1. travel
2. tourist destinations
3. canada

The A*s in
Mark F. Longhurst, mD, CCFP; Hugh I. Grant, MA
Medicine 1807 Images of Illness: Death
Richard W. Swanson, MD, CCFP; Richard Spooner, MD, CCFP
Features 1821 Essential Hypertension:
When and How to Initiate Treatment
Jacques Lemelin, MD, CCFP
1829 Does Antihypertensive Therapy Need to be Life-Long?
Robert Smith, MD, FRCGP, FAAFP
1835 Management of Chronic Headache
Colin D. Marchant, MD
1841 The Red Ear-drum: To Treat or Not To Treat?
S. Elmer Thompson, MD, FRCSC
1851 Urinary Tract Infections in Female Patients
Peter Small, MD, FRCPC, FACP
1859 Allergies: Review of the Evidence
J.W. Feightner, MD, CCFP
1865 Prevention and Early Detection
in Family Medicine: Where Are We?
R. W. Elford, MD, CCFP; M.A. Yeo, RN, MSc; B. Hougesen, mD, CCFP, FRCPC; V. Todd, RN
1873 Lifestyle Change: A Critical Look
E. Sandra Byers, PhD
1883 Prevention and Treatment of Relationship Distress
Margo Lemelin; Jacques Lemelin, MD, CCFP
1891 Enuresis: Are We Using the Optimal Treatment?
Paul E. Lefort, MD
1895 Chronic Low Back Pain: A Personal Approach
Graham Worrall, MB, BS, MRCGP, CCFP
1903 The Challenge of Urinary Incontinence in the Elderly
Earl V. Dunn, MD, CM CCFP
1909 Exercise after Myocardial Infarction:
Appraisal of the Literature
Designer's Note:
The Top 20 Problems in Family
Medicine - Play it again, Doc.
The opinions expressed in articles and claims made in advertisements
appearing in Canadian Family Physician are the opinions of the authors
and advertisers respectively and do not imply endorsement by The
College of Family Physicians of Canada.
Cover Design: Bill Woods
Published monthly by The College of Family Physicians of Canada,
4000 Leslie St., Willowdale, Ont., M2K 2R9. Editorial Offices: 1200
Sheppard Ave. E., Suite 507, Willowdale, Ont., M2K 2S5. Telephone:
(416) 492-0740. Montreal Office: 6 Magnolia, Dollard des Ormeaux,
Que. H9H 1S4. Authorized second class mail-registration number
5380. Post Office Department, Winnipeg and for payment of postage,
paid at Winnipeg. This journal is listed in Current Contents/Clinical
Practice, and indexed in Excerpta Medica, FAIvI: Family Medicine
Literature Index, and Canadian Magazine Index.
In this issue: Our features section analyzes the problems that
family physicians encounter with their patients every day. This
month's writers offer a comprehensive review on the current
practices and developments for treating these problems.
Copyrightc The College of Family Physicians of Canada/
Le College des medecins de famille du Canada
NOTE: All prescription drug advertisements in CFP have been
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989 precleared by the Pharmaceutical Advertising Advisory Board.
1707
Canadian
Editorial Director
Reg L. Perkin, MD, CCFP, FCFP
Director of Publications
Peter D. Taylor, MA
Scientific Editor
Tony Dixon, MD, CCFP, FCFP
Managing Editor
Alexandra Poley
Associate Editor
Elizabeth Betsch
News Reporter/Photographer
Louisa Blair
Editorial Assistant
Colleen Wassegijig
Editorial Secretary
Elizabeth Wallace
General
Production Manager
William Armstrong
Production Assistant
David Drimmie
Art Director
Bill Woods
Art Assistant
Ulla Hakanson
Advertising Manager
Jack T. Hayes
Associate Advertising Manager
Nancy Kent
Advertising Assistant
Louise Galarneau
Editoral Advisory Board
Verity Livingstone, MB, BS, CCFP
Vancouver (Chairman)
Khalid J. Hasan, MD, CCFP,
Fredericton
Jacques Lemelin, MD, CCFP,
Wakefield
Stan Lubin, MD, CCFP, Vancouver
Shaun McGuire, MD, Gloucester
Alan Pavilanis, MD, cCFP, Montreal
Susan Phillips, MD, CCFP, Kingston
Yves Talbot, MD, Toronto
Translation
Computex Enr.
nformation
Information for Authors
Canadian Family Physician is a peerreviewed scientific iournal intended to
meet the needs of those persons practising
teaching, and researching in the fields of
family medicine general practice, and
primary care.
Articles are invited that critically and
constructively contribute to the family
practice literature, and that relate either to
the journal's planned monthly themes or to
any other area relevant to clinical practice.
Original research is especially welcome,
as are papers reviewing the literature as it
relates to dilemmas encountered in
practice, papers concerning all areas of
education in family medicine and primary
care, and papers that offer personal points
of view.
Manuscripts
Canadian Family Physician accepts only
original material that is not under
consideration by any other publisher.
Papers should be typewritten, be
double-spaced, and hiave ample margins.
The first page should be a tit[e page
containing 1) the name(s) and principal
academic degrees of the author(s); 2 the
title of the paper; 3) a Summary of about
100 words, detailing the principal
conclusions; 4) each author's current
position; and 5) an address for
correspondence. Three copies should
accompany the original document.
References
References should be double-spaced.
They should be numbered as they appear
in the text and should be limited to works
cited in the article.
Personal communications are not
acceptable as references. Unpublished
material should be included only if an
address can be given from which a copy of
the material cited is available.
Authors are responsible for accuracy of
references, which should follow the
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
Uniform Requirements for Manuscripts
Submitted to Biomedical Journals. (Can
Med Assoc 1 1985; 132:401-5.)
Authors are responsible for obtaining
permission to publish any copyright
material quoted in their submitted
material.
Authors should refer to drugs
generically. If necessary, they may insert
brand names in parentheses after a generic
name. All measures should be reported in
SI units, followed by traditional units in
parentheses.
Illustrations, Charts, and Tables
Authors should submit, on a separate
page, each illustration, chart, or taible,
clearly identified in Arabic numerals. The
top of each illustration, if not obvious,
should be clearly labeled. Legends for
illustrations (which should be referred to as
'Figures') should be typd double-spaced
an clearly
on a separate piece o
numbered to correspond with the
illustration to which they refer. Tables,
which should be appropriately titled, as
well as numbered in their order of
presentation, must supplement the text
without duplicating it.
Illustrations should be either black-andwhite glossy photographs or India ink
drawings. Unless previous agreement has
been reached with the editor, colour
illustrations can be published only at the
author's expense.
Coxehtance of a paper will imply
assignment of copyright by its author to
Canadian Family hyszcian, but the author
will be free to use his or her material in
subsequent publications written or edited
by himself or herself, provided that the
Managing Editor is notified and that
Canadian Family Physician is acknowledged
as the original publication.
Reprints
Authors will receive a complimentary
copy of the issue of Canadian Family
Physician in which their article appears,
along with 50 unbound copies of their
article. Reprint order forms for future use
are sent to authors with their
complimentary copy.
Information for Advertisers
Please see detailed information
concerning advertisin& rates at the
beginriing of the Classified Ads section.
(See Contents page.)
Subscrption Rates
Canada and United States:
$25.00
per annum:
single copy:
2.50
All other countries:
$40.00
per annum:
3.50
single copy:
To order, wrnte to: Subscriptions,
Canadian Family Physician, 4000 Leslie
Street, Willowdale, Ont. M2K 2R9
Telephone: (416) 493-7513
Themes of Forthcoming Issues
1989
October: General Medicine
November: Occupational Medicine
December: Clinical Practice
1990
January: International Health
February: Neurology
March:
Rheumatology
Otolaryngology &
April:
Ophthalmology
May:
Malignant Diseases
Infants & Children
June:
Education in Family Medicine
July:
August: Practice Management
September: Pharmacology
1711
Progress Notes
Reg L. Perkin, MD, Executive Director
Bilingualism
THE COLLEGE of Family Physicians of Canada
(CFPC) is a national and bilingual organization committed to providing its members with services in
both official languages. A number of French-language
services are already being provided from the national office, but the organization is still perceived as an anglophone institution by the majority of francophone members. Clearly we need to change this perception.
Under the leadership of past president, Dr. Roch Bernier, the CFPC Executive Committee devoted considerable
time and effort over the past year to develop a bilingual
policy for the College. Draft proposals were presented to
the CFPC Board of Directors in November 1988 and referred to the 10 provincial Chapters for further discussion.
Amendments brought forward by the Chapters were incorporated into the final draft document, which was ratified by the Board of Directors at the May 1989 meeting in
Saskatoon. The major features of this bilingual policy are
provided here for the information of our readers.
Written and Verbal Communication
The reception and processing of all written and verbal
communication should be fully bilingual. Information
should be available to the membership in both official languages at the same time and distributed to each member
in the language of his or her choice.
This policy will require staffing changes at the CFPC national office. A fully bilingual receptionist is an absolute requirement. Improved translation services from English to
French, and French to English, will be required; and, because the skills are different, more than one person will
probably be needed. There should be at least one bilingual employee in each of the departments at the national
office. The services of the Library of Family Medicine
should have more French-language capability. The Executive Director and senior staff should be encouraged to
improve their French-language skills, and a bilingual Associate Executive Director should be sought.
The CFPC already provides a considerable amount of
written information in both official languages. This includes the Certification in Family Medicine and Emergency Medicine examination regulations, the
actual examinations themselves, the CFPC
bylaws, the Mission Statement, the College
v
Prayer, the Convocation program, diplomas
and awards, sections of the Canadian Fami-
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
ly Physician journal, and the newsletter of the National
Advisory Council on Family Medicine Training. Francophone members already receive their regular correspondence in the French language. The College endeavours
to provide important policy statements and press releases
in both languages. The recent promotion of the limited
partnership investment opportunity in the College's new
national office was done in both French and English.
The new bilingual policy will see an expansion of these
services. The resolutions of the Board of Directors, as
well as policy statements and official reports, will be published in both languages. Canadian Family Physician will
soon appear with a new cover design, and will gradually
publish more of the regular features in both languages, as
well as encouraging more original articles in French. The
College newsletter, CFPC-UPDATE, will become a bilingual publication as soon as possible, which will also require a name change to achieve a French title with more
appeal.
The Annual Scientific Assembly will be promoted in
both languages and, when certain criteria are met, a bilingual reception desk and final program, along with simultaneous translation, will be provided at the time of the Assembly. The CFPC will continue to encourage our
francophone members to present papers in French.
Meetings
Simultaneous translation at meetings of the Board of
Directors would be desirable. Implementation will depend
in part on the availability of financial assistance from the
federal govemment. Interim measures would be to have a
translator available to assist francophone members, and
to encourage the Quebec Chapter to include a bilingual
member as one of its three representatives to the Board
of Directors.
The most important College committees to achieve bilingual status are those associated with the certification
examinations in family medicine and emergency medicine. Simultaneous translation at these meetings, and the
provision of minutes and reports in both languages, are
objectives of the CFPc bilingual policy. The plans for the
new national office include a translation
booth with access to both meeting rooms.
Educational Activities
All candidate materials and some examC<XX|
1721
iner materials for the certification examination in family
medicine have been provided in French and English since
1975. The Certificate of Special Competence examination
in emergency medicine has followed a similar policy since
its inception in 1982. This policy will be expanded now to
provide all written and video resources for the use of examiners in both languages. Even the names of simulated patients will be compatible with French culture for francophone candidates. With the change in licensing
requirements in the Province of Quebec, the number of
francophone candidates for the Certification Examination
in Family Medicine will increase dramatically in 1990, and
the membership of the Quebec Chapter CFPC is anticipated
to increase significantly in the next few years.
Collaboration is being arranged between the CFPC Section of Teachers and the Colloque des enseignants in
Quebec, so that family medicine teachers from all regions
of Canada will have an opportunity to share information
with each other. A conjoint meeting will be held in Montreal in October, and more are being planned.
A joint program of accreditation of the postgraduate residency training programs in the 16 Canadian medical
schools has been under way for the past two years. The
1 722
CFPC now makes these on-site visits in co-operation with
the Royal College of Physicians and Surgeons of
Canada. The program began in Quebec and involved the
Corporation professionnelle des m6decins du Qu6bec as
the third partner in the conjoint accreditation. As this program moves across the country, the licensing body in
each province becomes a partner in the process.
Conclusion
The CFPC is a strong national organization, complemented by equally strong provincial Chapters. It is very
important for the College to have a clearly defined policy
on bilingualism. Although not all our francophone members live in Quebec, the new policy will obviously have the
most impact in that province. It comes at a time when
family practice residency training has been mandated by
the Quebec government and the Quebec CFPC Chapter is
growing rapidly.
The bilingual policy of the CFPC must be practical, effective, cost-conscious, and achievable within the limits of
our resources. Some components of this new policy must
await the move of the national College into its new office,
but we believe it will be possible to implement most, if not
all, of the bilingual policy during the next 18 months. U
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
Notes
d'evolution
Reg L. Perkin, MD, directeur general
Bilinguisme
LE COLLEGE des medecins de famille du Canada
(CMFC) est un organisme national bilingue qui s'efforce d'offrir a ses membres des services dans les
deux langues officielles. Notre bureau central offre d6ja
un certain nombre de services en francais, mais la plupart
des membres francophones continuent de nous percevoir
comme une institution anglophone. 11 nous faut donc
changer cette perception.
Pendant l'annee ou le Dr Roch Bernier fut pr6sident du
CMFC, le Comite de direction a consacre passablement de
temps et d'energies a developper une politique de bilinguisme pour le College. En novembre 1988, des propositions ont ete soumises au Conseil d'administration du
CMFC pUiS pr6sentees au 10 sections provinciales pour
fins de discussion. Celles-ci ont propose certains amendements qui ont ensuite ete inclus dans le document final,
lequel fut adopte par le Conseil d'administration lors de la
reunion tenue a Saskatoon en mai 1989. Afin de mieux
renseigner nos lecteurs, nous pr6sentons ici les grandes
lignes de cette politique de bilinguisme.
Communications verbales et 6crites
Toutes les communications verbales et ecrites que
nous recevons et que nous envoyons devraient etre traduites dans les deux langues. Tous les renseignements
transmis aux membres du College devraient etre distribues en meme temps, dans les deux langues, permettant
ainsi a chacun l'acces a l'information dans la langue de
son choix.
Cette politique du CMFC necessitera des modifications
de personnel a notre bureau central. 11 devient absolument necessaire d'obtenir les services d'une receptionniste bilingue. 11 sera aussi necessaire d'ameliorer les services de traduction de l'anglais au francais, et du francais
a l'anglais; et, puisque ces services necessiteront differentes habiletes, il faudra obtenir les services de plus
d'une personne. 11 devrait y avoir au moins un(e) employe(e) bilingue dans chacun des departements de notre
bureau central. 11 faudrait augmenter la
composante francophone de nos services
biblioth6caires en medecine familiale. Le directeur general et le personnel cadre du
CMFC devront s'efforcer d'ameliorer leur
francais; il devient necessaire aussi d'embaucher un adjoint au directeur general qui
soit bilingue.
4
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
Le CMFC r6dige deja la plupart de ses communications
dans les deux langues officielles. A ce chapitre, nous retrouvons les reglements concernant l'examen de Certification en medecine familiale et en m6decine d'urgence,
ces examens eux-memes, les Statuts et reglements du
CMFC, la Mission et la priere du College, le programme de
la ceremonie de remise des certificats, les dipl6mes et les
differents prix, certaines sections de la revue Le MWdecin
de famille canadien et le bulletin d'information du Conseil
national aviseur sur la formation en m6decine familiale.
Les membres francophones recoivent deja leur correspondance reguliere en francais. Le College s'efforce
aussi de transmettre ses plus importantes d6clarations de
principes et ses communiqu6s de presse dans les deux
langues. La campagne publicitaire que nous avons men6e r6cemment sur l'opportunite d'investissement dans
une soci6t6 en commandite pour la construction de l'edifice devant abriter les futurs locaux du bureau central du
College a ete publiee en francais et en anglais.
La nouvelle politique de bilinguisme va accro-itre les
services existants. La r6solutions du Conseil d'administration, de meme que les declarations de principes et les
rapports officiels, seront publi6s dans les deux langues.
Le Medecin de famille canadienaura bient6t une nouvelle
page couverture et veut graduellement publier davantage
d'articles dans les deux langues et encourager la presentations d'articles en francais. Le bulletin d'information du
College, CFPC UPDATE deviendra prochainement une
publication bilingue; nous en modifierons d'ailleurs le nom
afin de le franciser et le rendre plus attrayant.
La publicit6 entourant l'Assemblee scientifique annuelle sera publi6e dans les deux langues et, des que les
ressources le permettront, nous comptons mettre a la disposition des congressistes un bureau de reception bilingue, offrir le programme final dans les deux langues et
des services de traduction simultanee pendant I'Assembl6e. Le CMFC continuera d'encourager ses membres francophones a pr6senter leurs conf6rences en francais.
R6unions
11 serait souhaitable daoffrr des services
de traduction simultanee lors des reunions
du Conseil d'administration. La mise en application de ce service depend en partie de
I'aide financiere que pourra nous accorder
le gouvernement federal. Les mesures tem-
1723
poraires pourraient consister a ce qu'un traducteur assiste
aux reunions afin d'aider les membres francophones et
aussi a encourager la section qu6b6coise a nommer un
membre bilingue parmi ses trois representants au Conseil
d'administration.
Les comites du College pour lesquels il serait le plus
important d'assurer des services de traduction sont ceux
des examens de certification en medecine familiale et en
m6decine d'urgence. La politique de bilinguisme du CMFC
prevoit offrir un service de traduction simultan6e lors des
reunions de ces comit6s et la traduction des proces-verbaux et rapports. Les plans du nouveau bureau central du
College pr6voient une cabine de traduction donnant acces aux deux salles de r6union.
Une rencontre conjointe se tiendra a Montr6al en octobre
prochain, et d'autres sont pr6vues.
Depuis deux ans, le College a mis sur pied un programme conjoint pour l'agr6ment des programmes de
r6sidence en m6decine familiale des 16 facuft6s de m6decine canadiennes. Le CMFC effectue maintenant ces visites conjointement avec le College royal des m6decins
et chirurgiens du Canada. Au QuAbec, nous avons commenc6 a effectuer ces visites en y ajoutant la participation
d'un troisieme organisme, soit la Corporation professionnelle des m6decins du Qu6bec. Nous allons dor6navant
effectuer nos visites d'agrement conjointement avec l'organisme responsable d'octroyer les permis de pratique
dans chacune des provinces.
Activites p6dagogiques
Depuis 1975, tout le mat6riel distribu6 aux candidats et
une bonne partie des documents destin6s aux examinateurs pour l'examen de Certification en m6decine familiale ont ete traduits dans les deux langues. La meme politique s'est appliqu6e au Certificat de comp6tence
speciale en m6decine d'urgence depuis sa mise sur pied
en 1982. Cette politique ira jusqu'& inclure la traduction
de tout le mat6riel destine aux examinateurs, y compris le
materiel vid6o. Meme les noms des patients seront adaptes a la culture des candidats francophones. Les exigences pour l'obtention du permis de pratique dans la province de Quebec entraineront in6vitablement une hausse
importante du nombre de candidats francophones a 1'examen de Certification en medecine familiale de 1990, et
nous anticipons, au cours des prochaines ann6es, une
augmentation significative du nombre de membres au niveau de la section qu6becoise du CMFC.
La Section des enseignants du CMFC et le Colloque des
enseignants du Qu6bec sont en train d'unir leurs efforts
afin que les professeurs de m6decine familiale de toutes
les regions du Canada puissent communiquer entre eux.
Conclusion
Le CMFC est un organisme national solidement implant6
dont les sections provinciales jouissent de la meme solidit6. 11 est trbs important que le Collbge ait une politique
de bilinguisme qui soit clairement d6finie. Mime si tous
nos membres francophones ne r6sident pas exclusivement au Qu6bec, c'est dans cette province que notre
nouvelle politique aura le plus d'impact. Le moment semble opportun, depuis que le gouvemement du Qu6bec a
rendu obligatoire l'acces a l'omnipratique par la voie des
programmes de r6sidence en m6decine familiale et que
le nombre de membres de la section qu6b6coise va en
augmentant.
La politique de bilinguisme du CMFC doit se faire de facon pratique, efficace, et tenir compte des coOts et des
ressources dont nous disposons. Meme si certains aspects de cette nouvelle politique verront le jour seulement
lorsque le College aura emm6nag6 dans ses nouveaux
locaux, nous croyons n6anmoins qu'il sera possible d'appliquer la majeure partie de cette politique de bilinguisme
U
au cours des prochains 18 mois.
1724
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
CFPC Annunces
Certification in Family Medicine
Congratulations
to the following family physicians who have been successful in
the examination leading to Certification in Family Medicine
by the College of Family Physicians of Canada.
Those family physicians will receive their Certificates at the
Convocation Exercises to be held on July 22, 1990
in St. John's, at the College's 32nd Annual Scientific Assembly.
Atam V. Abbi, Edmonton, Alta.
Hilary Adams, Calgary, Alta.
Ravi Aggarwal, Markham, Ont.
Robert Ian Algie, Fort Frances, Ont.
Naved A. Ali, Edmonton, Alta.
Susan Alton, Edmonton, Alta.
Heather J. Amundson, Nepean, Ont.
Darlene M. Antosh, Regina, Sask.
Marilyn Archibald, Ancaster, Ont.
Susanne E. Arndt, Regina, Sask.
Alexander W. Ashenhurst, Georgetown, Ont.
Lyne Audet, Calgary, Alta.
Kathleen Gail Baergen, Red Deer, Alta.
Renu Bajaj, Kingston, Ont.
Kenneth Barss, Halifax, N. S.
Judith G. Bartlett, Winnipeg, Man.
Christine Bassal, St-Leonard, P. Q.
Jane Bassoon-Swedler, New York, NY
Laurel A. Bates, Toronto, Ont.
Kent Evan Bauman, Waterloo, Ont.
Robin M. Beardsley, Ottawa, Ont.
Pierre Beaupre, Lac Beauport, P. Q.
Ian G. Beauprie, Deep River, Ont.
Barbara Ann Bell, Toronto, Ont.
Stephen John Bell, Edmonton, Alta.
Donald J. Bethune, Calgary, Alta.
Sanjeev Bhatla, Yellowknife, N. W. T.
Darlene A. Bilawski, Mississauga, Ont.
Elizabeth Blachford, Regina, Sask.
Karen Grace Blachford, Ladner, B.C.
C. M. Blackwood, Mission, B.C.
Nina Lynette Bland, Vancouver, B. C.
Harvey Blankenstein, Willowdale, Ont.
Martine Blaquiere, Dieppe, N.B.
Nathalie Boileau, Mount-Royal, P. Q.
Isabelle Boily, La Prairie, P. Q.
Mireille Boily, Alma, P. Q.
George H. Borchert, Iqaluit, N. W. T.
Risa B. Bordman, Willowdale, Ont.
Elizabeth Bosse, Sherbrooke, P. Q.
Anne Bourbonnais, St-Laurent, P.Q.
Robert Michael Boyko, Toronto, Ont.
Michel Claude Bracka, Carleton, P. Q.
Harold Phillips Braden, Toronto, Ont.
Teddy Braun, Saskatoon, Sask.
David B. R. Brignall, Ottawa, Ont.
W. Mark Brown, Calgary, Alta.
Jeffrey Reynold Brubacher, Montreal, P.Q.
Nicole Antoinette Bruinsma, Old Chelsea, P. Q.
Kenny Paul Buchholz, Annapolis Royal, N.S.
Heinz E. Budau, Vancouver, B.C.
Karen R. Bullock Pries, Steinbach, Man.
Richard A. Bunio, Calgary, Alta.
Helene Bureau, Sherbrooke, P. Q.
Jeff Bury, Calgary, Alta.
Robert Karl Butler, London, Ont.
Peter Bzonek, Hamilton, Ont.
Betty Calam, Queen Charlotte City, B.C.
Paul G. Cantarutti, Maple, Ont.
Celine Cardinal, Montreal, P. Q.
Lucie Carignan, Ste-Foy, P. Q.
Catherine Anne Carlson, Oakville, Ont.
Catherine Ann Carmichael, Oakville, Ont.
Douglas E. Carmody, Charlottetown, P.E.I.
Renee Caron, Charlesbourg, P. Q.
Brent Carson, Calgary, Alta.
Lucinda J. Cassells, London, Ont.
Andrew James Cave, Somerset, England
Margaret Elizabeth Cawkwell, Toronto, Ont.
Paul Richard Cervenko, Kingston, Ont.
Eric Chaize, St-Laurent, P. Q.
Donald R. Chan, Edmonton, Alta.
Mildred Wei-Ming Chang, Winnipeg, Man.
Allison Chapman, Calgary, Alta.
Jocelyn Elizabeth Charles, Thornhill, Ont.
Alice Illum Chen, Regina, Sask.
Christopher Kuo Chun Chiang, Toronto, Ont.
Anthony S.K. Chiu, Calgary, Alta.
James Church, Burnaby, B.C.
John E. Clarke, Fairview, Alta.
Karen Anne Clarke, Halifax, N. S.
Jane Roberta Clarkson, Calgary, Alta.
Sylvie Clement, St-Jean, P. Q.
Karen Helen Clements, Burlington, Ont.
Johanne Cloutier, Edmunston, N. B.
Helen C. Cluett, London, Ont.
John Edward Coady, Kingston, Ont.
John E. Cockburn, Manotick, Ont.
Adrienne Faith Cohen, Calgary, Alta.
Colleen Collar, Calgary, Alta.
Ronald Collette, Vancouver, B.C.
Richard L. Cone, Prince George, B.C.
Cathy A. Connell, Burlington, Ont.
Continued on page 1730
CAN. FAM. PHYSICIAN Vol.35: SEPTEMBER 1989
1729
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
1729
Continued from page 1729
Michelle A. Conrod, Moncton, N.B.
Catherine Louise Cook, Winnipeg, Man.
Judith Anne Cooper, Niagara Falls, Ont.
Louis Cossette, Chapais, P.Q.
Thomas George Costello, Wabush, Nfld.
Donna Courchesne, Huntingdon, P. Q.
Julie Couture, Levis, P.Q.
Carol Couvrette, Brockville, Ont.
Marlyn A. Cox, Winnipeg, Man.
David James Alexander Crawford, Winnipeg, Man.
Angela Kathleen Cullen, Port Coquitlam, B.C.
Joyce Curtis, Halifax, N.S.
Anthony G. Czaharyn, Montreal, P.Q.
Steve Daigle, Iles-de-la-Madeleine, P. Q.
Robin Dancose, Montreal, P. Q.
Peter Edward Daniel, London, Ont.
Amna F. Daudi, Toronto, Ont.
Christiane Dauphinais, Quebec, P. Q.
Martin Edward Davies, Saskatoon, Sask.
Elizabeth Margaret Dawe, Toronto, Ont.
Andrew Dayneka, Dryden, Ont.
Alaine Marie Debono, Weston, Ont.
Michel Decarie, Candiac, P. Q.
Catherine Dery, Willowdale, Ont.
Jose6 Desrochers, Ile Bizard, P. Q.
Maria Dibb, Invermere, B.C.
Janique Dion, Sillery, P.Q.
Heidi Dischinger, Calgary, Alta.
Marjorie Ann Docherty, Kelowna, B.C.
Julie Dorion, Longueuil, P. Q.
Sylvia Ducceschi, Ottawa, Ont.
Martine Ducharme, Chomedey, P. Q.
Daniel Dufour, Ottawa, Ont.
Pauline S. Duke, St John's, Nfld.
Barbara R. Duncan, Richmond, B.C.
Jacinthe Dupont, St-Ferreol-les-Neiges, P.Q.
K. Edmonds, North Vancouver, B.C.
G. Edye-Mazowita, Winnipeg, Man.
Scott H. Elliott, Brantford, Ont.
Mark L. Enright, London, Ont.
Angela S. Ernst, Montreal, P. Q.
Mark Essak, Montreal, P. Q.
Nora J.M. Etches, Hazelton, B.C.
Elizabeth M. Falls, Montreal, P. Q.
Bernard Fallu, Cap Rouge, P. Q.
Catherine Reid Faulds, London, Ont.
Randy James Fedorchuk, Hope, B.C.
Marilyn Louise Fell, Surrey, B.C.
Nicolette Katherine Fellegi, Ottawa, Ont.
Matthew J. Ferrao, Bonnyville, Alta.
Catherine Ferrier, Montreal, P. Q.
Margaret Jean Flanagan, Aylmer, P. Q.
Violet Lai Yee Foo, Vancouver, B.C.
Andrew John Forbes, Trenton, Ont.
Marie-Chantal Forget, Montreal, P. Q.
Nathan P. Frank, Toronto, Ont.
Denise Frechette, LaSalle, P. Q.
Catherine E. Frederick, London, Ont.
Mark C. Freitag, Calgary, Alta.
Kenneth G. Frick, Regina, Sask.
Theresa M. Fryer, Sioux Lookout, Ont.
Fabienne Gagnon, St-Marie-de-Beauce, P. Q.
Perry Gall, Winnipeg, Man.
Kristy L. Gammon, Burlington, Ont.
Susan Elisabeth Garber, Calgary, Alta.
Rudolph E. Gasparelli, Wawa, Ont.
Michel Gemme, Quebec, P. Q.
Sameera Ghaznavi, Ancaster, Ont.
Nathalie Girouard, Montreal, P.Q.
Josee Giroux, Montreal, P.Q.
Brian 0. Goertz, Regina, Sask.
Elisabeth Gold-Smith, Toronto, Ont.
Mark Larry Goldstein, Willowdale, Ont.
Joseph Goodman, Calgary, Alta.
Maria Goodridge, Florenceville, N. B.
Beverly Joan Goodwin, Newmnarket, Ont.
Katherine Marian Graber, Oakville, Ont.
Norah C. Graham, Digby, N.S.
Barbara Grandy, St. John's, Nfld.
Carl 0 Graves, Vancouver, B.C.
Donovan O.N. Gray, Winnipeg, Man.
Violet M. Greiner, Millgrove, Ont.
Yasmin Gulamali, Regina, Sask.
Alan Lee Gunning, Oakville, Ont.
Jeffrey S. Habert, Toronto, Ont.
Duncan James Hadley, Fredericton, N. B.
Angela Leslie Hallett, Shubenacadie, N. S.
Keith Campbell Hankinson, Cambridge, Ont.
Kevin Hanrahan, Calgary, Alta.
Kenneth Hashman, Calgary, Alta.
Christopher H. Hassell, Richmond Hill, Ont.
Sigurdur Helgason, Ancaster, Ont.
Katherine Ann Helleur, Calgary, Alta.
Scott Charles Hennes, Medicine Hat, Alta.
Greg Arthur Higgins, Kingston, Ont.
Thi Kim Phuong Ho, LaSalle, P.Q.
Michael Burnell Hodgins, Markdale, Ont.
Tommy Hong, Mississauga, Ont.
R. Allen Hooper, Bragg Creek, Alta.
Mary F. Howson, Whitby, Ont.
Douglas Raymond Huber, Regina, Sask.
Ivo J. Hudlicky, West Vancouver, B.C.
Margaret Hughes, Montreal, P. Q.
Susan Jane Hunter, Hamilton, Ont.
Mary Kathryn Huntley, Kingston, Ont.
Marcos A. Iglesias Jr., Mississauga, Ont.
Carey Isaac, Winnipeg, Man.
Lauren Elaine Jackson, Victoria, B.C.
Alexandra Jacob, Outremont, P. Q.
Evelyn Jain, Calgary, Alta.
R.H.B. James, Saskatoon, Sask.
Brian W. Jensen, High River, Alta.
Anthony Jeraj, Regina, Sask.
Karen Johnston, Toronto, Ont.
Robert Glyn Jones, Oakville, Ont.
Gerdur Jonsdottir, 110 Reykjavik, Iceland
Heinz Wilfried Kaethler, Steinbach, Man.
Leonard M. Kahansky, Ottawa, Ont.
Norman Joseph Kalyniuk, Newmarket, Ont.
Tarit Kumar Kanungo, Regina, Sask.
Vikas Kamik, Winnipeg, Man.
Shelby Karpman, Edmonton, Alta.
Tomas Kaufman, Westmount, P.Q.
1730
CAN. FAM. PHYSICIAN Vol.35: SEPTEMBER 1989
1 730
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
Paul Keith, Hythe, Alta.
Diana M. Kelland, Silverton, B.C.
Victoria L. Kendrick, Calgary, Alta.
Karen M. Kennedy, Don Mills, Ont.
Margaret C. Keresztesi, Comox, B.C.
Mike Kiltz, Calgary, Alta.
Karen Kimmett, Twillingate, Nfld.
Susan Kingston, Yellowknife, N. W. T.
John C. Kirk, Montreal, P. Q.
Tessa A. Kitai, Maniwaki, P.Q.
Bharat Kohli, Toronto, Ont.
Eleonor Kopylenko, Thornhill, Ont.
James R. Kozan, Regina, Sask.
Deanna Marie Krasilczuk, Hamilton, Ont.
Daniel Metro Krawczuk, Sudbury, Ont.
Stanley George Kroeker, Castor, Alta.
John F. Krotchko, Linden, NY
Elspeth M.C. Kushnir, Oakville, Ont.
Carson Chwen Cherng Kwok, Mississauga, Ont.
Trevor Pak Hai Kwok, Hamilton, Ont.
Timothy David LaBelle, Kingston, Ont.
Alain-Paul Lalonde, Chapais, P. Q.
Claude Lamarre, Montreal, P.Q.
Christian Lamoureux, Victoriaville, P. Q.
Kenneth John Neil Landin, Calgary, Alta.
Pearl Langer, Willowdale, Ont.
Stephen Wayne, Langford, Ear Falls, Ont.
Jean Lapointe, Charlesbourg, P. Q.
Marc Larocque, Roberval, P. Q.
Lyne Laurendeau, Montreal, P. Q.
Mireille Lavoie, St-J'r6me, P. Q.
Natalie Le Sage, Ste-Foy, P. Q.
Constance LeBlanc, Ste-Foy, P. Q.
Hau Man Herman Lee, Manitouwadge, Ont.
Manon Lefebvre, St-Vincent-de-Paul, P. Q.
Sylvie Lefebvre, Ottawa, Ont.
Francine Leger, Sherbrooke, P. Q.
Barbara Lent, London, Ont.
Robert S. Lepage, Ottawa, Ont.
Manon Leroux, Matane, P.Q.
Marie Jose Lesperance, Jerseyville, Ont.
Lucie Lessard, Ste-Foy, P. Q.
Laura Lee Lewin, Ottawa, Ont.
Ann Lih-Ing Li, Willowdale, Ont.
Laurie Jane Liberman-Nadolny, Toronto, Ont.
Alexandra Leslie Lindberg, Victoria, B.C.
Tina T.S. Liu, North York, Ont.
Daphne J. Lobb, Vancouver, B.C.
Kathryn Lockington, Kingston, Ont.
Brenda Bonnie Loewith, Lynden, Ont.
Terry Longair, Lethbridge, Alta.
Sarah Hope Lovell, Kingston, Ont.
Bligh Kee Wai Low, Delta, B.C.
Ronald R. Low, Brooklyn Center, MN
Steven L. Low, Coaldale, Alta.
William Low, Surrey, B.C.
John D. MacLeod, Liverpool, N.S.
Iain A MacPhail, Ottawa, Ont.
Anne P. Madigan, Toronto, Ont.
Stanley W. Mah, Edmonton, Alta.
Donna G. Mahoney, Thornhill, Ont.
Andrew David Mai, London, Ont.
Andrew F. Major, Saskatoon, Sask.
Paul William Mallam, Prince George, B.C.
Craig James Maltman, Scarborough, Ont.
Drue H. Mandel, Richmond Hill, Ont.
Howard Elliot Mandel, Hamilton, Ont.
Emmanuelle Manny, Montreal, P. Q.
David Marcassa, Timmins, Ont.
Catherine A. Marchetti, Islington, Ont.
Hubert Marcoux, St-Augustin, P. Q.
Kevin Mardell, Belmont, Ont.
John Julian Marsden, Vancouver, B.C.
Denise Irene Marshall, Strathroy, Ont.
Diane C. Martin, Port Alberni, B.C.
Julie M-C Martin, Kingston, Ont.
Rene Francis Martin, London, Ont.
Marie S. Martineau, Laval, P.Q.
Solange A. Masson, St-Lambert, P.Q.
Douglas G. Mastel, Medicine Hat, Alta.
Susan Allison Mather, London; Ont.
Marie Mathieu, Sherbrooke, P. Q.
Nicolas Mathieu, L'annonciation, P. Q.
Brenda Maxwell, Winnipeg, Man.
Maureen A. Mayhew, Aylmer, P.Q.
Michael J. McConvey, Barrie, Ont.
Mary McDonagh, Kitchener, Ont.
Gerald Paul McFetridge, Quesnel, B.C.
Shaun N. McGuire, Gloucester, Ont.
Joanne M. McLeod, Regina, Sask.
J. Stewart McMillan, Regina, Sask.
Heather McNally, Waterloo, Ont.
Marie Louise McNaughton-Filion, Pickering, Ont.
Robert David Menzies, Vancouver, B.C.
Elizabeth Anne Messervey, Ottawa, Ont.
I. L. Roy Metcalfe, Ancaster, Ont.
James Meuser, Toronto, Ont.
Andre S. Michalchuk, Calgary, Alta.
A. Millers, Toronto, Ont.
Cynthia Louise Mitchell, Calgary, Alta.
David A. Mitchell, Don Mills, Ont.
Jacqueline R. Mitchell, North York, Ont.
Richard Allan Moffatt, Moose Jaw, Sask.
Scott M. Moffatt, Florenceville, N. B.
Barbara J. Monahan, Verdun, P.Q.
Anne Marie Monforton, London, Ont.
Bryan Craig Moran, Toronto, Ont.
Champaklal Morar, Crystal City, Man.
Louis Morissette, Ottawa, Ont.
Stephen Jan Morys, Edmonton, Alta.
Michael Joseph Murphy, Aylmer, P. Q.
Cynthia Barbara Mylrea, Calgary, Alta.
Gary J.M.J. Nadeau, Sudbury, Ont.
Arun Nayar, Kelvington, Sask.
Marna J. Nelson, Vancouver, B.C.
Mary Louise Neufeld, Winnipeg, Man.
Peter Michael Neweduk, Etobicoke, Ont.
Christine Newton, Calgary, Alta.
Henry C.P. Ngai, Vancouver, B.C.
Jannick Nicolet, Montreal, P.Q.
Heather Lucille Noble, Guelph, Ont.
Peter W. Nord, Islington, Ont.
Fraser Rae Norrie, Vancouver, B.C.
Continued on page 1732
CA.FM
PHYSICIAN---Vol-.35:---SEPTEMBER---
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
1989---17311731
Maoffmomm
Continued from page 1731
Eric Notebaert, Outremont, P.Q.
David J. Nunn, Kentville, N.S.
Mary Gail O'Brien, Edmonton, Alta.
Daniel Finnbar O'Connell, Metchosin, B.C.
Janice Lea O'Hara, Edmonton, Alta.
Peter O'Malley, Port Alice, B.C.
Carmen Angela Catherine O'Neill, Bridgewater, N. S.
Helen Olijnik, Edmonton, Alta.
Albert John William Oliver, Vancouver, B.C.
Doreen Oneschuk, Edmonton, Alta.
Helen Ostro, Toronto, Ont.
Carol Jane Ostry, Edmonton, Alta.
Walter Dale John Owsianik, Hamilton, Ont.
Robert C. Paddon, St Thomas, Ont.
Hazel S. Park, Toronto, Ont.
Colin Hope Partridge, Victoria, B.C.
Claude Patry, Charlesbourg, P. Q.
Tomas Michael Pauk, Barrie, Ont.
Lawrence K. Pawluk, Edmonton, Alta.
Jean Pelletier, Montreal, P. Q.
Jerry Pelletier, Edmonton, Alta.
Louise Pelletier, Daaguam, P.Q.
Mark Robin Pellow, Thornhill, Ont.
Michael Perley, Woodstock, N. B.
Howard L. Petroff, Toronto, Ont.
Manon Poirier, Ste-Anne-des-Monts, P. Q.
Liette Poitras, Edmundston, N. B.
Jean Prenovault, Winnipeg, Man.
Sylvain Proulx, Dolbeau, P. Q.
Wendy Margaret Pullan, Ottawa, Ont.
Thomas Mark Quigg, Willowdale, Ont.
Gerard Quinn, Cambridge, Ont.
France Quintal, Sherbrooke, P. Q.
Glenna Lee Ramsay, Edmonton, Alta.
Dino William Ramzi, Hampstead, P.Q.
Bernadette Mary Raupach, Coldstream, B.C.
Heinz Dieter Raupach, Coldstream, B.C.
Denis Raymond, St-Jean-Port-Joli, P. Q.
Janet Russell Reid, King City, Ont.
Ben Reiter, Montreal, P. Q.
Caroline Rheaume, Charlesbourg, P. Q.
Thomas C. Richard, Gananoque, Ont.
Gisele Rioux, Ville-Marie, P.Q.
Eva Risling, Vancouver, B.C.
Michele Rivest, St-Laurent, P. Q.
Elizabeth Rivington, Morrisburg, Ont.
Dean R. Roehl, Edmonton, Alta.
R. Susan Roman, London, Ont.
George Rosenkranz, Ponoka, Alta.
Stephen Eli Rosenthal, Montreal, P. Q.
Leslie Andrew Rosoph, Montreal, P. Q.
Donald A. Ross, Abbotsford, B.C.
Theresa Aileen Ross, Calgary, Alta.
M. Rotbard, Toronto, Ont.
R. Winona Rowat, Vancouver, B.C.
Carol Rowntree, Edmonton, Alta.
Suzanne M. Roy, Sherbrooke, P. Q.
Nene 0. S. Rush, Winnipeg, Man.
Norman Sabin, Cote-des-Neiges, P. Q.
Perie A. Saeed, Montreal, P. Q.
Gail Frances Saiger, Port Alberni, B.C.
1 732
Gweneth Lorraine Sampson, Stouffville, Ont.
Jennifer R. Schatz, Ottawa, Ont.
Benjamin Z. Schiff, Montreal, P. Q.
Ted David Schnare, Ottawa, Ont.
Kane Alexander Scott, Thunder Bay, Ont.
Michael Denton Scott, Brandon, Man.
Catherine Lee Scrimshaw, Fogo, Nfld.
Brian Charles Sharpe, Lumsden, Nfld.
Lauren M. Shaw, Vancouver, B.C.
Grant Leon Shechtman, Toronto, Ont.
Elizabeth Anne Sheridan, Mississauga, Ont.
Raphael Eugene Shew, Nepean, Ont.
Jerry Shockey, Calgary, Alta.
Joanne Patricia Shreeve, Windsor, Ont.
Jaime Siclait, Brossard, P.Q.
Miriam Alison Siderson, Edmonton, Alta.
Eric S. Silver, Toronto, Ont.
L.E. Silvester, Calgary, Alta.
Greg Peter Ronald Siren, Nelson, B. C.
Barry Slapcoff, Montreal, P. Q.
Jay Michael Slater, St John's, Nfld.
Patricia Ruth Smith, Calgary, Alta.
Rose Louise Smyth, Calgary, Sask.
T. Drew Sommerfeldt, Lethbridge, Alta.
John J. Song, Brampton, Ont.
Joanne Suk-Wah Soo, Montreal, P.Q.
Amerigo D. Sparanese; Kingston, Ont.
Mary Spiridigliozzi, St-Leonard, P. Q.
Richard St-Pierre, St-Augustin Desmaures, P. Q.
Terri Lynn Staniland, Edmonton, Alta.
Carina Ninette Starok, Windsor, Ont.
Wade Steed, Okotoks, Alta.
Harold Nicholas Stefanyk, Edmonton, Alta.
Reginald Benjamin Stobo, London, Ont.
Carol Lynn Story, Vancouver, B.C.
John E. Stronks, Palmerston, Ont.
Joyce Sun, Vancouver, P.Q.
Dorothy Jean Sunderland, Scarborough, Ont.
Beatrice Superville, Lac Mistassini, P. Q.
Felicity Ruth Suttor, Kingston, Ont.
Kathleen Anne Swayze, Jordon Station, Ont.
Angelika Frieda Szabo, London, England
Monir Taha, Mississauga, Ont.
Stephane Tari, Sherbrooke, P. Q.
Stanley Teitelbaum, Toronto, Ont.
Luke MacKenzie Teskey, Toronto, Ont.
Paule Tessier, Ste-Foy, P. Q.
Sylvie Tessier, Montreal, P. Q.
Raymond Thibodeau, Joliette, P.Q.
Keith Alexander Thompson, London, Ont.
Angela D. Thompson, Saskatoon, Sask.
Brian Carson Tobin, Toronto, Ont.
Alex Tolton, Winnipeg, Man.
Garry A. Towill, Tempe, AZ
Alison Margaret Trant, Nepean, Ont.
Donald F. Trant, Georgetown, Ont.
Myriam Tremblay, Havre-St-Pierre, P. Q.
Nancy Elizabeth Trimble, Barrie, Ont.
Kevin Mark Troughton, Ottawa, Ont.
Jane L. Tucker, Hamilton, Ont.
Holt Turner, Hamilton, Ont.
Patricia Joyce Turner, Hamilton, Ont.
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
1 1 1 -1 1 1 .M
Paul Vincent Turner, Perth, Ont.
Steven Leslie Turner, Jackson's Point, Ont.
Edgar R. Turski, Kimberley, B.C.
Shifra Tyberg, Montreal, P.Q.
Kim Tysdale, Hamilton, Ont.
Thomas E. Ungar, Toronto, Ont.
Richard Upenieks, Don Mills, Ont.
Mylene Vachet, Ottawa, Ont.
Karen E. Vaillant, Burlington, Ont.
Susan van Baardwijk, Hamilton, Ont.
Helen Vasilikaki-Baker, Ville St-Pierre, P. Q.
Janice C. Veenhuizen, Vancouver, B.C.
Jacqueline Lorraine Verge, St John's, Nfld.
Janet Vickers, London, Ont.
Denis Vincent, Edmonton, Alta.
Lakshmi Visvanatha, Gloucester, Ont.
Mary Michelle Volkert, Haileybury, Ont.
Ruby Lynn Wagner, Woodstock, Ont.
Kingsley F. Watts, Toronto, Ont.
Irma Ashley Skrob Webb, Hamilton, Ont.
Constance M. Weicker, Willowdale, Ont.
Ronald Stephen Weiss, Ottawa, Ont.
Laurie Lynn Wells, Hamilton, Ont.
Richard M. Welsh, Clearbrook, B.C.
Cynthia R. Whitehead, Toronto, Ont.
Avram David Whiteman, Westmount, P.Q.
Wendy Lee Wickstrom, Sudbury, Ont.
Richard John Wiginton, Kingston, Ont.
Nigel A. Williams, Edmonton, Alta.
Lee Ann Marie Wills, London, Ont.
J. Scott Wilson, Truro, N. S.
Harvey Brian Winfield, Gananoque, Ont.
Ian M. Wishart, Edmonton, Alta.
Martin John Withers, Echo Bay, Ont.
Susan A. Witt, Edmonton, Alta.
Mark F. Woldnik, Terrace Bay, Ont.
James Mantai Wong, Edmonton, Alta.
Patrick Gum Way Wong, New Westminster, B.C.
Paul Chung-Ho Wong, North Vancouver, B.C.
Marjorie Lamb Wood, London, Ont.
Georgia June Woods, Hamilton, Ont.
Bruce Wright, Calgary, Alta.
Joan L. Yap, Vancouver, B.C.
Sami Youakim, Montreal, P.Q.
Dori-Lynn Yukich, Sault Ste Marie, Ont.
Mark S Zalter, Montreal, P. Q.
Rudolf Andrew Gerard Zimmer, London, Ont.
HOW TO PIN DOWN
A ROUNDWORM
DA ROUND UP A PINWORM.
....
.,~~~'q7p
lippollill,
11.1.4111111.1.1.
.
Pleasant caramelflavoured
suspension (50 mL)
W
X /hen common worms find families too
accommodating, recommend Combantrin.
It's the anthelmintic that offers families a choice.
Tablets or suspension. Two formulations to pin
down roundworms and round up pinworms. In just
one convenient dose.
-
12 TAEBLETS
Easy-to-swallow tablet
(blisterpack of12)
Leeming Division,
Kirkland, Quebec H9J 2M5
Product monograph available on request.
Pid
om ban
PAABI
lCPP
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
_|111 I
trnM
1
1 733
The College Sustaining Fund Awards
These awards are designed to provide
financial support to CFPC members
interested in furthering their professional development through a defined
program of study or research activity.
The amount of the award will vary
depending on the annual contributions to the fund and the number of
applicants.
* Travelling Scholarships: To enable CFPC members to study for a
minimum of three weeks at a centre
outside Canada.
* Clinical Traineeships:
To enable
CFPC members to pursue clinical
studies for at least three weeks under
the direction of a clinical department
at a Canadian university.
* Graduate Study Awards: To enable CFPC members to study parttime for at least six months. The
members will continue in practice
while attending the course on a regular (e.g. weekly) basis.
* Awards for Research or Development: To provide "seed money" to
fund preliminary proposals, and
thereby allow someone with a good
idea to get started. Larger grants are
also available for which applicants
must submit a more formal research
proposal.
* Practice Enrichment Awards:
To
enable a CFPC member to study
under the direction of a Canadian
university for at least three months in
the following areas:
1. Emergency
or
geriatric medi-
cal profession, allied health professionals and the public. Value: $5,000
plus travel expenses for recipient and
cine
2. Anesthesia or obstetrics and gy-
necology
spouse.
3. Sports or occupational medicine
Value: $3,000 per award.
* Family Medicine Update Awards:
To enable a CFPC member to pursue
an update course in family medicine
under the direction of a Canadian
university for at least three months.
Value: $3,000.
* Awards to Provincial Chapters: To
assist in the development of projects
within the terms of the Sustaining
Fund, i.e., to promote research, education and library services.
Examples: setting up a provincial research unit or project; sharing in the
cost of a specific workshop; providing
support for a regional library or other
special educational service.
* National Awards: To support cooperative studies in education and research with other national or international organizations.
* Donald I. Rice Merit Award:
To
enable a nationally or internationally
renowned leader in family medicine
to travel for approximately one
month to one or more Canadian
provinces to pursue educational activities with the provincial chapters of
CFPC, university departments of
family medicine, continuing medical
education programs, family physicians and other members of the medi-
D.M. Robb Research Award: This
award honours the late D.M. Robb, a
past-president of the New Brunswick
Chapter of CFPC, who was keenly interested in research. Preference will
be given to a community-based family physician who wishes to conduct
research on a topic relevant to family
medicine. The research may consist
of refining a proposal, developing a
pilot project or completing a research
project. Value: $2,500.
*
Applications for the Sustaining Fund
Awards can be obtained by writing
to:
The Director of Administration
The College of Family Physicians
of Canada,
4000 Leslie Street
Willowdale, Ont. M2K 2R9
Deadline for receipt of applications
is December 1, 1989.
This annual announcement of the
CFPC awards program again provides
an opportunity to invite members and
friends of the College to support the
endowments/awards program by contributing to the College's Sustaining
Fund. This fund is registered as a
charitable trust fund, and all contributions may be claimed for tax purposes.
The Sustaining Fund
The College of Family Physicians of Canada
4000 Leslie Street, Willowdale, Ontario M2K 2R9
I/we pledge $_
to The Sustaining Fund of The College of Family
Physicians of Canada to foster the professional development of family
physicians through the promotion of research, education and library services.
Name
Address
City
Date
Postal Code
Prov.
Signature
Contributions are tax deductible. Registration No. 0373142-25-13
1 734
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
Capsules
The family medicine literature is
wide and varied, and not all to be
found in Index Medicus. In this
section, our librarian, Lynn
Dunikowski, provides synopses of
articles from the current literature,
full texts of which can be obtained
from the Canadian Library of Family
Medicine, Natural Sciences Centre,
University of Western Ontario,
London, Ont. N6A 5B7.
Alternatively, local medical libraries
or hospital libraries may be able to
help.
Child Abuse
cardiac or esophageal. Typical or
atypical chest pain can be difficult to
diagnose and has even generated investigational protocols to help diagnose acute chest pain in the emergency room. Nonetheless, symptoms can
be poor indicators of the underlying
disorders. The common innervation
to the heart and esophagus may help
explain the similarity of symptoms in
cardiac and esophageal disorders.
Disorders of the esophagus are the
most common causes of non-cardiac
chest pain. The authors emphasize
esophageal motility disorders and
gastroesophageal reflux disease
(GERD). Characteristic features are
examined to determine when the
physician should suspect an esophageal origin. The pathophysiology of
the disorders, diagnostic tests, and
medical and surgical treatments are
discussed. The authors review the potential link between the heart and the
esophagus in terms of similar responses to pain.
Badger LW. Reporting of child abuse:
influence of characteristics of
physician, practice, and community.
South Med J 1989; 82:281-6.
This survey of 120 Alabama pediatricians, family physicians, and general
practitioners investigated the relationships between physician, practice, and community characteristics
and the factors that impede reporting
of detected child abuse. Solo practi- Gestational Diabetes
tioners and rural physicians were concerned most about the effect of re- Ales KL, Santini DL. Should all
porting on their relationships with pregnant women be screened for
their patients. Small-town physicians, gestational glucose intolerance?
recent medical school graduates, and Lancet 1989; i:1187-91.
physicians who had attended child Although gestational glucose intolerabuse workshops were most likely, ance is associated with the remote deand urban physicians least likely, to velopment of diabetes mellitus, the
endorse an ethical or legal responsi- risk to the mother during the index
bility to report. Attendees of work- pregnancy and the risk to her fetus
shops were more confident in their remain uncertain. Nevertheless, uniability to recognize abuse and less versal screening for gestational glulikely to think they could best handle cose intolerance has many strong adThe scientific data
the case themselves. Male physicians vocates.
were reluctant to report abuse be- supporting a universal screening procause of the likelihood of having to gram - showing that treatment of
appear in court. All physicians were gestational glucose intolerance does
reluctant to report cases about which more harm than good - are limited.
they were uncertain and were con- Until the evidence can be extended
cerned about the lack of prompt ac- beyond that on infant birth weight, a
tion after their reports; general prac- more restrained approach than unititioners expressed reluctance to versal screening may be appropriate.
report due to a variety of factors.
Esophageal Pain
Rustgi AK, Chopra S. Chest pain of
esophageal origin. J Gen Intern Med
1989; 4:151-9.
Chest pain is a common problem that
has far-reaching diagnostic, therapeutic, psychologic, sociologic, and economic consequences. Its cause can be
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
Headache
Diamond S, Freitag FG. Current
treatments for headache. Fam Pract
Recertif 1989; 11(3):25-7, 32, 42
passim.
The most common kinds of headache
are migraine, muscle contraction, or
cluster headache, or the mixed headache syndrome. Most persons with
the disorders respond well to traditional therapies specifically designated for their particular kind of
headache-usually
,-blockers,
a-agonists, calcium channel antagonists, nonsteroidal anti-inflammatory
drugs, antidepressants, or ergotamine
preparations are successful. Nonetheless, treating headache can be frustrating. Despite extensive scientific
investigation, pathophysiology of
headache is only partially understood, and the drugs available are at
times ineffective. Recently, a variety
of new therapeutic modalities have
beconme available for migraine and
other headaches, and research is ongoing. The author reviews the traditional therapies and newer methods
of treatment that are in use or under
investigation.
Hearing Loss
Weinstein BE. Geriatric hearing loss:
myths, realities, resources for
physicians. Geriatrics 1989;
44(4):42-8, 58, 60.
Hearing impairment is one of the
three most prevalent chronic conditions affecting the physical health of
older persons. It is estimated that as
many as 60% of persons older than 65
years and over 90% of persons 80
years and older have some degree of
hearing impairment, and about 55%
of adults with hearing loss severe
enough to inhibit communication are
65 years or older. The deterioration
in hearing sensitivity of older adults
and associated difficulties understanding speech pose significant problems for individuals and for their families. Further, a hearing loss that is
undetected or unaddressed can interfere with medical and psychosocial
management. Because of the effects
of an undetected hearing loss, early
diagnosis and management are imperative. The author discusses the
role of the primary care physician in
the identification and management
process and examines rehabilitation
technology for the hearing-impaired
elderly patient.
Hiv Infection
Lo B, Steinbrook RL, Cooke M,
Coates TJ, Walters EJ, Hulley SB.
Voluntary screening for human
immunodeficiency virus (HIV)
1813
infection. Weighing the benefits and
harms. Ann Intern Med 1989;
110:727-33.
Voluntary screening for human immunodeficiency virus (HIV) infection
may help prevent the spread of the
HIV epidemic if persons who test positive alter behaviours that may transmnit infection. Protecting persons
from unknowing exposure to HIV infection must be balanced against respecting the autonomy of individuals
being screened. Seropositive patients
may be subject to discrimination if
confidentiality of test results is
breached. In patients without highrisk behaviours, the positive predictive value of HIV testing may be substantially increased if tests are done
in reference laboratories and if further confirmatory tests are run on a
second blood specimen. For persons
with high-risk behaviours, HIV testing
can be recommended to those who
want to reduce uncertainty about
their HIV status or whose medical care
would change if they were seropositive. Health care workers can maximize benefits of screening and minimize harm by educating and
counselling patients before HIV test-
ing, discussing the confidentiality of
HIV test results, urging patients to disclose positive results to sex partners,
and advising patients on how to reduce high-risk behaviours.
Hypertension
Kligman EW, Higbee MD. Drug
therapy for hypertension in the
elderly. J Fam Pract 1989; 28:81-7.
Essential hypertension is a major
health care problem in the elderly
and requires effective treatment to
lower morbidity and mortality. The
traditional stepped-care approach to
therapy consists of diuretics, sympatholytic agents, or a-blockers for all
age groups. Indeed, initial therapy
with these agents is effective in 50%
to 60% of elderly patients, but may
produce adverse effects. A high incidence of adverse responses, including
sexual dysfunction and central nervous system impairment, has been reported with diuretic or a-blocker
therapy, and a reduction in several
measures of quality of life has been
noted during therapy with methyldopa or propranolol. Administration of
an angiotensin-converting enzyme
(ACE) inhibitor is as effective as the
traditional stepped-care approach
without producing these ill effects.
Combining an ACE inhibitor with a diuretic produces additive antihypertensive effects while minimizing diuretic-induced metabolic alterations.
Orthostatic hypotension with the first
dose can be minimized by ensuring
that patients are not hypovolemic
from previous diuretic therapy. Nevertheless, in controlled trials, the
combination of an ACE inhibitor and a
diuretic has been effective in up to
85% of patients. Also, using an ACE
inhibitor may benefit the hypertensive patient with concomitant congestive heart failure. Most important,
the patient's quality of life is maintained during therapy with an ACE inhibitor alone, or in combination with
a diuretic.
Melanoma
Becker JK, Goldberg LH, Tschen JA.
Differential diagnosis of malignant
melanoma. Am Fam Physician 1989;
39(5):203-14.
Malignant melanoma accounts for
only 3% of all skin cancers, but is responsible for two-thirds of deaths due
to cutaneous malignancies. This dis-
ERYC I~S BRAD+
Fg
e1^
ne
r
a, unqu eletzd deli'very syte desgne to deiver erythromycin to fthsml HWinete for
imprvdabopion and reduced potentialfor GI upset. It's an emerging chiein Canada.
rFore anMcedpatient compia&feC ERYCmabe takenP R
Nlwmith .sbo4od leves reain in the therapeti range).
Ei
D
VShir
Scarborough, Ontario MIL 2N3 J~
ease has had a 500% rise in incidence
over the past four decades, which is
the most rapid increase in any cancer
except lung cancer. Unlike most other
malignancies, melanoma is a visible
lesion with identifiable characteristics
that make early detection an attainable goal. People have become more
aware of the dangers of melanoma and
look to their family physicians for
evaluation of suspect lesions. Since a
variety of skin tumours and conditions
may resemble melanoma, knowledge
of the differential diagnosis and a systematic approach to the evaluation of
a suspect lesion are essential.
Obesity
Holmes MD, Zysow B, Delbanco TL.
An analytic review of current
therapies for obesity. J Fam Pract
1989; 28:610-6.
The obese adult patient poses a frustrating problem for every physician.
Success in achieving sustained weight
control is rare, although weight loss is
a cornerstone treatment for many
common diseases, such as hypertension, diabetes, heart disease, and degenerative joint disease. Substantial,
prolonged weight loss is difficult to
achieve. Nutrition counselling, very
low calorie diets, behaviour modification, exercise, intragastric balloon,
and gastric restriction surgery are interventions that physicians may recommend for obese patients. This paper analyzes the efficacy of these
methods with attention to attrition
rates, maximum weight loss, longterm maintenance of weight loss, and
morbidity. Strategies for intervention
for various classes of obese patients
are recommended.
Pap Smears
Koss LG. The Papanicolaou test for
cervical cancer detection. JAMA 1989;
261:737-43.
The complex detection system leading to finding and treating precancerous lesions and early cancer of the
cervix is described in detail and discussed. By far the most difficult and
underestimated component of this
system is the screening and interpretation of cervical (Papanicolaou)
smears. Cytologic case finding may
fail because of inadequate samples,
insufficient time devoted to screening, or human fatigue. Other weak
points of the system, such as inadequate patient compliance, poor repro-
Hasmophilu infuenae
I~~~~~~~~~Frrsrbn Inomto
m
3a lll ;;
ducibility of diagnoses, and ineffective aftercare are also described. For
example, obtaining a second smear to
confirm or refute a diagnosis of cellular atypia is often a misleading practice. The Pap smear has been effective
in reducing the morbidity and mortality rates from invasive cervical cancer
in appropriately screened populations. There is no evidence, however,
that the Pap test has successfully eradicated this theoretically preventable
disease anywhere. It is important to
inform the public about the potential
failures of the system and the reasons
for them.
Postherpetic Neuralgia
Schmader KE, Studenski S. Are
current therapies useful for the
prevention of postherpetic neuralgia?
A critical analysis of the literature.
J Gen Intern Med 1989; 4:83-9.
The purpose of this study was to determine whether current therapies
are useful in preventing postherpetic
neuralgia (PHN), by meta-analysis of
all controlled studies investigating
PHN prevention in the immunocompetent host. Articles were identified
through MEDLINE, Index Medicus,
and bibliographic reviews of major
texts and review articles. Studies
meeting eligibility criteria were independently assessed using explicit
methodologic criteria for validity and
generalizability in clinical trials.
Pooled analysis was also performed
where appropriate. Twenty-one investigations met eligibility criteria and
primarily addressed the use of antiviral agents and corticosteroids. Among
studies with strong designs, no evidence of benefit was found for acyclovir or corticosteroids. Pooled results
showed no significant effect of acyclovir on the prevention of PHN. Studies
that found the strongest potential efficacy in PN prevention involved adenosine monophosphate and idoxuridine in dimethyl sulfoxide, but
problems with clinical application limit the use of these compounds. Outcome definition, compliance assessment, power estimation, and method
of randomization were infrequently
addressed aspects of design. The authors conclude that there is currently
no proven useful therapy for the prevention of PHN. The benefits of acyclovir and corticosteroids are limited, but
key questions about these medications
remain. A clear consensus definition
of PHN is needed to improve future in- ized to the internal medicine clinic:
vestigations.
$7193 for intemal medicine patients,
compared with $5764 for family practice patients. The professional costs
Practice Styles
per hospitalization showed greater
Bertakis KD, Robbins JA. Utilization variation: $913 for internal medicine
of hospital services. A comparison of clinic patients and $629 for family
internal medicine and family practice. practice clinic patients. The mean
J Fam Pract 1989; 28:91-6.
length of hospitalization was longer
At a large university hospital, 520 for internal medicine patients (7.5
new patients were randomly and pro- days) than for family practice patients
spectively assigned to receive care in (6.3 days). The authors conclude
either the internal medicine clinic or that, in this clinical environment,
family practice clinic. Previous analy- hospitalization patterns differ for pases of out-patient data showed that tients assigned to the internal medithe frequency of visits to the primary cine clinic compared with the family
care clinic, acute care clinic, emer- practice clinic: both cost and length
gency room, and consultant clinics of care for hospitalization are less for
for patients randomized to internal those followed by the family practice
medicine were all significantly higher clinic.
than for family practice. In this study,
patients' charts were reviewed for in- Sigmoidoscopy
formation about hospitalizations.
During the 3.4-year study, there were Selby JV, Friedman GD.
a total of 61 hospital admissions for Sigmoidoscopy in the periodic health
internal medicine (35 of 249 pa- examination of asymptomatic adults.
tients), and 58 for family practice (27 JAMA 1989; 261:595-601.
of 271 patients). Age (mean 47 years) Periodic screening sigmoidoscopic exand sex of patients in both groups amination of asymptomatic persons
were equivalent. The average total has been recommended for more
cost of hospitalization for each pa- than 30 years as a means of reducing
tient was greater for those random- mortality from colorectal cancer. Evi-
Efeciveanllergy relief Dayl in,
dence supporting this practice is limited, however, and expert opinions differ as to whether sigmoidoscopy
should be included in the periodic
health examination (PHE). The authors review available evidence on the
efficacy and effectiveness of periodic
screening sigmoidoscopy in averagerisk persons. The sensitivity, specificity, and acceptability of screening sigmoidoscopy are also considered, as
are recommendations for screening
high-risk groups. The rules of evidence used by the United States Preventive Services Task Force for ranking quality of evidence and for
recommending inclusion (or exclusion) of screening tests in PHES accompany the article. These rules have
been modified from guidelines developed by the Canadian Task Force on
the Periodic Health Examination.
Somatic Fixation
McDaniel SH, Campbell T, Seaburn
D. Somatic fixation in patients and
physicians: a biopsychosocial
approach. Fam Syst Med 1989; 7:5-16.
Somatic fixation occurs when the patient or physician focuses exclusively
on the somatic aspects of a complex
disorder. This common and challenging problem results from individual,
family, and cultural factors that promote communication and the expression of emotional experience through
somatic symptoms. An unrewarding
cycle of interactions occurs when the
physician first rules out organic illness in the somatically fixated patient
and then searches for psychosocial
explanations. This article presents a
biopsychosocial approach to somatic
fixation in which the physician or a
treatment team establishes a collaborative relationship with the patient
system and strives to reach a mutually
acceptable explanation for the symptoms. Biomedical and psychosocial
evaluation are integrated from the
beginning, and the patient's somatic
defences and mode of communication
are respected. Limited goals are established and levels of patient functioning, rather than symptoms, are
monitored. Collaboration with another physician or a family therapist of-
ten helps to increase success and enjoyment of these difficult cases.
Thromboembolic
Disorders
Brunader REA. Diagnosis and
evaluation of thromboembolic
disorders. J Am Board Fam Pract
1989; 2:106-18.
The most common types of thromboembolic disorders are deep venous
thrombosis of the leg and pulmonary
embolism. Since the effectiveness of
anticoagulation therapy for deep venous thrombosis and pulmonary embolism was established in 1960,
knowledge of these disorders has increased rapidly. It has become clear
that the nonspecificity of symptoms
and signs of these disorders has led to
both overdiagnosis and undertreatment. The author reviews the natural
history and clinical manifestations of
deep venous thrombosis and pulmonary embolism and discusses their diagnostic evaluation.
ONCE-YONCE-A-DAY, ALL
SEASON LONG.
JANSSEN
PHARMACEUTICA
Mississauga.Ontario
*Trademark C Janssen 1989
LONG.
MEMBER
HE1402E
Continued from page 1926
therapists must work within those
values, not try to impose our generation's values on them . . . . the two
just don't mesh.'`9
Smythe MA. Golden years' discord.
In: Perspective. Ottawa: Royal Ottawa
Health Care Group, 1989:3.
are prone to be developmentally impaired, a Danish researcher says.
The neonatologist said her research
shows that these children should be
followed so that any lack in psychomotor development can be detected.
In her study, ultrasound was used
to assess early fetal growth in 99 insulin-dependent and 101 nondiabetic
women. Intrauterine growth delay at
eight to 14 weeks was detected in 42
of the diabetic mothers and three of
the nondiabetic mothers.
All available children were evaluated with the Denver developmental
screening test at four to five years of
"(Diabetic mothers' fetuses whose age. Only 23 of 34 children of diabetgrowth is delayed in early gestation ic mothers with early intrauterine
Fetal Growth
Delay in
Diabetics
DOSAGE AND ADMINISTRATION
The absorption of VASOTEC* (enalapril maleate) is not affected by food.
Dosage must be individualized.
HYPERTENSION
Initiation of therapy requires consideration of recent antihypertensive
drug treatment, the extent of blood pressure elevation and salt
restriction; the dosage of other antihypertensive agents being used with
VASOTEC* may need to be adjusted.
The recommended initial dose in patients not on diuretics is 5 mg once a
day. Dosage should be adjusted according to blood pressure response.
The usual dosage range is 10 to 40 mg per day administered in a single
dose or two divided doses. In some patients treated once daily, the
antihypertensive effect may diminish toward the end of the dosing
interval. In such patients, an increase in dosage or twice daily
administration should be considered. If blood pressure is not controlled,
a diuretic may be added.
The maximum daily dose is 40 mg. Raising the dose above that level is
not recommended because of the possibility of increased adverse
reactions.
Symptomatic hypotension occasionally may occur following the initial
dose of VASOTEC* and is more likely in patients who are currently being
treated with a diuretic. The diuretic should, if possible, be discontinued
for two to three days before beginning therapy with VASOTEC' to
reduce the likelihood of hypotension (see WARNINGS).
If the diuretic cannot be discontinued, an initial dose of 2.5 mg (break the
5 mg tablet) should be used to determine whether excessive
hypotension occurs.
To date there is insufficient experience with VASOTEC* in the treatment
of accelerated or malignant hypertension. VASOTEC*, therefore, is not
recommended in such situations.
Dosa In the Elderly (over 65 years)
The starting dose should be 2.5 mg. Some elderly patients may be more
responsive to VASOTEC' than younger patients.
Dosing Adjustment In Renal Impairment
The doses should be reduced in patients with hypertension according to
the following guidelines:
Renal Status
Normal Renal
Function
Mild Impairment
Moderate to
Severe Impairment
Dialysis Patients
8089 - VASOTEC* 5 mg Tablets are white, barrel-shaped, biconvex,
scored tablets, engraved 712 on one side and VASOTEC on the other.
Available in bottles of 100.
9873 - VASOTEC' 10 mg Tablets are rust-red coloured, barrel-shaped,
biconvex, tablets, engraved 713 on one side and VASOTEC on the other.
Available In bottles of 100.
9874 - VASOTEC* 20 mg Tablets are peach coloured, barrel-shaped,
biconvex, engraved 714 on one side and VASOTEC on the other.
Available in bottles of 100.
PRODUCT MONOGRAPH AVAILABLE ON REQUEST
(441-a,7,87)
*eTrademark
I
PA A B
P-0
BOX 1005.
POINTE-CLAIRE
HBA 4P6
DORVAL. OUESEC
Initlal Dose
mg/day
>80 mL/min
(>1.33 mUs)
5 mg
80 >30 mUmin
(Q1.33 >0.50 mL/s)
<30 mL/min
5 mg
-
Check babies of diabetics for hnpaired development. The Medical Post
1988 Sept 6:42(col 5).
AVAILABILITY
MEER
(60.50 mL/s)
normal scores.
Children with early intrauterine
growth delay exhibited more problems in personal-social development,
gross motor development, and particularly in language and speech
development. 9 7
CONGESTIVE HEART FAILURE
VASOTEC* is to be used in conjunction with a diuretic and digitalis.
Therapy must be initiated under close medical supervision, usually in a
hospital. Blood pressure and renal function should be monitored, both
before and during treatment with VASOTEC-, because severe
hypotension and, more rarely, consequent renal failure have been
reported (see WARNINGS and PRECAUTIONS).
Initiation of therapy requires consideration of recent diuretic therapy
and the possibility of severe salt/volume depletion. If possible, the dose
of diuretic should be reduced before beginning treatment.
The recommended initial dose is 2.5 mg once a day.
In the absence of, or after effective management of symptomatic
hypotension, the dose should be increased gradually, depending on the
patient's response, tothe usual maintenancedose (10-20 mg), given in a
single dose or in two divided doses. This dose titration may be performed
over a two- to four-week period, or more rapidly if indicated by the
presence of residual signs and symptoms of heart failure.
The maximum daily dose is 40 mg.
%M%OMM
Creatinine
Clarance
mL/mln (mids)
growth delay had normal test scores,
compared to 46 of 50 children of diabetic mothers with normal intrauterine growth, the researcher said.
The 46 children had scores very
similar to those of children of nondiabetic mothers, of whom 76 of 86 had
2.5 mg
2.5 mg on
dialysis days"
Dosage on nondialysis days should be adjusted depending
on
the
blood pressure response.
1 850
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
^ l | l l l | | l |_*Medical Digest
THIS MONTH
* Associating rheumatologic disorders with the HIV virus * Following through on the
effects of fetal growth delay in children of diabetics. How to handle feeding difficulties
among infants * Explaining the relationship between alcohol and gout * Improving
northern health care through modern communication systems * How NSAIDS can affect
major organ systems * Markers for identifying alcoholic patients in family practice * How
marital harmony evolves during retirement
Rheumatologic
Problems
in HIV Patients
( Investigators at the University of
South Florida College of Medicine
have concluded that specific rheumatologic syndromes can be associated
with human immunodeficiency virus
(HIV) infection. The investigators described rheumatologic manifestations
in a series of 101 patients with HIV infection. The musculoskeletal system
was involved in 72 of these patients:
35 patients presented with arthralgias; 10 had Reiter's disease; two had
psoriatic arthritis; two had myositis;
and one had vasculitis. Two previously unreported syndromes were also
noted. The first, seen in 10 patients,
consisted of severe intermittent pain
lasting only two to 24 hours and involving less than four joints. The second occurred in 12 patients and consisted of arthritis lasting from one
week to six months and usually involved the lower extremities.;;
News briefs. Am Fam Physician 1988;
38(3):384.
Effect of
NSAIDS on the
Lower GI Tract
C.Q. I have seen three patients
the last several years who have
developed diarrhea in association
with the use of several chemically unrelated nonsteroidal anti-inflammatory agents (NSAIDS). In the most recent
case, the patient developed uncontrollable diarrhea while using ibuprofen (Motrin), naproxen (Naprosyn),
piroxicam (Feldene), and indomethacin (Indocin). Has this adverse effect
over
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
been described? What is the mechanism thought to be? Are there specific agents with which this would be
less likely to occur, such as nonacetylated salicylates?
A. The major organ system affected
by adverse reactions to NSAIDS is the
gastrointestinal (GI) tract. Although
we focus on the side-effects produced
in the upper GI tract by these agents,
lower GI tract side-effects, including
diarrhea and lower GI tract bleeding,
have been reported with the use of
these agents.
Diarrhea is most commonly seen
with the use of meclofenamate sodium (Meclomen), occurring with a frequency of up to 30% in clinical trials.
The incidence of diarrhea with use of
other NSAIDS is probably no more
than 1% and not significantly different from what occurs in patients receiving placebo in controlled clinical
trials.
The mechanism of action underlying this toxic reaction is likely related
to inhibition of prostaglandin biosynthesis in the colonic mucosa. The explanation for the increased toxicity
associated with use of meclofenamate
is most likely the enterohepatic recirculation of the active drug, which
leads to an increased concentration in
the lower GI tract.
Recently, researchers reported
eight cases in which flare-ups of inflammatory bowel disease were associated with the use of NSAIDS. In light
of this report, it is interesting to note
that one of three patients reported
earlier had ankylosing spondylitis and
Crohn's disease; the latter was diagnosed only after the patient developed diarrhea and lower GI tract
bleeding during ibuprofen therapy.
Therefore, it seems prudent that patients who develop severe diarrhea
during therapy with NSAIDS, especial-
ly if it is complicated by lower GI tract
bleeding, be evaluated for occult inflammatory bowel disease. Further,
we have recently seen two patients
with collagenous colitis develop severe diarrhea while taking indomethacin.
I am unaware of any data concerning the relative relationship of nonacetylated salicylates compared with
other NSAIDS in causing diarrhea.
However, if prostaglandin inhibition
is an important mechanism explaining
the side-effect, it seems reasonable
that nonacetylated salicylates may be
less likely to produce severe diarrhea;
the nonacetylated salicylates are less
potent prostaglandin inhibitors than
either ASA or nonsalicylated
NSAIDS.'~9
Questions and answers. JAMA 1989;
261(21):3081.
Images from
the North
C(The University of British Columbia's Department of Biomedical
Communications is testing a new video communication system in the
Northwest Territories that should
bring better health care to over 50 remote communities. Known as colour
video fax, the system transmits high
resolution video and audio signals between nurse practitioners in the far
north and hospitals in Yellowknife
and Vancouver. The images are so
vivid that nurses can transmit live images of patients for dermatology examinations or send X-ray films for
immediate analysis. 'Right now, patients are often sent to Yellowknife
by medivac flight, and that can cost
between $5000 and $25 000 a flight,'
says the department director. 'With
the colour video fax system, the diag1921
Diet and the hypertensive patient.
nosis could be done remotely, saving
thousands of dollars.' Initial testing
was done in February between Cambridge Bay in the central arctic and
Vancouver. Ultimately, 54 northern
communities will be connected with
hospitals in Yellowknife, Edmonton,
and Vancouver. Testing is continuing,
with funding provided by the Kitikmeot Health Board in Cambridge
Bay, N.W.T.9
News. Can Nurse 1989; 85(5):13.
Influences of
Alcohol on Gout
"(Alcohol and gout have long been
associated in the medical and lay
.knowledge. More than 100 years ago,
fermented liquors were thought to be
the most powerful of all predisposing
causes of gout, whereas more recent
research showed that, for victims of
gout, eating and drinking were two of
life's greatest pleasures. What might
explain this association?
The metabolic disorder in gout re1922
sults in too much urate in the blood
and tissue fluids, and there are several possible ways that alcohol contributes to this excess. The high energy
content of alcohol predisposes toward
obesity, and body weight and uric
acid concentrations are related.
Drinking alcohol to excess produces
moderate
hypertriglyceridemia,
which is associated with hyperuricacidemia and gout. Alcohol may have
a role in 'washing down huge platters
of meat,' which is known to predispose toward gout.
Acute alcoholic intoxication may
produce transient lactic acidemia and
ketosis, leading to inhibition of the
renal tubular secretion of urate and
to hyperuricacidemia. Long-term oral
and short-term intravenous administration of alcohol to patients with
gout showed that alcohol increases
the synthesis of urate by increasing
the turnover of adenine nucleotides.
Beer drinkers may have to contend
not only with the hyperuricacidemic
effects of alcohol, but also the high
purine content of beer. Taken togeth-
er, these studies suggest that the
long-term consumption of alcohol increases the synthesis of urate, while
acute intoxication makes things worse
by reducing its excretion.
Some doctors and patients believe
that certain alcoholic drinks (e.g., red
wine and port) are more conducive to
gout than others (e.g, white wine and
whisky). If this is true, no satisfactory
explanation for the differences has
been proposed.
These findings have clear implications for treating patients with hyperuricacidemia and gout. Patients
should be carefully assessed for any
factors that are possibly contributing
to their hyperuricacidemia and counselled to avoid them. Many patients
who accept the advice will become
normouricacidemic and remain so.
(Ceasing to overeat and overdrink is
likely to be beneficial itself, quite
apart from its effect on hyperuricacidemia.) Drug treatment should be
reserved for gout patients who remain hyperuricacidemic despite having corrected their eating and drinkCAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
ing habits or who, as is unfortunately ous preparations to counter infant
often the case, disregard this wind may have been tried, but withadvice.99
out any improvement to the baby's
condition.
Scott JT. Alcohol and gout
In my opinion, this situation is in[Editorial]. Br Med J 1989; 298:1054. variably
due to excessive hunger,
which leads to gulping at the nipple
and the consequent swallowing of air.
This causes painful gastric distension
with a disinclination to feed and episodes of crying. A vicious circle of in" Maternal difficulties with infant creasing hunger producing ever more
feeding are common. In my practice, air swallowing rapidly intensifies the
over 50% of mothers experience problem. Sometimes nasal obstrucmoderate to major feeding difficulties tion from mucus, poor positioning
with their first baby, and about 25% during breast-feeding, or an upper reof mothers with their second or sub- spiratory infection initiates the condisequent infants. The problem is often tion, but often the cause is not apparmismanaged, particularly by well- ent.
meaning friends and relatives of the
Fortunately the condition responds
new parents. By the time they see rapidly to management. The method
their family doctor, both parents are outlined below will usually resolve
usually tired, confused, and agitated. excessive crying and irritability and
The usual story is that the infant is will ensure the establishment of nor'windy,' cries for considerable peri- mal feeding behaviour before the end
ods, and takes little from the breast of the second day. A particular ador bottle, with resultant poor weight vantage of this method is that it is
gain. The parents may report colic, likely to be perceived as 'natural,' so
irritability, and disturbed sleep. Vari- that good compliance is obtained.
Feeding Problems
Among Infants
The hvny)
During the consultation, first examine the infant and establish the history of the condition adequately to
exclude other conditions. You may
gain useful support for the diagnosis
of a simple feeding problem by carefully observing the infant during and
after feeding. Gulping, followed by
rapid cessation of feeding, then crying and eructation of swallowed air
are usually diagnostic. Failure to respond to the management protocol
within three days, however, suggests
an incorrect diagnosis. The following
program can be advised for the parents.
* If nasal obstruction is present, use
children's decongestant nose drops
three times daily for several days.
Carry the infant in a front papoose
sling. This position provides soothing
action for the baby and allows swallowed air to escape more readily.
* Day 1. Feed the baby. When the
baby seems to have had his or her fill,
cease feeding and burp the infant for
a few minutes. Ten minutes after, refeed. One hour later, feed, burp, wait
10 minutes, feed. Repeat this cycle
*
Rinsiv whn mnntiniie tn Rmokn
Exercise and the hypertensive patient.
through day 1 with night feeds as required.
* Day 2. Identical to previous day,
except allow two hours between
closely coupled feeds, with burping in
between.
* Day 3. At this stage, the feeding
problem should be reduced, and
feeding either every four hours or on
demand should be resumed as mother and baby choose.x
Baker PG. Practice tip: feeding dif
culties In Infants. Ast Fan Physician
1968; 17(9):7X.
Detecting
Alcoholism
in Family Practice
"6Patients who are problem drinkers are likely to visit their family physician almost twice as often as patients without an alcohol problem,
according to a recent study by a researcher from the Addiction Research Foundation (ARF). The study
1924
recommends that family doctors be
more aggressive in identifying and
treating alcohol abusers..
The ARF study compared, 108 problem drinkers to control subjects of
similar age, sex, and socio-economic
circumstances. Problem drinkers visited their family physician six times a
year on. average, -compared with
about three visits for the control
group.
The researcher showed that patients' reasons for office visits included social and mental health problems; such injunres as broken bones,
cuts, and burns; and digestive disorders. 'These.are flags that are raised
problems a doctor should -be particularly sensitive to', n trying to identify a problem drinker, he said.
The researcher said there is an 'increasing concem that physicians are
not generally aware of alcohol problems in their practice and may tend to
think that problem drinkers don't visit that often.' In fact, problem drinkers represent 10% to 20% of a physician's patients and account for a
disproportionate share of health care
costs, he said.
The ARF estimates that alcohol
abuse costs Ontario about five billion
dollars each year in the form of additional health care, social welfare, and
law enforcement costs and lost productivity. More aggressive intervention by family physicians could reduce those expenditures.
Several techniques for identifying
problem drinkers are known to be effective. A physician can:
* ask patients brief, but structured,
questions about warning signs of alcohol problems, such as morning
drinking and concern among family
members;
- use the Alcohol Clinical Index, a
more comprehensive review of the
patient's nmedical history and health
status; and
* test patients to evaluate liver function.
Unfortunately, however, these
procedures 'have yet to be accepted
in general practice.' With this study,
the higher consultation rate for probCAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
lem drinkers can now be used as a
"legitimate variable" to evaluate
the effectiveness of physicians' intervention, the researcher said
'If the rate decreases because of
effective treatment, the potential
savings would encourage more
widespread involvement of family
physicians in the identification and
treatment of problem drinkers,' he
said.
The rate of consultation of family
members of problem drinkers is another area that deserves further research, he added.)9
Problem drinkers see MD twice as often: study. Ontario Report 1989;
2(18):1.
tackled together. Three months after
John's colleagues bid him a fond farewell, however, retirement bliss had
turned to marital discord.
Uprooted from the structured routine of the business world, John felt
lost in the sphere of domesticity.
Nothing was familiar except his wife.
She became his anchor and, like an
insecure puppy, he followed her everywhere. May, after 30 years as a
homemaker, had developed a routine
of her own and resented his intrusion
into her private world. Their life became a conflict of wills - John trying
to tie May to him, and May trying
desperately to break free.
Marital discord is not the exclusive
domain of young or middle-aged couples, says a long-time social worker
with the geriatric psychiatry services
at the Royal Ottawa Hospital (ROH).
While marital therapy is as beneficial
to couples in their 70s as it is to those
in their 30s, elderly couples seldom
" CFor nearly a decade John and May seek help.
'They have been conditioned to
had planned their retirement; their
script for their sunset years included keep their marital discontent to
trips to exotic lands and new hobbies themselves. It is very difficult for el-
Lifestyle Changes
During
Retirement
work
derly couples to talk about their marriage and how they are coping,' explains the social worker. 'It might
take two or three sessions before
even the hint of a problem surfaces.'
Some problems are long-standing
unresolved conflicts over such issues as child-rearing or handling of finances, adds an ROH geriatric psychiatry services staff psychologist. 'One
partner may have compromised many
years ago for the sake of harmony,
but the compromise wasn't without
resentment.' It is almost impossible
to help these couples resolve their
current conflict, says the social worker, because today's battle is really all
about the unresolved battles of the
past.
'Retirement requires considerable
adjustment by both partners,' the
psychologist emphasizes. In some
cases, the husband cannot adjust to
an undisciplined life and, like John,
becomes dependent on his wife for
companionship. Or the husband
might suddenly take over the administration of the household, leaving his
wife, who has probably always con-
in::isoI
You're starting your patient on a CHD risk
reduction program. Now consider an antihypertensive
that is unlikely to compromise your patient's lifestyle
changes.
M13
*
imnpress *
*
(prazosin HCl/pfizer)
Because lowering blood pressure is not enough.
Becuse l
prazosin HCl/pfizer)n
b
Because lowering blood pressure is not enough.
Prescribing Infomation
TherapeuUe ClaIfication
Antlhyperbnsive
Dermatolokg: Rash, pruritus. Genitournary: Urinary frequency,
Indlelions and Clinial Use:
MINIPRESS (prazosin hydrochloride) is indicated in the treatment
of hypertension. It is mild to moderate in activity.
It is employed in a general treatment program in conjunction with
a diuretic and/or other antihypertensive drugs. It may be employed as thelnitial agent in the treatment of mild hypertension
when treatment should be started with a vasodilator rather
than a diuretic.
Conbtindalenos:
MINIPRESS is contraindicated in patients with a knonn sensitivity
to the drug.
Warnings:
MINIPRESS may cause syncope with sudden loss of consciousness. In most cases this is believd to be doe to an excessive
postural hypotensive effect although occasionally the syncopal
episode has been associated with a bout ofsevere tachycardia
with heart rates of 120-160 beats per minute. The incidence of
syncopal episodes is approximately 0.896 when the grai dose
build up described under dosage and adminisraton is follwed.
The incidence is higherif the inital dose exceeds 0.5mg. Syncopal episodes have occurred within 30 to 90 minutes of the initial dose of the dru. They have also been reported in association
with dosage increases or the introduction of MINIPRESS into the
regimen ofa patient taldng another antfhypertensive agent or a
dluretic. Phyicians are herefore advised to limit the initial dose
of the drug to 0.5mg b.i.d. or tid., to subsequenty increase the
dosage slowly and to introduce any additional antihypertensive
drugs into the patient's regimen with caution. Patients whose
blood pressure is not adequatelycont bylhigh doses of a
beta-adrnergic blocking agent such as propranolo may develop
acute hypotension when MINIPRESS is added.
To minimize the incidence of acute hypotension in such patients,
the dose of beta-adrenergic blocking agent should be redoced before MINIPRESS is administered. A low inital dose of MINIPRESS
is also strongiy recommended (see dosag and administration).
If syncope occurs, the patient should be placed in the recumbent
position and supportive measures instituted. This adverse effect
is self-limiting and in most cases does not recur once a steady
maintenance level is initiated. Patients should be cautioned to
avoid situations where injury could result should syncope occur
during MINIPRESS therapy especially in the initial dose adjustment period.
More common than loss of consciousness are the symptoms
often associated with lwering of the blood pressure, namely
dizziness and lightheadedness. The patient should be cautioned
about these possible adverse effects and advised what measures
to take should they develop.
Use During Pregnancy:
The safety of MINIPRESS use during pregnancy or lactation has
not been established. In these situations, the potential benefits of
the drug must be weighed against the potential risks to mother
and child.
Use For Children:
MINIPRESS is not recommended for the treatment of children
under the age of twelve years.
Prcaulons:
Use in Patients with Moderate to Severe Grades ofRenal
Impairment:
Therapy should be initiated at 0.5mg daily and dose increases
instituted cautiously.
Ad sN Ractions:
Postural dizziness (11%), nausea (9.5%), drowsiness (8.7%),
headache (&4%), palpitations (6.696), dry mouth (5.6%), weakness (4.6%), and fatigue/malaise (4.5%). In most instances side
effects have disappeared with continued therapy or have been
tolerated with no decrease in dose of drug. The following reactions
have also been observed during MINIPRESS administration,
some of them rarely:
Gastrointestinal: Vomiting, diarrhea, constipation, abdominal discomfort and/or pain. Cardovascular: Syncope (See WARNINGS),
edema, dyspnea, tachycardia. CNS: Nervousness, vertigo,
depression, paresthesia.
impotence. EENT: Blurred vision, reddened sciera, epistaxis,
tinnitus, nasal congestion. Other: Diaphoresis.
Pigmentary mottling, serous retinopathy and cataract development have been reported, although the exact causal relationship
has not been established.
In more specific slit-lamp and funduscopic studies, no drugrelated abnormal ophthalmological findings have been reported.
Dosage and Amdnlmote:
NOTE: When titration is to be undertaken using the tablet formulation it will be necessary to split the 1 mg scored tablet to obtain
the 05mg starting dose. It is recommended that the starting
dose of Q5mg be given with food preferably with the evening
meal, at least two or three hours before retiring. The dose should
be built up gradually starting with 05mg given b.i.d. or t.i.d. for
at least three days. Unless adverse effects occur and subject to
the blood pressure lewering effect, this dose should be increased
to 1 mg given b.id. or t.i.d. for at least a further three days.
Thereafter, as determined by the patient's response, the dose
should be increased gradually. Response is usually seen within
one to fourteen days if it is to occur at any particular dose. When
a response is seen, therapy should be continued at that dose until
the degree of response has reached the optfmum before the next
dose increment is added. Incremental increases should be confinued unfil a desired effect is achieved or a maximum daily dose
of 20mg is reached. The maintenance dose may be given as a
twice daily dosage regimen. In patients with moderate to severe
grades of renal impalrment, it is recommended that therapy be
initiated at 0.5mg daily and that dose increases be insfituted
gradually.
Us WIh Other Drugs:
Patents Receiving Diureic Therapy:
The diurefic should be reduced to a maintenance dose level for
the parficular agent and MINIPRESS initiated at O5mg b.i.d.
or t.i.d. After the initial period of observaton, the dose of
MINIPRESS should be gradually increased as determined by
the patient's response.
Paients Receiving Other Antlertensiwe Agents:
Because some additive effect is anticipated, the other agent
should be reduced with appropriate precautions and MINIPRESS
inifiated at 05mg b.i.d. or t.i.d. Subsequent dosage increase
should be made depending upon the patient's response.
Patients on MINIPRESS To Whom OerAnihyper iv Agents
Are Added:
When adding a diuretic or other antihypertensive agent, the dose
of MINIPRESS should be reduced to 1 mg or 2mg b.i.d. or t.i.d.
and retitration then carried out.
Dosage Form:
Tablets
MINIPRESS is available as scored tablets containing prazosin
hydrochloride equivalent to 1 mg (orange, flat oblong), 2mg
(white, round) or 5mg (white, diamond) of prazosin. Botties of
100 (all tablet strengths) and 500 (1 mg only) tablets.
Product monogaph avIlabile on request.
ReWenebes
1. Grimm RH and Hunninghake DB. Lipids and hypertension,
implications of new guidelines for cholesterol management in the
treatment of hypertension. Am J Med 1986;80(2A):56-63.
2. Ames RP. The influence of non beta-blocldng drugs on the
lipid profile: are diuretics outclassed as initial therapy for
hypertension? Am HeartJ 1987;114(4, part 2):998-1006
3. Stokes GS. Selective alpha-inhibition: an overview of efficacy.
Clin her 1987;9(suppl. D):37-45.
4. Jens TJ. Effects of smoking on the heart and peripheral
circulation. Am HeartJ 1988;115:263-266.
5. Kaplan NM. Strategies to reduce risk factors in hypertensive
patients who smoke. Am HeartJ 1988;115:288-294.
'Prepared by Pfizer Canada Inc. (R.U.)
Pfier Inc. TM Owner
PfizerCanada Inc. 1989
Kirkland, Quebec
H9J 2M5
1926
PAAi
CCPI
sidered the household her domain,
battling a bout of depression because
she is suddenly out of a job. Perhaps
the wife views her husband's retirement as an opportunity for renewed
intimacy. His plans, however, might
involve fishing trips, golf tournaments, and curling bonspiels, in the
company of his male friends.
All three scenarios have the makings of marital bombshells. They give
rise to feelings of resentment, 'usually by the wife,' adds the social worker, whose statement that women report marital strain more often than
men is based on her own observations
as well as on the findings of several
American surveys. Although the resentment may simmer quietly unchecked for a while, it inevitably
reaches the boiling point. According
to the psychologist, it is often a matter of one spouse's not realizing the
consequences of his or her actions.
'Once each partner is helped to see
the situation from the other spouse's
viewpoint, they can usually negotiate
a mutually satisfactory compromise.'
Illness can also undermine marital
harmony. 'When a spouse becomes
ill, many times the other partner becomes the exclusive caregiver, shunning all help from family and friends,'
the social worker contends. The supporting partner becomes overextended and, frustrated by his or her inability to cope, becomes resentful of the
spouse's illness. In the same situation, the supporting spouse may be
frail and find it necessary to place the
other in an institution. Although the
ill partners will receive the care they
need, they may also feel abandoned.
Although both elderly and young
couples are subject to marital stress,
there is a noticeable difference in
how each generation resolves conflict. Today, if a young or middleaged couple cannot come to terms
with their differences, they often divorce. While many elderly couples
openly admit that they would not be
together if they belonged to the
younger generation, for them divorce
simply isn't an option. "These are
couples for whom the vow 'for better
or for worse' is as sacred today as it
was 25, 30, or even 50 years ago, the
social worker said.
'Their marriages are based on an
entirely different system of values,'
the psychologist stresses 'and we as
Continued on page 1850
JAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
Calendar_
SEPTEMBER
S
M
T
W
T
3
4 5 6 7
10 11 12 13 14
17 18 19 20 21
24 25 26 27 28
F
1
8
15
22
29
S
2
9
16
23
30
Recommended Courses
10-15 Sixth World Congress of Emergency and Disaster
Medicine. Hong Kong. Information: Dr. Michael
Moles, Anaesthetic Unit, Prince Philip Hospital, 34,
Hospital Road, Hong Kong (30 hours)
13 Geriatrics. Hamilton, Ont. Information: Program in
C.M.E., McMaster University, Rm. IM6, Health Sciences Centre, 1200 Main St. W., Hamilton, Ont. L8N
3Z5 Telephone: (416) 525-9140, ext. 2223
13 Pediatrics/Pediatric ENT. Kingston, Ont. Information:
Dr. Heather Onyett, Dept. of Pediatrics, Queen's University, Hotel Dieu Hospital, Kingston, Ont. K7L 5G2
Telephone: (613) 544-3310
14 Investigation and Treatment of Lipid Disorders.
Trenton, Ont. Information: Frances Tung, Trenton
Memorial Hospital CME Committee, 64 Ontario St.,
Trenton, Ont. Telephone: (613) 392-2516
14 The Investigation and Management of Lipid Dysfunction. Trenton, Ont. Information: F.Y. Tung, 64
Ontario St., Trenton, Ont. K8V 6H9 (1 hour)
14-16 Office Orthopedics. Saskatoon, Sask. Information:
Co-ordinator, Continuing Medical Education Office,
University of Saskatchewan, Saskatoon, Sask. S7N
Owo
14-17 Comprehensive Review in Toxicology. Victoria,
B.C. Information: Dr. John Maccagno, 1459 Jamaica
Rd., Victoria, B.C. V8N 2C9 Telephone: (604) 4777559
15 Emergencies in a Community Hospital. Rexdale, Ont.
Information: Dr. Calvin Gutkin, Director, Emergency
Dept., Credit Valley Hospital, 2300 Eglinton W., Mississauga, Ont. L5M 2N1 Telephone: (416) 820-8144
(6.5 hours)
15 Diabetic Foot: Problems in Diagnosis and Management.
Toronto, Ont. Information: Dr. R. Harris, 200 Elizabeth St., Toronto, Ont. MSG 2C4 Telephone: (416)
595-4170 (10 hours)
15-18 Sixteenth Annual Meeting of the Canadian Sex Research Forum. St. Donat, Que. Information: Dr.
R.W.D. Stevenson, University Hospital, Shaughnessy
Site, 4500 Oak St., Vancouver, B.C. V6H 3N1 Telephone: (604) 875-2027 (12 hours)
16 Care and Management of Common Foot Problems.
Kingston, Ont. Information: Dr. George M. Merry,
P.O. Box 2189, Kingston, Ont. K7L 5J9 Telephone:
(613) 544-2886 (6 hours)
16 C.G. Jung Foundation Lectures & Seminars/
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
Send all information on courses to Calendar, 1200
Sheppard Ave. E., # 507, Wiliowdale, Ont., M2K 2S5,
at least three months before the date of the course.
Readers wishing to register or obtain further information
on courses should write to the address, or telephone
the number listed under 'Information', and NOT to
Canadian Family Physician.
Workshops 1989-1990: Psychological Aspects of Midlife. Toronto, Ont. Information: Dr. C. Conway
Smith, C.G. Jung Foundation of the Analytical Psychology Society of Ontario, 27 Wycliffe Cres., Willowdale, Ont. M2K 1V5 Telephone: (416) 226-5039
18-19 Geriatric Medicine for the Practising Physician.
Toronto, Ont. Information: Dr. Karen L. Cronin, 3695
Keele St., Downsview, Ont. M3J 1N2 Telephone:
(416) 633-3711 (8.5 hours)
19 C.G. Jung Foundation Lectures & Seminars/
Workshops 1989-1990: Masculinity in Women.
Toronto, Ont. Information: Dr. C. Conway Smith,
C.G. Jung Foundation of the Analytical Psychology
Vaginitis
Confused Emotions?
Multiple Symptoms?
Complex Cause?
Flagystatin
(trichomonacide/moniliacide)
A single effective solution
cream * ovules * vaginal inserts
Flagystati i
(metronidazole/nystati n)
More than just an antifungal
iP
RHONE-POULENC
Rh6ne-Poulenc Pharma Inc.. 8580 Esplanade, Montreal. Quebec
Full prescribing information available on request R TM. registered user
1929
Society of Ontario, 27 Wycliffe Cres., Willowdale, Ont.
M2K 1V5 Telephone: (416) 226-5039
20 Fall Seminar: Ontario Association of Optometrists, District VI. Waterloo, Ont. Information: J.M. Wilkinson,
B.Sc., O.D., 1342 King St. E., Kitchener, Ont. N2G
2N7 (5.5 hours)
20 Twenty-Fifth Annual Cancer Symposium. London,
Ont. Information: Continuing Medical Education, The
University of Western Ontario, Medical Sciences, London, Ont. N6A SC1 Telephone: (519) 661-2074
20 Type A Behaviour Pattern (TABP) and Cardiovascular
Disease (cvD). Ottawa, Ont. Information: Dr. Malcolm
Rose, 1053 Carling Ave., Ottawa, Ont. K1Y 4E9 Telephone: (613) 761-4754 (6 hours)
20 Rational Use of Lab Tests. Hamilton, Ont. Information: Program in CME, McMaster University, Rm. IM6,
Health Sciences Centre, 1200 Main St. W., Hamilton,
Ont. L8N 3Z5 Telephone: (416) 525-9140, ext. 2223
20-23 Annual Scientific Assembly of the Saskatchewan
Chapter, (cFPc). Regina, Sask. Information: Mrs. Lois
Hislop, Saskatchewan Chapter Office, College of Family Physicians of Canada, P.O. Box 7111, Saskatoon,
Sask. S7K 4J1 Telephone: (306) 665-7714
22-24 Rehabilitation: Restoration and Renewal. North
York, Ont. Information: Dr. Geoffrey Secord, 50
Lake St., Sault Ste. Marie, Ont. P6A 4A5 Telephone:
(705) 949-0725 (6 hours)
23 Fiftieth Anniversary Medical Staff Clinical Day: St.
Vincent's Hospital. Vancouver, B.C. Information: Dr.
J.H. Birchall, c/o St. Vincent's Hospital, 749 W. 33rd
Ave., Vancouver, B.C. V5Z 2K4 Telephone: (604)
876-7171, ext. 2353 (5.5 hours)
23 C.G. Jung Foundation Lectures & Seminars/
Workshops 1989-1990: Psychological Aspects of Midlife. Toronto, Ont. Information: Dr. C. Conway
Smith, C.G. Jung Foundation of the Analytical Psychology Society of Ontario, 27 Wycliffe Cres., Willowdale, Ont. M2K 1VS Telephone: (416) 226-5039
23-24 Pediatric Update Course. Niagara-on-the-Lake,
Ont. Information: Program in CME, McMaster University, Rm. IM6, Health Sciences Centre, 1200 Main St.
W., Hamilton, Ont. L8N 3Z5 Telephone: (416) 5259140, ext. 2223
26 C.G. Jung Foundation Lectures & Seminars/
Workshops 1989-1990: Masculinity in Women.
Toronto, Ont. Information: Dr. C. Conway Smith,
C.G. Jung Foundation of the Analytical Psychology
Society of Ontario, 27 Wycliffe Cres., Willowdale,
Ont. M2K 1V5 Telephone: (416) 226-5039
27 Sexual Health: The Future. Don Mills, Ont. Information: Jeff Bamford, East York Health Unit, 150 Laird
Dr., Toronto, Ont. M4G 3V7 Telephone: (416) 4678200 (7 hours)
27 Role of Prevention in Health Care. Burlington, Ont. Information: Program in CME, McMaster University,
Rm. IM6, Health Sciences Centre, 1200 Main St. W.,
Hamilton, Ont. L8N 3Z5 Telephone: (416) 525-9140,
ext. 2223
28-29 Geriatric Symposium: Alternate Solutions for an
Aging Population. Scarborough, Ont. Information: Dr.
J.E. Lessard, Director of Geriatric Services, Scarborough General Hospital, 3050 Lawrence Ave. E., Scarborough, Ont. MlP 2V5 Telephone: (416) 431-8111
(8.5 hours)
29 Adult Asthma. Sudbury, Ont. Information: Esther F.
Mitchell, Co-ordinator, Ontario Respiratory Care Society, 573 King St. E., Toronto, Ont. MSA 4L3 Telephone: (416) 864-1112
29 Grief Counselling and Therapy: A Training Workshop
for Health Professionals. Ottawa, Ont. Information:
Dr. Neville A. Taylor, Suite 1216, 1 Nicholas St., Ottawa, Ont. KlN 7B7 Telephone: (613) 238-6886 (5.5
hours)
CONGRESS ON RECENT
ADVANCES IN
MEDICINE AND SURGERY
February 16 to 21, 1990
Bangkok & Pattaya, Thailand
Presented by The General Practitioner Association of Thailand
With Special Invitation toTheSection of General Practice, BC Medical Association,
and British Columbia Chapter, College of Family Physicians of Canada
- Open to All Physicians For further information contact:
British Columbia Chapter, College of Family Physicians of Canada
115-1665 West Broadway, Vancouver, B.C. V6J 5A4
Telephone: (604) 736-5551 Fax: (604) 736-4675
1930
30 C.G. Jung Foundation Lectures & Seminars/
Workshops 1989-1990: Psychological Aspects of Midlife. Toronto, Ont. Information: Dr. C. Conway
Smith, C.G. Jung Foundation of the Analytical Psychology Society of Ontario, 27 Wycliffe Cres., Willowdale, Ont. M2K 1V5 Telephone: (416) 226-5039
30-Oct. 1 Clinical Hypnosis Workshop. Saskatoon, Sask.
Information: Continuing Medical Education Office,
University of Saskatchewan, Saskatoon, Sask. S7N
OWO
Other Courses
10-15 The World Association for Emergency and Disaster
Medicine: 6th World Congress. Hong Kong. Information: Dr. Michael Moles, Chairman, 6WCEDM, Anaesthetic Unit, Prince Philip Hospital, 34 Hospital Rd.,
Hong Kong
10-15 Third International Symposium on Inflammatory
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
Bowel Diseases. Jerusalem, Israel. Information: KENES,
Organizers of Congresses and Special Events Ltd., P.O.
Box 5006, Tel Aviv, 61500 Israel
11 Team Building. Newmarket, Ont. Information: York
County Hospital, 596 Davis Dr., Newmarket, Ont.
L3Y 2P9 Telephone: (416) 895-4521, ext. 2301
11-16 Fortieth International Congress on General Practice: Societas Internationalis Medicinae Generalis
(sIMG). Klagenfurt, Austria. Information: Secretariat
of the SIMG, Mrs. Sigrid Taupe, A-9020 Klagenfurt,
Bahnhofstrasse 22, Austria Telephone: International
(0463) 55449
12-14 Defensive Management. Wingham, Ont. Information: Wingham & District Hospital, 270 Carling Terrace, Wingham, Ont. NOG 2W0 Telephone: (519) 3573210, ext. 264
13-16 Lumbar Spine. Calgary, Alta. Information: Sharon
Bamson, Faculty of Continuing Education, The University of Calgary, 2500 University Dr. N.W., Calgary,
Alta. T2N 1N4 Telephone: (403) 220-4729
14-15 Financial Management for Nurse Managers.
Toronto, Ont. Information: Ontario Hospital Association, Management Education, 1st Floor, 150 Ferrand
Dr., Don Mills, Ont. M3C 1H6 Telephone: (416) 4292661, ext. 3302
14-15 Drugs and Pharmaceuticals in the Biblical World.
Pittsburgh, PA. Information: Irene Jacob, Rodef Shalom Biblical Botanical Garden, 4905 Fifth Ave., Pittsburgh, PA 15213 U.S.A. Telephone: (412) 621-6566
14-16 Dermatology '89: Therapeutic Update. Vancouver,
B.C. Information: Dermatology '89, 204-402 W., Pender St., Vancouver, B.C. V6B 1T6 Telephone: (604)
732-9106
14-16 S.I.M.G. Conference. Klagenfurt, Austria. Information: Dr. Gottfried Heller, A-9020 Klagenfurt,
Bahnhofstr. 22, Austria. Telephone: 0463/55449
14-17 Comprehensive Review in Toxicology. Victoria,
B.C. Information: Dr. John Maccagno, 1459 Jamaica
Rd., Victoria, B.C. V8N 2C9 Telephone: (604) 4777559
15 After the Tears. Toronto, Ont Information: Canadian
Association for Children of Alcoholics, Box 159, Station "H", Toronto, Ont. M4C 5H9 Telephone: (416)
533-6203
15-17 Ninth Annual C.P.R. Educational Symposium.
Toronto, Ont. Information: Laurie Docimo, The
Heart and Stroke Foundation of Ontario, 4th Floor,
477 Mount Pleasant Rd., Toronto, Ont. M4S 2L9 Telephone: (416) 489-7100
16 Unnecessary Losses: The Pain that Doesn't Heal Itself.
Toronto, Ont. Information: Canadian Association for
Children of Alcoholics, Box 159, Station "H", Toronto, Ont. M4C 5H9 Telephone: (416) 533-6203
16 Saturday at the University Im. Toronto, Ont. Information: Lois Cranston, Continuing Education, Faculty of
Medicine, University of Toronto, Medical Sciences
Building, Toronto, Ont. M5S 1A8 Telephone: (416)
978-2718
17-18 Cervical Spine. Calgary, Alta. Information: Sharon
Bamson, Faculty of Continuing Education, The University of Calgary, 2500 University Dr. N.W., Calgary,
Alta. T2N 1N4 Telephone: (403) 220-4729
17-23 European Undersea Biomedical Society: xvth Annual Scientific Meeting. Eilat, Israel. Information: KENES,
Organizers of Congresses and Special Events Ltd.,
P.O. Box 5006, Tel Aviv, 61500 Israel
18 OHA Management Education: Series I. Windsor, Ont.
Information: Health Sciences, Continuing Education,
St. Clair College, 2000 Talbot Rd., Windsor, Ont.
N9A 6S4 Telephone: (519) 972-2711, ext. 501
18 Team Building. Newmarket, Ont. Information: York
County Hospital, 596 Davis Dr., Newmarket, Ont.
L3Y 2P9 Telephone: (416) 895-4521, ext. 2301
18-Nov. 27 OHA Management Education: Series I (Monday Evenings). Oshawa, Ont. Information: Registrar's
Department, Durham College, P.O. Box 385, Oshawa,
Ont. L1H 7L7 Telephone: (416) 576-0210
20 Bi-Annual Medical-Dental-Legal Sports Medicine Symposium. Toronto, Ont. Information: Dr. Patrick
McGrath, One Medical Place, Suite 310, 20 Wynford
Dr., Don Mills, Ont. M3C 1J4 Telephone: (416) 4412422
20 Practical Workshop of Lumbar and Cervical Techniques. Calgary, Alta. Information: Sharon Bamson,
Faculty of Continuing Education, The University of
Calgary, 2500 University Dr. N.W., Calgary, Alta.
T2N 1N4 Telephone: (403) 220-4729
20 OHA Management Education: Series I. London, Ont.
Information: M. Richards, Fanshawe College, Continuing Education, P.O. Box 4005, London, Ont. N5W
Shl Telephone: (519) 452-4255
20-22 Quality Assurance in Health Care. Toronto, Ont.
To treat the symptoms of anxiety, call for 'Lectopam'.
JUu .U.11
.1
am
k i
Hoffmann-La Roche Limited, Etobicoke, Ontario M9C 5J4
I Registered Trademark Product Monograph available on request. D4388
SEPTEMBER 1989
CAN. FAM. PHYSICIAN Vol.35:
1989
Vol. 35: SEPTEMBER
1931
1931
4
Information: Quality Assurance in Health Care, Conference and Seminar Services, Humber College, 205
Humber College Blvd., Etobicoke, Ont. M9W 5L7
20-22 National Conference on Mental Health: Community
Reinvestment. London, Ont. Information: Kelly
McKinley, National Conference Co-ordinator, CMHA
London/Middlesex Branch, 355 Princess Ave., London, Ont. N6B 2A7 Telephone: (519) 434-9178
20-Nov. 22. OHA Management Education: Series I
(Wednesday Evenings). Newmarket, Ont. Information:
Admissions Office, Seneca College, Newmarket Campus, 112 Yonge St. S., Newmarket, Ont. L3Y 6Y9
Telephone: (416) 898-6199
22 Prevention and Rehabilitation of Stroke. Toronto, Ont.
Information: Jean Twiner, Organising Secretary, Sunnybrook Medical Centre, 2075 Bayview Ave., Toronto, Ont. M4N 3M5 Telephone: (416) 480-4287
22 Healing Co-Dependency: The Journey from Shame to
Respect. Toronto, Ont. Information: LifeCycle Learning, Suite 305, 1320 Centre St., Newton, MA 02159
U.S.A. Telephone: (617) 964-5050, Fax: (617) 9655054
220HA Management Education: Series I. Chesley, Ont.
Information: Karen King, c/o Chesley & District Memorial Hospital, 39 2nd St. S.E., Chesley, Ont. NOG
lLO Telephone: (519) 881-1220
22 OHA Management Education: Series I. Kingston, Ont.
Information: Ontario Hospital Association, Management Education, 1st Floor, 150 Ferrand Dr., Don
Mills, Ont. M3C 1H6 Telephone: (416) 429-2661, ext.
3302
22-23 Risk Management in Long-Term Care. Victoria,
B.C. Information: Dr. John Maccagno, 1459 Jamaica
Rd., Victoria, B.C. V8N 2C9 Telephone: (604) 4777559
23 OHA Management Education: Series II-Long-Term
Care. Waterloo, Ont. Information: Conestoga College
of Applied Arts & Technology, Continuing Education,
Waterloo Campus, 435 King St. N., Waterloo, Ont.
N2S 2Z5 Telephone: (519) 885-0300
230HA Management Education: Series II. Mississauga,
Ont. Information: Sheridan College, Mississauga Campus, 100 Dundas St. W., Mississauga, Ont. LSB 1H3
Telephone: (416) 279-3731
23-24 Canadian Association of Physical Medicine and Rehabilitation. Edmonton, Alta. Information: Dr. Lee
Kirby, Nova Scotia Rehabilitation Centre, 1341 Summer St., Halifax, N.S. B3H 4K4
24-27 Focus on Child Abuse: Facing the Challenges Together. Toronto, Ont. Information: Dorothy Malcolm,
The Institute for the Prevention of Child Abuse, 25
Spadina Rd., Toronto, Ont. M5R 2S9 Telephone:
(416) 921-3151
24-28 Ninety-third Annual Meeting of the American Academy of Otolaryngology. New Orleans, GA. Information: American Academy of Otolaryngology-Head and
Neck Surgery, Suite 302, 1101 Vermont Ave. N.W.,
Washington, DC 20005 U.S.A. Telephone: (202) 2894607
24-30 Royal Australian College of General Practitioners
Conference. Tasmania. Information: Penelope Archer,
Tasmania Faculty, Royal Australian College of GenerCAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
BRIEF PRESCRIBING INFORMATION
-
E RYC*
(encapsulated enterc-coated erythromycin pellets)
Therapeutic classifcation: Antibiotic.
indiceations: The treatment of the following infections when caused by susceptible
strains of micro-organisms: upper and lower respiratory tract infections; skin and soft
tissue infetio; gonorrhea; syphilis; Legionnaires' disease; pertussis; diphtheria; short
term prophylaxis of bacterial endocarditis in patients hypersensitive to penicillin.
Containdicatlons: Known hypersensitivity to erythromycin.
Pec ons: The possibility of superinfecton caused by overgrowth of nonsusceptible
bacteria or fungi should be lept in mind durng prolonged or repeated therapy with ERYC.
In such instances, the administration of ERYC should be discontinued and appropriate
treatment insfituted if necessary.
Erythromycin is excreted principally by the liver. Caution should be exercised when
administering ERYC to patients with impaired hepatic function.
The concomitant administration of erythromnycin and high doses of theophylline may
be asscated with increased serum theophylline lels and possible theophyline toxicity.
The dose of theophylline may require reduction while patients are receiving ERYC.
The safety of ERYC for use in pregnant patients has not been established.
There is placental transfer and excretion of erythromycin in breast milk.
Adverse El cts: The most frequent side effects are gastrointesinal and are dose-related.
They include nausea, vomiting, abdominal pain, diarrhea and anorexia. Symptoms of
hepatic dysfunction and/or abnormal liver function test results may occur.
Serious allegic reactions ha been e_rmly lIrequenL Mild alleriIc reacin
such as ahe wkilh or wNu pr ,ut carb, bulous ruptins and ema 1ha
been reported wHh erythromycin.
DOSAGE AND ADMINISTRATION
ERYi and ERYV 125 capsules are administered one hour before meals or in the fasting state
in order to obtain opfimum serum concentrations of erythromycin.
Adulls: The usual dose is ERYC capsule 250 mg every 6 hours. Depending on the severity of the infection, larger doses may be considered, however, a single dose should not
exceed 500 mg.
Children: Age, weight, and severity of the infection are important factors in determining
the proper dosage. The usual dosage is 3-50 mg/kg/day in equally divided doses. For
the treatment of more severe infections, this dosage may be increased. The entire contents of an ERYC 125 capsule should be sprinkled on a small amount of appesauce, fruit
jellies, or ice cream immediately prior to ingestion. SUBDIVIDING THE CONTENTS OF
A CAPSULE IS NOT RECOMMENDED. If desired, ERYC capsule may be swallowed
whole.
PROPHYLAXIS
For continuous prophylaxis against recurrence of streptococcal infections in persons
with a history of rheumatic heart disease, the recommended dose is 250 mg twice a day.
For the prevention of bacterial endocarditis due to alpha-hemolytic streptococci in
penicillin-allergic patients with valvular heart disease who are to undergo dental procedures or surgical procedures of the upper respiratory tract, the adult dose is 1 g one
hour prior to the procedure and 500 mg six hours lateri The pediatric dose is 20 mg/kg
(maximum 1 g) one hour before surgery, followed by 10 mg/kg (maximum 500 mg) six
hours later.
Primary syphilis: 2-4 grams per day for a period of 10 to 15 days.
Intestinal Amoebiasis: 250 mg four times daily for 10 to 15 days for adults.
Legionnalree Disease: Optimal doses have not been established. Doses utilized in
reported clinical data were 0.5 to 1 g every 6 hours.
Perussis: Although optimal dosage and duration of therapy have not been established,
doses of erythroryrin utilized in reported clinical studies were 40-50 mg/kg/day, givn
in divided doses for 5 to 14 days.
ERYC capsule is a two-tone clear and orange opaque capsule each containing 250 mg
erythromycin base as enteric-coated pellets. Available in bottes of 100 and 500.
ERYC 125 capsule is a two-tone clear and orange opaque capsule containing 125 mg
erythromycin base as enteric-coated pellets. They bear the inscription 'This End Up'
and "P-D" on the cap and "Eryc 125" on the body. Available in bottes of 100.
Store at room temperature below 300C.
Protect from moisture and light.
Full prescribing information is available on request.
PARKE-DAVIS
Scarborough, Ontario MiL 2N3
[^i1 T.M. Warner-Lambert Companly Parke-Davis
LcC.!!IDivision, Warner-Lambert Canadi Inc. auth.user.
^'
1933
al Practitioners, 107 New Town Rd., New Town, Tasmania Telephone: (002) 28 6271
25 OHA Management Education: Series I. Windsor, Ont.
Information: Health Sciences, Continuing Education,
St. Clair College, 2000 Talbot Rd., Windsor, Ont.
N9A 6S4 Telephone: (519) 972-2711, ext. 501
25 Team Building. Newmarket, Ont. Information: York
County Hospital, 596 Davis Dr., Newmarket, Ont.
L3Y 2P9 Telephone: (416) 895-4521, ext. 2301
25-26 Promoting Professional Services. Toronto, Ont. Information: Ontario Hospital Association, Management
Education, 1st Floor, 150 Ferrand Dr., Don Mills,
Ont. M3C 1H6 Telephone: (416) 429-2661, ext. 3302
25-26 Focus on Patient Assessment. Mississauga, Ont. Information: Conference and Seminar Services, Humber
College, 205 Humber College Blvd., Etobicoke, Ont.
M9W 5L7 Telephone: (416) 675-5077
26 OHA Management Education: Series II. Ottawa, Ont.
Information: Dept. of Staff Development, Ottawa Civic Hospital, 1774 Kerr Ave., Ottawa, Ont. K2A 1R9
Telephone: (613) 761-4228
26 OHA Management Education: Series I. Niagara/St. Catharines, Ont. Information: Niagara College, Welland
Campus, P.O. Box 1005, Woodlawn Rd., Welland,
Ont. L3B 5S2 Telephone: (416) 735-2211
26-28 Evenings at the OHA Centre: Defensive Management.
Don Mills, Ont. Information: Ontario Hospital Association, Management Education, 1st Floor, 150 Ferrand
Dr., Don Mills, Ont. M3C 1H6 Telephone: (416) 4292661, ext. 3302
26-Nov. 21 Evenings at the OHA Centre: Developing Positive Influencing Skills. Don Mills, Ont. Information:
Ontario Hospital Association, Management Education, 1st Floor, 150 Ferrand Dr., Don Mills, Ont. M3C
1H6 Telephone: (416) 429-2661, ext. 3302
26-Nov. 21 Evenings at the OHA Centre: Security for
Health Care Facilities. Don Mills, Ont. Information:
Ontario Hospital Association, Management Education, 1st Floor, 150 Ferrand Dr., Don Mills, Ont. M3C
1H6 Telephone: (416) 429-2661, ext. 3302
26-Nov. 28 OHA Management Education: Series II (Tuesday Evenings). Toronto, Ont. Information: Toronto
Institute of Medical Technology, 222 St. Patrick St.,
Toronto, Ont. M5T 1V4 Telephone: (416) 596-3117
26-27 Medical Emergency Disaster Strategies II.
Edmonton, Alta. Information: Dr. M. Girotti, EN 9234, Toronto General Hospital, 200 Elizabeth St., Toronto, Ont. M5G 2C4 Telephone: (416) 595-4522
27-28 Defensive Management. Wingham, Ont. Information: Wingham & District Hospital, 270 Carling Terrace, Wingham, Ont. NOG 2W0 Telephone: (519) 3573210, ext. 264
27-28 Survival Skills. Thunder Bay, Ont. Information:
Ontario Hospital Association, Management Education, 1st Floor, 150 Ferrand Dr., Don Mills, Ont. M3C
1H6 Telephone: (416) 429-2661, ext. 3302
27 OHA Management Education: Series I. London, Ont.
Information: M. Richards, Fanshawe College, Continuing Education, P.O. Box 4005, London, Ont. N5W
SH1 Telephone: (519) 452-4255
27-28 Computer Confidence. Toronto, Ont. Information:
Ontario Hospital Association, Management EducaCAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
tion, 1st Floor, 150 Ferrand Dr., Don Mills, Ont. M3C
1H6 Telephone: (416) 429-2661, ext. 3302
27-Nov. 22 Evenings at the oHA Centre: Public Policy and
Politics. Don Mills, Ont. Information: Ontario Hospital Association, Management Education, 1st Floor, 150
Ferrand Dr., Don Mills, Ont. M3C 1H6 Telephone:
(416) 429-2661, ext. 3302
27-Nov. 22 Survival Skills (Wednesday Evenings).
Mississauga, Ont. Information: Ontario Hospital Association, Management Education, 1st Floor, 150 Ferrand Dr., Don Mills, Ont. M3C 1H6 Telephone: (416)
429-2661, ext. 3302
27-Dec. 6 Evenings at the OHA Centre: Series I. Don Mills,
Ont. Information: Ontario Hospital Association, Management Education, 1st Floor, 150 Ferrand Dr., Don
Mills, Ont. M3C 1H6 Telephone: (416) 429-2661, ext.
3302
28 OHA Management Education: Series II. Brantford,
Ont. Information: Ontario Hospital Association, Management Education, 1st Floor, 150 Ferrand Dr., Don
Mills, Ont. M3C 1H6 Telephone: (416) 429-2661, ext.
3302
28-29 Health Care Education: Level 1. Niagara/St. Catharines, Ont. Information: Niagara College, Welland
Campus, P.O. Box 1005, Woodlawn Rd., Welland,
Ont. L3B 5S2 Telephone: (416) 735-2211
28-Oct. 19 Team Building (Saturdays). Waterloo, Ont.
Information: Conestoga College of Applied Arts &
Technology, Continuing Education, Waterloo Campus, 435 King St. N., Waterloo, Ont. N2S 2Z5 Telephone: (519) 885-0300
28-Nov. 16 Evenings at the oHA Centre: Computer Confidence. Don Mills, Ont. Information: Ontario Hospital
Association, Management Education, 1st Floor, 150
Ferrand Dr., Don Mills, Ont. M3C 1H6 Telephone:
(416) 429-2661, ext. 3302
28-Nov. 30 OHA Management Education: Series I (Thursday Evenings). Toronto, Ont. Information: Toronto
Institute of Medical Technology, 222 St. Patrick St.,
Toronto, Ont. M5T 1V4 Telephone: (416) 596-3117
28-Nov. 30 OHA Management Education: Series II. Don
Mills, Ont. Information: Ontario Hospital Association,
Management Education, 1st Floor, 150 Ferrand Dr.,
Don Mills, Ont. M3C 1H6 Telephone: (416) 429-2661,
ext. 3302
28 Postpartum Depression. Vernon, B.C. Information:
Chris Kostka, 2625 Queensview Dr., Ottawa, Ont.
K2B 8K2 Telephone: (613) 596-5850
28 Seminars in Current Practice: Reproductive Care in
Family Medicine. Toronto, Ont. Information: Ms.
Marcia Richards, Dept. of Family and Community
Medicine, Suite 101, 222 Elm St., Toronto, Ont. M5T
iK5 Telephone: (416) 586-8819
28-Oct. 1 Conference on Pre-Hospital and Emergency
Room Care for: Physicians, Nurses, Paramedical Staff.
Winnipeg, Man. Information: Mr. J. Greenberg, Dept.
of Continuing Medical Education, S104-750 Bannatyne
Ave., Winnipeg, Man. R3E 0W3 Telephone: (204)
788-6660
29 OHA Management Education: Series I. Peterborough,
Ont. Information: Admissions, Sir Sandford Fleming
College, 526 McDonnel St., Peterborough, Ont. K9J
7B1 Telephone: (705) 743-5610, ext. 549
1935
The College of Family Physicians of Canada
APPLICATION FOR MEMBERSHIP
(Please print or type)
Name in full
Office address
Residence address
Place and date of birth
Female
Male
Sex
Medical Education-Medical School
Date of graduation
Licensed to practice in
Other qualifications and diplomas
City
City
Postal Code
Postal Code
Prov.
Prov.
Livy I UV
province(s)
Year.
Year
Year
Year
Internships-Hospitals
and/or
Residencies-Universities.
e
a
Teaching appointments
No O1
Yes OAre you in active family practice?
If "yes", how long have you been engaged as a family physician?
If "no", what is your present activity.?
No O1
Yes El
Are you a member of a hospital staff(s)?
Consulting El
Associate El
Active El
In what category? - Honorary El
Name of hospital(s)
Courtesy Ol
medical society
medical society
medical society
Member of
Declarationfor membership in The College of Family Physicians of Canada.
hereby make application
Retired El
Associate OSustaining El
Senior El
Life-Retired E
membership, in accordance with present membership fees.
Life-Active El
See "Conditions of Eligibility for Membership."
understand that the money will be refunded if my application is not approved.
In submitting this application, I hereby agree to abide by the regulations of The College of Family Physicians of Canada.
References (Must be members of the College of Family Physicians of Canada).
am enclosing my fees for a 12-month period in the class of Active El
ADDRESS
NAME
1.
2.
Date.
Signature of Applicant
Membership Certificate: wish to have my membership certificate in the French language (
)
English language (
Membership applications should be sent to:
The College of Family Physicians of Canada
4000 Leslie Street
Willowdale, Ontario M2K 2R9
This application form supersedes all similar forms issued prior to January 1988.
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
1959
Answer to
Dermacase
(page 1746)
THE COLLEGE OF FAMILY PHYSICIANS OF CANADA
4000 LESLIE STREET, WILLOWDALE, ONT. M2K 2R9
1. Angiokeratoma of Fordyce
CLASSIFICATION OF MEMBERSHIP
A. MAJOR CLASSIFICATIONS
Active Member
Is a fully licenced physician engaged in or
concerned with the practice of family medicine. The Active member is required to complete fifty hours of approved post graduate
studies every year, pay the annual membership fee(s) and practice in accordance with
the College's Code of Ethics. Active members in their first year of practice are required to pay a fee equivalent to 50% of the
member fee.
active
Associate Member
Is a physician holding an educational license, who is engaged as an intern or resident in an approved residency training
program in family medicine. Associate memership is renewable annually each July 1st
and terminates automatically upon successful completion of the Certification Examination in Family Medicine or upon ceasing to
be enrolled in a family medicine program.
The Associate member is not required to
pay an annual membership fee nor submit
etvudence of a program of postgraduate
B. SUBCLASSIFICATIONS
Certificant
Certification shall be granted to eligible candidates following the satisfactory completion
of the Certification Examination in Family
Medicine. The privileges, rights, duties and
requirements of Certificants are determined
by the membership classification to which
they belong.
F
is an honorary distinction conellow
ferred by the Board of Directors upon members of the College. Candidates for
Fellowship may be proposed by provincial
chapters or two or more College members;
such recommendations must be accompanied by the appropriate documentation. The
number of Fellows is limited to 10% of the
Certified membership. The privileges, rights,
duties and requirements of Fellows are determined by the membership classification
to which they belong.
Noedent
Nonresident s
Nneintmembershwoar eidents ouatsidet
Canada. The privileges, rights, duties and
A not uncommon disorder of the genital area in both males and females,1-3
angiokeratoma of Fordyce is usually
made up of small red-purple papules
on the scrotum or shaft of the penis in
male patients, on the vulva in female
patients, and at times on the lower
abdomen and thighs of both sexes.
The lesions occur during the late
teens and 20s, but often are unnoticed until relatively late in adulthood. The early lesions are soft and
compressible, but later lesions are
quite purple and firm with a keratotic
roof. These papules may be associated with increased venous pressure
in the area.
A case was reported with superficial ectasiae of the gingiva and oral
cavity.4
Histological examination reveals
study.
requirements of Nonresident members are
determined by the membership classifica- telangiectasia, not true hemangioma.
The dilated vessels are found within
tion to which they belong.
Sustaining Member
Is a physician who is not engaged in the
the papillary rete ridges.5 Treatment
practice of family medicine, but has entered C. FEES
U
is unnecessary.
another field of endeavour and wishes to 1. Membership
keep affiliation or become affiliated with the
College. The Sustaining member is required
to pay the annual membership fee(s) but
need not submit evidence of a program of
postgraduate studies.
a) National
Active
Active 1st Year In Practice
Associate
Senior
Sustaining
Nonresident
Senior Member
Is a physician who has attained the age of
sixty-five and has been in the practice of
medicine for thirty years or more. The senior
member who is actively engaged in or concerned with the practice of family medicine
is required to pay the appropriate annual
membership fee(s) and comply with the
other components of the Active membership
classification.
Retired Member
Is a physician who is no longer practicing
family medicine on a full time or part-time
basis and who is no longer engaged in professional activities. The retired member is
not required to pay the annual membership
fee(s) and need not submit evidence of a
program of postgraduate studies.
Life Member - Active
Is a physician who has attained age seventy. The life member who is actively engaged in or concerned with the practice of
family medicine is not required to pay the
annual membership fee(s) but is required to
comply with the other components of the Active membership classification.
Life Member - Retired
Is a physician who has attained age seventy. The retired life member is not required
to pay the annual membership fee(s) and
need not submit evidence of a program of
postgraduate studies.
1960
Retired
Life
b) Provincial
1) Associate - No fee
Provincial fee.
British
Columbia
Alberta
Saskatchewan
Manitoba
Ontario
-Active
- Sustaining
- Senior
Nova Scotia
New Brunswick
Newfoundland
Quebec
Prince Edward Island
1i. Section of Teachers
III. Self Evaluation
Associate Member
Member
$285.00
$142.00
No fee
$142.00
$142.00
$142.00
No fee
No fee
$80.00
$75.00
$40.00
$65.00
$123.00
$ 80.00
$ 80°00
40.00
15.00
35.00
40.00
30.00
$ 50.00
$
$
$
$
$
References
1. Domonkos AN, Arnold HL, Odom
RB. Andrew's diseases of the skin. 7th ed.
Philadelphia, PA: WB Saunders Co.,
1982.
2. Fitzpatrick TB, Eisen AZ, Wolff K,
Freedberg IM, Austen KF. Dermatology
in general practice. 3rd ed. New York:
McGraw-Hill Co., 1987.
3. Rook A, Wilkinson DS, Ebling FJG.
Textbook of dermatology. 3rd ed. Oxford:
Blackwell Scientific Publications, 1986.
4. Rappaport I, Shiffman MA. Multiple
phlebectasia involving jejunum, oral cavity, and scrotum. JAMA 1963; 185:437.
5. Lever WF, Shaumberg-Lever G.
Histopathology of the skin. 6th ed. Philadelphia, PA: J.P. Lippincott Co., 1983.
$ 20.00
$ 96.00
$150.00
Cheques should be made payable to the
College of Family Physicians of Canada and
mailed to 4000 Leslie Street, Willowdale,
Ontario M2K 2R9. New applications for
membership must be accompanied by the
appropriate membership fees.
The description of membership classification and subclassifications found herein is a
summary of the wording as contained in the
College By-Laws and must be interpreted as
RV78
written in the By-Laws.
RV78
Non Member
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
Le College des medecins de famille du Canada
DEMANDE
moulees
(Ecrire en Iettres
D'ADHESION
ou dactylographier)
Nom au complet
Adresse du bureau
Adresse r6sidentielle
Lieu et date de naissance
Homme
Sexe
-
Prov
Prov
Ville
Ville
Femme
Etudes m6dicales-FacultM
Date de la promotion
Permis de pratique pour la(les) province(s) de
Autres qualifications ou diplOmes
Code postal
Code postal
Dipl6me obtenu
Ann6e
lnternat-H6pitaux
et/ou
Residence-Universites
Annee
Ann6e
Annee
Postes d'enseignement
Non O
Oui
Pratiquez-vous activement la medecine familiale?
de
temps?
combien
Si "oui", depuis
Si "non", quelles sont vos occupations actuelles?
Non 1Oui O1
D6tenez-vous des privileges hospitaliers?
Consultant EL
Associe OI
Actif LQuel type de privileges? - Honoraire OI
hospitalier(s)
Nom du(des) centre(s)
Courtoisie LI
Liste des organismes medicaux dont vous etes membre
Declaration
Je demande, par la presente, A devenir membre du College des medecins de famille du Canada.
Retrait6 El
Senior L
Associe OI De soutien El
Je joins les frais pour une p6riode de 12 mois dans la categorie: Actif E
A vie-Actif OI A vie-Retraite OI conformement aux frais ci-joint. Voir "Conditions d'admissibilit6 pour l'adh6sion".
Les frais verses me seront rembourses dans la cas oQ ma demande ne serait pas accept6e.
En soumettant cette demande, j'accepte de me conformer aux reglements du Collge des medecins de famille du Canada.
R6f6rences: (par des membres du Coll6ge des m6decins de famille du Canada)
ADRESSE
NOM
2.
3.
Date
Signature du requ6rant.
Certificat d'adh6sion: je desire que le certificat soit 6mis en franQais (
)
anglais (
)
Les demandes d'adh6sion doivent dtre achemin6es au:
Coll6ge des m6decins de famille du Canada
4000 rue Leslie
Willowdale, Ontario M2K 2R9
Ce formulaire de demande remplace tout formulaire semblable 6mis avant janvier 1988.
CAN. FAM. PHYSICIAN Vol. 35: SEPTEMBER 1989
1965