'HydergIne' in the treatment of diffuse cerebral insufficiency PRESCRIBING INFORMATION DOSAGE ND for4 weeks

.D

for6 weeks ED (JJ)G) Afterward the daily dose can, if warranted, be reduced to 2 tablets. Patients should be convinced of the necessity and importance of taking their medication regularly every day, preferably with their meals and at bedtime. The difference between success and failure is often directly related to the way the patient follows the dosage schedule. Composition - Tablets: Each 1 mg tablet contains the methanesulfonates of d ihyd roergocorn me, dihydroergocristine and dihydroergokryptine in equal proportions. Ampoules: Each 1 ml ampoule contains 0.3 mg Hydergine consisting of the methanesulfonates of dihyd roergocornine, dihydroergocristine and dihydroergokryptine in equal proportions.

Side Effects - Hydergine is usually well tolerated even in larger doses. Side effects are few and very slight. In addition to nasal stuftiness, there may be nausea, gastric pressure, anorexia, and headache, especially in patients with autonomic lability. In such cases, it is advisable to reduce the dose or administer it during or after meals.

Contraindications - Severe bradycardia and severe hypotension.

Supply: Bottles of 100 and 500 tablets; Boxes of 6 and 100 ampou les. Full prescribing information is available upon request

SANDOZ DORVAL

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Sandoz Phamaceuticals Division of Sandoz(Ganada) Limited Doroel, Quebec

The authors stated, "These predetermined criteria are agreed upon by the entire medical staff before the study begins," and also, "Most of the audit results confirmed the opinion of the physicians that their patterns of practice largely conformed to the standard model which they had set for themselves." There is a certain circularity in this logic. If the inclusion of criteria requires unanimity it would be surprising if the patterns of practice did not conform to the criteria. It is necessary to remember that the ultimate objective, the "bottom line", is the effect of audit on quality of outcome. Nobrega and colleagues' have recently questioned the validity of the method of explicit process criteria, and their report suggested that in the case of a set of explicit criteria relating to hypertension no relation exists between a process and an outcome assessment of quality of care. They stated, "Perhaps the assumption that a general list of process criteria when applied by physicians to patients with a specific condition will assure a good outcome is inappropriate and unrealistic." The matter is, of course, controversial; Brook2 raised many of the problematic issues. What is important is that there are several possible approaches to audit and the study of the quality of care: structural, process, outcome and concurrent peer review. As Brook2 suggested, one approach may be to focus on very simple process criteria as a means of correcting major deficiencies in care. Such a concept lends itself to audit by exclusion, a much more economical procedure than a comprehensive structured criteria system. We hope that the already scarce resources available for audit will not be pre-empted by an extension of the clinical appraisal demonstration project throughout Canada, to the exclusion of other types of audit. JAMES H. BROWN Chairman Medical information committee KAThLEEN HOLMES, RRL Director Medical information services Health Sciences Centre 700 William Ave. Winnipeg, Man.

References I. NOBREGA FT. MORROW GW, SMOLOT RK, et al: Quality assessment in hypertension: analysis of process and outcome. N Engi .1 Med 296: 145, 1977 2. BROOK RH: Quality - can we measure it?

Ibid, p 145

To the editor: We completely agree that there are several possible approaches to audit and study of quality of care. In the "Guide to Hospital Accreditation 1977" we pointed out on page 22 the six essential characteristics of an acceptable patient care evaluation proce-

dure. The words "structural, process, outcome and concurrent peer review do not appear in the list of essential characteristics. The Canadian Council on Hospital Accreditation is at present initiating a project to develop a modification of the criteria system of audit applicable to long-term-care centres. By basing criteria on observable elements in the treatment plan it is possible to use this methodology of audit to determine the progress and quality of care of long-term-care patients even when there is no hope of cure. I cannot close without a reference to "a certain circularity in this logic". While being delighted with this phraseology, I must point out that Dr. Robert Brook,1 in one of his earlier writings, quoted a study by the American Society of Internal Medicine in which the actual performance of a group of internists was compared with their agreedupon criteria for the ideal conduct of a case. In this study compliance of actual practice with agreed-upon criteria was very low. We felt that the adoption of realistic criteria by the participants in our trial was worthy of special note. JAMES H. MURRAY, MD, FACPM Associate executive director Canadian Council on Hospital Accreditation 25 Imperial St. Toronto, Ont.

Reference 1. BROOK R: Quality assurance, the state of the art, in The Hospital Medical Staff, Chicago, American Medical Association, March 1974

Existing MRC reviewing procedure To the editor: In view of the limitation of funds for scientific research and development in Canada, we should not only voice our concern regarding the grave consequences of such a (lack of) policy, but also must review the present system of grant allocation, for researchers must maximally use the available funds and talents through a wider distribution of grant money than the present system permits. For a given system to function properly it is essential that the system be periodically reviewed, and in grant distribution by the Medical Research Council of Canada (MRC) three areas require attention: applicants' notification of the reasons for the action taken by the committee; submission of grant applications (for 2-year and term grants) on a once-ayear basis only and abolition of annual grants; and distribution of available funds among a greater number of meritorious investigators. Improvement in the reviewing process could be achieved by transmitting

CMA JOURNAL/APRIL 23, 1977/VOL. 116 841

PHARMACEUTICALS BELLEVILLE,ONTARIOK8N5E9

scale. Regional disparity in fund distribution might be partially rectified. KJ. KAico, MD Department of physiology Eacuity of medicine University of Ottawa Ottawa, Ont.

Gangrene caused by woollen mitten To the editor: I bring your attention to

an unusual accident that occurred in our community. A 6-week-old girl was brought in for medical attention because her mother had been unable to remove a woollen mitten from the baby's left hand. The mother had put the mittens on the baby 3 days previously because the infant was scratching and the mother was wary of cutting the long fingernails. A thread of wool from the mitten had encircled the index finger, resulting in gangrene (Fig. 1).

therapy with antibiotics in the preoperative preparation of the colon for elective surgical procedures. The literature now contains reports on good prospective, randomized, controlled studies of this practice.14 As these studies indicate, the aminoglycosides neomycin and kanamycin are very effective in reducing the incidence of wound infection and anastomotic breakdown and the total morbidity following colonic operations. These drugs, as used by Nichols and colleagues,1 are given for four doses only on the day prior to operation; this regimen has not resulted in the development of resistant microorganisms or overgrowth by other enteric pathogens, as Perry and Guyatt suggested. The use of erythromycin in bowel preparation is not "unorthodox", as Perry and Guyatt believe: against anaerobes the aminoglycosides are not effective but erythromycin is. Metronidazole also has been shown by Goidring and associates3 to be effective against anaerobes. Certainly the nonabsorbed sulfa drugs succinylsulfathiazole and phthalylsulfathiazole are not effective and therefore not indicated in the preoperative preparation of the colon. Their extensive use, as in one of the hospitals studied by Perry and Guyatt, appears not to be justified. R.M. BAIRD Ste. 42. 1144 Burrard St. Vancouver, BC

References 1. NICHOLs RL, Biomo P. CONDON RE, Ct al: Effect of preoperative neomycin-erythromycin intestinal preparation on the incidence of infectious complications following colon surgery. Ann Surg 178: 453, 1973 2. WASHINGTON JA u, DEAlING WH, JUDD ES, et al: Effect of preoperative antibiotic regimen on development of infection after intestinal surgery: prospective, randomized, doubleblind study. Ann Surg 180: 567, 1974 3. GOLDRING J, Scorr A, MCNAUGHT W, et al: Prophylactic oral antimicrobial agents in elective colonic surgery. Lance: 2: 997, 1975

FIG 1-Gangrene of index finger caused by thread of wool from mitten Treatment was conservative

The

gangrenous portion had sloughed by day 10 and the wound had healed by day 18 Radiographic examination confirmed that the distal phalanx was removed completely T VANDOR. MD Wrinch Memorial Doctors Services Hazeiton. BC

Antimicrobial drug use in hospitals To the editor Studies on the overuse of antimicrobial drugs such as that of Perry and Guyatt (Can Med Assoc J 116 253 1977) are welcome for there is probably no group of drugs more poorly used by the practising medical profession But I take exception to the authors comments on the use of oral

To the editor: At the end of the interesting paper by Perry and Guyatt is a third-hand quotation about the abuse of a broad-spectrum antibiotic by a family doctor. It is a pity that such an excellent article should be rendered unscientific by an unverified third-hand quotation. Such a statement could well have been laid on the doorstep of any medical specialist and I have to react to the suggestion of Perry and Guyatt that family doctors are the only ones remiss in this problem. A. BOGGlE, BA, MD, CcFP

Head, department of family medicine Vancouver General Hospital Vancouver, BC

To the editor: Although some clinical trials provide evidence for the effectiveness of preoperative antibiotic therapy in preventing wound infection and other complications following colonic operations, others do not. The usefulness claimed for such chemoprophylaxis is still highly controversial. The latest edition of Goodman and Gilman's textbook1 and The Medical Letter,2 for instance, do not recommend routine oral use of antibiotics before elective surgical procedures on the bowel. I agree with Dr. Baird that careful prospective controlled studies of the possible usefulness of various antimicrobial drugs in preventing the complications of bowel operations are worth conducting. Chemoprophylaxis limited to less than 24 hours prior to surgery, as was the case in the first reference he cites, seems more likely to prove effective than does prophylaxis of longer duration. However, none of the three references he gives supports his contention strongly. The numbers of patients studied prospectively in the first and third studies were small, and the lack of placebo administration in the third study casts some doubt on its blindness.

CMA ANNUAL MEETING (Quebec City, June 19-24) Hurry up and register for the CMA Annual Meeting (more details on pages 931-934) and you can save $25.00 If you plan on bringing your children to Quebec City or wish to participate in the social optional events (excursions to Murray Bay, lie d'Orl.ans, St-Jean-Port-JoIi, just to name a few) we need your cooperation. Please complete your request for tickets and mail it JUST AS SOON AS POSSIBLE to the: ANNUAL MEETING COORDINATOR CMA House, POB 8650 Ottawa KIG 0GB, Ontario Do it todoyl CMA JOURNAL/APRIL 23, 1977/VOL. 116 843

Existing MRC reviewing procedure.

'HydergIne' in the treatment of diffuse cerebral insufficiency PRESCRIBING INFORMATION DOSAGE ND for4 weeks .D for6 weeks ED (JJ)G) Afterward the da...
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