Digitized by the Internet Archive in 2016
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half-life
Just one built-in advantage
Ensures smooth therapeutic effect even If a dose is missed The relatively longer half- life of Vallum" (diazepam/Roche) has impor- tant clinical and pharmacological implica- tions. Steady-state levels generally are reached within 5-7 days with no further accumulation. At this plateau, the patient benefits from the consistent, steady response you expect. Sharp blood level variations, frequently attributed to agents with a short half-life, do not appear with Valium.
Avoids sudden symptom breakthrough
Once steady-state levels are achieved, sudden reemergence of symptoms is unlikely. Diazepam and its active metabolites exhibit overlapping half- lives that are advantageous not only during therapy but espe- cially when pharmacologic support is discontinued. Elimination rates are gradual with Valium and thus provide a compatible
the patient. In comparison, blood levels of short-acting agents with inactive metab- olites decrease more rapidly and are more likely to be associated with withdrawal symptoms if medication is stopped abrupt- ly.* With Valium unwanted effects other than drowsiness or ataxia are rare. Patients should be cautioned about driving and advised to avoid alcohol.
Tapers naturally; complements gradual dosage reduction at discontinuation
When any psychoactive medication is discontinued, it is good medical practice to gradually reduce the dosage. From your own experience you know this is rarely necessary after a short course of Valium therapy, but for patients on extended therapy, gradual reduction of dosage is advisable. This regimen, along with the self- tapering feature of Valium, provides a smooth transition to independent coping.
♦Sellers EM: Drug Metab Rev 8{ 1):5-11, 1978
effective therapg through
efficient pharmacodynamics
Before prescribing, please see summary of product information on next page
This Journal is owned and published monthly by the IOWA MEDICAL SOCIETY. It contains material of scientific and socioeconomic interest mainly to Iowa physicians. The IOWA MEDICAL SOCIETY has 3,000 member physicians in 92 county medical societies. The IMS Head- quarters is at 1001 Grand Avenue, West Des Moines, Iowa 50265.
BOARD OF TRUSTEES
WILLIAM R. BLISS, MD, Ames President
HORMOZ RASSEKH, MD,
Council Bluffs Chairman of the Board MAURICE E. KRAUSHAAR, MD,
Fort Dodge
Trustee/Secretary-Treasurer JOHN E. TYRRELL, MD, Manchester Trustee
JOHN H. KELLEY, MD, Des Moines President-elect EMMETT B. MATHIASEN, MD,
Council Bluffs Vice President
PAUL M. SEEBOHM, MD, Iowa City Immediate Past President
SCIENTIFIC EDITORIAL PANEL
MARION E. ALBERTS, MD,
Des Moines
RICHARD M. CAPLAN, MD,
Iowa City
DANIEL F. CROWLEY, MD,
Des Moines
DENNIS J. WALTER, MD,
Des Moines
EDITORS
MARION E. ALBERTS . MD,
Scientific Editor
ELDON E. HUSTON, Executive Editor DONALD L. NEUMANN, Managing Editor POLLY l. LYNCH, Assistant Managing Editor
IDENTIFICATION INFORMATION: The JOURNAL is published monthly by the Iowa Medical Society, 1001 Grand Av- enue, West Des Moines, Iowa 50265. Subscription Price: $15 per year. Printed by The Ovid Bell Press, Inc., Fulton, Mis- souri 65251. Second-class postage paid at West Des Moines, Iowa, and at addi- tional mailing offices. POSTMASTER: Send address changes to Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265. (ISSN 0021-0587)
NATIONAL ADVERTISING BUREAU: State Medical Journal Advertising Bureau, Inc., 71 1 South Blvd., Oak Park, III. 60302. Phone 312/383-8800
IOWA ADVERTISING: Contact Mrs. Polly lynch, Journal of the Iowa Medical Soci- ety, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone 515/223- 1401
EDITORIAL CONTENT: The work of vari- ous authors is found in the diversified content of the IMS Journal. The Society respects these individual efforts but is unable to assume responsibility for the accuracy of that which is submitted. Manuscripts and editorial inquiries should be directed to Editor, Journal of the Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265
Copyright 1981 Iowa Medical Society
IN THIS ISSUE
1 1 Medical Manpower In Iowa: Surplus or Shortage?
Dr. Paul M. Seebohm reviews Iowa physician supply
14 A Point of View
Des Moines surgeon voices his opinion on use of prophylactic antibiotics
15 One, Two, Now Three Years — Training the "Family Specialist"
Dr. Paul M. Paulman reports on 3-year training program at Broadlawns Medical Center
19 Phenothiazines Induced Keto-Acidosis
This is a discussion of potential dangers of large doses of phenothiazines
25 Drug Therapy Review
Parenteral nutrition: definition and indications
42 In The Public Interest
How the IMS Claim Review Panel works
REGULAR FEATURES
|
3 |
News/Products, Programs, Etc. |
23 |
Our Man on Education |
|
5 |
President's Privilege |
25 |
Drug Therapy Review |
|
7 |
Things You Should Know |
29 |
State Department/Public Health |
|
8 |
Questions/Answers |
32 |
About Iowa Physicians |
|
10 |
Vox Docs |
38 |
Iowa Medical Assistants |
|
21 |
Commenting Editorially |
42 |
In the Public Interest |
ABOUT THE COVER — The Vial of Life program operates in several Iowa communities. One is co-sponsored by St. Joseph Mercy Hospital in Clinton with its Auxiliary. Vials to cover disposable syringes are converted to in- formation receptacles and placed appropriately in refrigerators of senior citizens, handicapped persons, etc. Medical and other important info is in- serted into the Vial and a red identification seal is placed on the refrigerator door. Rescue personnel are keyed to check for this information. A representa- tive of the Clinton fire department is pictured on the cover as he locates a Vial of Life.
yaliumk
diazepam/ Roche
Before prescribing, please consult complete product information, a summary of which follows:
Indications: Management of anxiety disorders, or short-term relief of symptoms of anxiety; symp- tomatic relief of acute agitation, tremor, delirium tremens and hallucinosis due to acute alcohol withdrawal; adjunctively in skeletal muscle spasm due to reflex spasm to local pathology; spasticity caused by upper motor neuron disorders, athe- tosis, stiff-man syndrome, convulsive disorders (not for sole therapy)
The effectiveness of Valium (diazepam/Roche) in long-term use, that is, more than 4 months, has not been assessed by systematic clinical studies The physician should periodically reas- sess the usefulness of the drug for the individual patient
Contraindicated: Known hypersensitivity to the drug Children under 6 months of age v Acute narrow angle glaucoma, may be used in patients with open angle glaucoma who are receiving appropriate therapy Warnings: Not of value in psychotic patients Caution against hazardous occupations requir- ing complete mental alertness When used adiunctively in convulsive disorders, possibility of increase in frequency and/or severity of grand mal seizures may require increased dos- age of standard anticonvulsant medication; abrupt withdrawal may be associated with tempo- rary increase in frequency and/or severity of seizures Advise against simultaneous ingestion of alcohol and other CNS depressants With- drawal symptoms similar to those with barbitu- rates and alcohol have been observed with abrupt discontinuation, usually limited to ex- tended use and excessive doses Infrequently, milder withdrawal symptoms have been reported following abrupt discontinuation of benzodiaz- epines after continuous use, generally at higher therapeutic levels, for at least several months After extended therapy, gradually taper dosage. Keep addiction-prone individuals under careful surveillance because of their predisposition to habituation and dependence
Usage in Pregnancy: Use of minor tranquilizers during first trimester should almost always be avoided be- cause of increased risk of congenital malformations as suggested in sev- eral studies. Consider possibility of pregnancy when instituting therapy; advise patients to discuss therapy if they intend to or do become pregnant.
Precautions: If combined with other psycho- tropics or anticonvulsants, consider carefully pharmacology of agents employed, drugs such as phenothiazmes. narcotics, barbiturates, MAO inhibitors and other antidepressants may poten- tiate its action Usual precautions indicated in patients severely depressed, or with latent de- pression, or with suicidal tendencies Observe usual precautions in impaired renal or hepatic function Limit dosage to smallest effective amount in elderly and debilitated to preclude ataxia or oversedation
Side Effects: Drowsiness, confusion, diplopia, hypotension, changes in libido, nausea, fatigue, depression, dysarthria, jaundice, skin rash, ataxia, constipation, headache, incontinence, changes in salivation, slurred speech, tremor, vertigo, urinary retention, blurred vision Paradoxi- cal reactions such as acute hyperexcited states, anxiety, hallucinations, increased muscle spas- ticity. insomnia, rage, sleep disturbances, stimulation have been reported; should these occur, discontinue drug. Isolated reports of neu- tropenia, jaundice, periodic blood counts and liver function tests advisable during long-term therapy
/ \ I
< ROCHE > i
\ /
Roche Laboratories
ROCHE > Division of Hoffmann-La Roche Inc. Nutley, New Jersey 07110
NEWS/PRODUCTS, PROGRAMS, ETC.
Information on various products, programs, etc., is received regularly by the ims journal. Here are short items sifted from the mail by the Scientific Editor. A reference to a specific product is not in- tended to suggest any particular endorsement. Ad- ditional information on any entry may be obtained by contacting the ims journal.
GUAIFENESIN IN NEW FORM — The Breone- sin brand of guaifenesin expectorant in soft gelatin capsules has been introduced by Breon Laboratories. Each Breonesin capsule has 200 mg of guaifenesin, equivalent to 2 teaspoons of the liquid expectorant. Dosage recommended is one or two capsules every 4 hours. The cap- sules are claimed to be as effective as the liquid form and contain no alcohol.
DRUG VOLUME — A new, fully cumulative edition of USAN and the USP Dictionary of Drug Names is available. The new 501-page, 8" x 11" edition has more than 15,000 entries, exclusive of cross-references and the appendices. All USAN released from June 15, 1961, when the U. S. Adopted Names program began, through June 15, 1980, are included.
USAN are adopted by the United States Adopted Names Council, co-sponsored by the American Medical Association, the American Pharmaceutical Association, and the Pharma- copeial Convention, and with participation by the U. S. Food and Drug Administration.
Orders for the new edition of USAN/USP- DDN should be addressed to the USAN Divi- sion, USP Convention, Inc., 12601 Twinbrook Parkway, Rockville, Maryland 20852. The price remains the same as for last year's edition: $19.50 per copy, with quantity discounts for 11 or more copies.
January 1981 / 3
This Journal is owned and published monthly by the IOWA MEDICAL SOCIETY. It contains material of scientific and socioeconomic interest mainly to Iowa physicians. The IOWA MEDICAL SOCIETY has 3,000 member physicians in 92 county medical societies. The IMS Head- quarters is at 1001 Grand Avenue, West Des Moines, Iowa 50265.
BOARD OF TRUSTEES
WILLIAM R. BLISS, MD, Ames President
HORMOZ RASSEKH, MD,
Council Bluffs Chairman of the Board MAURICE E. KRAUSHAAR, MD,
Fort Dodge
Trustee/Secretary-Treasurer JOHN E. TYRRELL, MD, Manchester Trustee
JOHN H. KELLEY, MD, Des Moines President-elect EMMETT B. MATHIASEN, MD,
Council Bluffs Vice President
PAUL M. SEEBOHM, MD, Iowa City Immediate Past President
SCIENTIFIC EDITORIAL PANEL
MARION E. ALBERTS, MD,
Des Moines
RICHARD M. CAPLAN, MD,
Iowa City
DANIEL F. CROWLEY. MD,
Des Moines
DENNIS J. WALTER, MD,
Des Moines
EDITORS
MARION E. ALBERTS , MD,
Scientific Editor
ELDON E. HUSTON, Executive Editor DONALD L. NEUMANN, Managing Editor POLLY L. LYNCH, Assistant Managing Editor
IDENTIFICATION INFORMATION: The JOURNAL is published monthly by the Iowa Medical Society, 1001 Grand Av- enue, West Des Moines, Iowa 50265. Subscription Price: $15 per year. Printed by The Ovid Bell Press, Inc., Fulton, Mis- souri 65251. Second-class postage paid at West Des Moines, Iowa, and at addi- tional mailing offices. POSTMASTER: Send address changes to Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265. (ISSN 0021-0587)
NATIONAL ADVERTISING BUREAU: State Medical Journal Advertising Bureau, Inc., 711 South Blvd., Oak Park, III. 60302. Phone 312/383-8800
IOWA ADVERTISING: Contact Mrs. Polly Lynch, Journal of the Iowa Medical Soci- ety, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone 515/223- 1401
EDITORIAL CONTENT: The work of vari- ous authors is found in the diversified content of the IMS Journal. The Society respects these individual efforts but is unable to assume responsibility for the accuracy of that which is submitted. Manuscripts and editorial inquiries should be directed to Editor, Journal of the Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265
Copyright 1981 Iowa Medical Society
IN THIS ISSUE
51 Proper Use of Rh Immune Globulin: Report of a Statewide Study
A continuing medical education presentation
54A Continuing Medical Education Quiz
61 Improving Survival Rates in Renal Transplantation
A current report on the Iowa Transplantation Service
65 Arthroscopic Knee Surgery
Author describes increasing use of arthroscopy
72 Drug Therapy Review
Treatment of moderate and severe chronic pain syndromes
86 In the Public Interest
Utilization review
REGULAR FEATURES
49 President's Privilege
50 Things You Should Know 57 Vox Docs 59 Questions/Answers 67 Commenting Editorially
69 Letters to Editor
70 Our Man on Education 72 Drug Therapy Review 78 State Department/
Public Health 80 About Iowa Physicians
ABOUT THE COVER — This month's cover directs attention to a new con- tinuing medical education opportunity contained in this issue of the IMS JOURNAL. You are encouraged to complete the quiz shown on the orange insert and return it according to the instructions to earn one hour of Category I CME credit. The project is a joint effort of the Iowa Foundation for Medical Care, the University of Iowa College of Medicine and the IMS.
YaSum
diazepam /Roche
Before prescribing, please consult complete product information, a summary of which follows:
Indications: Management of anxiety disorders, or short-term relief of symptoms of anxiety; symp- tomatic relief of acute agitation, tremor, delirium tremens and hallucinosis due to acute alcohol withdrawal; ad|unctively in skeletal muscle spasm due to reflex spasm to local pathology; spasticity caused by upper motor neuron disorders, athe- tosis, stiff-man syndrome, convulsive disorders (not for sole therapy)
The effectiveness of Valium (diazepam/Roche) in long-term use, that is, more than 4 months, has not been assessed by systematic clinical studies The physician should periodically reas- sess the usefulness of the drug for the individual patient
Contraindicated: Known hypersensitivity to the drug Children under 6 months of age Acute narrow angle glaucoma, may be used in patients with open angle glaucoma who are receiving appropriate therapy Warnings: Not of value in psychotic patients, Caution against hazardous occupations requir- ing complete mental alertness When used adiunctively in convulsive disorders, possibility of increase in frequency and/or severity of grand mal seizures may require increased dos- age of standard anticonvulsant medication, abrupt withdrawal may be associated with tempo- rary increase in frequency and/or severity of seizures Advise against simultaneous ingestion of alcohol and other CNS depressants With- drawal symptoms similar to those with barbitu- rates and alcohol have been observed with abrupt discontinuation, usually limited to ex- tended use and excessive doses Infrequently, milder withdrawal symptoms have been reported following abrupt discontinuation of benzodiaz- epines after continuous use, generally at higher therapeutic levels, for at least several months After extended therapy, gradually taper dosage Keep addiction-prone individuals under careful surveillance because of their predisposition to habituation and dependence
Usage in Pregnancy: Use of minor tranquilizers during first trimester should almost always be avoided be- cause of increased risk of congenital malformations as suggested in sev- eral studies. Consider possibility of pregnancy when instituting therapy; advise patients to discuss therapy if they intend to or do become pregnant.
Precautions: If combined with other psycho- tropics or anticonvulsants, consider carefully pharmacology of agents employed; drugs such as phenothiazines. narcotics, barbiturates, MAO inhibitors and other antidepressants may poten- tiate its action Usual precautions indicated in patients severely depressed, or with latent de- pression, or with suicidal tendencies. Observe usual precautions in impaired renal or hepatic function Limit dosage to smallest effective amount in elderly and debilitated to preclude ataxia or oversedation
Side Effects: Drowsiness, contusion, diplopia, hypotension, changes in libido, nausea, fatigue, depression, dysarthria. |aundice. skin rash, ataxia, constipation, headache, incontinence, changes in salivation, slurred speech, tremor, vertigo, urinary retention, blurred vision Paradoxi- cal reactions such as acute hyperexcited states, anxiety, hallucinations, increased muscle spas- ticity. insomnia, rage, sleep disturbances, stimulation have been reported; should these occur, discontinue drug Isolated reports of neu- tropenia, jaundice; periodic blood counts and liver function tests advisable during long-term therapy
family
practitioners
Seekinga board certified/eligible family practitionerto join family practitionerand general internist in a high quality growing practice in northcentral rural Wisconsin. Modern clinic building adjoined to community hospital. Call shared with two other physicians in a nearby community. Associate membership, then membershipaffiliation with a large multispecialty medical group 60 miles distant offering the full spectrum of consultingservicesand providing laboratory and administrative support and continuing medical education opportunities. Salary and fringe benefits excellent. Practice experience desirable but not mandatory. This isan excellent opportunity to exercise yourtalents in adult medicine, pediatrics, and OB-GYN in a small community environment practicing with skilled col leagues while enjoying a reasonable call schedule, freedom from business administration, and thesecurity of ready access to consulting specialists in all fields. Send curriculum vitae and the names of persons who can be contacted for reference to:
FREDERIC WESBROOK, M.D. Marshfield Clinic, 1000 North Oak Marshfield, Wl 54449
Roche Laboratories
ROCHE > Division of Hoffmann-La Roche Inc. Nutley, New Jersey 07110
/ \ I
< ROCHE > i
\ I
February 1981 / 47
This Journal is owned and published monthly by the IOWA MEDICAL SOCIETY. It contains material of scientific and socioeconomic interest mainly to Iowa physicians. The IOWA MEDICAL SOCIETY has 3,000 member physicians in 92 county medical societies. The IMS Head- quarters is at 1001 Grand Avenue, West Des Moines, Iowa 50265.
BOARD OF TRUSTEES
WILLIAM R. BLISS, MD, Ames President
HORMOZ RASSEKH, MD,
Council Bluffs Chairman of the Board MAURICE E. KRAUSHAAR, MD,
Fort Dodge
Trustee/Secrefary-Treasurer JOHN E. TYRRELL, MD, Manchester Trustee
JOHN H. KELLEY, MD, Des Moines President-elect EMMETT B. MATHIASEN, MD,
Council Bluffs Vice President
PAUL M. SEEBOHM, MD, Iowa City Immediate Past President
SCIENTIFIC EDITORIAL PANEL
MARION E. ALBERTS, MD,
Des Moines
RICHARD M. CAPLAN, MD,
Iowa City
DANIEL F. CROWLEY, MD,
Des Moines
DENNIS J. WAITER, MD,
Des Moines
EDITORS
MARION E. ALBERTS . MD,
Scientific Editor
ELDON E. HUSTON, Executive Editor DONALD l. NEUMANN, Managing Editor POLLY L LYNCH, Assistant Managing Editor
IDENTIFICATION INFORMATION: The JOURNAL is published monthly by the Iowa Medical Society, 1001 Grand Av- enue, West Des Moines, Iowa 50265. Subscription Price: $15 per year. Printed by The Ovid Bell Press, Inc., Fulton, Mis- souri 65251. Second-class postage paid at West Des Moines, Iowa, and at addi- tional mailing offices. POSTMASTER: Send address changes to Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265. (ISSN 0021-0587)
NATIONAL ADVERTISING BUREAU: State Medical Journal Advertising Bureau, Inc., 711 South Blvd., Oak Park, III. 60302. Phone 312/383-8800
IOWA ADVERTISING: Contact Mrs. Polly Lynch, Journal of the Iowa Medical Soci- ety, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone 515/223- 1401
EDITORIAL CONTENT: The work of vari- ous authors is found in the diversified content of the IMS Journal. The Society respects these individual efforts but is unable to assume responsibility for the accuracy of that which is submitted. Manuscripts and editorial inquiries should be directed to Editor, Journal of the Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265
Copyright 1981 Iowa Medical Society
IN THIS ISSUE
96 Iowa Foundation for Medical Care Outpatient/Same-Day Surgery List
Medical and surgical procedures for outpatient/same-day surgery
101 Fractures of the Scaphoid: Important But Easily Missed Injuries
How to recognize and treat scaphoid fractures
1 16 Prophylactic Antibiotics in General Surgery: A Medical Opinion
Author cites rationale for use of antibiotics in abdominal surgery
130 In the Public Interest
Status report on Iowa's only health maintenance organization
REGULAR FEATURES
|
93 |
President's Privilege |
114 |
News/Products, Programs, Etc. |
|
94 |
Questions/Answers |
115 |
Our Man on Education |
|
98 |
Things You Should Know |
116 |
Drug Therapy Review |
|
99 |
Vox Docs |
118 |
State Department/Public Health |
|
111 |
Commenting Editorially |
125 |
About Iowa Physicians |
|
112 |
Letters to the Editor |
130 |
In the Public Interest |
ABOUT THE COVER — At the 1981 American Medical Association National Leadership Conference (February 13/14), the Iowa Medical Society received a plaque recognizing the fifth consecutive year in which Iowa physicians have exceeded their previous year's level of AMA MEMBERSHIP. Shown on the cover is IMS President-elect John H. Kelley, M.D., left, accepting the plaque from AMA President Robert B. Hunter, M.D., Sedro Woolley, Washington. The smaller photo is of the plaque. COVER PHOTO CREDIT: Joe Fletcher, American Medical Association
Valium®
diazepam/Roche
family
practitioners
Before prescribing, please consult complete product information, a summary of which follows: Indications: Management of anxiety disorders, or short-term relief of symptoms of anxiety; symptomatic relief of acute agitation, tremor, delirium tremens and hallucinosis due to acute alcohol withdrawal; adjunc- tively in skeletal muscle spasm due to reflex spasm to local pathology; spasticity caused by upper motor neuron disorders; athetosis; stiff-man syndrome; convulsive disorders (not for sole therapy)
The effectiveness of Valium (diazepam/Roche) in long- term use, that is, more than 4 months, has not been assessed by systematic clinical studies. The physician should periodically reassess the usefulness of the drug for the individual patient.
Contraindicated: Known hypersensitivity to the drug. Children under 6 months of age. Acute narrow angle glaucoma; may be used in patients with open angle glaucoma who are receiving appropriate therapy Warnings: Not of value in psychotic patients Caution against hazardous occupations requiring complete mental alertness When used adiunctively in convulsive disorders, possibility of increase in frequency and/or severity of grand mal seizures may require increased dosage of standard anticonvulsant medication; abrupt withdrawal may be associated with temporary increase in frequency and/or severity of seizures. Advise against simultaneous ingestion of alcohol and other CNS de- pressants. Withdrawal symptoms similar to those with barbiturates and alcohol have been observed with abrupt discontinuation, usually limited to extended use and excessive doses. Infrequently, milder withdrawal symptoms have been reported following abrupt discon- tinuation of benzodiazepines after continuous use, generally at higher therapeutic levels, for at least several months. After extended therapy, gradually taper dosage. Keep addiction-prone individuals under careful surveillance because of their predisposition to habituation and dependence
Usage in Pregnancy: Use of minor tranquil- izers during first trimester should almost always be avoided because of increased risk of congenital malformations as sug- gested in several studies. Consider possibility of pregnancy when instituting therapy: advise patients to discuss therapy if they intend to or do become pregnant. Precautions: If combined with other psychotropics or anticonvulsants, consider carefully pharmacology of agents employed; drugs such as phenothiazines, narcotics, barbiturates. MAO inhibitors and other anti- depressants may potentiate its action. Usual precau- tions indicated in patients severely depressed, or with latent depression, or with suicidal tendencies. Observe usual precautions in impaired renal or hepatic function. Limit dosage to smallest effective amount in elderly and debilitated to preclude ataxia or oversedation.
Side Effects: Drowsiness, confusion, diplopia, hypotension, changes in libido, nausea, fatigue, depression, dysarthria, jaundice, skin rash, ataxia, constipation, headache, incontinence, changes in salivation, slurred speech, tremor, vertigo, urinary retention, blurred vision Paradoxical reactions such as acute hyperexcited states, anxiety, hallucinations, Increased muscle spasticity, insomnia, rage, sleep disturbances, stimulation have been reported; should these occur, discontinue drug. Isolated reports of neutropenia, jaundice; periodic blood counts and liver function tests advisable during long-term therapy. Dosage: Individualize for maximum beneficial effect. Adults Anxiety disorders, symptoms of anxiety, 2 to 10 mg b i d. to q.i.d ; alcoholism, 10 mg t.i.d. or q.i.d. in first 24 hours, then 5 mg t.i.d. or q.i.d. as needed, adjunctively in skeletal muscle spasm, 2 to 10 mg t.i d or q i d ; adjunctively in convulsive disorders, 2 to 10 mg b i d to q.i.d. Geriatric or debilitated patients 2 to 21/2 mg, 1 or 2 times dally initially, Increasing as needed and tolerated. (See Precautions ) Children 1 to 21/2 mg t.i.d. or q.i.d initially, increasing as needed and tolerated (not for use under 6 months)
Supplied: Valium®(diazepam/Roche) Tablets, 2 mg,
5 mg and 10 mg — bottles of 100 and 500; Tel-E-Dose® packages of 100, available in trays of 4 reverse-num- bered boxes of 25, and in boxes containing 10 strips of 10; Prescription Paks of 50, available in trays of 10
Seeking board certified/eligible family practitionerto join three family practitioners, three general internists, a pediatrician, and a general surgeon in high quality group practice in a northern Wisconsin community. Clinic building adjoins community hospital. Associate membership, then membershipaffiliation with a large multispecialty medical group 100 miles distant which provides the full spectrum of consultingservicesand laboratory and administrative support and continuingmedical education opportunities. Salary and fringe benefits excellent. Practice experience desirable but not mandatory. This isan excellent opportunity to practice family medicine with skilled colleagues in a small community environment while enjoyinga reasonable call schedule, freedom from business administration, and thesecurity of ready access to consulting specialists in all fields. Send curriculum vitae and names of persons who can be contacted for reference to:
HOWARD CHATTERTON, M.D. 906 College Avenue, West Ladysmith, Wl 54848
Roche Laboratories
Division of Hoffmann-La Roche Inc.
Nutley, New Jersey 07110
March 1981 / 91
This Journal is owned and published monthly by the IOWA MEDICAL SOCIETY. It contains material of scientific and socioeconomic interest mainly to Iowa physicians. The IOWA MEDICAL SOCIETY has 3,000 member physicians in 92 county medical societies. The IMS Head- quarters is at tOOl Grand Avenue, West Des Moines, Iowa 50265.
BOARD OF TRUSTEES
WILLIAM R. BLISS, MD, Ames President
HORMOZ RASSEKH, MD,
Council Bluffs Chairman of the Board MAURICE E. KRAUSHAAR, MD,
Fort Dodge
Trustee/Secretary-Treasurer JOHN E. TYRRELL, MD, Manchester Trustee
JOHN H. KELLEY, MD, Des Moines President-elect EMMETT B. MATHIASEN, MD,
Council Bluffs Vice President
PAUL M. SEEBOHM, MD, Iowa City Immediate Past President
SCIENTIFIC EDITORIAL PANEL
MARION E. ALBERTS, MD,
Des Moines
RICHARD M. CAPLAN, MD, Iowa City
DANIEL F. CROWLEY, MD,
Des Moines
DENNIS J. WALTER, MD,
Des Moines
EDITORS
MARION E. ALBERTS MD,
Scientific Editor
ELDON E. HUSTON, Executive Editor DONALD L. NEUMANN, Managing Editor POLLY L. LYNCH, Assistant Managing Editor
IDENTIFICATION INFORMATION: The JOURNAL is published monthly by the Iowa Medical Society, 1001 Grand Av- enue, West Des Moines, Iowa 50265. Subscription Price: $15 per year. Printed by The Ovid Bell Press, Inc., Fulton, Mis- souri 65251. Second-class postage paid at West Des Moines, Iowa, and at addi- tional mailing offices. POSTMASTER: Send address changes to Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265. (ISSN 0021-0587)
NATIONAL ADVERTISING BUREAU: State Medical Journal Advertising Bureau, Inc., 711 South Blvd., Oak Park, III. 60302. Phone 312/383-8800
IOWA ADVERTISING: Contact Mrs. Polly Lynch, Journal of the Iowa Medical Soci- ety, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone 515/223- 1401
EDITORIAL CONTENT: The work of vari- ous authors is found in the diversified content of the IMS Journal. The Society respects these individual efforts but is unable to assume responsibility for the accuracy of that which is submitted. Manuscripts and editorial inquiries should be directed to Editor, Journal of the Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265
Copyright 1981 Iowa Medical Society
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APRIL 1981 / VOLUME 71 NUMBER 4
UNIVERSITY ISSUE
140 The Continuous Quest
Dean John W. Eckstein reports on U. of I. Clinical Research Center
143 Questions/Answers: The Teaching Hospital
John W. Colloton discusses the role of the teaching hospital in the 1980's
149 Toxic-Shock Syndrome In Iowa
Two cases of TSS are described by Iowa physicians
153 Infection Morbidity After Cesarean Section
Discussion and treatment of postoperative infection
160 Appreciation to Physician Preceptors
Physicians who have served as preceptors are recognized
178 In the Public Interest
U. of I. medical students comment on preceptorship experiences
|
REGULAR FEATURES |
|||
|
137 |
President's Privilege |
157 |
Letter to Editor |
|
139 |
Things You Should Know |
162 |
Drug Therapy Review |
|
143 |
Questions/Answers |
168 |
State Department/Public Health |
|
147 |
Vox Docs |
173 |
About Iowa Physicians |
|
157 |
Commenting Editorially |
178 |
In the Public Interest |
ABOUT THE COVER — The long-standing Iowa preceptor program is shown in action. Junior medical student Curtis Hanson from Villisca examines a youthful patient under the watchful eye of Preceptor Carlyle C. Moore, M.D., Emmetsburg. Junior students must take a 2-week preceptorship in primary care. A number return for more study in the senior year. Elsewhere in this issue recognition is extended to Iowa preceptors. Also, this month's In The Public Interest contains preceptee comments on their experiences. COVER PHOTO: Jane E. Whitmore, Emmetsburg Publishing Company
138 / Journal of Iowa Medical Society
PRESIDENT’S
PRIVILEGE
We talk a lot in our daily conversations about trust. We probably are prone to speak more about its absence than presence. We are apt to conclude that trustworthiness as a human trait is less conspicuous than it was in earlier days.
We go to our mechanic trusting him to do our repair work. We expect conscientious ser- vice. We expect lasting craftsmanship. And we expect the charge to be fair — in line with the time spent and the materials used. When these expectations are met we frequently take it for granted.
When the results and the costs are off the mark we express our criticism often and emphatically. Such expression tends to foster a belief that providers of services or products are out to take an unsuspecting public. This type of thinking promotes distress between the pro- fessions.
A mechanic has been used for illustrative purposes, but we could use a physician just as easily. It is understandable that greater ex- pectations are present where personal health is involved. The need for trust and understand-
ing is far more important in the doctor-patient context. We need to do all possible within our individual practices and collectively within our profession to create a climate of openness and trust among ourselves, our patients, and other professionals. By doing so, we can set the kind of example expected from us.
The practice of medicine is truly the ultimate in one human being's service to another. It should be undergirded by trust. It is the kind of service relationship that must emanate from mutual respect and confidence. It must emerge from the human will and not from regulatory edict or fear. Please think about this.
Please let me finish these comments, too, by acknowledging this University issue. We are greatful for the excellent spirit of cooperation which exists between the College of Medicine and the Society.
William R. Bliss, M.D.
April 1981 / 137
This Journal is owned and published monthly by the IOWA MEDICAL SOCIETY. It contains material of scientific and socioeconomic interest mainly to Iowa physicians. The IOWA MEDICAL SOCIETY has 3,000 member physicians in 92 county medical societies. The IMS Head- quarters is at 1001 Grand Avenue, West Des Moines, Iowa 50265.
BOARD OF TRUSTEES
WILLIAM R. BLISS, MD, Ames President
HORMOZ RASSEKH, MD,
Council Bluffs Chairman of the Board MAURICE E. KRAUSHAAR, MD,
Fort Dodge
Trustee/Secretary-Treasurer JOHN E. TYRRELL, MD, Manchester Trustee
JOHN H. KELLEY, MD, Des Moines President-elect EMMETT B. MATHIASEN, MD,
Council Bluffs Vice President
PAUL M. SEEBOHM, MD, Iowa City Immediate Past President
SCIENTIFIC EDITORIAL PANEL
MARION E. ALBERTS, MD,
Des Moines
RICHARD M. C ARLAN, MD,
Iowa City
DANIEL F. CROWLEY, MD,
Des Moines
DENNIS J. WAITER, MD,
Des Moines
EDITORS
MARION E. ALBERTS . MD,
Scientific Editor
ELDON E. HUSTON, Executive Editor DONALD L. NEUMANN, Managing Editor POLLY l. LYNCH, Assistant Managing Editor
IDENTIFICATION INFORMATION: The JOURNAL is published monthly by the Iowa Medical Society, 1001 Grand Av- enue, West Des Moines, Iowa 50265. Subscription Price: $15 per year. Printed by The Ovid Bell Press, Inc., Fulton, Mis- souri 65251. Second-class postage paid at West Des Moines, Iowa, and at addi- tional mailing offices. POSTMASTER: Send address changes to Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265. (ISSN 0021-0587)
NATIONAL ADVERTISING BUREAU: State Medical Journal Advertising Bureau, Inc., 711 South Blvd., Oak Park, III. 60302. Phone 312/383-8800
IOWA ADVERTISING: Contact Mrs. Polly Lynch, Journal of the Iowa Medical Soci- ety, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone 515/223- 1401
EDITORIAL CONTENT: The work of vari- ous authors is found in the diversified content of the IMS Journal. The Society respects these individual efforts but is unable to assume responsibility for the accuracy of that which is submitted. Manuscripts and editorial inquiries should be directed to Editor, Journal of the Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265
Copyright 1981 Iowa Medical Society
IN THIS ISSUE
189 What Are Iowa Physicians Thinking?
Results of recent IMS survey
192 Everything's Up to Date in Kansas City
IMS Scientific Session
197 Subarachnoid Hemorrhage: An Unusual Presentation of Infective Endocarditis
Dr. Rappoport presents a case report
200 Physician Involvement in Health Planning — 1981
Dr. Tyrrell calls for voluntary physician leadership
214 Highly Purified Insulin
Dr. Ginsberg reviews new insulins
226 In the Public Interest
Profile of Iowa medical practice
REGULAR FEATURES
184 News/Products, Programs, Etc. 211
185 President's Privilege 213
195 Questions/Answers 214
196 Things You Should Know 216
199 A Point of View 221
206 Commenting Editorially 226
Vox Docs
Our Man on Education Drug Therapy Review State Department/Public Health About Iowa Physicians In the Public Interest
ABOUT THE COVER — Borrowing on the old cliche, "Everything's Up to Date in Kansas City," this month's cover invites Iowa physicians to attend the 1 98 1 IMS Scientific Session June 24 to 26 at the Alameda Plaza. The program for the Scientific Session appears on pages 192-193 of this issue. You are encouraged to consider this continuing medical education event.
186 / Journal of Iowa Medical Society
PRESIDENT'S
PRIVILEGE
This will be my last time to fill this space. I have appreciated the opportunity to com- ment. As is the case with most interesting ex- periences, my year as IMS president has gone quickly. Thanks to all for the high level of in- terest and support.
My concluding thoughts this month tend to parallel what was said in April about the need for physicians to be fully trustworthy. In this swan song, I would carry the theme a step further by underscoring the importance of re- sponsibility within medical ranks.
Let me illustrate.
Nationally, through the American Medical Association House of Delegates, the profes- sion has spoken in favor of eliminating federal- ly mandated utilization review. Putting it simply, the AMA House has called for repeal of the Professional Standards Review (PSRO) Program. In step with this desire has come an announcement from the Administration of its plans to phase out PSRO by 1983.
So, if PSRO, as statutorily required, is cast to the winds, what next? Few physicians will argue against the need for assuring quality care; this was and presumably is the under- lying intent of PSRO — even though cost re- straint has become a more conspicuous mission. If PSRO is dismantled, does not the medical profession need to come forward with a volun- tary alternative?
Here is where the element of responsibility may be tested. How does the profession act responsibly — in the absence of any federal mandate — to make sure the care delivered to Iowans is of high quality?
Various honest and legitimate opinions will come to bear on this question in the ensuing months. Such discussion is on tap to occur during the 1981 IMS House of Delegates.
Matters of quality assurance at the commu- nity and state levels demand leadership from the medical profession. We have the responsi- bility to furnish this leadership on a conscien- tious basis.
William R. Bliss, M.D.
P.S. Your attention is called to information else- where in this issue about the 1981 IMS Scientific Session. It'll be a fine time in Kansas City. Please join us.
May 1981 / 185
This Journal is owned and published monthly by the IOWA MEDICAL SOCIETY. It contains material of scientific and socioeconomic interest mainly to Iowa physicians. The IOWA MEDICAL SOCIETY has 3,000 member physicians in 92 county medical societies. The IMS Head- quarters is at 1001 Grand Avenue, West Des Moines, Iowa 50265.
BOARD OF TRUSTEES
JOHN H. KELLEY, MD, Des Moines President
MAURICE E. KRAUSHAAR, MD,
Fort Dodge
Chairman of the Board JOHN E. TYRRELL, MD, Manchester T rustee/Secretary-T reasurer EMMETT B. MATHIASEN, MD, Council Bluffs Trustee
HORMOZ RASSEKH, MD,
Council Bluffs President-elect
GEORGE L. BAKER, MD, Iowa City Vice President
WILLIAM R. BLISS, MD, Ames Immediate Past President
SCIENTIFIC EDITORIAL PANEL
MARION E. ALBERTS, MD,
Des Moines
RICHARD M. CAPLAN, MD, Iowa City
DANIEL F. CROWLEY, MD,
Des Moines
DENNIS J. WALTER, MD,
Des Moines
EDITORS
MARION E. ALBERTS, MD,
Scientific Editor
ELDON E. HUSTON, Executive Editor DONALD l. NEUMANN, Managing Editor POLLY L. LYNCH, Assistant Managing Editor
IDENTIFICATION INFORMATION. The JOURNAL is published monthly by the Iowa Medical Society, 1001 Grand Ave- nue, West Des Moines, Iowa 50265. Sub- scription Price: $15 per year. Printed by The Ovid Bell Press, Inc., Fulton, Missouri 65251. Second-class postage paid at West Des Moines, Iowa, and at addition- al mailing offices. POSTMASTER: Send address changes to Iowa Medical Socie- ty, 1001 Grand Avenue, West Des Moines, Iowa 50265. (ISSN 0021-0587)
NATIONAL ADVERTISING BUREAU: State Medical Journal Advertising Bureau, Inc., 711 South Blvd., Oak Park, III. 60302. Phone 312/383-8800
IOWA ADVERTISING: Contact Mrs. Polly Lynch, Journal of the Iowa Medical Socie- ty, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone 515/223- 1401
EDITORIAL CONTENT: The work of var- ious authors is found in the diversified content of the IMS Journal. The Society respects these individual efforts but is unable to assume responsibility for the accuracy of that which is submitted. Manuscripts and editorial inquiries should be directed to Editor, Journal of the Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265
JUNE 1981 / VOLUME 71 NUMBER 6
IN THIS ISSUE
236 Priorities/Responsibilifies In Perspective
Immediate past president comments on his year of service
236 Continue Unmatched Record
New president challenges the profession
245 Pulmonary Paragonimiasis: A Case Report
Southeast Asia immigrant presents uncommon medical problem
249 Lyme Arthritis in the Midwest: A Diagnostic Challenge Recently identified disease appears in the Midwest
253 Arthroscopic Meniscectomy
Short term results of arthroscopy
258 Treatment of Atypical Pneumonia
Small group of pneumonias unreponsive to usual regimen
270 In the Public Interest
1981 IMS House Actions
REGULAR FEATURES
232 News/Products, Programs,
Etc.
234 President's Privilege
235 Questions-Answers 241 Thin