assume that she has a fixed appointment 48 hours later. If a doctor wishes a patient to return, the patient should be advised to arrange an appointment with the secretary, who is then able to fit the patient into the time frame without disrupting the schedule. Finally, a doctor should be prepared for the unforeseen. Every practice has a number of unscheduled patients. These may be drop-ins or people with urgent problems. A doctor who finds that in his practice there are one, two or three such patients each day should leave one, two or three blanks in the appointment schedule. Then, when one of these patients shows up, it is almost as if he were scheduled and the blank period in the timetable will allow the doctor to avoid falling behind.E
SALARIED PHYSiCIANS continued from page 170 and what kind of successes you want to achieve." Dr. Napke believes there is a more critical endpoint to the bargaining process than achieving dollar parity between salaried and fee-for-service physicians - however one defines parity. That endpoint is the recognition of professionalism. "There is a certain mystique that goes along with professionalism," says THE UPJOHN COMPANY OF CANADA Napke. "You have to give up certain DON MILLS, ONTARIO things because you enjoy the job. You can't bargain for overtime or call-back. 178 CMA JOURNAL/JULY 17, 1976/VOL. 115
If the job is there, as a professional you handle it. If you don't like the job, get out of it. "The real question is, who are we? Are we still the people responsible for making decisions? What makes a professional a professional?" The answers to such questions may remain elusive, but Dr. Napke believes that an improvement in the general level and status of any one segment of the medical profession benefits all physicians. The corollary is straightforward: when the professional status and role of salaried physicians are fully recognized, the entire profession is strengthened.E
M.trin (ibuprofen)
Indications and Clinical Uses: Ibuprofen is indicated for the treatment of osteoarthritis and rheumatoid arthritia. Contraindicationa: Ibuprofen should notbe uaed during pregnancy or in pmdiatric patienta becauae ita aafety under these conditiona haa not been establiahed. Ibuprofen ahoutd not be uaed in patienta with a history of acetylsalicylic acidinduced bronchospasm. Precautions: Ibuprofen should be used with caution in patients with a history of gastrointestinal ulceration. ibuprofen has been reported to be associated with toxic amblyopia. Therefore precautions should be taken to ensure that patients on ibuprofen therapy report to their physicians for full ophthalmological examination if they experience any visual difficulty. Medication should be discontinued if there is any evidence of toxic amblyopia. Adverse Reactions: The following adverse reactions have been noted in patients treated with ibuprofen. Gastrointestinal: Nausea, vomiting, diarrhma, constipation, dyspepsia, epigastric pain and gusiac positive stools have been noted. A few cases of gastric or duodenal ulceration, Including some complicated by bleeding or perforation have occurred. Central Nervous System: Dizziness, light-headedness, headache, anxiety, mental confusion and depression were noted in some patients treated with ibuprofen. Ophthalmologlcal: Blurred vision was noted in some patients and rarely a sensation of moving lights was observed following administration of ibuprofen. in addition there are three published cases of toxic amblyopia associated with the use of ibuprofen. Although a definite cause and effect relationship was not established, the attending physicians considered them to be drug related. The condition was characterized by reduced visual acuity and difficulty in colour discrimination. Defects (usually centrocucsl) were observed on visual field examination. Symptoms were reversible on discontinuation of treatment. Skin: Maculopapular rashes, urticaria, and generalized pruritus have been reported with ibuprofen therapy. Occasional cases of .dema have also been reported. Laboratory Teats: Sporadic abnormalities of liver function tests have occurred in patients on ibuprofen therapy (SGOT, serum bilirubin and alkaline phosphatase) but no definite trend was seen indicating toxicity. Similar abnormalities of white blood count and blood urea determinations were noted. A slight fall in hamoglobin and hmmatocrit has been noted in some patients.
Symptoms and Treatment of Overdosage: One
case of overdosage has been reported. A oneyear-old child ingested 1200 mg ibuprofen and suffered no Ill effects other than being drowsy the next day. Blood levels of ibuprofen reached 711 mcg/ml, which is considerably above the 90 mcg/ml previously recorded as the highest level seen In adults after a single oral dose of 800 mg. The SGPT level, nine days post-Ingestion, was 72. No specific antidote is known. Standard measures to stop further absorption and maintain urine output should be Implemented at once. The drug is excreted rapidly and excretion is almost complete in six hours.
Dosage and Administration: To obtain rapid re-
sponse at the start of treatment, particularly when transferring from other anti-inflammatory therapy, Motrinshould be given at a dose of 1200 mg per day In 4 divided doses. Depending on the therapeutic response, the dose may be adjusted downward or upward keeping the 4 times a day dosage schedule. The daily dose should not exceed 2400 mg. Maintenance therapy, once maximum response is obtained, will range from 800 to 1200 mg per day. Due to lack of clinical experience, ibuprofen is not indicated for use in children under 12 years of age. Supplied: 200 mg yellow coated tablets and 300 mg white coated tablets in bottles of 100 and 1000.
E.D
CPHA annual meeting: ambitious program despite transport troubles
Additional prescribing information INDICATIONS
Treatment of steroid-reOPOt5lVC bronchial asthma: but (1) In patients who in the pent hove not been on steroids the severity of their condition warranto noch treatment. oral (21 In oteroid.depetdett patients so replace or redoce systemic medication through gradoal withdrawal of steroldo. CONTRAINDICATIONS or unActive or quiescent untreated puiwonary tuberculosis, children treated fungal, bacterial and viral islectioss, and in onder sic. Statos asthmat:cus, and in patients with moderate to severe broschlectasis.
WARNINGS
in patients previously on high doses of systemic steroids, transfer to BECLOVENT Inhaler may cause withdrawal sympIn toms soch as tiredness, aches and pains, and depression. several cases, acute adrenal insufficiency may occur necessitating the temporary resumption of systemic steroids. is The development of pharyngeal and laryngeal candidiasis the cause of concern because the en tent of its penetration oftreatrespiratory tract is unknown. If cendidiasis develops thetherapy ment should be discontinutd and appropriate antifungal Initiated. The incidence of candidiasis can generally be held to a minimum by having patients rinse their mouth with water after each inhalation.
PRECAUTIONS I.
2. 3.
4.
5. e. 7.
It is essential that patients be informed that BECLOVENT Inhaler is a preventive agent must be taken at regular attach. intervals, and is not to be used during an anthroatic The replacement of a systemic steroid with BECLOVENT by the Inhaler has to be gradual and carefully supervised AdmInistration physician the guidelines under Dosage and should be followed In each case triunnecessary administratIOn of drugs during the first may mester of pregnancy Is undesirable. CorticosterOids way mask some signs of infection and new infections has appear. A decreased resistance to localized stection longbeen observed during cornicosceroid therapy. During term therapy, pituitary-adrenal function and hematolosital status should be periodIcally assessed. Fluorocarbon propellasts may be hazardous if they are of deliberately abused. Inhalation of high concentrations efaerosol sprays has brought about cardiovascular toult of fects and even death. asp.ially under conditions hypoula. However, evidence attests to the relative safety of aerosols when used properly and with adequate ventilation. There is an enhanced effect of cornicosteroids on patients with hypothyroidism and in those with cirrhosis. Atetylsallcyllc acid should be used cautiously in conjunction with corsicosteroids in hypoprothromhinenlia. Patients should be advised to luform subsequent physicians of the prior use of corticosteroids.
ADVERSE REACTIONS
No major side-effects attributable to the use of recommended doses of SECLOVENT Inhaler have been reported. No systemic below effects have been observed when the daily dose was plasma 1 mg (twenty puffs). Above this dose, reduction of occur. cortisol Indicating adrenocortical suppression. may albia did Can of the appearance Therapeutic doses may cause cane in the mouth and throat. The replacement of systemic steroids with SECLOVENT Inhaler may unmask symptons of allergies which were preas viously suppressed by the systemic drug. Conditions such allergic rhinitis and eczema may thus become apperent during SECLDVENT therapy after the withdrawal of systewit corticosteroids. SYMPTOMS AND TREATMENT OP OVERDOSAGE Overdosage way cause systemic steroid effects such as adrenal suppression and hypercortltlsnt. Decreasing the dose will abolish these side-effects.
DOSAGE AND ADMINISTRATION The optimal dosage of BECLOVENT may vary widely and must be individually determined, but the total dully dose should not euceed mg of beclomethasone dipropionate 120 puffs). Adults: times The usual dose is two inhalations 11110 mcgl three to four initially. daily. If this dose is not sufficient, It can be doubled As a maintenance dose, many patients do well on two inhalaclose daily. ChIldren:in use for Issufficient information is available to warrant the safedose children under siu years of age. The average ofdaily body weight. children over siu years of age is S mug/hg
IMPORTANT: As a steroid aerosol, Seclovest inhaler is for maintenance end therapy. It Is out intended to give immediate relief, proper technique effectiveness depends both on regular use and of inhalation. Patients must be instructed to tahe the inhaleaerobronchodilator due at regular intervals and not, as with symptoms sole, when they feel a need for relief of They should also he instructed in the correct method of use, which is to gohale completely, then place the lips tightly as the around the mouthpiece. The aerosol should be actuatedmaximum patient brealheu Is deeply and ulowir. This ensuresbe held as breath should penetration into the lungs, and the long as possible following each InhalatIon. The patients attention should be drawn to the Instruction Sheet, enclosed In each Seclovent pack. In the presence of eucessive mucus secretion, the drug may fail to reach the bronchioles. Therefore, if an obvious be response is not obtained after ten days, attempts should and/or with a made to remove the mucus with eupectorants short course of systemic corticosteroid treatment. previously Careful attention must he given to patients treated for prolonged periods with systemic corticosteroids. the when transferred to SECLOVENT. Initially BECLOVENT anddose systemic steroid must he given concomitantly while the withof the latter is gradually decreased. The usual rateof of2.5 ma is the equivalent drawal of the systemic corticoid of prednisone every four days if the patient is under close oheervatios. If continuous supervision is not feasible, the withdrawal of the systemic steroid should be slower, approximately 2.5 mg of prednisone (or equivalent) every ten days. If withdrawal symptoms appear, the previous dose of the systemic is drug atdecrease disabeold be resumed for a week before further tempted. There are some patients who cannot completely a minimum continue the oral corticosteroid. In these cases, SECLOVENT to in addition be given should dose maintenance Inhaler. SUPPLIED 50 BECLOVENT inhaler is a metered-dose aerosol delivering micrograms of beclomethasose dipropionate with each depres5105 of the valve. There are two hundred doses in a container.
Official product monograph on request.
EE. Allen & Hanburys
/44 Toronto, Canada a Glaxo Canada Limited Company
DAVID WOODS Despite the air strike, more than 350 delegates managed to show up for the 67th annual meeting of the Canadian Public Health Association in Moncton, June 22 to 25. Greater numbers of delegates had been expected, and it's ironic that a bilingual meeting in a bilingual city was affected by a bilingual issue. One Montreal registrant, arriving at 1:00 am, enquired "Est-ce qu'il y a un chariot pour mes bagages?" The hotel clerk replied "I don't speak French". Even to this essentially unilingual reporter, it was clear the man wanted a chariot for his baggage. Whatever the merits of the bilingualism issue in the air, this one on the ground in Frenchspeaking New Brunswick was clear-cut. "You should speak French", said the Montrealer without malice, and quite correctly. In any event, the meeting itself seemed worth the heroic efforts made by many delegates to get there, even if several scheduled speakers were unable to show up, and even if the ambitious program, featuring such promising session titles as 'Is current knowledge about health being applied?' often failed to address that or other similarly broad questions. The opening keynote address was presented by Dr. Kerr L. White who spoke on 'Evaluation of health care how can nations cope?' Dr. White, a professor of medicine at Johns Hopkins University, said that Canada is the only country that has produced such a "startling statistical analysis" as health minister Marc Lalonde's "A new perspective on the health of Canadians". While this isn't the last word on the topic (of evaluating health care), said Dr. White, it's a beginning, and its message is clear: "The vast bulk of funds invested in health goes to the provision of curative medical care, the component that contributes least to the health status of society. Biological and genetic factors, environmental factors, behaviour and lifestyle", said White, "are the major determinants of health and health status, not curative medical care." Dr. White saw four major areas that those interested in the public's health need to rethink, especially if there's going to be any counterweight to what he sees as the "increasing mystification
176 CMA JOURNAL/JULY 17, 1976/VOL. 115
of medicine as an arcane, technologically-based science... The first is health information and statistics; here, said White, we need an epidemiological approach to assess health status, needs, demands, use and satisfaction; further, he said, we need uniform classification and terminology for ambulatory, hospital and long-term care. "The rules for coding associated with the International Classification of Diseases", said Dr. White, "do not focus on determining the reasons why patients seek help of a nurse or physician in the first place, or on the reasons for the patient's being hospitalized. It is this kind of information that is essential for managing patients' health problems, managing health care institutions, allocating resources, setting priorities and evaluating the outcomes of care." Second, Dr. White turned to the matter of health benefits, noting that we've reached a point where it's no longer ethical to prescribe or use any form of medical intervention that has not had its efficacy, toxicity, utility and impact fully assessed. Collective responsibility Third, on health education, White stressed that what's important is not teaching but learning - learning that all of us are collectively responsible for most of the factors that influence our own health and well-being. Taking a Jesuitical approach, Dr. White said that early instruction in human biology and behaviour, and in sex and ecology, would establish a much firmer basis for learning healthy patterns of living than do the traditional courses in hygiene and nutrition still taught in many schools. And anyway, he asked, have we even used what we already know about the learning process in the interests of improving health? Finally, on the subject of health manpower, Dr. White suggested that our societies, especially the industrialized ones, "will insist on having someone they can call 'doctor' as their principal source of care. This doctor", he said, "will be a compassionate, caring counsellor, thoroughly and appropriately trained in behavioural and biomedical sciences to help with the recognition, management or resolution of 90% of the general health problems presented by general populations."
Jean Lupien, federal deputy minister of health, was introduced as "being likely" to discuss the subject of government and the increasing costs of health care; instead, however, M. Lupien opened with a couple of smokescreen issues having to do with noncommunication among different professionals in the health field and the "pressing problem and priority" of Canada's indigenous population where health is
concerned. Important issues, certainly, but perhaps not ones to be raised and left hanging, however articulately. But Lupien did get around to costs, noting that health consumes 7% of GNP in Canada and that this isn't an unduly large amount, particularly when one considers that the United States, without a government health insurance plan, devotes about 8 % of its GNP to health care. The scare that costs would run wild under medicare was unfounded, said M. Lupien; however, now that the "curative infrastructure" has been built, he said, it may be time to deploy funds differently. It may well be, he allowed, that total health care dollars are inefficiently allocated, that expenditures are reaching a point of diminishing returns, and that there should be a new emphasis on lifestyle and environmental factors in the health care delivery process. That process, said M. Lupien, should aim at meshing curative and preventive medicine and should be conducted as close to the people as possible; it might embrace such elements as home care, nursing care and ambulatory services and, above all, it should place the patient, not the health care professional, at the focal point. Whose business? In the somewhat desultory debate that followed, a member of the audience asked the speaker if he wasn't recommending "areas of change that we don't know enough about"; is it possible, he asked, to get people to lose weight or stop smoking? And, more important, is it any of the government's business? M. Lupien agreed that the question of intervention in people's lifestyles is a difficult one, but felt that government should certainly inform the public not proscribe or dictate - on the issues involved, a commendable viewpoint, but one on which Lupien may find himself at odds with his boss, Marc Lalonde, whose plans for the liquor industry were being unveiled at the time of the Moncton meeting. The core of this meeting consisted of 18 sessions held in concurrent batches;
Lupien: inform not dictate
their main themes were: assessment of existing programs, new roles and new members in community health, changing modes of delivery and changes required in outlook. In one of the sessions, titled 'Is current knowledge about health care being applied?', the panellist who came closest to answering this question said No. He said that our best resources, both of personnel and technology, are being directed towards treatment of acute illness; those in the field of prevention, he said, are controlled by bureaucrats and are paid less. The reason the public doesn't respond to health information, the panellist suggested, is because it's constantly assailed with messages of one kind or another and tends to select only those that have some immediate application. This speaker, a dentist, noted that government attempts to encourage preventive measures are hampered by the fact that expenditures on items that give quick results, and are more visible, make more sense politically; he cited the Nova Scotia government's axeing of preventive aspects of that province's dental plan and urged health professionals to apply the techniques of the media in getting across the message about preventive medicine.
Eroding services In a session on the effect that rationing health care dollars has on standards, Dr. D.R. Kinloch, special adviser on health policy and programs to Quebec's
deputy minister, said that budget cuts are eroding services, but for different reasons than those generally advanced. Dr. Kinloch said that health care is overfinanced as a result of overmedication, unnecessary surgery and "diagnostic and therapeutic overkill". There's also, he suggested, an overuse of technology, one example of which is the radiation hazard inherent in mass screening programs for breast cancer. He said that the 80 000 surgical procedures done annually in Quebec account for 300 000 hospital days and that much of this represents a misuse of acute hospital beds in that many of these procedures could have been done on a day-surgery basis. Restraints that are imposed, said Kinloch, are often done simplistically by using percentages. Administrators say they have to cut back on ambulatory care while leaving coronary bypass operations on the schedule. There's a need to look at alternative methods of financing, he said, and at payments to doctors; money shouldn't be wasted on services that are clinically worthless. We must ask, said Kinloch, if there's a specific need, a proven efficacy or superior alternatives. Looking at the question of whether present day providers of health care are standard-bearers or obstructionists, panellist Dr. R.W. Sutherland, associate professor in the University of Ottawa's school of health administration, said that the health professionals have obstructed patients enjoyment of their basic rights as well as attempts to examine what they themselves do. MDs, said Sutherland, perpetuate the theory that only they can diagnose and treat and have obstructed the entry of nonmedical administrators and attempts at manpower planning. Among the standard-bearers, Sutherland singled out public health nurses and gerontologists, while noting that most other standard-bearing is associated with building empires. Responding to a speaker from the audience who said that existing fee schedules don't encourage standardbearing (at least onto the field of preventive medicine), Sutherland said that since MDs control that schedule, why don't they revise it to place lower value on a tonsillectomy and higher value on, say, a period of thorough prenatal care. Involvement Retiring CPHA president Dr. E.A. Watkinson said in his valedictory address: "No matter what developments take place in health care delivery or in what direction it grows, public health authorities become completely involved sooner or later;" he said he couldn't recall a time when the association had
CMA JOURNAL/JULY 17, 1976/VOL. 115 177
been more involved in the mainstream of national activities and thought dealing with public health and the delivery of health care. His successor is Dr. Kenneth I.G. Benson of Vancouver, and next year's CPHA meeting will be held in that city. The Moncton meeting concluded
with the approval of resolutions on compulsory seat-belt legislation in provinces where there is none, on field trials for swine 'flu vaccines, on opposition to financial cutbacks in such areas as home care and community geriatric programs, and on recruitment of native peoples into the public health field and the CPHA.E
APPOINTMENT SYSTEM continued from page 161 Remember, people do not mind waiting if they know beforehand how much time may be involved. Another basic rule is that the doctor should be prepared to modify his system. One of the advantages of the front-end load system is that it lends itself to modification. When problems arise, the doctor or receptionist should note the time when the delay occurs. By this means, the pattern of the difficulty can be established and the system changed accordingly. In one case where the system was used, the mornings ran smoothly; however, the doctor fell behind every day in the afternoon. During discussions with the doctor and his staff it was mentioned that he tended to slow down after lunch each day. His activity curve dropped for the first hour and a half after lunch and then picked up to surpass his morning rate. The solution was to schedule two fewer patients during the first part of the afternoon and one more per hour for the remainder of the afternoon. The fifth basic rule in establishing an appointment system is that the scheduler should have autonomy. One of a medical secretary's duties is to schedule appointments, and providing the ground rules are explicit (for instance, complete physical examinations on
Wednesdays, Thursday afternoons off) only this person should keep the appointment record. This means that the physician should not book appointments. It is always interesting to look objectively at any communications transaction. It quite often happens that what the speaker said, what he meant, and what was interpreted are three different things. For example, when a doctor after examining a patient decides that a follow-up visit is required, he should not say "Mrs. Jones, I would like to see you again in about 2 days' time" because the patient may assume that she has a fixed appointment 48 hours later. If a doctor wishes a patient to return, the patient should be advised to arrange an appointment with the secretary, who is then able to fit the patient into the time frame without disrupting the schedule. Finally, a doctor should be prepared for the unforeseen. Every practice has a number of unscheduled patients. These may be drop-ins or people with urgent problems. A doctor who finds that in his practice there are one, two or three such patients each day should leave one, two or three blanks in the appointment schedule. Then, when one of these patients shows up, it is almost as if he were scheduled and the blank period in the timetable will allow the doctor to avoid falling behind.E
SALARIED PHYSiCIANS continued from page 170 and what kind of successes you want to achieve." Dr. Napke believes there is a more critical endpoint to the bargaining process than achieving dollar parity between salaried and fee-for-service physicians - however one defines parity. That endpoint is the recognition of professionalism. "There is a certain mystique that goes along with professionalism," says THE UPJOHN COMPANY OF CANADA Napke. "You have to give up certain DON MILLS, ONTARIO things because you enjoy the job. You can't bargain for overtime or call-back. 178 CMA JOURNAL/JULY 17, 1976/VOL. 115
If the job is there, as a professional you handle it. If you don't like the job, get out of it. "The real question is, who are we? Are we still the people responsible for making decisions? What makes a professional a professional?" The answers to such questions may remain elusive, but Dr. Napke believes that an improvement in the general level and status of any one segment of the medical profession benefits all physicians. The corollary is straightforward: when the professional status and role of salaried physicians are fully recognized, the entire profession is strengthened.E
M.trin (ibuprofen)
Indications and Clinical Uses: Ibuprofen is indicated for the treatment of osteoarthritis and rheumatoid arthritia. Contraindicationa: Ibuprofen should notbe uaed during pregnancy or in pmdiatric patienta becauae ita aafety under these conditiona haa not been establiahed. Ibuprofen ahoutd not be uaed in patienta with a history of acetylsalicylic acidinduced bronchospasm. Precautions: Ibuprofen should be used with caution in patients with a history of gastrointestinal ulceration. ibuprofen has been reported to be associated with toxic amblyopia. Therefore precautions should be taken to ensure that patients on ibuprofen therapy report to their physicians for full ophthalmological examination if they experience any visual difficulty. Medication should be discontinued if there is any evidence of toxic amblyopia. Adverse Reactions: The following adverse reactions have been noted in patients treated with ibuprofen. Gastrointestinal: Nausea, vomiting, diarrhma, constipation, dyspepsia, epigastric pain and gusiac positive stools have been noted. A few cases of gastric or duodenal ulceration, Including some complicated by bleeding or perforation have occurred. Central Nervous System: Dizziness, light-headedness, headache, anxiety, mental confusion and depression were noted in some patients treated with ibuprofen. Ophthalmologlcal: Blurred vision was noted in some patients and rarely a sensation of moving lights was observed following administration of ibuprofen. in addition there are three published cases of toxic amblyopia associated with the use of ibuprofen. Although a definite cause and effect relationship was not established, the attending physicians considered them to be drug related. The condition was characterized by reduced visual acuity and difficulty in colour discrimination. Defects (usually centrocucsl) were observed on visual field examination. Symptoms were reversible on discontinuation of treatment. Skin: Maculopapular rashes, urticaria, and generalized pruritus have been reported with ibuprofen therapy. Occasional cases of .dema have also been reported. Laboratory Teats: Sporadic abnormalities of liver function tests have occurred in patients on ibuprofen therapy (SGOT, serum bilirubin and alkaline phosphatase) but no definite trend was seen indicating toxicity. Similar abnormalities of white blood count and blood urea determinations were noted. A slight fall in hamoglobin and hmmatocrit has been noted in some patients.
Symptoms and Treatment of Overdosage: One
case of overdosage has been reported. A oneyear-old child ingested 1200 mg ibuprofen and suffered no Ill effects other than being drowsy the next day. Blood levels of ibuprofen reached 711 mcg/ml, which is considerably above the 90 mcg/ml previously recorded as the highest level seen In adults after a single oral dose of 800 mg. The SGPT level, nine days post-Ingestion, was 72. No specific antidote is known. Standard measures to stop further absorption and maintain urine output should be Implemented at once. The drug is excreted rapidly and excretion is almost complete in six hours.
Dosage and Administration: To obtain rapid re-
sponse at the start of treatment, particularly when transferring from other anti-inflammatory therapy, Motrinshould be given at a dose of 1200 mg per day In 4 divided doses. Depending on the therapeutic response, the dose may be adjusted downward or upward keeping the 4 times a day dosage schedule. The daily dose should not exceed 2400 mg. Maintenance therapy, once maximum response is obtained, will range from 800 to 1200 mg per day. Due to lack of clinical experience, ibuprofen is not indicated for use in children under 12 years of age. Supplied: 200 mg yellow coated tablets and 300 mg white coated tablets in bottles of 100 and 1000.
E.D
