Fiftieth anniversary of the Royal College of Physicians and Surgeons of Canada Since its foundation the Canadian Medical Association (CMA) has sponsored a number of medical and health-related bodies. Through expertise and, not infrequently, financial support, the CMA has also contributed to the launching of organizations as diverse as the College of Family Physicians of Canada and the Canadian Board for Certification of Prosthetists and Orthotists. The concept, the lengthy preliminary discussions and the organizational phase - elements that preceded the founding by the CMA of the Royal College of Physicians and Surgeons of Canada - are indicative of the forward thinking and patience of our predecessors. Persons familiar with organized medicine know that for a group of physicians to reach a decision is a process that is at times as tedious, as complicated and as soul-searching as the proclamation of sainthood by the Church of Rome. Nine years elapsed between Dr. S.E. Moore's resolution calling for the appointment of a committee to consider - only to consider - the founding of the Royal College of Physicians and Surgeons of Canada and the royal assent that was finally granted. Disunity between the members of the medical curia (read, the professors), reciprocal suspicion between physicians and surgeons, remnants of colonialism
and lack of confidence in Canadian initiatives caused proponents to suggest a limit on membership, the creation of two separate colleges or symbiosis with British, French or American entities. Thanks to wise senior statesmen and one great catalyst - time - a single and independent college finally emerged. The college has, indeed, become a symbol of Canadian unity and Canadian medical unity. Le Coll.ge royal des m.decins et chirurgiens du Canada, grace . son bilinguisme, est devenu, d.s sa fondation, un symbole de l'unit. canadienne et de l'unit. au sein de la profession. Ii a d.montr. avec .clat l'universalit6 de la m6decine. Alors que la Corporation professionnelle des m.decins du Quebec a institu6 son propre regime d'examens, la majorit. de nos jeunes coll.gues d'expression fran.aise a voulu, et veut encore, en sus des examens de la Corporation, preparer et affronter les 6preuves du Collage. Ils peuvent poursuivre et atteindre ce but chez eux, en fran.ais, au sein de leurs institutions, sous l'.gide de leurs maitres. Il est heureux et significatif de constater que r6cemment on a institu. un regime d'examens simultan.s au niveau de plusieurs sp6cialit.s. Au cours du demi-si.cle de son existence le Coll.ge a su forger de
solides amities canadiennes, celle, par exemple, qui le lie avec l'Association des m6decins de langue fran.aise du Canada. De m.me, sa reputation sur la sc.ne internationale est acquise et reconnue. R.cemment l'organisation du Centre d'examens et de recherches R.S. McLaughlin a soulev6 l'int.r&, la curiosit. et l'envie des organismes intemationaux. Assur.ment le College royal jouera dans l'avenir un r6le de plus en plus influent au sommet de la m.decine canadienne et & l'6tranger. At the annual meeting of the CMA in Victoria in 1926 a committee of 60 members (it has been suggested that its size was calculated to ensure its inability to perform) was charged with the following responsibility: "the setting up of a College of Physicians and Surgeons of Canada which shall be entirely and distinctly Canadian, with the sole purpose of offering to Canadian young men (and women) the inducement to . [take] advanced courses of training in the science and art of Medicine and Surgery."1 Since then the college has not only offered inducement, but has also approved training facilities, arranged for examinations, abolished certification to establish the single standard of fellowship, and adopted a Cerberic attitude against the undue proliferation of specialties. Recently the college established the R.S. McLaughlin
CMA JOURNAL/JANUARY 20, 1979/VOL. 120 115
Examination and Research Centre. This project has triggered the interest, curiosity and, indeed, envy of similar organizations abroad. The college publishes its annals, which are recognized for the three-star quality of the presentations. The annual meetings of the college, where originality is the keyword, are the largest and finest scientific gatherings in this country. Those who relate only to the past and the present are dying; what really counts is the future. The college must look ahead and brace itself against inevitable major changes. The writing is on the wall. Already the emphasis is shifting from cure to prevention of disease and maintenance of health. The problems of ageing and chronicity will soon be overwhelming. The risk factor, computerized and applied to large segments of the population, will call for rigorous syncretic measures. Inexorably medicine is adopting a social and community connotation; in future these aspects will have to be more understood by physicians and assimilated by them through formal education and training. The persons now at the helm of the college who control its destiny share immense responsibilities. It has been predicted, for instance, that studies towards specialization should not only be shortened but also be more goal-oriented. By the same token, the need for continuing medical education is constantly growing. The time may soon come when to be a specialist should be only a temporary state of affairs. I predict that the college will be confronted during the next decade with more crucial decisions than it has faced during its first 50 years of operation. G. GINGRAS, cc, MD, FRCP[C]
Former president Canadian Medical Association Chancellor University of Prince Edward Island Director, rehabilitation services Prince Edward Island Ministry of Health
Charlottetown, PEI
Reference 1. Lnwis DS: Royal College of Physicians and Surgeons of Canada, McGill U Pr, Montreal, 1962, p 17
(levodopa and carbidopa combination) INDICATIONS Treatment of Parkinson a syndrome with exception of drug induced parkinsonism. CONTRAINDICATIONS When a sympathomimetic amine is contraindicated; with monoamine oxidase inhibitors, which should be discontinued two weeks prior to starting SINEMET*; in uncompensated cardiovascular, endocrine, hematologic, hepatic, pulmonary or renal disease; in narrowangle glaucoma; in patients with suspicious, undiagnosed skin lesions or a history of melanoma. WARNINGS When given to patients receiving levodopa alone, discontinue levodopa at least 12 hours before initiating SINEMET* at a dosage that provides approximately 20% of previous levodopa. Not recommended in drug-induced extrapyramidal reactions; contraindicated in management of intention tremor and Huntington's chorea. Levodopa related central effects such as involuntary movements may occur at lower dosages and sooner, and the 'on and off' phenomenon may appear earlier with combination therapy. Monitor carefully all patients for the development of mental changes, depression with suicidal tendencies, or other serious antisocial behaviour. Cardiac function should be monitored continuously during period of initial dosage adjustment in patients with arrhythmias. Upper gastrointestinal hemorrhage is possible in patients with history of peptic ulcer. Safety of SINEMET* in patients under 18 years of age not established. Pregnancy and lactation: In women of childbearing potential, weigh benefits against risks. Should not be givento nursing mothers. Effects on human pregnancy and lactation unknown. PRECAUTIONS General: Periodic evaluations of hepatic, hematopoietic, cardiovascular and renal function recommended in extended therapy. Treat patients with history of convulsions cautiously. Physical Activity: Advise patients improved on SINEMET* to increase physical activities gradually, with caution consistent with other medical considerations. In Glaucoma: May be given cautiously to patients with wide angle glaucoma, provided intraocular pressure is well controlled and can be carefully monitored during therapy. With Antihypertensive Therapy:Assymptomatic postural hypotension has been reported occasionally, give cautiously to patients on antihypertensive drugs, checking carefully for changes in pulse rate and blood pressure. Dosage adjustment of antihypertensive drug may be required. With Psychoactive Drugs: If concomitant administration is necessary, administer psychoactive drugs with great caution and observe patients for unusual adverse reactions. With Anesthetics: Discontinue SINEMET* the night before general anesthesia and reinstitute as soon as patient can take medication orally. ADVERSE REACTIONS Mest Cemmen: Abnormal Involuntary Movements-usually diminished by dosage reduction-choreiform, dystonic and other involuntary movements. Muscle twitching and blepharospasm may be early signs of excessive dosage. Other Serleus Reactiens: Oscillations in performance: diurnal variations, independent oscillations in akinesia with stereotyped dyskinesias, sudden akinetic crises related to dyskinesias, akinesia paradoxica (hypotonic freezing) and on and off' phenomenon. Psychiatric: paranoid ideation, psychotic episodes, depression with or without development of suicidal tendencies and dementia. Levodopa may produce hypomania when given regularly to bipolar depressed patients. Rarely convulsions (causal relationship not established). Cardiac irregularities and/or palpitations, orthostatic hypotensive episodes, anorexia, nausea, vomiting and dizziness.
116 CMA JOURNAL/JANUARY 20, 1979/VOL. 120
Other adverse reactions that may occur: Psychiatric: increased libido with serious antisocial behaviour, euphoria, lethargy, sedation, stimulation, fatigue and malaise, confusion, insomnia, nightmares, hallucinations and delusions, agitation and anxiety. Neurologic: ataxia, faintness, impairment of gait, headache, increased hand tremor, akinetic episodes, akinesia paradoxica', increase in the frequency and duration of the oscillations in performance, torticollis, trismus, tightness of the mouth, lips or tongue, oculogyric crisis, weakness, numbness, bruxism, priapism. Gastrointestinal: constipation, diarrhea, epigastric and abdominal distress and pain, flatulence; eructation, hiccups, sialorrhea; difficulty in swallowing, bitter taste, dry mouth; duodenal ulcer; gastrointestinal bleeding; burning sensation of the tongue. Cardiovascular: arrhythmias, hypotension, nonspecific ECG changes, flushing, phlebitis. Hematologic: hemolytic anemia, leukopenia, agranulocytosis. Dermatologic: sweating, edema, hair loss, pallor, rash, bad odor, dark sweat. Musculoskeletal: low back pain, muscle spasm and twitching, musculoskeletal pain. Respiratory: feeling of pressure in the chest, cough, hoarseness, bizarre breathing pattern, postnasal drip, Urogenital: urinary frequency, retention, incontinence, hematuria, dark urine, nocturia, and one report of interstitial nephritis. Special Senses: blurred vision, diplopia, dilated pupils, activation of latent Homers syndrome. Miscellaneous: hot flashes, weight gain or loss. Abnormalities in laboratory tests reported with levodopa alone, which may* occur with SINEMET*: Elevations of blood urea nitrogen, SGOT, SGPT, LDH, bilirubin, alkaline phosphatase or protein bound iodine. Occasional reduction in WBC, hemoglobin and hematocrit. Elevations of uric acid with colorimetric method. Positive Coombs tests reported both with SINEMET* and with levodopa alone, but hemolytic anemia extremely rare. DOSAGE SUMMARY In order to reduce the incidence of adverse reactions and achieve maximal benefit, therapy with SINEMET* must be individuallzed and drug administration continuously matched to the needs and tolerance of the patient. Combined therapy with SINEMET* has a narrower therapeutic range than with levodopa alone because of its greater milligram potency. Therefore, titration and adjustment of dosage should be made in small steps and recommended dosage ranges not be exceeded. Appearance of involuntary movements should be regarded as a sign of levodopa toxicity and an indication of overdosage, requiring dose reduction. Treatment should, therefore, aim at maximal benefit without dyskinesias. Therapy in Patients not receiving Levodopa: Initially 'A tablet once or twice a day, increase by 'A tablet every three days if desirable. An optimum dose of 3 to 5 tablets a day divided into 4 to 6 doses. Therapy in Patients receiving Levodopa: Discontinue levodopa tar at least 12 hours, then give approximately 20% of the previous levodopa dose in 4 to 6 divided doses. FOR COMPLETE PRESCRIBING INFORMATION, PARTICULARLY DETAILS OF DOSAGE AND ADMINISTRATION, PLEASE CONSULT PRODUCT MONOGRAPH WHICH IS AVAILABLE ON REQUEST. HOW SUPPLIED Ca8804-Tablets SI NEMET* 250, dapple-blue, oval, biconvex, scored, compressed tablets coded MSD 654, each containing 25 mg of carbidopa and 250 mg of levodopa. Available in bottles of 100 and 500. *Trademark SNM-9-487-JA
O MERCK ARP CANADA LIMITED PDINTE CLAIRE, QUEBEC
and lack of confidence in Canadian initiatives caused proponents to suggest a limit on membership, the creation of two separate colleges or symbiosis with British, French or American entities. Thanks to wise senior statesmen and one great catalyst - time - a single and independent college finally emerged. The college has, indeed, become a symbol of Canadian unity and Canadian medical unity. Le Coll.ge royal des m.decins et chirurgiens du Canada, grace . son bilinguisme, est devenu, d.s sa fondation, un symbole de l'unit. canadienne et de l'unit. au sein de la profession. Ii a d.montr. avec .clat l'universalit6 de la m6decine. Alors que la Corporation professionnelle des m.decins du Quebec a institu6 son propre regime d'examens, la majorit. de nos jeunes coll.gues d'expression fran.aise a voulu, et veut encore, en sus des examens de la Corporation, preparer et affronter les 6preuves du Collage. Ils peuvent poursuivre et atteindre ce but chez eux, en fran.ais, au sein de leurs institutions, sous l'.gide de leurs maitres. Il est heureux et significatif de constater que r6cemment on a institu. un regime d'examens simultan.s au niveau de plusieurs sp6cialit.s. Au cours du demi-si.cle de son existence le Coll.ge a su forger de
solides amities canadiennes, celle, par exemple, qui le lie avec l'Association des m6decins de langue fran.aise du Canada. De m.me, sa reputation sur la sc.ne internationale est acquise et reconnue. R.cemment l'organisation du Centre d'examens et de recherches R.S. McLaughlin a soulev6 l'int.r&, la curiosit. et l'envie des organismes intemationaux. Assur.ment le College royal jouera dans l'avenir un r6le de plus en plus influent au sommet de la m.decine canadienne et & l'6tranger. At the annual meeting of the CMA in Victoria in 1926 a committee of 60 members (it has been suggested that its size was calculated to ensure its inability to perform) was charged with the following responsibility: "the setting up of a College of Physicians and Surgeons of Canada which shall be entirely and distinctly Canadian, with the sole purpose of offering to Canadian young men (and women) the inducement to . [take] advanced courses of training in the science and art of Medicine and Surgery."1 Since then the college has not only offered inducement, but has also approved training facilities, arranged for examinations, abolished certification to establish the single standard of fellowship, and adopted a Cerberic attitude against the undue proliferation of specialties. Recently the college established the R.S. McLaughlin
CMA JOURNAL/JANUARY 20, 1979/VOL. 120 115
Examination and Research Centre. This project has triggered the interest, curiosity and, indeed, envy of similar organizations abroad. The college publishes its annals, which are recognized for the three-star quality of the presentations. The annual meetings of the college, where originality is the keyword, are the largest and finest scientific gatherings in this country. Those who relate only to the past and the present are dying; what really counts is the future. The college must look ahead and brace itself against inevitable major changes. The writing is on the wall. Already the emphasis is shifting from cure to prevention of disease and maintenance of health. The problems of ageing and chronicity will soon be overwhelming. The risk factor, computerized and applied to large segments of the population, will call for rigorous syncretic measures. Inexorably medicine is adopting a social and community connotation; in future these aspects will have to be more understood by physicians and assimilated by them through formal education and training. The persons now at the helm of the college who control its destiny share immense responsibilities. It has been predicted, for instance, that studies towards specialization should not only be shortened but also be more goal-oriented. By the same token, the need for continuing medical education is constantly growing. The time may soon come when to be a specialist should be only a temporary state of affairs. I predict that the college will be confronted during the next decade with more crucial decisions than it has faced during its first 50 years of operation. G. GINGRAS, cc, MD, FRCP[C]
Former president Canadian Medical Association Chancellor University of Prince Edward Island Director, rehabilitation services Prince Edward Island Ministry of Health
Charlottetown, PEI
Reference 1. Lnwis DS: Royal College of Physicians and Surgeons of Canada, McGill U Pr, Montreal, 1962, p 17
(levodopa and carbidopa combination) INDICATIONS Treatment of Parkinson a syndrome with exception of drug induced parkinsonism. CONTRAINDICATIONS When a sympathomimetic amine is contraindicated; with monoamine oxidase inhibitors, which should be discontinued two weeks prior to starting SINEMET*; in uncompensated cardiovascular, endocrine, hematologic, hepatic, pulmonary or renal disease; in narrowangle glaucoma; in patients with suspicious, undiagnosed skin lesions or a history of melanoma. WARNINGS When given to patients receiving levodopa alone, discontinue levodopa at least 12 hours before initiating SINEMET* at a dosage that provides approximately 20% of previous levodopa. Not recommended in drug-induced extrapyramidal reactions; contraindicated in management of intention tremor and Huntington's chorea. Levodopa related central effects such as involuntary movements may occur at lower dosages and sooner, and the 'on and off' phenomenon may appear earlier with combination therapy. Monitor carefully all patients for the development of mental changes, depression with suicidal tendencies, or other serious antisocial behaviour. Cardiac function should be monitored continuously during period of initial dosage adjustment in patients with arrhythmias. Upper gastrointestinal hemorrhage is possible in patients with history of peptic ulcer. Safety of SINEMET* in patients under 18 years of age not established. Pregnancy and lactation: In women of childbearing potential, weigh benefits against risks. Should not be givento nursing mothers. Effects on human pregnancy and lactation unknown. PRECAUTIONS General: Periodic evaluations of hepatic, hematopoietic, cardiovascular and renal function recommended in extended therapy. Treat patients with history of convulsions cautiously. Physical Activity: Advise patients improved on SINEMET* to increase physical activities gradually, with caution consistent with other medical considerations. In Glaucoma: May be given cautiously to patients with wide angle glaucoma, provided intraocular pressure is well controlled and can be carefully monitored during therapy. With Antihypertensive Therapy:Assymptomatic postural hypotension has been reported occasionally, give cautiously to patients on antihypertensive drugs, checking carefully for changes in pulse rate and blood pressure. Dosage adjustment of antihypertensive drug may be required. With Psychoactive Drugs: If concomitant administration is necessary, administer psychoactive drugs with great caution and observe patients for unusual adverse reactions. With Anesthetics: Discontinue SINEMET* the night before general anesthesia and reinstitute as soon as patient can take medication orally. ADVERSE REACTIONS Mest Cemmen: Abnormal Involuntary Movements-usually diminished by dosage reduction-choreiform, dystonic and other involuntary movements. Muscle twitching and blepharospasm may be early signs of excessive dosage. Other Serleus Reactiens: Oscillations in performance: diurnal variations, independent oscillations in akinesia with stereotyped dyskinesias, sudden akinetic crises related to dyskinesias, akinesia paradoxica (hypotonic freezing) and on and off' phenomenon. Psychiatric: paranoid ideation, psychotic episodes, depression with or without development of suicidal tendencies and dementia. Levodopa may produce hypomania when given regularly to bipolar depressed patients. Rarely convulsions (causal relationship not established). Cardiac irregularities and/or palpitations, orthostatic hypotensive episodes, anorexia, nausea, vomiting and dizziness.
116 CMA JOURNAL/JANUARY 20, 1979/VOL. 120
Other adverse reactions that may occur: Psychiatric: increased libido with serious antisocial behaviour, euphoria, lethargy, sedation, stimulation, fatigue and malaise, confusion, insomnia, nightmares, hallucinations and delusions, agitation and anxiety. Neurologic: ataxia, faintness, impairment of gait, headache, increased hand tremor, akinetic episodes, akinesia paradoxica', increase in the frequency and duration of the oscillations in performance, torticollis, trismus, tightness of the mouth, lips or tongue, oculogyric crisis, weakness, numbness, bruxism, priapism. Gastrointestinal: constipation, diarrhea, epigastric and abdominal distress and pain, flatulence; eructation, hiccups, sialorrhea; difficulty in swallowing, bitter taste, dry mouth; duodenal ulcer; gastrointestinal bleeding; burning sensation of the tongue. Cardiovascular: arrhythmias, hypotension, nonspecific ECG changes, flushing, phlebitis. Hematologic: hemolytic anemia, leukopenia, agranulocytosis. Dermatologic: sweating, edema, hair loss, pallor, rash, bad odor, dark sweat. Musculoskeletal: low back pain, muscle spasm and twitching, musculoskeletal pain. Respiratory: feeling of pressure in the chest, cough, hoarseness, bizarre breathing pattern, postnasal drip, Urogenital: urinary frequency, retention, incontinence, hematuria, dark urine, nocturia, and one report of interstitial nephritis. Special Senses: blurred vision, diplopia, dilated pupils, activation of latent Homers syndrome. Miscellaneous: hot flashes, weight gain or loss. Abnormalities in laboratory tests reported with levodopa alone, which may* occur with SINEMET*: Elevations of blood urea nitrogen, SGOT, SGPT, LDH, bilirubin, alkaline phosphatase or protein bound iodine. Occasional reduction in WBC, hemoglobin and hematocrit. Elevations of uric acid with colorimetric method. Positive Coombs tests reported both with SINEMET* and with levodopa alone, but hemolytic anemia extremely rare. DOSAGE SUMMARY In order to reduce the incidence of adverse reactions and achieve maximal benefit, therapy with SINEMET* must be individuallzed and drug administration continuously matched to the needs and tolerance of the patient. Combined therapy with SINEMET* has a narrower therapeutic range than with levodopa alone because of its greater milligram potency. Therefore, titration and adjustment of dosage should be made in small steps and recommended dosage ranges not be exceeded. Appearance of involuntary movements should be regarded as a sign of levodopa toxicity and an indication of overdosage, requiring dose reduction. Treatment should, therefore, aim at maximal benefit without dyskinesias. Therapy in Patients not receiving Levodopa: Initially 'A tablet once or twice a day, increase by 'A tablet every three days if desirable. An optimum dose of 3 to 5 tablets a day divided into 4 to 6 doses. Therapy in Patients receiving Levodopa: Discontinue levodopa tar at least 12 hours, then give approximately 20% of the previous levodopa dose in 4 to 6 divided doses. FOR COMPLETE PRESCRIBING INFORMATION, PARTICULARLY DETAILS OF DOSAGE AND ADMINISTRATION, PLEASE CONSULT PRODUCT MONOGRAPH WHICH IS AVAILABLE ON REQUEST. HOW SUPPLIED Ca8804-Tablets SI NEMET* 250, dapple-blue, oval, biconvex, scored, compressed tablets coded MSD 654, each containing 25 mg of carbidopa and 250 mg of levodopa. Available in bottles of 100 and 500. *Trademark SNM-9-487-JA
O MERCK ARP CANADA LIMITED PDINTE CLAIRE, QUEBEC
