PAGENO="0001" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY HEARINGS BEFORE THE SUBCOMMITTEE ON MONOPOLY OF THE SELECT COMMITTEE ON SMALL BUSINESS UNITED STATES SENATE NINETY-FOURTH CONGRESS SECOND SESSION ON PRESENT STATUS OF COMPETITION IN THE PHARMACEUTICAL INDUSTRY PART 30 APRIL 28, MAY 10 AND 24, 197~l PHARMACEUTICAL INDUSTRY AND MEDICAL EDUCATION (VOL. 1) 0 Printed for the use of the Select Committee on Small Business U.S. GOVERNMENT PRINTING OFFICE 73617 WASHINGTON 1976 For sale by the Superintendent of Documents, U.S. Govetnment Printing Office Washington, D.C. 20402 - Price $4.40 PAGENO="0002" SELECT COMMITTEE ON SMALL BUSINESS [Created pursuant to S. Res. 58, 81st Cong.] GAYLORD NELSON, Wisconsin, Chairman JOHN SPARKMAN, Alabama JACOB K. JAVITS, New York THOMAS J. McINTYRE, New Hampshire J. GL11I~N BEALL, JL, Maryland SAM NIJNN, Georgia BILL EROCK, Tennessee J. BENNETT JOHNSTON, Louisiana LOWELL P. WEICKER, JR., Connecticut WILLIAM D. HATHAWAY, Maine DEWEY F. BARTLETT, Oklahoma JAMES ABOUREZK, South Dakota PAUL LAXALT, Nevada FLOYD K. HASKELL, Colorado BOB PACKWOOD, Oregon WALTER F. MONDALE, Minnesota JOHN C. CULVER, Iowa WILLIAM B. CHERKASKY, Ea,eoutive Director BENJAMIN GoRDON, Staff Economist JUDAH C. SOMMER, Minority Coisnsel KAREN YoUNG, Research Assistant SUBCOMMITTEE ON MONOPOLY GAYLORD NELSON, Wisconsin, Chairman THOMAS J. McINTYRE, New Hampshire DEWEY F. BARTLETT, Oklahoma WILLIAM D. HATHAWAY, Maine J. GLENN BEALL, JR., Maryland JAMES ABOUREZK, South Dakota BOB PACKWOOD, Oregon FLOYD K. HASKELL, Colorado JACOB K. JAVITS,* New York *Ex officio member. (II) PAGENO="0003" CONTENTS Testimony of- Calesa, Edward F., president, Health Learning Systems Inc., Bloom- field, N.J., accompanied by Edward Saltzman, executive vice Page president, Health Learning Systems Inc 14002 Crout, J. Richard, M.D., Director, Bureau of Drugs, Food and Drug Administration, accompanied by Peter H. Rheinstein, M.D., Director, Division of Drug Advertising, Bureau of Drugs, FDA; and William W. Vodra, Associate Chief Counsel for Drugs, FDA_ - 13914 Kelly, John C., M.D., chairman of the board, American Academy of Family Physicians, Kansas City, Mo., accompanied by Dr. B. Leslie Huffman, Jr., speaker of Congress of Delegates; and Dr. William Hunter, member of the board, American Academy of Family Physicians 1399& Raeben, Jay E., president, Visual Information Systems, Division of Republic Corp., New York, N.Y 13950 Scherago, Earl J., president, Sclierago Associate~, Inc., New York, N. Y., accompanied by John Ringle, assistant editor, "Science" Magazine; and Robert Ormes, managing editor, "Science" Magazine 13981 Simmons, Henry E., M.D., M.P.H., senior vice president, J. Walter Thompson Co., New York, N.Y 1396T APPENDIX Material supplied for the record by the Subcommittee on Monopoly: Statement of Committee on Scientific Exhibits in regard to pharma- ceutical support of scientific exhibits, James M. Moss, M.D., Sept. 17, 1975 14019 Letter dated Apr. 8, 1974, to Alan B. Lisook, M.D., Bureau of Drugs, Food and Drug Administration, from George A. Schumacher, M.D., professor of neurology, University of Vermont 14022 Letter dated July 1, 1974, to Dr. Alexander M. Schmidt, Director, Bureau of Drugs, Food and Drug Administration, from George A. Schumacher, M.D., professor of neurology, University of Vermont_ - 14025 Letter dated April 12, 1973, to Sylvia Covet, editorial director, Modern Medicine Publications, from George A. Schumacher, M.D., pro- fessor of neurology, University of Vermont 14027 Letter dated Feb. 13, 1973, to George A. Schumacher, M.D., professor of neurology, University of Vermont, from John H. Rosenow, M.D., senior medical editor, Modern Medicine Publications 14029 Article, "The Management of Migraine," by George A. Schumacher, M.D., professor of neurology, University of Vermont 14030 Letter dated July 31, 1972, to George A. Schifltiacher, M.D., pro- fessor of neurology, University of Vermont, from John H. Rosenow, M.D., executive medical editor, Modern Medicine Publications 14033 Circulatory letter dated Dec. 30, 1975, from Thomas F. Bird, director, broadcast services, Physicians Radio Network 14034 Letter dated Oct. 29, 1974, to Quentin D. Young, M.D., chairman, Department of Medicine, Cook County Hospital, Chicago, Ill., from Roger F. Palmer, M.D., chairman, Department of Pharma- cology~, School of Medicine, University of Miami 14035 Letter dated Dec. 13, 1974, to Roger F. Palmer, M.D., chairman, Department of Pharmacology, School of Medicine, University of Miami, from Quentin D. Young, M.D., chairman, Department of Medicine, Cook County Hospital, Chicago, Ill 14037 (III) PAGENO="0004" Iv Material supplied for the record-Continued Memorandum dated Oct. 17, 1974, from William J. Silverman, director, Cook County Hospital, Chicago, Ill., to all department, Page division, and section heads 14039 Letter dated Feb. 5, 1976, to Jere E. Goyan, Ph. D., School of Phar- macy, University of California, from A. I. Wertheimer, Ph. D., R. Hammel, M.S., M. I. Smith B.S., P. A. Parish, M.D., J. L. Boot- man, B.S., H. Framm, B.S., D. B. Christensen, M.S., F. R. Curtiss, B.S., and A. Stergachis, B.S 14040 Article, "The AACP-SAPhA-COS Split," from Action in Pharmacy, Vol.8, No. 5, January 1976, excerpt 14041 Letter undated, to the Select Committee on Small Business, U.S. Senate, from Lewis A. Miller, editor-in-chief, Patient Care, with accompanying enclosure 14043 Letter dated July 27, 1976, to Senator Gaylord Nelson, Chairman, Select Committee on Small Business, U.S. Senate, from John M. O'Brien, publisher, Consultant, The Journal of Medical Consultation 14046 Prepared statements: Calesa, Edward F., president, Health Learning Systems Inc., Bloom- field, N.J 14050 Crout, J. Richard, M.D., Director, Bureau of Drugs, Food and Drug Administration 14064 Table, circulation of U.S. medical journals with total circulation over 70,000 according to Mar. 24, 1976, issue of Standard Rate and Data Service 14104 Editorial, "Anti-Substitution Success/Medical Device Disaster," by Llewellyn H. Rockwell, Jr., from Private Practice, April 1976, excerpt 14105 Index page from Primary Cardiology, Vol. 2, No. 3, March 1976, excerpt 14106 Transcript of American Osteopathic Association audio educa- tional service tape sponsored by Abbott Laboratories 14107 Transcript of Vistaril tape 14109 Leaflet intended for pharmacists describing telesessions to be held for Pennwalt's Zaroxolyn 14110 Official program for the 27th Annual Scientific Assembly of the American Academy of Family Physicians, October 1975, pages 66, 67, 76, 77 14111 Official program for the 57th Annual Session of the American College of Physicians, April 1976, pages 138, 139 14115 Article, "The undermedicated society-charges of overprescribing are all the rage-but what about the equally dangerous ten- dency to underprescribe?," from Current Prescribing, January 1976, pages 31-33 14117 Article, "Migraine . . and more, treatment and prevention- serotonin inhibitors, antihistamines, antidepressants, beta blockers-they're all in the new wave of `headache remedies'," from Current Prescribing, April 1976, pages 46-58 14120 Article, "County Medical Societies Campaign to Beat Drug Substitution-Medicine and Politics Don't Mix," by the editors of Private Practice, March 1976, pages S-i to S-10 14130 Examples of publications which appear to be independent but are actually sponsored entirely by a single pharmaceutical company 14146 Letter dated May 27, 1976, to Senator Gaylord Nelson, Chair- man, Select Committee on Small Business, U.S. Senate, from J. Richard Crout, M.D., Director, Bureau of Drugs, Food and Drug Administration 14222 Letter dated June 18, 1976, to Paul Cutler, M.D., professor of medicine, University of Texas, from J. Richard Crout, M.D., Director, Bureau of Drugs, Food and Drug Administration___ 14224 PAGENO="0005" V Prepared statements-Continued Kelly, John C., M.D., chairman of the board, American Academy of Page Family Physicians, Kansas City, Mo 14226 Scientific exhibit application form of the American Academy of Family Physicians, Twenty-eighth Annual Scientific Assembly, Sept. 20-23, 1976 14238 Scientific exhibit evaluation form of the American Academy of Family Physicians, Twenty-eighth Annual Scientific Assembly, Sept. 20-23, 1976 14244 List of nine program elements, "Scene of Expanded Medical Education Opportunities," Hynes Veterans Auditorium, Boston, Mass 14245 Raeben, Jay E., president, Visual Information Systems, Division of Republic Corp., New York, N.Y 14246 List of the board of consultants of the Network for Continuing Medical Education (NCME) 14255 Programs catalog of the Network for Continuing Medical Education, 1976 edition 14259 Letter dated July 9, 1976, to Senator Gaylord Nelson, Chairman, Select Committee on Small Business, U.S. Senate, from Jay E. Raeben, president, Visual Information Systems 14400 Scherago, Earl J., president, Scherago Associates, Inc., New York, N.Y 14402 "Purposes of Society Publications," excerpts from a statement made by Robert Ormes, managing editor of Science Magazine, published by the American Association for the Advancement of Science 14406 "Scientific Journals: An Endangered Species," by Robert A. Day, managing editor, American Society for Microbiology News, presented at the Annual Meeting of the American Association for the Advancement of Science, Boston, Mass., Feb. 22, 1976, excerpt 14407 "The Impact of Biomedical Resea~ch on Health Care," by Donald S. Fredrickson, director, National Institutes of Health, presented at the Annual Meeting of the American Association for the Advancement of Science, Boston, Mass., Feb. 18, 197&. - 14408 Table, circulation of U.S. medical journals with total circulation over 70 000 according to Mar. 24, 1976, issue of Standard Rate and Data Service 14409 Table, total 1975 billings for throwaways serving the laboratory and scientific fields 14410 Simmons, Henry E., M.D., M.P.H., senior vice president, J. Walter Thompson Co., New York, N.Y i4411 HEARING DATES April 28, 1976: Morning session 13913 May 10, 1976: Morning session 13949 May 24, 1976: Morning session - 13981 PAGENO="0006" PAGENO="0007" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY (Present Status of Competition in the Pharmaceutical Industry) WEDNESDAY, APRIL 28, 1976 TJ.S. SENATE, SUBCOMMITTEE ON MoNOPoLY or THE SELECT COMMITTEE ON SMALL BUSINESS, Washington, D.C. The subcommittee met, pursuant to notice, in room 318, Russell Senate Office Building, Senator Gaylord Nelson (chairman of the subcommittee) presiding. Present: Senator Nelson. Also present: Benjamin Gordon, staff economist; and Karen Young, research assistant. Senator NELSON. The Monopoly Subcommittee of the Senate Small Business Committee resumes its hearings on competitive problems in the drug industry. Today, on May 10 and 24, and on other days we shall be concerned with the problem of how the medical profession gets information about drugs and the relationship to prescribing practices, competition, and the health and welfare of the public. Dr. Charles D. May, the eminent medical educator and clinician, 15 years ago warned' that the traditional independence of physicians and the welfare of the public are being threatened by the new vogue among drug manufacturers to promote their products by assuming an aggressive role in the "education" of doctors. Dr. May asked the fol- lowing questions.: Is the public likely to benefit if practicing physicians and medical educators must perform their duties amidst the clamor and striving of merchants seeking to increase the sales of drugs by conscripting "education" In the service of promotion? Is it prudent for physicians to become greatly dependent upon pharm~ceu- tical manufacturers for support of scientific journals and medical societies, for entertainment, and now also for a large part of their "education"? t~o all concerned realize the hazard of arousing the wrath of the people by an unwholesome entanglement of doctors with the makers and sellers of drugs? These questions are still relevant today. The courses which doctors take for their. postgraduate education, the books, journals, and other printed material they receive, the exhibits at conferences and medical conventions they see, the closed circuit TV and radio programs they see and hear, are virtually all sponsored by the drug industry. No one 1 Charles D. May: "Selling Drugs by `Educating' Physicians," Journal of Medical Edu- cation, issue of January 1961. 13913 PAGENO="0008" 13914 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY can ignore the many important contributions the drug companies have made, but the intrusion by the industry into the education, per- haps it would be more accurate to say the almost complete takeover by the industry of postgraduate medical "education," is cause for alarm. The London Observer on October 1, 1967, stated in its comments on the Sainsbury Committee's report on the pharmaceutical industry: Far more alarming is the basic conflict between the aims of the Industry and those of good medical practice. The industry must seek to maximize consump.. tion of its products; doctors (good doctors at any rate) seek to minimize it. Dr. Richard Crout, Director of FDA's Bureau of Drugs and one of today's witnesses, told the Pharmaceutical Advertising Club on January 17, 1974, that: In any discussion of drug advertising, it is important to recognize that the intrinsic objectives of the advertiser are by nature in conflict with certain principles of good therapeutics. The principle of parsimony in exposing patients to drugs is an obstacle to the sales objectives of the drug industry, and It is unrealistic to expect the industry to promote this principle with enthusiasm. Given this irreconcilable conflict between the interests of the drug industry and what medical experts regard as good medical practice, `how can we trust any program sponsored by the industry as being educational rather than promotional? This is, in short, the subject of these hearings. Specifically, we shall inquire about t'he various "educational" courses offered to the medical profession, their contents and sponsorship; how "education" is dis- tinguished from advertising and the resulting regulatory problems; the identification of individuals who select the program content; whether the postgraduate "education" which doctors receive is re- flected in drug prescribing practices; the general problem of the transfer of medical information to doctors; the role of advertising companies in medical "education"; the pretesting of drug advertis- ing, and the measurement of the doctors' response to it; the purpose and content of commercial and scientific exhibits at medical conven- * tions, the dependence of conventions on drug-company-supported ex- hibits; the effect on competition and small business. Our witness `today is Dr. Richard Crout, Director of the Bureau of Drugs, Food and Drug Administration, the Public Health Service of the Department' of HEW. * Dr. `Crout, please identify for the reporter your asäociates so that the record will be accurate. STATEMENT OP 1. RICHARD CROUT, `M.D., DIRECTOR, BUREAU or DRUGS, FOOD `AND DRUG ADMINISTRATION, ACCOMPANIED BY PETER H. RHEINSTEIN, M.D., DIRECTOR, DIVISION OP DRUG ADVERTISING, BUREAU OP DRUGS, FDA; AND WILLIAM W. VODRA, ASSOCIATE CHIEF COUNSEL FOR DRUGS, FDA Dr. CROUT. Thank you very much, Mr. Chairman. I am `accompanied this morning by Dr. Peter Rlaeinstein on my right who is Director of the Division of Drug Advertising of the Bureau of Drugs, Food and Drug Admin~stration, and by Mr. Wil- liam Vodra on my left who is Associate Chief Counsel for Drugs for the Food and Drug Administration. PAGENO="0009" COMPETITIVE PROBLEMS IN TIlE DRUG INDUSTRY 13915 I am delighted to appear today to discuss at your invitation the relationship between the pharmaceutical industry and medical edu- cation. This is an important topic and a timely one. There is con- siderable evidence that the pharmaceutical industry plays a very important, perhaps a dominant, role in the postgraduate education of physicians, dentists, and other health professionals. This role of the pharmaceutical industry in supporting postgraduate medical educa- tion has increased rapidly in recent years and, in my opinion, is a problem deserving of national attention. Let me emphasize from the start that I do not consider this issue to be primarily a problem in drug regulation. While I will draw upon the experience of the Bureau of Drugs in citing a number of examples in this testimony, my remarks will also reflect views devel- oped during two decades of personal experience as a student and a teacher of medicine before coming to the Food and Drug Administra- tion. I testify today as a concerned physician who believes that the growing in~Iuence of the pharmaceutical industry on medical educa- tion is a long-term threat to the integrity of my chosen profession. Before considering the many ways in which the pharmaceutical industry is involved with the education of physicians, I would like to comment briefly on trends in medical education since the turn of the century. Today the education of medical students is under the control of universities and customarily consists of a 4-year curriculum, at the end of which the student receives his M.D. degree. A century ago, however, there were, in addition to university-based medical schools, a number of private trade schools training physicians. Be- cause of the low professional competence of the graduates of these trade schools, the training of physicians became a national scandal early in the 1900's. After publication of the Flcxner report in 1910, medical education came under the full control of universities; thus nearly every physician now in practice in this country was trained at a university as a medical student. The second great advance in medical education in this century was the development of full-time faculties in medical schools. This has occurred as a result of our national investment in biomedical research and training since World, War II. Today's medical student thus graduates with a rich and broad education in medical science after a 4-year exposure to university faculties dedicated to teachi~ig, patient care, and medical research. In such an environment pro- fessional competence, commitment to scientific principles, and high personal standards are emphasized as the physician's primary and necessary attributes. After graduation from medical school, the modern physician then takes several additional years of training in a medical specialty or in family medicine. This training typically occurs in medical in- stitutions, including university hospitals, military `and Government hospitals, larger private hospitals, and some community hospitals. After such experience many physicians take advanced examinations, known as board examinations, to become certified as specialists. At this point the physician is probably as highly trained technically as he will ever be in his, life, and he enters the practice of medicine, the product of an extended and expensive educational process. PAGENO="0010" 13916 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY From tMs point on, the physician is in large part left to his own devices to maintain and update his fund of knowledge. He can maintain his university contacts by joining a clinical teaching fa- culty, an excellent approach to staying abreast of advancing medical knowledge, but an opportunity usually available only to board- certified specialists in cities with medical schools. He can also seek out any of a number of short courses sponsored by specialty societies and conducted in medical institutions. He can also read the medical literature, attend medical meetings, and take advantage of a variety of audiovisual presentations, either in the privacy of his car, home, or office, or in staff meetings at his local hospital. In recent years, several States and specialty societies have recog- nized the physician's need for continuing education to keep his medical knowledge current and have attempted to encourage greater efforts at self-education. These States and societies have imposed on the physician requirements for a specified number of credit hours, usually 150 in 3 years, to qualify for license renewal or recertifica- tion. The American Medical Association grants a physician's recog- nition award to physicians completing 150 hours of continuing edu- cation in 3 years. There are aspects of continuing education for physicians that are* unique. While other professionals must also maintain their skills and be aware of new developments, as the tax lawyer must be aware of changes in the tax code, there is no field I can think of in which keeping up is so closely related to learning about new products or new uses of old, products. Certainly, there is other information necessary also-knowledge of newer diagnostic techniques and new insight into disease mechanisms-but a significant portion of what an up-to-the-minute doctor needs to learn about is related to ad- vances in therapeutics, especially drugs and medical devices. Senator NELSON. May I go back to your statement on the bottom of page 3, top of'page 4, in which you say that: In recent years several states and specialty societies have recognized the p~iys1cian's need for continuing education to keep his medical knowledge cur- rent and have attempted to encourage greater efforts at self-education. These states and societies have Imposed on the physician requirements for a specified number of credit hours, usually 150 In three years, to quality for license renewal or recertification. The American Medical Association grants a Physician's Recog- nition Award to physicians completing 150 hours of continuing education In 3 years. How many States have licensing on relicensing requirements? Do you have those figures? Dr. CROUT. I don't think we have those precise figures. It is on the order of a third or something, or it is less. I am sorry. I am told it is less than that. Senator NELSON. Less than a third? Dr. CR0UT. It is an increasing number. Senator NELSON. Do you have the statistics at .the FDA? Dr. CROUT. We do not at the FDA. Senator NELSON. Arid then you refer to recertification. I assume that includes the professional societies and the various disciplines? Dr. ClOUT. Yes, or to maintaiii membership in these societies, for example in the American Academy of Family Physicians, is a re- quirement of that type. PAGENO="0011" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 13917 Senator NELSON. Do all the various disciplines such as internal medicine have such a requirement? Dr. CROUT. Not yet. There is a good deal of effort toward volun~ tary education and I believe that within a few years- Senator NELSON. What is the nature of the courses of study that are required? Are these self-assessment tests mostly? Dr. CROUT. That is an interesting question. Some are. Some are courses that people go to at medical meetings and some, as we will see, are articles in journals. Some courses and teaching materials we will see this morning. Senator NELSON. How many of them have self-assessment tests, I think internal medicine may have a self-assessment test? Dr. CROUT. Many have self-assessment tests. Senator NELSON. What is the quality of these tests? Do they have a chance to review and evaluate? Dr. CROUT. Some excellent and some poor. By and large the quality of the exam is good. The monitoring of them, the fact that they are graded by an outside party is not-but the examinations per se as teaching devices, I think, are acknowledged as good. Senator NELSON. These tests-are most of them or all of them. self -assessment tests? Dr. CROUT. Yes. Senator NELSON. Are they graded by somebody else? Dr. CROtTT. Usually not. One simply certifies that he has taken the test and will get an hour's credit. Senator NELSON. How does he know whether he has kept up to date in some aspect of his discipline if it is not graded by an in- dependent person? I-low does that work? Dr. CRotrr. This largely is a voluntary system at this point. The tests per se are rather good. The monitoring of them is poor. It is the monitoring, however, and the grading by an outside party which is the voluntary part of it, or at least is not done in the classical education mode of an outside teacher. Senator NELSON. Does the one who takes the test get the results' of the test? Dr. Cnou'r. The self-assessment test comes with the answers in the same package. It is like doing a crossword puzzle and looking and finding the answers. Senator NELSON. What is the objective of the test? Dr. CROUT. Tests are, I think, rather routinely aimed at content, scientific content in particular articles. These are technical tests and you would recognize similar kinds in medical school. Senator NELSON. The objective is to expose physicians to the most modern techniques and practices in his discipline, and then permit him to find out whether or not he is up to date. Is that correct? Dr. CROUT. It is a test of what was in a particular article. The test will concern itself with the content of that particular learning system. Senator NELSON. I thought the objective was to allow the physi.~ cian to find out whether or not he is up to date on the most modern diagnostic practices, the utilization of drugs, or whatever he has in his discipline. Isn't that the function? PAGENO="0012" 13918 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Dr. CROUT. You are correct. There are some special societies that give tests that are of a general and broad nature, not related to any particular course or magazine article or what have you, which are in the nature of a broad review-they give those. They are ex- cellent. They are taken on a voluntary basis. That is correct. That sort of test is something different from what we are talking about this morning. Mr. GORDON. As I understand it, some specialties, some organizations like the American Medical Association gives a certain number of credits if you go to a medical convention; is that correct? Dr. CROUT. That is correct. Mr. GORDON. Suppose you go to a convention and you do not even know what is said. Instead, you spend your time in the barroom or you are outside in a neighboring poolroom. Do you still get credits for that? Dr. CROUT. One can falsely certify to the AMA, I suppose, that he is at scientific parts of the meeting. Mr. GORDON. As I understand it, also, there are credits given for reading certain articles in some throwaway magazines. Dr. CR0-OP. That is correct. Mr. GORDON. What assurance is there that th~ person really read the article? Dr. CROtrr. This is an honor system. Senator NELSON. Perhaps you should be given more credit for not reading it! Go ahead. Dr. CRour. To understand the importance of postgraduate educa- tion to the physician's use of drugs, one must appreciate how rap- idly information on drugs changes. Ninety percent of prescriptions written today are for drugs which were not even on the market a generation ago. New information about the uses and potential ad- verse effects of drugs appears almost continuously. Since the pro- fessional career of the average physician spans 30 to 40 years, it is evident that most of what he learns about new drugs occurs after he completes his formal medical training. It thus is not surprising that the drug industry is vitally in- terested in the educational materials the practicing physician re- ceives. In view of the great financial resources available to the in- dustry it should also not be surprising that it has come to support a large and growing proportion of such educational materials. It has long been recognized that the industry-supported detail man is an important and influential source of information on drugs for the practicing physician. Drug labeling and drug advertising, which are closely regulated by FDA, also provide information. Tt is less well recognized, however, that much of the written and audiovisual teaching material supplied to the physician on all medical subjects throughout his professional career is also supported by the pharma- ceutical industry. This includes the vast majority of medical mag- azines which fill his mailbox, the clinical symposia that discuss specific drugs or general approaches to therapeutics. the audiovisual teaching systems he studies in his spare time~ the films and closed- circuit TV tapes he sees in his hospital conferences, and even the scientific exhibits and presentations by panels of experts he en- PAGENO="0013" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 13919 counters at medical meetings. This extensive underwriting of post- graduate medical education and communication by the drug indus- try has occurred primarily in the past decade, and is the problem I want to emphasize in this testimony. Mr. GORDON. Would you contrast this vast array of industry- supported material, medical information with nonindustry-supported material? Dr. CROtTT. There h:as also been a growth of courses offered by our medical schools, usually sponsored by our medical societies like the American College of Physicians and the American College of Surgery, and these are excellent and widely attended. I do not want to give the impression that the sole source of information in the postgraduate years to the doctor comes from industry-supported endeavors. What I do want to emphasize is that the information which he does not `actively seek out himself, which comes to him in the array of encounters with hospital sta if meetings, mail, et cetera, that largely comes from the drug industry. I think that medical specialists who maintain their professional ties with medical schools and postgraduate courses feel such contacts are their primary source of information and would not finger the industry-sponsored material as their primary source. But certainly that would vary a lot from physician to physician. Mr. GORDON. Even the Medical Letter has only about 55,000 sub- scribers and they have to perform a conscious act to subscribe, whereas the industry material generally comes unsolicited. Dr. CuouT. Correct. Senator NEI~SON. You have to be on some sort of mailing list? Dr. CRotTT. That is east to get on. Mr. GORDON. What percentage of the doctors are likely to take these courses that you are talking about-the ones connected with medical schools? Dr. CROTJT. Again, I could not give you a percentage. I think that-certainly a large number and certainly those who- Mr. GORDoN. We heard a long time ago, in the earlier part of our hearings, that probably fewer than one-tenth of the doctors take these courses. Does that sound reasonable to you? Dr. CRO1TT, In what period of time, one-tenth per year? Mr. GORDON. Say, per year. Dr. CROtrr. I hate to speculate on that. I am sure it is a rapidly changing scene because of the postgraduate education imposed by the State and professional society requirements. Let me note that while the drug industry has a natural interest in the postgraduate education of physicians, it is not alone in fostering this trend. Pharmaceutical industry financing of such en- deavors has been encouraged by medical institutions ~ager for at- tractive teaching materials, by respected investigators and clinicians eager to make their work and opinions more widely known, by practicing physicians under increasing pressure to participate in formal training to maintain li.censure. and by medical societies facing growing demands to make such training available. These groups are well aware of the vast resources the industry has at its PAGENO="0014" 13920 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY disposal, particularly in comparison with medical institutions and medical societies. Make no mistake, modern educational materials are costly. There has been a growing sophistication in the tech- niques used to educate people, and the old methods-lectures, re- view articles, textbooks-are perceived by some as dull and tedious. Instead we now have learning systems generally involving films or videotapes accompanied by elaborate graphics and self-instruction materials. It may well be true that these newer kinds of materials can be prepared only with special subsidies, assuming their added value as educational instruments is worth the extra money. There is a cost involved, however, in giving substantial control over that subsidy to the drug industry. That cost is the introduction ~f systematic bias. Without contending that industry-supported materials are regularly inaccurate, which is not the case, I believe that these sponsored materials are consistently tilted in the di- Tection of therapeutic enthusiasm. There has been a rapid growth in expensive, slick audiovisual materials, conferences, symposia, and publications which have the appearance of independent, scholarly productions but which are in fact an integral part of the drug industry's overall promotional efforts, a more subtle part, of course, than straightforward promotional materials like advertising. Let me emphasize that the systematic bias I am describing does not arise because the medical authorities who contribute to these teaching programs present knowingly biased views because of pharmaceutical industry support. The problem is not that drug industry money corrupts medical experts, in my view, but rather that the industry sponsor can choose from among the many med- ical authorities on any given topic to support only those whose views already coincide with the interests of the sponsor. This ability of the pharmaceutical industry to select the medical authori- ties it wishes to support is the basic cause of the biases we shall see. Mr. GORDON. Let's take a specific example. The Pfizer Co. spon- sored on January 21, 1976, a nationwide, live, closed-circuit television symposium. Do you have a list of the physicians participating in the symposium? Dr. Cuou~. Yes. Mr. GORDON. Were the participants generally those who use the oral hypoglycemia drugs? Dr. ClouT. I am not sure that I would say that was their uniform position. Let me phrase the question slightly differently. Do they favor the use of oral hypoglycemia drugs without what I would consider sufficient sensitivity of the University Group Diabetes Pro- gram [UGDP] study? The answer is, yes. Senator NELsoN. We had some rather extensive hearings on this question on two occasions and my memory is that even the critics of the study and proponents of the use of hypoglycemics-I would have to check the record on the percentage-stated that probably not more than about 1 percent of diabetics who use these drugs should be using them in contrast to a diet, and that in those cases, ~tliey were simply people who could not be relied upon for some -reason or another to stick to their diet. PAGENO="0015" COMPETITIVE PROBLEMS IN THE DRUG INDUST~ 13921 Dr. CROUT. I think the consensus figure might be closer to 20 to 25 percent. Senator NELSON. Twenty to twenty-five percent? Dr. CROUT. In either event the number is substantially lower than prescribed in practice. The 1 percent figure, if I recall, was given by the Commissioner, and the 20 percent figure was given by Dr. Bradley. Senator NELsoN. I know there was something in the 1 percent figure. Mr. GORDON. Dr. John Davidson of Grady Memorial Hospital and the Commissioner gave 1 percent. Senator NELSON. According to Dr. Davidson of Atlanta, almost everybody was taken off the drugs and the patients did very well on diet. For about 1 percent of the diabetics, however, one Of the hypoglycemics might be indicated; is that correct? Dr. .Cnotr~. Yes. Senator NELSON. Now, does the FDA have advanced script of what was said on this nationwide closed-circuit television sym- posium? Dr. CROUT. No, Dr. Rheinstein was at one of the sessions, but we do not have a transcript. Senator NELSON. Can you summarize what they were saying on this subject, particularly any evaluation of the IJ~GDP study? Dr. RHEIN&rEIN. In terms of that particular study, there was not much emphasis on it. Senator NELSON. In terms of the conclusion of the study, what posture were they taking? Were they pushing the use of the drugs? What was your impression? Dr. RHEINSTEIN. They were neither actively pushing it nor were they actively advising additional caution. What in fact they were doing in the context of the program though was reassuring the physician of Pfizer's role in the treatment of diabetes. Senator NELSON. They were doing what? Dr. RHEIN5TEIN. They were reassuring the physician of Pfizer's role in the treatment of diabetes. You have to look not only at the words `that were said but at the entire context of the program. One went to a ballroom in the best hotel in the city, sat there with a large number of physicians~ saw a panel of experts before the program began. The Pfizer detail men for that city were there, shaking hands with everybody- Senator NELSON. May I interrupt? At that moment were you seeing closed-circuit programs conducted in various hotels, that sort of thing paid for by the Pfizer Co. Dr. RHEIN5TEIN. It was a single seminar held at one univet'sity. It wss by closed-circuit television transmitted to a number of cities. I thhik 23, and physicians saw it in each of these cities in a ballroom of a major hotel. There was a locally prominent physician acting as * the chairman at each hotel ballroom. There was a question and an- swer session where one question was taken from each participating city so the panel was seen on closed-circuit TV screen answering questions taken from the cities in which the seminar was meeting. Senator NELSON. Were the reservations for these hotels in the 25 cities, motels, whatever they were, made by the Pfizer Co.? PAGENO="0016" 13922 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Dr. RiEINSTEIN. Pfizer did not put anybody up in the rooms. They did take the ballrooms. Senator NELSON. F~r the symposium room, they paid for it? Dr. RHEINSTEIN. Yes, and for the refreshments. Senator NELSON. They selected the physician panels? Dr. RHEINSTEIN. The physician panels were selected either by Pfizer or by the. company which put the program on for Pfizer. Pfizer contracted with another company called Health Learning Systems to do the entire production. Senator NELSON. Did the panel, at any place in the program, indicate that the TJGDP study and the Food and Drug Administra- tion concluded that there is almost no use for oral hypoglycemic drugs? Dr. RHEINs~IN. They certainly did not say that. However, in response to one of the questions which was let through by the local chairman, the question was asked and was heard by the entire audi- ence-should a physician get informed consent prescribing a hypo- glycemic drug? The panel member, to whom that question was addressed, stalled for a few moments and then started to say some- thing on the order of "considering the source of funding" and at that point looked off to the side of the stage and stopped speaking. Then he resumed in a moment or two and talked a little bit about the caution that should be taken in using these agents. Then the chairman of the symposium came on and he. said, at any rate such a consent would not be useful in malpractice cases. Then he went on to `the next question. Senator NELSON, But they did not at any time call attention to the 10-year study of the TJGDP and the conclusions reached by it? Dr. RHEINSTEIN. I believe it was mentioned in a way that it was quite deemphasized and you came away reasonably reassured that you could go on using the product at least to the extent used pre- viously in your practice. Senator NELSON. We have a copy of a letter indicating that phy- sicians attending the symposium are entitled to 2 credit hours under category I of the American Medical Association's Physician Recog- nition Award. Well that is not newsworthy because it is typical of the American Medical Association. Is there any other observation you had about the symposium? Dr. RHEINSTEIN. In line with what you are saying about people getting credit hours and being absent and not hearing the whole thing, a number of people left early. Senator NELSON. Is there any indication how many people at- tended the symposium in these 25 cities? Dr. RIIEINSTEIN. There were only about 40-50 physicians in our room in the Lord Baltimore, which is where I attended. They had apparently expc'cted a much larger crowd because they had reserved a very large ballroom. It was said that previous seminars sponsored by Health Learning Systems had up to 8,000 physicians Seeing closed-circuit broadcasts at one time. I did not get specific figures from Pfizer. Senator NELSON. What is the name of the company, the Learning what? PAGENO="0017" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 1392~ Dr. REIEINSTEIN. Health Learning Systems Inc., an independent producer of media in New Jersey. It is owned by two former pro- gram detail men who are very skilled in medical communications. I believe there is a little bit about it here in the testimony. Senator NELSON. Are they hired by drug companies to put on programs, is that it? Dr. RIIEINSTEIN. Yes, they would work on contracts for anyone who had an idea that they would want to communicate or that they would want to develop the program on particular diseases or par- ticular drugs. Senator NELSON. Do you have anything else? Go ahead Dr. Crout. Dr. CEOUT. Because of time consideration I will skip along certain paragraphs and not read the testimony in its entirety.1 Senator NELSON. Go ahead. Dr. CRotrr. In the discussion to follow, I will present a number of examples of medical communication which will illustrate the problem I have been describing. In some cases these merely present a particular point of view. Other examples will be shown of medical communication which, in my judgment, do not constitute the sort of disinterested, balanced, scholarly products we expect educational materials to be. I recognize that I have selected these examples to make a par- ticular point. They will show that drug promotion can masquerade as education. I have certainly not attempted to present a full review of all the medical communication sponsored by the drug industry. I am aware of many examples of excellent industry-sponsored mater- ials. Nevertheless, I believe it is inevitable that the educational materials produced by and for an industry with an interest in in- creasing sales of drugs will, on balance, be biased in a direction intended to promote drug use. The examples presented in this testi- mony are not atypical and were not difficult to find. I also believe the growing proportion of medical communication that is supported by the drug industry threatens the integrity of the whole process of postgraduate medical education. I would now like to turn to some examples to illustrate my concerns. Appendix A is a list of the 28 n~iedical publications having a cir- culation of 70,000 or more. The list was compiled from the March 24, 1976 issue of Standard Rate and Data Service which contains circu- lation figures for all major publications. Of these 28 publications, only one, The New Enp7and Journal of Medicine, is financed to any major extent by subscriptions; 25 of these 28 leading publications are sent to physicians free of charge and are paid for entirely by industry funds. Senator NELSON. Are these the 28 largest circulation publications? Dr. CR0UT. Yes. Two other publications, American Medical News and the Jourma~ of the American Medical Association, are financed through a com- bination of dues paid to the Amerh~an Medical Association and by pharmaceutical advertising. 1 See prepared statement and supplemental information submitted by Dr. Crout begin- ning at page 14064. 73-617----76-----2 PAGENO="0018" 13924 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRT Only two of the journals, The New England Journal of Medicine and the Journal of the American Medical Association, are scholarly journals, that is, journals which primarily print reports of original research submitted by the investigator after review by independent expert reviewers. The remainder are publications which the pharma- ceutical and publishing industries call "controlled circulation" pub- lications. They are also known popularly as "throwaways". They generally do not publish original work and usually do not have a rigorous review of papers of the type conducted by the scholarly journals. They are sent to physicians, not because they are requested, but simply because the physicians' names appear on mailing lists. Senator NELSON. You state that these are entirely supported by drug advertising, is that what you were saying? Dr. CROUT. Or directly by a drug firm, a single firm. Senator NELSON. What is the total circulation of these 25 that are sent to physicians free of charge and paid for by industry funds. Do you have any notion what that total is? Dr. CRODT. If you will turn back to appendix A, the distribution figures for each one are listed there. Mr. GORDON. There are others that are not on this list. Isn't that right? Dr. CROtTT. Yes. Senator NELSON. This is a list of publications with 10,000 circu- lation or more? Dr. CROUT. Yes. Senator NELSON. So there are a good many others that have fewer than that. Dr. CRotr'r. Yes. Senator NELSON. What is the total number of practicing physicians in this country? Do you know? Dr. RHEINSTEIN. About 200,000. I say on the order of 200,000. Dr. Cnour. Practicing-probably 220 or 230 thousand practicing. Senator NELSON. So some of these publications like the American Medical News is going to a number, which is the equivalent of all practicing physicians plus some others. Dr. CR0UT. I assume medical students and others. Senator NELSON. Please proceed. Dr. CROUT. Of the 26 leading journals which are throwaways, four concentrate on legal and socioeconomic aspects of medical care. The remaining 22 focus on medical treatment. The medical publications sent to the physician thus constitute a literature overwhelmingly sup- ported by the drug industry. We have brought with us today a number of examples of these journals. Each one consists of a number of drug advertisements plus a number of articles which appear to be independently written. It is not easy to assess the scientific quality of the controlled cir- culation journals. Much of it appears, on its face, quite reasonable, tending to be oriented toward review articles and articles dealing with particular clinical problems, as how to diagnose and treat lower hack pain. At the same time, however, I must wonder whether a journal that subsists wholly on sales of advertising space to the drug industry is able to present a skeptical attitude toward drugs in PAGENO="0019" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 13925 general or toward specific drugs. I have some comments about edi- torial policies. FDA has received complaints from some authors that when they prepare an article unfavorable to drug products the articles are rejected by the controlled circulation journals even when they were solicited by the journal in the first place. The reasons given for rejection are that the article does not meet some unspecified tech- nical standard, but whether or not this is the entire reason is difficult to determine. Members of our staff have had several meetings with editors of controlled circulation journals asking specifically about editorial policy regarding articles adverse to the product of an advertiser. A common answer is that such articles rarely are received because physicians are more interested in reporting successes than failures and that, furthermore, successes make more interesting reading than failures. Another common answer is that the journal sells space on the basis of reader interest and to sustain this interest the journal must contain objective articles. Usually, however, it is acknowledged that whenever material severely adverse to a sponsor is received, that sponsor is given the opportunity to rebut that material befOre it goes into the journal. Mr. GORDON. What happens if the advertiser does not like the material? Dr. CJROTIT. I am told another article rebutting it would be placed next to it. Mr. GORDON. Do you have any specific examples? Dr. CROUT. This ~s information that is hard to come by. Let me relate a personal experience, which I feel comfortable about discuss- ing, rather than relating what I have heard from someone else. I was interviewed on FDA policy in relation to bioavailability and my interview was sent back for editing and I did get a chance to edit it. It was then without my knowledge sent to the Pharma- ceutical Manufacturers Association and published in association with an article from the PMA, so they got the chance to publish their point-by-point rebuttal to my interview from their standpoint. But I got no chance to see their rebuttal prior to publication. Mr. GORDON. Sort of a one-sided deal. Dr. CROUT. That is the one personal experience in this area that I have. Mr. GORDON. Mr. Chairman, I ask that a letter from Dr. Schu- macher, University of Vermont to Dr. Alan B. Lisook, of FDA's Bureau of Drugs be inserted in the record of these hearings. Appar- ently he wa~ invited by Modern Medicine to write a piece on head- aches. He was told that it does not make any difference how you feel about this subject. You can take a radical position or any kind of position. So he wrote the article and the editors knocked out or tried to knock out a section in which he decried the use of a drug called Fiorinal, which,. incidently, the National Academy of Sciences ~aid, i-ad no evidence of efficacy. I would like to put the whole series of letters between him and the journal into the record.1 1 See lettsr date4 April 8, 1974, to Alan B. Lisook, M.D., Bureau of Drugs, PDA, from George A. Schumacher, M.D., Professor of Neurology, University of Vermont, page 14022. PAGENO="0020" 13926 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Senator NELsoN. The letter will appear in the record at the appro- priate place. Please continue. Dr. CROUT. In any event, and for whatever reasons, the editoriar content of these controlled circulation journals is overwhelmingly optimistic about drug therapy. A recent editorial appeared in the~ January 1976 issue of Current Prescribing. The article, entitled "The tTndermedicated Society," laments that underprescribin~ and not overprescribing is a major problem in American medicine. Thern author.states: The family physician's alleged propensity to overprescribe has provoked well- publicized Investigations, both Congressional and clinical. But what of the other side of the problem-underpreScribiflg? Do doctors sometimes prescribe too little? In interviews with experts In several specialties, Current Prescribing found that the answer is yes. For many conditions, and with a number of drugs, M.D.'s may be giving their patients therapeutic short change. I am submitting a copy on this article for the record.1 The editorial position is not without merit, but several questions arise. The editorial writer was not a physician and had to seek advice about matters like underprescribing and overprescribing from phy- sicians. In selecting his consultants, could the support of his magazine have affected his choices? Is a journal wholly dependent upon th~ pharmaceutical industry for support willing to editorialize on the ex- cessive use of a drug class? Perhaps the answer is "yes," but one must wonder. Senator NELSON. Well, let me ask a question. This committee has taken extensive testimony over ai~ 8-year period from distinguished pharmacologists and without exception in that 8-year period there has not been a single medical expert who addressed himself to that question who did not say that drugs are widely overused or over- prescribed. Is there any evidence that you are aware of that these experts are wrong? Chloramphenicol, is an example right off the top of my head. We took testimony from the late Dr. Dameshek of Mt. Sinai, and a half dozen others, I think Dr. Dameshek said that in his judgment perhaps the drug was indicated for only about 5 percent of the people who died from using it. The pathologist who testified thought that at the most it would be only 1 percent and that he had never seen a person who died from the use of chioram- phenicol who had been given the drug for an indicated purpose. Go back to the studies by Drs. Stolley and Lasagna and other dis- tinguished physicians who found that 95 percent of the doctors prescribed something for the common cold and that 65 percent pre- scribed an antibiotic. In all the testimony we have taken, medical experts have testified that drugs are vastly overprescribed. Do you know of any studies which indicate that there is a massive underpreseribing of drugs in this country? Dr. CROUT. I think your subcommittee has very properly focused heavily in the area where there are more historical examples of overprescribing. 1 See artIeh~, "The undermedleated soclety-eharges of overpreserthing are all the rage- but what about the equally dangerous tendency to underprescribe ?," from Current Pre- scribing, Tan. 1976, page 14117. PAGENO="0021" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 13927 In the hypertension area there is a general concensus among ex- ~perts in the field that they are not yet treating many hypertensives, and this is an example which is usually focused upon when talking ~of underprescribing. You will see in a film we want to show here later at least one meth-. cal view of the treatment of depression. I do not subscribe to it, but you ought to see what is being said by certain physicians in that ;area and you make up your own mind about it. I believe one has to look at overprescribing in relation to drug ~ilasses, ~Mr. GORDON. I presume there are some people who cannot afford to buy drugs. Some of them should be getting drugs and they do not get them. But in those terms- Dr. CROUT. I am simply saying that a general phenomenon of overprescribing and underprescribing is, I believe, a case harder to make than when one looks at specific drug classes. Senator NELsoN. Well, Let's look at total sales. We have had extensive testimony on overprescribing in the tranquilizer field ai~d in the whole antibiotic field. These are the two largest classes of drugs used. Even assuming that in certain specialized categories as hypertensives there is underprescribing. What can we say about drugs as a whole? Are they being overused? Certainly, as we have seen, many widely used drugs or classes of drugs like the oral hypo- glycemics are overused. Would you be equating the size and dimen- sion of the problem in hypertension or some other field against the antibiotics or tranquilizers? Dr. `CROTJT. One could. The underprescribing in hypertension is at least as great today, or certainly was 2 or 3 years ago when the Department began the task force on Hypertension Education, as overprescrfbing is in the antibiotic area. Senator NELSON. I can't remember who the witness was a few years ago who said that the available evidence indicates that the damage from overprescribing in the antibiotic field may very well be greater than the benefit from it, or words to that effect. Dr. CROTTP. Mind you, I do not want to endorse the concept of overprescribing. But if you are asking where do I believe overpre- scribing is the biggest problem, it is most conspicuous in the anti- ~biotic area. I think you will find more argument about other thug c1asses. The lesson to be learned is that other drug classes can get out of hand i.n the future, which is one of the things we are talking about this morning. Let me comment on the unproven uses of drugs. The pages of the controlled circulation journals freauently are employed to bring to the physician's attention new uses for a drug product which are not yet approved by the Food and Drug Administration, something the manufacturer is not permitted to do through the usual channels of ~drug advertising and detailing. A typical example is an article en- titled "Mi~rane . . . and More~ Treatment and Prevention" from the April 1976 issue of Cu~rent Pre$cribing. I will also submit a copy of this article for the record.' 1 ~ee article, "Migraine . . . and More Treatment and Preventlon-Serotonin InhibitOrs, antihistamines, antidepressants. beta blockers-they're all in the new wave of `headache remedies'," from Current PrescribIng. April 1976, page 14120. PAGENO="0022" 13928 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY The American Medical Association grants 1 full hour of cate- gory I, the highest category of continuing education credit, for study of thi.s article. This article describes unapproved uses for Ayerst's Inderal, Knoll's Octin, Carnrick's Midrin, Merck's Periactin, and Sandoz's Sandomigran. Sandomigran is an investigational drug not marketed in this country. The issue is not whether the article is scientifically correct or whether it is proper to publish such infor- mation. There can be no doubt that scholarly medical journals should contain new information about drugs and should not be limited to the contents of approved package inserts. The issue here is whether such an article in a colltrolled industry circulation journal presents, in the guise of a scientific paper, promotional information which otherwise could not be legally published as drug advertising or drug labeling. The article in question did not pass through the rigorous independent editorial review common to scholarly journals. I would point out, in addition, that the editorial policies of these journals are often consistent with the position of the large pharma- ceutical manufacturers. For example, in a special supplement of the March 1976 issue of Private Practice, a controlled circulation jour- nal sponsored by the Congress of County Medical Societies, the editors report on a campaign launched with the help of the publish- ers of Private Practice to fight repeal of Oklahoma's strong antisub- stitution law. A copy of this article will be submitted for the record.' Later in an editorial in the April 1976 issue of the same magazine, the editors report on the success of this educational campaign in changing public opinion in regard to drug substitution. The pub- lisher of Private Practice offers to make available, free of charge, the newspaper mats, video and audio tapes, and brochure text to any county medical society wishing to mount a similar campaign. A copy of the pertinent section of this editorial is attached as appendix B. Let me emphasize that I am not implying, for purposes of this testimony, that these campaigns are improper or not in the public interest. The important question is: Is it likely, or even possible, that a controlled circulation journal dependent upon drug industry support would take another point of view? Senator NELSON. The publication you just mentioned, Private Practice, pointed a violent assault on the Department of Defense because of the Department's posture respecting one of its own em- p~oyees. The long story, also included an attack on this committee. Private Practice misstated the facts and drew conclusions which were unjustifiable. The whole article was nothing, in short, but a mishmash of misrepresentations. So we wrote a detailed, and very careful refutation of everything the magazine had said, but they refused to run it anyway. They also refused to run a letter which devastated their assertions because it made them look like fools. They do not run, I can assure you from personal experience, anything that is contrary to their posture or the posture of the people who are sup- porting the magazine. I guess that is to he expected. Go ahead. Dr. CROUT. I would like to call your attention to one of these publications, the March 1976 issue of Primary Cardiology. It would 1 See article. "County Medical Societies Campaign to Beat Drug Substitution- Medicine and Politics Don't Mix," by the editors of Private Practice, March 1976, page. 14130. PAGENO="0023" COMPETITIVE PROBLEMS IN THE DRUG INDIffiTRY 1392~ take a perceptive reader indeed to see the fine print at the bottom of page 5 of this issue which says: "TJSV Pharmaceutical Corpor- ation sponsors PRIMARY CARDIOLOGY TM as a continuing edu- cational service to the practicing physician." A copy of the page on which this quote appears is attached as appendix C. The controlled circulation journals represents a large proportion of the total literature reaching physicians, are entirely dependent on the drug industry for support, and appear to be generally e'i- thusiastic about drug therapy. This is not to say they do not pro- vide very useful information. These journals specialize in carefully presented practical discussions designed to help the physician deal with most common problems. These journals are excellent communi- cators and they must be having some impact. There is no avoiding the question of whether it is desirable that they be financed entirely by an interested party. In addition to controlled circulation journals supported by the advertising of many pharmaceutical companies, there are a number of publications which appear to be independent but are actually sponsored entirely by a single pharmaceutical company. We have brought with us today several examples of this type of publication, which we will submit for the record.1 Such house organs are regu- lated as drug labeling and cannot be inconsistent with the approved package insert for the drugs discussed. Senator NELSON. Does the magazine indicate on the editorial page or any other place who is the owner or publisher? Dr. CROUT. It is there, but is very difficult to see. I point this out for example, Prin'i~amj Ca~dioZogy, which givcs every appearance of being an independent medical journal. It has distinguished people writing for it, and one has to turn to the fine print on page 5. We have this in one of the appendixes. It is appendix C. If you look at the fine print at the very bottom underneath the table of con- tents to read "IJSV Pharmaceutical Corporation sponsors Primary Cardiology as a continuing educational service to the practicing physician." senator NELSON. Is this appendix C a reproduction of that whole page? Dr. CRotrr. Yes. Senator NELSON, The article titles and so forth are on `the same page as this fine print that identifies the publisher. Dr. CR0UT. Yes, down at the bottom. Senator NELSON. What page is that on? Dr. ORotrr. It is on page 5 of the journal, it is the index page. Senator NELSON. The table of contents page? Dr. CROUT. If you glance through the magazine, you will see by coincidence that all the ads are `[ISV drugs, from the same firm, and that might be the only other sign in this entire publication of this particular company. Senator NELSON. All the ads are for what? Dr. CROUT. For drugs manufactured by `[ISV. Senator NELSON. Oh. i See examples of publications which appear to be independent but are actually spon- sored entirely by a single pharmaceutical company, page 141413. PAGENO="0024" 13930 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Dr. Cnorrr. At this point I want to turn to the subject of industry- sponsored seminars. The drug industry sponsors numerous medical symposia and seminars. These have been discussed in PiUs, Pro fits, aind Politics, by Silverman and Lee, as follows: One customarily practiced device is the drug industry sponsored conference ~r symposium devoted either to a particular new drug product or to a clinical problem in which the product may seem to have value. The nominal host may be a medical group, a medical school, or a medical or scientific academy. The speakers may include various Americans, although European participants sup- posedly provide desirable glamor. It is generally considered useful to include :a hundred or more physicians in the audience of newspaper, magazine and trade journal writers. The indoctrination of the doctor in the audience Is viewed as helpful, but more importance is placed On the accounts filed by the press representatives present and on the formal published proceedings of the ~conference, which may be used for months as "scientific" background. Since the publication of the Silverman and Lee book, the live audience has been extended by the use of closed-circuit television. Tn January 1976, Pfizer Laboratories, division of Pfizer, Inc., spon- sored such a closed-circuit nationally televised seminar on the diag- nosis and treatment of diabetes mellitus. The program seminar provided a learned discussion of this disease but attempted to steer clear of the findings of the university group, diabetes program and the resulting adverse publicity surrounding oral hypoglycemic drugs, including Pfizer's Diabineso. Without debating in this testimony the merits of the UGDP study, it is difficult to imagine how a modern discussion of diabetes treat- ment fail to emphasize its findings. I am aware of at least one roundtable discussion in a controlled circulation journal, Patient ~Care, which discussed the implications of the study in a balanced way, ultimately taking a middle-of-the-road position which sug- gested that many physicians who treat diabetes felt the oral hypo- glycemic drug should be used more sparingly. This certainly seems a minimum position. The Pfizer symposium, however, largely avoided the whole issue. Another example is a symposium sponsored by Wyeth Labora- tories which was devoted entirely to its product Serax-oxazepam- a benzodiazepine tranquilizer similar to Librium and Valium. The proceedings of this conference were published as a supplement to the May 1975 issue of Diseases of the Nervous System. The special issue did not reveal the symposium's sponsorship~ but contains articles which suggest special advantages that the Wyeth product may have over the other benzodiazepine tranquilizers. I want to emphasize again that medical investigators must be free to write whatever they wish about drugs and to speculate about advantages one drug may have over another. In this case, however, the investigators were selected by the manufacturer to participate in an industry-sponsored meeting, the proceedings of the meeting were published without reference to such sponsorship, and the papers all turn out to be favorable to Serax. Even if the investigators, who are well-known physiciahs in their field and investigators of known integrity, are accurate in every- thing they say, the process through which this supplement to a medi- cal publication was produced is cause for concern. The fastest growing areas in continuing medical education today are audiovisual materials and multimedia learning systems. PAGENO="0025" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 139~i One example is that of radio broadcasts. The physicians radio network, PRN, broadcasts the latest news of medicine to physicians 24 hours a day. I will demonstrate a PRN radio' portion of one of these broadcasts in a moment, but I would point out that the radios themselves and the programing on them are financed entirely by' the sale of advertising time to pharmaceutical manufacturers. Each 60 minutes of programing contains 8 minutes of advertising for brand-name drugs. Routine listing `to PRN is approved for category' 5A continuing medical education credit by the American Medical Association. We can turn on the radio right now, I do not know what is going to come out. This broadcast goes on 24 hours a day. [At which time a radio `broadcast was heard.] Senator NELSON. You didn't plan it that way? This is a letter to physicians from Thomas Bird, director of broad- cast services of the Physicians Radio Network. He stated that the serv- ices called the Physicians Radio Network, is now broadcasting in Chicago, providing 24 hours, 7 day a week coverage, broadcasting political, `socioeconomic news about the practice of medicine. `the' broadcasts are heard only by `those who have a special PRN radio. The ra'd'io and all programing are free, supported entirely by phar- maceutical advertising. "You need only fill out and return the enclosed form and your radio will be s'hipped without charge. The instrument is compact, attractive and fits nicely on your bookshelf" and so forth and so on. This letter will be printed in the appropriate place in the record.t Dr. CROUT. Visual Information Systems also produce the network of continuing medical education, a biweekly, hour-long video tape distributed to hospitals, courtesy of Roche Laboratories, division of Hoffmann-LaRoche, Inc. Nearly every major pharmaceutical company is engaged in pro- ducing materials for continuing education. These materials com- monly use formats one associates with disinterested educational `efforts-as expert panels and lectures by distinguished physicians. Despite their appearance, and despite the fact that they may be generally accurate, they are often promotional of particular drugs or drug classes and, on the whole, are one-sided. One does not often find in these materials the sort of healthy skepticism of a particular therapy that a journal like the "Medical Letter" brings to its readers. Typically, one does not see on such panels those physicians who believe oral hypoglycemic agents `are dangerous, who believe anti- anxiety agents and sedatives are overprescribed. I want to illustrate `the kind of examples I am talking about. The first example is a video tape on depression. This is the longest tape, it will run about 10 minutes, but I think you will get a flavor of what we are talking about, recognizing this as an educational tape snonsored by the American Psychiatric Association, financed by Pfizer Pharmaceuticals. The program is `made available to groups of physicians by Pfizer detail men. Some segments of the program will demonstrate that the tape, while ~robably refl&~ting the participants~ views fairly, strongly encourages use of antidepressants generally and to some degree Pfizer's product Sinequan specifically. 1 See letter dated December 80, 1i~75, from Thomas F. Bird, director, broadcast services,. Physicians Radio Network, page 14034. PAGENO="0026" 13932 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY [At which time a tape recording was heard.] Dr. CROUT. I wanted to spend a little time today so that you get the flavor of what is in the hour the physician puts in. As you will see, the tape begins by mentioning that there are 4 to 8 million people with depression, and that the tape is sponsored by the American Psychiatric Association and financed by Pfizer. A series of scenes then suggested that depression is far more per- vasive than one might have suspected. First an estimate of 20 mil- lion people per year is proposed as a more probable alternative to the 4 to 8 million figure. Depression is broadly defined as "the absence of joy, anhedonia" and various examples illustrate its rav- ages: The housewife, the undera~hiever, people with psychosomatic complaints, insomnia, or sexual dysfunction. The increase in recent years of the use of tricyclic antidepressants is noted and is accounted praiseworthy. Finally, the last speaker of the symposium suggests that tricyclic an.tidepressants are particularly good drugs and indi- cates certain advantages that Sinequan, Pfizer's tricyclic, has. The message is quite clear: Depression is everywhere and being underdiagnosed. Patients need not be actually depressed-insufficient joy, psycho- somatic complaints, or underachieving, may be the only signs or symptoms and may be enough to make a diagnosis of depression. Sinequan is the best of a good group of drugs, whose use, for- tunately for the American public, is finally increasing to high levels. The physician should join this welcome trend and use the drugs more. There is every reason to believe that the physicians participating in the taped discussion are voicing with full personal integrity, their best medical opinions. It is also likely, however, that the drug firm knew what each physician would say before they invited him and thus assured the emergence of a particular point of view in its edu- cational production. Audio cassette tapes come to physicians in ever-increasing num- bers. They are particularly useful to the physician because they allow him to make use of time that ordinarily is lost while driving in his car. I would like to play for you an excerpt from a February 1976 tape from the American Osteopathic Association audio educational service, sponsored by Abbott Laboratories; the speaker is an osteo- pathic physician inter~i~wed for this particular program. Senator NELSoN. May I ask a question before you proceed. Your statement earlier suggested that certain drugs-your example was hypertension, not depression-were underprescribed. Dr. CROUP. Yes. Senator NELSON. With respect to the question of underprescribing, I take it that that was, what the panel was saying of drugs for depression. I assume that the specialty best qualified to diagnose the problem of depression is the field of psychiatry. Dr. CRotIT. Yes. Senator NELsoN. Would it also have indicated that there are not very many psychiatrists, and that not very many people get to visit a psychiatrist as compared with other physicians. PAGENO="0027" COMETITTV]~ PROBLEMS IN THE DRIYG INDt~STRY 13933 There is quite a difference between diagnosing depression and detecting an infection, although care should be taken to identify the target organism. But in any event it is not too difficult to conclude that there is a sore throat or an elevated temperature and to give an antibiotic. On the other hand, to prescribe, an antidepressant prop- erly requires some sophistication in the psychiatric field. The symp- toms which show a need for an antibiotic are clearer than those for an atitidepressant. Dr. CROUT. I would agree with the thrust of your remarks. De- pression can be difficult and complex and its diagnosi.s subject to am- biguity. It is seen by a large number of physicians and is a common enough problem that depression has to be handled by physicians well beyond the field of psychiatry. My suspicion is that most of the drugs in this class are actually prescribed by nonpsychiatrists. This is a problem handled by a large number of practicing physicians. Your question was: "Who is best qualified to make the diagnosis?" I believe that psychiatrists are, but the facts of life are that a large number of patients- Senator NELSON. Maybe I did not make it very clear. There are a large number of people who feel a bit depressed and do not even know that they are depressed. Doesn't that give some ex- planation for the claim that there is underprescribing in this field? Dr. CROUT. Yes; I agree with that. This tape you are about to hear will last about 21/2 minutes. The speaker is an osteopathic physician sponsored by Abbott Laboratories. Again a clear message is given: Anxiety is everywhere and chemo- therapeutic agents are the treatment of choice. The program tells the physician that minor tranquilizers are the preferred drugs and men- tions that a once-a-day regimen is best. Abbott's Tranxene SD hitp- pens to be the only minor tranquilizer with a once-a-day dosage regimen. [At which time a tape recording was heard.] Dr. CROUT. Again I point out you are hearing what is factually correct but is in a point of view many would consider one-sided. Also I point out that Abbott Tranxene happens to be the only minor tranquilizer with a once-a-day dosage regimen, which explains the coincidence that Abbott is sponsoring this particular speaker who prefers a once-a-day regimen. Before I am accused of the same thing, let me plead guilty to sOme selective editing in showing you these particular samples. We have edited portions of these tapes to make a point, and I would point out that in the course of the entire tape some degree of balance may emerge and some of these programs may be excellent. On the other hand the problem of selection by the drug firm is the issue I am con- cerned with in this overall process. This is a lecture on Stress, Anxiety, and the Cardiovascular Sys- tem by Hans Selye, M.D., Ph. D., D.Sc. In the words imprinted on the audio cassette, the lecture is, "Sponsored as a service to physicians by Pfizer Laboratories Division." [At which time a tape recording was heard.] Dr. CROUT. Again without a hard sell, the message is the same: More people need more tranquilizers for longer periods of time. Pfizer Labs manufactures the minor tranquilizer Vistaril and the trade PAGENO="0028" 13934 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY name Vistaril is displayed prominently on both sides of the cas- sette. Transcripts of the excerpts I have just played are attached~ as appendices D and E. As another example, Roche Laboratories, manufacturer of Librium and Valium, sends out records of heart sounds in various types of heart disease. The records themselves are excellent and I believe quite useful. Each record is jacketed with promotion for Librium and~ Valium, interspersed with textual material. The unmistakable impres- sion given is that the presence of heart disease, rather than the pres- ence of anxiety, calls for tranquilizers, despite a fine print disclaimer, "the editorial content of this series is not intended to suggest the use' of any specific drug or treatment program." Our experiences with several organizations which planned to pro- duce a large number of educational materials provide some interest- ing insights. As an example, 2 years ago, Synapse, a subsidiary of the' J. Walter Thompson Co., proposed to produce a series of 48 disease- oriented video tapes to be sold to physicians under the auspices of the American Academy of Family Physicians. The cost of' producing each tape was to be paid by a pharmaceutical manufacturer. The first tape was on urinary tract infections and was to contain commercials for Eli Lilly's cephalospori'n antibiotics. The advertising agency ex- pressed considerable dismay when FDA ruled that if the products ad- vertised were intended to treat the disease discussed by the tape,. then the entire tape would be considered drug labeling. This meant that the content could not deviate significantly from the labeling in. the package insert. Synapse's contention was that no company would sponsor such an educational undertaking unless it could be related to one or more of that company's drugs, and, indeed, the series' did not go forward. This contention has been repeated over and over again by' media suppliers in discussions with the Agency. Increasingly, pharmaceutical companies are providing continuing education materials for use at hospital staff meetings. These materials'. generally are produced by independent companies such as' Medcom and Health Learning Systems on contract for pharmaceutical man- ufacturers. Now let me give you examples of multimedia presentations. In a multimedia presentation a closed-circuit television tape is coupled with a brochure which the physician uses as a self-learning device. On a positive side, there is the Health Learning System in coop- eration with the National High Blood Pressure Education program,. the Council for High Blood Pressure Research of the American Heart Association, and the National Kidney Foundation has pro- duced an excellent series of materials on hypertension. The series,. called Dialogues in Hypertension was produced under an educational grant from Smith Kline and French Laboratories (SKF), manu- facturers of Dyazide, a fixed-combination diuretic indicated for hypertension. Let me emphasize that none of the materials produced' were favorable to Dyazide specifically and, if anything, deemphasized the product. In this instance the educational materials, while industry sup- ported, were under the total control of a Federal-private program of unquestioned independence and prestige which was furthering the' widely accepted goal of assuring that more people with high blood. PAGENO="0029" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 13935 pressure were diagnosed and treated. SKF did no more than pay the bills. The goal of the overall program happened to coincide with the goals of manufacturers of drugs used in treating hypertension and `with good medical practice. In many other cases, however, increased use of medication is not `necessarily consistent with good medical practice. One such example is a learning system on the subject of stroke de- veloped by Health Learning Systems, Inc., and sponsored by Marion `Laboratories. The learning system consists of two motion picture films, accompanying workbooks, tests to be taken by physicians, plus materials used to advertise the learning system to directors of medical education and to hospital medical staffs. Marion Laboratories markets papeverine hydrocloride in a sus- tained release oral dosage form named Pavabid. The drug is claimed `to be a cerebral vasodilator and to imjirove circulation to the brain; let me note parenthetically that the usefulness of this drug has nQt, in our view, been demonstrated. Senator NELSON. How could you make that claim? Dr. CROUT. It is a complex problem relating to the claimed "grand- father" status of the drug. We are currently planning to review its effectiveness, in spite of its status as an old drug and that point is flow under review. In the April 5, 1976, issue of the Federal Register, the FDA called for marketers of papaverine to submit evidence of safety, efficacy, and possible "grandfather" status of the drug. The Federal Register state- ment said that the drug would be removed from the market if such evidence were not submitted. At a September 19'T4 meeting of the Western Pharmaceutical Mar- keting Research Group, held in Chicago, a representative of Health Learning Systems, explained why Marion Laboratories was interested in sponsoring a learning system on stroke. Marion's Pavabid already had more than 60 percent of the cerebrovasodilator market and Marion felt that no amount of advertising would increase this per- centage very much. It was also felt, however, that if the total market for cerebrovasodilators could be expanded, Marion Laboratories would get a high percentage of the increased sales. One way to expand the market for cerebrovasodilators was to convince physicians that these drugs were useful in the prevention and treatment of stroke. The first segment of the learning system made no direct claims for the effectiveness of Pavabid in the `treatment or prevention of stroke but simply focused on the transient ischemic attack [TIA], a brief episode of focal neurologic deficit, as an early warning sign of stroke. It then provided prescribing information for Pavabid and a logo of a linegraph superimposed over a longitudinal slice of a brain. The second part of the learning system discussed the "Diagnosis and Treatment of Cerebral Vascular Insufficiency." The relatively un- common cases which can be helped by surgical intervention were dis- cussed in a superb presentation by Dr. Michael E. DeBakey, president of the Baylor College of Medicine. The final segment of the learning system considered vasodilator therapy. The accompanying workbook pointed out that intravenous papaverme, which is not marketed in the United St~cs, is one of the most effective vasodilating drugs and then proceed~s 1, in a leap in PAGENO="0030" 13936 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY logic, to recommend the use of oral papaverine in patients recovering from completed strokes and transient ischemic attacks. Again, despite the educational format and the appearance of dis- tinguished physicians, the learning system is not a disinterested ef- fort. First of all, it is directly linked to a frankly promotional effort. The linegraph-brain logo that appeared in the film was subsequently reproduced in journal advertisements and promotional labeling for Pavabid. Those promotional efforts are directed, just as the learning system was, at the use of Pavabid in the treatment and prevention of transient ischemic attacks. In addition, although some physicians be- lieve cerebrovasodilators are useful, a great many others disagree. The learning system did not refer to these negative views and a user of the system would necessarily gain a very incomplete view of the current opinion of experts regarding these agents. Another new continuing education modality is the medical tele- phone conference system. These telesessions, sponsored by pharmaceu- tical firms, enable physicians from around the country to discuss a disease for which the company's product is offered with the guidance of a company representative. Appendix F is a leaflet intended for pharmacists describing tele- sessions to be held for Pennwalt's Zaroxolyn. Noteworthy are the statements "AMA Credit" and "Positive Effects on Sales Shown by Previous Participating Companies in Other Therapeutic Categories: Roche, Abbott, Burroughs Wellcome, Smith Kline & French." While we do not know precisely what fraction of educational materials is industry-sponsored, we believe it is large. The examples provided show clearly that the educational content is commonly promotional in intent. At most medical meetings there are numerous exhibits, some of which are commercial exhibits promoting various drug products, others of which are scientific exhibits describing the work of inde- pendent scientists. These latter are usually not bound by the kind of limits our regulations place on drug labeling or advertising, because they have been considered equivalent to scientific publications. As a result, such scientific exhibits frequently discuss new uses of drugs, drugs not yet approved, and comparative properties of drugs not made in approved labeling. Recently, agency action related to the regulation of drug labeling has raised serious questions about these exhibits. In ~n attempt to de- fine ways in which a drug company could distribute independently prepared educational materials, such as standard textbooks of phar- macology, we suggested guidelines under which such information would not be considered drug labeling. For the most part, these guidelines attempted to assure that such materials were wholly in- dependently developed and edited. We did not feel that materials which discussed products of a single manufacturer or which dis- cussed drugs and were produced with drug company funds could avoid being labeling if a drug company distributed them. We have discussed these guidelines with representatives of the American Medical Association and the Pharmaceutical Manufac- turers Association who indicate that many scientific exhibits depend upon the support of individual pharmaceutical companies whose products are described in the exhibits. PAGENO="0031" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 13937 Senator NELSON. Did you state that the AMA protested that many scientific exhibits could be wiped out? Did they formally protest to the FDA about the guidelines? Dr. CROUT. Let us say we formally discussed it. Protest is not quite the word. The guide gave them a good deal of concern. Yes, we met on several occasions with their representatives. Senator NELSON. Did the PMA have the same position as the AMA on this question? Dr. CROUT. Let us say that from their point of view neither one endorses our guidelines, each for somewhat different reasons. Senator NELSON. Did you modify the guidelines? Dr. CROUT. They have not yet appeared in a formal sense and will appear as part of our proposed revisions of regulations made. Mr. GoimoN. I have a document from the Committee on Scentific Exhibits of the AMA concerning industry support of scientific ex- hibits. It states that according to the FDA's definition, approximately 80 percent of the scientific exhibits at AMA meetings are promotional and probably half of those are in noncompliance with the regulations of pharmaceutical products as set forth in the Federal Regi.ster. This is a document signed by James M. Moss, M.D., who is the head of the AMA here in Washington on scientific exhibits. Are you familiar with that statement? Dr. CROUT. That is quoted from the memorandum in our testimoziy. Mr. GORDON. Mr. Chairman, I ask that the letter be included at the appropriate place in the record.1 Dr. Cnon~, In the same memorandum, the author estimated that the total cost of a scientific exhibit is $5,000 to $40,000 and concluded: Few physicians or scientific investigators can afford to have an exhibit unless they receive financial support. In the past, large clinics and medical centers supported exhibits as part of their public relations and professional education programs. The source of these funds has been severely reduced lately. Some exhibits have been supported by professional societies and lay health organiza- tions, but too often these organizations are more interested in recruiting mem- bers and raising funds than in educating physicians. Support from the Fed- eral Government through the National Institutes of Health, the Armed Forces Institute of Pathology, the Food and Drug Administration and the military forces has helped in the past, but this has been greatly reduced. The only other source of. financing exhibits has been pharmaceutical companies. Either directly or indirectly this pays about 80 percent of the cost of the scientific exhibits. Using a scientific exhibit for promotional purposes is contrary to the spirit of the regulations of the AMA. However, the AMA cannot be responsible for anything that happens to an exhibit or to the brochures after the meeting. In this highly competitive society, few pharmaceutical companies can afford to support a purely educational exhibit. In the use of scientific exhibits to promote unapproved drugs, ap- pendix G shows, as an example, pages 66 and 67 and 76 and 77 of the official program for the Twenty-seventh Annual Scientific Assembly of the American Academy of Family Physicians, AAFP, held in October 1975. A large percentage of the exhibits are drug related. Ap- pendix H shows pages 188 and 139 of the program of the American College of Physicians' Fifty-seventh Annual Session held in April 19T6. In both programs, there is an exhibit by the same physiciai~ de- scribing the development of an antihypertensive drug, prazosin hydrochloride. I See statement of Committee on Scientific Exhibits in regard to pharmaceutical sup- port of scientific exhibits, page 14019. PAGENO="0032" 13938 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Let me note that under FDA regulations pharmaceutical manufac- turers may not promote their drug products prior to approval for marketing. In this case, although it was not noted in the program, the investigator was a full-time employee of the drug manufacturer which had developed prazosin. Prazosin had not been approved for marketing at the time of either meeting. In the AAFP program, there are two scientific exhibits on Tol- metin, a diug developed by McNeil Laboratories for treatment of rheumatoid arthritis. At the time of the AAFP meeting, Tolmetin had not been approved for marketing in the United States. In re- sponse to the Agency's questions, a representative of the firm stated that the construction of both exhibits was financed by McNeil. The representative went on to state that his company customarily financed such exhibits when its medical monitor was pleased with an investi- gator's results. He stated that such scientific exhibits were shown at two to four conventions each year and that while attending the con- vention, each exhibitor received an honorarium of about $250 per day plus reimbursement of all expenses. Mr. GORDON. You mentioned that under the FDA regulations, pharmaceutical manufacturers may not promote their drug products using certain marketing practices. Was this a violation of the law and what can they do about it? Dr. CROUT. I should point out that we have recently looked into the issue of scientific exhibits and are reporting to you some of the things we have found. In our view this type of thing is a violation of the current regulations on drug labeling. But, as I pointed out, moving into that area would, according to the testimony of AMA, essentially wipe out 80 percent of the scientific exhibits. So I am reporting to you this problem that we have recently identified. We will attempt to address it in the advertising regula- tions, but we have not moved against specific cases at the present time. Mr. GORDON. When are these advertising regulations going to be put in the Federal Register? Dr. CROUT. We had hoped-it always seems to take longer than one hopes; I must say at this point it is unlikely before late summer. Mr. GORDON. Is it true that, as Dr. Moss of the AMA stated, if these regulations being proposed are finally adopted, about 80 percent of their exhibits would be wiped out? Dr. CROUT. If the guidelines which are stated in page 80 are adopted in final form, I believe that is what the AMA would say; yes. So those regulations, which will make it clear that drug labeling laws extend to scientific exhibits and multimedia systems, will have an enormous impact in this area. Mr. GORDON. Will you please explain briefly how you distinguish between scientific exhibits and commercial exhibits? Dr. CR0UT. At a medical meeting there is usually a large hall reserved for exhibits and there are a large number of commercial exhibits by drug manufacturers, instrument manufacturers, book salesmen, and so forth. These are little booths and displays with representatives there. PAGENO="0033" COMPETITIVE PROBLEMS IN THE 1M~TJG INDUSTRY 13939 When a drug manufacturer maintains such a booth and~ promotes his drug there, that clearly falls under the drug labeling and drug advertising regulations. In a separate section of the floor, or even in a separate room, there are booths where physicians or research scientists present their work as an alternate form of presenting their scientific discoveries. Some- times people present their work as a speaker on a scientific program, and other times they will present it at a booth. So the scientific exhibit has always been viewed as equivalent to a scientific paper on a program. The extent to which funding of the scientific exhibits has shifted to the pharmaceutical industry for support is a matter of concern and surprise to us. Senator NELSON. is that a recent phenomenon? Dr. CROUT. Yes, that is a recent phenomenon. I think the AMA memorandum points this out. Many of these were formerly supported by grant funds from NIH and so on. Again, let me stress that I have no reason to believe that these in- dustry-supported scientific exhibits represent anything other than the honestly-held beliefs and legitimate findings of the investigators involved. Many contain high-quality work. It is nevertheless a mat- ter of great concern that most of the content of scientific exhibits is to a great degree selected by the drug industry. The exhibit com- mittees of the conventions no doubt can eliminate the more frankly promotional exhibits, but they can do little to alter the fact that an exhibit unsupported by a drug company will usually not be produced and submitted for their review. Mr. Chairman, let me turn at this point to the possible role of regu- lation in addressing this overall problem. The FDA is responsible for regulating drug advertising and labeling, and I believe we do that well. On the other hand, we also have a responsibility not to restrict legitimate educational materials which are not under the authority of the Federal Food, Drug, and Cosmetic Act. I would like to make one point unequivocally clear. Any scienti~t, physician, or other person can say or write anything he wants aboi4 a drug, so long as this effort is not subsidized by the drug industry. The Federal Food, Drug, and Cosmetic Act poses no threat whatso- ever to scientific communication and debate on drugs, to the reporti~ig of research on drugs., or to the voicing of any medical opinion on drugs, providing industry funding of that communication is not involved. Once a drug firm distributes written or audio-visual materials about a drug, or in association with one of its drugs, however, that material comes under the labeling provisions of the law. Labeling t~as been defined quite broadly in the Federal Food, Drug, and Cosm~tic Act and by the courts and includes virtually all printed materials about drugs placed into interstate commerce and supported by a drug. firm. Senator NELSON. Are you saying that an article by a scienti~t~- physician or otherwise-in a throwaway journal supported by the drug industry that make claims for drugs that were not supported by scientific evidence is controlled by the FDA, but if written for a 73-017-76-----3 PAGENO="0034" 13940 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY scientific journal or some other journal which is not entirely sup- ported by drug advertising, then it could not be controlled by the FDA~ Dr. CROUT. I think it is important to emphasize that any piece of material distributed with a drug, or information sent by a manu- facturer about a drug can be called drug labeling, so we have to look at both the content and its distribution.. I can't answer your question clearly for every case. It would depend a little on what the physician wrote in the article, his independence from the industry, and whether it was distributed by the industry as a promotional effort. Now the guidelines we have proposed here are an attempt to sepa- rate out what material we believe should properly be called drug labeling and what should properly be called medical education that is not under the Federal Food, Drug, and Cosmetic Act. The policies on this will be in our proposed regulations that are coming out. Senator NELSON. You say the Food, Drug, and Cosmetic Act poses no threat to scientific communication, reporting research or to the voice of any medical opinion, providing industry funding of that communication is not involved. Suppose a physician simply disagrees with, say, the FDA approved indications for the use of a drug as included in the labeling. He writes that he has been using the drug for many, many years, and in his judgment and experience, the 1~DA is wrong. The drug has been, in his judgment, very effective in controlling a certain illness. He writes an article. on this subject and takes a very strong position, also recommending to other physicians that they use it in nonindi- cated cases, or at least he argues the ease. If that is published in a nondrug publication with no drug adver- tising involved, I assume what you are saying is that the act does not affect this kind of a situation. Dr. CROUT. That is correct. Senator NELSON. If I have such an article published in a magazine wholly supported by tb~ drug industry, would that be controllable. Dr. CROUT. That is the marginal case in which our policy is being developed at the present time and will be in the proposed regulations. We are not acting against those cases per se at the present time. Let me cite one extension of this, however, which we do take action on. Once an article is used in a promotional effort, meaning literally distributed by a detail man in association with the drug, then that article becomes drug labeling and if the article references to unproved uses and so on, we will take action against it. Senator NELSON. Is it aüother level of case if the physician or scientist is paid for writing the article as contrasted with one writing it totally unsolicited and not paid for. Dr. CROUT. That is an important issue in our view, yes. Senator NELSON. Go ahead. Dr. CROUT. Under present law, FDA has regulatory authority over some of the materials I have been using as illustrations. Cassettes which discuss a particular drug, for example, must meet standards for drug labeling and may not promote nonapproved uses of drugs, minimize hazards, or make comparisons not supported by evidence. This still does not; of course, mean that they are neutral educational materials as their formats might suggest. PAGENO="0035" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY' 1394j Recently, FDA was asked by a medical society whether a drug company could legally distribute a monograph prepared by the so- ciety without including prescribing information. The society objected strongly to the presence. of such information because it would, they felt, have suggested that the monograph was promotional or prepared by the drug manufacturer when in fact it was not. In an attempt to define the circumstances in which we would consider information~1 material disseminated by a drug manufacturer not to be drug labe1~ ing, and thus not obliged to contain package insert information or to maintain strict conformance to the content of the approved package :nsert, we suggested the following five tests: One: The material, has been prepared solely for educational use `mci not with any intent that it be used for other' purposes, as sale to ~ r distribution by the pharmaceutical industry. Two: The material is not promotional in nature taken as a whole, ~tnd is in the form of balanced educational materials. For example, the material may not contain any significant emphasis on uses for drug products that are not approved by the Food and Drug Adminis- tration as saf~ and effective, such as use for unapproved indications or in deroga~ti~m of r&juired ,contraindications and warnings. Al- though the material may contain' occasional references to such cases, such references may not be frequent or be given major consideration or importance. Three: The material has been prepared independently; that is, the pharmaceutical industry has not participated in the preparation of the material and has not exercised editorial review over the content of any of the material. Four: The `material covers a number of `different drugs, and does not support use of one `particular drug or the drugs of a particular pharmaceutical company. Five': The material is not associated in any way with a promotioti~il campaign for any drug product by the pharmaceutical firm suppQrt- ing the exhibit. The material may contain reference, to support by a pharmaceutical firm. `rhese tests, let me stress, were intended to permit truly indepe~id- ently prepared educational materials which do not have an overall promotional message to be distributed by drug manufacturers. When we were asked about scientific exhibits, we suggested essentially th~ same criteria. We are currently drafting an extensive revision' of our drug adver- tising and labeling regulations, and we expect to include guidelines such as those noted above in these proposed regulations. We arc eon- cerned that both the American Medical Association and the Phar~na- ceutical Manufacturers Association believe that these criteria would virtually eliminate scientific exhibits and industry-sponsored sym- posiums. These regulations could thus have an enormous impact on postgraduate medical communications `and we would not take suCh a step lightly. We expect extensive comment on these regulations and will consider such comments carefully. At the same time, the ex- tensive influence of the drug industry in these educational media is well illu~trated' by the profomid effect our , suggested guidelines could have. PAGENO="0036" 13942 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY In brief, then, regulation under the Federal Food, Drug, and Cos- metic Act is an important restraint on some promotional eft~orts spon- sored by the drug industry. I would not want to suggest, however, that regulation is the best approach to take for all of the educational materials supported by the drug industry. The idea of the Federal Government and Madison Avenue locked in eternal battle over every piece of educational material sent to physicians is not particularly attractive. Neither of these parties should have primary control over educational materials. Such control properly belongs with the pro- fession itself and its medical schools. Mr. Chairman, I would like to summarize the problem in broad terms. The technical knowledge required for the optimal practice of medicine is continually advancing at a rapid pace. Because of this, there is need for excellent conrses and teaching materials to assist the modern physician in maintaining his professional competence throughout his career. This need is increasingly recognized by spe- cialty societies and State boards of licensure. Thus, physicians are coming under increasing pressure to demonstrate in a formal way their participation in various courses, hospital seminars, and other teaching programs. To fill the need for teaching materials the communications industry has moved aggressively in recent years to produce an enormous va- riety of brochures, books, monographs, magazines, controlled cir- culation journals, closed-circuit TV video tape~, movies, audio cas- settes, and self-instructional learning systems. Many of these are sent free to physicians, some under the sponsorship of professional organi- zations. These materials are highly professional from the standpoint of communications technology and obviously expensive to produce. Outstanding medical authorities commonly are featured, and the scientific content of these communications is often excellent. While some of these communications relate to specific drugs and are readily recognizable as promotional material, many others deal with' broad issues in medicine, including the diagnosis and general management of various diseases. Others may describe specific technical advances in a variety of specialty fields. The financial support for Pall of this activity comes predominantly from the pharmaceutical industry, which in turn obviously passes the cost along to the consumers of drugs. The proliferation of industry-supported educational materials has increased to the point where they now constitute the bulk of educa- tional information provided to the practicing physician in his practice. Mr. GoRDoN. How much money is involved in this, actually? Dr. CROUT. The round figure for the total' promotional effort by the drug industry in the particular area of prescription drugs is on the order of $1 billion. Senator N~r~soN. You are talking about all promotional activities? Dr. CEOUT. But the bulk of that must be for detail men but also a big piece of it must be for the kinds of promotional efforts we have been talking about this `morning. ` ` `The `sm~1lest' piece today is probably advertising th medical jour- nals, which is the classical form of drug advertising. ` PAGENO="0037" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 13943 Mr. GORDON. I understand that expenditures on medical schools per year are a little over $500 million and that the expenditure by the pharmaceutical industry on advertising and promotion is about twice as much as the money we spend in this country on education in medical schools. From the material that we haire read-we got a figure yesterday from the `Library of Congress-annual expenditures on all medical schools in the country was a little over $500 million. Dr. CROUT. I am not in a position- Mr. GORDON. You mentioned $1 billion for advertising and promo- tion so that makes it about twice as much. Senator NELSON. But you are saying that the bulk of the educa- tional information with respect to drugs is sponsored by the drug industry. Dr. CROUT. Everything provided to physicians is supported by the pharmaceutical industry. Senator NELSON. You stated that industry-sponsored material now constitute the bulk of educational information encountered by the practicing physician in his practice. Dr. CROUT. I meant provided. I am sorry. The final version of the testimony says "provided to the practicing physician in `his practice." Senator NELSON. You have the word encountered. You changed that. Dr. ClOUT. Right. Provided, to the practicing physician in his practice. Senator NELSON. What does .that mean-provided to? What are you talking about, something that comes free? Dr. CROUT. Where his information comes through attendance in hospital seminars, through the mail, through listening to tapes and so on. The next sentence goes on to say that It think lie has other oppor- tunities for postgraduate medical education, including a variety of courses conducted by medical schools, scientific meetings, and the medical literature. The relative impact of these different educational opportunities on physician behavior is not clear. Physicians are trained to think for themselves, to be critical, and to engage in lifelong learning. I do not consider my colleagues to be pawns of the communications industry. Neverthel~ss, it is reasonable to a~k why our profession should be subject to an onslaught of allegedly educational material, not subject to the kind of independent review given the scholarly medical literature, which is financed by the drug industry, and ulti- mately, paid for by our patients. My concern, Mr. Chairman, is with this system, because it places the postgraduate education of an entire profession too much under commercial, nonuniversity influence. I believe it is self-evident that the drug industry would not be supporting this field so heavily if it did not believe such support was beneficial to the sale of drugs. Let me emphasize that, while .1 have used the words "phy~ician" and "drug industry" throughout this testimony, a similar situation applies to other health-related professions and industries. The post- graduate education of dentists, veterinarians, and pharmacists is also heavily influenced by the drug industry. Nor is this industry alone PAGENO="0038" 13944 COMPETITIVE PROBLEMS IN TIlE DRUG INDUSTRY in its behavior. My testimony applies equally well to the medical device industry and the diagnostic p~oducts' industry. The best solution to this problem is easy to describe, in concept, but difficult to. envision without major cb.angcs in the whole ,~tr~c- cure of postgraduate medical education. As I have emphasized re- peatedly, I believe that control of the educational process for phy- sicians properly resides with university-based medical schools. The pre-Flexnerian era taught us that medical~ education should not be entrusted to a commercial trade school environment, and our society should not have to learn' that lesson over again. Medical schools, however, are not financially in a position to accept responsibility for the postgraduate eduëation of physicians. I believe it is important that ~this problem be discussed openly, and I commend your subcommittee for undertaking these hearings. If the extent of' the problem is as great as I suspect, and if my con- cerns are confirmed by others, society must entertain innovative solu- tions, even drastic changes in some of our current behavior. The possibility of permanent pharmaceutical industry dominance over the total postgraduate education of physicians and other health professionals is too seriOus for us to ignore. Thank you. Senator NELSON. You made some ref erence-I think very briefly- to medical textbooks. Has the FDA done any survey about how many conipanies that are in drug advertising or in tb.e publication of drug-industry-supported magazines also publish textbooks. McGraw-Hill is one, I guess, that publishes textbooks in this field. Mr. GORDON. Does McGraw-Hill produce medical textbooks? Dr. CROUT. I believe so, yes. Senator NELSON. Here is an ad which claims that McGraw-Hill is the largest healthcare publisher in the world. It says that Dr. Seymour Schwartz, who edited "Principles of Surgery", a basic text `for medical schools, is also chief editor of one of its industry-sup- ported magazines. Are you familiar with textbooks that are pub- lished by McGraw-Hill and/or any other companies in similar business? Dr. CROUT. I cannot speak specifically about McGraw-Hill or any survey of the' industry. I suspect that some firms are very likely to produce both textbooks and the kinds of multimedia communication systems you have seen today. Senator NELSON. Would anybody in your medical library be knowl- edgeable about that? Dr. CROUT. We can try to get knowledgeable if that would be helpful. Senator NELSON. I would not want to p~it. `ypu to all kind's of extra work. I think it would be worthwhile, to know how much involvement in, the formal textbooks publication business is the pharmaceutical industry, directly or indirectly Dr. CROUT. Interesting question. I am not aware of direct or indirect- ` Senator NELSON. Maybe we could find it out from the Library of Congress. If anybody in the FDA happens to be knowledgeable please submit it for the record because' it may or may not be of consequence. ` PAGENO="0039" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 13945 Dr. CR0UT. May I make a comment. I think many of these teach- ing materials that `are produced in postgraduate education are find- ing their way into, medical school training, so that it is con~eivab1e to me that some of the material is competing with the standard textbooks and the classical medical scientific journal as a source o~ information to medical students. This I think would be highly variable from school to school, and testimony on this from others might be interesting. Senator NELSON. We will put this in the record. This is a lette~' written a couple of years ago by the head of the Department of Pharmacology, School of Medicine, university `of Miami. It is ad- dressed to Dr. Young of Cook County Hospital in Chicago.1 Is there a considerable involvement by the pharmaceutical rndustry in the pharmacy schools, department of pharmacology in medical schools and teaching hospitals? In their teaching consulting programs? Dr. CROUT. To my knowledge most medical and major teaching hospitals do not permit detail men to freely meet with students çr house staff. This is a practice which is discouraged. The letter you have here came about from unusual circumstances. I talked about it with Dr. Palmer on the phone, and Dr. Palmer along with several other clinical pharmacologists is engaging in an experiment incorporating a detail man into their own teaching pro- grams for medical students and for graduate fellows. Mr. GORDON. Would you repeat that? Dr. CROtJT. Training detail men to be better presenters of drug information. Senator NELSON. You mean this is a program of educating detail men? Dr. CROUT. Yes; this is a program of educating detail men and the spirit is one, a little bit of, if you can't lick them, join them, or let us try this as an approach. So this letter is admittedly ambiguous, I think an embarrassment to Dr. Palmer, but that is the context in which it is written. `Senator NELSON. Well, does the detail man have a valid scienftfic function to transmit pharmacological information to ,the practicing physician. Should that be the physician's source of knowledge about what he is prescribing. Dr. CROUT. I think that we would all say the answer is "No." Senator NELSON. Why even a secondary source? Dr. CROUT. The issue is, the detail man e~ists because of the na- ture of our free enterprise system, should he have some kind of training in the area that is independent from his employer. I ~am not endorsing that notion or rejecting it at this particular pint. Senator NELSON, `If the whole system is bad, `then it is even worse to make the promoter more sophisticated than he is and give him better-looking credentials. If he is the physician's source of k~owl- edge, then I wouldn't go near' his office. I w9uld like to have him consulting the experts, not a promoter of the dn~g.~ So if that is a program at the ITniversity of Miami-that khid of infiltration of our medical schools-I wonder about what else the `Seo letter dated Oct. 29, 1974, to Quentin Young, M.D.. Cook County r~ospita1, from Roger F. Palmer, M.D., School of Medicine, University of Miami, page 14035. PAGENO="0040" 13946 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY industry is doing in the medical schools and the effect on sound scientific practice. Dr. CROUT. Dr. Palmer could speak for himself on that issue. I just want to be sure his intent was represented properly. Senator NELSON. We do not have any way of getting a good sur- vey but here is another case of involvement, this time in a pharmacy school. Here is a letter to Jere E. Goyan, Ph. P., School of Phar- macy, University of California, San Francisco, College of Pharmacy. It was written February 5, 1976~ and is signed by nine scientists including some Ph. D.'s and an M.D.1 They refer to distribution, so apparently the school was distribut- ing this publication. It just raises another question as to how deeply involved are the pharmaceutical manufacturers in the education at the college level. Are you aware of any studies of this kind of in- volvement made at medical colleges in the country? Dr. CROUT. Studies, no; I believe that any knowledgeable dean or chairman of a major department could tell you, though, with reason- able accuracy about the pharmaceutical funding of research, teach- ing, and so on in medical schools. Dr. Rheinstein knows of a study being done now. Dr. RIIEINSTEIN. Mr. Chairman, Dr. William Haddad of the Committee of T~gislative Oversight in the State of New York is currently looking into the amount of involvement of pharmaceutical manufacturers in medical education and is in contact with the deans of the medi~ai schools in the State of New York. Senator NELSON. Just within the State of New York? Dr. RIIEINSTEIN. Yes. He has commented that there is substantial involvement at each of these schools and I think we will have more at a future date. Senator NELSON. Who is doing the study? Dr. RHEINSTEIN. The man's name is Dr. William Haddad and he works for the Committee of Legislative Oversight for the State of New York. Mr. GORDON. Has the FDA or the Department of HEW done anything to encourage medical schools to adopt extension courses or continuing education courses? Dr. O~ouT. The FDA does not support this area directly. I could not comment extensively on that, but cert/ainly the Federal Gov- ernment has supported postgraduate education. This is a feature of many of the regional medical programs, and that sort of support was undertaken with some enthusiasm several years ago and it is still going on. I think, if you would be willing to call demonstration projects and communications systems postgraduate education, and a number of such communications systems that have been set up, there is a fair amouni of public support. Mr. GORDON. The public pays for these courses, anyhow. Ultimately they pay in purchasing drugs, ~o if they pay ultimately why not do it directly through Government; Federal and/or State grants? Do you see any possibilities there? 1 See letter dated Feb ~S. 1976, to fere 131. Goyan, Ph. D., School of Pharmacy, Univer~ ilty of California, page 14040. PAGENO="0041" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 13947 Dr. CROUT. That is an option to be considered. Certainly the fund- ing of postgraduate educational materials and courses would clearly appear to be available. We are talking about somebody paying for what you see today. It will be paid for in one of two ways. I should say one of three ways: (1) by Government; (2) by the profession, the medical profession-that is, payment for their own postgraduate education; and (3) by the manufacturers of drugs, or some combi- nation of these three. Right now Government is clearly running third among those three. Senator NELSON. The medical society's memo indicates that a sub~ stantial percentage of these are promotional. Since they are tax deductible, 50 percent of the cost of the exhibit are paid for by the taxpayer, anyway. Thank you very much Dr. Crout for your very interesting presentation. Dr. CROUT. Thank you Mr. Chairman. Senator NELsoN. These hearings will resume at 9:30 on Monday, May 10. [Whereupon, the hearing adjourned at 12:45 p.m.] PAGENO="0042" PAGENO="0043" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY (Present Status of Competition in the Pharmaceutical Industry) MONflAY, MAY 10, 1976 U.S. SENATi, STJBCOMMITTEE ~N MONOPOLY OP THE SELECT COMMITTEE ON SMALL EtISINESS, Wa$hington~ DJ~. The subcommittee `met, pursBant to recess, at 9:30 a.m., in, rçom 318, Russell Senate Office Building, Senator Gaylord Nelson (chair- man of the subcommittee) presiding. Present: Senator Nelson. Also present : Benjamin Gordon, staff economist; and Karen Young, research assistant. Senator NELSON. Today is tlie second in a series of hearings on the role of the drug industry in the postgraduate education of physicians. The Monopoly Subcommittee of. the Senate Small Business Com- mittee has been studying for quite some time problems rei~ated to the development, marketing, and use of drugs. Since the prescribing physician is in reality the purchasing agent for the patient, our sub-~ committee has been particularly interested in the sources of infor- mation on which doctors depend for information a.bout drugs~ It is well known that the drug industry spends vast sutils of money on advertising and promotion. It is not well known, on the other hand, that the drug industry has also come to occupy a, ~igni~ ficant role in. the postgraduate "education" of the doctor. Thi~ s~tua- tion, in my judgment, is bad both for the public and for the medical profession. On April. 28, Dr. Richard Crout, Director `of the Ft~A~s Bureau of Drugs expressed grave concern that the growiflg influence of the industr~y-sp~nsored medical education is a long-t&r~n threat to the integrity of his profession. . , Dr. Crout testified that much ~f the written and audiovisual teach- ing materials on drugs and all other medical subjects. a physician encounters throughout his professional career, are snpported by the pharmaceutical industry. . , . . . , , This includes the vast majority of medical maga~4nes whléb clQg hi~ daily mail, the clinical problems, the audiovisual teaching systems he studies in his spare time, the, films and closed-circuit TV tapes h~ sees In' his bospital conferences, and even' the scientific exhibits and presentations by panels of ex- pei~ts he'encounters at medical meetings. 13949 PAGENO="0044" 13950 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY The drug industry has vast resources at its disposal. Its expendi- ture for advertising and promQtion of drugs is now well over $1 billion per year or about $5,000 per physician per year. This is about twice as much as we are spending each year to educate our doctors in our country's 116 medical schools. These massive expenditures on advertising and promotion are ultimately borne by the public. A more important cost to the public, however--not measureable in monetary terms-is the systematic. bias in what industry passes off as educational material but which is in reality part of the industry's promotional efforts. These activi- ties should be of grave concern to the medical profession and its edu- cational establishment. The subcommittee plans to hear from those who prepare this ma- terial, arrange conventions and exhibits, as well as medical organiza- tions that sponsor them. In addition, at future hearings we expect to hear from outstanding medical educators. These are the people- the medical profession and its* schools-who have the responsibility for educating physicians not only in undergraduate medical educa- tion but also in postgraduate education. Our first witness this morning is Mr. Jay Raeben, president, Visual Information Systems, Division of Republic Corp., New York, N.Y. Mr. Raeben, your statement will be printed in full in the record. You may present it however you desire.' Mr. RAEBEN. Would it not be preferable simply for me to read it as written, Mr. Chairman. Senator NELSON. However you desire, sure. STATEMENT OP ~AY E. RA~BEN, PRESIDENT, VISUAL INFORMA- TION SYSTEMS, DIVISION OP REPUBLIC CORP., NEW YORK, N.Y. Mr. RABBEN. This statement identifies Visual Information Sys- tems' activities. I will describe briefly those concerned with medical communication or education, and at a somewhat greater length, deal with those likely to be of special interest to the subcommittee. As each activity is discussed, I will make an effort to respond in that section to the subcommittee's concerns as suggested in its invitation letter of April 6. Our company was formed in October 1962 and became part of Republic Corp. in 1969. Its first activities were in closed-circuit television at conventions. Since then we have provided business and university instruction on video tape and made smaller forays into sports and entertainment. VIS' principal activities and those of interest to the subcommittee are in medicine and this statement is limited to them. Senator NELSON. May I interrupt, Mr. Raeben ~ I note that you state that VIS became, in 1962, a part of the Republic Corp. What is the Republic Corp. and what other business activities are they engaged in in addition to what VIS does? Mr. RAEBEN. Republic Corp. I think was referred to at its peak about 1970 or 1971 as a conglomerate. It was during that process of conglomeracy that we were acquired in 1969. .1 think it. has since 1 See prepared statement of Mr. Raeben beginning at page 14246. PAGENO="0045" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRI 13951 shaken out into a more coherent company with two principal branches, one in communications-printing, graphics, film process- ing of which we are a part, and another branch, steel specialities~- not to be confused, however, with Republic Steel. It is a moderately sizeable company traded on the New York Stock Exchange. We are one of 24 divisions. Senator NELSON. VIS is one of 24 divisions? Mr. RAEBEN. Yes. Senator NELSON. All right. Go ahead. Mr. RAEBEN. Thank you. Our medical activities are: Convention television, which we began in 1962; the Network for Continuing Medical Education [NCME], which we began in 1965; Audio Visual Education in Neurosurg~ry [AVENS], which we began in 1969; the American Academy of Ophthalmology and Otolaryngology Continuing Education on Tele- vision, which we began in 1971; and the Physicians Radio Network, or PRN, which we began in 1974. Convention television began in 1962 at a meeting of the American Dental Association. The service, to which we attached the name ilotelevision, enabled dentists in their own hotel rooms to watch programs on dentistry prepared by the association. Since that date, Hotelevision and other forms of convention television have been sup- plied by us to about 70 association meetings, predominately for phy- sicians. All programing is developed under the direction of the asso- ciation and the service has been supported by perhaps a dozen pharmaceutical companies in all. When product messages accompany the telecast, they are always unrelated to the content of the program. To my knowledge, no studies have been done to measure the impact on physicians prescribing practices. Senator NELSON. You say when products messages accompany the telecast, they are always unrelated to the content of that particular program. So. if a program dealt with infectious diseases there would not be the promotion of any drug that was an anti-infective. Is that what you are saying? Mr. RAEBEN. I would expect that that would be the case, yes, sir. Senator NELSON. Does each one of these programs have some drug promotion in the program? Mr. RAEBEN. Perhaps that is more easily understood if I e~piain it more fully. Most of these services were fairly lengthy, perhaps 35 to 40 hours of television programing over; let's say, a week-long convention; usually early morning from 7 to 9 before physicians would leave for regular meetings, and then beginning around 5 p.m. until perhaps around 11 or 12. Senator NELSON. You mean these would be closed-circuit tele- vision programs delivered into the rooms? Mr. RAEBEN. Yes, sir, into the individual sleeping rooms of the physicians, the thought being that through the service, the conven- tion hours, which are normally 9 to 5, could be extended to make the convention day a little longer. And the programs are frequently taped either that day or the day before at the convention with, usually, physicians wh6 are attending the meeting and who had been assembled by the as~ociation as having something that the a~socia- tion wished to receive wider dissemination.. PAGENO="0046" 13952 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Senator NELSON. I do not follow that. You mean these programs were simply a closed-circuit television repeat of what had actually occurred live at the convention itself? Mr. RAEI~EN. I would say an extension rather than a repeat. Either, for example, a physician who was not going to be on the formal meeting program speaking during the day in one of the meeting rooms would be given time on the closed-circuit telecast. Or in some instances, a physician who had a paper of some impor- tance, which, let us say, was allowed 30 minutes for presentation during the meeting day, would be given maybe an additional, half- hour or an hour on television that evening orthe next day to amplify on his comments, frequently questioned by his fellow physicians. Senator NELsoN. On page 2 you state "Since that date, Hotelvision and other forms of convention television have been supplied, by us to about 70 association meetings, predominately for physicians." Do you mean to 70 different associations or to 70 different meetings, some of them being repeating? Mr. RAEBEN. The latter. Senator NELSON. Now, do any of these programs involve a pre- pared tel&vision program on some aspect? Mr. RAEBEN. Yes. In a couple of instances I can think of, the Amer- ican Medical Association was quite interested in developing materials which would be, oh, perhaps accreditable by the association itself. These programs were developed, unlike the bulk of those seen, well in advance of the meeting, weeks and sometimes a couple of months ahead. The association would pick physicians, and a topic, and nor- mally we would videorecord them,. although in some instances, the association made arrangements for that itself. In another case-a couple of cases that I c~n recall-one associa- tion~ Southern Medical Association, which was not able to fill all the hours o~ programing with materials that would be taped at the meeting, asked us to supply from Our ci~rrent library `of pro- grams developed for another project' which I would be speaking about later, NCME, to supply some of those programs for `exhibi- tiOn on. this dosed-circuit Southern. Medical As~ociation network. Senator NELSON. Back to the original question about advertising or mention or promotion of a drug on any of'. these programs, whether they are repeats or run live on c}osed-c~ircuit televisiOn at the conven- tion-do any. of those `contain any promotion of `any drugs at all?, Mr. RAEBEN. Yes. The `programs are accompanied by-that is to say-the advertising always appears between' program subjects. There might be speakers on one subject' for `half an hour, and ~pe.ak- ers on another for, say, 15 minutes, and `there' may well be a product message or occasionally an institutional message in. between those two. Senator NELSON. if you had a 6-hour ~p~ogram or something with 10, 12,. 14 different subjects or presentations, would there always be an ad between' each one? is that what you are saying? Mr. RAEBEN. Not necessarily between each `one, but I would guess in each hour. I am trying to recall; the pattern has varied so. But there ~might well be three or four `certainly in each hour. Senator. NELSON. And how ` is this financed? Your `organization supplies this service. Is all .oi~ `part of it paid for by the drtig' coni~ PAGENO="0047" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 13953 panics or all or part by the medical association or what? Flow does that work? Mr. RAEBEN. Well, there, have been two methods. I guess you might ultimately say that the bulk of the n'~onies have come from the pharmaceutical industry. In some instances, the industry pays the association which then hires us to supply the service. In other instances, industry has paid us to supply the service to the associa- tion, which has then accepted the service, and the association is al- ways in coutrol of the programing under either arrangement. Senator NELSON. So in some cases the `drug company would pay a medical association, which would hire VIS. In other cases, the drug company would directly retain or hire VIS to supply the pro~ grams. Is that correct.? Mr. RAEBE~. That is correct. Senator NELSON. And then what happens?. The association itself then requests the kind of programs it wants or how does that work? Mr. RAEB~N. Well, normally I believe they actually arrange for the programs. That is to say once they have learned-normally sev- eral months ahead of the meeting that the television service will be available, their own staff selects physicians and subjects to be part of the television service. Most of the programs-in some cases a 100 percent, in some cases perhaps only 80 or 90 percent-are taped at the meeting itself. Doctors come into ~ temporary studio which we erect during the week of the meeting, and they are brought in by association officials and. then they speak on whatever it is they feel important. Senator NELSON. What drug companies participate in sponsoring these programs? Does its trade `association, for example, itself ever participate, the Pharmaceutical Manufacturers Association ~s an association, or is it individual firms? Mr. RAEEEN. It is individual companies. Senator NELSON. And which individUal companies? ` Mr. RAEBEN. Well, over the years there have `been quite' a fe~, I guess the first one that we were involved with was Wyeth Laborathr- ics, which was a sponsor of the American Dental Association meet ing. I believe Upjohn has sponsored some. Hoechst Pha~rmacentic~ls, Roche Laboratories, quite a substantial number `in'our oWn, expOri-' ence, moi~e than any Qther company.' I believe `áib~. `I cannot re4ail the names at this moment. ` ` ` ` ` . ` ` Senator NELsoN. This could be the,American College of Physicians or it could be in the field of surgery or family practice or what have you. Is that correct? Mr. RABBEN. Yes. . "` Senator NELSON. Conventions for any one of the `medical disci'-, plines. Is that' what you are `sa~ying?, Mr. RAEBEN. That is eerrect. , ` ` Senator NELSON. And then VIS provides the professional ex~er- tise in managing these programs. Is that it?, Mr. RAEBEN. That is correct. Senator NELsoN. Does VIS design and develop programs oJ~ `its own in the field of medicine? Mr. RAEBEN. We do, yes, sir, in other projects, not the convention television service but in other services that I was going to describe in more detail. PAGENO="0048" 1~954 COMPETITIVE PROBLEMS IN TH1~J DRtTG INIflJSTRY Senator NELSON. All right. We will get to that then. Go ahead. Mr. RARBEN. Thank you. Mr. GORDON. Excuse me. May I ask one question at this point? I am trying to get the rationale as to why, if you were having a program on infectious diseases, you would not have advertisements for antibiotics or other such products instead of, let us say, tranquil- izers or other products unrelated to the program. What is the ra- tionale behind that? Mr. RABBEN. You are speaking of the convention, television service now? Mr. GORDON. I am talking about what we were just talking about, the hotelevision. Mr. RAEBEN. To begin with, I would say that the product mes- sages which were provided by the pharmaceutical company in ad- vance of the meeting. in prerecorded form, given to our directors and technical staff for insertion between programs, were done at a time when the sponsor would have no idea of what the content of individual programs would be like. Mr. GORDON. But do you know? Mr. RABBEN. Yes. Mr. GORDON. Because ion arrange it. Mr. RAEBEN. Correct. ~ Mr. GORDON. And this sounds like a policy of yours. Mr. RABBEN. Yes. Mr. GORDON. What is the rationale behind that policy? M:r. RARBEN. We have ourselves felt. sensitive to possible implica- tion of, for example, implied endorsement of a product. If the physicians were speaking about a clinical entity, and then there were to be a product advertised just before or just after that pro- gram which dealt with that clinical entity, a casual viewer might think that there was an implied endorsement by the doctors in the program of the advertising message. We would not like that con- fusion to occur. Mr. GolmoN. It does not appear that you would have any casual viewers., ~eople would be planning on seeing it. You would have experts. You would have physicians. This is what bothers me. I would like to know why you have this policy. Mr. RARBEN. Well I think when you consider the environment in which people would watch these particular programs-in their hotel rooms perhaps while dressing to go to the meeting, or at the end of the day while changing their shirts before going out to dinner or something of that sort-they might see a telecast, and they might see a product message, and they might have even looked away from the screen and had just been looking for a few minutes. II would not be difficult for some kind of connection erroneously to be drawn. I do not think the listening is all that careful. I think any of us could testify to that from our own television viewing experi- ence. So it is to prevent just such a confusion, we felt that it was wisest to make a clear separation where this was possible. It was not always possible, I might add. Sometimes in a program intended to be, maybe, on a soci.oeconomics subj~ect somebody might have in- troduced at the last moment, let us say, on a live telecast-although PAGENO="0049" COMPETIPIVE I'EOELEMS IN THE DRUG INDUSTRY 13955 these are normally taped-some comment about a disease entity. But I say that where we could plan, we avoided the connection. And I am pleased to say that our sponsors seemed content with this separation. Senator NELSoN. What is the length of most of these association conferences or conventions? A week? Mr. RAEBEN. Yes; the major associations tend to gather on the weekend and then people start going home on Thursday or Friday. Senator NELsoN. And could you give us a figure on what the average cost to the drug companies would be for retaining your organization to present the convention and whatever else you pre- sent? What would that cost be usually? Mr. RARBEN. I would say the services ranged in cost from, in one instance for a somewhat abbreviated version of what we are speak- ing about, as low as perhaps $7,000 or $8,000 up to perhaps as much as $45,000, and perhaps $50,000. Senator NELSON. And that involves the presentation of the closed- circuit television. It does not involve displays or things of that kind, or do you do that, also? Mr. RAEBEN. No; we do not. It's just the television. Senator NELSON. Yes; all right, go ahead. Mr. RAEBEN. Thank you. The activity I think that we are probably best known for, at least prior to our radio effort, is called the Network for Continuing Med- ical Education, NCME. This was established in 1965 with the sup- port of Roche Laboratories. This was the first effort in any field to use the emerging video technology for publishing. We employ what we think of as a "journal" concept with three "articles" or programs in each reel. Unlike the way motion pictures have been used,, we put forward the notion, which was then unusual, that an audience as small as a single viewer was adequate and that viewing should take place at the convenience of the viewer, not the exhibitor. These ideas I think now seem commonplace. In 1972, with the introduction of the video cas'~ette machine, a cassette subscription plan was developed. This has enabled hospitals to build their own video cassette libraries and offer them as com- munity resources. Today, all 70 NCME hospitals subscribe, paying $1,200 to $1,600 yearly. Senator NELsoN. You say "all NCME." What do you mean "NCME hospitals"? That iS just a hospital that subscribes to that service, you mean? Mr. RAEBEN. Yes, sir, that IS correct. Senator NELSON. You have 700 of them paying $1,200 to $1,600 yearl~y. For that they receiVe these c~ssett~s? Mr. RAEEEN. Yes. Senator NELSON. Does VIS then develop the cassettes? It that it? Mr. RAEEEN. We do. I was going to get into the process of their development in another moment. I want to point out also that the `remainder of the cost of the service is borne by Roche Laboratories, Senator NELSON. What do you mean "the remainder of the cost"? Mr. RAEBEN. The moneys that the institutions pay represents about one-third of the total cost of the service. 73-E3i7-7~3--4 PAGENO="0050" 13956 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Senator NELSON. So this annual subscription fee paid by the NCME hospitals of $1,200 to $1,600 yearly represents about one- third of the total cost of the product that they are receiving. Is that it? Mr. EAEEEN. That is correct. Senator NELSON. What is the total cost for tTiose 700 hospitals? Over a million dollars, I suppose.. Mr. RALBEN. Well, it would be more than that. It would be between $1'/2 and $2 million, I would say. Senator NELSON. The cost to the hospital is one-third .of the total cost which is around $21/2 million; is that correct? Mr. RAEBEN. That is correct. Mr. GORDON. Perhaps you have not mentioned it yet, but the next thing you say in your prepared statement is: "About 145,000 phy- sicians have regular access to these programs." Now, who pays for that? Mr. RA'EBEN. Well, nobody, pays for that. The physician is some- one who attends at the 700 hospitals. The 145,000 includes, I should add, interns and residents. Perhaps 20,000 to 25,000 of the 145,000 are house staff. The remaining-perhaps 120,000-are attending phy- sicians who in the normal course of their workweek would ~spend several hours in the hospital perhaps coming in to see patients, and it is on that occasion that they would see these programs. They would presumably pay nothing as their institution had subscribed. Senator NEI~soN. Do the 700 hospitals you mentioned have a reg- ular scheduled showing time for these cassettes on various kinds of medical problems which are announced so that physicians who prac- tice within the hospital would have an opportunity to look at them ~ is it just something the doctors view at their convenience? * Mr. RARBEN. Well, many do have such a regularly scheduled showing time. In the days before the video cassette machine, prior to 1972, that was the practice. Since the video cassette machine caine along, that is somewhat easier to operate-easy enough for a .physi-~ cian or any nonexpert `technical person to operate. The machinery is usually kept in some location' such as, say, the. library, `and the physician looks at the cassette on the same demand basis that he might go into the library .to pick up a copy, of the Journal.' And that, in fact, is the form of use we encourage~ ~We think it is much' better than having `a schedule which he would have to try to meet. Senator NELSON. Are there also occasions when physicians~ who may be experts in the subject matter being shown, are available for questions or is that not a common practice? ` Mr. RAEBEN. Yes. Particularly in smaller communities, I, would say this service itself is one which is more useful in the smaller community hospital than, let us say, the big city medical center where there is an awful lot of live expertise available. But in the smaller institutions, quite commonly at their monthly st'affruieetings, for example, they will play a program or two and arrange for a discussion to take place at that time. That is a frequent `practice. Senator NELSON. Do any of the medical. colleges produce these kinds of cassettes and make them available to hospital's? Mr. RAEEEN. There have been a number of efforts. First of all, a number of medical colleges do. In fact, I would guess all no~v., have PAGENO="0051" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 13957 video tape producing capability. Probably 100 percent of the medical colleges do. They vary greatly in their effort to extend the service outside their own walls. Briefly, during the heyday of th~ regional medical program, an effort was made to have the medical center be sort of a production fountainhead for the general and community hospitals within its region. In most instances, that did not go very far. There have alsç been efforts in one or two States-California, notably-to have pro- grams produced. For example, TJCLA had a fairly extensive service to about 60 or 70 hospitals which it had going for. some time. As a matter of. fact, during its early stages we gave . it considerable support. They did not have the duplication facilities and we sup- plied them for them gratis just to encourage them. Senator NELSON. Go ahead. Mr. RABBEN. This is further to your questions. When we began the service we really thought that we would be a clearinghouse. I expected that the programs would be produced by medical schools, which were at that time just acqujring video tape equipment or, in some instances, by Government facilities, for example, the National Naval Medical Center, or Waiter Reed Army Medical Center,. which were interested and active in medical television. In short, we expected to vest responsibility for producing the programs in the academic medical community. We expected just to be a duplicator. That programing, however, proved to be quite often not suitable for distribution for technical or production reasons. In a few instances, it was simply not available to us. It, became more effective for NCME to provide direct production assistance to the physicians at those very same medical centers whose work was to be the subject. of the programs. In short, the doctor who would have been in the program produced by his institutioi~ produced the same program. We supply the di.rector, the cameras, the medical artwork and so forth. . .. Senator NELSON. Well, if an institution-a teaching hospital for exampl&-was going to supply the expertise for.. some progtam, the practicing and teaching physician would participate and VIS would supply the technical personnel to film whatever is presented. Is that what you aresaying? . Mr. RAEBRN. That is correct. And . normally a writer as. well to work with the physician in developing the script., . ` Senator NELSON. How many university teacMng `hospitals or hospitals of any kind do you have an association with of that nature? Mr. RAEE~N. Well, it is a very large number. I can hardly think of a medical center in this country~ where we have not produced programs. I guess you would have to say over a several year period we have ..produced programs at virtually all major medical centers in this country. There maybe some exceptions. Senator NELSON. I notice you refer in your statement to "700 NCME hospitals." Let me Cask the question another way. Can you separate out those that are medical-college-affiliated teaching hos- pitals from those that are not? My question being, how ma~iy of the medical colleges in this country, through their teaching hospitals PAGENO="0052" 13958 COMPETITIVE PROBLEMS IN TEE DRUG INDUSTRY and staff, produce programs to be video taped by VIS? Do you know them? Mr. RAEBEN. Well, again, I think it is virtually all. However, I think it would be perhaps misleading if I do not reorient my state- ment here. It is not so much that the medical center has itself said we wish to produce a program. Would you, VIS, please come in and do it for us? Rather, what has happened over the years increas- ingly is that physicians at those medical centers who are teachers, whose work has been identified by our medical advisers as being good, are nominated as presenters of program subjects. We have then actively gone `to them and said, "Would you, care to present your work on television?" So you might say the initiation, the start of the effort, has come from us. At least, that is how it is nowadays. Senator NELSON. Of the 700 affiliated hospitals, that is, those of the NCME, do you have some regular program development with all of them, or is it `sporadic, or was it regularly with some and irregularly with others? Mr. RAE1mN. Yes; it is actually not done by institution basis. It is done by subject or scientist basis. Senator NELSON. Now, when one of these programs is developed, is there drug advertising in each of the programs then? Mr. RAEBEN. Well, yes; there is. Again, I think if I might cover it in the statement itself. Senator NELSON. All right; go ahead. Mr. RABBEN. Thank you. I guess' I might close this particular sequence to which you have addressed questions with a comment that programs produced totally by a `medical center still are occasionally distributed on NOME. I think in the past year, for example, Ohio State University pro- duced some programs and just simply made `them available to us for national distribution. We distribute each year 69 different program subjects, and they are assembled onto 23 1-hour reels; that is, 3 subjects on `a reel. Senator NELSON. Twenty-three 1-hour reels? Mr. RABBEN. Twenty-three 1-hour reels in the year. Basically, it is a biweekly service, except in `the summertime when it is every month. Senator NELSON. These reels have' advertising on them ~ Mr. RAEBEN. They do, and I do intend to describe that in a moment, unless you prefer to ask questions about it right now. Senator NELSON. Go ahead. Mr. RABBEN. Thank ydu. I would like to have entered in the record if it is possible the catalog of our programs and their participants that have been re- Corded over the years. The subjects themselves in a sense, you" might say, testify to the direction of the network. Senator NELSON. We ~ili receive' it and have the staff examine it to see whether it is appropriate for printing in the hearing record. Otherwise, it will go into' the ftles. We would be glad to look it over.1 Mr. EABBEN. Thank you. ~ See ?~ograms C~ta1og of the xetwork for Continuing Me~11ca1 Education, page 14~59. PAGENO="0053" COMPETITIVE PROBLEMS IN TILE DRUG INDUSTRY 13959 The program subjects themselves and their content are determined in the following way. First of all, we have a national board o~ physicians concerned with education. They include such persons as Lowell Coggeshall, who was formerly vice president at the Univer- sity of Chicago and, as it happens, the Nation's first Assistant Scc~ retary for Medical Affairs at Health, Education, and Welfare George Aagaard, who, I think was the Nation's first dean of con~ tinuing medical education, who is now a professor at Washington University School of Medicine; Edmund Pellegrino, chairman of the board, Yale-New Haven Medical Center. I have a complete list which I have provided in the appendix to this statement. This board provides overall direction to the network. For exampk~, at the board's meeting later this May, it will discuss steps NCME must take to meet the accreditation requirements of various accredit- ing bodies. Another group, the Medical Advisory Committee, is made up of physicians. I have listed all of their names in the appendix to my statement as well. They meet regularly to select the specific program subjects and often to suggest participants for them. The participant himself then determines the specific content of his program, although NCME staff guide him on ways to make the programs more visual. The staff also sometimes recommends for or against programs based on their suitability for television. The sponsor does not ask us, and we do not volunteer, to produce particular programs or to treat programs in any particular way. As with any publisher or broadcaster, otir goal is to. provide subjects likely to be of interest and value to large audiences, because if they are not, doctors will not watch, hospitals will not subscribe and our sponsor will cease his own support. If one were to view these programs he would find that the majority of them do not deal with drugs, and that when they do, it may be as much against as for their greater use. Product messages appear preceding each program on the reel. The schedule of product messages is prepared months in advance by the sponsor without knowledge of the programs they are to ac- company. However, when the reel is assembled, our staff takes care to avoid even the accidental juxtanosing of product messages with programs dealing with the same clinical subject. No study has ever been done to determine the extent to which product messages on NCME affect drug prescribing practices. And, of course, no studies have been done on the influence of the programs themselves on drug prescribing. Few of these programs, if any, would lend themselves to such studying in any event. Mr. GORDON. May I interject a ouestion at this point? Is it reasonable to assume that drug firms would be spending. their money if it did not affect in some way their drug sales? Maybe you do not have a study, but I am just wondering if the drug firms who advertise have studies to indicate to them whether they are speeding their money wisely. Mr. RAEBEN. Well, I know that drug firms regularly do study media in many ways. I would say that we have probably, at least in what we do. have not been carefully studied because of the clear nondirect relevance between the advertiising they can do inour media PAGENO="0054" 13960 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY and what they might be seeking to measure. For example, input on sales. I just think we do not lend ourselves to such a stndy. Mr. GORDON. But if, as you say, the drug companies do studies- and I am sure they do these studies-and they keep on spending the money, is it not reasonable to assume that it does have a favor- able effect on their sales, or at least that is their decision? Mr. RAEBEN. Well, I cannot say. Mr. GORDON. We all agree th~t they must think it does them some good. Is that right? Mr. RAEBEN. I certainly think that would be the way I would put it. Thank you. I suppose it would be nice for us in some ways if we Could show a more direct connection perhaps on their fortunes to their support of the things we do. Senator NELSON. Well, I assume your next sentence tends to answer that. You say "Surveys are done to determine if physicians watch our programs and find them useful." If those surveys indicate a positive response, obviously, the doctor watches the program and thinks the program is useful, then the advertiser can assume that if his advertising is any good it also helps his product. I assume that is the case. Mr. RAEBEN. I think he makes just that assumption. Senator NELSON. Who does the surveys, Mr. Raeben, to ascertain if the physicians watch the programs? Are they done at the conven- tion or are these the ones at the hospital? Mr. RAEBEN. These are the ones at the hospital. And we do quite a bit of surveying ourselves. It is very important for us to know, both with respect to individual programs as well as annually, what the viewership is. And I know that the advertiser-the sponsor- surveys it directly to find out as we:fl as he can what the tendency is. Senator NELSON. Well, of the 700 NCME hospital affiliates-as I recall, you stated that those programs are `available to 145,000 phy- sicians~ which included interns~do you collect any stati~tics from the affiliated hospitals `as to how many times these programs were run and how many' viewers saw' them? Do you have those statistics? Mr. RARBEN. Yes; we do' cofleet such information. I have to say that-and this is probably anoth~r common phenomenon-informa- tion provided to' one by hospitals that receive our programs `prob- ably is biased in an op'tiniistic direction. They tend to say everybody watches them a whole lot. A~nd we have to go behind"that' level of surveying, and' literally ~ali a sample: of `physicians on `the telephone and ask them what their own experience has' been.' And it is I think tilat data that `is somewhat more trusted by' us in determining the accuracy of that ai~swer. ` " ` Senator NELSON. `And you do' make those `kinds cf surveys. Is that correct? Mr. RAEBEN. We do' and the sponsor does as well. Mr. GORDON. Mr. Raeben, you say that your Medical Advisory C~mmitf'ee `meets regularly to select specific program subjects and often to suggest participants for them. Who has, the responsibility for seleeting the participants'? . ` ` Mr. `RARBEN. Well, I suppose `you wbuld ultimately' have to say that our own staff does. What the Medical Advisory Committee will PAGENO="0055" COMPETITIVE PROBLEMS IN THE DEVG INDUSTRY 13961 do in identifying a program subject at normally the meeting, s~ty, held at our offices, they will then say Dr. Jones is very good in this field, and if you cannot get Jones get Smith. And then our staff will be in touch with, let us say, the recommended physicians. If it turned out that neither of them was available to appear in the pro- gram, they might look for an alternative. If they found an alter- native physician, they would then go back informally to the Medical Advisory Committee, in this case, by telephone, and say we ht~ve found Dr. Brown, Jones and Smith being unavailable. What do you think of him? And if the committee says, oh, he is a splendid man, so we would proceed with him. Mr. GORDON. I see. The committee merely gives suggestions and recommendations, but your staff makes the final decision as to what programs will be shown, who participates, and so on. Is that correct? Mr. RAEBEN. I do not think I would say it that way, particularly as the subjects, first of all, are pretty much determined by the advi- sory committee. They pick the subjects, not we. The only area in which we exert discretion-I guess there are two-if the physicians that they recommend are unavailable or if' they are unavailable to appear on the day scheduled, then we have to find a physician, and, by phone or correspondence say here is someone who has been identi- fled to us as a good presentor. What do you think? And if the committee then endorses him, we proceed with him. Mr. GORDON. Do you or your staff exercise any editorial review? Mr. RAEEEN. Only in respect to, you might say, the television verities. There are some subjects, which do not seem to do well on television, for which print, I would say, is a far better medium to present certain conceptual subjects which are hard to justify tele- vision for. Television is best for procedures or behavioral matters. In that sense then we might vote against doing a program, or maybe having developed a program, not go ahead and release it because it would justt~4rn out to be boring. Mr. GORDON. Well, let me ask a specific question.. Suppose that you had a program-~or pe~rhaps you would avoid it completely-which denigrates the product of a particular adver- tiser. Would you run it? And have you ever run such a: program? Mr. RARBEN. Well, over the y~ars there are denigrating statements in our programs about the products of many, many pharmaceutical companies, including those of Roohe Laboratories, which has' been the sponsor of NOME. I do not believe there has been~ let us say, one program whose title would be, oh, I' do not. know, "What is Wrong With the Drug Industry," something of `that sort. But there are many unfavorable comments mad~ `about the products of our own sponsors as well as others. ` ~ Mr. GORDON. Do you have any specifir examples? `` Mr. ~AEREN. Well, I' did not bring any. I would be very i~leased to assemble I think probably a very, very long list of such for you subsequent to today. ` : `Mr. GORDON. Did you ever~ have any programs on diabetes, fOr example ~ ` ` ` Mr. RABBEN. Oh, we have had a number of programs on diabetes. Mr. GoRDoN: Did you' ever have a review Of the UGDP" study; that is, what it found, and any of the confirmatory studies which PAGENO="0056" 13962 COMPETITIVE PROBLEMS IN TW~ PRUO INDUSTRY show that there is a higher rate of mortality in those who use the oral hypoglycemic drugs as against those who do not use them? Mr. RAEBEN. I cannot answer that from memory. It is just pos- sible that I will discover that in the catalog. Now, I am afraid, how- ever, I may be under pressures of ti~me and I might not. Mr. GORDON. How about the dangers of chloramphenicol, and clindamycin and lineomycin? Have you ever had programs like that? Mr. RARBEN. Yes; we have, had u~any such programs. And I do think I deleted because it seemed m~jodramatic as I reread it to myself this mornings the statement that thes~ programs are our silent witnesses here. There were many programs ~r portions of pro- grams which do indeed point out hazards of drugs in ways that perhaps would not make some members of industry happy. The phy- sician is not told what to say or what not to say at all, and presum- ably he expresses his own best judgment. I do think that in assessing the dispassionateness on those issues of these programs, the best witness is the program. And if you would like I would be pleased to as~emble examples for you where you are welcome to select at random from the catalog and your staff can examine them. Mr. GORDON. Could you submit those for the record? Mr. RAEBEN. I would be very pleased to.1 Mr. GORDON. Well, let me ask you this: Do you know of any re- lationship between the members of your national board, your Medical Advisory Committee, and the drug industry? In other words, have they ever been consultants, investigators, officers or any way con- nected with the industry? Mr. RALBEN. Well. I think Dr. Coggeshail was on the board of directors at Abbott Laboratories at one time, I guess that is the only relationship I know of. I cannot speak from my own knowl- edge beyond that. Mr. GORDON. Well, we asked the Food and Drug Administration if they had any record of the people that you have on the board of consultants and the Medical Advisory Committee, and they said that their records show that 9 of the 19 are connected in some way with the pharmaceutical industry. About the rest we do not know. They may be or they may not be. But we know of at least nine. Mr. RAEBEN. Excuse me. Are those nine connections of the sort that would cause you to call in to question their probity? Mr, `GORDON. Well, they are investigstors for the industry. They have some connection, Of course, as you stated. Dr. Coggeshail was a director of the Abbott Laboratories. lVhat that means, I do not know, but it is an interesting fact, nei~ertheless. Go ahead. You were on page ö. Mr. RABBEN. I gaess I was going to say that we h~ve worked with Government or~anizations' at some len~'th. We have rendered assis- tance to the National Library of Medicine. We have disseminated information to physicians at the request of the National Center for Disease. Control. and for many years we have supplied p~gr~ms without cost to VA and other Government hospitals and institu~ions. 1 `See letter ~ate~ July 9, i97~. to Senator Nelson, from Jay B. Raeben, preskleat, V~~ual Information Syatems, page 14400. PAGENO="0057" COMPETITIVE PROBLEMS IN THE DRtTG INi~USTRY 13963 Another project in which we are active is called AVENS, audio- visual education in neurosurgery. That is a video cassette, mono- graph, and slide service, what is popularly termed a multimedia system. Subjects and their presenters are chosen by the Society of Neurological Surgeons which began the project with the support of a grant from the John and Mary R. Markle Foundation. The programs are sold to neurosurgical training centers and to individual neurosurgeons. But as the number of subscribers is small-about 125 have bought the first series of 10 programs-the pro~ject is far from self-sustaining. Because the distribution and production, ap- paratus constructed for NCME is available to us, we can contimie AVENS at our own expense and we are doing so. Some of the pro- grams are said to be among the better teaching of any sort ever done in neurosurgery. Without foundation support, however, AVENS could not have been begun and without our own assistance, I am not sure it could continue. Senator Ni~so~. How does AVENS, audiovisual education in neurosurgery, fit in with your NCME program? Are they related? How does that work? Mr. RAEEEN. Well, there is an overlay of some staff and technical facilities. Were it not for that overlay, I think the point I was making was that AVENS probably could not exist. It is independent of it in every other sense. And, of course, there is no pharmaceutical company involved in AVENS. Senator NELSON. What you are saying, then, is that there is no funding directly for this specific project by pharmaceutical com- panies. Mr. RAEBEN. That is correct. Senator NELSON. Go ahead. Mr. RAEBEN. The next project we are engaged in is the American Academy of Ophthalmology and Otolaryngology which was estab- lished in 1971 as continuing education in video cassette form. We act as the academy's video publisher. Production moneys have been provided by the academy. Program subjects and presenters are selected by the academy, and the majority of programs are produced by the presenter, often with university television facilities. The pro- grams are sold to ophthalmologists and otolaryngologists. About 200 subscriptions have been sold to each group. The cost to duplicate, market, and distribute these programs is borne by VIS, The service will require a very substantial increase in sales to be self-sustaining. As with AVENS, we are pleased to be associated with the project because, in the long runs it should Qnhance our position as a pub- lisher of good medical education in television form. As with AVENS, however, it raises the question, can such education exist at present, and in these forms, without subsidization? Physicians Radio. Network, or PRN, is our most recent service. It is ~a 24-hour-a'day, 7-day-a-week medical news, information and education service for physicians. It is transmitted over special FM frequencies. It requires a special receiver provided by us without charge to the doctor. Senator NELSoN. Does Physicians Radio Network then have an FM channel of its own? PAGENO="0058" 13964 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Mr. RAEBEN. No; we lease what I refer to as SCA's or sidebands of FM stations in different cities and transmit from our offices by wire the same way that, let us say CBS or NBC transmits really, to the transmitter of the individual station which is the FCC licen- see which holds those frequencies. Senator NELSON. `rue Physiei~ns Radio Network does not have any stations of its own. Mr. RAEBEN. That is correct. Senator NELSON. You lease a band from an established licensed radio station. Is that it? Mr. RAEB~N. Yes. That is correct. Senator NELSON. And then you broadcast your programs through the station from which you had leased a band and they run it. Is that correct? Mr. RAEBEN. No. Senator NELSON. Well, how does it work? Mr. RAEBEN. We broadcast from our offices to the individual cities where the stations are. The signal then goes out into the air just as a radio signal normally does. Senator NELSON. That is what I thought I was saying. Mr. RAEBEN. Oh, I am sorry. Senator NELSON. YOu send it to this station from which you leased a band on FM, do you not? Mr. RAEBEN. Yes. Senator NELSON.. And then they broadcast it on that band. Is that correct? Mr. RAEBEN. Yes. Senator NELSON. They are transmitted from your headquarters or office. Is that correct? Mr. RAEBEN. Exactly, yes. Senator NELSON. Then it goes to this special receiver which the physicians will have. Mr. RAEEEN. That is correct. Senator NELSON. I see. Mr. RAEBEN. I am sorry. When you used the word "company," for a moment I thought you were referring to pharmaceutical companies. I was confused. Senator NELSON. No, I did not intend that. * Go ahead. Mr. RAEBEN. We began research .on the technical feasibility of PEN in 1965. Over *a period of several years I tried unsuccessfully to interest both the Federal health establishment and major medical associa- tions either in supporting this project, or in joining me in a com- mon search for support. In April 1974, broadcasting was started in two cities . to test whether physicians would. ~isten and whether they might pay for the service. We learned that a ~physician.subscription approach was impractical. However, listenership was quite high and it encouraged us to go to industry for support. We offered PEN both as a new a ~lvertisrng medium and one, with high prospective social utility. Today, five companies advertise on PEN. They are; CIBA Pharma- c~iitical Co., Merck Sharp & Dohme, Pfizer Laboratories Division, PAGENO="0059" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 13965 Roche Laboratories, Smith Kline & French Laboratories and S.K. & F. Co. We hope to have more sponsors in time. There are eight 1-minute advertising messages in each hour. These fall in a strict rotation planned weeks ahead, clearly with n~ knowledge of the news items they will eventually be adjacent to. The service now broadcasts in 23 cities to about 21,000 physicians. By yearend we should be on-the-air in 30 cities, reaching 75,000 physicians. Our longer-term goal is about 150,000 physicians, half the Nation's doctor population but far more than half of those active in patient care. At present, PRN programing is a single hour, repeated 24 times and changed each dat. In each city, local medical news is also broad- cast every hour, generally with the cooperation of the local medical society. This summer we expect to begin updating the programing twice each day and we can broadcast an important bulletin any time. Although PRN has been primarily a news service~ we are now beginning a continuing education series as well. This is a pro- gram, 15 minutes or so long, and repeated 20 to 30 times in t1~e week. It is accompanied by printed self-assessment forms mailed to the physician. If our audience finds this programing useful, we think it should be a regular part of the radio service. Senator NELSON. May I interrupt there? Two or three sentences above you say, "At present, PRN programing is a single hour, repeated 24 times `and changed each day." And you say that you are "beginning a continuing education' series," which would be 15 minutes or so long and repeated 20 to 30 times in the week. What is the 1-hour program that you have now that is repeated 24 times a day? Mr. RAEBEN. It iS essentially news, L- 2- or 3-minute long seg- ments. If there was a medical meeting going on someplace this week, reporters might have interviewed a physician at the meeting to* get a statement from him. If there was something `that happened in Washington that might affect the' practice of medicine, that sort of thing. Senator NELSON. So it is a 1-hour program each day run 24 times? Mr. RAEBEN. Yes. It is just run continuously. Senator `NELSON. And that is just news on medical events of some kind or another. Is that it? Mr. RARBEN. Yes, that is correct, Senator NELSoN. And now you ha~re started an education program of 15 minutes? Mr. RAEBEN. We are going to try to takeS portions of this Veat amount of time, this 24 hours in the clay, and see if we cannot pro- vide materials that Can have additional benefits to the audience. So a sort of an obvious thing is to take; longer periods rather than the 2 or 3 minutes devoted to news `and try to teach something.. Senator NELSON. What is the current `cost of putting on these pro- grams and what is the project cost `when you iziitiate' it?.. How large an audience do you expect to have-around 175,000? Mr. RAEBEN. Perhaps 150,000 physicians if we are successful. Senator NELSON. What is the current cost now to the: drug com- panies for sponsoring these programs? ` PAGENO="0060" 13966 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Mr. RAEBEN. The drug companies'-depending upon the size of their advertising commitment-cost ranges from about $200,000 for a year up to perhaps $700,000 for the year. This is a function of the amount of advertising time they have purchased. Senator NELsoN. What is the total cost for all the companies? Mr. RAEBEN. Well, this is a fluctuating number as we hope to be acquiring additional advertisers. Senator NELSON. I was wondering, what is the current annual cost of the program., not to the advertiser, but the total cost? Mr. RAEBEN. Well, the cost is at this point substantially in excess of our revenues since we are in the building stage. This is really an investment activity of our corporation and it is substantially in excess of what we can recover from advertisers. I think it will be some time before advertising has caught up to our own expenses. Senator NELSON. I am interested in the total costs, if you have it at hand. Receipts from advertising don't cover all your costs. You have your own costs, which are higher than that, because you are making some capital investments. Is that it? Mr. RAEBEN. Yes. Senator NELSON. Well, then what is the total advertising budget thus far on an annualized basis? ~ Mr. RAEEEN. Well, at the moment I suppose our advertising reve- nues might be running at the rate of $2 million for the year. It is a difficult calculation for me to do at this moment. And as I say, we hope that for any given period-say, the calendar year-it will be a different number. Senator NELSON. All right. Go ahead. Mr. RAEBEN. If practicable, we intend to offer blocks of time for teaching purposes to the general and special medical associations which presently have the training and education responsibility for their constituencies. It seems surprising to us that until PRN, medicine had no medium to transmit important information quickly. If regional or national health crises threatened, there was no way, except in sometimes in- appropriate public media, for medicine to communicate about it. Setting aside the matter of emergen~ies, if a scientific advance of any importance takes place, many months normally elapse from authorship to publication. Many more months elapse before con- firmation or rebuttal by others. Our hope is that by accelerating this process, by telescoping into a few months, or even weeks, a dialog that now may take years, PRN can have a genuine impact on medical progress not achievable in any other way. PRN news is reported by medical correspondents throughout the United States and by a permanent office staff of experienced medical journaiists. Decisions on which 25 or 30 stories make up the daily broadcast are made solely by the editorial staff. Advertisers play no part. We have made a considerable effort to determine how much physicians listen to PRN and I believe we have excellent information on this, better perhaps than that possessed by many other media used for medical communication or education. We assume also that sponsors will ultimately try to employ advertising measurement tech- niques on PRN messages. We do feel it is certainly important to protect education from un- due bias. And it is always reasonable to fear that he who pays the PAGENO="0061" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 13967 piper may call the tune. That, however, has not been our experience and I hope thatmy presentation bears this out. Tha~rk you. If I might add a comment to my presentation. Senator NELsoN. Yes. Mr. RAEBEN. It has been difficult to think while speaking, but I have been reflecting briefly over Mr. Gordon's observation that nine of our medical advisors appear to have or have had some relationr ships to the pharmaceutical industry. Two thoughts come to mind. One is there may be a very considerable difference between having a relationship to an industry and being in some sense controlled by or responsive to it. Again, it is certainly well to look into it. But 1 think in respect to people we know on the board we have worked with, it would be astonishing for me to discover that they were indeed especially compliant to industry and I think that should not be left as an inference for anyone to draw from that earlier statement. The other observation is that the board has been assembled by us normally one educator identifying another, saying Dr. Smith is very active in the American Academy of Family Practice and is very in- terested in continuing medical education. And then we would go see him and ask him if he would be willing to serve. If it turns out that at some time in his career he had done some clinical investigation or something of this sort for a pharmaceutical firm, we have never done the research that the FDA apparently has been diligent enough to do so we would not know that. And I have to say, and again I think our programs bear this out, there would appear to us to be no irnjus- try bias in the programing content, and I do think they are the wit- nesses that the subcommittee should examine with respect to that point. Senator NELSON. Thank you very much, Mr. Raeben, for taking time to appear this morning. Mr. RAEBEN. Thank you for having me. Senator NELSON. We appreciate it. Our next witness is T)r. Henry Simmons, senior vice president, J. Walter Thompson Co., formerly Director of the Bureau of Drugs in the Food and Drug Administration. Dr. Simmons, the committee is very pleased to have you take the time to appear this morning and give us your views. We appreciate it. STATEMENT OP H1~NRY E. SIMMONS, M.D., M,P.H., SENIOR VICE PRESIDENT, L WALTER THOMPSON CO., NEW YORK, N.Y. Dr. SIMMoNs. Thank you, Mr. Chairman. Likewise, I appreciate your invitation to testify today, the subject being the transfer of medical information, or technology transfer, h~w to bring about appropriate behavior changes in the use of drugs by the public and health professionals, but most specifically, hOw the tool of social marketing can help bring about necessary improv~ments in these areas. We are all aware of the serious problems which today face the health care system. Those include rising costs~ quality of care, lack of standards for care, problems in compliance with therapeutic regimens and problems on information and technology transfer. And for the purposes of this discussion, I will consider any useful new medical PAGENO="0062" 13968 COMPETITIVE PROBLEMS IN TH~ DRUG INDUSTRY information as synonymous with technology which must be trans- ferred from its point of origin to those who need it-in other words, to health professionals and consumers-to enable them to make ra- tional decisions and ultimately to maximally enhance or preserve the health of the public. Many of our problems in the health care system are due to de- ficiencies in information transfer or deficiencies in efficient and effec- tive technology transfer. And there is a wide and probably widening gap between what we know should be done and what is done or practiced in this Nation's medical care system. Problems here exist in the premature introduction of inadequately tested technology, the failure to eliminate outmoded technology promptly and the failure to rapidly adopt new technology which has been established as bene- ficial. Examples of the latter include the inadequate use of drugs available for the treatment of hypertension and immunization against the common childhood diseases. We have all witnessed with dismay the spectacle of important new scientific information falling on deaf ears, or, worse, remaining unspoken at all. Time and time again, the objective of research, which is benefit to the consumer public, has been frustrated as the communications abort. Mr. GORDON. Dr. Simmons, where are you reading from? Dr. SIMMONS. I am on page 2 of my statement. Mr. GORDON. All right. Dr. SIMMONS. The disparity between our operant knowledge of communications and its application is crippling and, finally, intoler- able. Mr. Chairman, you are well aware of the frustrations of the Congress as it surveyed HEW's efforts in technology transfer. And that is why I ventured into the world of communications, to see if there were elements we have been overlooking in our efforts to implement the health information we possess. And the answer to that inquiry is resoundingly positive. A brief overview of the technology process of biomedical research communications point them up. There seem to be two factors which necessitate taking a fresh look at how effectively biomedical communication or technology transfer are conducted. One is the fact of the sheer volume of information now being generaited, many thousands of discrete items per year, and the other is the fact that many of these findings now require the active cooperation, oftentimes necessitating a reversal of long-term prac- tice, attitudes and behavior, not only of health professionals but of the public at large in order to become beneficial. A pair of commu- nications t.asks are then manifest: Sensitive priorities and persuasive messages. The two tasks are inextricably intertwined ait each of three stages of communication between: (1) Scientist and scientist; (2) between scientist and practitioner; and (3) between scientist/prac- titioner and the public. CommunicatioDs between scientist and sci- entist are the most effectively managed at present, and a communi- cations expert would probably attribute that to the following factors: (a) Biomedical scientists are a relatively hornogenous population conditioned by a well-understood set of procedures and underlying principles of investigation; (b) Scientists communicate with considerable precision through the use of an assiduously defined and a carefully used set of lan- guage and symbols; PAGENO="0063" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 13969 (c) The scientific community is largely premotivated to under- stand and implement accurately what new information is communi- cated to them, as the price of neglect to do so is eventual if not im- mediate failure at one's life work, giyen the high degree of peer review and testing operative in science; to discover error is to fur- ther one's success, in pure terms; (d) The channels of communication-primarily scientific journals, seminars, and working papers-are relatively few in number and are attended by virtually all scientists active in a given field; addition- ally, they have ready access to supplementary data through efficient storage and retrieval systems now in place; (e) The context of communications' reception is businesslike and absent of significant diversionary messages or efforts to persuade opposite conclusions for nonscientific reasons. Although some of the assumptions above may be subject to thoughtful evaluation in the field, requiring some modification, they are probably reasonable, for our purposes. Taking the same cate- gories, however, and applying them to subsequent stages of cOm- munication en route to the goal of consumer-benefit, it quickly be- comes clear why the process breaks down. Between scientist and practitioner, the factors are different: (a) Practitioners' diversity is encouraged by such forces as the development of medical specialities, the emergence of para- .and sub- professionals, and the flourishing of competing attitudes and philos- ophies of treatment, oftentimes influenced by such idiosyncratic ele- ments as practitioners'. personality; (b) The motives of practitioners are highly diversified, ranging from the totally altruistic to the totally materialistic, and the re- sponsiveness of practitioners to new information is not as subject to the rigorous process of peer review and interdependence which characterizes the scientist-to-scientist communication; nor is the con- troverting of previously held data taken as sheer advance of knowl- edge: The authoritative contradiction of current practices may be thought-by both the practitioner and his client-to reflect unfav- orably on the practitioner; (c) Channels of communication drawn upon by the practitioner include not only professional literature from sanctioned scientific sources but also professional polemics, pharmaceutical and other medical industry information or rebuttals, Federal and other reg- ulatory documents, continuing education materials of uncertain con- sistency, and popular media; and (d) The context of reception of communication is awash with di- verting and/or competing messages. Now as complex as the factors in the scientist-to-practitioner stage appear, they all but pale when compared with efforts to com- municate with the public whose informed cooperation is increasingly the sine qua non of translating scientific advance into personal health benefit. And here we h.ave to contend with awesome obstacles: (a) The diversity of the public is patent, manifested in literally dozens of subgroups segmentable by demographics, and medically relevant predispositional factors. (b) And far from sharing a finely honed operational language constantly redefined in function, the various publics rely on figura- tive and connotative-and even nonverbal-communications for the PAGENO="0064" 13970 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY most part; and these, of course, are subject to a nearly infinite range of local and regional expressions and interpretations; (e) Whereas the motives of the scientist to heed new knowledge are relatively clear-cut and positive, the motives of the individuals in the public are thoroughly contaminated with inhibiting forces, ranging from fear of discovering disease or risk, to unconscious perpetuation of self-defeating behaviors, to lifestyle habits; and the example of their peers tends, by and large, to support a willful re- sistance; (d) The channels of communication used by the public are legion, including every imaginable medium of mass communication, local health professionals, family and friends; (e) And, finally, the context into which health communications come, is cluttered with stimuli to an unimaginable extent; it is esti- mated that in a given day, the average person is subject to more than 5,000 separate communications seeking to promote. some re- sponse; no small number of these seek to reinforce the behaviors which may be inimical to health, and others reinforce misinforma- tion and confusion. Now, in addition to recognition of the awesome obstacles to com- munication mentioned above, a communicator must be aware of cer- tain principles of effective communication. They are: One: The first of these principles is to assume noncompliance from your audience. In the case of physicians, we know that they are bom- barded with literally thousands of messages in the course of a month which deal with technical drug information, new drug intro- ductions, new research findings on existing drugs, new FDA regu- lations, and so forth. We should assume that these physicians will not necessarily do what the messages ask them to do or even listen to the messages. Two: A mistake is commonly made in communications to assume that information is enough to produce behavioral change. Now, if information were enough, very few people in this country would still be smoking. On the side of every pack of cigarettes sold in this country there is a warning from the Surgeon General stating that cigarette smoking is harmful to health. We can assume that every smoker has been informed. Many, however, have not yet been per- suaded. Three: It is unwise to assume that a need is recognized by the intended consumer of a product or program. As an exampl~, per- sonal hygiene is a self-evident need from the point of view of health departments everywhere, yet in country after country that need has had to be explained, or, if you will, sold. And very few farmers rec- ognized that they needed a tractor the first time t:hey saw one. Four: Do not take relevance for granted. It is possible to per- ceive a need without understanding its applicability to you. It is pos- sible to listen to a message and yet not hear it because the language is that of another age group, another social class, another ethnic group. Five: The mass market is a fiction. Our population is made up of an accumulation of special markets with special attitudes and interests. Communications must be designed with a precise knowl- edge of the group or groups to which they are addressed. PAGENO="0065" CO~PEpITflrE Pfl0flL~MS TN TH)~ DRTYG I USThI~ 13~7i Six: Repetition is necessary both for widespread awa~reness and for the mamtenance of that awareness. Seven: Conflict of information exists in most significant com~ municationg areas. It must be allowed for and dealt with. Eight: In all areas there are barriers to persuasion. In the health care area these are frequently profoundly emotional and must b~ clearly understood before communications are undertaken; and Nine The relationship between stimulus and response must be clearly understood. A message is a Stimulus, the teceivér's reaction to that message is the response Professional communications start by identifying the response that is desired from the target audience before `developing the message. The desired response should dictate the message, not vice versa. It is very dangerous to assume that your audience will receive your idea exactly as written. They will color it; they will change it; they will interpret it. In short, by making it their own, they can also make it different from what you int~nded. Mr. GoRDoN. Dr. Simmons; may I interrupt you for a second? At one time you were the Director of the FDA's Bureau of Drugs, and you had a lot to do with professional review organizations, tao, the PRO's. During that time studies have shown that certain drngs have been misused and overused, and the FDA and its expert ad- visory committees have tried to change the prescribing habits of the medical profession. What methods were and are being used by the FDA to try to accomplish this end? Dr. SIMMONS. Mr. Gordon, it is difficult for me to answer that because, remember, I haste been away from FDA for 3 years, and it would really be unfair for me to answer that question. I think 1~hat is more appropriately posed to the Bureau Director or `somebody also. I assume they are at least using what we used at the time, I am not clear enough on what has been `added to that `armamentarium since that time. At that time, as you remember, we had warnings, regulations, drug bulletins, and sometimes press conferences, those traditional kinds of things. How much that has been buttr~ssed since that time I do not know. Mr. GORDON. All right. I think it is about the same at this time, the FDA bulletins, t~ear Doctor letters, FDA consumer messages. Is it your opinion, then, that the methods now being used are in~ adequate and do not achieve t'he desired results? Dr. SIMMONs. Well, I think you would have to answer the point question by question, frankly. In some areas, clearly, the informa- tion does get over; in some areas it does not get over, The drug in- dustry has the same problem, you know, in getting the profession to understand the need to treat hypertension. Both Government and the pharmaceutical industry have been trying very hard to get across a v~ry important and worthwhile message and it is a terribly dif- ficult kind of a thing. So in that area, I would say both Govern.~ ment and the pharmaceutical industry have been less successful than would be warranted in the public interest. In others, you know, I think, as I said, case by case it would be easier for me to answer that. PAGENO="0066" 13972 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY So in the marketing of goods and services, which for 106 years has been the daily business of the J. Walter Thompson Co., they have developed a plan for the production of communications which help solve a client's marketing problem. This. is called the "T" plan and consists of five steps. The "T" plan process contains, no magic. It is simply organized commonsense, a method designed to help arrive at an accurate fact base and to help avoid operating under false assumptions. It in- volves the posing and answering of five very basic questions, ques- tions designed to focus and concentrate thinking where it will be most productive. And though I will list these questions in a certain order during the development process, as the environment changes or `new information becomes available, we will backtrack, reasking and reanswering certain questions. It is, in short, a fluid process that we can never assume is finished. And even when success is achieved, continual pressure must be used to maintain that degree of success. In attempting to motivate people, in making a deliberate attempt to influence change and not just passively react to events, we need the best planning possible. In answering the following questions, we make important strides toward that end. Those questions are: Where are we and why are we there? Where do we want to be? How do we get there? Are we getting there? And should we change direction? In the application to social problems of the principles I have de~ scribed, coupled with the asking and answering of the questions I have just posed, is what we describe as "social marketing." Social marketing is defined as the design, implementation, and control of programs, calculated to influence the acceptability of social ideas. It involves considerations' of program or product planning, pricing, communication or education, distribution, and marketing research. And these marketing techniques, serve as the bridging mechanisms between the simple possession of medical or health. knowledge and the socially useful implementation of what such knowledge allows. So that in the hands of its best practitioners, "social marketing" is applied behavioral science. I would now like to describe how the technique of social market- ing would be applied to solve, a major current medical problem involving a type of drug use, and the case in point is the necessity to immunize almost 200 million Americans ao~ainst swine influenza before a new flu season begins this fall. A re~iated and also urgent problem, is the need to raise the present dangerously low immuniza~ tion `levels of many American children to the recommended levels `for the common childhood thseases. Now without use of these social marketing techniques it is' unlikely that success in either~ area will be achieved sjnce both problems are much more complex than they would appear to,be, at first glance, and both will require wide public understanding, acceptance, and support ~if we are to succeed. So the first 4uestion posed in such a program would be where are we and why' are *~ there? And we. find that, posing the question in this problehi seems simple, but the, intelligent answering of the ques- tion `will probably require the employment of a number of dif- PAGENO="0067" COMPEPTTIVE PROBLEMS IN TBE DRUG INDUSTRY 13973 ferent research techniques. We must know what consumers' attitudes are toward immunization in general and toward the swine vaccine in particular. Does the very name "Swine Influenza" create confu- sion? In other words, someone asking, since I have not been near a pig in the last year, am I safe? What do doctors think of this immunization effort? Do they agree with the position taken by au- thorities? And certainly not all agree. And the press in recer,tt week~s has given a great deal of attention to doctors of opposing views who maintain that immunization itself poses a greater risk than tho imagined epidemic it wants to alleviate. Will newspapers and journal- ists considerably hamper this effort or are they doing so now? And those are but a few of the points that must be clarified. The second question we must ask is one that sets the goal we a~e attempting to achieve, "Where do we want to be?" And, again, we should attempt to answer this in the most detailed manner possible. Not only do we wish to have immunization of all Americans by later this year, but we would like to have immunization of high-risk individuals first. In short, a complete timetable must be developed for different audience segments, identifying high-risk groups and areas as well as a host of other factors. The third question takes us from the area of planning and into the harsh reality of execution. Question No. 3 is "How do we there?" And I will not go through a detailed listing of all the strat- egies that are involved in the process, but I would like to mention a few. First: In the area of audiences and audience segmentation, we would begin by specifically identifying our target audience, their geographic and demographic characteristics; in short their prof1l~s and what groups they would logically fall into, And having iden- tified our audience, we would define through market research those specific appeals most effective at eliciting the desired response from each segment. For instance, it may be found that the suburban house- wife should be the primary target for our communications in kid- west areas where the median income is $20,000 and above; and it might be determined that the appeal most effective with her would be love of family or the desire to be a "good mother." It may, l~ow- ever, be found that in other income areas of the city that the father should be the target, and perhaps the most effective appeal with him would be pride in being a good protector. In short, we must develop the most appropriate fact base and make the most effective appeals to the proper audiences, and we must rigorously resist operating under false assumptions. We would also identify the actual materials and messages, and the actual public relations strategies and approaches that wou1~l be needed. Mr. GORDON. Dr. Simmons, may I interrupt you for a second? Dr. SIMMONS. Yes. Mr. GORDON. Are these the principles that drug companies use to construct the programs to sell drugs? Dr. SIMMONS. I do not know if they use all of them, Mr. GOrdon. I would imagine that they use some of them. And 1 think that the technique you would use would depend on what particular thing you are trying to accomplish. And I am trying to describe fot you PAGENO="0068" 13~74 COMPE1~XTWI~ 1~ROBLEMS IN TIlE DRTLTG INDUSTRY the most complex kind of a social change involving a drug use that we have on our doorstep right now, to point out to you that it is much more difficult than most laymen realize, and that is `what I am trying to get across in this whole piece of testimony, that sim- ple solutions are probably not going to work. And maybe at the end of this testimony some other questions might `be helpful to clarify. Mr. GoimoN, Well, many of these principles are used,. though, in constructing a campaign to sell drugs or a particular' drug. Is that not correct?' Dr. SIM~.ONS. Some of them are, yes. Mr. GoRDoN. Now, since the doctor's character, personality, social status, and so on, has been analyzed before he is' even approached, `how can `he resist the sales campaign when it comes? It is rather difficult, is it not? Dr. SxM~xoNs. Well, I am not sure how difficult it is. I think it would be the same way as you and I as human beings resist many of the thousands of messages we get every day. We all filter them. We sill believe certain sources of information: and `automatically reject others. I am not sure that automatically because a message `comes, somebody immediately collapses, and succumbs, and agrees. That is not an easy job to `do. And, `again,' I think it would depend on who you are `trying to reach. Some people are much easier to `convince than others~ and physicians being the same way. And one of the purposes of your research is to see what the background is, what the biases' are, what the barriers are, in the whole variety of audiences that you must reach with what you consider a useful message. So there is no one answer to that. Some will be easy to reach, others will be diffiëult to reach. You `have got to identify that before you can be successful in accomplishing your goal. I will not go through then the number of things you might have t'o prepare for the campaign, but as you can see, it is a fairly im- pressive list of things that would have to be produced. And all of those materials that are outlined there in the upper part of page 13 have to be developed in various language versions for `there are many in our society today who are illiterate or non-English speak- ing. Having segmented `the audience, identified the appeal, developed the creative materials, the next step is media placement; and in this step, as in all other steps, you must have planning which includes stated objectives, strategy to meet those objectives, an agreed upon timetable, and also a method' of' evaluation to find out if, iii fact, you have met your' objectives, and if not, `how you can make adjust- ments in the overall plan. In the area of media it is imperative that reach-defined as the percentage of each audience segment you wish to `appear before- and frequency-or the number of appearances-targets be developed for all `audier~ces, developed on a week-by-week plan, and that in the influenza campaign specifically, build toward a peak before October 1976, which might be your target date. Another crucial factor is manpower. We might broadly subd~vide this into three different areas, and those, of course, can be subdjvid'ed `again arid again. For purposes of this `discussion, let us concentrate PAGENO="0069" CO~tPETITIVE PROBLEMS IN TEE DRUG INDUSTRY 13975 broadly on volunteer organizations, professional organizations and business organizations. Certainly the core of the effort in the influenza area will be the professional organizations, and we must secure the active assistance of such groups as the medical profession, nurses, and others outlined in that paragraph. In the area of implementation, certainly a de- tailed plan must he made for each group dovetailing their actions with the other manpower groups. A second group would be volunteer organizations, and there is a vast reservoir of organizational and creative talent, a reservoir whose efforts are vital to the success of this effort. And the campaign w~ would have to enlist, `train and supply with localized market plans, community action plans, timetables and quotas. I will skip now, Mr. Chairman, to' page 15 because there i.s de- tail there that I `do not believe we need to go into. But strategically we want to plan for the optimum use for the system of delivery and the manpower that we have available. We want control traffic flow. And certainly that program will be a failure if all children appeared on Monday, October 25 for immunizations. We must con- trol the flow of traffic. We must plan for and attempt as far as pos- sible `to guarantee the orderly use of clinics, `school locations, ar~d others. And having established the system,' we must also, through com- munications, create an awareness `of the locations, times of opera- tion, the fact of its convenience. And those arc just the highlights of some `of the actions required for a successful program. But hav- ing put a pl'an in motion, question four arises. In other words, "Are we getting there?" And in far too many cases, programs are enacted at great e~pe'nse and never evaluated. Only by answering' this question do we have a sufficient fact base for future decisionmaking. As it pertains to immunization, we must ascertain what our suc- cess ratios are with each of our target publics. Are we rca~hing the inner cities but not the suburbs? If so, why? Are we 20 percent' more successful in the Midwest than on the east coast? If so, w'hy? Are our late night television commercials or television shows on shows that `have a sufficiently high rating? And only when we have this kind of information can we make the decision called for in our final question~ in other words, "Should we change direction?" We must believe that no part of a strategy is sacrosanct, and if we `have been thoroughly objective in our answering of question four, we will `have set the stage `for effective decisionmâking at this point. We might simply engage in finetuning., such as seeking increased commercial exposures to the 20 to 30 age groups or by eliminating mobile van immunizations as inefficient delivery tools. We might, however, have to rework our entire appeal or possibly scale down our objective. Now, Mr. Chairman, I apologize for going into such detail, but I thought here is a social cog in front of us. It involves the u~e of drugs that is a worthy purpose, and I do it mainly to illustrate `for this committee the difficulties of the communication process. Social marketing is a tool in the bringing about ~ social eh'~nge. And the approach I have just described for a successful immuniza- PAGENO="0070" 13976 COMPRTITIVE ?ROELEMS IN THE DRUG INDUSTRY tion effort might be equally for the successful transfer of any new information on drugs, the achievement of appropriate behavior change in the use of the drugs in question, or improvement in com- pliance with therapeutic regimens which, is today such a serious problem. A case in point would be the implementation of the drug- use changes warranted by the results of the coronary drug project or indeed the implementation of any new beneficial or adverse drug information. Some of these same social marketing techniques should be applied before major fundamental procedural changes are promulgated in the drug area, such as the requirement for patient~ package inserts for all prescription drugs. For unless this is required~ neither so- ciety or policymakers will have any way of knowing whether a de- sirable end is achieved by a new policy. In summary, I have attempted to describe for you the difficul- ties inherent in the communication process, and the techniques nec- essary to bring about successful technology, and appropriate be- havior change on the part of health professionals and the public. It is clear that we are not doing this' job well today. And it is equally clear that information alone, or a seminar report, or a sci- entific article, or a study report, or a drug bulletin, or a press re- lease, or a regulation, or a warning alone, are not enough. The technique of social marketing does not share Government's apparent confidence that the public or health professionals care to listen, and to `act on what they hear~ Rather, the' practitioners of social mar- keting assume just the opposite, that both are bombarded with a surfeit of messages day and night, and they will resolutely ignore all but the most carefully crafted and persuasively conveyed com- munications which attract their attention. It is high time for all of us concerned about the health care sys- tern to acknowledge the clear truth of that assumption. There are many illustrations' of the bankruptcy of a passive communications policy.' Mr. GoRDoN. Dr. Simmons, what you are talking about is not ~ust the transfer of technology, as I see it, but `a method of changing beliefs and values, also. Do you see any possible dangers if the Government' uses these techniques to influence the public's attitudes and behavior? Dr. SIMMoNs. There is always a potential danger, Mr. Goraon, in these techniques in the hands of all who would use them. Clearly, that has to be recognized. And that has been recognized in instances where social marketing has been used before. In our society, where it is obvious to many groups as to what goes on. I believe that you can bring about the necessary controls and necessary `watching of this kind of a system by Government. The point I wish to make is that there are some important ends that society is trying to reach through the actions of its Government. Just abo~ut every major' government in the world uses communica- t~on differently than we do. The Government itself does. They use it because they feel the societal ends to be gained are appropriate to use the communication channels that way. `I believe there are in- stances here in our society where that same exists.' Mr. GoRDoN. How can we guard against abuses? PAGENO="0071" COMPETITIV~ PROBtEMS IN THE ~RTXG n~v~r~ 13977 `Dr. SIMi~tONS. W~ii; T think ~by tl~e very openness of the process that we work through ~ our society.' There is a press~ There are critics. There is the ability to speak out, the opportumty to corn- m~nt~ Theth ~tre divergent :vIews that ~an be brought to anybody's thessage I believe those are the safeguards~ in this syst?m Clearly~ it i~ important. Mr. GORDON. Is there any greater danger if ~th~ Government uses these techniques than if large corporations use them? Dr. `SIMMONs. Well I think there are `advantages t both entitieC using these techniques. Clearly, a businessman who has a product to sell has `to let somebody know about that product. As you know, that is ~iot only small business but big business has to do that. The Government also has messages that have to be made known. So, clearly, it should have use of that `technology also. But, they are certainly both appropriate, both warralhited. Mr. GoRuoN. I have a rather interesting example here. It. is an example where the techniques you advocate have been used in what, I am sure, you would regard as contrary to the public interest. Here is a release from the Pontotoc and Pottawatomie County Medical and Pharmaceutical Group.' It is fOr immediate `delivery and here it :1g. Generic Drug Substilution sppporters are few and far between now In Ol~la- homa's Pontotoc and Pbttawatomie Counties. Through the month of February, local physicians and pharmacists ran an ex- tensive advertising campaign to see if they could affect public opinion `about the question and generate enough tattgible evidence of this opinion to' defeat a substitutio~i bill currently pending in the Oklahoma Senate. Wheeler reported that the first survey showed that in Shawnee * * * that is in Pottowatomie County test city-S * * * over 38 percent of those questioned had beard about generic substitution, and' of these, `52 percent were for substitution, the majority of this group tndl- cating that they thought substitution would "help the elderly and make drugs generally less expensive". The survey indicated that 32 percent were against the question and 15 percent had no opinion. What happened wa's that the industry that they brought in con- ducted a campaign using techniques `that you rne~tioned, and here is an official quoting. ` , ` `We were surprised at the large percentage ot people in both cities who had heard about substitution and had fairly definite `opinions ouC way or the other. It would have been mi~cb easier to, start with the majority being uniufřrmed * * * we now recognized that our campaign bad to not: only implant~ an opinion but also to change existing opinions. What are the results of this campaign? ` ` Wheeler said that well over 2,000 cards and letters of protest were received by the legislators who represented these counties. In addition to generating what we feel is more than enough tangible evidence of opinion, our second survey showed the campaign did an exceptional job of changing public opinion. And it certainly did. For example, before the~ campaign, 54 per~ cent heard about the problem and 89 percent afterward. There was a 35 percent change in one area after the survey. Then for~ substi- tution, 43 percent, and 38 ~percent against it. But after th~ cam- paign, 16 percent was for it and~ 84 percent against it. In other words, there was a change of 46 percent. And in another. are~ there PAGENO="0072" 13978 COMPETITIVE PROBLEMS IN THE I)RUQ INDVSTRY was a change of 45 percent. In fact, the techniques you suggest were in changing the mood of the legislature and induced it to defeat any chan~es in the antjsubstitution law. This gives you an example of how that kind of technique can be used, not only to do things for the public but also-to do what I would regard and I think what you would regard as contrary to the public interest. Dr. SIMMONS. Well, Mr. Gordon, the techniques we are talking about here obviously have potential benefits and potential harm to them. My plea would be that clearly there has to be a balance. Every- body has a right to get their message across in this country as best they can. I personally would fight very hard to preserve that. My concern is that in answer to the question possibly one view is getting across more than another, some people have suggested that we ban the individual's ability to give his view. And one case in a hearing just here ~ weeks ago, I guess, before this committtee sug- gested that part of the answer may be to limit the educational ma-. terial flowing to physicians or to place some controls on that. Now, my plea is that is one approach. You know, the answer may well not be that is the best one. It may be to enable others to make their message heard also. And in that debate that ensues, per- haps the public's interest will really be better served. In other words, I do not believe that the answer may simply be to ban~l anybody's ability to tell anybody about what he does, whether it is a major corporation, the drug industry, or Government as far as that is con- cerned. And if we could get some balance into that, the balance could be brought by raising the ability of those who have informa- tion and t~hnology-NIH, FDC, CDC-to be heard equally well. And I do become a little concerned that the answer may be merely to inhibit ~he ability of one side to give its message. I am not sure that is the best answer~ Mr. GORDON. All right. Now let us take this specific case. The forces to retain the antisub- stitution laws had a lot of money. This is a very expensive cam- paign. Those who wanted to change, to remove, the antisubstitution laws had very little money. The public is unorganized. how can a public, which is unorganized, compete against well-organized, well- heeled private interest groups using these techniques? Dr. SIMMONS. Well, that is always going to be a potential prob- lem. That is what Government is here for, to bring some balance into the arena in the public interest. Further in my statement I make this plea. Mr. GonDoi~. Do you think the Government could have interfered in this local matter of antisubstitution laws? Dr. SIMMONS. Well, I am not sure that that is a governmental problem. But that was the right of a particular person to, espouse his views. And I do not think that anybody is recommending that we .elimiiiate that right. Mr. GORDON. It is certainly one sided., Dr. SIMMONS. In that instance. it was. And the answer is not nec* essarily to eliminate that individual's ability to say that but to en- able someone else with an opposing view to add his to the debate. And that really is, I believe, another possible solution to this. PAGENO="0073" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 13979 At any rate, in final conclusion, the health establishn~ent does have a "product," and it is a worthy on~ at that. And that prod- uct is information-vital, lifegiving information. But the hiegiving capacity of those data are often aborted in the absence of a deter- mined and effective effort to make them heard and heeded. The application of the techniques of social marketing will be nec~ essary for the technology transfer that NIH and FDA and others are required to `accomplish, and to impact on the prevention, early diagnosis of, and appropriate and timely therapy of disease. That will involve communicating with the public and the health profes- sions in such a way as to bring ~about apprQpriate attitude and b~- havior changes. At this point, it might be useful to recount some real life exam- ples of social marketing in several other countries. In Great Britain, we happened to undertake a 2-year e4ucational effort to prepare the entire population for the changeover from pound-shilling to decimal currency. We believe that this~ represents the most intense and successful social marketing campaign ever undertaken. And this necessarily involved not only the' comprehe~i- sive promulgation of somewhat technical data to a wide variety of publics-consumers, mer~hants, bankers, teachers-but also the c~il- tivation of attitudes favorable to cooperating in the effort. After all, they were phasing out a custom and habit of 400 years' stand- ing for the nation, and of perhaps 60 or 70 years' standing for many indi\riduals. But the campaign was profess~onaily wrought, govern- mentally financed, and publicly respected. It was effective beyond the most optimistic expectations. The Harvard Business School has happened to develop a case study on that which is being used now for teaching, and Mr. Chair- man, I would like to include that in the hearing record. Senator NELSON. We will receive it for the record.~ Dr. SIMM0N5.The same was true for an antidrug program in West Germany, directed primarily to potential teenage abusers. Once again, the professional marketing communicators employed their unparalleled understanding of their audience and of how cornm~ini- cation'~ might be used to effect real social change. They avoided mistakes made by other well-intended but less astute antidrug cam- paigns, and the project appears to hare rendered a demonstrable public serviee. in the eyes of the government of West Germany. * And I believe there are areas where we must now bend to our own ends the competence of professional communicators, in a delib- erate stroke of public policy, to accomplish widely desired health benefits. Such a policy is prefigured in other areas of public priority; the military, for instance. Al'l of the iTnited States armed serv- ices routinely engage in the use of marketing communications and paid media to ensure fulfillment of their recruiting obiectives And surely the objectives of the National Institutes of Health, ~`DA, and innumerable other health agencies are no less worthy. Every public agency which is party or privy to the development of technology has an obligation, it seems to me, to actively foster the fruitful application of that technology It is clear that in~orma- tion dissemination alone does not necessarily bring about `appropri- 1 Material not available at th~ie of going to press. PAGENO="0074" 13980 COMPETITIVE ~ROBLEMS i~ ~ DRT~ I~DTJSTEY ate change. The Congress can make that obligation explicit and ir- refutable by ~a'liing for each agency to demonstrate the provisions it has made to market its knowledge. Only then can we achieve a conscionable balance among medical technology, medical practice; the rights of the private ~sector to promote its viewpoint; agency ac~ countability, and, ultimately, the health of our citizens. Mr. Chairman, in the final reports submitted by the President's Biomedical Research Panel to the President just recently, which you I am sure have seen or read about. One of the major points they make is that' the transfer of technology from whoever has it into the public* arena for the public's benefit needs~ some significant improvements, that transferring technology down to where the rube ber meets the road,' the actual use by the public, significant prob~ lems in that area. The purpose of my statement is to describe a tool that could be useful to bring `that about. I mentioned as examples a major need in this country, the much more successful therapy of hypertension. We have useful drugs. We have a disease that have many millions affected by it. Many are being inappropriately treated. These kinds of techniques* are what I am talking about being applied `to an area of social need to bring about desired change. Thank you very much. Mr.' U0RDO~S'. Ho,w can small ,business firms take advantage of these techniques in selling its products in competition with larger ~1rms? Is there any way that you can think of that small business firms could do that? ` Dr. Sn~MoNs. They do it, reasonably successfully, now, Mr. Gor~ `don, when they haye a good product.' The examples `that I would think of woul4 be in the commercial area. Y,ou know, you could start back with the Xčroxes of the' world. When Xerox,started and when I?olaroid started, they were not major giants,, they `were very small. They `had something that was `seen' by society as `an advance, as something useful, something that they wanted to use. They used techniques such as this to establish their product and themselves and now they are large. ` I am sure it is not an easy process because the noise level in corn- `muniCation i's v~ry high. But is doable. And I think we have seen, as I have said, a number of examples in our own lifetime. `Some of the small pharmaceutical firms* that have deveioped~ good products That have gone from very small to having successfully entered the market through the, use `of these kinds of techniques.' `Mr., GORDON. Do you know which small firius? Dr. ,SIMMONS. I guess the one, that .1 might think of `specifically ~w'ould probably be the Syntex example, for ~aving developed a very useful class of products, having, started as, really a very small firm awhile back, n:ow, you know, being recognized, a `successful, reput- `ab1e~ useful firm. Senator NELSON. Thank you very, much, Dr. Simmons, for your very thoughtful testimony We appreciate your taking time to come here to appear this m,oriung ". Dr. SIMMONS. Thank y~u, sir. , `[Whereupon, at' 11:40 a.m., the hearing in the abOve titled matter was adjourned.] ` ` PAGENO="0075" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY (Present Status of Competition in, the Pharmaceutli~a1 Industry) MONDAY, MA~Y 24, 1976 U.S. SENATE, SUBOOMMITrEE ON MoNoPoLY OF THE SELECT C0MMIrrEE ON SMALL I3TJSINESS, Washi~rtgton, D.C. The subcommittee met, pursuant to notice, at 9:40 a.m,, in room 318, Russell Senate Office Building, Senator Gaylord Nelson (chair- man of the subcommittee) presiding. Present: Senators Nelson and Laxalt. Also. present: Benjamin Gordon, staff economist; and Karen Young, research assistant. Senator NELSON. Our first witness this morning is Mr. Earl Scher- ago, of Scherago Associates, New York, N.Y. Mr. Scherago, the committee is pleased to have you here this morning. Your statement will be printed in fttll in the record. You may present it however you desire. Would you identify the as~oci- ates here with you today so that the record will be correct.' STATEMENT OP EARL J. SCELItAGO, PRESIDENT,~ SCHERAGO, ASSO- CIATES, INC., NEW YORK, N.Y., ACCOMPANIED BY IOHN RINGLE, ASSISTANT EDITOR, "SCIENCE" MAGAZINE; AND ROBERT ORMES, MANAGING EDITOR, "SCIENCE" MAGAZINE Mr. SOHEBAGO. Thank you, Senator. On my left is `Robert Ormes, the managing editor of "Science" magazine. On my right is John Ringle, who is assistant editor of "Science" magazine. Senator NELSON. Go ahead, please. Mr. SCHERAGO. I want to thank you for inviting m~ here today. I have been asked to alert you to a problem which is jeopardizing the scientific and technical capabilities of our Nation. It is a threat which, if not aborted, could well produce a serious delay in the solving of many medical and scientific problems. Dr. Crout of the Food and Drug Administration, in his recent testimony before' this committed, touched on the probleuis con- trolled circulation, or throwaway, publications have gene~ated in 1 See prepared statement and euppleinental information of Mr. Scherago beginning at page 14402. ., 139$1 PAGENO="0076" 13982 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY the medical field. I will discuss with you today the financial impa~ of throwaway journals, not only upon the medical profession, but the entire scientific research community as well. Before I begin, however, I would like to tell you a little abou1 what our firm does so that you will have a better understanding of how we fit into the picture. Scherago Associates has for the last 20 years served as a publisher's representative for scientific and medical societies:. In essence,. this involves the solicitation of advertising for placement in peer review, or scientific journals. As a scientist, I have long recognized that scientific societies need revenue other than membership dues in order to publish their jour- nals. Most scientific societies. do. not have their own sales staff because. they prefer not to be involved in the commercial aspects of publish- ing. Because of this, they leave such details to us.. In the marketplace we compete with the advertising sale~ staffs o.f the throwaway maga- zines published by profitmaking organizations. Because of our involvement with the sale or loss of advertising in society journals, we are in an advantageous position to evaluate the impact of throwaways on association publishing programs. Before proceeding further with my discussion, however, I think it is necessary to define the meaning of peer review, as it applies to magazines. From the beginning of scientific research, the accepted method of recording results has been through peer review scientific journals. Each area of scientific specialty has its own journal and serves as a means of communication with other scientists in the field. These scientists of like interest often band together into groups, which ultimately grow into scientific societies. Such societies range in size from a few members to the 140,000 constituency of the American Association for the Advancement of Science. Early in the history of organized science it became apparent that a system of assuring the authenticity of the scientific work appear- ing in society journals was essential, for the scientific community was not without some charlatans. Since each piece of research in a given area served as a baths for further work in the same scientific field, an erroneous piece of infor- mation could cause untold damage to the whole field. Mr. GounoN. Do you know of any examples to illustrate that? Mr. SCIIERAGO. There was a recent case at Sloane-Kettering. Mr. GORDON. Would you please speak a little louder? Mr. SCHERAGQ. There was a recent ease at Sloane-Kettering, I believe, but I do not know all of the details on it. Senator NELsoN. Go ahead. Mr. Sonr~u~oo. In it~ simplest forms this doctrine says that no pi~ce of scientific research can he considered valid unless it has been reviewed by at least two recognized authorities in the field of science involved. Furthermore, these reviewerS can have no financial or academi.c involvement in the work reviewed and in most cases are to remain unknown to the. performer of the work. Senator NELSON. Are you talking about every article on any ad- entific matter that goes into any scientific journal? Is it peer re- viewed in this fashion? PAGENO="0077" COMPETITIVE PROBLEMS IN T~IE DRUG' INDUSTRY 13983. Mr. `Scinnw~o. Yes sir, every article of scientific content. Senator N~soN. Is peer reviewed in the fashion you are talking about here? Mr. SCHERAGO. Yes, sir. Senator NELSON. That is true of all of the scientific journals that you are familiar with? Mr. SCHERAGO. That we are involved with, yes; all of those that I am familiar with, yes. Senator NELsoN. Which ones are you involved with? Mr. SCHERAOO. "Science ;" "Clinical Chemistry ;" "The Americati Journal of Medical Technology ;" "Pathologist ;~ and "The Journal of Family Practice." Senator NiLSON. To your knowledge, the other scientific journals that you are not involved with use the same procedure? Mr. SCHERAGO. Yes, sir. That is correct. Senator NELSON.. And are peer reviewed by at least two independ- ent knowledgeable scientists in the field involved? Mr. SCHERAG0. Correct. Senator NELSON. Go ahead. Mr. GORDON. May I ask a question at this point? Senator NELSON. Yes. Mr. GORDON. What about the "Journal of the American Medical Association ?" Is that supposc~d to be peer reviewed? Mr. SCHERAGO. I could not say, sir. You would have to check with them. I am not aware of what procedures they use. Mr. GORDON. I recall several years ago the AMA Journal had an article by Dr. Varley, who was the medical director of the UpjOhn Co. in which he claimed that generic tolbutamide (Orinase being the trade name), does not have the same bioavailability as the trade name product manufactured by the Upjohn Co. Well, the Upjohn Co. had an exclusive license from the patantee, a German firm, and there was no generic product on the market; the so- called generic product having been fabricated in the la~boratories of the Upjohn Co. That was a lead article. So, I am just wondering! It does not seem possible that any h~de- pendent people had reviewed that article. Mr. SCHERAGO. I cannot say. I am not familiar with their oper- ation. In its simplest form, this doctrine of peer review says that no piece of scientific research can be considered valid unless it has been reviewed by at least two recognized authorities in the `field of science involved. Through the years scientists have tenaciously stuck to the peer review system of journal editing. At this time I would like to turn the witness chair over to Mr. Ringie, who will .give you some idea as to how "Science" magazine handles the peer review process.. Senator NELSON. Did you give your full name and identifli~ation to the reporter? She has that? GoocL Mr. RINeu~. Mr. Chairman, I will describe the peer review system at "Science." Most scientific journals u~e some system similar to this. Most scientific journals are reviewed., as are all of the journals published PAGENO="0078" 13984 COMPfl~ITIVE PROBLEMS I~ THE DRUG INDUSTRY by the American Physical Society-for instance, "Physical Review Letters"-the journals published, by the American Physical Society, the "Journal of the American Chemical Society," and several other :3ournals in that family. `A journal that is peer reviewed is an authentic journal. One that receives papers that are just accepted by an editor is a sort of second rate operation. Now, each paper submitted to "Science," is reviewed by at least two reviewers. We receive approximately 5,000 manuscripts for re- view a year, so that involves obtaining about 10,000 reviews. Senator NELSON. How many? Mr. RINGLE. About 10,000 reviews for 5,000 papers. We maintain an active file of approximately 8,000 scientists who review papers for us. This file changes. Some people are discarded as reviewers. Additional reviewers are added every year. Basically, what we want to find out by peer review is "Are the findings reported supported by the evidence in the paper?" In other words, is the paper technically sound? Now, besides that, to select from all of these papers that we re- ceive, we want to find out if the findings are significant. Does it make a real advance in the field? Has the author given adequate and fair reference to the related work of others? Are his conclusions supported by the evidence in this paper and other published evidence? That basically is what the peer review system is. Senator NELSON. Thank you. Mr. SCHERAGO. The tremendous strides in science and medicine of the last 100 years would not have been possible without strict adher- ence to peer review and the use of society journals as a means of communicating peer reviewed information to other scientists. I would like to emphasize that once a piece of scientific work is published in a peer review journal, it becomes forever a part of the archives of science. Consequently, peer review or society journals are often referred to as archival or scholarly journals. Most archival journals are published by nonprofit medical or scientific societies. This is mainly because commercial publishing firms have found that it is very difficult to make a profit with peer review journals. I think that this committee should know that peer review journals as a group are in serious financial difficulty, so much so, in fact, that more and more meetings are being held by society journal edi- tors to discuss the problem. One such symposium took place at the `annual meeting of the American Association for the Advancement of Science, the largest scientific society in the world, in February of this year. In a paper delivered to this meeting, Robert Day, managing editor of the publications of the American Society for Microbiology, made this statement, and I quote: But will the current trend of rising costs continue? If they do, the scientific `journal as we know it today, that is, a package of research papers which Is dis- tributed each month directly into the hands of many of the scientists who are peers of the authors and Into virtually all of the departments and laboratories involved with similar research will no longer be endangered; it will be extinct. PAGENO="0079" CO~fPETITIVE PROBLEMS IN THE DRUG INDUSTRY 13985 Mr. Day is not alone in his concern. Virtually every peer review journal has seen its number of scientific pages dwindling to half their former numbers., Dr. Leland Stoddert, treasurer of the International Academy of Pathologists, said in a recent paper:. Let me speak clearly about the importance Of editorial review and the publ~- cation of sound, critically reviewed and edited papers in scientific journals, The demands of editorial review sharpen the work of scientists and refluie their con- clusions. It would be an unhappy day If the edited journal disappeared from the scientific world for economic reasons because scientific standards would not be maintained. I might add here that the National Institutes of Health has trhd to set up currently a special committee to deal with the problem of dissemination of medical information and technology, and that tids committee would concentrate on such problems as the failure to dis- seminate research findings of potential value as rapidly or as effec- tively as they might. Senator NELSON. Where are you now? Mr. SCHERAGO. That is not in the text, sir. We just discovered that. Most societies have increased membership fees to ,the point where fewer and fewer scientists can afford them. Mr. Day says that the subscription price for the "Journal of Bacteriology" has tripled since 1968, and by 1985 will triple again. Most society officials agree that they have reached the point where no further reduction in scientific papers and increases in membership dues and subscriptions can be made. Let me dwell a minute here on the current state of scientific research. Each year this country spends almost $18 billion on scientific re- search. A substantial portion of those research funds are supplied by the Federal `Government. The National Institutes of Health alone spends almost $2 billion in grants and intramural research. Senator NELSON. Two billion dollars? Mr. SCIrERAGO. Two billion dollars. This colossal investment in research activity has in recent years produced an avalanche of new important scientific and medical information. Dr. Donald S. Frederickson, Director of the National Institutes of Health, said in a speech at the recent meeting of the American Association for the Advancement of Science, "Biomedical knowl-~ edge, like all scientific knowledge, has been accumulating at an exponential rate, as reflected in the output of scientific literature. `One sampling of biomedical publications suggests an average an- nual increase in scientific papers of between 4 percent and 5 percent for each, year, from 19~5 to 1978," and that is `only in the biomedical field. Not. all papers which are delivered before a society are `published in peer review journals.. Some authorities estimate that less than 60 percent. of sciefltific papers ever appear in established scientific or `medical journals. It is ironic to think that much of the productive research generated by this enormous expenditure in research dol- lars is never seen by the scientists and doctors who could best utilize it. PAGENO="0080" 13986 COMPETITIVE PROBLEMS IN THE DR~O IN~tJSTRY At this time I would like to turn the witness chair over to Mr. Ormes of "Science," who will give you some information on how many papers are published and what is refused. Senat6r NELSON. Thank you. Would you please pull the microphone up closer? Mr. O~. As you heard from Mr. Ringle, "Science" has to re- view 5,000 or 6;000 papers every year, and we have to get 8,000 to 10,000 reviewers fo~ those papers. Sen~tor N~soN. How many of the 5,000 to 6,000 are printed annually? Mr. ORMES. That is what I am going to mention here. In 1975, we received a total of 5,000 manuscripts, and we printed 1,200. That is at a rate of about 25 percent of what we receive that is accepted. The number is changed somewhat. Back in 1q71, it was 6,000 man- uscripts, and we published 1,400. The decline in the number pub- lished represents efforts to meet inflation and paper costs, postage costs, and other factors that affect the amount that we can handle. Mr. SCIIERAGO. Bob, would you say those ~gures are representative of other scientific journals? Mr. ORMES. I do not know if they are really representative of others. This is what we have done. Nearly everybody has had finan- cial difficulties, but I do not know specifically. Mr. SOHERAGO. Four factors have been at work during recent his- tory, which have created this problem. The first of these is the tremendous increases in the number of scientific papers competing for the available pages in scientific journals. The second is the rapidly spiraling costs of journal production. The cost for printing a page of material in the average journal has increased 30 percent in the last 2 years. Postage, too, has increased substantially. Increase~ in labor and salaries due to inflation are well-known facts. Most societies have sought to fight these spiraling costs by increas- ing membership dues. This in turn has lead. to a downturn in asso- ciation members, which not only keeps the net increase in society revenue small, but decreases the number of people expose.d to valu- able scientific information. Reduction in scientific papers published is also an unsatisfactory solution. All things considered, attempts at cost reduction and in- creases in subscriptions and dues will not solve the problem. The third factor, and by far the most critical, is the decrease, or lack of advertising revenue in peer review journals. Societies have traditionally subsidized a good portion of their publication costs with paid advertising from firms selling products used by doctors and scientists. However, these advertisers are never allowed to influ- ence the scientific content. This is because the control of the scientific materials published is in the hands of reviewers who did not par- ticipate in the revenue from advertising. True peer review journals have steadfastly refused to let advertisers influence their scientific content. This policy had led advertiser~ to seek other means of com- municating with their customers which would allow them greater input. PAGENO="0081" COMPETITIVE PROBLEM~ IN THE DRUG INDUSTRY 13987 The business trade press, recognizing this need, has provided that service in the form of controlled circulation magazines, which are often called throwaways by doctors and scientists. Controlled cir- culation nonpeer review magazines constitute a serious finaneud problem for peer review journals. Furthermore, the scientific articles in them do not undergo a stringent review pocess, as do scholarl~ journals. Consequently they add no new information to the sciell- tific or medical archives. Each year such publications attract sizeable amounts of advertis- ing revenue from peer review journals. Last year, as a group, ~O publications distributed to the research and laboratory field alone čollectively billed over $7 million in advertising revenue, money that could have gone to publish peer review scientific material, had those ads appeare~ in scholarly journals. At this point it might be helpful to look at the various types of nonpeer reviewed controllOd circulation journals. Essentially there are three types. The first are product tabloids. These publications publish as their sole nonadvertising content, product descriptions supplied by adver- tisers, which are essentially free ads. In general, these publications are newspaper size and it is often accepted in the trade that one must advertise in a tabloid in order to get articles published about one's product. The second type are clinical or research-type journals. These have the appearance of scholarly journals, but do not utilize any accepted review process for their scientific content. It is not unknown for these journals to allow an advertiser to write an article or to accept an article from an individual designated by the advertiser. Three, news publications-these contain news releases from indus- try, reviews or abstracts of articles appearing in peer review jour- nals, interviews with scientists who give scientific meetings, and staff written material prepared by the publication's own news staff. It is often possible for a scientist or a doctor to obtain publicity in such a magazine about scientific theories or drugs which are held in disrepute by most scientists. In this manner, an unscrupulous scientist or doctor may circumvent the traditional peer review process. Scholarly publications have great difficulty competing effectively in the advertising marketplace with throwaway journals because they are not willing to make the compromises with established scien- tific practice necessary to interest advertisers. To do so would mean that they would no longer be peer review journals. Better to preserve the few that survive under the old system than to have no communication system for authentic scientific material. Let us look now at what throwaways do for advertiser~ that learned journals cannot. First of all, they usually send all copies. of their magazines to the place where scientist~ an4 doctors work. Advertisers feel that pro- fessionals read on their jobs more than they do at home.. For the most part, scholarly scientific and medical journals are sent to home addresses at the request of the subscribers. This would seem to mdi- cute that advertisers are wrong about where scientists and doctors read professiOnal journals. 73-617-76-6 PAGENO="0082" 13988 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY On the other hand, advertising managers often ask their salesmen what publications they see on their prospect's desk. Obviously a salesman sees fever scholarly journals on customer's desks because the doctor receives them at home. Since throwaway publishers send their magazines to laboratories and doctors' offices, most professionals receive at least 6, and some as many as 12, of these kinds of journals. Another reason that learned journals cannot compete with throw- aways is that no peer review journal will allow an advertiser or prospect to influence its scientific content. Furthermore, learned journals often print adver~e reference to advertisers' products or present views which are unpopular with groups of advertisers. In no instance will an authentic scholarly journal ever agree to run articles or product descriptions in exchange for advertising. Advertisers dislike intensely the journal practice of grouping ads in the front and back of scholarly journals. They prefer to see their ads mixed in with articles because they believe they will receive more attention there. Learned journals bunch ads together in the front and back in order to keep from continuing articles. Editors of peer review journals resist mixing ads with articles because they feel it implies advertisers' influence. In general, advertisers group publications in the field into bunches and interspersed, depending on whether ads are grouped. Most society journals are bunched, and all throwaways are interspersed. Another prime reason for the popularity of throwaways with ad- vertisers is that it is easier to understand the articles in them. In general, nonscientists do not believe that scientists or doctors would read articles written in scholarly style. Advertisers see them as dull and uninteresting. One other advantage throwaways enjoy is that society journals usually have drab and uncolorful formats, while throwaways make ample use of expensive graphics, color and artwork to make their journals more attractive. So, it is easy to see that in the classic sense of providing the customer with what he wants, throwaways have done a much better job' of serving the advertiser. Scholarly journals have concentrated, onthe other hand, on giving the scientific and medical community what it needs. It is interesting to pote that in virtually every case where throw- aways are competing with society journals for advertising, the soci- ety journal was in existence long before the throwaway. Ijsually it was the scholarly journals' volume of advertising which `accumulated because there were no other journals in the field that attracted the throwaway in the first place. History has shown that every time a controlled circulation publication enters a field served by a learned journal, it drains off a substantial portion of its advertising. This often produces disastrous results. One scholarly chemical journal has lost over 40 percent of its advertising revenue to two throwaways in the field. It is common practice in the journal field to make scientists pay to have their papers published in a scientific journal. This is espe- cially true in the case of journals having little or no advertising revenue. It is an interesting paradox that some scientists are paying to have their papers published while buying products from firms who support that journal's throwaway competition. PAGENO="0083" COMPETITIVE PROBLEMS IN ~E'HE DRUG INDUSTRY 13989 For the last 10 years business publishers have lobbied intensely to force societies to pay tax on their advertising revenue. In 1969, the Internal Revenue Service established new guidelines which have resulted in many societies having to pay taxes on advertising reve~ nue. Thus, the society uses money to pay taxes that otherwise would go `to publish more scientific information. The paradox here is some- what ludicrous. On the one hand `the Government creates a nonprofit status for scientific societies so that continued scientific excellence will be assured, and then takes away a `substantial portion of its money in taxes. The business publishers have insisted that the tax-free status Of societies constitutes unfair competition. They say this even though the society was there first; `and, as we have seen, it is very difficult for a scholarly journal to compete affectively against a throwaway. In Dr. Crout's testimony, he listed for you 28 publications which have circulations of 70,000 or more. Of these publications, only two employ the peer review system. I have here a list of these same publications, which is available, indicating the total advertising billings of these publications for the year 1975. These 26 throwaway publications billed over $60 million collectively. Senator NELSON. This is for advertising? Mr. SCHERAGO. This is for advertising. Also, you may be interested ,in knowing that of all publications serving the medical field, the total billings are about $106 million. Senator NELsoN. What do you mean by all publications serving the medical field? Mr. SCHERAGO. Controlled and peer review. Senator NELSON. And when you say medical, you do not mean all scientific? Mr. SCHERAGO. I do not mean all scientific. In other words, pttbli- cations circulated primarily to doctors, practicing doctors. Senator NELSON. The total advertising is what? Mr. SCHERAGO. About $110 million. Senator NELSON. And of that $110 million, $60 million is in the so- called throwaways? Mr. SCrrE1t~Go. No; more than that. Sixty million dollars is in the journals, that Dr. Crout listed. Timse are journals that have circula- tions of over 70,000. I do not have figures on what percentage of the $60 million goes into peer review, but it is a small percentage of the total, In fairness to the people who buy advertising, it is important to mention here the auditing services which evaluate the readership of medical publications. These firms are somewhat similar to the television rating systems used to evaluate the audience for TV pro- grams. *These auditing services are unbiased, independent research organizations, who continuously monitor the readership and distri- bution of journals distributed to doctors. One of these services audits primarily whether and how well doc- tors read the material in the magazines and journals they receive. The other measures the number of doctors in a given field who re- ceive each journal, and to some degree also measures readership. PAGENO="0084" 1~99O COMPETTTIVE ~ROI3LEMS IN THE DRUG ~NDUSTRY Throwaway nonpeer reviewed publioations often receive high scores on these audits, frequently better than the scholarly journal in the field. Advertising buyers place great emphasis on these audits and the magazine with consistenly low scores has little or no chance of survivaL Some firms use these audits as their sole basis for selecting the journals in which they advertise~ It is obvious that doctors do read these publications. Throwaways have an advantage in those audits which measure coverage of a specific field of medicine, because they send their magazine free to all the doctors in that specific field who are known. Society publications, because they are essentially paid for through society dues, seldom show up as well, because no society can claim as members all of the doctors in a given specialty. Thus, advertisers feel that controlled publications provide them with better coverage Qf their market. In the scientific or diagnostic laboratory field there are no such audits. This is primarily because the total advertising dollars spent in these types of publications is much smaller and audit services do not find it lucrative enough to study them. However, because the scientific and diagnostic laboratory consti- tutes the ultimate buyer of an advertiser's product, many adver- tisers evaluate these publications on the basis. of their response to advertising. The throwaways always are sent to laboratories, rather than homes, as are the society journals. Thus throwaways also claim more complete coverage of a specific field *than a society journal because of their controlled free ~iistribution. Throwaway publications in the scientific and laboratory fields al- mOst always draw more response for advertisers than do scholarly journals. They can also eliminate subscribers who advertisers feel are not likely to buy their products, such as students and nonman- agement personnel. It remains for the societies to educate these people. Mr. Chairman, I hope that the facts that I have presented here today will arouse some concern on the part of this committee for. the plight of the scientific societies and their journals. If science is to survive, you must find some way to help. Here are some ways that I feel this committee might be helpful. One: I respectfully submit that the IRS regulation requiring scientific societies to pay taxes on their advertising revenues is con- trary to the public interest and should be repealed. Two: I suggest that this committee might meet with representa- tives from industry with the purpose of discussing ways in which a portion o~ the money now spent in advertising and throwaways might be rechanneled into peer review journals. I think it only fair to mention here that there are already many companies who recog- nize the importance of peer review journals and set aside a portion of their ad budgets to support them. Unfortunately, there are not enough. If this committee should decide to propose legislation with respect to advertising in this field, I sincerely hope it will not be in the form of eliminating all advertising. To do so would injure the peer review PAGENO="0085" COMPETITIVE PTtOBL1~MS IN THE DRiX~ INIYtYSTnY 13~)91 journals as well as the throwaways. Rather I would suggest some form of licensing of the editorial in journals which propose to pub- lish scientific or medical articles in scholarly form. Senator N~soN. You mention that the tax code provisions requii~e associations to pay tax on their advertising. Would you explain that? Do you mean the nonprofit scientific journals? Mr. SCHERAGO. Yes, sir. A 501 (*c) (3) society which is scientific and educational' has to pay tax on the advertising revenue that it receives; considering only the costs of publishing advertising, and including some costs ot editori~i, and anything in excess of that they have to pay tax on. It is not audited as a whole picture business operation. Senator NELSON. Well, what costs are, the scientific journals entitled to write off against the income from advertising t Mr. SOHERAGO. The cost of printing the ads; the. costs of sales; and some editorial costs, I believe. Is that correct? Mr. ORMES. The formula for taxation says that the gross' adver- tising revenue minus gross advertising costs is maximum taxable revenue. Then, against that can be set o~ the editorial costs to th~ extent that they exceed circulation revenue~ The difficulty is in determining the circulation revenue becouse there is an elaborate formula for calculating what proportioi~ of society dues must be allocated to the magazine in order to determine the total circulation revenue, including nonmember subscriptions, and other such revenues. Senator NELSON. I still do not quite follow that. The implication is that there is a profit made by- Mr. ORMES. The indicatiŕn is that if there is a profit made, then the advertising tax must be paid on it. Senator NELSON. And in determining whether there is a profit, you are saying that you are not entitled to write off all business costs, publication costs, circulation costs..? Mr. ORMES. You are entitled to offset all publication costs con- nected with-you have to separate the editorial costs' of the ~ublica- tion from the advertising costs of the publication, including the printing and any other costs, and you make calculations: One where advertising costs are measured . against advertising revenue; the other one where editorial costs are measured against editorial or circulation revenue; and to `the extent that advertising net income exceeds editorial costs are measured `against editorial or circniatioii revenue; and to the extent that advertising net income exceeds edi- torial i~et costs, you pay tax. It is a complex formula. Senator NELSON. You pay a tax to `the extent that editorial net costs- Mr. ORMES. Exceed advertising net. revenue, or are subtracted from advertising net revenue. I beg your pardon. Senator NELSON. I would have to see a more detailed bre~kdown to see what the impact of `that is. How much difference does that make, for example, ~Uo "Science" magazine? Mr. ORMES. We paid a tax of $8~,000 for last year, on gross advertis- ing revenue of about $2.2 million. PAGENO="0086" 13992 COMPETITIVE PROBLEMS IN. TUE DRUG INDUSTRY Senator NELSON. If you had not paid that tax, would the money have gone into a reserve, or what? Mr. ORMES. Well, other things being equal, that money would have gone. into more pages of text. We cannot l~now as we operate during the year exactly how we are going to come out. But other things being equal, the amount of text we publish is determined by and large by the amount of revenue we have to pay for'i't. Mr. SCHERAGO. Mr. Chairman, let me say a wo.rd here. Sometimes societies publish more than one journal, and not all of these journals carry advertising, so .that the tax money a society pays on one journal might have gone to publish scientific informa- tion in their other journals which do not carry much, if any, adver- tising. Senator NELSON. So, if it is a corporation publishing three jour- nals and two of them lose money and one of them makes money, you cannot use the profit from one to subsidize the others? You have to pay the tax first? Mr. SOHERAGO. Yes, sir. It is my understanding that that is the case. And that also applies to any other sOcietal activities which they are conducting. Advertis- ing revenue cannot be used to offset the cost of a meeting from which comes a good deal of the information published in society journals. Senator NELSON. I see. Did you' have any questions, Mr. Gordon? Mr. GORDON. Yes, thank you. I just want to get this clear. At the bottom of page 7 I. think you implied, did you not, that the throwaways do allow an actual or prospective advertiser to influ- ence their editorial and scientific content! Mr. SCHERAGO. It is possible, and sometimes it has happened. Mr~ GORDON. `You also implied that this type of publication does not generally print unfavorable references to advertisers' products or present views which are unpopular views for the advertisers. Is that also correct? Mr. SCH~RAGO. It would be extremely poor business to do so. Mr. GORDON. So that is why they do not do it? * Mr. SCHERAGO. That's right. Mr. GORDON.' Just one more point. You also said that advertising content for scholarly journals varies from zero up to about 30 percent,. and occasionally up to 40 percent. `Is this not also a rather dangerous situation if you are dependent on advertising to the extent of 40 percent? Mr. SCHERAGO. Yes, that is true. That is one of the `problems. But Mr. Ormes can' answer that question better than I. in general it is considered poor practice for a journal to run less than 60 percent editorial to 40 percent advertising. Is that not true, Bob? ` ` ` Mr. ORMES. I think that is true. We try to run 75 percent' text, and we make every effort to make sure that the distinction, the independence `of the advertising content from the editorial content, is total. The decision of an advertiser to place an ad has nothing whatever to do with the decision of the editor PAGENO="0087" COMPETITIVE PEOBT~E1~tS IN THE DRUG INDUSTRY 1399~ to print an' article. They are haridlin~ tl'~at wjtli different staffs and from different places. The effort is made to keep them totally separate. Mr. SCEIERAGO. Let,mQ just say a `word about the question that you asked relative to that. Most of the business publishers who got ipto this business have lots of other publications in the trade area, that i~, in skiing, restaurants, things like that. It is not considered unethical or Out of the ordinary for advertisers to. obtain editorial coverage in those `journals, either by the publishing industry itself, or by the, people who receive,tho~ publications. That is because the impprtance of accuracy `is not as great as it is in thp scientific or medical area. But these publishers pretty much see' all advertising objectives as a trade area. What has really happened is that they have made the scientific apd medical fi'eld a trade area by their method of publishing. So, it de- pends on how you look ~t it,,as to ~hether,or not it is bad publishing practice. ` In' other words, it is accepted in some area~, and, of: cOurse, in the scientific, area if cannot be bec~ause unless you are assured that the material in there,is accurate,' there is no way that science can cOntinue. Mr. GORDON. What disturbs me is that a firm,' a business firm, has to make money. If it advertises, you have to p~eas~~;the advertiser. So, if you are dependent to a large extent op, advertising, how is it pos~ sible to ~be independent?. Mr. SCHERAGO. There' are many commerci,al publishers, who print and publish peer reiriew journals. It is not a question of where the money comes from. It is a question of who controls the..editorial. It is possible to place the control of that editorial in the hands of people who are not on the publication staff, who do not share in the revenue, and who do not have that incentive. ,. ` Mr. GQRDo~. You are saying that the old problem `Of "he who"pays the piper calls the tune" does not apply?' , Mr. SCHERAC0. Not in this case; not necessarily. I am not saying that the opportunity for bribery, which is what we are talking about, is not always there. It is. But, in the case of the societies, there are, so many safeguards set up in peer review that it would be pretty difficult for that to happen. There is an editorial board which selects in general what types ~f articles go into the pub- lication. So, you would have to `get to them. That is usually-what- 12 or 13 people? Then you would have to get to the' reviewers which- again, I am not saying it could not happen. But I think it is much more unlikely that it would happen with the control of the editorial external from the p~ublication. ` Mr. GORDON. Well, look what happened to the New York Times. Mr. SOHERAGO. You would give me an exception. Mr. GORDON. Do you recall, what happened to "The New York Times" as a result of `printing something unfavorable to the industry? As a result of publishing an article unfavorable to the drug in- dustry, they lost $500,000, in advertising. Senator NELSON. Their magazine only did. "The New York Times" did not. Mr. GORDON. The New York Times CorpOration did. Senator NELSON. It was a publication owned by "The New York Times." "The New York Times" did not lose the advertising. PAGENO="0088" 13994 COM~ETiPIVE PROBLEMS IN THE ~RUO flThUSThY Mr. SCHERAGO. But even if that is true, "The New York Times" i~ not a peer review publication. Mr. GORDON. You are confusing me. Senator NELSON. "The New York Times" is the owner of "Modern Medicine." They ran a series of articles that you may be familiar with that was critical of the drug industry. Then the magazine owned by "The~ New York Times" lost advertising. That is a good, clear case of the drug advertiser putting economic pressure upon a publica~ tion owned by a paper that was critical of their business, I think that is rather a common practice. Mr. SCHERAGO. I am sure it is. Often many publishing operations are owned by conglomerates that have other activities, even some who do Government contract work. You know, there are all kinds of ways you can apply pressure. It does not necessarily have to be with the person or division of that company that does something that an advertiser does not like. Pres- sure, as you point out, can be applied through the magazine to some other publication. Senator NELSON. l3ut in the case of a peer review journal, such as "Science" or others,, you have a standing panel of scientists who have been selected for their expertise in various and particular disciplines. Mr. SCHERAGO. Right. Senator NELSON. And articles are submitted to "Science," and are thon peer reviewed by an independent scientist not associated in any way with the magazine, and not receiving- Mr. SCIIERAGO. True. Senator NELSON. And then they review it, and whatever conimen- tary they have comes back to the editorial board of the magazine. Is that it? Mr. SOHERAGO. Right. Senator NELSON. And who is the editorial board? Are they em- ployees of "Science?" Mr. ORNES. No. They are advisors to the editor. Senator NELSON. They are, advisors to the editor? Mr. ORMES. Advisors to the editor; personal advisors to the editor. Senator NELSON. What is the nature of their expertise, their qualifications? Mr. ORMES. To extend his knowledge. Senator NELSON. Who are. they? How are they selected-is their selection based upon some scienti~c qualifications? Mr. ORMES. Oh, yes-scientific qualifications and variety of dis- cipline and personal knowledge. Senator NELSON. So, they are not employees, but are advisors to the editor? IMr. Ormes nods affirmatively.] Senator NELSON. And they review the article plus the commentary of the two peers who reviewed it. Is that correct? Mr. ORMES. This happens in many ~ournais. At "Science," the edi- torial board does not participate in the reviewbig procesS. It is just the peer reviewers who do the reviewing. The editorial board are ad- visors to the editor on coverage of snb~ects that ought to be in the magazine. PAGENO="0089" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 1.3995 Senator NELsoN. So, of the 5,000 articles that are submitted, the editorial board advises as to what mix, what variety of scientific articles ought to be included? Mr. OR~Es. They would provide advice on that, yes. Senator NELSoN. The members of your peer review group are inde pendent; they review independently of each other, is that correct? Mr. ORMES. Yes, sir. Senator NELSON. And what is the standard by which you measure their peer review? On what grounds? If they say it is mediocre, or not well done, or not soundly based, does the editor then autom,ati~- ally reject? Mr. SOJIERAGO. John? Mr. RINGLE. That's right. If both peer reviewers say this article is not up to acceptabje scientific standards, we would reject it. If they were split in their opinion, we would seek another opinion, or try to decide on some basis. If the negative reviewer seemed to have very good reasons why he thought this was not up to standard, we would likely re)ect it, since we have to reject about 80 percent of all material we receive anyway. Senator NELSON. Well, are most or all of the articles that appear endorsed by the two peer reviewers? Mr. RINGLE. Yes, sir. IMr. Ormes nods affirmatively.] Mr. RINGLE. Almost all of them. Senator NELSON. Do you have any more questions, Mr. cordon? Mr. GoRnoN.~ No, sir. Mr. SOJIERAGO. Senator, just one other thing in that respect. I really do not feel that, except for tabloids, there is a great dleal of exchanging articles for advertising. I think that if there is any in- fluence, it comes from the types of articles that a niaga~ine accepts because obviously it has to publish the kind of editorial that wilt at- tract advertisers, that is, the direction that it takes and the fields that it covers. So, in that sense, I think there is more influence than there is in the actual trade, although that does happen. Senator NELSON. I did not understand your point. Mr. SCHERAGO. The point~ is, the direction of editorial conten1~ can also be influenced by advertisers as well as the content of a specific article. Senator NELSON. In a nonpeer review? Mr. ScixEnAGo. In a nonpeer review. Senator NELSON. Thank you very much., gentlemen. I appreciate your taking the time to come. Our next witness is Dr. Jack Kelly, chairman of the board, and Dr. Leslie Huffman, Jr., speaker of the Congress of Delegates, Amer- ican Academy of Family Physicians. Senator Laxalt was here and intended to introduce Dr. Kelly, but had to leave prior to your appearance. I am sure you saw bun this morning. He regrets he could not be here to introduce you. Go. ahead, please. Would you identify your associates so that the record *111 be. accurate? PAGENO="0090" 13996 COMPETITIVE ?ROBLEMS IN THE DRUG INDUSTRY STATET%~ENT OP JOHN C. KELL~, M.D., C~AIRMAN OP THE BOARD, AMERICAN ACADEMY OP PAMIL~ PHYSICIANS, KANSAS Cuff,5 MO., ACCOMPANIED BY DR. B; LESLIE RTThTMAN, SB., SPEAEER `OP CONGRESS OP DELEGATES; AND DR. WILLIAM HUNTER, MEMBER OP THE BOARD, AMERICAN ACADEMY OP PAMILY PHYSICIANS S S Dr. KELLY. Thank you. ` S S I am Dr. John Kelly of Reno, Nev. I am currently chairman of the board of the American Academy of Family Physicians. To my left is Dr. Leslie Huffman, who is speaker `of the House of Delegates of the Congress of the Academy of Family Physicians, and from Grand Rapids, Ohio To~ my right is Dr William Hunter from Clemson, S C, who is the chairman Qf the Legislation and Governmental Affairs Commission for the academy~ Rather than belabor the Senator with reading my testimony, I would like to have the opportunity of basically outlining it and giv- ing some dialog and comments as we go along. Please feel free to in- terrupt me for questions as you see fit. S Senator NELSON. Fine. S Your statement will be printed in full in the record. You may present it however you desire.' S Dr. KELLY. Thank you, sir. S S S One of the most important thing~. relative to family medicine and to medicine in general is the educational experience. I would like to comment on the educational experience of our annual meeting. The American Academy of Family Physicians has an annual meeting that draws approximately 5,000 physicians a year. This meeting is a multifaceted meeting, and at this point in time I would like to ask Dr. Huffman to comment on the d~ifferent types of educa~ tional experience available at that meeting. Dr. HUPPMAN. Mr. Chairman, in order to give you some idea of the perspective with which we are dealing, the annual Scientific Assembly of the American Academy has 10 major elements. Senator NELSON. Ten major what? Dr. HTJPFMAN. Ten major elements. In fact, sometimes we af- fectionately refer to it as the 10-ring circus because we have such a variety of things that are offered to o:ur members. These include 518 clinical seminars; 12 continuing education courses; 14 live teaching demonstrations; 14 dialog programs; 10 programed in- structions; 10 taping and strapping demonstrations.; 10 fractures demonstrators; 100 scientific exhibits; 16 lectures; and 185 techni- cal exhibits. Dr. KELLY. Sir, our request at this particular point in time was to be limiting our testimony to prepared comments relative to scientific exhibits and delineation of same. S `The American Academy recognizes two types of scientific ex- hibits-commercial and purely scientific. To distinguish between the two is a task that is somewhat direct and' simple. The primary purpose of a scientific exhibit is to provide information to. phy- 1 See prepared statement and supplemental information of Dr. Kelly beginning at page 14226. PAGENO="0091" COMPETITIVE PROBLEMS IN THE DRUG `thDUSTRY 13997 sicians through the disseminatiôn of research material. It is awarded in our academy on the basis of relevance to family practice, legibility, and scientific accuracy associated with ethical ŕontent. This is h~ opposition to the commercial exhibit, which is a mechanism for soliciting support for our annual meeting and which is paid for. Our scien;tific exhibits we accept no remuneratiOn directly for, and also the scientific exhibits are unsolicited, whereas we do solicit the commercial exhibits. Scientific exhibits, in general, are picked be- cause of their relevance to family practice, and they are picked be- cause of content. If they fail to meet these, we through our com- mittee, or our subcommittee `of our scientific assembly, sugge~t changes in the format, but not in `the basic content of the material, to meet a format of application which ,we have. This is attached in the testimony as exhibit A.. The second point that you requested us to respond to is sponsor- ship of our scientific exhibits. This sponsorship can vary. It varies from private industry, universities, armed forces. As mentioned by Dr.. Crout in his discussion of the 28th,, also from pharmaceuti- cal firms. The figure that Dr Crout cited in his earlier testimony, of 80 percent of scientific exhibits being sponsored by drug firms upon our review, appears to be reasonable. The third point that you asked us to address is who prepai~es the scientific exhibits. This is a multifaceted approach also. The individ- ual exhibitor may prepare his own exhibit. In the 19Z5 academy meeting, the scientific assembly's excellence award was won by an individual who prepared and printed his own, `material o,n a poster board situation. Or, the preparation of the exhibit can also cOme from individuals, such as universities, in concert; with the exhibitor, or in some instances pharmaceutical firms supplying economic ~up- port for the researcher and then assisting in the development of the format. The other modality is, of course, the commercial exhibiting Com- panies which prepare the exhibit on a protocol based on the desires based on the particular exhibitor and physician. You asked relative to the editorial review, we have a subcommittee that reviews all scientific requests. As previously stated, we asked them, to adopt to our format, without changing the content. If they cannot adopt to the format as established by the academy, we rec- ommend that they not* attend. We have rejected because Qf this very fact. We have had some problems in the past, and this year we are in the process of work- ing a review situation prior to the opening of `the exhibits with the PMA, and this is outlined in our testimony. I must stress at this point in time that the protocal relative to this will be the protocol established by the academy, and not the protocol established by the Pharmaceutical Manufacturers A~socia- tion. Mr. GoiwoN. May I ask a question at this point? Dr. KELLY. Yes, sir. Mr. GORDON. What is the function of the PMA? I am nOt sure I get that. Dr. KELLY. Well, relative to our testimony, the PMA has been asked to critique the scientific exhibits prior `to opening our Con- PAGENO="0092" 13998 coMrz'rITIVE PR0BLE~S IN THE DUUG INDIJSTRY gress as far as content to protocol, relative to the criteria that we have set up, and those criteria are included in our format. This is an unbiased third-party situation, hoping teh lack of bias comes from the broad base from which the PMA springs. Mr. GoRDoN. So the PMA is really performing the review process? Dr. KELLY. No; the PMA in concert with the Academy Scientific Assembly Comrnitteeis doing the review. Mr. Go~ooN. Then you regard the PMA as an unbiased reviewe; is that It? Dr. KELLY. Well, if you had a group representing multiple facets of any industry, and one had a chance to be one up, I think that the leveling of an aliover inclusive look would tend to make that oneupmanship a little bit less. Senator NELSoN. I am still puzzled as to how you could accept the Pharmaceutical Manufacturers Association as an objective re- viewer of any scientific matter affecting drugs, since th.ey are owned by, controlled by, paid for by, hired by, et cetera, by the pharina- ceutical manufacturers. I think it is obvious, don't you, from the beginning, that in any event nothing critical of the drug industry or any method, any ad- vertising, any promotion that they do would ever appear in any educational format in w~iich they participate, is that not correct? Dr. KELLY. I would agree with that, except for one simple fact-the criteria being established are our criteria, and not the pharmaceutical manufacturers criteria. The academy sets the proto- col. They have been asked to observe and comment on that protocol; but the protocol is ours and not the PMA's. Senator NELSON. Well, I do not know what the protocol is. Dr. KELLY. The protocol for review, sir, is in part of the exhibits that wehave attached. Senator NELSON. I see. All I know is that the AMA had a protocol for advertising in their journals. It read very well and was very specific-we had hearings on it-except they violated it continuously and finally de- cided to throw out the protocol so that they could continue to ac- cept advertising which, if they had adhered to their protocol of standards, they should hav.e totally re~jected. Dr. KELLY. That may be true, sir. But we are not discussing ad- vertising at this poiht in time. We are discussing the relevance of scientific exhibits, which are specificially based on the Academy's protocol, prohibited in advertising. This is one of the reasons for the PMA's involvement. Senator NELSON. All right. Go ahead. Dr. KELLY. The fifth point that you asked us to address is the convention and the dependency on drug support. I would like to have Les give us some basic numbers on that. Dr. HUFFMAN. Actually, of the nine elements of the annual meet- ing, which I outlined to you previously, It is interesting that only three of these elements have funding in part or supported in part by educational grants from pharmaceutical firms. The remainin e~cments are dependent upon registration fees which are charge. for the seminars; registration fees are charged for the continuing PAGENO="0093" COMPETITIVE PROBLEMS IN THE ]~RVG INDVSThY 1399~ educational courses; and then we have a registration fee for the whole, or general admission registration fee, which handles our administr~- tive costs or underwrites the remaining elements of the program from the general fund. The three particular portions of this that do have some pharm~- ceutical industry import in the form of educational grants are en- tirely organized by the committee on scientific programs. They a~'e given a. completely free rein, with no strings attached, as far as what these programs will include. For example, I tried to be very critical and go through and see if there were any real points where I could say that a company's products had. been favored by one of these. In the most critical re- view that I could come up with, I could not find but maybe one ~ut of thirteen different presentations in one of these segments that would even be related to a product of that company. So, I think the committee has been~ very diligent in trying to maintain their own independence in putting on what they feel is best for the annual meeting in selecting both the topics and the speakers, regardless of whether or not the support has come from the pharmaceutical companies. Senator NELSON. How much support do the pharmaceutical com- panies give to these three exhibits? What would the total be? Dr. KELLY. May I answer that? An example-in 1975, the total income was $475,463. Senator NELSON. The total income for what? Dr. KELLY. For the annual assembly. The total expenses were $579,031. Expenses exceed income by $103,568. Of this income, $247,000, or over 50 percent was from the saie of technical exhibit space. Senator NELSON. The sale of what? Dr. KELLY. The sale of technical exhibit space. The pharmaceutical firms paid for that. Senator NELSON. Two hundred and what was it? Dr. KELLY. $247,000, or over 50 percent of the total cost. Senator NELSON. Was paid for exhibition space? Dr. KELLY. By the pharmaceutical firms. Yes, sir. Senator NELSON. And then did I understand that in three of the elements there were contributions by the pharmaceutical firms in ad- dition to the payment for advertising, the exhibit space? Dr. HtJPFMAN. Yes, sir. Those were educational grants. Senator NELSON. What did they total? Dr. HUFFMAN. The total was $5,000. No, sir, I am sorry. I am on the wrong line. It was $1,700. There was a $1,700 income for dialogue and live teaching. Senator NELSON. That was for the three elements that you men- tioned, where there was some contribution by the company? Dr. HUFFMAN. That is correct. Senator NELSON. Please go aheaçl. Dr. KELLY. That basically covers what we came t~ ~teli you, sir. Did you have anything else? PAGENO="0094" 14000 COMPETITIVE PROBLEMS IN TIlE DRUG INDUSTRY Senator NELSON. I did not have a chance, because I just got your testimony this morning, to go all the way through it. Did you cover all of. the major points within your prepared text.? Dr. KELLY. Yes, sir. Senator NELSON. All right. Thank you very much, gentlemen, for taking the time to come. I do appreciate it. Mr. Gordon has some questions. Mr. GORDON. The previous witness, Mr. Scherago, stated that early in the history of organized sciences it became apparent that a system of assuring the authenticity of a scientific work appearing in society journals was essential; that to . protect themselves scientists established the. peer review doctrine. In its simplest form this doc- trine says that no piece of scientific research can be considered valid. unless it has been reviewed by at least two recognized authorities in the field of science involved. Furthermore these reviewers can have no financial or academic involvement in the work reviewed, and in most cases are to remain unknown to the performer o.f the work. Do you follow this peer review procedure for your scientific ex- hibits? Dr. KELLY. For the scientific exhibits? Mr. GORDON. Yes. Dr. KELLY. The peer review is done by the subcommittee, yes, sir. Mr. GORDON. That is two independents, as outlined by Mr. Scherago-two independent experts who are not involved at all financially? Dr. HUFFMAN. Mr. Gordon, with your permission, I would like to answer that. I happen to have been Chairman of the Committee on Scientific Programs. When we introduced a means of evaluating the scientific exhibits, we did so in a very careful and uniform manner to be con- ducted by the Committee on Scientific Programs. The scientific exhibits that we do select in the final analysis are selected based on a standard set of criteria which we established in 1969, and these are reviewed carefully by at least two members of the Committee on Scientific Programs. In many cases the entire committee has seen some of these exhibits and can give their im- pressions or opinions. But we have at least two reviewers on the committee to complete an evaluation form on every scientific exhibit. Mr. GORDON. But they are not independent reviewers-they are two people from the committee itself. This is quite different from what Mr. Scherago described as the peer review doctrine. Dr. HUFFMAN. That is correct. Actually, peer review for a publication is a different sort of thing, and is another subject. We have peer review there which is outside peer review. Mr. GORDON. Do you know of any scientific exhibits paid for by the drug firm which was unfavorable to the use of a drug-any drug atall? .. . . Do you recall? Dr. KELLY. No, sir, I do not. [Dr~ }Iuffman nods negatively.] PAGENO="0095" COMPETITIVE PROBLEMS IN THE .DBUG INDUSTRY 14001 Mr. GORDON. Can. you give us any examples. of the comparison of efficacy and safety. of drugs. p~esentcd in your exhibits, and would this be included in a commercial or scientific exhibit, and who would sponsor this kind of exhibit? Dr. HUFFMAN. In commercial exhibits, of course, this information has to be given out at the time that they are talking to a doctor about a drug. They have the standard information on the drugs at the commercial exhibit. Of course that is the commercial approach. Mr. GORDON. I am talking about scientific exhibits. Dr. HtTFFMAN. Again, the data is reviewed for subjectivity and has to include all of the adverse reactions that occurred, the con- traindications, et cetera. Dr. KELLY. If you have a generic type of material, the entire spectrum of that, whether it is produced by one, two, or four drug companies, is part of the evaluation. Mr. GORDON. Coming back to this peer review business, you are saying also that the peer review is conducted by the PMA, as well as your committee. Is that correct? Dr. HUPFMAN. Actually, we are probably overemphasizing the PMA . or the activity of the liaison committee from the PMA. The liaison committee of the PMA is asked to review the exhibits after they have been set up. Now this is long after the peer review, the committee review, has taken place. They are asked to review the exhibits after the setup to be sure that we have not missed a reference to a commercial brand name, or that we have not allowed someone to slip in with something that is really a blatant commercial promo~ tion. As Dr. Kelly said, we hope that we have safety in numbers by having a number of those companies represented on those committees, and they would be very careful to see to it that no one had violated their protocol. That comes long after the active selection process of the Committee on Scientific Programs. Mr. GORDON. So, we have a situation where the drug industry sponsors 100 percent of the commercial exhibits, 80 percent of the scientific exhibits, and then the PMA reviews the exhibits to see if they are satisfactory. S Is that it? S Dr. K1~LLY. That is partially true-100 `percent of the commercial exhibits; 80 percent of the scientific exhibits; but the PMA. is involved after the peer review has been accomplished by the Academy for ethical content and relevancy to family practice. They are in- volved in a protocol relationship rather than generic one-upmanship or commercial advantage. That is their involvement. Senator NELSON. Thank you very much, gentlemen. Our next witness is Mr. Edward F. Calesa, president .of Health Learning Systems Inc., of Bloomfield, N.J. Mr. Cales~, the committee is very pleased to. have you~' here this morning. Your ~tatement will be printed in full, in the record. You may present it however you desire.' . S ,, 1 See prepared statement of Mr. Calesa beginning at page 14050. PAGENO="0096" 14002 C0MPEflTIVE P1~OBT~EMS IN TIlE DETYG INDUSTRY STAtEMENT OP EDWARD P. CALESA, P1~ESflTh1NZ ERALTE LEA1U~ ING S~STEMS INC., BLOOM)?IED, NJ., ACCOMPANIED BY EDWARD SALTZ1VIAN, EXECUTIVZ VICE PRESIDENT, HEALTH LEARNING SYSTEMS INC. Mr. CALESIt. Would you like me to begin, Mr. Chairman? Senator NELSON. Pardon? Mr. CALESA. Should I begin? Senator NELSON. Go ahead. Mr. CALESA. First of all, let me thank you for inviting me today. This is our very first time here in the Senate building, and we are very excited about it. I am here with Edward Saitzman, who is executive vice president of the Health Learning Systems. Ed Saitzman and I are pleased to be. here to answer your questions about our contribution to medical education. We contribute through two separate corporations with one common objective-improving the quality and lowering cost of patient care through meaningful education. The Health. Learning Systems Corp. achieves this objective by providing continuing medical education for physicians, interns, nurses, and other allied health professionals; and the HLS Press Corp., through health education directly for the patient~ We will concentrate today on Health Learning Systems. The primary reason for our existence is to help translate medical research. findings from branches of the National Institutes of Health and university-based medical centers to improved patient care. The need is based upon the fact that new research findings reportedly double every 7 to 10 years, and affect numerous aspects of pre- vention, diagnosis, management, and rehabilitation of disease. More importantly, these findings are not adequately reaching the practic- ing physician for clinical application with the patient. This concern is well recognized by the Congress in its direction to the National Institutes of Health. To effect change, there is a need for continuing medical education through improved communication techniques. . The need for con- tinuing medical education of practicing physicians is well docu- mented by every major study in medical educatiolt. It is further substantiated by the American Medical Association, 9 medical spe- cialty societies, and 14 States, all of which require that members participate in a fixed number of education hours to maintain their membership; 5 States have education requirements to maintain their license in that State; 3 more States will institute relicensure laws by January 1978. All medical specialty boards and .subspecialty boards have endorsed recertification examina,tions. Mr. GORDON. May I ask a question here~ Mr. (ItLESA. Sure. Mr. GoRDoN. How do you get the. scientific Information which is developed at NIH and various educational institutions? How do you collect the information you wish to transfer to the practicing physician? Mr. CALESA. From the medical advisors whom we work with on the various programs we develop. I think we will cover that when we get to the medical advisers. PAGENO="0097" COMPETITIVE PRGBLEMS JN THE DRUG INDUSTR1' 14003 Did I answer your question? Mr. GORDON. Not really, but go ahead, Mr. CALESA. Congress has passed the Bennett amendment to the Social Security Act in October 1972 requiring the establishment of professional standard review organizations, with the primary objective to increase the quality of care through physician educa~ tion. The problem of malpractice in this country can often be related to this need, The major consequences to society of not ade- quately fulfilling this need for continuing medical education are increased morbidity and mortality statistics and. the extremely high ~nd spiraling cost of health care. Traditionally this need is being assumed by medical schools and hospitals that provide courses, hospital staff conferences and meej~- ings, traveling medical educators, medical textbooks, scientific jour- nals, and conventions. Problems with these approaches include: Prac- ticing clinicians may not have time to travel and attend courses, particularly those physicians farthest away from the medical centers; the lecturing medical educator may not have adequate teaching tools, ~tnd is limited by the amount of time he can devote to this activity; the printed word is often outdated, overused, and not necessarily the best communication medium, particularly for medical subjects. Local meetings can fail to provide national or international perspective. Upon recognjzing this need, Health Learning Systems was or- ganized in 1971 to act as a catalyst in marshaling the resources and disciplines prerequisite to affecting improvement in~ patient care through education. The disciplines we integrated in our corporation are the following: First and foremost, medicine to provide selection of subjects, physician participants, content control and accuracy; second, education to insure the achievement of learning objectives; third, communications to enhance the speed and accuracy that in- formation could be communicated and provide professionalism and quality in this area; fourth, marketing to find funding ,for pro- grams and assist in the distribution of completed . programs. Inte- gration of these four disciplines is the basis for producing `high- quality medical education materials that are up to date, accurate, and professional. The most impor1~ant discipline in our organization is medicine. We have developed a medical faculty of more than 400, physicians representing Federal health agencies, medical associations, medical soáieties, medical boards, medical schools, and teaching hospitals from around the world. This is. spearheaded by our medical director, Dr. Arthur I3ern- stein, clinical professor of medicine, New Jersey College of' Medicine and Dentistry; and Dr. Shervert Frazier, psychiatrist in chief, Mc- Lean Hospital and professor of psychiatry Harvard Medical School, a nonpaid member of the board of directors of Health Learning Systems. ` . Included in our list of experts from the Federal Government pith `whom we have worked are Dr. Theodore Cooper, Assistant Secretary for Health. Department of Health, Education, ~and. Welfare; Dr. `Donald S. Fredrickson, Director, National Institutes of Health; Dr. Robert I. Levy, Director, National Heart and Lung Institute; rand Dr. Ronald A. Chez, Chief, Pregnancy Research Branch, ~a- tional Institute of Child Health and Human Development, Na- tional Institutes of Health. 73-617-7~---7 PAGENO="0098" 14004 COMPETITIVE PEOflLEMS IN TEE DRUG IND~TSThY Some of our 400 physician. advisors from academic medicine in- dude Dr. James C. Hunt, professor and chairman, department of medicine, Mayo Clinic and Mayo Medical School; Dr. Morton I-I. Maxwell, clinical professor of medicine, UCLA School of Medicine; Dr. Clark H. Millil~an, professor of neurology, Mayo Clinic and Mayo Medical School; Dr. Edward J. Quilligan professor and chairman, department of obstetrics and gynecology, University of Southern. Caiiforn~a School of Medicine; Dr. Michael E. DeBakey, president~ Baylor College of. Medicine, Texas Medical Center; and HarOld D. Itskovitz, professor of medicine, Medical College of Wis- consin. Mr. GoRDoN.. Mr. Calesa, would you please. describe how all of this works? You say you have developed a medical faculty of more than 400 physicians. Are they On your payroll? Do you compensate them for their time? What precisely do they do? Mi~. ;CALESA. Whenever we are producing or developing a program, we call upon people who are leaders in a particular field of medicine, and for the time ~hi~h they direct'y work for us we compensate them. They are not full-time employees. None of them. are full-time employees of Health Learning Systems,Corp. Dr. Frazier is on the board of directors of Health Learning Sys- tems, but he is not compensated for, h~ participation on the, board. i-Ic is the third member of the board of directors along with Mr. Saitzrnan and myself. Mr. GORDON. You say that you work wi.th Government people. ~s `~n example you mentioned Dr. Levy, Director of the National heart and Lung Institute. I understand he edited one of your programs,? ` Mr. CALES.A. Yes. Mr. S~iTz~AN.He edited anumbčr of them. Mr. CALRSA. He, along with Dr. Cooper, edited one of our pro- grams,. the program ou hyperten~ion. Dr~ Levy has edited more than one of our programs. Mr. SALTZMAN. To answer your question, Mr. Gordon, about corn- pensation for people like Dr. Cooper and Dr. Levy, they have never been compensated at all, including their travel exp~nses.. `Mr.~ CALES~. The physicians in academic medicine who we work with, th~ leaders, they are compensated for their `time; but Federal Government employees are not. They work with us on a voluntary basis. Mr. GORDON. You compensate them directly, not the "sponsor. of thG program, is that correct.? Mr. CALESA. Yes; we compensate them directly. Mr. SALTz~AN. We receive a grant from the company, and we c~mpe.nsate the physician from this. Mr. CALESA. Should I continue? FSenator Nelson nods affirmatively.] Mr. CALESA. We `have collaborated and worked cooperatively with the National Board of Medical Examiners and representatives asso- ciated with the American Board of Internal Medicine,, American Board of Family Practice, National Institute's `of Health, American Board of Psychiatry `and `Neurology, American Fertility Society, PAGENO="0099" COMPETXTIV~ PflOELEMS IN TH~ IYRUG INflt5T~~ 14OO~ Epilepsy Foundation of America, American Heart Association, National Kidney Foundation, and many others. It is this working relationship We have with medicine that is the basis for us to produce highly credible education programs funded and distributed by industry which are beneficial to the participants in medical schools, physicians in private practice, and patients. It. is the integrity, reputation, and knowledge of this. group that provid~s the peer review and controls over the educational materials. The critical questions we faced were first how to fund and how to distribute the programs that we could develop. We considered three alternatives. The first was for us to raise capital, develop programs at our own expense, and sell completed programs to physicians in practice. We rejected this alternative because our `studies indicated physicians would not pay for the programs, and we had no system of distribu- tion. Second, we considered proposals to appropriate Federal Gov- ermnent agencies. We rejected this. idea beéause of restrictions in F~d~ral health care spending, the time involved in getting proposals written and approved, and most importantly, the inability of the Federal Government to provide adequate distribution. The ~ proach we settled' on was to utilize, the. resources of industry. They have the financial `resources, the responsibility to good medical prac- tice, and the distribution outlets to insure awareness and usage of completed programs. Mr. GORDON. What are these distribution `outlets that' you. ar~ talking about? Mr. .CALRSA. I' am talking about primarily the fact' that they have distribution outlets through their sales representatives, through journal and mail promotional avenues which physicians in practice have come to accept and expect from pharmaceutical manufacturers, and thus have the ability to reach directly. into the private pra~tice of physicians' offices. Th~.s is something fbr which. they have a mi~que situation-a situation unique to the pharmaceutical industry. Mr. GORDON. I guess the principnl way is `the. detail men who b~ing it to the doctors' offices, is that. correct? Mr~ CALESA. Yes, sir, that is correct-not exciusiveky-but you said~ principally. Mr. GORDON. That is exactly what I' said. ~. CALESA. Why would industry use these resources to support `ed~i~ti~nal' programs for physicians? The answer is that pharma- ceutical manufacturers develbp excellent products that' undergb ex- tensive testing before being sold to the public. These products are cH~fferentiat.ed by scientifically proven `benefits as well as positive and negative side effects. Each product becomes a potential therapy in the physician's pharmacopeia. The problem is how to properly `and accurately communicate the benefits, side effects, and therapeutic role each product has in the diagnosis and treatment of a patient~ in'. marketing medioal products, industry does not sell products" to a~ doctor, but rather fulfills' needs that a doctor has in the comprehensive care. of his' patients. Accept- ing this statement as dogma; it is~ an' absolute necessity to p~ovide adequate and accurait~e information which allows the physic4un to PAGENO="0100" 14006 COMPETITIVE PROBLEMS 1N. THE DRUG INDUSTRY make informed decisions in selecting methods of diagnosis and treat- ment for his patients. A comprehensive continuing medical education program under the rigorous scrutiny of medical peer review, which discusses can- didly when drugs shouid `and should not be used and criteria for drug selection, which ,includes all major drugs in that field as well as nondrug methods, is a way for industry to fulfill its communi- cation responsibility with the physician. Additional .factors are that the manufacturer is trying to upgrade the level of knowledge of the pharmaceutical sales representative, so a better dialog can take place between the physician and the rep- resentative. This can be accomplished by exposing the pharmaceuti- cal representative to the same educational materials to which the physician is exposed. There are other factors as to why the manufacturer will support ~educational materials, but the most important is that the manu- * facturer with high-quality products, that have a definite role in the `management of patients in a particular therapeutic field, will bene- ~fit by providing fair balanced educational material to the practicing physician. However, since industry was to provide the financial and distribu- tion resources, it was imperative that certain safeguards be built into ~the educational process to avoid any potential for abuse. It is our unequivocal contention and therefore policy that these -safeguards must be under the control of academic medicine through medical peer review and not regulated either by any Federal agency or interfered with by the pharmaceutical manufacturer. We have consistently maintained these safeguards in the following way: First: The educational program is developed and produced by an independent organization, such as Health Learning Systems, rather than by the pharmaceutical manufacturer. Second: The intention of the program is educational rather than promotional. Specifically, we feel that the educational materials should not be exclusively about drugs, but rather encompass the entire area of diagnosis and management of a particular disease. Third: The executive editor and editorial board participants in the program be selected independently of the manufacturer provid- ing * the grant. We will accept suggestions from the manufacturer regarding participant selection, but only as it relates to providing a fair "balanced presentation. All editorial, board participant selections must rest with the executive editor of the program.. Fourth: The editoriSl board participants include a minimum of four independent participants to rule out bias. Fifth: The editors selected be eminent in their field, be located at leading medical centers and represent the major opinions in that disease area. * Sixth: The content be completely under the control of the editors and not subject to change by the grantor. ` Seventh: Th~ program be sponsored by a prestigious medical school, medical school department, health agency, or organization. Eighth: Educational content peer review be provided by a Federal Government agency and/or medical association active in that'field. PAGENO="0101" COMPETITIVE ?ROBL~iMS Th4~ TH~ D~UG INDUSTRY 14007 Ninth: The content be reviewed for accreditation by all of the leading accrediting organizations in that field. Tenth: Any, discussion of drugs be done in fair balance to allt drugs in that field. Eleventh Both the indications as well as the side effects of alit drugs discussed be highlighted in the program. Senator NELSON. Do you have any examples? You said the indi~- cations for the use of the drug and the side effects of the drug are~ presented. Mr. CALESA. Yes; that is what I said. Every one of the programs we establish, educational criteria programs, includes every one of these,' and I think that Dr. Crout, when he was here, specifically named our program, "Dialogues in Hypertension," which did exactly this. This is only one of the criteria which we feel are essential. Senator NELSON. Do you have examples of some drugs for which you presented fully the indications for use and the contraindications and the side effects? Mr. CALESA. Mr. Chairman, every one of our programs, and I would he happy to send you samples of all of our completed material- Mr. SALTZMAN. If you are referring to full disclosure, we do not get involved in labeling and therefore we do not include all of the `indications for `all products aiid all of the side effects of all products. But the editors who control the content list the indications for all `of the drugs in the therapeutic field, as well as the side effects for all drugs discussed and programed in that therapeutic field. Senator NELSON. Would you send us some examples? Mr. CALESA. We would be delighted to send you all of our ma- terial, sir. Senator NELSON. Thank you.1 Mr. CALJ~SA. Twelfth: Product advertising not be included in the educational material. Thirteenth: The material confbrm as closely as possible to ap- proved package inserts for all products. Fourteenth: All material, clearly `identify the medical center and association sponsors, the producer, and the manufacturer providing the educational grant. And finally, that the manufacturer actively participate in the dis- tribution of the program. When these criteria are met, we have the basis for achieving a common objective of our organization, academic medicine, organized medicine, the pharamecutical industry, and the Congress in pro- viding better patient care through education. Mr. GORDON. Mr. Calesa, may I interrupt for a moment, please? From the middle of page 5 to paragraph 3 on page 6, as I read it, what you are saying is that the two primary reasons why th~ indus- try sponsors these programs are: (1) they produce drugs a~id they want to inform the physician about their proper usage; and (2) they wish to improve the detail men's knowledge of the products that they are promoting. Is that not correct? Is that not what you said? Mr. CALESA. Yes, sir. I Material too voluminous to be printed but retained in the committee files. PAGENO="0102" 14008 COM~TIV~ PROBLEMS IN `T~I~ DBU~ INDUSTBY Mr. GORDON. Now, on page ~, `you kave used the word "indepen- ~dent" in several places-one, two, three, maybe more places. The previous witness from the Academy of Family Physicians stated, ~and I am quoting from his statement: It is accurate to suggest that drug -companies are likely to support those ex~ -hibits which are favorable to a particular product of the company. `Certainly it ~wou1d be diMcult, if not impossible, to envision a situation in which a drug corn- ~pany would support an exhibit which was unfavorable to a product of that com- pany. Now, Dr. Crout, Director of the FDA's Bureau of Drugs, and also a medical educator, testified that the educational materials subsidized by the drug industry have a systematic bias and are consistently tilted in the direction of therapeutic enthusiasm. He said that these materials have the appearance of independent scholarly productions, but which are, in fact, an integral part of the drug industry's over- all promotional efforts, a more subtle part, of course, than straight- forward promotional materials like advertising. Then he added subsequently "The problem is not that drug industry ~money corrupts medical experts, but rather that the drug industry sponsor can choose among the many medical authorities, on any given topic to surpport only those whose views already coincide with the interests of the sponsor. This ability of the pharmaceutical in- dustry to select medical authorities that it wishes to support is the basic cause of the biases, as we shall see." * So, the inevitable question is, given your complete or almost com- plete financial dependence on the drug industry, how can you achieve independence and objectivity-that is one question. Two, who are your sponsors? And three, have your programs condemned the use of a drug marketed by one or more `of your sponsors? Mr. CALESA. OK. There were a lot of. things said there. Let me see if I can take that apart piece `by piece. First of all, to answer your question, the peer review system which we have established-the reason we can have objectivity is because we do not have the pharmaceutical manufacturers select the physician participants. That is point No. 1. - Point No. 2, if we establish *a multiple number of criteria, which includes review by as many different people, groups~ organizations, and societies as we possibly can find, anyone who is willing to re- view the material that we produce in a field-if we are doing a `program on epilepsy, we ask everyone involved in the field of epi- lepsy to review that particular program. Mr. GORDON. Well, let's be specific. There has been a lot of talk about the overuse of antibiotics and its consequences. There has been a `lot of talk about the overuse of chioramphenicol. There has been a lot of talk about the overuse of cliudamycin and lincomycin. There has been a lot of talk about the overuse of oral hypogly- cemic drugs. Have you had any programs at all which brought this out? Mr. CALESA. We have produced no programs either in the field of diabetes or infectious disease at this time. We have not been involved in those areas. The areas we have been primarily involved in are the areas of prevention. The areas where we have done the vast amount of our work have been hypertension, hyperlipidemia, obesity. PAGENO="0103" C0~ETiTIVE PBOBI~MS IN T~I~ DRtQ INDUSTR~ 14009 Mr. GORDON. How about obesity? How about the use of auo~ec1ie drugs? We have had testimony from various experts that they are not much good and that they should not be used. Have you had any programs along those lines? Mr. CALRSA. We produced a program on the diagnosis and man-~ agement of obesity which did not even mention drugs, except in one sentence, I believe, which said something to the effect that if drugs are used, then they should only be used on a short-term basis and a very highly critical review should be made b~r the physician before using any such drugs, and specific criteria were spelled out in that direction. That was like about a one-paragraph statement out of ~ 30-minute film, along with about a 32-page monograph. The emphasis of the program that we did on obesity was behavior modification-first diet, then therapy, drugs on a short-term basis if absolutely necessary, and behavior modification to effect perma- nent weight control. Mr. GORDON. Do you have a copy of the transcript of that par- ticular program? Mr. CALESA. Yes; I do. I will send it to you.1 Mr. SALTZMAN. Referring to Dr. Crout's statement, you ~entioned something about do our programs ever include neg~tives on the sponsoring client's product or~ any other product. I think the pro- gram for which Dr. Crout gave us some credit, that we developed in conjunction with the National Heart and Lung Institute, I be- lieve Dr. Crout's statement indicated that, if anything, the manu- facturer who supported the program's product was put in an extremely negative position. Mr. CALESA. That program was called, "Dialogues in Hypertension." I would also like to comment on this. I am not certain that I have gotten in all of the parts and pieces of your original question, ~ how things are tilted toward therapeutic enthusiasm. I think there was one misconception. 1 say that in this context. I happen to agree with a great deal of what Dr. Crout had to say. One of the misáon- ceptions is that what we are doing is providing educational programs about drug therapy. We arenot. What we are doing is providing educational programs about the diagnosis and management of a particular disease in a particular therapeutic area. I would say along those lines the emphasis is per- haps, let's say out of a 1-hour educational program, it is perhaps 10 percent, if that much, devoted to drugs. And when we do devcte a section to drugs-this is not always true; I no not want to say that- but it is primarily true. When we discuss drugs, we are talking about all drugs in the field. It may range up to 40 percent; but it is certainly not 100 percent. And we do discuss all alternative methods of therapy, including and starting with norrdrug therapy and nondrug methods. I do not know now if I have gotten through answering all of your questions, except that I would like to go back and say this. If the pharmaceutical manufacturer is going to sponsor educational ma- 1 MaterIal too voluminous to be printed but retained in the eomi~iIttee files. PAGENO="0104" 14010 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY terial, and he is going to dO it in accordance with the criteria which we have established, what he is doing is providing us with a grant of funds and allowing us the opportunity to produce a fair, balanced, and honest educational program which has been reviewed by as many groups and as many different people and in as many different ways as we possibly can before the educational program is provided to the physician. Now, I think the very important thing here is who supports these kinds of efforts. I think the answer to that question is the manufacturers with the better products, the high-quality products. Mr. GoimoN. What do you mean by "high quality products?" Is' there anyone with a low-quality product on the market? Mr. CALESA. Let me state it differently. People who are leaders in a particular therap&iitic field, people who have, let's say, the better recognized products. Mr. `GORDON. You are talking about the brand name companies, the trade name companies, are you not? Mr. CALESA. Yes, sir, I am. Mr. GORDON. The members of the PMA? Mr. CALESA. Yes; I am. Mr. GoRDoN. OK. Let's not talk about high-quality products, because according t& the Food and Drug Administration, all of the products on the market are high-quality products. Mr. CALESA. OK, fine. Did I answer all of your questions? Should I go on? Mr. GORDON. I think you have answered them, Mr. CALESA. It must be pointed out that there is a difference be- tween what I have described as education which does not meet all drug labeling requirements and education which does meet all drug labeling requirements and is considered as advertising. If all education supported by pharmaceutical manufacturers is to be considered as advertising and thus subject to all drug labeling requirements, serious shortcomings will occur. First, that automatically means that the pharmaceutical manu- facturer will be involved in the selection' of. physician participants and that they will review, edit, and have final content approval of all content. The reason is that, by Federal requirements' they must protect themselves against physician participants saying that may be considered accepted medical practice or the individual physician's opinion but deviates from the approved labeling. The editorial board participants do not accept this infringement by Federal Government authority over what they want to say. In addition, package inserts in the educational material are a tacit endorsement of the manufacturer's products. The effect of drug labeling on education is an infringement on free speech and pre- supposes that content control cannot be achieved by the medical profession. The Food and Drug Administration has proposed a series of guidelines to differetitiate education from advertising to over~come these problems. As you can see, we agree with all hut one of these guidelines and have introduced additional guidelines. PAGENO="0105" COMPE'IITIVE PROBLEMS IN THE DRUG INDUSTRY 1401 1~ There is one serious difference of opinion. They propose that the~ intent should not be for ultimate distribution by the pharmaceu- tical industry. If the manufacturer supporting the program meets all of these criteria, why can't he give it away? He has the distri- bution channels and can use them to get the program to the doctor. If he paid for the program and has the ability to help get it used~ correctly, why shouldn't he do this? If' he can't do this, why `should industry pay for it? Finally, our opinion is that if the manufacturer is forced to pro- duce educational materials as advertising, we will all lose-the medical educators, medical schools, organized medicine, the pharma- ceutical manufacturer, the doctor in practice, and because of the~e' losses the patient and the American public loses. Mr. GORDON. Sometimes, Mr. Calesa, the line between education and a subtle form of advertising is rather thin. The FDA has to~ make that determination. Is it a subtle form of advertising, or is it really education? Mr. CALESA. I think the FDA has spelled out criteria to define' how that line should be evaluated, and we, as I just mentioned, ~re~ in full agreement with the cri'teria that they have spelled out, with the exception of one, which is distribution. So, I accept that problem, and I accept the way they propose to handle that problem. Mr. GORDON. One thing that puzzles me is why will the doctors" not pay for this? Lawyers and economists and other occupations pay' for their education. Why would a doctor not want to do that? Mr. CALESA. Well, they perhaps were spoiled by the industry a number of years ago. But the hospitals will; the hospitals will' pay' for educational material. They will pay for the hospital staff, and' they will pay fOr the allied health professional. But physicians in private practice will not. According to our studies, the `physiciatis in" private practice never had the kinds of demands being placed on them for obtaining continuing medical education, as there are now. We have produced programs both with and without labeling. Obviously, we favor the former as do all of our medical advisors. As a matter of fact, Dr. Crout, in his appearance before this com- mittee, complimented Health Learning Systems for a program we - are producing `called, "Dialogues in Hypertension," which is de- veloped in cooperation with t'he national high blood pr~essur~ edu- cation program of the National Heart and Lung Institute, the Council for High Blood Pressure Research of the American Heart Association, and the National Kidney Foundation, under an edu- cational grant from Smith Kline and French Laboratories. This' program is produced according to the criteria previously discussed. Dr. Crout then went on to describe a program which we produced' under' a grant from Marion Laboratories which he said was an ex- ample of education that was promotional. In this case it should be pointed out that the `program produced met the criteria for dnig~ labeliiig. It contained the package insert on the films and in the - monographs and was edited by `the Marion Laboratories' medical' and legal departments in accordance with labeling requirements.. It is exactly for this reason that we feel labeling should not be a part of an educational program,' assuming the other criteria have' PAGENO="0106" 14012 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY been met. I would like to point out for the record that it was in- correctly stated at these hearings that Health Learning Systems was the producer of a closed-circuit television symposium on diabetes under contract to Pfizer Laboratories. The question has been raised regarding the extent of industry- sponsored educational material. We contend at this stage that it is quite small in relationship to their total marketing expenditures. Specifically, from industry-re- ported sources, the percentage expended for audiovisual presen- tations was .8 percent in 1972, 1.7 percent in 1973, and 2.1 percent in 1974. This is against a base in 1974 of $909,534,000. Mr. GORDON. Mr. Calesa, I think that is not a relevant statement. The question is what percentage of the postgraduate educational material is industry sponsoring, not what percentage of its adver- tising and promotional expenditure constitutes the kind of expendi- ture that you are talking about. Mr. CALESA. On the next page I go into that. I was just trying to make a point that the amount of total advertising expenditures against a base of $1 billion is relatively small and insignificant in relation to the total amount of dollars being ezpended, so that there is not an overwhelming volume of money being poured into this aspect of pharmaceutical marketing. That is the only point I wanted to make. I said this mainly as a prelude to the next statement that I would like to make, which is that the "Journal of the American Medical Association" publishes an annual report on medical education in the United States. In the most recent publication it listed 4,862 courses from 554 different primary sponsors for the year 1975-1976. The sponsors were medical schools, hospitals, medical societies, and voluntary health agencies, not pharmaceutical companies. Mr. `GORDON. Do you know the percentage, the number of people who are exposed to this type of educational material as contrasted with the university-based medical schools? Mr. CALESA. I do not have those figures. But I was just going to `say that in this issue of "JAMA," whatever facts are available are published in here, and I can send that to you if you wish. Mr. GORDON. Thank you, but we have that. Mr. CALESA. I do not know the answer, except for what is in there. The question has been asked how do we select subjects and phy- sician participants? The answer to that question is that we use our medical faculty of advisors whom we consult with regularly. In addition to advice from these consultants for selection of sub- ~ects, we use the "Forward Plan for Health," published by the De- partment of Health, Education, and Welfare, and "Health U.S.-~ 1975," Department of Health, Education, and Welfare, and surveys formerly conducted by regional medical programs among phy- sicians. From these sources we select subjects and attempt to obtain funding from the companies who are leaders in the selected field. Once funded, we approach a medical school, medical school de~ partment, or health agency to sponsor the program and determine an appropriate executive editor. The executive editor selects the edi- `tonal panel. We make agreements with all of the physicians that ~editorial content controls rests exclusively with them. They have PAGENO="0107" COMPETITIVE P~tOBLEMS IN `rrn~ ix~ira Thtr%Th~ 14013 final sign-off on the content before we go into production of any of the materials. When the content is ready to go into production or during the production, we submit the material to as many reviewing medical organizations ~s possible for accreditation and/or endorsement. When the education program is completed, we ask the sponsoring agency to write letters and other materials to create awareness of the availability of the educational program. We then give the com- pleted programs to the pharmaceutical manufacturer who distributes the material, making all physicians aware of its availability and use, at no cost to the hospital, medical society, medical school, or physician. It is the responsibility of the manufacturer to get the materials to the user an.d assist in making physicians and allied health profes~ sionals aware of the program. The only involvement of the grantor is to determine the media and this is based upon their available budget, pay the bills, and assist in the distribution of the program. This is not true where labeling is to be included with the educational material. In this case, the manufacturer is very actively and directly involved in the content of the educational programs. We have attempted to work very closely with the Food and Dri~g Administration in developing our educational programs and for the most part, with the exception of distribution noted previously, we agree with all of their criteria for program development. Based on what we have described today, we feel that high quality medical education programs can be developed effectively to meet the ultimate needs of the patient. If the Government were the primary source of funding for continuing medical education, Health Learning Systems would attempt to be the producer and would take the exact same approach in producing programs as we currently take if XYZ pharmaceutical manufacturer were providing the grant. We have had the. opportunity to observe dramatic results with ç~ur programs. We have received numerous letters of praise from Govern- ment officials, from academic medicine, and most importantly, bur learners, the practicing physicians, who have participated in and been exposed to the programs we have produced. On a recent closed-circuit television program which we produced, attended by over 11,000 physicians and allied health professionals, we asked the audience to evaluate the program content. With 1,993 responses, the results were: Met my expectations-99 percent; provided important information-97 percent; provided help for better patient care-97 percent; rated speakers excellent to good- 100 percent. On the closed-circuit television program produced by Health Learn- ing Systems on hypertension which was the basis for producing "Dialogues in Hypertension" for which we were complimented by Dr. Crout, I would like to quote a letter dated January 7, 1974, from Dr. Theodore Cooper, then Director of the National Heart and Lung Institute, to Mr. Robert F. Doe, president of Smith Kline and French Laboratories: As you are undoubtedly aware, one of the principles of the National High Blood Pressure liiducation Program Is that by combining the resources, and by cooperating with each other, the private sector and the Federal Gove~nment PAGENO="0108" 14014 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY ~an make very significant accomplishments in this critical public health area. If you have no objections, we would like to use the development of this symposium. as an example of this principle in action. As one of the primary companies involved in the communications~ program toward physicians on hypertension, we have seen from a 1974 study from the National Heart and Lung Institute called "Hypertension Detection and Followup Study" that initial visits to doctors increased 38 percent for hypertension and hypertensive heart disease since 1971. The number of people with hypertension not aware of their disease decreased from 50 percent to 29 percent, and in a separate study of 760 clinicians published in the May 1975, issue of "Medical Opinion," it revealed that the number of physicians; who take blood pressure readings increased in 5 years from 50 percent to 90 percent, that 73 percent of physicians routinely use laboratory tests for hypertensive patients, and that the number of patients now talking about hypertension with their physician in- creased from 9 percent 5 years ago to 36 percent today. We are pleased to say at this time we are working with the National Board of Medical Examiners to produce a national self- assessment on hypertension for physicians under an educational grant from Smith Kline and French Laboratories. This is an out- growth of our "Dialogues in Hypertension" program. Every day we receive letters on one or more of our programs from physicians in practice who thank us for our contribution to their patient care needs. We are young and this industry is young. We have made mistakes. We have not always been able to include all the Food and Drug Administration criteria described in this statement in every one of our programs. We are concerned, dedicated, and proud to be part of an effort where we have seen visible signs that in some small way we have contributed to an improvement in the quality of health care in this country and abroad. Thank you for allowing me to share this with you. Senator NELSON. Thank you very much. Without personally commenting on the quality* of the programs, since I have not seen them I am not qualified to judge them anyway, is it not true, nevertheless, that the drug companies are: (1) Involved obviously, because their interest is in promoting the sales of their products; (2) does not this type of system in which they distribute the programs and materials to the hospitals and the physicians themselves gives them a formalized relationship with the insti- tutions, with the medical schools, if they use the materiais~ hospitals, teaching hospitals, other hospitals, give them a formalized insti- tutional standing which strengthens their position in order better to promote the business that they are engaged in? Is that not true? Mr. CALESA. Well, Mr. Chairman, I do not think that it gives them a feeling of association with that particular university. I do think it gives them a better stature. I do think it gives them, let's say from an institutional advertising point of view, greater stature than someone else might have by virtue of the fact that they have spon- sored a program that a multiple number of people are involved in. But I have to go back again to the most fundamental issue, and PAGENO="0109" COMPETITIVE PEOBLEMS IN ~~HE DR~YG INDi7STR~ 14015 ~that is, if we are developing a program which includes in its criteria a total number of direčtional inputs and content control from all of the major factors ir~ the medical community involved in that par- ticular field of medicine, and then providing that, handed out by the pharmaceutical representative, what we have done i~ we have con- trolled the content and the quality of the type of story, the dialogue between the representative and the physician to the greatest extent that we possibly can-that is what we do, and that is what we at- tempt to do. Senator NELSON. Well, that is the purpose of the hearing. But I think it really raises the fundamental question of whether drug companies, promotors of drug products, should be allowed by hospi- tals and physicians to intrude into the education business in any fashion whatsoever since everybody knows their bias. In other words, would it not be much better if they were just out of this business totally, and if all of the postmedical education were in the hands of the scientific community and the medical schools, since, it seems to me, there is no way to avoid the iiiterjection of substantial bias and/or ban prestige and benefit to the promotor of the sale of drugs? Mr. CALESA. Well, Mr. Chairman, again I have to say that by vir- tue of the fact that we address ourselves in every case to direct sponsorship by a medical school or a medical school department, ~ are, in fact, doing exactly what you are saying, which is keepitig control of the course within the medical school and the medical universities. What we are doing, and what we happen to believe in very strongly, is a spirit of cooperation, and that spirit of cooperation asks that all of us provide the resources that we have, that they can contribute most effectively, and what the pharmaceutical manu- facturer is contributing, based on the criteria we have outlined here today, are fundamentally financial resources and distribution resources. Senator NELSON. I understand that. Since I do not know, let's assume that your programs or anybody else's programs paid for by the drug companies are of the highest scientific quality. Let us assume that. That probably is even worse, as a matter of fact~ If they were of low quality, it might be ultimately beneficial to the medical pro- fession because the reputation of the company would not be enhtrnced. * What you really have is you produce a high-quality program. So, there is this wonderful company doing these wonderful things. However, in the promotion of their drugs elsewhere, in the medical journals and in the throwaways, none of that criteria is followed, except that which is forcibly imposed upon them by the FDA; so, they have the prestige now because they did something very high quality on hypertension. No~v comes their promotion of drugs in that field, or in aiiy one of a dozen others. The physician already has subtly been co-opted by the company because if they produce such a good program on hypertension or something else, what they are saying Over here, in, their advertising and promotion miist be of the sante quality. PAGENO="0110" 14016 COMPETITIVE PROBLEMS IN TUE DRUG INDUSTRY I am not so naive as not to understand that. Neither are you; nor are they. That is their purpos&-to infiltrate the whole educa- tional system in order to promote the sale of drugs, at which they have been tremendously successful. There are some of the finest clinicians in this. country testifying that we probably use ~ or 5 times, and some of them have said 10 times, as many drugs as in the interest of the health of the patient. They have already co-opted a good part of the medical profession in terms of their selling them the idea that you ought to prescribe a drug for everything else. How would anybody explain that in some careful studies done by physicians themselves, they find that 95 percent of the doctors are prescribing something for a common cold, and of those, 65 percent is an antibiotic. Since a cold is a viral infection, the target organism is not affected by an' antibiotic. Every witness we have had has testified that there is no way to justify the prescribing of an antibiotic for the common cold. Then why Were they prescribed? Because the company was very good at selling. This, it seems to me, is another subtle technique for enhancing their prestige in order to make more acceptable their promotion of their products in other forms and media, through detail, men, through advertjsing in the magazines. Isn't that clearly what is going on? Mr. CALESA. Well, I would take some exception to that, Mr. Chairman. I would' say the following. * First of all, at several hearings here, one of the things I keep reading about in the pink sheet is that pharmaceutical manufac- turers are being encouraged to educate and to inform, rather than to promote. I think what we are trying to do is to be the impie- menter or the catalyst ~f that kind of approach. I think by virtue of the fact that we can comprehensively package educational material in a therapeutic field, and provide it in a fair and balanced format, and provide it both to the sales representative as well as to the physi- cian, you now have the basis for a better dialog, so that many `of the problems that you are describing are not going to occur. What do you do without it? You iust maintain the same basic system that you have expressed concerns about in the past. What we are trying to do is to step forward. We are trying to say, OK, perhaps there were problems with what took plac~ in the past. Let's now do something about it, and that is what we are at- tempting `to do. Senator NELSoN. I am not commentmg on the quality of the work that your group does at all. The tragedy, I think, is that there is a vacuum here. There has been a failure on the part of the medical profession, the medical, schools, to provide the' continuing education of the physician in an adequate way. So, along comes the drug com- panies and they say let's jump into the vacuum, which is what they have done. They do not belong there. That is for the medical schools. That is for the scientific' community, and in my judgment not for the drug company. I am not quarreling about your organization and its work at all. I think the great sadness i's that there' is a vacuum for which ap- parently some'need is supplied by the wrong people. That is all. They are perfectly fine peop'le~ They do not belong in the drug education business. That is for the scientific community. PAGENO="0111" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14017 Mr. CALESA. I agree with you, and that is exactly the approach that we take. We keep them out only to the extent that they are providing the funding and the distribution. I agree with you. I think they do not belong there. Senator NELSON. But that is the real subtlety of it. They gain great prestige by promoting education, and they gain access, and they gain reputation, which enhances their credibility, of course, in terms of selling the products, which is what they are in the business of doing. That is clear enough. Mr. CALESA. Yes; that is the business they are in. There is n~ question about that. Senator NELSON. Fine. Thank you very much, everyone. We appreciate your taking the time to come. We will be hearing next from some medical educators on this whole problem. Thank you. Mr. CALESA. Thank you. [Whereupon, *at 11:55 a.m., the subcommittee recessed, to reco~i- vene upon the call of the Chair.] PAGENO="0112" PAGENO="0113" APPENDIX MATERIAL SUPPLIED FOR THE RECORD BY THE SUBCOMMITTEE ON MONOPOLY [September17, 1975} STATEMENT OF COMMITTEE ON SCIENTIFIC EXHIBITS IN REGARD TO PHARMACEUTICAL SUPPORT OF SCIENTIFIC ExHIBITS The scientific exhibit is ttn established and efficient method of continuing medi- cal education that brings new information from the research scientist and revised correlations of old information from the academic community for the attention of the practicing physician. A scientific exhibit is designed to emphasize a few points and not to be an in depth presentation of any subject. Because exhibits that contain tOo much information seldom attract a large audience, it is necessary that the amount of information on any exhibit be limited. By reviewing scientific exhibit's, physicians are able to learn more in less time about a wider variety of subjects than by any other educational method. The depth of the education is regulated `by the interest and perceived needs of the physician. Those who wish a superficial knowledge of the advances in spe- cialities other than their own, may take a quick walk through the entire exhibit. Those who wish to learn more about a subject may spend considerable time ask- ing questions of the exhibitor. This informal discussion between the exhibitor and the practitioner is a valuable learning experience for both `and not Infre- quently leads to further correspondence between the `two. The sciehtific exhibit has been one of the main attractions of the American Medical Association ~neet- ings for the past `seventy-five years and `this educational method should be preserved. Recently, the Food and Drug Administration has ruled that those exhibits which have been sponsored by pharmaceutical companies should be considered to be promotional rather than educational even though no trade names áhd no names of a pharmaceutical company are used. The fact that the exhibitor has tabulated the data and is responsible for the editorial content of the exhibit, does not keep those exhibits from being promotiOnal. If an exhibit i's desl~nated as promotional it must conform to the Standards of approved labeling. This means that unapproved indications and unapproved dose schedules cannot he used. All data in regard to comparative efficacy and safety must be based upon controlled clinical trials and not upon clinical experience. By this definition, approximately 80 percent of the scientific exhibits `at the AMA meeting are - promotional and probably half of these are in non-compliance with the regula- tions for the labeling of pharmaceutical products as set forth in the federal register. If these proposed FDA regulations are complied with, few pharmaceutical companies will be willing to sponsor scientific exhibits. The scientific exhibit will degenerate into a collection of homemade displays prepared by a few physicians who feel strong enough about a given subject to spend several thousand dollars of their money. Past experience has shown that few of these unsponsored exhibits are worthwhile. Strict interpretation and enforcement of the proposed rules would seriously retard medical communication. It is recommended that the AMA should take a strong stand in attempting to persuade the FDA to adopt more reasonable and permissive attitudes toward the scientific exhIbit A knowledge of the logistics and the costs involved are necessary before any- one can formulate reasonable regulations for scientific exhibits. Presenting a scientific exhibit involves the following steps: 14019 73-6170-76-8 PAGENO="0114" 14020 co~nEPITIvE PROBLEMS IN THE DRUG INDUSTRY 1. COLLECTION OF SCIENTIFIC DATA tlsually the exhibit serves as a method of presenting the conclusions of re- search that the exhibitor has worked on for several years. If the data is old and has been published, reprints can be reviewed before exhibits are accepted. How- ever, this i~ impossible with new data and the exhibit committee is' forced to rely upon the abstract, the reputation of the exhibitor and the reputation of the institution from which he comes. The support for this research may have come from a pharmaceutical company but often It has come from several sources. Exhibits which serve as a review of a particular disease may have data that comes from several sources and not the research of the exhibitors. 2. DESIGN OF THE EXHIBIT Exhibitors sometimes design their own exhibits but professional help is usually needed to have an exhibit that effectively conveys the message of the exhibitor. 3. EDITING OF COPY Each exhibitor decides what is to go in his exhibit and has complete editorial responsibility for the text of both the exhibit and the brochure. Before an exhibit is made, it is customary to have the proposed copy reviewed by several people. If a pharmaceutical product or medical device is mentioned, it is especially help- ful for the manufacturer to review the copy for accuracy, legality and clarity of presentation. This review of copy does not imply that the exhibitor has delegated editorial control or responsibility for the exhibit to anyone else. If this review did not exist, exhibitors might make what they believe to be honest statements about a product but which are more extravagant than the company would make. This editorial review helps to prevent errors and should be continued. 4. ExHIBIT CONSTRUCTION A few exhibits are con:struCted at home with cardboard, wrapping paper and crayons, but these seldom receive enough attention to justify the time and effort of the exhibitor. Therefore, most exhibitors use professional exhibit makers to construct a free-standing, self-contained exhibit `that will attract `the attention of physicians. 5. SHIPMENT, SETUP, DISMOUNTING AND STORAGE In most convention halls it is necessary for the exhibitor to hire members of the Teamsters Union to transport the exhibit to the designated space, union carpenters to set up the exhibit, and union elecricihns to screw in the bulbs and plug in the cords. Union personnel are also required to dismantle an exhibit. This is not only expensive but requires considerable experience and time on the j~art `of the exhibitor to see `that it is properly done. Many pharmaceutical companies have experts in this field who can do the job more efficiently than the average physician. 6. BROCHURES Phytacians wish a summary of many exhibits to review at leisure. If the material has previously been published, reprints may be used but the lag time between competition ~f a project `and the publication in `a medical journal usually makes this impossible. Some brochures `are simply photographs of the exhibit, but most are more carefully prepared by `an artis'tic and Innovative printer. Pharmaceutical companies often obtain extra copies of those brochures that are favorable to their products `ai~d use `this in their sales promotion. Brochures that contain material that has a substantial disagreement with the package insert cannot be used. Consequently it is desirable for the pharmaceutical companies to review the brochure before it is published. 7. PERSONNEL STAFFING THE EXHIBIT For a meeting as large as the AMA it is necessary to have two physicians in attendance in order to keep the exhibit staffed at all times. In some cases, other PAGENO="0115" COMPETIPtVE PROELEMS IN THE DRUG INDUSTRY 14021 professional personnel such as nurses and technicians may be used instead of/or in addition to the physician's. An unattended exhibit loses much Of its `teaching value. Unless the personnel staffing an exhibit are adequately compensated, only the most dedilcateci will stand there all day. 8. ESTIMATED COST OF PREPARING AN EXHIBIT FOR THE AMA 1. `Oo'llection of !da'ta_$lOO to $100,000; 2. Design of Exhi'bi't-$200 to $1,000. 3. Editing of Copy-$100 to $1,000. 4. Construction of Exhibit-$3,000 to $30,000. 5. Shipping and Setup-$400 to $1,200. 6. Preparation of `broehures-$300 to $3,000. 7. Expenses of personnel-$600 to $3,000. 8. Total cost for exhibit (except No. 1)-$5,000 to $40,000. Few physicians or scientific investigators can afford to have an exhibit unless they receive financial support. In the past, large clinics ~nd medical centers supported exhibits as part of their public relations and professional education programs. The source of these funds has been severely reduced lately. Some exhibits have been su~pported by professional societies and lay h~aith organiza- tions, but too often these organizations `are `more interested in recruiting mem- bers and raising funds than in educating physicians. Support from the federal government through National Institutes of Health, Armed Forces Institute of Pathology, the Food and Drug Administration and the military forces has helped in the past, but this has recently `been greatly reduced. Approximately half of the federally supported exhibits have had good scientific value, but the other half have been ineffectively presented propaganda designed to enlist the physicians' support for a specific government program. The only other source of financing exhibits has been pharmaceutical companies. Either directly or indirectly this pays about eighty percent of the cost of the scientific exhibits. If ill-conceived federal regulations eliminate this support the scientific exhibit will disappear. Not only will the medical profession lose this most efficient single method of medical education but many of our great medical conventions will disappear. The AMA and most of the state medical societies would cease to have large scientific programs and would settle for a business meeting of the House of Delegates. Continuing Medical Education would then consist of the free standing papers in the specialty societies and the planned courses and symposiums put on by various groups. No longer would there be one place where physicians from all `different specialti~s could meet and freely exchange knowl- edge. Some pharmaceutical companies do have altruistic medical directors wl~o are willing to support a purely educational exhibit but the financial directors who approve the expenditure of funds must be assured of getting `their money's worth. Corporate Identity is possible in the "sponsored teaching exhibits", but is not now possible in the scientific exhibits. Product identity in the scientific exhibits is possible, but is obscured by the use of generic terms throughout the body of the exhibit. Using a scientific exhibit for promotional purposes is contrary to the spirit of the regulations of the AMA. However, the AMA cannot be respon- sIble for `anything `that `happens to `an exhibit or to `the `brochures after the meeting. In this `hlgthiy competitive society few pharmitceutical companies can afford to support a purely educational exhibit and very few would be willing to support an exhibit under the proposed FDA rules. There is a gray area of promotional exhibits `that lies between the truly scientific exhibits and the known commercial exhibits. It has been the policy of the AMA exhibit committee to guard against promotional abuse in the scientific exhibit. We think that we have done a good job in the pa'st and hope' to continue. However, the rigid Implementation of the rules propose~1 by the Food and Drug Administration would retard medical communication and not improve patient care. It is recommended that representatives of the AMA meet with the Food and Drug Administration to consider ways of modifying the severity of these rules. JAMES M. Moss, M.D. PAGENO="0116" 14022 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY The University o~Ver~r~ont ±~ DEPARTMENT OF NEUROLOGY, DEGOE580IAI4D UNIT MEDICAL CENTER HOSPITAL OF VERMONT ~ BURLINGTON, VERMONT 05401 April 8, 1974 Alan B. Lisook, M.D. FDA Bureau of Drugs Washington, D.C. 2DDDD Dear Doctor Lisook: Having read of your excellent investigation of experimental trials of therapy, especially in cooperation with drug manufacturing concerns, I thought I should address this letter to you, though it may be more appropriate to call to the attention of the Commissioner of the FDA what I have to report. Would you be good enough to let me have your reaction to this matter and, if appropriate, pass the information along to whatever other person in the organization you think it best review the matter. Enclosed are copies of an initial letter from Modern Medicine Publications soliciting my participation in a Forum and also of subsequent correspondence between us. As you can see from the initial letter, dated July 31, 1972, I was asked to submit a statement concerning the management of migraine. I believe three other authorities around the country were also asked to contribute. The initial manuscript which I submitted was returned with some deletions to which I objected because of the initial assurance in thg soliciting letter than any point of view was acceptable. I was struck by the fact that my emphasis on the lack of specific value of a brand name shotgun preparation (Fiorinal) had been deleted. Also deleted was the statement, "The criteria for distinguishing purely muscle contraction headaches from vascular headaches are tenuous and vague" ,~ a statement directly counter to the manufacturer's (Sandoz) claim of specificity of their di~ug for "tension headache". Because of my insistence, the Editor agreed to a compromise version which left my opinion intact. Elsewhere in the manuscript I state, "No drug to date, whether by controlled or impressionistic trials of therapy, has been shown to be predictably or permanently effective in eliminating attacks in the majority of cases". Further on, I state, "none has been shown to be more effective than conscientiously and sympathetically applied psychotherapy. Once the migraine personality becomes well known to the physician and he develops increasing skill in dealing with it, including assistance to the patient in modifying his attitudes, habits of living, patterns of emotional reaction, and/or environmental stress, the results are as good as with prescribing anything that comes out of a bottle. Common sense psychotherapy is every doctor's business, but the cost in time and energy for carrying out the only truly effective approach to the prevention of recurrent headaches causes it to be almost universally neglected in favor of pharmacotherapy alone -- an easier way out but less successful. This is not to say that agents counteracting emotional tension and promoting relaxation are not often useful accessories." PAGENO="0117" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14023 A later statement was, "That drugs with possible preventive vaso- constrictor action regularly administered (methysergide, inderal)* are useful once status migrainus sets in has not yet been established." (* San~ert, Propranolol). In the first paragraph of the manuscript I originally had some rather strong statements suggesting mismanagement of headache based on faulty conceptions of mechanism, which might assuage the p~y5j~j~fl~5 consoionce but dupe the patient and the fact that patients often improved temporarily and non- specifically in response to any management, which protracted the unintentional charlatanry. I later spontaneously realized this language was too strong and deleted it, substituting entirely innocuous language. This all took place before an abrupt and unexpected letter of rejection from a Miss Sylvia Covet, Editorial Director, in a position apparently to supersede the decisions of Dr. Jnhn H. Rosenow, the Senior Medical Editor, with whom I had been corresponding. Just two days prior to receiving her letter, we had a long distance telephone call from the Editorial offices requesting a different photograph, since the one sent was too dark for reproduction. About this time I also learned of the pressure Sandoz was under to substantiate its claims for Fiorinal by the FDA and also Sandoz's solicitation of investigators for alleged sound experimental trials of therapy utilizing this drug with the very inviting proposition of payment of $200 for each subject so investigated. I have enclosed copies of my remonstrance to Editor Covet and her replies. Nevertheless, in view of the specific provisions in the initial solicitation to the effect that any stated opinion would be acceptable, the hours of time and of effort I devoted to the project, my nationally known insistence on integrity in experimentation, especially trials of therapy, the cavalier and discourteous and disrespectful action taken by Editor Covet, I frankly was outraged and strongly suspicious of spoken or unspoken collusion between Modern Medicine and Sandoz. Whether I am correct about the latter or not, there is no question that the initial promise was not held to and the agreement not kept. Therefore, I would like to see this matter pursued further if it is within the province of the FDA to do so. As I indicated in the letter to Miss Covet, this sort of bias on drugs indulged in by a magazine that subsists entirely on advertising revenues and distributes its issues free to physicians all over the country should perhaps come as much under the scrutiny of the FDA as do the manufacturers and pseudo-scientific clinicians who carry out their experimental trials of therapy. If you would like further indications of my experience with problems of headache, previous experimental work with H. G. Wolff at Cornell over many years, and published papers, of mine in connection with aspects of experimental trials of therapy in other areas, I should be glad to supply them. I would be glad to send you a copy of the first version of the manuscript, but my request to the Editor to return copies of the revised manuscripts which I sent have never been complied with. PAGENO="0118" 14024 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Since I visit Washington from time to time in connection with my collaborative work with Dr. Sever in the MINDS, I would be happy to stop at your office for further discussion of this matter if you deemed it of any Sincerely yours, Gebrge A. Schumacher, M.D. Professor of Neurology GAS/sam Enclosures 8 PAGENO="0119" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14025 The University of Vermont DFPAOTMFNT OF NOUROLOGY, 00000SBOIAND UNIT PIRDICAL CONTOR IIOSFITAL OF VORMONT BURLINGTON, VOOMONT 05401 July 1, 1974 Dr. Alexander N. Schmidt Director, Bureau of Drugs Food and Drug Administration 5600 Fischer Lane Rockville, Maryland 20852 Dear Doctor Schmidt: On April 8th, I sent a letter to Dr. Alan B. Lisook summarizing a situation which I thought constituted unethical action in drug promotion, or at least in suppressing criticism of a manufacturer's product, by one of the so-called "throw-away" journals, namely, Modern Medicine, distributed free to hundreds' of thousands of physicians and supported financially solely by advertisements. The Editors of this publication solicited a manuscript from me on the treatment of migraine, an area in which I have had considerable experience and originally did research work when still associated with Dr. Harold C. Wolff at Cornell Medical School in New York years ago. The essay was solicited without promise or expectation by me of any compensation, and I was happy to provide what I thought was a statement based on sound scientific opinion. I enclose a copy of the original letter of solicitation. In my treatment of the subject, I frankly minimized the value of certain drugs, particularly Fiorinal, cast doubt on the entity, "tension headache" for which it had been promoted for years as an almost specific remedy and in general suggested that the reliance on a variety of drugs instead of other more time consuming~and mote effective approaches represented simply an easy way out for the doctor. It was only after I had submitted the manuscript that I learned to my surprise that Fiorinal was being subjected to critical investigation by the FDA and that Sandoz was under some compunction to prove its allegedly specific value, and providtng handsomA financial grants to physicians to carry out allegedly controlled experimental trials of therapy (this after the drug had been on the market for 20 or more years). My manuscript was initially modified by the Editor, deleting some of my critical comments about the drug approach to headache treatment and especially omitting the statement that, "The mystique of the therapeutic specificity of Fiorinal for `tension headac1~e'needs to be dispelled with the realization that it is merely APC combined with barbiturate". Because of my strenuous objections to this deletion, it was re-instated and I subsequentl~' softened some of the harsher criticism I made of the usual approach to the treatment of headache. PAGENO="0120" 14026 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Nevertheless, at the point of publication, when a picture had been solicited and sent in, there was a sudden and unexpected rejection of the manuscript by the top Editor, Miss Sylvia Covet, apparently in a superior position to the Editor with whom I had been corresponding. The explanation was simply (after six months and three revisions), "Your comments do not meet the criteria established for this series". I forwarded additional material, including copies of correspondence and a copy of my manuscript, to Dr. Lisook because of my awareness of his interest in sleuthing the way in which drug houses get physicians to carry out trials of therapy with their drugs without adequate scientific control and suggested that this might be a matter for the FDA to investigate, that is, the possible unethical bias of magazines of this sort in their attempt at control of what authors say in relation to therapeutic approaches or drugs that might run counter to the interests of the pharmaceutical firms on whose advertisements they depend financially. I have had no response from Dr. Lisook, but am sufficiently concerned about the matter to want to press it and hence at this time am writing to you about it and expect that you will find time to let me have your reaction to it. Sincerely yours, 4;. C~orge A/i Schumacher, M.D. 1rofessd~J of Neurology GAS/sam cc: Dr. Alan B. Lisook Enclosure PAGENO="0121" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14027 April 12, 1973 Miss Sylvia Covet Editorial Director Modern Medicine Publications 4015 t'est 65th Street 1~inncapolis, Minnesota 55435 Dear Miss C'vet: I regret that your letter of March 26, 1973 provides neither adequate explanation nor justification of your abrupt action in rejecting the manuscript on headache. I~was rather evasive and d~d not truly respond to the facts I had pointed out in my previous letter which I still feel represent the essential truth of the matter. It has become apparent now that even a journal, such as Modern Medicine, as well as drug manufacturers themselves, can have a biasing influence upon readers in connection with sound scientific appraisal of treatments ~ medications because of ulterior motivation. In view of this, I believe the FDA should bring a journal such as yours under its scrutiny as well as drug manufacturers and it is my intention to bring this matter to the notice of the PDA in complete detail. To reject the manuscript because it was too `incendiary' is a ludicrous cooment in view of the strong differences of opinion that sometimes exist between critical scientists. It is an especially weak excuse after the wording of the initial solicitation of a paper from me by your Executive Medical Editor, stating specifically that the statement might contain "a scorching condemnation or a paean of praise'. This sction of yours is really quite a turnabout and could be explained only by the following relevant facts, Sandoz now has full-page ads for Fiorinal on the back covers of the issues of the archives of Neuro1og~. The FDA, however, and rightly, has expressed s~e concern about the claims of the manufacturer for this drug. have had the same criticism for twenty or more years. Plus, this situation provides one plain reason why you editorially deleted the cocrecent in my manuscript Indicating the non-specificity of this shot-gun preparation and raising the question about the validity even ofa headache syndrome for which it is alegedly specific. Your action is further more understandable in view of the decision by Sandoz, following the FDA's scrutiny, to recruit physicians in the headache field around the country to carry out therapeutic trials of the drug (paying the physician $200 for each patient included in this study) after the drug has been on the market for twenty years. This also tends to explain why Modern Medicine has decided to publish a Forum on the medical treatment of migraine. It would seem that it may have been suggested by Sandoz, probably PAGENO="0122" 14028 coi~rr'ETITIVE PROBLEMS IN THE DRUG INDUSTRY in cor.sultation with and the approval of Dr. Arnold Friedman who put Fiorinal on the market, enabling Sandoz to make millions. It is obvious that both Dr. Friedman, professionally, and Sandoz, financially, have a large stake in what appears in the Forum, in view of the coming evaluation by the FDA. Though you may have had other reviewers, I suspect that the dampers were put on the publication of my views by Dr. Friedman. I cannot conceive of any other clinical scientist in the headache field objecting to any aspect of the content of my statement. I have been practicing these principles and teaching them to students and physicians for thirty-five years with reasonable evidence of success. To request the opinions of four different physicians (whom I presume were sound clinical scientists with recognized research and clinical experience in the field) and then to turn the views of one down because of the negative ccersnenta of a reviewer with whose opinions my views did not coincide, is a grossly dishonest action. The matter is sufficiently important to me so that I shall attempt to have it further publicized. I am submitting my statement on the management of migraine which you solicited and then rejected to whatever reputable neurologic journal might accept it, accompanied by a letter to the editor for publication describing the sequence of events in this case. I will speak personally to the Editor-in-Chief of one of the journals who is a friend and whose esteem and respect I have always had, Though I doubt you will be interested, I am enclosing three mimeographed handouts, prepared by me, for medical students, physicians, and patients on the subject of headache. One is an outline of headache mechanisms and appropriate therapies derived from the work of Dr. Harold C. Wolff, with whom I worked and carried out research for. many years at Cornell before coming here. Another is a reprint of a published panel on headache to which I contributed extensively held in New York several years ago. The third is a pamphlet for patients discussing the headache problem and its treatment in comprehensive, yet simple and lucid form. Although it may appear a bit conceited to you, I am sure that if you take the trouble to read these, you will understand why I believe that your journal and the phya4cians who read it, as well as the vast army of headache sufferers, are the losers, not I, by your fundamentally dishonest decision to exclude ray manuscript on a last minute basis from the Forum to which you invited its contribution. Yours truly, Ceorge'A. Schumacher, M.D. Professor of Neurology CAS/sam Enclosures - 3 PAGENO="0123" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14029 MODERN MEDICINE PUsUCAT~ONS 4 ~ *~ ~ ~ Februa±-y 13, 1973 George A. Schumacher, M.D. The University of Vermont Department of Neurology Medical Center Hospital of Vermont Burlington, Vermont 05401 Dear Dr. Schumacher: I am enclosing a revised copy of your remarks for the Forum on headache. We have incorporated the changes you suggest and are using the "compromise" paragraph three that you submitted in your letter of February 5th. On some of the changes our people made, there was per- haps a too-zealous insistence on our particular style and conceptions of grammar. On many of these, it seems to me, there is room for honest difference of opinion, and we are therefore using your versions. In some of the changes that we made in your paragraph three, I think we were just plain wrong. Thank you for your interest and concern. Your contri- bution will make this Forum stimulating, interesting and worthwhile. I'd appreciate it if you could return the approval form as soon as possible. Sincerely, John H. Rosenow, M.D. Senior Medical Editor JHR: lbs Enclosures PAGENO="0124" 14030 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY THE MANAGEMENT OF MIGRAINE Significant progress in the management of what H. G. Wolff termed "manes most prevalent distress" is unlikely until presumably authoritative writers and the vast majority of practicing physicians abandon unproved and unscientific concepts, reliance on anecdotal experience, and semantic misnomers. Notions of such alleged entities as "histaminic cephalgia", "allergic headache", "sinus headache" (excluding acute suppurative inflama- tion), "eye-strain headache" and a host of others persist in common medical parlance for ordinary vascular headache (HA) and continue to provide con- venient handles for (mis)management which assuage the physician's conscience and dupe the patient. The fact that the patient often improves -- temporarily -- protracts this unintentional charlatanry. Though all the links in the chain of pathogenesis remain yet to be ascertained, for practical purposes recurrent (HA's)unassociated with demonstrable intracranial, extracranial, or paracranial disease should be considered as owing to cranial artery distension, with or without components of sustained cranial muscle contraction. The criteria for distinguishing purely muscle contraction HA's from vascular HA's are tenuous and vague. If "tension" HA's exist, they form but a small fraction of the vast army of vascu~ar MA (migraine) sufferers, constituting lOll of the world's population. For HA's of moderate intensity a nap, with or without aspirin or APC, often suffices. Strong black coffee and aspirin(with or without barbiturate) is effective in a few subjects. The mystique of the therapeutic specificity of "Fiorinal" for "tension" HA needs to be disspelled with the realization that it is merely APC combined with barbiturate. When HA is too severe to respond to simple analgesics, caffeine, and/or sedatives, more intensive pharmacotherapy directed toward cranial vasoconstriction is indicated. PAGENO="0125" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14031 Ergotamine tartrate (Gynergen) is the best agent, most predictably effective intramuscularly or intravenously, but also, in perhaps 2/3 of subjects, orally (sublingual or ingested) rectally, or inhaled via spray atomizer. Its combination in proprietary preparations with caffeine (also a cranial vaso- constrictor) for oral or rectal administration appears to enhance its effect. In isolated failures there is little choice but to fall back on potent narcotic analgesics such as meperidine (Demerol) or codeine. The necessity for several hours or a day's rest following relief from a headache is usually neglected by the physician or ignored by the patient. Though the availability of reasonably predictable relief from a nagging headache or an acute "splitting' hemicrania is reassuring knowledge to the patient, the most desired aspect of management most certainly is prevention of recurrent attacks. No drug to date, whether by controlled or impressionistic trials of therapy, has been shown to be predictably or permanently effective in eliminating attacks in a majority of cases. An advantage over placebos has been demonstrated in some agents, including methysergide (Sansert); rarely with preventively administrated ergotamine tartrate (alone or in combination with barbiturate sedative and other questionable agents, in cautiously planned regimens); inderal (Propranolol), and opipramol (Insidon), but the reliability of these imperfect trials of therapy and experience to date have not y'et been adequate to warrant their routine use with confidence by the physician. None has been shown to be more effective than conscientiously and sympathetically applied psychotherapy. Once the migraine personelity becomes well known to the physician and he develops increasing skill in dealing with it, including assistance to the patient in modifying his attitudes, habits of living, patterns of emotional reaction, and/or environmental stress, the results are as good as with prescribing anything that comes out of a bottle. PAGENO="0126" 14032 COMPETITIVE PROBLEMS IN THE DRtTG INDUSTRY Common sense psychotherapy is every doctor's business, hut the cost in time and energy for carrying out the only truly effective approach to the prevention of recurrent headaches causes it to be almost universally neglected in favor of pharmacotherapy alone -- an easier way out but less successful. This is not to say that agents counteracting emotional tension and promoting relaxation are not often useful accessories. Indeed, in the vascular headache crisis, known as "status migranus", where headaches have reached an unremitting, daily frequency lasting weeks, or even months, the almost certain fact of an under- lying depressive illness is too often unrecognized by the physician. The primacy of this basic problem, the headache then being a psycilophysiologic epiphenomenon, must be dealt with by continued reassurance, at times investi- gating and dealing with psychodynamics, almost always by separation of the patient from his usual environment, and the judicious application of anti- depressants. Cranial vascconstrictors at such times a~e often useless, though if a headache fluctuates, waxes and wanes, ergotamine during a new exacerbation may he helpful. Other than this, encouraging the patient simply to endure the pain, providing occasional relief by a narcotic, and predicting with absolute confidence that the attack will ultimately end, is all that can be offered in status migrainus. That drugs with possible preventive vasoconstriCtor action regularly administered (methysergide, inderal) are useful once status sets in has not yet been established. George A. Schumacher, M.D. Professor of Neurology University of Vermont college of Medicine Burlington, Vermont PAGENO="0127" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14033 MODERN MEDICINE PUBLICATIONS ~i15 \~EST (5TH SSTIET. M!\\E~PQ: July 31, 1972 George A. Schumacher, M.D. College of Medicine Dept. Neurology, University of Vermont Burlington, Vermont 05401 Dear Dr. Schumacher: The editors would like to have you take part in a Forum based on an abstract published in MQDERN MEDICINE. I am enclosing a copy of the abstract. The question for discussion is "What are the best prophy- lactic and therapeutic medications for the treatment of migraine?" Your views will be read with interest by thousands of readers. (More than 200,000 physicians regularly receive MODEME MEDICINE.) Essays are to be about 300 words long and should reach us in about a month to allow time for editing and submission of the edited copy to you for approval. We suggest an informal style, without extensive documentation or multiple literature citations. Would you also please send us a recent photograph of yourself that we can print along with your remarks? The picture will, of course, be returned. We have been queried as to how these essays should be oriented in relation to the abstract cited. If you believe it merits a scorching condemnation or a paean of praise - fine. You may prefer to use the abstract and question as a springboard for a more general discussion of your opinions and experience. That's fine, too. In each Forum, we solicit statements by persons who have contributed significantly in the field to which the abstract relates, and who represent various points of view. In this way, our readers get a spectrum of reaction to problems ~i~which there is room for honest difference among men of experience, ability and integrity. This should be a lively, informative Forum. I look forward to hearing from you. Sincerely yours, John 11. Rosenow, M.D. Executive Medical Editor JI-IR: lbs PAGENO="0128" 14034 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 15 Columbus Circle NewYork NY, 10023 Physicians Radio Network (212)5418384 December 30, 1975 Dear Doctor You may have heard your colleagues talking about a new medical news service operating at no cost to physicians. The service is called the Physicians Radio Network (PRN) and is now broadcasting in Chicago providing 24-hour, 7-day-a-week coverage of clinical, socio-economic and political news affecting the practice of medicine as well as local reports prepared by the Chicago Medical Society. The broadcasts are closed circuit" and can be heard p~yby those who have a special PRN radio. The radio and all programming are free, supported entirely by pharmaceutical advertising. You need only fill out and return the enclosed form and your radio will be shipped without charge. The instrument itself is compact, attractive and fits nicely on a bookshelf or desk. PRN seeks to bring important medical news to you quickly and at your convenience. Major stories are repeated hourly throughout the day; bulletins are broadcast at once. For instance on December 9th, PRN listeners heard a report on the use of antacids to reduce the complications of gastric aspiration in obstetric patients; a report from the Maryland Institute of Emergency Medicine on the development of a new delayed-action shock syndrome - - hepatic insufficiency; a report from Wales that an allergic reaction similar to bronchial asthma may account for some forms of proctitis; and from Washington, organized labor's reaction to the AMA's National Health insurance proposals. These are four of the twenty-four medical news items offered that day. From tinie to time, postgy~4u~~,c00I~g.e progra are also offered w~ich permit you to take part iq,~aqc~g~It~d, cent ~medrna1 education. Already, more than 1, S00 Chicago doctors have their free radio receivers at their homes or offices. Five hundred additional receivers are now available for distribution. If you would like to receive one, please return the enclosed card promptly. Later replies will be filled in the order received, it will take approximately 12 months to supply all Chicago physicians with radios. Please fill out and return the enclosed card now. If you have any questions, please call us collect at (212) 541-8384. mas F. Bird Director, Broadcast Services PAGENO="0129" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14035 UNIVERSITY OF MIAMI MIAMI, FLORIDA 33152 DEPARTMENT OF PHARMACOLOGY TELEPHONE (305) 547-6643 SCHOOL OF MEDICINE P.O. BOX 520575, BISCAYNE ANNEX October 29, 1974 Quentin Young, M. D. Cook County Hospital 1825 W. Harrison Chicago, Illinois 60612 Dear Dr. Young: Keeping up with the growing body of knowledge that has such profound influence on medical practice today is a problem with which we are all familiar. In no area of medicine is the change more constant or the need more acutely apparent than in Clinical Pharmacology. But just recognizing the problem isnTt enough. Where can we go for consipte~n~ current information on appro~~jgt~e.~ g, the rapt? In an attempt to expand our already-established sources of drug informa- tion, an innovative program has been developed at the University of Miami School of Medicine. It wa~ designed to increase the benefit potential of an existing resource ~ ing p ysician--the informed pharmaceutical representative. By~extending his role ma way that permits greater functioning in the cap~ci~y of active member of the health care team, he has more opportunity to work with you in answering some of the questions that arise daily concerning ~ Roche Laboratories is cooperating in a Pharmaccutical Consultant Program-- the first of its kind--in which pharmaceutical representatives work side by ~ ment. Your Roche represenE~ive, Mr. Rook, was one of forty recently selected to participate in this program at the University of Miami School of Medicine. Here are some of the things this program included: ~ an intern with whom he shared two weeks of clinical experience, he was ~ ~ s, an r s ~? Clinic rmoiogy s eminar s.It was a unique opportunity for exposure to multiple aspects of clinical medicine in an academic setting, and this was possible from a distinctive vantage point--at the patientst bedsides. 73-617 0 - 76 - 9 PAGENO="0130" 14036 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY After completing this program, the Roche Pharmaceutical Consultant can be expected to have a more in-depth understanding of the pharmacologic action of a variety of therapeutic agents which encompass not only Roche products but those of other pharmaceutical companies as well. Inaddi- tion, le has the advantage ol being actj ely involved in patient care in a ~ This program has the endorsement of the University of Miami Medical School and the Department of Pharmacology and has been presented to the National Ace derny _çjqflc~g~~ZW~al. Research Council Drug Research Board. A~Theprograrn progresses, we anticipate ihe endorsement of the Am en can Society fqr_ Ph~r.m~co1ogy and Experim~nta1 Therayeutics (ASPET). You will also he reading about this program in forthcoming issues of pro- fession-al journals. At the moment, we are in the process of assessing the program. The results of our study, along with the quantifying data obtained, should pro- vide the necessary information to permit our proceeding on a broader scale. We would appreciate any comments you might like to provide regarding the Roche Pharmaceutical Consultant_Proeram. With your cooperation I believe we can help meet an essential need of practicing physicians everywhere. V y trul yours Roger F. Palmer, M. D. Professor and Chairman Department of Pharmacology Professor of Medicine and Chief Division of Clinical Pharmacology Department of Medicine University of Miami School of Medicine PAGENO="0131" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14037 Cook County Hospital 1825 West Harr,son St.. Chicago. (lUnols 60812 (312) 633.6000 December 13, 1974 Roger F. Palmer, M.D. Professor and Chairman Department of Pharmacology Professor of Medicine and Chief, Division of Clinical Pharmacology Department of Medicine University of Miami School of lOedicine Dear Dr. Palmer: I have your letter of October 29, 1974 and am sorry for the delay in responding to it. Mere at Cook County Hospital we have taken a diametrically opposed position to the one you have developed. Increasingly distressed by the inappropriate function of the ound it neces~yQ elimin gir acti~itf~o Qn~gur campus~ ~ Our position is that the responsibility for the trainin of medical stu en s an house officers, not to mention the continuing educa- ~ dent y vested in representatives of commercial asencies. ~. ~ .. .. ..~ (_ .~ The Executive Medical Staff reached this fi lusion un~niotous1 upon review of our ex ensive me at -. ence with the arm of drug salesmen whim occupied our institution. While it may be that these ~nts individually are personable and intelligent people, their motivation is not suitable for achiev- ing the most objective, saf e, and economical application of pharma-~ cology in the clinical setting. Thatmotivationqfcours~ is to maximize the sales and the profits of the drug companies which they PAGENO="0132" 14038 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY represent. It is just such practices that have resulted in un- necessary cost to the entire oublic, as veil as unmeasured roap- propriate and excessive pea of ge orhealth care $yStH~ Sincerely yours, Quentin D. Young, Chai~an, Deparunent of Mediin~) QDY : run Copies: National Academy of Sciences! National Research Council Drug Research Board IRe Medical Letter The American Society for Pharmacology and Experimental Therapeutics Health Research Group PAGENO="0133" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14039 Cook County Hospital 1825 West Ha'risc~n St.. Chicago. IllInois 60612 (312) 6336000 October 17, 1974 All Department, Division, and Section Heads FROfl: Mr. Will jam J, Si 1 verman Director SUBJECT: Policy Regarding Vendors and Salesmen of Pharmaceuticals On the recommendation of the Drug and Formulary Cbmrnitte~, af- ~ ~edica1 Staff of Cook t~unty Hospital, effective immediat~ly, vendors, salesmen, and detail me reti__g~medfc~Lnd~ur ~y iouses an ~ceuLical comoanies will not be allowed on or in hoscital e inc uoing Karl fleyer Hall except y aDpointment wit ne ~ ments for exceptions to this rule may be made only with the ap- proval of the Purchasing Department, the Pharmacy Department, or this office. WJS/gw cc: James G. Hauahton, M.D. Department Heads, HHGC PAGENO="0134" 14040 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY UNIVERSITY OF MINNESOTA College of Pharmacy TWIN CITIES 318 Harvard Street SE. Minneapolis, Minnesota 55O1L February 5, 1976 Jere E. Goyan, Ph.D. School of Pharmacy Llniversity of California San Francisco, CA 94143 Dear Dean Goyan: It is unfortunate that a letter such as this is necessary, but we believe it is long overdue that the students and faculty of your institution should seriously question the continued existence of a pharmacy publication. Enclosed you will find a copy of the latest issue of Action in Phars-~acy. We are confident that you are aware of this type of publicatT~i~7' The publication presents as facts to the pharmacy students, opinions of its edi- tors and authors who remain anonymous from their articles. It does not fully cite purported references and attempts to manipulate the students into a more ~ ~ ________ id for b Parke, Davis Not surprisingly Action in Pharmacy ~ ~ which Parke, Davis and Company ~ ~`rudYb~fl~ńh~wEris a re9~dThj1lOT We hope that you will examine the current enclosed issue, paying special atten- tion to the discussion of formularies, the rational health insurance `information', and to the review of the Wharton School of Business study (page 4). ~ who refuses to ~ We would further hope th ouwouTd f~Jti~t~xamine this entire situation with the best interests of your students in mind. Sincerely, S Albert I~ Wertheimer, Ph.D. Peter A. Parish, M.D. Dale B. Christensen, M.S. Associate Professor, Director Hill Visiting Professor Graduate Fellow Richard Hammel, M.S. J. Lyle Bootman, B.S, Fred R. urtiss, B.S. Graduate Assistant Graduate Fellow Graduate Assistant Michael Ira Smith, B.S. Helene Framm, B.S. Andy Stes-gachis, B.S. Graduate Fellow Research Assistant Research Assistant Enclosure PAGENO="0135" It is no secret that the quality of edu- cation provided by pharmacy schools has shown a marked improvement in recent years Part of this improvement can be attributed to the federal funds received by the schools under The Health Manpower Act of 1971, Federal funds have become an integral part of pharmacy education and according to the American Association of Colleges of Pharmacy (AACPI account for 26 per- cent ot the various schools' budgets A major portion of these funds have been used to develop clinical pharmacy pro- grams in various schools The Senate Subcommittee on Health heard testimony from AACP asking for continuation of federal money to support and evpand pharmacy educa- tion However, the Student American Pharmaceutical Association ISAPhAI vehemently opposed any further funding in its present form in their testi- mony before the same Subcommittee. The Council of Students ICOSI dis- agreed with SAPhA's testimony in a written communication to Senator Kennedy - the chairman of the subcommittee. In essence, pharmacy went before the Subcommittee divided. Third party payers including the Medicaid programs of various states have been attempting to curtail the utilization of drugs by adopting either an open, semi-open or closed formulary. A formulary is a list of drugs which are authorized for prescribing and dispensing. It has been argued that since most formularies represent a collective judgment of several experts, this system should encourage rational The facts of the matter are simple. Pharmacy schools need federal help to maintain the quality of education now being provided to pharmacy students. Existing legislation demands that the standards of pharmacy education in general and clinical pharmacy in particular be upgraded. It is ironic that SAPhA should oppose the continuation of those very funds which are responsible for upgrading educational standards. The SAPhA's testimony tends to indicate that even with the withdrawal of federal capitation funds, the schools will somehow find alternate sources of funding to maintain high quality education. We fail to recognize the wisdom of this statement. Another part of SAPhA's testimony which baftles us is its contention that in federal funds are to be given, these should be spent to meet the needs on a case-by-case basis. We question the rational" ~of this approach since it is neither tactical nor democratic. SAPhA's testimony, at least to us, shows the influence of APhA on the public statements of SAPhA. (See AACP, page 2) primary purpose of a formulary is to control costs of drugs dispensed to the beneficiaries of the programs. It is noteworthy that in the past, several third party payers had considered formularies as a useful tool in limiting the drug costs.j~,~eL.~. recent study proves the point that a closed formulary might not curtail dru co r a . T e recent research of One of the journals that we reKeive each month is Private Practice published by the Congress of County Medical Societies. It largely speaks to the interests of the local practitioners and sometimes is controversial and certainly critical of many of the federal programs that are being proposed. There are many instances, when you must agree with the conclusions they reach and while we have never had the opportunity of meeting Francis A. Davis, MID, publisher of this journal, many of the articles he and his colleagues publish relate to the tragedy that could occur in the United States in the area of socialized medicine. Their December issue points out the fact that the Department of HEW has recently estimated that the s~ennedy- Corman style NHI bill would cost the taxpayers 113 billion dollars the first Dr. Davis says that with the total working population of Si million people that the program at a 150 billion per year, which probably is more realistic to its actual cost, would average out at a -$1,851 per year for every person working. He also makes note of tha fact that with Medicare and Medicaid as guides you would have every reason to expect the cost to rise rather rapidly within five years and probably reach about $3,000 for every working person. As you will note in another article in this journal we have made mention of the status of the national debt, the importance that it has to us at this point in history. It would certainly appear to us that Dr. Davis has pointed out a basic flaw in any thinking that projects governmental medicine on any wide scale. It may be simplistic to say uo, but to COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14041 VOL. 8, Number 5 JANUARY, 1976 The AACP - SAPhA - COS Split PAGENO="0136" 14042 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY TheReport of the Study Commission on Pharmacy was presented in Washington D.C on December 5 and was the result of two years of work. The reactions were mixed but many did express disappointment with the report. Part of this disappointment probably stems from the fact that the report did not come forth as a blueprint of how to change pharmacy or that clinical pharmacy was not the answer to pharmacy's problems. Pharmacists for thyj~5~yy, the title of the report, is a futuristic view of the practice of pharmacy. It offers concepts, findings and recommendations and should be read by everyone associated with pharmacy. While we cannot reproduce the entire report, it is available from the American Association of Colleges of Pharmacy. One of the areas we would like to acquaint you with is the "clinical scientists" for pharmacy and pharmacy education. The commission states that "phar- macy education is in a most difficult situation. Many roles or tasks have been suggested for pharmacists but they have not been scientifically analyzed as to the competencies involved. It is difficult, if not impossible, to identify with precision the relevant science basic to a competency which has not been clearly defined and evaluated", What is needed, according to the report, is a clinical scientist -one who is expert at the patient's bedside and equally competent in the laboratory. This person would be able to discern that portion of his science which it Drs. Smith and Garner of the University of Mississippi demonstrates that the "savings" from a closed formulary used by Mississtppi for two classes of widely used drugs is indeed question- able. It is probable, according to these researchers, that either the physicians are prescribing another formulary drug of a questionable therapeutic value for a given condition or they are leaving it up to the patient to pay from his pocket for the drug not included in the formulary. But the costs of drug therapy are not lowered. Another study published in the relevant to the care of the patient. He would then be able to assist his colleagues "in making the choice of those parts of his scientific discipline which must be given the highest priority within the curriculum". Therefore the commission recom- mended: 1, "That serious efforts be made by all colleges of pharmacy tu provide members of the faculties effective opportunities to practice pharmacy in some role to the end that they may be more conscious of the essential relationship of knowledge and skill and, further, serve as role models for their students. 2, That ,the research efforts of pharmacy faculty members be directed as much as possible to the solution of problems of pharmacy practice. 3. That a concerted effort be made to organize and finance a program to appropriately educate and train a small number [c. 100] of `clinical scientists' for pharmacy and pharmacy education." These "clinical scientists" could be of great benefit to pharmacy in helping the other health professions see the benefits of pharmacy. Medicine has its "clinical scientists" but we only have a handful and it could be that our "clinical scientists" might even be called upon to assist in the education and training of the other health professionals. This is a great opportunity for pharmacy and we would hope that some of you would begin looking into this and seek education so that you could help fulfill this need. December 1975 issue of Pharmacy Times comes to nearly the same conclusions. Here the ~j~enyj.p.g. patterns for most commonly used drugs were analyzed and several differences were observed under different types of third party programs. There is a marked shift in the dispensing of several important drugs under the formulary system, although the economic impact of this shift has not been studied. We are of the opinion that the formulary system has more disadvai~ I ~ne its, It inter eres with the prescri~jpg,,..fri~~oT"ile ~~sic~in"is infIex~ble,,,and...bggopseu The United Slates declares bankrupt- cy! Impossible you say. Whoever heard of such a thing. Well, how about New York City? The "Big Apple" is in serious difficulty and the Federal government had to help out. But who will offer assistance to the Federal government when it faces this problem. The gentlemen we have placed in Washington have mismanaged the nation's finances to a fare-thee-well. It was lyndon Johnson who became the first president to propose a $100 billion budget and now the budget gap is approaching $100 billion, The gross public debt is $548 billion and seven years ago it was $358 billion. It is easy to see that we have spent almost $200 billion more than we could raise in taxes. Tax reforms, spending cuts and a balanced budget are needed. It can be anticipated that many political plat- forms will be built around these themes. There will be reductions in welfare and social programs and we may see less interest in Congress about National Health Insurance programs. Our experience with Medicare has told us that it will cost over double what was expected and NHI could increase the government's consumption of our GNP from 37 percent to about 45. Medicaid programs in many states are nearing bankruptcy and pharmacy fees for drugs are being cut. The New York lesson seems fairly clear. You cannot keep spending more than you make. ~dlyout~8ted.WhekbetJtencQ~- ages raHonal use ofdrugshilLqpepto question and from the limited evidence ormiilăneso not result in ~~ng~to the third parties. Administra- ~ cases, simplify the reimbursement mechanism but our emphasis should be on serving the patient's needs first. More comprehensive studies are needed in this area before drug formularies become an accepted tool in the hands of the third parties. It may end up that the only function the formularieu serve is to interfere with the practice of medicine without any monetary benefit. PAGENO="0137" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14043 16 THORNDAL CIRCLE DARIEN, CONNECTICUT 06820 (203) 655-8951 Dear Sir: J. Richard Crout, MD, director of the Bureau of Drugs of the FDA, recently testified before the Senate sub- committee on monopoly chaired by Senator Gaylord Nelson on the issue of pharmaceutical industry "dominance" over continuing medical education. Enclosed is a preprint of an editorial challenging Dr. Crout's testimony, which will appear in the August 1, 1976 issue of Patient Care, a controlled circulation publication received by approximately 100,000 primary physicians twenty-one times a year. Because of your membership on a congressional committee involved with matters of health, we felt you would want this editorial called to your attention. Although we properly can speak only for Patient Care, we believe -- and we hope you do, too -- that the issues raised by Dr. Crout in his testimony deserve a balanced review. For this reason, we would welcome any comments you may have. Sinc ewis A. Miller Editor-in-Chief MILLER AND FINK CORPORATION PAGENO="0138" 14044 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY A respected physician who should know better has used overkill and innuendo in an attack on the phar- maceutical industry, on controlled circulation publications such as Pa- tient Care, and-by implication--on physicians who use such journals for continuing medical education. The attacker is J. Richard Crout, MD, director of the Bureau of Drugs of the FDA, who has enjoyed a reputation as an advocate of fair balance and factual presentation in communications--at least until his aberrant performance before the Senate subcommittee on monopoly. Dr. Crout's thesis is that the in- fluence of the pharmaceutical in- dustry over the continuing educa- tion of physicians is growing rapidly and is a long-term threat to the integrity of the profession. One major form of undue influence, he claims, is exerted through advertis- ing support of controlled circulation journals, which, by his definition, usually "do not have a rigorous re- view" of editorial content of the type conducted by what he calls the "scholarly medical journals." His cure is to place control of CME materials with the medical schools, and he leaves the door open for Government to help bring this about. We reject Dr. Crout's thesis as specious, simplistic, and unsup- ported by evidence. His testimony is short on carefully researched data and long on personal political rhetoric-subtly worded state- ments of so-called fact that are nothing more than hollow specula- tion-and negative innuendos. Here are some selected examples: >) "It is reasonable to ask why our PATIENT CARE i AUGUST 1, 1976 profession should be subject to an onslaught of allegedly educational material, not subject to the kind of independent review given the scholarly medical literature, which is financed by the drug industry, and ultimately paid for by our pa- tients." >) "I must wonder whether a jour- nal that subsists wholly on sales of advertising space to the drug in- dustry is able to present a skeptical attitude toward drugs in general or toward specific drugs. . . . For whatever reasons the editorial con- tent of these controlled circulation journals [mailed to physicians with- out charge] is overwhelmingly opti- mistic about drug therapy." )> "Usually it is acknowledged [by editors of controlled circulation journals] that whenever material severely adverse to a sponsor is received, that sponsor is given the opportunity to rebut that material before it goes into the journal." )) "The problem is that the industry sponsor can choose from among the many medical authorities on any given topic to support only those whose views already coincide with those of the sponsor. This ability is the basic cause of the biases." )> "There can be no doubt that scholarly medical journals should contain new information about drugs and should not be limited to the contents of approved package inserts. The issue here is whether such an article in a controlled circu- lation journal presents, in the guise of a scientific paper, promotional information which otherwise could not be legally published as drug ad- vertising or drug labeling. . .. The Federal Food, Drug, and Cosmetic Is the pharmaceutical industry subverting CME? Editor's Unworthy attack: The head of the FDA Bureau of Drugs has charged that C growing Influence of drugmakers over postgraduate education threatens the Integrity of the profession. Using rhetoric, not facts, he accuses journals such as Patient Care of slanting editorial content and, by implication, duping physician readers. We reject his thesis as unreal, undocumented, and uncharacteristic of a government official usually known for fair balance. Lewis A Miller Editor-in-Chiel Reprinted from the August 11976, issue u-asILENT CARE®. Copyright © 1976, Miller and Fink Corporation. All rights le5erved. PAGENO="0139" COMPETITIVE PIWIBLEMS IN THE DRUG INDUSTRY 14045 Act poses no threat to. . . the voice of any medical opinion on drugs, providing industry funding of that communication is not involved." It is about as frustrating to re- spond intelligently to these cleverly worded statements as it is to come to grips with a bowl of Jello. The anecdotal evidence that Dr. Crout occasionally provides is exactly the sort of material he so rightly rejects when presented in support of drug claims. We find it inconceivable that, without more substantiation, Dr. Crout would charge the phar- maceutical industry with attempted subversion of CME, medical jour- nals, and the medical profession. We do not believe that the influ- ence of the pharmaceutical industry on continuing medical education is a threat to the integrity of the pro- fession. We do believe that such influence exists, just as we believe that influence on continuing medical education exists from Government sources such as PSRO, NIH, and FDA. Wherever money or politics provides power, pressure and influ- ence are bound to exist. Pharma- ceutical advertising supports all of the major medical journals and many of the minor ones. Directly or indirectly, pharmaceutical adver- tisers in some instances may influ- ence selection and direction of edi- torial content, a condition that responsible editors abhor and that should be corrected. The frequency with which this occurs is unknown; in fact, Dr. Crout did not give a single documented instance. On the whole, industry support of medical journals has been beneficial rather than detrimental to the profession; without it, many valuable publica- tions would die or become sere and insubstantial. Dr. Crout's attitude toward the medical profession is condescending if not outright condemnatory. "I do not consider my colleagues to be pawns of the communications in- dustry," he says at one point. Yet the wording of his statements im- plies that the typical practitioner has no more brains than a turkey. Is it really possible that physician readers are permitting themselves to be corrupted and duped by jelly- fish editors who quiver in response to a frown or a finger pointed by a pharmaceutical advertiser? We infer from his words that a doctor reading a controlled circulation journal could not discriminate be- tween factual and biased informa- tion on unapproved uses of drugs. He confuses the issue by further suggesting that the reader would be magically protected from distortion and harm if he were to read such information in scholarly medical journals. These innuendos insult both readers and editors. Which are the "scholarly" medical journals? Of journals with greater than 70,000 circulation, he names only two, JAMA and the New Eng- land Journol of Medicine. Both are substantially dependent on phar- maceutical advertising as a source of revenue, yet in Dr. Crout's cloudy visio~h, the editors of such scholarly journals would be imnlune from the kinds of advertiser pres- sure that supposedly affect those of us who have fallen from grace, the editors of controlled circulation journals. Speaking for Patient Care's editors, we find this compar- ison invidious and repugnant. We, like the editors of JAMA and the New England Journal, have a re- sponsibility to our readers and their patients, a responsibility faithfully executed for nearly 10 years with credibility and acceptance by prac- titioners asid acadenlicians~ Every artigld iWrP~~tjent Core is researched wff.h.~S&herp of not one but s ~or ~ a nsultants. It is re- viewe~4s3~ ~t?~1 ~heij~o1l1~ltants and by a panel of reader repre- sentatives (true peer review). It is published with a fair and clear ex- pression of both majority and mi- nority opinions. Our review prac- tices are independent and rigorous, subjectfln ~no ;~in~1e infl~nce, but responsYve to the ~lu~ali(Ar of influ- ences that are a part of our free society, most particularly to the in- fluence of our readers' needs. Editor's Corner. For the record, we must also state that Patient Core articles have been skeptical "toward drugs in general or toward specific drugs" when warranted in the opinion of our consultants; and we can docu- ment this statement with refer- ences.9 Patient Core editors do not give advertisers the opportunity to rebut material adverse to their products as a matter of policy, though we are not afraid to recog- nize that a manufacturer i~ a knowledgeable resource about his drug. Nor does Patient Care permit its advertisers to select its medical authorities; what is more, we have not been asked to do so. In fairness to Dr. Crout, a~ no point did his testimony level such charges specifically at Patient Care. In fact, he singled out a Patient Care article on oral hypoglycemic agents** as discussing the implica- tions of the University Group Dia- betes Program study "in a balanced way, ultimately taking a middle of the road position." This minor compliment notwith- standing, Dr. Crout's broad based attack on the drug industry and on controlled circulation medical jour- nals is undeserved and untharac- teristic of him. We choose to treat it as a momentary aberration caused by Potomac Fever; we take his word that he is not campaigning for FDA regulation of the editorial policies of journals whose financial support comes from pharmaceutical advertising. But on the outside chance that his testimony was a trial balloon for such regulation, we are putting this response on the record and encourage you to write to him*** with your reactiQns (copy us if you will).-LAM "S~97isg tst tptitss trith spstifir srttibittiss," Nt- ~smbtr' 1, 1973, psgr 43. "Pt-prsntk~l ft- rrhith ttgits patitrtts?" Mts'th 15, 1974, p1~ 92. "Syrtt- ptthtrttitttttits-Ctttt'tllittg psthstitt itt rss'dstget shtAk," Jtrttr 15, 1974, psgs 20. "First thistgs 5rst At dr'tg i56'trtittts," Dttssrtbrs' 1, 1974, ptgs 17L "Mt-tOg tOrt thsilrrtgt- itt rtr'tkt,' April 1, 1976, psgt 24. "Chttrittg diw'rtitr ftr tptimsl st-stilts," J&sne 15, 1970, psgt 22. ~~Sts "Orti hyptglyttrrtios? Yss, Nt, Msybt." Pt- tistt Ct-U, Fsbs'ttsry 15, 1976, pags 102. **sJ. Rirhad Csttt, MD, Bttssaatf Ds'tsgs, Ft-rd sstd Dt'tg Adstittistrstitst, 5600 Fishss's Lssts, RttkrilIs, MD 20204. PATIENT CARE I AUGUST 1, 1976 PAGENO="0140" 14046 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY The Journal of Medical Consultation consultant 000 WEST PUTNAM AVENUE / GREENWICH, CONN. 06030 (203) 661-0600 - (212) 993-0440 July 27, 1976 Senator Gaylord Nelson Chairman Select Committee on Small Business Senate Office Buildings 424 Russell Washington, D.C. 20510 Dear Senator Nelson: As the publisher of CONSULTANT magazine, owned by Cliggott Publishing Company of Greenwich, Conn., I would like to respond to the statement made by Earl J. Scherago before the Subcommittee on Monop- oly of the Senate Select Committee on Small Business on May 24, 1976. Copies of this letter are being sent to the other members of your committee, Mr. Scherago and Dr. J. Richard Crout of the FDA who also made some critical remarks in a statement before your committee in April. CONSULTANT is a controlled circulation monthly publication which reaches approximately 143,000 private practicing physicians. Controlled circulation assures that the physicians who receive the journal will find it of greatest value to them. Articles can be directed exclusively to this clearly defined circulation. CONSULTANT has been published continuously since 1961 and contains entirely original, clinical articles. Mr. Scherago states that for 20 years he has been a publisher's representative involved in the solicitation of advertising in journals published by non-profit societies. Since he claims he is active solely in advert- ising sales, I assume he has little or no direct contact with the editorial phase of the publication he represents. It is difficult to see how Mr. Scherago would have sufficient knowledge of the procedure of article develop- ment used by CONSULTANT or many of the other controlled circulation journals he criticizes. PAGENO="0141" COMPETITtVE PROBLEMS IN THE DRUG INDUSTRY 14047 Mr. Scherago goes to considerable lengths to define the doctrines of Peer Review and its importance in establishing authenticity for scientific work. "In its simplest form this doctrine says that no piece of scientific research can be considered valid unless it has been reviewed by at least two recongnized authorities in the field of science involved", declares Mr. Scherago. He goes on to imply that Society Journals are Peer Review publications while controlled circulation journals are not. This impression is entirely false. Society Journals do not enjoy exclus- ivity in this procedure. CONSULTANT magazine is a Peer Review Journal. We have always employed a Peer Review technique despite Mr. Scherago's puzzling remark, "that is because commercial publishing firms have found that it is very difficult to make a profit with Peer Review Journals." Our present masthead lists 47 eminent physicians in 25 medical disciplines who make up the CONSULTANT Advisory Board. Members of this advisory board together with specialists in many disciplines, execute our Peer Review procedure. Since a number of controlled circulation journals enjoy Peer Review why can't the "Scholarly" public- ations compete effectively in the market place with these journals? Mr. Scherago would have you believe that Scholarly Journals "aren't willing to make the compromise with established scientific practice which advertisers demand." This is a totally false, misleading state- ment without substantiation which infers that an advertiser can influence the editorial content of our magazine. All of the articles in CONSULTANT are written by invitation of our editorial staff. Leading clinicians are asked to write on a subject of current importance to the practicing physician. The paper will be edited for form and style, but is entirely the authors' views and he must approve the final manuscript. Advertisers simply have no say in any articles which appear in the publication whether the opinions expressed are popular or unpopular. CONSULTANT does not run pro- duct descriptions in its pages and never has nor will it publish articles in exchange for advertising. The doctors who read medical journals are not easily fooled. Any hint of advertiser influence or the slightest departure from complete objectivity in editorial pre- sentation would result in a disastrous loss o~ confidence in the journal by the reader. PAGENO="0142" 14048 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY We have indicated that CONSULTANT and other fine clinical journals utilize the vital Peer Review system. They also publish without compromise to author or advertiser. Why, then, has it been so difficult for Scholarly journals to compete? Mr. Scherago reported that Peer Review Journals as a group were in serious financial difficulty. He quotes from a paper deliv- ered in February, 1976 by Robert Day, Managing Editor of the publications of the American Society for Microbiology at the annual meeting of the American Association for the Advancement of Science to emphasize the problem of continously rising publishing costs. These rising costs are certainly not the exclusive concern of Peer Review Journals. All publishers, Peer Review or not, realize that the only way to maintain the quality and quantity of their article pages in the face of rising costs is to improve efficiency and increase revenues. The key to increasing advertising pages is to provide evidence to advertisers that the physicians who receive your publication actually read it and find the information it contains of value to them. Many pharmaceutical companies conduct their own readership studies and, in addition, there are syndicated readership reports available. I suggest that the major problem facing Mr. Scherago and many Peer Review Journals is that ~y ~ competing successfu~J~y for the y~cians attentic?~. This is unfortunate as there is an important place among journals for both the scholarly publication and those of the controlled circulation type. When medical publications present authoritative important (and useful information in an attractive and readable format they will achieve satisfactory readership levels among the physicians in their circulation. Establishing a public- ation chronologically first in a field is not, of itself, sufficient reason for success. Many Peer Review Journals should be examining their publications to discover why they are not attaining acceptable readership levels and should be making whatever changes are necess- ary to achieve improved readership. If the problem is not with readership perhaps the Peer Review Journals should evaluate the quality of their sales representation. The controlled circulation publications are healthy when many society journals are not because they are PAGENO="0143" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14049 providing the kind of information and continuing medical education that the practicing physician needs. Controlled circulation journals perform a vital service in the dissemination of important, timely develop- ments in medicine to the doctors of this country. To verify this you need only go out and talk with the physicians who are providing the day to day care of the American people. We have written you because as a small, independent medical publishing firm we are gravely concerned about any developments which might lead to legislation or regulations inhibiting a free medical press. In an effort to balance the inaccuracies and mis-statements in Mr. Scheragots testimony I respectfully request that my letter become a part of the record of your hearings. Very truly yours, 2 / //,, -~2~ ~ John M. O'Brien Publisher JMO' B : nam PAGENO="0144" 14050 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY PREPARED STATEMENTS STATEWENT BY EDWARD F. CALESA, PRESIDENT, HEALTH LEN?NING SYSTEMS INC. 1455 BROAD STREET, BLOCMFIELD, NEW JERSEY 07003 BEFORE SUBCOMMITIEE ON MDNOPOLY SENATE SMALL BUSINESS CC~1MTITEE MAY 24, 1976 Edward Saltzman and I are pleased to be here to answer your question about our contribution to medical education. We contribute through two separate corporations with one cannon objective -- improving the quality and cost of patient care through meaningful education. The Health Learning Systems corporation achieves this objective by providing continuing medical education for physicians, interns, nurses, and other allied health pro- fessionals; and the IlLS Press corporation, through health education directly for the patient. We will concentrate today on Health Learning Systems. The primary reason for our existence is to help translate medical research findings from branches of the National Institutes of Health and university based medical centers to improved patieht care. The need is based upon the fact that new research findings reportedly double every seven to ten years, and affect numerous aspects of prevention, diagnosis, management, and rehabilitation of disease. MDre importantly, these findings are not adequately reaching the practicing physician for clinical application with the patient. This concern is well recognized by the Congress in its direction to the National Institutes of Health. To effect change, there is a need for continuing medical education through improved ccnniunication techniques. The need for continuing medical educa- PAGENO="0145" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14051 tion of practicing physicians is well documented by every major study in medical education. It is further substantiated by the American Medical Association, nine medical specialty societies, and fourteen states all of whom require that members participate in a fixed number of education hours to maintain their membership. Five states have education requirements to maintain their license in that state. Three more states will institute relicensure laws by January, 1978. All medical specialty boards and sub- specialty boards have endorsed recertification examinations. Congress has passed the Bennett Amendment to the Social Security Act in October of 1972 requiring the establishment of Professional Standard Review Organizations, with the primary objective to increase the quality of care through physician education. The problem of malpractice in thiS country can often be related to this need. The major consequences to society of not adequately fulfilling this need for continuing medical education are increased morbidity and mortality statistics and the extremely high and spiraling cost of health care. Traditionally this need is being met by medical schools and hospitals that provide courses, hospital staff conferences and meetings, traveling medical educators, medical texthooks, scientific journals, and conventions. Problems with these approaches are that practicing clinicians may not have time to travel and attend courses, particularly those physicians farthest away from the medical centers, the lecturing medical educator may not have adequate teaching , he is limited by the amount of time he can devote to this activity, the printed word is often outdated, overused, and not necessarily the best communication medium particularly for medical subjects. -2- 73-617 0 - 76 - 10 PAGENO="0146" 14052 COMPETITIVE PROBLEMS ThT TIlE DR~UG INDUSTRY Local meetings fail to provide national or international perspective. Upon recognizing this need, Health Learning Systems was organized to act as a catalyst in marshalling the resources and disciplines prerequisite to affecting improvement in patient care through education. The disciplines we integrated in our corporation are the following: First and forenrst, medicine to provide selection of subjects, physician participants, content control and accuracy. Second, education to insure the achievement of learning objectives. Third, corrmunications to enhance the speed and accuracy that information could be coriniunicated and provide professionalism and quality in this area. Fourth, marketing to find funding for programs and assist in the distribution of completed programs. Integration of these four disciplines is the basis for producing high quality medical education materials that are up to date, accurate, and professional. The mest important discipline in our organization is medicine. We have developed a medical faculty of core than 400 physicians representing Federal health agencies, medical associations, medical societies, medical boards, medical schools and teaching hospitals from around the world. This is spearheaded by our Medical Director, Doctor Arthur Bernstein, Clinical Professor of Medicine, New Jersey College of Medicine and Dentistry; and Doctor Shervert Frazier, Psychiatrist in Chief, McLean Hospital and Professor of Psychiatry, Harvard Medical School, a member of the Board of Directors of Health Learning Systems. Included in our list of experts from the Federal Government with whom we have worked are Doctor Theodore Cooper, Assistant Secretar!y for Health, Department of Health, Education, and Welfare; Doctor Donald S. Fredrickson, Director, National Institutes of -3- PAGENO="0147" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14053 Health; Doctor Robert I. Levy, Director, National Heart and Lung Institute; and Doctor Ronald A. Chez, Chief, Pregnancy Research Branch, National Institute of Child Health and Human Developnent, National Institutes of Health. Sane of our 400 physician advisors fran academic medicine include Doctor James C. Hunt, Professor and Chairmen, Department of Medicine, Mayo Clinic and Mayo Medical School; Doctor Mnrton H. Maxwell, Clinical Professor of Medicine, UCLA School of Medicine; Doctor Clark H. Millikan, Professor of Neurology, Mayo Clinic and Mayo Medical School; Doctor Edward J. Quilligan, Professor and Chairman, Department of Obstetrics and Gynecology, University of Southern California School of Medicine; Doctor Michael E. DeBakey, President, Baylor College of Medicine, Texas Medical Center; and Doctor Harold D. Itskovitz, Professor of Medicine, Medical College of Wisconsin. We have worked with the National Board of Medical Examiners, and representa- tives associated with the American Board of Internal Medicine, American Board of Family Practice, National Institutes of Health, Board of Psychiatry and Neurology, American Fertility Society, Epilepsy Foundation of America, American Heart Association, National Kidney Foundation, and many others. It is this working relationship we have with medicine that is the basis for us to produce highly credible education programs funded and distributed by industry which are beneficial to the participants in medical schools, physicians in private practice, and patients. It is the integrity, reputation, and knowledge of this group that provides the peer review and controls over the educational materials. -4-- PAGENO="0148" 14054 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY The critical questions we faced were first how to fund and how to distribute the programs that we could develop. Three alternatives were considered. The first was for us to raise capital, develop programs at our own expense, and sell completed programs to physicians in practice. We rejected this alternative because our studies indicated physicians would not pay for the programs, and we had no system of distribution. Second, we considered proposals to appropriate Federal Government agencies. We rejected this idea because of restrictions in Federal health care spending, the tine involved in getting proposals written and approved, and cost importantly, the inability of the Federal Government to provide adequate distribution. The approach we settled on was to utilize the resources of industry. They have the financial resources, the responsibility to good medical practice, and the distribution outlets to insure awareness and usage of ccinpleted programs. Why would industry use these resources to support educational programs for physicians? The answer is that pharmaceutical manufacturers develop excellent products that undergo extensive testing before being sold to the public. These pi~oducts are differentiated by scientifically proven benefits as well as side effects. Each product becomes a potential tool in the physician' s ansamentbrium. The problem is how to properly and accurately corimunicate the benefits, side effects, and therapeutic role each product has in the diagnosis and treatment of a patient. In marketing products, industry does not sell products to a doctor, but rather fulfills needs that a doctor has in the comprehensive care of his patients. Accepting this statement as dogma, it is an absolute necessity to provide adequate and accurate information which allows the physician to make informed decisions in selecting methods of diagnosis and treatment -5- PAGENO="0149" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14055 for his patients. A ccmprehensive continuing medical education program under the severe scrutiny of medical peer review, which discusses candidly when drugs should and should not be used and criteria for drug selection which includes all major drugs in that field as well as non-drug methods, is a way for industry to fulfill its coamunication responsibility with the physician. Additional factors are that the manufacturer is trying to upgrade the level of knowledge of the pharmaceutical sales representative, so a better dialogue can take place between the physician and the representative. This can be accaitplished by exposing the pharmaceutical representative to the same educational material that the physician is exposed to. There are other factors as to why the manufacturer will support educational materials, but the cost important is that the manufacturer with high quality products, that have a definite role in the management of patients in a particular therapeutic field, will benefit by providing fair balanged educational material to the practicing physician. However, since industry was to provide the financial and distribution resources, it was imperative that certain safeguards be built into the educational process to avoid any potential for abuse. It is our unequivocal contention that these safeguards must be under the control of academic medicine through medical peer review and not regulated by any Federal agency or interferred with by the pharmaceutical manufacturer. -6-- PAGENO="0150" 14056 COMPETITIVE PROBLEMS IN TIlE DRUG INDUSTRY We define these safeguards as follows: First, that the educational programs be developed and produced by an independent organization such as Health Learning Systems rather than by the phaimaceutical manufacturer. Second, that the intention of the program is educational rather than promational. Specifically, we feel that the ~fucational materials should not be exclusively about drugs but rather encompass the entire area of diagnosis and management of a particular disease. Third, that the executive editor and editorial board participants in the program be selected independently of the manu- facturer providing the grant. We will accept suggestions frau the manufacturer regarding participant selection, but only as it relates to providing a fair balanced presentation. All editorial board participant selections mast rest with the executive editor of the program. Fourth, that the editorial board participants include a minimum of four independent parti- cipants to rule out bias. Fifth, that the editors selected be eminent in their field, be located at leading medical centers and represent the major opinions in that disease area. Sixth, that the content be completely under the control of the editors and not subject to change by the grantor. Seventh, that the program be sponsored by a prestigious medical school department, health agency, or organization. Eighth, that educational content peer review be provided by a Federal Government agency and/or medical association active in that field. Nineth, that the content be reviewed for accreditation by all of the leading accrediting organizations in that field. Tenth, that any discussion of drugs be done in fair balance to all drugs in that field. Eleventh, that both the indications as well as the side effects of all drugs discussed be highlighted in the program. Twelfth, that product advertising not be included in the educational material. Thirteenth, that the material conform as closely as possible to approved package inserts for all products. -7- PAGENO="0151" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14057 Fourteenth, that all material clearly identify the medical center and association sponsors, the producer, and the manufacturer providing the educational grant. And finally, that the manufacturer actively participate in the distribution of the program. If these criteria are met, we have the basis for achieving a cc*rrron objective of our organization, academic medicine, organized medicine, the pharmaceutical industry, and the Congress in providing batter patient care through education. The rrost important result is decreased rrorbidity and rrortality for the patient and a reduction in health care costs brought about by knowledge in the diagnostic evaluation, laboratory procedures and management alternatives. The medical academic coninunity and Federal health agencies should be praised for their contribution, and the pharmaceutical industry should be encouraged and praised for its support. It must be pointed out that there is a difference between what I have described as education which does not meet all drug labeling requirements and education which does meet all drug labeling requirements and is considered as advertising. If all education supported by pharmaceutical manufacturers is to be considered as advertising and thus subject to all drug labeling requirements, serious shortcanings will occur. First, that autanatically means that the pharthaceutical manufacturer will be involved in the selection of physician participants and that they will review, edit, and have final approval of all content. The reason is that they must protect themselves against physician participants saying anything that may be considered accepted medical practice or the individual physician's opinion but deviates from the approved labeling. The -8- PAGENO="0152" 14058 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY editorial board participants do not accept this infringement by Federal Government authority over what they want to say. In addition, package inserts in the educational material are a tacit endorsement of the manu- facturer's products. The effect of drug labeling on education is an infringement on free speech and presupposes that content control cannot be achieved by the medical profession. The Food and Drug Administration has proposed a series of guidelines to differentiate education from advertising to overcome these problems. As you can see, we agree with these guidelines and have introduced additional guidelines. There is one serious difference of opinion. They propose that the intent should not be for ultimate distribution by the pharmaceuticalS industry. If the manufacturer supporting the program meets all of ithese criteria, why can't he give it away? He has the distribution channeis and can use them effectively to get the program to the doctor. If he paid for the program and has the ability to help get it used correctly, why shouldn't he do this? If he can't do this, why should he pay for it? Finally, our opinion is that if the manufacturer is forced to produce educational materials as advertising with labeling, we will all lose -- the medical educators, medical schools, organized medicine, the pharmaceutical manufacturer, the doctor in practice, and the patient. We have produced programs both with and without labeling. Obviously,, we favor the former as do all of our medical advisors. As a matter of fact, Doctor Crout, in his appearance before this Carznittee, complimented Health Learning Systems for a program we are producing called "Dialogues in Hypertension," which is developed in cooperation with the National High PAGENO="0153" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14059 Blood Pressure Education Program of the National Heart and Lung Institute, the Council for High Blood Pressure Hesearch of the American Heart Associa-~ tion, and the National Kidney Foundation, under' an educational grant fran Smith Kline & French Laboratories. This program is produced according to the criteria previously discussed. Doctor Crout then s~ent on to describe a program we produced under a grant from Marion Laboratories which he said was an example of education that was prcztotional. In this case it should be pointed out that the program produced iret the criteria for drug labeling. It contained the package insert on the films and in the nonographs and was edited by the Marion Laboratories' Medical and Legal Departments in accordance with labeling requirements. It is exactly for this reason that we feel labeling should not be a part of an educational program, assuming the other criteria have been met. I would like to point out for the record that it was incorrectly stated at these hearings that Health Learning Systems was the producer of a closed- circuit television symposium on diabetes under contract to Pfizer Laboratories. We were not the producer, nor did we participate in any way in this program. The question has been raised regarding the extent of industry-sponsored educational material. We contend at this stage that it is quite smell in relationship to their total marketing expenditures. Specifically, from indsutry-supported sources, the percentage expended for audiovisual presentations was 0.8% in 1972, 1.7% in 1973, and 2.1% in 1974. The expenditure for conventions and exhibits was 1.4% in 1972, 1.7% in 1973, and 1.7% in 1974. This is against a base in 1974 of $909,534,000. -10- PAGENO="0154" 14060 COMPETITIVE PROBLEMS IN TIlE DRUG INDUSTRY The ~Tournal of the American Medical Association publishes an annual report on medical education in the United States. In the mDst recent publication it listed 4,862 courses from 554 different primary sponsors for 1975 to 1976. The sponsors were medical schools, hospitals, medical societies, and voluntary health agencies, not pharmaceutical companies. Generally, this list which is a projection for the coming year is half the actual number of courses that will be given. The question has been asked how do we select subjects and physician participants? The answer to that question is that we use our Medical Faculty of Advisors whom we consult with regularly. In addition to advice from these consultants for selection of subjects, we use the Forward Plan for Health published by the Department of Health, Education, and Welfare and Health U.S.. - 1975, Department of Health, Education, and Welfare, and surveys formerly conducted by Regional Medical Programs airongst physicians. From these sources we select subjects and attempt to obtain funding from the companies who are leaders in the selected field. Once funded, we approach a medical school, medical school department, or health agency to sponsor the program and determine an appropriate executive editor. The executive editor selects the editorial panel. We make agreements with all of the physicians that editorial content control rests exclusively with them. They have final sign-off on the content before we go into production of any of the materials. -11- PAGENO="0155" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14061 When the content is ready to go into production or during the produčtion, we suhait the material to as many reviewing medical organizations as possible for accreditation and/or endorsement. When the education pro~ram is completed, we ask the sponsoring agency to write letters and other materials to create awareness of the availability of the educational program. We then give the completed programs to the pharmaceutical manufacturer who distributes the material, making all physicians aware of its availability and use, at no cost to the hospital, medical society, medical school, or physician. It is the responsibility of the manufacturer to get the materials to the user and assist in making physicians and allied health professionals aware of the program. The only involvement of the grantor is to determine the media and this is based upon their available budget, pay the bills, and assist in the distribution of the program. This is not true where labeling is to be included with the educational material. In this case, the manufacturer is very actively and directly involved in the content of the educational programs. We have attempted to work very closely with the Food and Drug Administration in developing our educational programs and for the cost part, with the exception of distribution noted previously, we agree with all of their criteria for program developoent. Based on what we have described today, we feel that high quality medical education programs can be developed effectively to meet the ultimate needs of the patient. If the Government were the primary source of funding for continuing medical education, Health Learning Systems would attempt to be the producer and would take the exact same approach in producing programs as we currently take if xyz pharmaceutical manufacturer were providing the funding. -12- PAGENO="0156" 14062 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY We have had the opportunity to observe dramatic results with our programs. We have received numerous letters of praise from Government officials, from acadmnic medicine, skid from practicing physicians who have participated in and been exposed to the programs we have produced. On a recent closed-circuit television program which we produced, attended by 11,000 physicians and allied health professionals, we asked the audience to evaluate the program content. With 1,993 responses, the results were: * Met my expectations - 99% * Provided important information - 97% Provided help for better patient care - 97% Rated speakers excellent to good - 100% On the closed-circuit television program produced by Health Learning Systens on hypertension which was the basis for producing "Dialogues in Hypertension' for which we were complimented by Doctor Crout, I Would like to quote a letter dated January 7, 1974 from Doctor Theordore Cooper, then Director of the National Heart and Lung Institute to Mr. Robert F. Dee, President of Smith Kline & French Laboratories -- "As you are un- doubtedly aware, one of the principles of the National High Blood Pressure Education Program is that by combining the resources, and by cooperating with each other, the private sector and the Federal Government can make very significant accomplishments in this critical public health area. If you have no objections, we would like to use the developTient of this symposium as an example of this principle in action." As one of the primary companies involved in the coimsunications program toward physicians -13- * PAGENO="0157" COMPEPIT~VE PROBLEMS IN THE DRUG INDUSTRY 14068 on hypertension, we have seen fran a 1974 study the National Heart and Lung Institute called "Hypertension Detection and Followup Study" that initial visits to doctors increased 38% for hypertension and hypertensive heart disease. The number of people with hypertension not aware of their disease decreased from 50% to 29%, and in a study of 760 clinicians published in the May, 1975 issue of Medical Opinion, it revealed that the number of physicians who take blood pressure readings increased in five years from 50% to 90%, that 73% of physicians routinely use laboratory tests for hypertensive patients, and that the number of patients now talking about hypertension with their physician increased from 9% five years ago to 36% today. We are pleased to say at this time we are working with the National Board of Medical Examiners to produce a national self-assessment on hypertension for physicians under an educational grant from Smith Kline & French Laboratories. This is an outgrci~ith of our "Dialogues in Hypertension" program. Every day we receive letters on one or more of our programs f ron physicians in practice who thank us for our contribution to their patient care needs. We are young and this industry is young. We have made mistakes. We have not always been able to include all the Food and Drug Administration criteria described in this statement in every one of our programs. we are concerned and proud to be part of an effort where we have seen visible signs that in sane small way we have contributed to an improvement in the quality of health care in this country and abroad. Thank you for allowing me to share this with you. -14- PAGENO="0158" 14064 COMPETITIVE PROBLEMS IN TUE DRUG INDUSTRY STATEMENT BY J. RICHARD GROUT, M.D. DIRECTOR BUREAU OF DRUGS FOOD AND DRUG ADMINISTRATION PUBLIC HEALTH SERVICE DEPARTMENT OF HEALTh, EDUCATION, AND WELFARE BEFORE THE SUBCOMMITTEE ON MONOPOLY SELECT COMMITTEE ON SMALL BUSINESS UNITED STATES SENATE APRIL 28, 1976 PAGENO="0159" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14065 Mr. Chairman: I am delighted to appear today to discuss at your invitation the relationship between the pharmaceutical industry and medical education. This is an important topic and a timely one. There is considerable evidence that the pharmaceutical industry plays a very important, perhaps a dominant, role" in the post-graduate education of physicians, dentists, and other health professionals. This role of the pharmaceutical industry in supporting post-graduate medical education has increased rapidly in recent years and, in my opinion, is a problem deserving of national attention. Let me emphasize from the start that I do not consider this issue to he primarily a problem in drug regulation. While I will `draw upon the experience of the Bureau of Drugs in citing a number of examples in this testimony, my remarks will also reflect views developed during two decades of personal experience as a student and a teacher of medicine before coming to the Food and Drug Administration (FDA). I testify today as a concerned physician who believes that the growing influence of the pharmaceutical industry on medical education is a long-term threat to the integrity of my chosen profession. THE PROCESS OF MEDICAL EDUCATION Before considering the many ways in which the pharmaceutical industry is involved with the education of physicians, I would like to cormient briefly on trends in medical education since the turn of the century. PAGENO="0160" 14066 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Today the education of medical students is under the control of universities and customarily consists of a four-year curriculum, at the end of which the student receives his M.D. degree. A century ago, however, there were, in addition to university-based medical schools, a number of private trade schools training physicians. Because of the low professional competence of the graduates of these trade schools, the training of physicians became a national scandal early in the 1900's. After publication of the Flexner report in 1910, medical education came under the full control of universities; thus nearly every physician now in practice in this country was trained at a university as a medical student. The second great advance in medical education in this century was the development of full-time faculties in medical schools. This has occurred as a result of our national investment in biomedical research and training since World War II. Today's medical studient thus graduates with a rich and broad education in medical science after a four-year exposure to university faculties dedicated to teaching, patient care, and medical research. In such an environment professional competence, commitment to scientific principles, high personal standards are emphasized as the physician's primary and necessary attributes. After graduation from medical school, the modern physician then takes several additional years of training in a medical speciality or in -2- PAGENO="0161" COMPETITIVE PROBLEMS IN TUE DRUG INDUSTRY 14067 family medicine. This training typically occurs in medical institutions, including university hospitals, military and Government hospitals, larger private hospitals, and some community hospitals. After such experience many physicians take advanced examinations, known as Board Examinations, to become certified as specialists. At this point the physician is probably as highly trained technically as he will ever be in his life, and he enters the practice of medicine, the product of an extended and expensive educational process. POST-GRADUATE MEDICAL EDUCATION From this point on, the physician is in large part left to his own devices to maintain and update his fund of knowledge. He can maintain his university contacts by joining a clinical teaching facul~Y, an excellent approach to staying abreast of advancing medical knowledge, but an opportunity usually available only to Board-Certified specialists in cities with medical schools. He can also seek out any of a number of short courses sponsored by specialty societies and conducted in medical institutions. He can also read the medical literature, attend medical meetings, and take advantage of a variety of audio-visual presentations, either in the privacy of his car, home, or office, or in staff meetings at his local hospital. In recent years, several States and specialty societies have recognized the physician's need for continuing education to keep his medical knowledge current and have altempted to encourage greater efforts at self-education. These States and societies have imposed on the physician -3- 73-617 0 - 76 - 11 PAGENO="0162" 14068 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY requirements for a specified number of credit hours, usually 150 in three years, to qualify for license renewal or recertification. The American Medical Association grants a Physician's Recognition Award to physicians completing 150 hours of continuing education in three years. There are aspects of continuing education for physicians that are unique. While other professionals must also maintain their skills and be aware of new developments (e.g., the tax lawyer must be aware of changes in the Tax Code) there is no field I can think of in which "keeping up" is so closely related to learning about new products or new uses of old products. Certainly, there is other information necessary also--e.g., knowledge of newer diagnostic techniques and new insight intO disease mechanisms--but a significant portion of what an up-to-the-minute doctor needs to learn about is related to advances in therapeutics, especially drugs and medical devices. To understand the importance of post-graduate education to the physician's use of drugs, one must appreciate how rapidly information On drugs changes. Ninety percent of prescriptions written today are for drugs which were not even on the market a generation ago. New information about the uses and potential adverse effects of drugs appears almost continuously. Since the professional career of the average physician spans thirty to forty years, it is evident that most of what he learns about new drugs occurs after he completes his formal medical training. -4- PAGENO="0163" COMPETITLVE PROBLEMS IN PIlE DRUG INDUSTRY 14069 DRUG INDUSTRY'S ROLE IN POST-GRADUATE EDUCATION It thus is not surprising that the drug industry is vitally interested in the educational materials the practicing physician receives. In~ view of the great financial resources available to the industry it should also not be surprising that it has come to support a large and growing proportion of such educational materials. It has long been recognized that the industry-supported detailman is an important and influential source of information on drugs for the practicing physician. Drug labeling and drug advertising, which are closely regulated by FDA,also provide information. It is less well recognized, however, that much of the written and audio-visual teaching material supplied to the physician on all medical subjects throughout his professional career is also supported by the pharmaceutical industry. This includes the vast majority of medical magazines which fill his mailbox, the clinical symposia that liscuss specil ic drugs or general approaches to therapeutics, the audio-visual teaching systems he studies in his spare time, the films and closed circuit TV tapes he sees in his hospital conferences, and even the scientific exhibits and presentations by panels of experts he encounters at medical meetings. This extensive underwriting of post-graduate medical education and communication by the drug industry has occurred primarily in the past decade, and is the problem I want to emphasize in this testimony. PAGENO="0164" 14070 COMPETITIVE PEOBLEMS IN THE DRtrG INDUSTRY Let me note that while the drug industry has a natural interest in the post-graduate education of physicians, it is not alone in fostering this trend. Pharmaceutical industry financing of such endeavors has been encouraged by medical institutions eager for attractive teaching materials, by respected investigators and clinicians eager to make their work and opinions more widely known, by practicing physicians under increasing pressure to participate in formal training to maintain licensure, and by medical societies facing growing demands to make such training available. These groups are well aware of the vast resources the industry has at its disposal, particularly in comparison with medical institutions and medical societies. Make no mistake, modern educational materials are costly. There has been a growing sophistication in the techniques used to educate people, and the "old' methods--lectures, review articles, textbooks--are perceived by some as dull and tedious. Instead we now have "learning systems" generally involving films or videotapes accompanied by elaborate graphics and self-instruction materials. It nay well he true that these newer kinds of materials can be prepared only with special subsidies (assuming their added value as educational instruments is worth the extra money). There is a cost involved, however, in giving substantial control over that subsidy to the drug industry. That cost is the introduction of systematic bias. Without contending that industry-sup~orted -6-. PAGENO="0165" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14071 materials are regularly inaccurate, I believe that these sponsored materials are consistently tilted *in the direction of therapeutic enthusiasm. There has been a rapid growth in expensive, slick audio-visual materials, conferences, symposia, and publications which have the appearance of independent, scholarly productions but which are in fact an integral part of the drug industry's overall promotional efforts, a more subtle part, of course, than straightforward promotional materials like advertising. Let me emphasize that the systematic bias I am describing does not arise because the medical authorities who contribute to these teaching programs present knowingly biased views because of pharmaceutical industry support. The problem is not that drug industry money corrupts medical experts, but rather that the industry sponsor can choose from among the many medical authorities on any given topic to support only those whose views already coincide with the interests of the sponsor. This ability of the pharmaceutical industry to select the medical authorities it wishes to support is the basic cause of the biases we shall see. In the discussion to follow, I will present a number of examples of medical communication which will illustrate the problem I have been describing. In some cases these merely present a particular -7- PAGENO="0166" 14072 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY point of view. Other examples will be shown of medical communication which, in my judgment, do not constitute the sort of disinterested, balanced, scholarly products we expect educational materials to be. I recognize that I have selected these examples to make a particular point. They will show that drug promotion can masquerade as education. I have certainly not attempted to present a full review of all the medical communication sponsored by the drug industry. I am aware of many examples of excellent industry-sponsored materials. Nevertheless, I believe it is inevitable that the educational materials produced by and for an industry withan interest in increasing sales of drugs will, on balance, be biased in a direction intended to promote drug use. The examples presented in this testimony are not atypical and were not difficult to find. I also believe the growing proportion of medical communication that is supported by the drug industry threatens the integrity of the whole process of post-graduate medical education. I would now like to turn to some examples to illustrate my concerns. THE MEDICAL LITERATURE Appendix A is a list of the twenty-eight medical publications having a circulation of seventy thousand or more. The list was compiled from the -8- PAGENO="0167" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14073 March 24, 1976 issue of Standard Rate and Data Service which contains circulation figures for all major publications. Of these twenty-eight publications, only one, The New land Journal of Medicine, is financed to any major extent by subscriptions. Twenty-five of these twenty-eight leading publications are sent to physicians free of charge and are paid for entirely by industry funds. Two other publications, American Medical News and the Journal of the American Medical Association, are financed through a combination of dues paid to the American Medical Association and' by pharmaceutical advertising. Only two of the journals, The New England Journal of Medicine and the JOurnal of the American Medical Association, are scholarly journals, i.e., journals which primarily print reports of original research submitted by the investigator after review by independent expert reviewers. The remainder are publications which the pharmaceutical and publishing industries call "controlled circulation" publications. They are also known popularly as "throw-aways". They generally do not publish original work and uually do not have a rigorous review of papers of the type conducted by the scholarly journals They are sent to physicians, not because they are requested,but simply because the physicians' names appear on m~4ling lists. Of the twenty-six leading journals which are throw-aways, four concentrate on legal and socioeconomic aspects of medical care~ The remaining twenty-two focus on medical treatment. The medical pu4mlicat~ons sent to the physician thus constitute a literature overwheiminqly supported by the drug industry. -9- PAGENO="0168" 14074 Coi~uETITIVE PROBLEMS IN THE DRUG INDUSTRY We have brought with us today a number of examples of these journals. Each one consists of a number of drug advertisements plus a number of articles which appear to be independently written. It is not easy to assess the scientific quality of the controlled circulation journals. Much of it appears, on its face, quite reasonable, tending to be oriented toward review articles and articles dealing with particular clinical problems, e.g., how to diagnose and treat lower back pain. At the same time, however, I must wonder whether a journal that subsists wholly on sales of advertising space to the drug industry is able to present a skeptical attitude toward drugs in general or toward specific drugs. Editorial Policies FDA has received complaints from some authors that when they prenare an article unfavorable to drug products the articles are rejected by the controlled circulation journals even when they were solicited by the journal in the first place. The reasons qiven for rejection are that the article does not meet some unspecified technical standard, but whether or not this is the entire reason is difficult to determine. Members of our staff have had several meetings with editors of controlled circulation journals asking specifically about editorial oolicv reqardino articles adverse to the product of an advertiser. A common answer is that such'articles rarely are received because physicians are more interested in reporting successes than failures and that,furthermore, - 10 - PAGENO="0169" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14075 successes make more interesting reading than failures. Another common answer is that the journal sells space on the basis of reader interest and to sustain this interest the journal must contain objective articles. Usually, however, it is acknowledged that whenever material severely adverse to a sponsor is received, that sponsor is given the opportunity to rebut that material before it goes into the journal. In any event, and for whatever reasons, the editorial content of these controlled circulation journals is overwhelmingly optimistic about drug therapy. A recent editorial appeared in the January 1976 issue of Current Prescri~j~9~. The article, entitled "The Undermedicated Society," laments that underprescribing and not overprescribing is a major problem in American medicine. The author states, "The family physician's alleged propensity to overprescribe has provoked well-publicized investigations, both Congressional and clinical." "But what of the other side of the problem - underprescribing? Do doctors sometimes prescribe too little? In interviews with experts in several specialties, Current PrescrJ~j~~ found that the answer is yes. For many conditions, and with a number of drugs, M.D.'s may he giving their patients therapeutic short change." I am submitting a copy of this article for the record. The editorial position is not without merit, but several questions arise. The editorial writer was not a physician and had to seek advice about matters like under- and ove~prescribing from physicians. In selecting his consultants could the support of his magazine have affected his choices? ~Is a journal wholly dependent upon the pharmaceudical industry - 11 - PAGENO="0170" 14076 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY for support willing to editorialize on the excessive use of a drug class? Perhaps the answer is yes, but one must wonder. Information on Unproven Uses of Drugs The pages of the controlled circulation journals frequently are employed to bring to the physician's attention new uses for a drug product which are not yet approved by the Food and Drug Administration, something the manufacturer is not permitted to do through the usual channels of drug advertising and detailing. A typical example is an article entitled "Migraine. . .and More, Treatment and Prevention" from the April 1976 issue of Current Prescribing. I will also submit a copy of this article for the record. The American Medical Association grants one full hour of Category I, the highest category of continuing education credit, for study of this article. This article describes unapproved uses for Ayerst's Inderal, Knoll's Octin, Carnrick's Midrin, Merck's Periactin, and Sandoz's Sandomigran. Sandomigran is an investigational drug not marketed in this country. The issue is not whether the article is scientifically correct or whether it is proper to publish such information. There can be no doubt that scholarly medical journals should contain new information about drugs and should not be limited to the contents of approved package inserts. The issue here is whether such an article in a controlled industry circulation journal presents, in the guise of a scientific paper, promotional information which otherwise could not be legally published as drug advertising or drug labeling. The article in question did not pass through the rigorous independent editorial review common to scholarly journals. - 12 - PAGENO="0171" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14077 Support for Brand Name Dru~gs I would point out, in addition, that the editorial policies of these journals are often consistent with the position of the large pharmaceutical manufacturers. For example, in a special supplement of the March 1976 issue of Private Practice, a controlled circulation journal sponsored by the Congress of County Medical Societies, the edit9rs report on a campaign launched with the help of the publishers of Private Practice to fight repeal of Oklahoma's strong anti-substitution law. A copy of this article will be submitted for the record. Later in an editorial in the April 1976 issue of the same magazine, the editors report on the success of this educational campaign in changing public opinion in regard to drug substitution. The publisher of Private Practice offers to make available, free of charge, the newspaper mats, video and audio tapes and brochure text to any county medical society wishing to mount a similar campaign. A copy of the pertinent section of this editorial is attached as Appendix B. Let me emphasize that I am not implying, for purposes of this testimony, that these campaigns are improper or not in the public interest. The important question is: Is it likely, or even possible, that a controlled circulation journal dependent upon drug industry support would take another point of view? I would like to call your attention to one of these publications, the March 1976 issue of Prirnury Cardiology. It would take a perceptive reader indeed to see the fine print at the bottom of page 5 of this - 13 - PAGENO="0172" 14078 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY issue, which says: `USV Pharmaceutical Corporation sponsors PRIMARY CARDIOLOGYtC as a continuing educational service to the practicing physician." A copy of the page on which this quote appears is attached as Appendix C. The controlled circulation journals represent a large proportion of the total literature reaching physicians, are entirely dependent on the drug industry for support, and appear to be generally enthusiastic about drug therapy. This is not to say they do not provide very useful information. These journals specialize in carefully presented practical discussions designed to help the physician deal with most common problems. These journals are excellent communicators and they must be having some impact. There is no avoiding the question of whether it is desirable that they be financed entirely by an interested party. In addition to controlled circulation journals supported by the advertising of many pharmaceutical companies, there are a number of publications which appear to be independent but are actually sponsored entirely by a single pharmaceutical company. We have brought with us today several examples of this type of publication, which we will submit for the record. Suchhouseorgans are regulated as labeling and cannot be inconsistent with the approved package insert for the drugs discussed. These magazines, however, do not look like drug labeling and their sponsorship is not easy to ascertain. - 14 - PAGENO="0173" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14079 INDUSTRY-SPONSORED SEMINARS The drug industry sponsors numerous medical symposia and seminars. These have been discussed in Pills, Profits, and Politics, by Silverman and Lee, as follows: "One customarily practiced device is the drug industry sponsored conference or symposium devoted either to a particular new drug product or to a clinical problem in which the product may seem to' have value. The nominal host may be a medical group, a medical school, or a medical or scientific academy. The speakers may include various Americans, although European participants supposedly provide desirable glamour. It is generally considered useful to include a hundred or more physicians in the audience of newspaper, magazine and trade journal writers. The indoctrination of the doctor in the audience is viewed as helpful, but more importance is placed on the accounts filed by the press representatives present and on the formal published proceedings of the conference, which may be used for months as `scientific' background." Since the publication of the Silverman and Lee book, the live audience has been extended by the use of closed circuit live television. In January 1976, Pfizer Laboratories, Division of Pfizer, Inc., sponsored such a closed circuit nationally televised seminar on the diagnosis and treatment of diabetes mellitus. The program seminar provided a learned discussion of this disease but attempted to steer clear of the findings of the University Group Diabetes Program (UGDP) and the resulting adverse publicity surrounding oral hypoglycemic drugs, including Pfizer's Diabinese. - 15 - PAGENO="0174" 14080 CO~fl'ETITIVE PROBLEMS IN THE DRUG INDUSTRY Without debating in this testimony the merits of the U(DP Study, it is difficult to imagine how a modern discussion of diabetes treatment fail to emphasize its findings. I am aware of at least one round-table discussion in a controlled circulation journal, Patient Care, which discussed the implications of the study in a balanced way, ultimately taking a middle-of-the-road position which suggested that many physicians who treat diabetes felt the oral hypoglycemic drug should be used more sparingly. This certainly see~ns a minimum position. The Pfizer symposium, however, largely avoided the whole issue. Another example is a symposium sponsored by Wyeth Laboratories which was devoted entirely to its product Serax (oxazepam), a benzodiazepine tranquillizer similar to Librium and Valium. The proceedings of this conference were published as a supplement to the May 1975 issue of Diseases of the Nervous System. The special issue did not reveal the symposium's sponsorship, but contains articles which suggest special advantages that the Wyeth product may have over the other benzodiazepine tranquil 1 i zers. - I want to emphasize again that medical investigators must be free to write whatever they wish about drugs and to speculate about advantages one drug may have over another. In this case, however, the investigators were selected by the manufacturer to participate in an industry-sponsored meeting, the proceedings of the meeting were published without reference to such sponsorship, and the papers all turn out to be favorable to Serax. - 16 - PAGENO="0175" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14081 Even if the investigators, who are well-known physicians in their field and investigators of known integrity, are accurate in everything they say, the process through which this supplement to a medical publication was produced is cause for concern. 0 EDUCATIONAL MATERIALS The fastest growing areas in continuing medical education today are audio-visual materials and multi-media learning systems~ Radio Broadcasts The Physician's Radio Network (PRN) broadcasts the latest news of medicine to physicians twenty-four hours a day. I will demonstrate a PRN Radio portion of one of these broadcasts right now. The radios themselves and the programming on them are financed entirely by the sale of advertising time to pharmaceutical manufacturers. Each sixty minutes of programming contains eight minutes of advertising for brand name drugs. Routine listing to PRN is approved for Category 5A Continuing Medical Education Credit by the American Medical Association. Physician's Radio Network is a subsidiary of Visual Information Services, itself a subsidiary of Republic Corporation. - 17 - PAGENO="0176" 14082 cO~nEPITIVE PROBLEMS IN THE DRUG INDUSTRY Video lanes Visual Information Systems also produces the Network of Continuing Medical Education, a biweekly, hour-long video-taoe distributed to hospitals, courtesy of Roche Laboratories, division of Hoffman'n-LaRoche, Inc. Nearly ever.y major pharmaceutical company is engaged in producing materials for continuing education. These materials commonly use formats one associates with disinterested educational efforts--i.e., expert panels and lectures by distinguished physicians. Despite their appearance, and despite the fact that they may be generally accurate, they are often promotional of particular drugs or drug classes and, on the whole, are one-sided. One does not often find in these materials the sort of healthy skepticism of a particular therapy that a journal like the Medical Letter brings to its readers. Typically, one does not see on such panels those physicians who believe oral hypoglycemic agents are dangerous, who believe antianxiety aqents and sedatives are overprescribed, or who think that hyperactivity in children is overdiaqnosed and overtreated with druqs. The result is a tone of therapeutic optimism, uncritical review of the subject and tack of balance. I want to illustrate the kinds of materials I am talking about by showinq a few examples of industry-sponsored educational materials related to the use of psychoactive drugs. - 18 - PAGENO="0177" COMPEPITrVE PROBLEMS IN THE DRUG INDUSTRY 14O8~ The first example is a video tape on depression, sponsored by the American Pyschiatric Association and financed by Pfizer Pharmaceuticals. The program is made available to groups of physicians by Pfizer detailmen. Some segments of the program will demonstrate that the tape, while probably reflecting the participants' views fairly, strongly encourages use of antidepressants generally and to some degree Pfizer's product Sinequan specifically. As you will see, the tape begins by mentioning that there are 4 to 8 million people with depression, and that the tape is sponsored by the American Psychiatric Association and financed by Pfizer. A series of scenes then suggests that depression is far more pervasive than one might have suspected. First an estimate of 20 million people per year is proposed as a more probable alternative to the 4 to 8 million figure. Depression is broadly defined as "the absence of joy, anhedonia" and various examples illustrate its ravages: the housewife, the underachiever, people with psychosomatic complaints, insomnia, or sexual dysfunction. The increase in recent years of the use of tricyclic antidepressants is noted and is accounted oraiseworthy. Finally, the last speaker of the symposium suggests that tricyclic antidepressants are particularly good drugs and indicates certain advantages that Sinequan, Pfizer's tricyclic, has. - 19 - 73-617 0 - 76 - 12 PAGENO="0178" 14084 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY The message is quite clear: --Depression is everywhere and being underdiagnosed; --Patients need not be actually depressed--insufficient joy, psychosomatic complaints, or underachieving may be the only signs or symptoms and may be enough to make a diagnosis of depression; --Sinequan is the best of a good group of drugs, whose use, fortunately for the American public, is finally increasing to-high levels; --The physician should join this welcome trend and use the drugs more. There is every reason to believe that the physicians participating in the taped discussion are voicing with full personal integrity, their best medical opinions. It is also likely, however, that the drug firm knew what each physician would say before they invited him and thus assured the emergence of a particular point of view in its educational production. Audio cassette tapes come to physicians in ever-increasing numbers. They are particularly useful to the physician because they allow him to make use of time that ordinarily is lost while driving in his car. - 20 - PAGENO="0179" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14085 I would like to play for you an excerpt from a February 1976 tape from the American Osteopathic Association Audio Educational Service, sponsored by Abbott Laboratories; the speaker is an osteopathic physician interviewed for this particular progt~am. Again, a clear message is given: anxiety is everywhere and chemotherapeutic agents are the treatment of choice. The program tells the physician that minor tranquilizers are the preferred drugs and mentions that a once-~a-day regimen is best. Abbott's Tranxene SD happens to be the only minor tranquilizer with a once-a-day dosage regimen. A second excerpt is from a lecture on Stress, Anxiety, and the Cardiovascular System by Han Selye, M.D., Ph.D., D.Sc. In the words imprinted on the audio cassette, the lecture is, "Sponsored as a service to physicians by Pfizer Laboratories Division." Again without a hard sell, the message is the same: More people need more tranquilizers for longer periods of time. Pfizer Labs manufactures the minor tranquilizer Vistaril and the trade name Vistaril is displayed prominently on both sides of the cassette. Transcripts of the excerpts I have just played are attached as Appendices D and E. As another example, Roche Laborathri~s, manufacturer of Librium and Valium, sends out records of heart sounds in various types of heart disease. The records themselves are excellent and I believe quite useful. Each record is jacketed with promotion for Librium and Valium, - 21 - PAGENO="0180" 14086 COMPETITIVE PROBLEMS IN ~HE DRUG INDUSTRY interspersed with textual material. The unmistakable impression given is that the presence of heart disease, rather than the presence of anxiety, calls for tranquilizers, despite a fine print disclaimer, `the editorial content of this series is not intended to suggest the use of any specific drug or treatment program.' P~harmaceutic Industry Benefits from Educational Materials Our experiences with several organizations which planned to produce a large number of educational materials provide some interestjng insights. As an example, two years ago, Synapse, a subsidiary of the J. Walter Thompson Company, proposed to produce a series of forty-eight disease oriented video tapes to be sold to physicians under the auspices of the American Academy of Family Physicians. The cost of producing each tape was to be paid by a pharmaceutical manufacturer. The first tape was on urinary tract infections and was to contain corrnercials for Eli Lilly's cephalosporin antibiotics. The advertising agency expressed considerable dismay when FDA ruled that if the products advertised were intended to treat the disease discussed by the tape, then the entire tape would be considered drug labeling. This meant that the content could not deviate significantly from the labeling in the package insert Synapse's contention was that no company would sponsor such an educational undertaking unless it could be related to one or more of that company's drugs, and, indeed, the series did not go forward. This contention has been repeated over and over again by media suppliers in discussions with the Agency. - 22 - PAGENO="0181" COMPETITIVE PROBLEMS IN THE DRUG INI)USTRY 14087 Increasingly, pharmaceutical companies are providing continuing education materials for use at hospital staff meetings. These materials generally are produced hy independent companies such as Medcom and Health Learning Systems on contract for pharmaceutical manufacturers. Examples of Multi-media, Presentations Health Learning Systems, in cooperation with the National High Blood Pressure Education Program, the Council for High Blood Pressure Research of the American Heart Association, and the National Kidney Foundation has produced an excellent series of materials on hypertension. The series, called ~j,~]p9ues in Hypertension was produced under an educational grant from Smith Kline & French (SKF) Laboratories, manufacturers of Dyazide, a fixed-combination diuretic indicated for hypertension. Let me emphasize that none of the materials produced were' favorable to Dyazide specifically and, if anything, deemphasized the product. In this instance the educational materials, whi'e industry-supported, were under the total control of a Federal-private program of unquestioned independence and prestige which was furthering the widely-accepted goal of assuring that more people with high blood pressure were diagnosed and treated. SKF did no more than pay the bills. The goal of the overall program happened to conincide with the goals of manufacturers of drugs used in treating hypertension and with good medical practice. In many other cases, however, increased use of medication is not necessarily consistent with qood medical practiceS - 23 - PAGENO="0182" 14088 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY One such example is a learning system on the subject of stroke developed by Health Learning Systems, Inc., and sponsored by Marion Laboratories. The learning system consists of two motion picture films, accompanying work books, tests to be taken by physicians, plus materials used to advertise the learning system to directors of medical education and to hospital medical staffs. Marion Laboratories markets papaverine hydrochloride in a sustained release oral dosage form named Pavahid. The drug is claimed to be a cerebral vasodilator and to improve circulation to the brain (let me note parenthetically that the usefulness of this drug has not, in our view, been demonstrated). In the April 5, 1976 issue of the Federal Register, the FDA called for marketers of papaverine to submit evidence of safety, efficacy, and possible grandfather' status of the drug. The Federal Re er statement said that the drug would be removed from the market if such evidence were not submitted. At a September 1974 meeting of the Western Pharmaceutical Marketing Research Group, held in Chicago, a representative of Health Learning Systems explained why Marion Laboratories was interested in sponsoring a learning system on stroke. Marion's Pavabid already had more than 60 percent of the cerebrovasodilator market and Marion felt that no amount of advertising would increase this percentage very much. It - 24 - PAGENO="0183" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14089 was also felt, however, that if the total market for cerebrovasodilators could be expanded, Marion Laboratories would get a high percentage of the increased sales. One way to expand the market for cerebrovasodilators was to convince physicians that these drugs were useful in the prevention and treatment of stroke. The first segment of the learning system made no direct claims for the effectiveness of Pavabid in the treatment or prevention of stroke but simply focused on the transient ischemic attack (TIA), a brief episode of focal neurologic deficit, as an early warning sign of stroke. It then provided prescribing information for Pavabid and a logo of a linegraph superimposed over a longitudinal slice of a brain. The second part of the learning system discussed the "Diaonosis and Treatment of Cerebral Vascular Insufficiency.' The relatively uncommon cases which can be helped by surgical intervention were discussed in *a superb presentation by Dr. Michael E. De Bakey, President of the. Baylor College of Medicine. - 25 - PAGENO="0184" 14090 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY The final segment of the learning system considered vasodilator therapy. The accompanying workbook pointed out that intravenous papaverine, wjiich is not marketed in the United States, is one of the most effec~tive vasodilating drugs and then proceeded, in a leap in logic, to recommend the use of oral papaverine in patients recovering from completed strokes and transient ischemic attacks. Again, despite the educational format and the appearance of distinguished physicians, the learning system is not a disinterested effort. First of all, it is directly linked to a frankly promotional effort. The linegraph-brain logo that appeared in the film was subsequently reproduced in journal advertisements and promotional labeling for Pavabid. Those promotional efforts are directed, just as the learning system was, at the use of Pavabid in the treatment and prevention of transient ischemic attacks. In addition, although some physicians believe cerebrovasodilators are useful, a great many others disagree. The learning system did not refer to these negative views and a user of the system would necessarily gain a very incomplete view of the current opinion of experts regarding these agents. - 26 - PAGENO="0185" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14091 Another new continuing education modality is the Medical Telephone Conference System. These "telesessions," sponsored by pharmaceutical firms, enable physicians from around the country to discuss a disease for which the company's product is offered with the guidance of a company representative. Appendix F is a leaflet intended for pharmacists describing telesessions to be held for Pennwalt's Zaroxolyn. Noteworthy are the statements "A.M.A. Credit" and `Positive Effects on Sales Shown by Previous Participating Companies in Other Therapeutic Categ~ories: Roche - Abbott - Burroughs Wellcome - Smith Kline & French." While we do not know precisely what fraction of educational materials is industry-sponsored, we believe it is large. The examples provided show clearly that the educational content is commonly promotional in intent. SCIENTIFIC EXHIBITS At most medical meetings there are numerous exhibits, some of which are commercial exhibits promoting various drug products, others of which are scientific exhibits describing the work of independent scientists. These latter are usually not bound by the kind of - 27 - PAGENO="0186" 14092 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY limits our regulations place on drug labeling or advertising, because they have been considered equivalent to scientific publications. As a result, such scientific exhibits frequently discuss new uses of drugs, drugs not yet approved, and comparative properties of. drugs not made in approved labeling. Recently, Agency action related to the regulation of drug labeling has raised serious questions about these exhibits. In an attempt to define ways in which a drug company could distribute independently prepared educational materials, such as standard textbooks of pharmacology, we suggested guidelines under which such information would not be considered drug labeling. For the most part, these guidelines attempted to assure that such materials were wholly independently developed and edited. We did not feel that materials which discussed products of a single manufacturer or which discussed drugs and were produced with drug company funds could avoid being labeling if a drug company distributed them. Ie have discussed these quidelines with representatives of the American ledical Association and the Pharmaceutical Manufacturers Association who indicates that many scientific exhibits depend upon the support of individual pharmarceutical companies whose products are described in the exhibi ts. - 28 - PAGENO="0187" COMPETITrVE PROBLEMS IN THE DRUG INDUSTRY 14093 The problem faced by the AM/\ is detailed as follows in a memorandum written by one of their committee chairmen: "By this definition (meaning sponsored by the manufacturer of the drug), approximately 80 percent of the scientific exhibits at the AMA meeting are promotional and probably half of these are in noncompliance with the regulations for the labeling of pharmaceutical products as set forth in the Federal Register." Cost of Scientific Exhibits In the same memorandum, the author estimated that the total cost of a scientific exhibit is $5,000 to $40,000 and concluded: "few physicians or scientific investigators can afford to have an exhibit unless they receive financial support. In the past, large clinics and medical centers supported exhibits as part of their public relations and professional education programs. The source of these funds has been severely reduced lately. Some exhibits have been supported by professional societies and lay health organizations, but too often these organizations are more interested in recruiting members and raising funds than in educating physicians. Support from the Federal Government through National Institutes of Health, Armed Forces Institute of Pathology, the Food and Drug Administration and the military forces has helped in the past, but this has been greatly reduced. The only other source of financing exhibits has been pharmaceutical companies. Either directly or indirectly this pays about 80 percent of the cost of the scientific exhibits. - 29 - PAGENO="0188" 14094 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY "Usino a scienti.fic exhibi~t for promotional purposes is contrary to the spirit of the regulations of the AMA. However, the AMA cannot be responsible for anything that happens to an exhibit or to the brochures after the meeting. In this highly competitive society few pharmaceutical companies can afford to support a purely educational exhibit." Use of Scientific Exhibits to Promote Unapproved Drugs Appendix G shows, as an example, pages 66 and 67 and 76 and 77 of the official program for the Twenty-seventh Annual Scientific Assembly of the American Academy of Family Physicians (AAFP) held in October 1975. A large percentage of the exhibits are drug related. Appendix H shows pages .138 and 139 of the program of the American College of Physicians' Fifty-seventh Annual Session held in April 1976. In both programs, there is an exhibit by the same physician describing the development of an antihypertensive drug, prazosin hydrochloride. Let me note that under FDA regulations pharmaceutical manufacturers may not promote their drug products prior to approval for marketing. In this case, although it was not noted in the program, the investiqator was a full-time employee of the drug manufacturer which had developed prazosin. Prazosin had not been approved for marketing at the time of either meeting. - 30 - PAGENO="0189" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14095 In the AAFP program, there are two scientific exhibits on Tolmetin, a drug developed by McNeil Laboratories for treatment of rheumatoid arthritis. At the time of the AAFP meeting, Tolmetin had not been approved for marketing in the United States. In response to the Agency's questions, a representative of the firm stated that the construction of both exhibits was financed by McNeil. The representative went on to state that his company customarily financed such exhibits when its medical monitor was pleased with an investigator's results. He stated that such scientific exhibits were shown at two to four conventions each year and that while attending the convention, each exhibitor received an honorarium of about $250 per day plus reimbursement of all expenses. Again, let me stress that I have no reason to believe that these industry-supported scientific exhibits represent anything other than the honestly-held beliefs and legitimate findings of the investigators involved. Many contain high-quality work. It is nevertheless a matter of great concern that most of the content of scientific exhibits is to a great degree selected by the drug industry. The exhibits committees of the conventions no doubt can eliminate the more frankly promotional exhibits, but thoy can do little to alter the fact that an exhibit unsupported by a drug company will usually not be produced and submitted for their review. - 31 - PAGENO="0190" 14096 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY ROLE OF REGULATION Mr. Chairman, let me turn at this point to the possible role of regulation in addressing this overall problem. The FDA is responsible for regulating drug advertising and labeling, and I believe we do that well. On the other hand, we also have a responsibility not to restrict legitimate educational materials which are not under the authority of the Federal Food, Drug, and Cosmetic Act. I would like to make one point unequivocally clear. Any scientist, physician, or other person can say or write anything he wants about a drug, so long as this effort is not subsidized by the drug industry. The Federal Food, Drug, and Cosmetic Act poses no threat whatsoever to scientific communication and debate on drugs, to the reporting of research on drugs, or to the voicing of any medical opinion on drugs, providing industry funding of that communication is not involved. Once a drug firm distributes written or audio~visual material about a drug, or in association with one of its drugs, however, that material comes under the labeling provisions of the law. Labeling has been defined quite broadly in the Federal Food, Drug, and Cosmetic Act and by the Courts and includes virtually all printed materials about drugs placed into interstate commerce and supported by a drug firm. - 32 - PAGENO="0191" C0MPETIPrVE PROBLEMS IN THE DRUG INDUSTRY 14097 Under present law FDA has regulatory authority over some of the materials I have been using as illustrations. Cassettes which discuss a particular drug, for example, must meet standards for drug labeling and may not promote nonapproved uses of drugs, minimize hazards, or make comparisons not supported by evidence. This still does not, of course, mean that t.hey are neutral educational materials as their formats might suggest. PROPOSED FDA GUIDELINES Recently, FDA was asked by a medical society whether a drug company could legally distribute a monograph prepared by the society without including prescribing information. The society objected strongly to the presence of such information because it would, they felt, have suggested that t~e monograph was promotional or prepared by the drug manufacturer when in fact it was not. In an attempt to define the circumstances in which we would consider informational material disseminated by a drug manufacturer not to be drug labeling, and thus not obliged to contain package insert information or to maintain strict conformance to the content of the approved package insert, we suggested the following five tests: 1. The material has been prepared solely for educational use and not with any intent that it be used for other purposes, e.g. sale to or distribution by the pharmaceutical industry. 31 - PAGENO="0192" 14098 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 2. The material is not promotional in nature taken as a whole, and is in the form of balanced educational materials. For example, the material may not contain any significant emphasis on uses for drug products that are not approved by the Food and Drug Administration as safe and effective, i.e., use for unapproved indicatior~or in derogation of required contraindications and warnings. Although the material may contain occasional references to such uses,~such references may not be frequent or he given major consideration or Importance. 3. The material has been prepared independently, i.e., the pharmaceutical industry has not participated in the preparation of the material and has not exercised editorial review over the content of any of the material. 4. The material covers a number of different drugs, and does not support use of one particular drug or the drugs of a particular pharmaceutical company. - 34 - PAGENO="0193" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14099 5. The material is not associated in any `ay with a promotional campaign for any drug product by the pharmaceutical firm supporting the exhibit. The material may contain referonco .0 support by a oharmaceutical firm. These tests, let me stress, were intended to permit truly independently prepared educational materials which do not have an overall promotional message to be distributed by drug manufacturers. When we were asked about scientific exhibits, we suggested essentially the same criteria. We are currently drafting an extensive revision of our drug advertising and labeling regulations, and we expect to include guidelines such as those noted above in these proposed regulations. We are concerned that both the American Medical Association and the Pharmaceutical Manufacturers Association believe that these criteria would virtually eliminate scientific exhibits and industry-sponsored symposia. These regulations could thus have an enormous impact on post-graduate medical communication and we would not take such a step lightly. We expect extensive comment on these regulations and will consider such comments carefully. At the same time, the extensive influence of the drug industry in these educational media is well illustrated by the profound effect our suggested guidelines could have. - 35 - 73-617 0 - 76 - 13 PAGENO="0194" 14100 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY In brief, then, regulation under the Federal Food, Druq, and Cosmetic /\ct, is an important restraint on some promotional efforts sponsored by the drug industry. I would not want to suggest, however, that regulation is the best approach to take for all of the educational materials supported by the drug industry. The idea of the Federal government and Madison Avenue locked in eternal battle over every piece of educational material sent to physicians is not particularly attractive. Neither of these parties should have primary control over educational materials. Such control properly belongs with the profession itself and its medical schools. AN OVERVIEW Mr. Chairman, I would like to summarize the problem in broad terms. The technical knowledge required for the optimal practice of medicine is continually advancihg at a rapid pace. Because of this, there is need for excellent courses and teaching materials to assist the modern physician in maintaining his professional competence throughout his career. This need is increasingly recognized by specialty societies and State boards of licensure. Thus physicians are coming under increasing pressure to demonstrate in a formal way their p~irticipatiOfl in various courses, hospital seminars, and other teaching programs. To fill the need for teaching materials the communications industry has moved aggressively in recent years to produce an enormous variety 36 - PAGENO="0195" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14101 of brochures, books, monographs, magazines, controlled circulation journals, closed circuit TV video tapes, movies, audio cassettes, and self-instructional learning systems. Many of these are sent free to physicians, some under the sponsorship of professional organizations. These materials are highly professional from the standpoint of communications technology and obviously expensive to produce. Outstanding medical authorities commonly are featured, and the scientific content of these communications is often excellent. While some of these conrmunications relate to specific drugs and are readily recognizable as promotional material, many others deal with broad issues in medicine, including the diagnosis and general management of various diseases. Others may describe specific technical advances in a variety of specialty fields. The financial support for all of this activity comes predominantly from the pharmaceutical industry, which in turn obviously passes the cost along to the consumers of drugs. The proliferation of industry-supported educational materials has increased to the point where they now constitute the bulk of educational information provided to the practicing physician in his practice. The physician, of course, has other opportunities for post-graduate medical education, including a variety of courses conducted by medical schools, scientific meetings, and the medical literature. -37 - PAGENO="0196" 14102 COi~IETITIVE PROBLEMS IN THE DRUG INDUSTRY The relative impact of these different educational opportunities on physician behavior is not clear.. Physicians.are trained to think for themselves, to be critical, arid to engage in life- long learning. 1 do not consider my colleagues to be pawns of the communications industry. Nevertheless, it is reasonable to ask why our profession should be subject to an onslaught of allegedly educational material, not subject to the kind of independent review given the scholarly medical literature, which is financed by the drug industry, and ultimately paid for by our patients. My concern, Mr. Chairman, is with this system, because it places the post-graduate education of an entire profession too much under commercial, non-university influence, believe it is self-evident that the drug industry would not be supporting this field so heavily if it did not believe such support was beneficial to the sale of drugs Let me also emphasize that, while I have used the words physician" and "drug industry" throughout this testimony, a similar situation applies to other health related professions and industries. The post-graduate education of dentists, veterinarians, and pharmacists is also heavily influenced by the drug industry. Nor is this industry alone in its behavior. My testimony applies equally well to the medical device industry and the diagnostic products industry. The best solution to this problem is easy to describe in concept, but difficult to envision without major changes in the whole structure of post-graduate medical education. As I have emphasized repeatedly, I 39 PAGENO="0197" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14103 believe that control of the educational process for physicians properly resides with university-based medical schools. The pre-Flexnerian era taught us that medical education should not be entrusted to a commercial trade school environment, and our society should not have to learn that lesson over again. Medical schools are not financially in a position to accept responsibility for the post-graduate education of physicians. I believe it is important that this problem be discussed openly, and I commend your Subcommittee for undertaking these hearings. If the extent of the problem is as great as I suspect, and if my concerns are confirmed by others, society must entertain innovative solutions, even drastic changes in some of our current behavior. The possibility of permanent pharmaceutical industry dominance over the total post-graduate education of physicians anu other health professionals is too serious for us to ignore. Mr. Chairman, my colleagues and I will be happy to answer any questions you or the other Subcoemiittee members might have. - 39 - PAGENO="0198" 14104 coi~~rr'EPinvE PROBLEMS IN THE DRUG INDUSTRY APPENDIX A Circulation of U.S. Medical Journals With Total Circulation Over Seventy Thousand According To March 24, 1976 Issue of Standard Rate and Data Service Journal Free Distribution Paid Distribution American Family Physician 108,714 American Medical News 258,811 2,307 Consul tant 142,120 Current Prescribing 118,168 Drug Therapy 113,793 Emergency Medicine 109,974 Hospital Medicine 178,687 Hospital Practice 187,134 Hospital Tribune 100,000 Infectious Diseases 139,840 Journal of the Americah Medical Association 27,579 211,856 Journal of Legal Medicine 125,626 MD Medical Newsmagazine 181,481 Medical Aspects of Human Sexuality 161,522 Medical Challenge 77,749 Medical Economics 169,624 Medical Opinion 152,191 Medical Tribune 150,000 Medical World News 164,652 Modern Medicine 170,311 New England Journal of Medicine 923 158,190 Patient Care 101,145 Physicians Management 179,386 Physician and Sportsmedicine 90,533 Postgraduate Medicine 108,068 Practical Psychology 104,092 Private Practice 171,659 Resident and Staff Physician 95,948 319 PAGENO="0199" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14105 APPENDIX B -~------~ Anti-Substftution Success / Medical Device Disaster by Liewellyn H. Rockwell, Jr. Must ~,(tht' pcopk Who tinderstood drug substitution in Ada and Shawnee, Oklahoma, were for it. Last month In PRIVATE PRACTICE we reported on the unique media campaign waged by county medi- cal societies, with the help of county pharmacists associations and the Congress of County Medi- cal Societies, to change that. "We wanted to see if we could educate our patients in the dangers of drug substitution," said Orange Welhorn, MD, an Ada general soorgo-on - ``and not ovato' tIoo'ooo to tako action agaioost tl~' so,lntotiotiooo bill that was then pending in our state legislature." "It worked," adds Roy Kelley, a Shawnee surgeon. "It worked splendidly. It turned apathetic pa- tients-and, I might add, doctors- into ossilit,ont foes of substitution. The story of the campaign, complete with reproductions of the ads used, was published in the March PRIVATE PRACTICE. The final results are now in. In January 1976, before the campaign, people in Ada and Shawnee were asked, "Have you heard about the drug-substitution bill that is pending in the Ok- lahoma Senate?" If they answered yes, they were then asked to ex- plain what it would mean, and whether they were for or against it. In Shawnee, 38% knew, 59% hadn't heard about it, and 3% weren'tsure. 26 PRIVATE PRACTICE/APRIL 976 Of those who know what it was, 52% were for substitution, 32% were against, and 6% were un- decided. "Cheaper drugs will help older people"; "We will get the same drugs for less" werC typical responses. In Ada, 54% knew what sub- stitution was; 45% didn't; one percent wasn't sure. Of that 54%, 43% were for substitution, 38% were against, and 18% were un- decided. "The elderly will he helped by generic names"; and ``Soibstitottion will 1)8' I'IO('at)o'r woic two of the coonomoo'i Cosohiniiog the two cities, tlse county onedical societies fmtnd that 48% had heard about sulsstitution; 51% hadot't. And of that 48%, 46% were for it, 36% against, and 17% were undecided. "Our job," said soorgeon Dr. J. B. Wallace of Ada, Was to chaugt' the percentages of people who had heard of sub- stitution and of those who were against it." The intensive five-week cam- paign combined newspaper ads, and TV and radio spots. The campaign ended with the county societies sponsoring a two-hour TV movie, with live breaks for telephoned questions to a panel of doctors and pharmacists. After the noedia campaign, the percentage of people in Shawnee who had heard of substitution went from 38 to 57; in Ada, it went from 54 to 89. In Shawnee, the percen- tage of people who opposed sub- stitution went from 32% to 77%; in Ada, from 38% to 84%, "Even more important that this exciting change in public opinion," said Dr. Kelley, "was the action we acre able to persuade our patients to take. Over 2,400 cards or letters of protest were sent to the state rep- resentatives, and senators from Shawnee and Ada. After the first week, they were taking Ootice, After the campaign, they were comotpletely oio our side. I believe we hay,' proved that this kinsl oil camupaigu will work." The Congress ofCounty Medic;ol Societies, Inc., agrees with I)r. Kelley, and the newspaper mats, video and audio tapes, and brochure text will be made av- ailable, free of charge, to any county so)ciety wishing to mount a similarcampaign. And the CCMS is considering the implementation of similar campaigns againnt National Health Insurance and the 1962 "efficacy" amendments to the Food and l)rug Act, which have causes1 the alarming fall-off in new droog development. What Congress did to the pharmaceutical industry, attd indirectly to patients and doctors, with the 1962 amendments, it is PAGENO="0200" 14106 COMPETITIVE PROBLEMS IN THE DRIJG INDUSTRY Letters to the Editor Photo Feature Is the lecture obsolete? Edward Gipsteln, M.D. APPENDIX C March 1976 Internal heart functions are monitored by noninvasive technique Case History Sanford S. Zevon, M.D. ECG of the Month Atrioventricular block PUBLISHING STAFF Editor Design Director Executivi Editor Edwin K. ZiOeII Frank DeMarco Robert V. R. Brown Managing Editor Associate Editor Associate Editor Lucy Kavaler Ann Terry Miriam Zwerin Art Editor Editorial Assistant Editorial Asslstsnt Gary Monteferante Anita Cooke Shaita Martin Editorial Coordinator Business Manager Production Manager Ginger Paulsson Earl B. Geer, Jr. Joaé Garcia Publisher Bruce Addison PRIM0RYCARDIOLOOY'°it published 10 Ones each eat by PW Eumrnaanicsiinns. inc., eaa Madison Avenue, New York, New York 10022. Itt edItorial content Is the sole reepoetalbitOy on PW Connunicatons and an independent board of edlttrs tOt! Phannsceuticst Coepoflano soonsons PRIMARY CARDIOLOOynoas a contiruint educational servIce tO tIre practicing physician. OCoDyniuht 1070 by ew ConnvnlcaOons, Inc. All hIt reserved. Permission In reproduce articles In. whole or In part nust be obtained in wnttblQ from the pabiistran. Price $1.00 per copy. Annual subacniptitn prim $15.00. 1017.50 Canada and Foreignl Appiicaitan no mall an controtled circulation rates It pendinu at Lancaster, Pa. Vol.2 No.3 Primary Cardiology Cardiovascular Medicine for the Primary Care Physician Warren J. Taylor, M.D. 10 Care of the Cardiac Surgical Patient Requires step-by-step planning Gordon K. Danielson, M.D. 14 Current Status of Prosthetic Valves Which patients are candidates? H.J.C. Swan, M.D. 20 Diagnosis & Treatment with the Balloon Catheter William Ganz, M.D. Its use is beiog extended Arthur A. Sasahara, M.D. 26 Diagnostic Sequence for Pulmonary Embolism Reducing that high mortality rate John J. Sampson, MD. 30 `Minor lnfarctions: What to Look For Are they benign or more serious? Louis M, Aledort, M.D.' 38 Anticoagulant Drugs-When to Use, and How First of a series Max Harry Well, M.D. 42 Pulmonary Edema: Treatment Depends on Cause Replenishment of plasma volume is important Edgar Haber, M.D. 46 Should Digitails Be Used In Treating Acute* Myocardial Infarction? There are conflicting practices, opinions DEPARTMENTS Editor's Page 5 8 18 34 48 F~IMARY CARDIOLOGrM publishes original articles by leading cardiol- ogists to assist the primary care physician in the diagnosis and treatment of cardionascular and misted illnesses frequently en- countered in his medical practice. PAGENO="0201" COMPETITIVE PROBLEMS IN TUE DRUG INDUSTRY 14107 APPENDIX D Transcriot of American Osteopathic Association Audio Educational Service Tape Sponsored by Abbott Laboratories The element of management which is probably the most readily available and most effective Darticularly for the physician who is not able to spend the amount of time for personal catharsis and for the patient who is unwilling or unable to avail himself of this type of help is the utilization of a chemotheraoeutic regimen. Let me say at the outset that you should use the least potent drug that will control the problem and, where possible, drugs that can be taken as infrequently ~s possible. Obviously, a once-a-day regimen would be the best for patient compliance. We'll consider briefly three general categories of psychotherapeutic drugs which may be effective in anxiety. The first general category and the one that the majority of anxiety cases can be treated with is the group known as the minor tranquilizers. These include such medications as Tranxene, meprobamate, Valium and Libruim. It is important to remember that even though these drugs are classified as minor tranquilizers, they are not without serious problems if abused. However, the advantage of their use is that they produce less side effects than the major tranquilizers or antipsychotic drugs and that there is less discomfort and, consequently, better compliance. And, I repeat, most anxiety problems can be adequately treated with this class of drug. PAGENO="0202" 14108 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY The second group that I will touch on are those defined as the.major tranquilizers. The most important being the phenothiazine group such as Thorozine and Stelazine. Then there are the butyrophenones such as Haldol, and thioxanthines such as Taractan. For many years, since these drugs have been available, they have been primarily used on psychotic individuals. However, even though they may not be specifically indicated in anxiety, if a patient is resistant to the minor tranquilizers, they may be of some benefit if the patient is known not to be psychotic and is having an exceptional amount of anxiety. If you use these drugs and do not see any results in a period of two to three weeks, then, perhaps, the extremely anxious patient should be referred to a psychiatrist. However, even though I recommend referral if you do not see results, you should not be afraid with any of the psychotherapeutic drugs to use dosages that would be effective. Many times a general practitioner will correctly diagnose a problem of anxiety or, perhaps, a more serious psychiatric problem, but fail to give an adequate dose of medication. The guidelines on the nackage insert or in the f~y~jcians' Desk Reference are wise to cor~suit, but you should not be afraid to increase the dosage of tnese medications within reasonable limits and see how your patient responds. Many times his reaction to the varying doses of medication will be an indication of the extent of his illness and drug administration can thus be a diagnostic tool in this sense. -2- PAGENO="0203" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14109 APPENDIX E TRANSCRIPT OF VISTARIL TAPE So whatever you do, you are under some stress, but that way be excessive and, in that case, some measure must be taken against it. There are lots of physiological or psychophysiological means through techniques of relaxation which we won't discuss today. We have to try to use psychological means and self-control in order to avoid anxiety, but its useless to tell a patient, "Don't be anxious." If he is the type, he is anxious and if you can't control it that way you have to help him by giving him some minor tranquilizer at least. Now, there, I think one should select one that is not particularly dangerous and has not too many side effects. One should take amounts which are not too soporific and do not derange the normal function to an excessive degree. Especially in the evening if you can't go to sleep before because of anxiety. Another aspect of the use of tranquilizers is that you should not only give it once, when the patient is in a case of acute anxiety, but that very often you may have to prolong treatment. For example, a ratlent who had a cardiac infarct will remain anxious after that too for months afterwards. In fact, if he is so disposed, even following complete recovery, he will spend the rest of his life in a state of anxiety worrying about whether he won't get another cardiac infarct. So, I think a mild condition of tranquilization, as long as it does not interfere with your normal functioning, for example, driving your car properly and so on, should in some cases, be a constant procedure. PAGENO="0204" 14110 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY (we ether ~ltI( f~ ~ ,),V:(fl/)lf 11/ IIif( r,n)tI(,,?) APPENDIX F ~j ~k5k~5~MLT ~~s~is Penrlwaft PrescriptkDn Products * Peer-Group Discussions * Nationwide * T_elephon? Convenience A.M.A. Credit No Cost to the Physician Unique )\lew Thousands of Physicians ~gtjt(y~ effect on Sales Medical Telephone Participating Nationwide shown by previous participating companies in Conference System Pennwait Excjusi~ie (Many in your area) QftMr therapeutic categories * General Practitioners Internists * Osteopaths * Roche Abbott * Barreaghs Weilcome SK&F cHECK YOUR STOCK NOW! SAVE ~`~NOW CHECK YOUR STOCKS NOW 0F1 [y" ZAROXOLYN 21/2mg 100's ] L~' ZAROXOLYN 5mg 100's 1 LV'. ZAROXOLYN 10mg iOO'sJJ Łd&r~cthxoJyrl MetoIazonePEr~Nw~II set -Ae123/763.5A PAGENO="0205" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14111. APPENDIX 13 THE SCLENTIFICEXHIBITS' ------.----.-. -~ AMERICAN UROLOGICAL S-1~ TOLMETIN VERSUS ASPIRIN S-115 ASSOCIATION ( IN THE TREATMENT OF RHEUMATOID ARTHRITIS FILM LIBRARY DAVID A. CILP, M.D., Unitersits' ot /o\va JEROME J. SCHNEYER. M.D., S. WONG, J. F. GARDOC1.~I s.sn T. P. PRUSS. Southfieki, Hospitals. Iowa city. This exhibit displays a series of basic coh~r. Midz. sound motion pictures designed for gradua~e In a six-month. double-blind study. tolmetin. and postgraduate medical education in tf~e a nonsteroidal anti-inflammatory agent. was field of urology. Films are distributed ib significantly superior to aspirin in the treat- the 8mm cartridge-loaded format for u~ ment of 50 patients with active rheunia- in the Fairchild Mark IV projector. ~n toid arthritis: 29 percent of the aspirin super 8 cartridges for the Fairchild Seventy patients and 92 percent of the tolmetin 07 projector and in l(~ mm as ssell. patients shossed marked or moderate re- (~ sponse to medication. Mean daily dosage: 1193 mg. tolmetin: 4533 mg. aspirin. 2 ROLE OF PROSTAGLANDINS 5-113 IN RHEUMATOID ARTHRITIS NONURINARY FINDINGS ON S-116 THE EXCRETORY PROGRAM: A DAVE) H. B~sisi)ER, PHD.. (`ni-say of SELF-ASSESSMENT PROGRAM Missouri-Kansas City. A presentation of the effect of prosta- PAUL B. HANDEL. M.D. Ar-a) MIcHAEL M. glandinson the initiation of the inflammatory WARREN. M.D., University of Texas Medical reaction resulting in rheumatoid arthritis. Branch, Galveston. and the pharmacologic basis for drugs in Excretory urography is often performed for the treatment of rheumatoid arthritis, urinary tract symptoms. Careful scrutiny of the entire x-ray film, however. may reveal significant disease in other organs-in the abdomen, skeleton and pelvis-without ad- RELATIVE EFFICACY OF S-114 ditional films. This exhibit gives examples CEPHRADINE AND CEPHALEXIN of some of these diseases in a self-assess- CAPSULES IN THE TREATMENT merit format. OF URINARY TRACT INFECTIONS DAviD J. ALae~, ~o., GEk~Lu ~ ~ ERM ,i S-117 NER, M.D., DATrA G. WAGLE, M,D.~(THERAPY IN PATIENTS WIT~/ JOSEPH B. GAMBACORTA. M.D.. Ba//a/a, N. ?~- RHEUMATOID ARTHRIT~S,..- A number of synthetic cephalosporins have ~ M.D., Albert E. Lie- appeared in recent years. This exhibit ex- plores the relative efficacy of one of the stein Medical C'enter, Philadelphia, newer cephalosporins. cephradine Igeneric THOMAS R. Honss, Camp Hill, Pa,, Lee J. name), compared with a commonly used CORDREY, M.D., Tampa, F/a., AND DANIEL cephalosporin, cephalexin Igeneric name), HAMATY. M.D., New Haven, Conn. in the treatment of acute. and chronic In a long-term (30 month). study with 430 urinary tract infections. The clinical eval- patients, tolmetin, a nonsteroidal anti-ifl- uation of each agent was derived from clini- flammatory agent, was found to produce a cal observations correlated with bacterio' significant reduction of symptomatQlo~y logical response. In addition the exhibit in patients with active rheumatoid arthritis. will contain an educational self-assessment Daily dosage of tolmetin ranged from 200- quiz whereby the `viewer can test himself 2000 mgmean: 1250 mgi. A high degree of on his knowledge of urinary tract infections, safety attended long-term administration. 66 PAGENO="0206" 14112 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY THE SCIENTIFIC EXHIBITS S-118 DIAGNOSIS OF CHRONIC S-120 PANCREATIC DISEASE F. \VARREN NUCENT. M.D.. ROBERT E; Wise. M.D.. M. GARAHEDIAN. M.D. ANt) CARL R. LARSEN. M.D.. Lahev Clinic Fundation, Boston. Current techniques in the diagnosis of chro- nic pancreatic disease will be described and compared. The diagnostic accuracy of con' ventional laboratory and barium examina~ tions will be compared with hypotonic duodenography. selective angiograph~ and pancreatograms obtained by transduodenal endoscopic cannulation of the pancreatic duct. The addition of selective angiograph~ has improved diagnostic accuracy and. more recently. the availability of pancreatograms by noninvasive technique has added another important to~1iagnosis. 5-119 `tHE DIAGNOSIS AND TREATMENT S*1~1 / OF OSTEOARTHRITIS - IBUPROFEN: ANTHONY A ALBANESE. PH.D.. ANI) EVELYN A NEW TREATMENT MODALITY H. Wri~, Burke R;habilitation Center. GARY E. RUOFF. M.D.. ~ Jsstas W. MEL- White Plains. N Y. AND EDWARD J. Lu \ L1ISH. M.D.. Kalamazoo. Mich. RENZE. III. M.D., Veterans Administration This exhibit demonstrates the clinical and Hospital. New York city, radiological diagnosis and treatment modali' Application of a quantitative radiographic ties of osteoarthritis. Ihuprofen. a new drug technique for the detection of bone loss in for the treatment of osteoarthritis. is high- some 3000 female and 1000 male "normal lighted. The efficacy of treatment and its healthy" volunteers indicated that bone \ lack of serious side effects. including oph' loss is an age-sex related phenomenon. \jhalmologic problems. will `be presenteçt~-1 The early detection of subclinical osteo ~ porosis has been found to afford a useful COMMUNITY-BASED S-200 criterion for study of etiological factors COMPREHENSIVE GERIATRIC and efficacy of various therapeutic modali- ties for overcoming or minimizing bone `SERVICES: A MULTIDISCIPLINARY loss. Quantitative data on the effects of a MENTAL HEALTH MODEL calcium supplement on the bone density of patients who have suffered hip fractures CHARLEs M. GAITz, M.D. A..'~D Roy V. will be presented. VARNER. M.D., Texas Research institute of Mental Sciences, Houston This exhibit demonstrates the practical operation of a comprehensive geriatric ser- vice providing psychological and physical care; it explains how a community-based mental health facility effectively mediates the various modalities required to meet the divetse needs of elderly persons; and it underlines thç major importance of pre- ventive and therapeutic intervention. :TOBRAMYCININ THE TREATMENT OF ACUTE URINARY TRACT INFECTIONS LAYNE 0. GENTRY. M.D. AND BRIAN B. WALKER. 51.1).. Bas'lor College of .`~fedicine. Houston AND Tl-IEoIx)RE McNirr. M.D.. Brooke Armt ~`!edic-al (.ente!'. Fort Swn Houston. Tohramvcin is an effective, safe, new amino- glycoside in the treatment of acute urinary tract infections caused by susceptible patho- gens. Data displayed suggest that concur- rent hacteremia is also effectiselv eradicated with this antibiotic. Resistant pathogens have been encountered. Re-infection com- monly is related to underlying urinar~ tract pathohegy rather than ineffective antibiotic therapy. OSTEOPOROSIS: DETECTION AND CLINICAL STUDIES Confirmation of airline reser- ~vations may be made in Amen- ~an Airlines booth on the + 20 `(lobby) Level near the, out- bound taxi stand at McCor- "mick Place. 67 PAGENO="0207" COMPETITtVE PROBLEMS IN THE DRUG INDUSTRY 14113 THE SCIENTiFIC EXHIBITS AND THOMAS CHEN. School of B~ic,t Mc/,- ca/Sciences. University otillinois. I `rhana. Try your hand at managing a 35 year-old ~uman (simulated by a computer~ who comes to you for help because of an in- creasing incidence of early morning oc- cipital headaches~ or a 14 vear~ld girl ssith an elevated temperature lO3.5~ F~ accom- panied by an overly-anxious mother. PRECEPTORSHIPS IN PRIMARY CARE HAROLD MOESSNER, MI).. RICHARD C~iis~s. M.D. ANt) Rotanti RAKEL. M.D.. Lnit'eraitt of Iowa College of M~dicin'. iowa City. This exhibit will demonstrate the results of ~) years experience with preceptor~hips in primary care at the University of lossa Col- lege of Medicine. The repeated esposure of medical students to the primary care setting through a preceptorship program does influence the medical student in his selection of primary care as a specialty and in his selection of his practice location. FRACTURES OF THE S-517 HAND AND FINGERS SIOURI) C. SANDZ~N, JR., M.D.. Ahington. Pa. Most hand and finger fractures and epiphy- seal injuries are managed conventionally. However, surgical intervention is indicated with open fractures, displaced articular frac- tures. unstable fracture dislocations. un- stable shaft fractures and certain ligamen- tai avulsions. Malalignment. mairotation, angulation and infection are prevented by proper fracture reduction and position maintainence with indicated surgical intervention. HALCINONIDE: A NEW.AGENT FOR THE TREATMENT OF PSORIASIS AND OTHER STEROID.RESPONSIVE DERMATOSES Flwbsoan K. BAGATELL. M.D., PH.D., Eu- ODIE LESBSOHN, M.D., D1ta~tst. Sa&~wtj, M.D. ~ PETEa C~~sPER,ssD,, Phoenix, AND H. BRI.s.s Ls.'~iws. st.o. .551) C. Sn ARt BUCHANA.5. M.D.. Winchester, ~ Halcinonide cream was compared with betametha.~sne valerate cream in double- hltnd paired comparison fashion in the treatment ot psoriasis and other steroid- responsive derrnatoses. There was a sta tisticallv struficant superiority of halcin onide *in the treatment of psoriasis. N differences ssere noted in the treatment ~ atopic dermatitis including pediatric pa S515 ttentst. Halcmontde cream was also sta tisticallv superi. r to its placebo cream. both in psortasts and in atopic dermatitis. ANAEROBIC INFECTIONS S-521 RoNsiD LEE NICHOLS. MI). AND VbtLLIA\t SCHt.'MER. M.D.. I flhitrSitv of Health Sci- ences. Chicago .%fedical School. Chicago. Si-irRwooI) GORRACH. M.D.. Joits Bstsii~-n. M.D.. L.'CL.4 School of .~ledicsne. Los Angeles AND Lzxivo NYHERS. si.D.. Lnii-c-r- sit of/i/moo C~.iIie e of Medicine. Abraham Lincoln School ot .%iedicine. (`hi~-ago. This exhibit will acquaint physicians with the types of anaerobic infections they ma~ encounter in their practice. Clinical clues and laborators techniques used to deter- mint- the diagnosis are offered. Typical case histories of pulmonary and abdominal sepsisare included. A review of preoperative colon preparation is included as well as a treatment plan. SALVAGE OF THE ISCHEMIC S-600 LOWER EXTREMITY IN PATIENTS. WITH POOR RUNOFF RmcuAni) T. PURDY. M.D.. ANt) PRAFULL S-519 BOLE, M.D., New York Medical College. New York City. Twenty-three patients with threatened loss of the lower extremity in the presence of poor runoff are presented. All had a fe- moropophiteal bypass despite the presence of trifurcation obstruction distally. There was long-term preservatjon of functional extremities in 21 of 22 surviving patients. 76 PAGENO="0208" 14114 cOi~rIETITIVE PROBLEMS IN THE DRUG INDUSTRY THE SCIENTIFIC EXHIBITS COMPARISON OF GUANETHIDINE AND METHYLDOPA IN MODERATE HYPERTENSION NoRMAN GLAZFR, M.D.. Lo,ü.sri//e. This exhibit describes a studs which com- pared the efficacy and safety of guanethi- dine and methyidopa given in conthination with a single daily dose of 5(? mg hsdr chiorothiazide to 33 patients with a stand~n~ diastolic hkx)d pressure of l(~) to 125 mm Hg. Blots.l pressure reduction after lh s~ees~ of treatment is compared with that obtained after two weeks of treatment with 1(X) rng * hydrochiort it hiazide. Results obtained ss tb the two drugs are also compared. Graphic illustrations are used to depict all studs results. XERORADIOGRAPHY OF THE BREAST RALPIt B. BEw;i~RoN. Yi,D.. Och.sner (. Itflw New Or/euro. This exhibit demonstrates the xerographic process of radiography of the breast. it shows illustrative examples of benign breast problems as well as malignant tumors. Dif- ferentation between benign and nialign~nt conditions is stressed. Indications for the examination and clinical usefulness are listed. Accuracy of diagnosis is mentioned in the general summary. DISCOVER~ AND CLiNICAL EVALUATION - A UNIQUE ANTIHYPERTENSIVE AGENT NORMAN E. ~ M.D. ANt) MARS S. 1). GuALi. Sit)., Groton. Conn. This exhibit features an audiovisual pre- sentation tracing the development of a new therapeutic agent. The discussion provides insight into the basic pharmacologic hyp~- Theses. animal testing and. finally. extensise `,d~nical evaluation leading up to a ne~ ~drug application. MICHAEL LFSSIS. Mi).. .%!oflte/!nr~.' Ho~pita/ anti .%kdicai Leiit~'i~ B,o,iv, V y The exhibit deals soth congenital disorders resulting in deformities of the craniofacial skeleton. The exhibit also emphasizes the role of the extended team. which includes the interdisciplinary evaluation ~ind treat- ment provided by plastic surgery. neuro- suruers. anesthesiology. neurolog~. speech pathology. otorhtnolaryngology. Jentistr~ psychiatry. pss chol&gy. audiologs. radiolt igs. pediatrics, internal medicine. ophthalmo' logs, social sersices .ind others in dealing with deformities of ~-raniofactal ~inatt `ms and physiology. GR..sHAM ~ ~`.`HD. .`~ationiaI /mtituWs 1 Ma/nh. Bt'n/ie.sda. .~!c/. The National High Bltss.l Pressure Educa- Lion Program is part of a nationwide cam- paign to deselop an awareness in the medi- cal profession and general public of the imfxirtance of diagnosing and controlling high blisid pressure. The exhibit contains information and materials for the profes. sional concerning the Programs recom- mended cuidelines fur screening, evaluation. drug therapy and patient education. STE\I.N M. Lki5ICK. Sit).. WILLIAM S. BLAKE- StoRE ANt) ROIWRr .1. NAVARRE. Sit). .~iet/i- eat LoJk'ge (If Ohio. Toledo. This exhibit on peripheral vascular disease discusses the principles of arterial and vCnuus examination with Doppler ultra- sound and hoss these apply to the evalua- tion of patients by primary physicians and by vascular surgeons. S-601 INTERDISCIPLINARY 5-604 EVALUATION AND MANAGEMENT OF CRANIOFACIAL DISORDERS S-602 NATiONAL HIGH BLOOD 5-605 PRESSURE EDUCATION PROGRAM 5-603 DOPIER ULTRASOUND IN PERIPHERAL VASCULAR DISEASE 5-606 77 PAGENO="0209" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14115 APPENDIX H 138-Scientific Exhibits tobramycin in 248 patients acutely ill with serious urinary tract infections. Approx- imately 50 percent had complicating features, i.e. obstructive lesions, tumors, stones, etc. Remission of signs and symptoms of infection occurred in 96 percent of all patients. The presence of an underlying disease did not unduly delay clinical improvement. Mild and transitory adverse effects occurred in 7 patients. Bac- teriological response was satisfactory in 80 percent of the patients. Thirty-four(14 percent) of the patients became bacteriuric within 3 weeks following therapy. Of these, 21 were reinfected with new organisms, most commonly Pseudomonas aeruginosa. It is hoped that the rational use of this new aminoglycoside antibiotic will delay appearance of significant numbers of strains which are resistant to it. BOOTH 707 ROLES OF CLINICAL PHARMACOLOGY Teaching Consultations Surveillance Research Duncan Hutcheon, M.D., F.A.C.P., Benjamin Calesnick, M.D., Walter W. Baker, Ph.D., Gerald Balakin, M.D. American College of Clinical Pharmacology New York, New York The exhibit consists of five panels summarizing the roles of clinical pharmacol- ogy in continuing medical education, research and patient care. The central panel consists of an audiovisual unit in which selected topics in clinical pharmacology are presented to illustrate principles of rational drug therapy. The goals, organiza- tion and drug information sources provided by the American College of Clinical Pharmacology are also displayed. BOOTHS 713 and 714 PSEUDOMONAS INFECTION Edward L. Quinn, M.D. Henry Ford Hospital Detroit, Michigan In recent years, such pseudomonas infections have become increasingly im- portant. Age, use of immunosuppressive agents, chronic diseases and heroin addiction have all been implicated in this change as well as use of respirators, urinary catheters and intravenous indwelling lines. Although new and unuSual clinical syndromes due to Pseudomonas aeruginosa have been recognized, the course and prognosis of these infections have been greatly Influenced by 1) new antibiotic agents, 2) new surgical techniques, and 3) new preventive measures. Check for Messages at Message Center 73-617 0 - 76 - 14 PAGENO="0210" 14116 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Scientific Exhibtts-139 BOOTHS 715 and 716 GASTRO.ESOPHAGEAL (G-E) SCINTISCANNING TO EVALUATE G-E REFLUX Robert S. Fisher, M.D., Leon Malmud, M.D., Ira Lobis, M.D., Eugene Mayer M.D., Richard Tolin, M.D., Marc Feldman, M.D., John Capuzzi Temple University Health Sciences Center Philadelphia, Pennsylvania Many techniques have been employed to detect symptomatic ref l~x. Recently, we have adopted scintiscanning techniques to the detection and quantitation of G-E reflux. This exhibit will be under four major headings: I. Symptoms of and diagnostic tests for G-E reflux: II. Technique of G-E scintiscanning. The sensitivity - of G-E scintiscanning will be compared to that of other diagnostic tests; Ill. Quantitation of G-E reflux. A group of normal subjects will be compared to patients with reflux; IV. Effects of therapeutic modalities used for reflux. Bethanechol, antacids, a combination of alginic acid with antacids and changing body position will be compared. BOOTH 717 DOES MAN HAVE TUMOR ANTIBODIES? National Naval Medical Center Bethesda, Maryland Radiographs will show unusual multiple Small pulmonary nodules from meta- static squamous cell carcinoma of the cervix. Tumor immunology, concepts of isoimmune response, photomicrographs and the gross tissue specimens are shown. BOOTH 718 DISCOVERY AND CLINICAL EVALUATION Norman E. Pitts, M.D., Allen P. Borger, M.D. Dept. of Clinical Research-Central Research Div. Groton, Connecticut This exhibit gives an overview of the process involved in the development of a new drug in the United States. It features an audiovisual presentation of the sequential discovery and development of a new antihypertensive agent, prazosin HCI. The research objective was to develop an agent which exerted its antihyper- tensive efficacy by arteriolar vasodilation. The search,was conducted in a novel chemical series, the quinazolines. Significant steps will be highlighted from discovery through clinical evaluation including biochemical/pharmacological goal of the research project, animal pharmacological profiling of the new agent, and the subsequent data which emerged from the NDA clinical, program. Visit the Exhibit PAGENO="0211" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14117 Charges of overprescribing are all the rage. But what about the equally dangerous tendency to underprescribe? Who is the "irrational prescriber"? It's usually said that be's the phy- sician who prescribes too much- whether it's oral hypoglycemics, minor tranquilizers, or antibiotics; whether for the wrong indication, with no indication, or in place of a safer, equally effective drug. The family physician's alleged propensity to overprescribe has provoked well- publicized investigations, both Con- gressional and clinical. But what of the other side of the problem-underprescribing? Do doc- tors sometimes prescribe too little? In interviews with experts in several specialties, CURRENT. PRESCRIBING found that the answer is yes. For many conditions, and with a number of drugs, MDs may be giving their patients therapeutic short change. Take pain, for example. Says Dr. John Bonica, professor and chairman of anesthesiology at the University of Washington and an internationally known authority on pain treatment: "Many physicians undermedicate with narcotics, especially in patients with chronic pain due to cancer and in those with acute postoperative pain. "This probably happens because our medical schools don't adequately teach the use of narcotics for clinical pain, either acute or chronic. For in. stance, they don't teach IV adminis- tration of narcotics, and physicians are afraid to use this route. B~ft with severe pain from a kidney stone a gallstone, or serious laceratio~ss, giv- ing a narcotic any other way is an er- ioc A subcutaneous or intramuscular dose is absorbed too slowly to reach a sufficiently high peak level. "It's true that serious reactions may occur with an IV dose-severe nausea, hypotension, hypertension, impaired cerebral furtction-but these are due to improper techniqt~e~ usual- ly too rapid injection. It's ~vonh re- emphasizing that in severe acute pain, this is the best and most effective route for the initial dose." Another mistake physicians tend to make, says Dr. Bonica, is prescrib- ing an analgesic on demand for chron- ic pain. "We've been taught to do it this way foc years, hut it actually fos- iers chronic pain behavior. In effect, Richard L. Peck Senior editor 1/76 Current Pr~sc,ibing 31 PAGENO="0212" 14118 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY The undermedicated society one rewards the patient for his com- plaints of pain. As for narcotics, they should be avoided in patients with chronic pais-except those with malignant disease. In suCh cases the narcotic ought to be given at fixed "S SI / ~ intervals and in sufficient doses to provide a steady level of adequate analgesia." Physicians are often overcautious in treating some childhood disorders, says Dr. Sydney Gellis, chairman of pediatrics at New England Medical Center and author of a widely used pediatric textbook. "Take salicylates for rheumatoid arthritis," he says. "Doctors are afraid of salicylate toxicity, but treat- ment may require doses as high as 1 ge/lb of body weight daily to be ef- fective. For assurance, blood levels should be taken, aiming at a serum level betweets 25 and 30 mg/l00 ml. "Meningitis is another example. Antibiotic doses ought to be calculat- ed according to the child's body weight, but often aren't. Instead, sub- optitnal doses are given." Another frequently underused drug in children, says Dr. Gellis, is peed- nisone (Delta-Dome, Deltasone, Meticorten, Orasone, Sterapred, et al). "The full dose is 2 mg/kg daily, and it should he given for severe asth- matic attacks or severe cases. of poison ivy or hives. But we often see family practitioners using doses of 0.25 tng or 0.5 mg/kg for these con- ditions, and that's not adequate. If the condition is severe enough tojus- tify corticosteroids, they should be given adequately. Otherwise, they shouldn't be given at all. "Phenobarbital (Eskabarb, Hyp. nette, Luminal, Solfoton) is under- dosed, too. Perhaps an eighth of a graits is used for an infant instead of the more appropriate quarter grain. Rather than quiet the child down, this only makes him more excitable." Finally, notes Dr. Gellis, there's the much discussed problem of pa~ tient noncompliance with antibiotic regimens. "Physicians tend to blame the parents ifs child doesn't complete the full 10 days of treatment in strep throat or otitis nedia, for example. But I suspect il's sometimes the doc- tor's fault for insufficiently impress- ing parents with the importance of compliance. He should do so not only verbally, but in written instructions. And he should make a point of telling parents that there's a way to get around the problem if their child re- fuses to take the oral preparation: They must bring him in for an injec- lion of long-acting antibiotic." Another physician who finds fami- ly practitioners sometimes erring on the side of caution is Harry M. Robin. son Jr., chief of dermatology at the University, of Maryland Hospital. "Many times we've seen cases of one of the reactive erythemas, such as erythema multiforme, in which we've really had to slug the patient with a huge dose of prednisone to overcome the basic problem. Their doctors had been using 10 to 15 tog a day, and we've had to triple or qttadruple the severe cases of bullous pemphigoid, pemphigus foliaceus, petnphigus vul- gain, and systemic lupus erythma- tosus. We've had patients come is completely denuded from some of these disorders, because they didn't receive a sufficiently high dosage of.prednisone. "Let's face it," continues Dr. Robinson, "when it conses to cases like these, some of the FDA-approved dosage recommendations are almost homeopathic. You can't send a boy to do a man's work." Depression No help at all is what too many phy- sicians give for depression, says psy- chiatrist Nathan S. Kline. In fact, Dr. Kline went so far as to catl depression "the most undertreated of all major diseases" in a 1974 JAMA article (227:1158, 1974). "The percentage of nonpsychiatrists attempting to treat depression is discouragingly small," Dr. Kline wrote, "and frequently treatment is not dose well." An ex- ample he cited was underdosisg-us- ing less than 25 tog of a tricyclic lid or dose-in fact, we've used as touch as qid [or less than 5 tog of nortrip- 100 to 150 tog a day. ` tyline HCI (Aventyl) lid or qid], or "The same thing happens with using whatever dose of a tricyclic for 32 Current Prescribing 1/76 PAGENO="0213" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14119 less than three weeks. Not everyone agrees completely with Dr. Kline. "I, for one, am not convinced that family physicians are equipped to treat depression as read. ily as Dr. Kline says they can," re- marks psychiatrist Daniel X. Freed~ man of the Pritzker School of Medi- cine, University of Chicago. "It's a `complicated matter, and most nonpsychiasrists need more training and readily available psychi. atric consultation to cope with these cases." But Dr. Freedman agrees that antidepressants are somCtimes mis- used by family physicians. "Hospital studies have shown that physicians tend not to monitor treat- ment closely enough, and that they don't tailor a drug regimen to the patient's needs. Drug therapy seems to be aimed at the average pa. tient, rather than the individual. The drugs are usually used when they're indicated, these studies show, but they're not used with enough care- ful thought. And some patients are undermedicated." Hypertension, of course, is the classic undermedicated condition, but physicians seem to be improving their performance with it, according to Dr. Richard S. Ross, president of the American Heart Association. He thinks physicians increasingly are treating mild and moderate cases, rather than waiting until the diastolic hits 115. Treatment ought to start at diastolic 105, according to the Na- tional Heart and Lung Institute, but Dr. Ross says that he and other phy- sicians regularly initiate treatment at 90 to 100 for some patients, depend- ing on such factors as age, family history, target organ damage, and cholesterol level. "In the last five years we've learned that there's no such thing as `benign' essential hypertension," says Dr. Ross. `We know that treat- ment of mild cases can reduce the in- cidence of stroke and cardiovascular- related mortality in later life." It's possible, though, says Dr. Ross, that physicians using informa- lion eight or ten years old are still treating only severe cases. It may also be that some physicians are discour- aged from taking on the extra burden because treatment, as Dr. Rosa puts it, "is a nuisance. You've got to do a lot of talking to convince a patient to take a drug that may make him feel worse to prtvent something hypothet- ical from happening. That's a difficult idea for some people to grasp." Of course, much hypertension goes untreated simply because people don't know they have it. But of the known hypertensirnes, according to the National Heart and Lung Institute, only one-fourth are getting adequate treatment. Doctors may be chang- ing that, as Dr. Ross says, but clearly there is plenty of room for improve- ment in this area. Antibiotics Even with that class of drugs that physicians are accused so often of overprescribing-antihiotics-there are occasions when they undermcdi- cats. "It's rare," says Dr. James J. Rahal Jr., chief of the infectious ctis- ease division at the New York (Man- hattan) VA- Hospital, "but it does happen-particularly with Group A streptococcal infections. Everyotte knows that streptococcal pharymogitis will usually respond to 125 to 250 mg of penicillin four times a day. So many physicians, when they see a strep infection like cellulitis, for example, think it wilt respond to the same small amount of penicillin. When it doesn't, they ask, `What clues this patient have? It can't be strep.' I used to do the same thing myself un- lit I got burned a few times. "Now, with really severe cas9s of streptococcus cetlulitis, I sometjmes have to give penicillin intravenously or intramuscularly, perhaps a half tuillion to a million units every four hours, and sometimes more," Dr. Rahal observes. These experts agree, then, that our supposedly overmedicated soci- ety is sometimes undermedicated. They're also in agreement about the remedy: Be confident of your diag- noses, know what the available med. ications can do (and package inserts aren't a/wa's a reliable guide), and tailor each prescription to the indi- vidual patient's needs. In so doing, you'll avoid the ranks of those irra- tional prescribers who are not cava- lier, but too cautious. 0 Undermedicated society: AddItional prescribing information For "ore irnformarior, on thenupesiho agents discussed is, this artic5e, see Physicians' Desk Reference, 1975 e5son. Nortrtptyftne P05 page Assentyt (Lilly) sn~,, Phenobarbitat Eskabarb (Sneth Kline & FrescO) 1383 Linninal (Werthrop) 1604 55115105 (Poyttnyss( 1193 P,ednlsone DoIta-Djnnnn (Dense) 741 DoIt.sssny (Upjohn) 1515 Menicor)es )Schenng( 1331 Orassrne(Roue(() 1291 1(76 Current Prescribing 33 PAGENO="0214" 14120 CO1~iflETITIVE PROBLEMS IN THE DRUG IN]iUSTRY Serotonin inhibitors, antihistamines, antidepressants, beta blockers -they're all in tbe new wave of `headache remedies.' text&test - Tre~me~ ~nd ~e~cn Headache sufferers are a desperate breed. Worn and confounded by their pain, they will ask for "something, anything" to relieve it, Happily, these days there are more remedies to offer them, Even for tnigraine, where the venerable ergot derivatives have stood almost olone, there are new possibilities. headaches and those with functional ones. Most patients are affected both by. somatic factors-tension in the muscles, vascular problems-and emotional factors. But regardless of the degree to which the psychologi- cal factors outweigh the somatic., all headache patients suffer real dis- comfort; their problems are not imaginary. Migraine CUTLER: Let's take the case of a 42- year-old woman who's had recurrent, severe, throbbing headaches for many years. They occur on one side of her head or the other, most often in times of stress. They're associated with nausea and vomiting, and preceded by flashing lights and diminished vi- sion on the side opposite the head- ache. They last for b to 12 hours. As a child, she was often carsick. And her mother used to have similar head- aches. What's the diagnosis, and what therapy would you prescribe. ALDREDGE: That's a classic history of migraine vascular headache ("Mi- graine's three phases," p 49), For with an organic basis generally have easily identifiable signs and symp- toms, and physicians can usually rule out hypertension, brain tumor, an- eurysms, and, meningitis by clinical observation, plus tests and x-ray films, when indicated, In fact, the vast majority of head- aches are functional and not associat- ed with organic brain disease. (The CUTLER: The most important thing is use of the term "functional," how- to identify the source of the headache. ever, doesn't negate the possibility For some reason, both patients and of some neurochemical basis.) These physicians tend to think first of or- headaches fall into four categories: ganic disease when they're looking migraine, cluster, tension, and tox- for the cause of recurring headaches. ic vascular. Dr. Fuller, would you As the sinuses, teeth, and eyes are agree? commonly implicated, many patients ~..FULLER: I don't think we should try to wander in vain from one specialist to make a hard and fast clinical dis- another seeking a cure. Headaches tinction between patients with organic Round table at the University of Texas Health Science Center at San Antonio Horatio R. Aidredge, MD Clinical assistantprofessorof neurology, division of neuroscience, department of medicine David S. Fuller, MD Associate professor of psychIatry, department of psychiatry Paul Cutler, MD, moderator Associatedeanforcontinuing medicaledacation, Everard J. Siller, MD professor and head, division of general internal Assistant prsfesssr of neurology, division of medicine, department of medicine neuroscience, department of medicine 46 Current Prescribing 4/76 PAGENO="0215" COMPETIT]NE PROBLEMS IN PEE DRUG INDUSTRY 14121 Migraine.. .and more be taken weekly. If oral medication is impractical, the patient can take one Cafergot suppository (2 mg ergota- mine, 100 mg caffeine) at the start of the attack and a second an hour later, if needed. Maximum is four to five per week. Still another ergotamine prepara- tion is Migral. Migral tablets contain I mg ergosamine, 25 mg cyclizine HCI, and 50 mg caffeine. Cyclizine is an antihistamine of the piperazine class and is noted for its antinauseant and antiemetic effects. It's most ef- fective when given in the prodromal phase; the usual dose is one tablet. For patients who have some in- or four times a day; or 1 nil (100 rng) - lM, repeated once its fourto six hours. Midrin, a product containing iso- metheptene mucate, dichloralpheiia- zone, and acetaminophen, is supplied in oral capsules; two capsules are tak- en at the onset of an attack, followed by one every hour up to an additional three capsules, with a weekly maxi- mum of 20 capsuleu.t In frequent, severe migraine, pro- phylactic treatment has to be coftsid- ered. The patient's tolerance for the attacks should guide you in deciding on preventive therapy. The most val- uable preparation is methysergide maleate (Sansert); dosage js one 2-mg tablet with each meal, up to four dai- ly- It may require two or three weeks for methysergide to take effect. It works by blocking the effect of sero- tonin, a substance which may be in- volved in the mechanism of vascular headache. Cyproheptadine HCI (Pen- actin), an antihistamine with mild to moderate antiserotonin activity, has also been used prophylactically, but may be only slightly more effective than a placebo.~ In addition, Bellergal, a combina- tion of ergotamine, belIadot~na alka- bids, and phenobarbital sodium, has been used for prophylactic adminis- ration, but I've not found it v~ery ef- fective for long-term use (prepara- tions containing ergotamine are prob- ably ill-advised for preventive or long-term use). To be fair, I must mention that many physicians have used it for years in the prevention of both migraine and cluster headaches. Pizotyline, which is closely related to cyproheptadine and is also known aa pizotifen or BC-lOS, is a relative- by new preparation sold as Sandomi- gran. It has had widespread trials in other Countries. Propranolol HCI (In- deral) has been reported effective pro- tlhe manufacturers suggested dosage limit is five capsutes within a 12-hour period. StJvrfor this medication has not hoes approvedby the FDA. acute treatment of vascular head- towed by one tablet every half hour aches, the most valuable drugs thereafter up to a total of six per at- are generally the vasoconstrictors. tack. No more than 10 tablets should They're most helpful early in the va- soconstrictive phase during the aura, but less helpful itt the vasodilatasion phase, when the full-blown headache has set in. The most useful vasoconstrictor is ergotamine tartrate, which is avail- able in parenteral form and oral tab- lets (Gynergen), in sublingual tablets (Ergomar), and its aerosol form (Mcd- ihaler-Ergotamise). The intramuscu- lar or subcutaneous dose is 0.5 to I cc at onset of attack, repeated in 40 min- utes, if necessary; maximum weekly dose is 2 cc. The average oral dose is two to six 1-mg tablets per attack, while the sublingual schedule is one Learn~ ob~cthCs * How to recognize the four basic types of headache * Causes of each headache type * How to treat and prevent migraine headache * How to treat cluster headaches * Use and limitations of psychotherapeutic aids * Role of food, drugs, and mood 2-mg tablet at the first sign of attack or tolerance for ergotamine, there's a as soon as possible after full onset, closely related preparation, dihydro- then one tablet as half-hour intervals; ergotamine mesylate (D.H.E. 45), if necessary, not to exceed three tab- which is usually given IM in doses up lets in 24 hours nor 10 mg a week. The to 2 or 3 cc per attack. injectable form is used most often and Another useful agent for treating seems preferable to me-oral therapy acute headache when ergotamine is may be ineffective because of the nau- inadvisable is the synthetic antispas- sea and vomiting that generally ac- modic isometheptese.° Single-drug compatsy the headache. products include Octin, available as When combined with caffeine, er- isometheptese mucate oral tablets and gotamine is siarketed as Cafergot, isonsesheptene HCI for IM adminis- in oral tablet and suppository forms. tration. Dosage is one tablet three Dosage foe oral Cafergot is two tab- *5J~~ for this ittdieation has not hero opproved by the less at onset of the syndrome, fol- FDA. 48 Current Prescribing 4/76 PAGENO="0216" 14122 COMPETITIVE PROBLEMS IN ~TIIE DRTJG INDUSTRY The third phase begins when edema of the opthalmic artery resuitsin a pounding headache with duller, steadier, more constant pain that's more diffuse in distribution, This phase may not always occur. phylactically in oral doses of 20 mg four times a day.s In my experience, however, it has been effective in only a small percentage of cases, Since depression may cause fre- quent, severe migraine headaches, prophylactic antidepressant therapy should also be considered to treat the underlying depression. We use the tricyclics, such as imipramine HCI (Imavate, Janjmine, Presamine, SK-Pramine, Tofranil) and amitripty- line HCI (Elavil, Endep) in preference to the monoamine oxidase inhibitors (MAOIs). CUTLER: Dr. Siller, you've had expe- rience with propranolol in migraine. Does it work well? SILLER: It's too early to tell whether it's effective. I'd use it only if stan- dard treatnsents don't bring improve- ment. CUTLER: Dr. Aldredge, you said that when a patient can't tolerate er- gotamine, you try one of the other agents. What do you mean by "can't tolerate?" `ALDREDGE: Ergotamine is a potent, long-acting vasoconstrictor, Many patients taking it experience not only~ gastric side effects, such as nausea and vomititig, but also paresthesias, muscle pain, or precordial pain, along with alterations of pulse and blood pressure. These are immediate con- trttindications to continued use. An- other is pregnancy, because the drug's a uterine stimulant. (Isometh- eptene, however, can be used safely in pregilancy.) Side effects have also been report- ed with methysergide. It's been at- sociateci with retroperitoneal, pleuro- pulmonary, and heart-valve fibrosis. Inseveral clinics with large series, it's been found safe when given up to six months, followed by periods of four tosix weeks off the medication. Con- traindications include peripheral vas- ~ foe this indication has not been approved by the FDA. Mi~th~e's t~r~ phases The initial phase is characterized by constriction of the ophthalmic artery, branching from the internal carotid artery andtransversing the optic nerve. Resulting ischemia causes central scotoma. In the second phase, the same artery is dilatated, and the patient experiences a throbbing, pounding headache. ________ _____- 4/76 current Prescribing 49 PAGENO="0217" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14123 Migraine.. .and n~iore cular disease, coronary heart disease, severe hypertension, and liver attd re- nal disease. CUTLER: Some patients insist on morphine sulfate or meperidine HCI (Demerol) for prompt relief, claiming that nothing else helps. They want to be "knocked out" and do seem to get good results. Why not use these agents? ALDREDGE: Occasional use of such agents for acute headache is accept- able. But I prefer vasoconstrictors, especially if attacks occur monthly ot- mote often, and there's no contrain- dication to their use. CUTLER: Wttat kinds of people get nigraine headaches? FULLER: Compulsive, perfectionist- ic, ambitious, intelligent people who have a lot of drive. They often have attacks as they let up after achieving one of their goats. Onset common- ly occurs on weekends or holidays- early or late in the day-when pa- tients are relaxing from their chronic tense state. CUTLER: How would you treat a pa- tient who gets migraine headaches for psychological reasons? FULLER: It's usually not feasible to try to change the persotsality of com- putsive, hard-driving, tense individu- als. It is helpful, however, to respect such patients for their usually superl- or intelligence and to fill th~m in on what's going on. Explaining things often pays off with the obsessive- compulsive. CUTLER: Foods cause migraine, too, don't they? SILLER: There's evidence to support this premise. Most patients for whom it's true tell you spontaneously that they have to avoid certain foods. If they don't, run through the list of foods on page 51 with them and see if they can conned any with their head- aches. Then restrict the implicated foods. * Many of the foods listed contain ty- ramine, which is dangerous not only * to patients prone to migraine bttt al- so to those taking MAOIs. Migraine patients are also very sensitive to the flavor enhancer monosodisim gluts- nate; some may even be prostrated after eating a Chinese dinner that's been "enhanced." Another rstle is to avoid cured meats and hot dogs. Sodiutn nitrite, a food preservative, is the offender and causes "hot dog headache." ALDREDGE: Going through this itt is more diagnostic thatt therapeutic. Very few headaches are clearly litiked to specific substances. If patients can associate one or Iwo foods with their headaches, this strengthens a diag- nosis of vascular headache. SILLER: One other point concerning food: Patients who tend to become hypoglycemic should eat three well- balanced meals daily, avoiding large quantities of carbohydrates. Low sug- ar threatens the integrity of braits neu- rons and may cause dilatation of the intracranial vasculatstre. CUTLER: Do oral cotstraceptives play a role in vascular headache? ALDREDGE: Probably. If your patient develops headaches when she's on the Pill, or if her pretnenstrual headacltes M~ç~jr~ne dr~: Your opt~o~s * Vasoconstriclora Ergotamine preparations tsometheplerte preparations' * Drugs that simulate action of serotonin on receptor sites, acting as competitive serotonin inhibitors Cyproheptadine HCI (Periactin)' Methysergide maleale (Sansert) Pizotylene or pizohiten (Sandomigran)' * Beta-adrenergic blocking agents, which prevent vasodilatation by acting on blood-v~sset receptors Propranolol HCI (Inderat)' * Drugs preventing depletion of vasoactive amines (catecholamines and histamine) by interfering with the action ot their deactivating enzymea:t Monoamine oxidase inhibitors Isocarboxazid (Marplari) Phenelzine aultale (Niardil) Tranylcypromine sulfate (Parnate) Tricyclic antidepressanta lmipramine HOt (tmavate, Janimine, Presamine, SK-Prnmine, Totrunil) Amitriptyline HCI (Elavil, Endep) `The FDA has not approved use iv migraine. tlhesedrugsare usodtotreattheunderlying ddpressionotmigraine, autthemigraineitselt. 50 Current Frescribing 4/76 PAGENO="0218" 14124 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY worsen, the drug should be stopped. She may be one of the patients in whom OCs allegedly cause stroke. Cluster headache CUTLER~ A 52-year-old man com- plains of a severe, unilateral, burning headache. It lasts about an hour, oc- curs frequently for a few weeks, and goes away for a year or more. It's as- sociated with marked tearing and con- siderable pain in one eye, and runny nose on the same side. There are no preceding netirotogic or eye syrup. torus. What does he have, and what do you do about it? SILLER: This is a cluster headache. Typically, an adult man is awakened every night for two or three weeks by the most severe headaches he's ever experienced. Some patients are jolted out of bed before they fully wake up. Then the headaches go away for per- haps a year or a year and a half. Cluster headache is a type of mi- graine; it's also called Horton's head- ache, after the physician who de- ncribed it, or histamine cephalalgia, after the substance thought to cause it. Many physicians still carry out his- tamine desensitization with patients suffering from this syndrome, though it's probably not indicated. Remem- ber, though, that the man with a clus- ter headache is probably sensitive to many vasodilative substances. Hista- mine desensitization may remove at least one from the list but you can't desensitize him to all vasoditators. The treatment of choice is ergota- mine, the same as for ordinary mi- graine headache. This drug is particu- larly suitable because a patient is usu- ally awakened at nearly the same houe each night. Tell the patient to set his alarm clock so he asvakes an hour be- fore he customarily is aroused by the headache, and to take two l-tssg tab- lets. He should do this for several con- secutive nights. This regimen usually averts the cycle and wins you a friend for life. CUTLER: Building up the dosage and tolerance of histamine has been the treatment of choice for many phy- sicians, and I've used it until today. Now you're telling me that this course really doesn't do much good and that we should treat cluster headache the same way we treat migraine. ALDREDGE: That's correct. CUTLER: What about breathing 100% oxygen for three to five minutes to re- lieve cluster headaches? ALDREDGE: You can often-though not always-get beneficial results with oxygen. Breathing pure oxygen may decrease COs, p~oducing central cerebral vasocottstriction. CUTLER: What about interval treat- nsent to prevent cluster headaches? SILLER: It's unnecessary and ineffec- tive. Treat the acute sitUation only. Tension headache CUTLER: Now let' stake up the case of a 56-year-old woman who has an al- ~o~d c~i b~ ~t 1~a~t If your patiertts can associate their headsches with any specific foods, restricting their diet may hotp. Here's a checklist of foods frequentty impticated: Food Cnusattve agent Alcohot, particutarly red wines and Histamine, tyramine champagne . . Strong or aged cheese, snpeciatly cheddar . Pickled herring . Chicken ttvers . . - Tyramine . Canned figs Pods of bread beans Chocolate Fish, especially smoked fish Dairy products Eggs Unknown Wheat Nuts Tomatoes Cured meats-such as hot dogs, bacon, Sodium nitrite ham, and salami Certain snack foods Chinese food L Monosodium J gtutamate 4/76 csrmsst Prescribing 51 PAGENO="0219" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14125 Migraine.. .and more most constant headache occurring all over her head. l'here are no prodro- mats. The pain is dull and feels like a constricting hand. She can sleep, hut when she wakes up, the headache is sttll there. Occasionally she has iau- sea and even vomits. What are we dealing svith, and how can we help? FULLER: You've cited a classic exam- ple of tettsion headache, probably the commotsest type of headache. It's mediated most commonly through in- creased tension of the posterior neck muscles, especially in association with psychological stress and unex- pressed resentments. Many patients with tension headache don't go to a doctor-they take over-the'counter analgesics. It's important to evaluate the head- ache patient for serious underlyittg psychiatric problems. Is he anxious? Depressed? Schizoid? Schizophren- ic? Treatment varies accordingly. A checklist designed to elicit pertinent psychiatric inforttiation is helpful: o While taking a history, try to determine your patients' personality configuration by observing their habitual pattertis of behavior and the coping mechanisms they repeat- edly use. The hysterical patient uses re- pression, suppression, and denial- often unconsciously and in a childlike manner playitig a role such as that of a sick person or even a sgxy doll- to avoid unpleasattt tealities and responsibilities. Obsessive-compulsive patients have great difficulty in exprqssing and dealitig with hostility and affection. Spme may be distrustful and ar~gry, maintaining a constant vigil for others who may do them harm. Finally, among other identifiable personality configurations, there's the long-suffering, self-sacrificing martyr who uncottsiously enjoys suf- fering. 0 Evaluate the patient's overall cop- The many wt~es o~ ~o~1c uasc~ar I~eadache * Febrite illnesses Infectious mononucleosis Influenza Malaria Measles Mumps Pneumonia Poliomyelilis Septicemia Tonsillitis Trichinosis Tularemia Typhoid fever Viral hepatitis * Other conditions Alcohol hangover Hypoglycemia Hypoxia (especially with rising Pcoa) Withdrawal from drugs: ergot (especially after prolonged treatment), caffeine, amphetamines, phenothiazines * Poisons Benzene Carbon monoxide Carbon tetrachloride Insecticides Lead * Other substances Alcohol Barbiturates Hydrelazine HCI (Apresoline, Lopress) tndomelhacln (Indocin) Monoamine oxidase inhibitors Monosodium glutamdle Nitrates and nitrites Oral progeslationat agents Oral vasodilalors Tyrarnine ing abilities, Does he adapt well undeC a variety of circumstatices or fall apart under minor stress? o Determine how well your patient relates to the people in his life. Does the person have meaningful relation- ships with relatives, friends, and with you? o It's especially important to deter- mine how well patients deal with the anger that accompatsies frustration. o Look for the areas in wltich the pa- tient is most likely to be experiencing life stress. In working txsen attd wom- en, sttspect a job situation; in hotise- makers, it's likely to be interpersonal conflict with family members. o Finally, do a quick evaluation of mental sthtus. First determine your patient's mood. Of course, it isn't always obvious-depressed patients don't always come in crying and say' ing they're sad. Instead, a patient may say, "I'm tired. I don't have any ener- gy. I wake up in the tniddle of the night.' Indeed, the depressed petient often has multiple somatic concerns. Take note of your patient's ~ensct- rium. In he confused or disoriented? DOes he have difficulty remember- ing recent events? Such a patient may have a major neurological probletn. Actually, many people who complain that they can~t remember are depressed, snd tf~ you check, you may find that their memories aren't impaired. * Evaluate your patient's intelli- gence. People with low-normal intel- Iigence-lQs of 85 or 90-may find it difficult to carry heavy respOnsibili- ties, This is especially true of patients who have large families. Finally, in evaluating mental sta- tus, attend to your patient's thought processes. Consider the possibility of schizophrenia. Studies of the nsost re- fractory headache patietsts have re- vealed people with very poor coping abilities-even psychoses. CUTLER: How do you select the prop- 52 current Prescribing 4/76 PAGENO="0220" 14126 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY er therapy for the patient with a ten- sion headache? FULLER: First, use your knowledge of the patient's personality to es- tablish a cooperative and support- ive relationship with him-this helps the patient's usual coping methods work better. For instance, bright ob- sessive-compulsive patients should be given informative explanations. With the hysteric, on the other hand, the doctorshould respond to the patient's need for security and atten- tion. The martyr should be given rec- ognition for his or her suffering, but should be challenged to work toward recovery rather than coddled. And with the distrustful, angry patient, try not to argue, but don't ignore the patient's complaints. After establishing a therapeu)ic relt~ionship, you can apply specific therapy to patients with particular clinical findings. You can usually helpbasically mature but acutely anx- ious headache patients by doing a good evaluation to rule out organic disease and offering reassurance that there's no serious medical problem that requires attention. Anxious pa- tients are most likely to benefit from minor tranquilizers, such as diazepam (Valium), 2 to 5 mg or up to 10 mg four times a day, or chlordiazepoxide HCI (Librium), 5 to 10 mg four times a day. Aspirin, alone or in conibi- nation with phenacetin and caffeine, or with a barbiturate-or all four in a Fiorinal-type product-is al- so stseful in tension headache. Matty depressed patients can ben- efit from tricyclic antidepressaists. Amitriptyline, because of its greater sedative effect, is especitilly helpful for patients who are bothered by ten- slots and agitation. For a depressed patient who's ancrgic atid lacks rnoti- vation, a better choice is itnipramine. You can give supportive psycho- therapy to some depressed patients, helping ttteni to express their resent- went and hostility and to feet com- fortable with these emotions, or to ac- cept giving up a cherished goal. How- ever, some severely depressed pa~ tients should be referred to a psychia- trist, especially if you suspect suicidal tendencies. Patients with long-standing, severe hypochondriasis are difficult to deal with. Most of them have problems be- sides headaches. Support these pa- tients, accepting them as people who feel deeply irtadeqstate and who tteed their headaches and other complaints to express their feelings of inadequ~- cy and hostility. Don't try to talk svith them too much about what's going on psychologically in their lives. Hypo- chondriacs often aren't psychologi- cally orietited, and they adapt best ~ecc~ op~tm In my experience. ergotsmines have no role in the treatment of cluster headache. In advocating the use of these drugs, Dr. Sifier says that `a patient is usually awakened by a cRater headache] at nearly the same hour each night. Actually it's extremely Un- usual for cluster headaches to occur at such specific time intervals. Whets more, most cluster headaches last only 30 minutes, and it would false longer than that for ergotamine medications to be helpful. As a rule, it's the cluster headache rather than the classic or common migraine that's most amenable to treatment with prophylactic medications. t believe that most physicians who treat headaches prefer to use methysergide maleate (Sansert) in cluster headache. However, it would seem that propranolol HCI (Inderal) may someday prove to be equally effec~ tive while having fewer potential aide effects. agree that breathing 100% oxygen is extremely beneficial therapy in cluster headache patients. A number of my patients keep an oxygen cylinder at their bedside to abort a middle-of-the-night attack. Also unmentioned is a precipitating cause for clus- tar headache. In my experience, alcohol and iitre- glycerin preparations are classic examples. As a matter of fact, sublingual nitroglycerin (Nitroprn, Ni- troatat) has been used diagnostically to precipitate a typical cluster headache-in about 45 minutes. Finally, while I agree that narcotics should usually be avoided in severe migraine headaches, I disagree that ergotarnines are helpful. In my experience, the ergotamines have no role in the treatment of severe headache accompanied by nausea and vomiting. tndeed, they may only make the patient sicker. In- stead, I've found that chlorpromazine (Chlor.PZ, Promachel, Promapar, Sonazine, Thorazine) is the most helpful therapeutic agent: 75 mg IM usually stopsthe nausea and vomiting, aborts the headache, induces sleep, and avoids the problem of potential drug abuse. In some patients, I have equally good results using 100-mg rectal suppositories of chlor- promazine (Thorazine). Charles 0. Rev!, MD Oahsner Feandatien Hasp/at New Orloana 4/76 Carrent Proscribisg 53 PAGENO="0221" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14127 Migr~e5. .and r~ore by being physically sick and seeking medical assistance. You can be of great help, especially if you don't try to rid them of their symptoms. Finally, headache patients who are schizophrenic are likely to benefit front an antipsychotic agent such as haloperidol (Haldol) or a phenothi- azine such as chlorpromazine (Chlor- PZ, Promachel, Promapar, Sonazine, Thorazine). Consider hospitalization only for those who are likely to ben. efit from such treatment or who can't adjust outside such a setting. SILLER: Underlying depression is by far the most common cause of fre- quent, recurring headaches of all sorts. For this reason, the Iricyc- lies are among the most valuable treatments. Toxic vascular headache CUTLER: Now, there's still another kind of headache besides the ml- graitie, cluster, and tension types- the toxic vascular headache. I lump it with functional headaches, as it's not usually associated with organic brain disease. SILLER: The common denominator is intracranial vasodilatation. Anything that dilates the large vessels at the base of the brain--for example, exercise, febrile illnesses, or drinking too much alcohol-can cause vsscu- Jar headache, sometimes as severe as migraine headache. (Not all morning- after headaches are the result of its- tracranial vasodilatation, however; some may be due to depression about having rode a fool of oneself the night before.) Hypoglycemia atsd hypoxia also threaten the integrity of the brain and cause vasodilatation. The challenge lies in finding out why the patient became hypoglycemic or hypoxic-not simply in determining that headache results front one of these conditions. Of course, head- aches due to encephalitis or menin- Headache patients--perhaps tc'ore than any others--abuse analgesics. When they have fiequent recurrences, they tend to take larger quantities of drugs that have serious side effects. For instance, nielhyncrgdo msleate (Sansert) may cause fibrosis, white certain artatgesics in large doses over a long period may cause renal dnmage. Aspirin causes St bleeding. Ergot compounds provoke ergotism and may precipitate or worsen angina end peripheral vascular disease. Of coutse, narcotics aro to be avoided because it's so easy for a patient with chronic headache to get hooked on mepetidi'ne HOt (Ds- merol) or morphine suliato. A physician should be especiully cautiouS with patients who say their headaches are never relieved by anything but a shot at morphine. Cutler Headaches: Additional prescribing information ttydnalaoine HO Ap,eso(,ho (chat Rot mute otoonahoo oo tbo'a~ect'n 6705$ d'sc.~ssnd 0 ho alOe see Ph~sv'ars ness Retoootoce. t97eed,oo,, Am)t,lplyl)*te Hel POe page Elavi (Me'uk 5h~tp & Oohme( 1070 Belladonna alkaloids, phenobonb)tel, and e~gstam)ne tantrata Hellotgal (000sey) . 764 ehlotd)azepnoldn HO L,bts,e Rode) 1290 Imtpramlee Hel En,a~ate )Robos) .lao~otoe (Abbott) Pce~am,ey 1350 Phatmaceyt,cal) 56.Pranooe (Sooth KAte & Ftsoch) te,'nonl )be'ey) tadomothauln bodocto (Meock Ohatp & boson) tsocarboxaald Marp(ao (Roche) 71)5 1263 523 14)8 827 1074 1292 858 she Isametheplone HO Ocnie Knoll) chlorpremacine cnat.w usv r'hatacev'cal) Thotaz,e (Sm,tl, 6580 & Fte,,ch) cyproheptadlne HO Per,aot,o (Mock SAttp & boOne) 1548 1457 tsemethopta,ne ,nocate Ode )Koo(t) Dlazepam Val,um (Roche) Dlhydroergotamlne mesylate tO HE 45 )5o~o)oa) tsometheptene macate, 1080 dictdoralphenazOne. and auetan~lnophen M.cetn )Ca,or~ck) 1357 Mepenldlna HO Deme'o) (W,nthtop) 0344 MHlhysarglde maleate 5,s-nse,t (Santlon) NitroglycerIn, sobllngoat Nnnostat )RetkeDacls) Engotamlne tant,atn Etgo'oat )l5~oo~) 505 Cyncrace (Soose) 1345 Ergotamlnc ta'l,ate and caffeine calegot )S000e) 1342 653 1654 1349 1158 1)128 591 1438 E'gota,n)ne tantrate, cyulIzlne gel, and Cafle)no M,~tal )8uttou~hs Weiloome) 678* Haloperldol Hal'Jol (MoNo)) 1011 Phenelzlne soltata 1s.,'at~l )W4'.',.~ Ch,lcott) Psopranolol HO lr*dota( lAyRtst) Trantytcyptomlna auffale lunate )Sn,o1, K(,t,o & `tend),) 54 Cunrenl Prcscnibing 4)76 PAGENO="0222" 14128 COMPETITIVE PROBLEMS IN THE DRt~G INDUSTRY gitis are actually organic in origin. CUTLER: Do YOU ever have difficulty with rebound headache phenomena following vasoconstriction? SILLER: Rebound usually occurs in patients taking ergot every day to avoid a migraine headache, or tak- ing more ergot thata they shostld. After the vasoconstricting drug is removed, rebound occurs, and patients may have the most devastating headache of their lives. 0 SUGGESTED READING * t)ian,end n. lakes Bi, Lecire NW: A resieo of the phae,nacotogy at doses used is therapy of eriurase. Headache 2:37, t972 * Datessio Di: Dietary oeigeaine. An Fate Physician 6:6t, t972 * Rest CC: Diagnosis and managemeetof commenheadachepeebteres. ModTeeae8:23t, t97t. This program is acceptable by the American Medical Association for one hour in Category 1 toward a Physician's Recognition Award. Familiarize yourself with the text, then take this test. Fill out the answer sheet (p 60) and mall it in with $5 to cover administrative cost, computer time, and the expense of mailing back the answers. You'll get a complete set of an'swers, notification of your grade and credit, and a printout of questions missed. Test answers will not be printedin CURRENT PRESCRIBING,SO please save the entire Text & Test section for reference. ONE: A 48-year-old executive suffers typical migraine headaches every two to three mouths. Your first treatment should he: A Tranquilizers B Antidepressants C Ergotamine tartrate or dihydroer- gotamine by injection when he gets the first indication of att attack D Meperidine l-lCl injection tim and insttuctions to go to bed E Ergotamine tartrate and caffeine tablets, four at once, thett otte tablet every half hour until ten are taken Two: The same patient, who got good symptomatic relief froto yottr treat- ntent, returtts two years later because his headache's have increased in fre- quency. They now come once or twice a tnonth. A careful history rules out underlyitig depression, orgattic disease, and relation to specific foods. You would now: A Contittue tlte same mattagetrtent because it's effective B Start methysergicle, 2 tog lid C Start propratsolol, 20 mg qid D Give a tricyclic antidepressatit even though there's no clear-cut evi- dence of depression E Prescribe Retlergal lid THREE: Yottr patient is now 56 and president of his cotnpany. He's on preventive therapy, but still gets two or three attacks per year. During a re- cent physical exatrt, he cotisplaitied of chest pain and intermittent leg pains and appropriate studies confirtnecl an- gina and claudication. For his head- ache attacks, you A Cotttinue the same matiagement B Cut the dose in half C Change to oral isometheptene D Give meperidine by injection and - send him to bed E Start psychotherapy FoUR: You see a 42-year-old man with typical cluster headaches: l)urittg cacti two- to three-week cycle he awakes nightly with an excruciating headache. Last night he had his first headache this year. Yottr advice is: A Take a sleeping capsule each night B Start histamine ddllensjtizatjon P Take dihydroergotamine at the onset of each attack D l'akc two ergotanniae tartrate atid caft's'itie tablets an tour before the predicted onset of the headaclte E Drink Iwo outtccs of alcohol at bedtinte FIVE: A 65-year-old wottian coto- Plains of alrtiost cottstant lteadachcs. They feel like a tight batid, are partly relieved by aspirin, hut seeni unrelat- ed to anyttiitig she does or eats. Ap- propriate examinations rule out an intracranial organic disease. She doesn't seem to be anxious, but she's depressed and is tired. If sIte has no orgattic disease, the treattoetit of choice is probably: A Diazepam, 2 to 5 tog lid B Amitriptyline, 25 tog lid C Aspirin 0,6 gm qid D Itiiipraniine, 25 nig lid E Either B or D Six: Concertiing birth control pills and their relation to headache, which of the following statements is false? A Patients with headaches shouldn't take the Pill B Patients who develop headaches after starting the Pill should slop oral contraceptive therapy C Patiettts with headaches that seem Id be made worse by the Pill should stop oral cotttraceptives D The eliologie relationship be- tween birth control pillsand head- aches hasn't been definitely estab- lished SEVEN: A 48-year-old man suffers from typical cluster headaches once or twice yearly. The last episode ended a week ago. He would like very much to avoid another series. Yott advise: A A series of histatrmine injections B Methysergide ftir prevention C Nothing D Avoid coffee, tea, cola drinks Conii,muecl ott page 58 4/76 Correct Prescrtbing 55 PAGENO="0223" C?1 ~ ~ ri ~ a 0 L~J 0 0 C) 0 PAGENO="0224" 14130 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY M~~1 ~ ~ .t~ by the editors of PRIVATE PRACTICE Increasingpressure on the Oklahoma State Legislature to repeal Oklahoma's strong anti-substitution law had doctors worried. "When I write a prescription for one of my patients," Dr. Orange Welborn of Ada, Oklahoma, told PRIVATE PRACTICE, "I want him to get the exact drug I prescribe -not a cheap generic some bureaucrat in Washington claims is equivalent to the brandname I have used and trust." But lobbying by labor unions, consumerists, and retired people's groups - using the chimera ofreduced prescription drug costs - was getting close to success. Soon, Oklahoma doctors might have their prescriptions changed and generic drugs substituted without their or their patients' knowledge. So instead of wringing their hands, the Pottawatomie and Pontotoc County Medical Societies and Pharma- cists Associations decided to do something about it. With the help of tlse Congress of County Medical Societies, they launched a massive media campaign in their Oklahoma counties - using `l'V, radio, and newspapers - to stop the repeal ofthe anti-substitution law. So far as PRIVATE PRACTICE has been able to dis- cover, this campaign is unique in Anserican medicine. "We know constituent lressure does influence legislators as nothing else does," Dr. Welborn said, "anti we are mobilizing the voters - our patients - througls advertising explaining that drug substitution can hurt their health. Believe me, the results so far show that the politicians listen, and listen very care- fully." A~e~ll~dIrr~3 `~ Ta I~IARCH 1976/PRIVATE PRACTICE 5.1 PAGENO="0225" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14131 THE RISKS OF SUBSTITUTION Dr. Francis A. Davis, chairman of the Pottawatonsie County Medical Society's legislative committee, noted: "If all the chensically identical medicines avail- able for substitution were really the same, there would be no danger to our patients at all. Butjust as a diamond and a chunk of coal start with the same chemical composition, and wind up completely different, so do medicines. "Those differences are enough to kill our patients or to cure them or to make them sicker or to make no difference at all. Substitution plays Russian roulette with our patients' health, and we just aren't willing to sit hack and let it happen." "One of the most serious instances," added Dr. Welborn, head of the campaign for the Pontotoc County Society, "concerned digoxin. In tests, equal dosages of different manufacturers' digoxin were absorbed at startlingly different rates. In some cases, myocardial infarctions and deaths resulted. Lanoxin avoids these troubles. And if I prescribe Lanoxin, I don't want a generic digoxin substituted. If drug sub- stitution becomes law, I'll have no way of knowing what my patients eventually get." "The quality of medic:sl care is certain to deterio- rate," says l)r. Davis, "if the I)h~'sirian'S choice of therapy is subject to economic considerations oser purely nsedical ones. In flict, the judicial Council of the AMA has held that `the physician has an ethical re- sposissbility to assure that high-quality products will he dispensed to his patients. Obviously, the benefits of the physician's skill are diminished if she patient receives (lrugs . , . of inferior quality.' If a doctor cares about Isis patients aisd cares about the quality of medicine he practices, he insist work to stop drug substitution." DOES SUBSTITUTION SAVE MONEY? Proponents of drug substitution say it would save substantial sums of money for patients, but Roy Kelly, MD, of Shawnee, Oklahoma, disagrees: "Studies have shown that generic substitution svould save patients 1.7Řon the dollaratmost, And, in fact,in Saskatehsewasi, Canada, prescription prices rose an average 19% after substitution was enacted, probably because pharnia- cists' malpractice premiums went up so much. In Kasse County, Illinois, doctors and pharmacists tried sub- stitution. The experinsent was ended after fifteess months, because patients didn't save any money." The anti-substitution campaign ended with a two-hour movie, and the commercial breaks were used to answer viewers' questions on substitution. During a segment of the movie, moderator Orange Welborn, MD (third from left), confers with Francis A. Davis, MD, president of the Congress of County Medical Societies (fourth from lef I). The other panel members are J. B. Wallace, MD (far left), William Bryan, RPh (second from left), and Gordon Richards, RPh (far right). In the background, members of Dr. Welborn's office staff have telephoned questions from viewers. 135 were received. ~ it :,, 7',. /1 7 73-617 0 - 76 - 15 PAGENO="0226" 14132 COMPETITIVE PROBLEMS IN PH~ DRUG INDUSTRY Cordon llich:uds, 111Th, of Shawnee, told P1tIVATE PRACTICE: "1 tel ny customers that tlieyve got to renieinlier that todays ned cat ions are more 1)oWerful than the~' used to he. So while individual tal `lets or capsules mae cost more, it takes fewer to treat then,. Because of this, the average dosage price has gone down, not ~`P, since 1960." PHARMACISTS ALSO OPPOSED TO SUBSTITUTION The American Pharmaceutical Association has heen pushing hard for substitution since 1970, even though it was instrumental in getting anti-substitution lass's passed in the early 1950s. Because of the APhA, many think that all pharmacists svant substitution. But ethical 1)haruacists do not, aod the t'ottawatoniie and Poototoc County Pharmacists Associations joined their medical colleagues in fighting it. Adds pharmacist Biehards: Drug sul)stitution is had for the prescriber, for the pharmacist, and, most of all, for the patient. I am completely opposed to it." The pharmacists scientific training makes him realize all the factors that can make chemically e(lual dri.igs act differently in the l)Ody. In my day-to-day dispensing, I have seen the unsatisfac- tory results of one drug, as compared to a similar drug, in the experience of my customers," said another I)harrnacist. `Drug substitution severs the lines of coinmuniCa- tion between the pharmacist and physician," said Mr. Richards. "It eliminates the `teamwork' lrom the health-care team by taking the physician out oftlie final choice of the drug to l)e used, \Vhen the pharmacist and physician work independently rather than together it is the patient who suffers most. It is in the best interest of the patient for the l)harfllaCist to consult the physician before isiaking any changes in the prescription lfdrug Sul)stitution were legalized, neither the physiciaa nor the patient could be certain that a prescription was dispensed exactly as written, it is important that the doctor and patient have confidence that the medicine dispensed was what the doctor intended." ADVERTISING In the Autumn of 1975, representatives of the two county medical societies net in Oklahonsa City with the Congress of County (continued on page S-4) I - `I J )`~ I) ` ,~ Ed-" )~ /1'.', `I,,, A doctor's office (above) and a pharmacy (below) during the anti'substitution campaign. \ 5, \(,\ \ ~ * AU if ~ ~ ~ `i/El 0 1':'. `~, I) MARCH 1975/PRiVATE PRACTICE S-3 PAGENO="0227" COMPETITiVE PROBLEMS IN THE DRUG INDUSTRY 14133 (continued from page S-3) Medical Societies and a wellknown local advertising agency, Adsociates. Out of the meeting grew the indepth TV, radio, and tews paper effort to stop substitution in its tracks. Working closely with physicians in l)ri\'tte practice, Berry \Vheeler, president of Adsociatcs, and his sttfi', crafted six full-page newspaper advs'rtiseiients, three T~ spots, and two radio spots (see Appendix) l)uring the five weeks, the full-page newspaper ads appeared regularly in the daily newspapers of the two counties, accompanied by good editorial support. `The 60-second radio and 30-second TV spots were used sparingly at first, and built to a crescendo during the last week. All told, the advertisements appeared on radio 700 times, on `IV 99 times, and in newspapers, 28 times. Each ad was designed to create interest and action. People were given a local phone number in each county, manned 24-hours a day, seven (lays a week, to call for information. Everyone who wanted more information wits sent a pamphlet, "Why Prescription Drug Substitution is Bad Medicine for Oklahoma," written for lay people by Francis A. Davis, Ml), and Gordon Richards, RPh (see Appendix), which con- tained a card to fill in and send to local representatives. Some people wanted to protest immediately to their legislators, and so cards were sent in their names by the two county medical societies, As a backup, every doctor's office and pharmacy in the two counties hada large counter card ott prominent display, headlined: "Oklahomans, Help Yourselves! Stop Prescription Drug Substitution Before It Becomes Law!" in two pockets at the bottom ofthe card were the Davis-Richards pamphlets and pre-stamped protest cards. The last night of the campisign, Saturday, Februtsry 21st, two hours of'FV time were l)urch.tsed for a stovie - T/te Brueos, starring George Peppard andl the 20 minutes ofc'otstmercial breaks were used to take phone calls front patients about tlse issue; a panel of doctors and phartacists answered their questions, telethon- style. POLITICS AND MEDICINE DON'T M~X Since the March iseue of PRIVATE PRACTiCE had to be at the printer before the fittal results were in, they will l)e reported iii our April issue. But there is enough evidence to support Shawnee's I)r, Leon Combs, who called the effort a "real success." Other county societies in Oklahoma are gearing up to repeat the S'4 PRIVATE PRACTICE/MARCH 1076 campaign )n their kreas, if necessary. But there is no doubt tlsat in the population of Pottawatomie and Pontotoc Conisties, some 70,1)00, thousands of peoplç' lsav~ becosse militant substitution-fighters. Many pro- td-st dardls and letters hit the State Capitol, causiasg quite a stir, and l)robably killing ~irug substitution in Ok- lahoma for the foreseeal)le future. The people agreed with the cuts/paign's slogan, "Politics and Medicine Don't Mix." Interestingly, older people ledI its number of protests, giving the lie to lobbyists wlso claim tl~at retire(l people support substitution, One letter from a woman in Shawnee to her state legislator read; "I am gravel)' concerned about the bill before the legislatitre which will permit (lrug stth- stitution for the person preceding a prescription from his or her physician to a drug store, "1 fe0l this is a very dangerous bill and could have far reaching effects on the individual patient, t have a chronic ear condition and the particular drug gre. scril)ed by my physician is quite effective in giving relief, If I should have this drug substituted it could increase the infection or tven might cause loss of hearing, In fact, this particular bill seems to be the rpost dangerous legislation which has been presented to the legislature, "Please exert every effort to defeat this particular bill and you will certainly have contributed a great service to all the people in your district," THE FUTURE "Now that we k~sow this kind of approach works - and works well," notes Dr. Combs, "we're ready to shat'e it with all the other county medical societies in America. Any county society wanting to run a similar canspaign will lsave to pay only for the media time - the Pottasvatomie and Pontotoc County Societies will supply video tapes, audio tapes, arid newspaper mats for free. Any county society that wants nsore infornsa- tion can write to the Congress of County Medical Societies [3037 Northwest 63rd Street, Oklahorna City, Oklahonsa 73116] or Adsociates [5929 North May Avenue, Oklahom,s City, Oklahoma 73112]. "Bight now our societies and the CCMS arc *orking to design a media campaign against the dissster of National Health Insurance for use in selected Con' gressional dlistnicts, The socialists haven't won this battle yet." PRIVATE PRACTICE will be reporting on this soon. 0 PAGENO="0228" 14134 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY I Here follow the texts of the anti-substitution pamphlet, and the radio and TVspots, along with actual reproduc- tions of the full~page newspaper advertisements, that were used so successfully in Oklahoma. Newspaper mats, video and audio tapes, and the rights to the pam- phlet, are available to any county medical society wishing to sponsor a similar campaign, tree of charge. Write to the Congress of County Medical Societies, Inc., 3037 NW. 63rd St., Oklahoma City, Oklahoma 73116. You may never have heard of Oklahoma's anti- substitution law, yet it's one of the most important pieces of consumer-protection legislation ever put on the books. Why? Because it helps protect your health - and the health of every patient in Ok- lahoma. There's nothing more important than that. But the Oklahoma anti-substitution law, and similar laws in moSt other states, are under attack. Right now. legislation is pending in the State House of Representatives to repeal this extraordinarily valuable law. What The Law Says Briefly, the law says that a pharmacist must fill the prescription your doctor writes for you exactly as written. Proposed legislation Would encourage the pharmacist to substitute a different drug for the one your doctor prescribes,w/thout his prior knowledge or consent. Anti-substitution laws were first passed in the 1950s to curb substitution abuses. Pharmacists, doctors, and legislators recognized that prescrip- tion drug substitution was unethical and definitely not in the best interests of patients or professionals. (continued on page 5-6) Why Prescription Drug Subsfltut~on is Bad Medicine for Oklahoma by Francis A. Davis, MD, and Gordon Richards, Jr., RPh Shawnee, Oklahoma MARCH 1e76/PRIVATE PRACIICE S-S PAGENO="0229" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14135 Three Myths of Prescription Drug Substitution Twenty years later, a minority of pharmacists, some politicians, and groups claiming to speak for consumers and olderAmericans, are pushing for the repeal of anti-substitution laws. The repeal effort is based on three myths: ONE, that pharmacists are more knowledgeable than physicians about prescription drug prod- ucts; TWO, that patients would reap large savings if "generically equivalent" drugs were substi- tuted for brandname products; THREE, that prescription drugs with the same chemical ingredients will have the same therapeutic effect. Myth One Pharmacists are very important, indeed indis- pensable, members of the patient-care team. But when it comes to knowing how drugs work in people, rather than in the abstract, physicians have more training and experience. Your doctor has listened to you, questioned you, examined you, and made a diagnosis of your condition. The drUg he prescribes Is based on the therapeutic-results he haS witnessed in previous cases. Only the physician knows the particular diagnosis for each case, and only the physician should have the final choice of drug to be used for The pharmacist is qualified to give you valuable advice concerning the usage, side effects, con- traindications, and usual dosage of your pre- scription; however, deciding what drug would work best for you is the right and responsibility of the physician. Without the final authority to choose the drug, the physician cannot effectively control the patient's therapy. Myth Two Then there is the claim that substitution will save you money. An independent research firm did an extensive survey to determine what the savings would be if all drugs were prescribed generically - essentially the same as permitting pharmacists to substitute, The savings of prescribing by chemical rather than brandname (using more cheaply made drugs) would average onlyl.7% (or lip on the dollar), Companies that cut corners in manufactur- ing and quality control can sell more cheaply than the national firrns.that do not, but not by a wide margin. In fact, America's pharmaceutipal industry has an enviable record in holding down costs. On the whole, the average tablet or dose costs less today than in iSiGO. There aren't many other prod- ucts you can say that about. But the study above is only a projection. What about the places where substitution has actually been iniplemented? It's legal in Saskatchewan, Canada, and instead of prices going down, they went up - 19% pn the average. Somethink the culprit was the Increased cost of malpractice insurance for pharmscists. When they started substituting, their liability Increased. In this country, fifteen months of substitution in Kane County, Illinois, ended when no savings to patients could be shown. In Massachusetts, Maryland, and Kentucky -~ where substitution has been implemented - no savings has resulted. Myth Three: The Critical Issue Myths Numbers. One and Two are not the crit(cal issues, however, Myth Three, and the risk it cart pose to your health, is. Drug expert William H. Haven~r, MD, givth seven reasons - and he says there are many more - why chemically equivalent drugs may not have the same effect, 1) Purity. Purity can vary greatly, Generic (non- brandname) penici(lins can contain up to 15% impurities, says the Food and Drug Administra- tion, and still b~ sold. Granted, penicillin im- purities are very hard to remove, but reputable brandname penicillin is 98% pure. In fact, pSople `with "penicillin allergies" are often allergic to the impurities rather than the penicillin; 2) Stab//it y. A product's package doesn't seem very important, but ill-packaged drugs can quickly deteriorate and become unusable,, ,but bythen, you've already paid for them; 3) Taste, smell, colřr, consistency. If you have children, you know how important these are in medicines. They're also vital in longterm adult therapy; 4) pH. What is the degree of acidity Or alkalinity? 5) Coating. The right kind of coatinp protects sensitive medicines. against destruction by stomach acids. The wrong kind can permit a pill PAGENO="0230" 14136 c,Oi~nETITIVE PROBLEMS IN THE DRUG INDUSTRY or capsule to pass through the body undissolved, with no medical effect whatsoever; 6) Defer/oration. Some drugs, if improperly produced, can deteriorate to ineffective or toxic substances. The widely used antibiotic tet- racycline, it dispensed in relatively acidic capsules, slowly transforms into a deadly kidney poison. Without appropriate and costly - sat eguards, this kind of problem can occur; 7) Absorption. How well a medicine is absorbed into the body depends on many factors, including how rapidly it dissolves, the nonactive ingre- dibnts used, stability in digestive juices, and how it reacts with food in the stomach. The Dangerous Effects of These Diflorerices Here are some specific examples from medical journals that also received some attention in newspapers. A few years ago, it was discovered that while Chloromycetin (brandname) is a very powerful and effective antibiotic for certain infections, all the generic equivalents of chloramphenicol (chemical name) would not do the job, no matter how much was given to patients. Digoxin (generic name) is used by millions of Americans to help their hearts beat more forceful- ly. In 1974 the Food and Drug Administration dis- covered that some manufacturers' digoxln varied so much in absorption rate from batch to batch, that patients could get dangerously high or low amounts from the same dosage. The FDA also noted that Lanoxin (brandname) had nosuch prob- lem. It was a little more expensive, but it worked, unlike its cheaper counterparts. Alan Tasoff, MD, writes of his experiences as an Air Force doctor in Thailand in 1972: "Struggling to overcome a penicillin-resistant gonorrhea epidemic among airmen - of the magnitude of twenty new cases per day - we were armed with an Italian- manufactured tetracycline, purchased in massive quantities by Congress. The drug was chemically equivalent - in the judgment of consumer groups - to hrandnarne drugs. The failure of this thug to dissolve in the alimentary tract was known to all physicians p~rescribing it, but supplies had to be consumed before a replacement could be made available. The ultimate cost to the'airmen involved was chronic, intractable urethritis and prostatitis." Two Branches of the Government Say All Drugs Aren't Equal With sf1 the controversy surrounding this ques- tion, the United States Senate Health Subcommittee asked the Office of Technology Assessment (OTA), an agency of Congress, to study the whole ~robIem of prescription drug bioequivalence (whether chemically equal drugs will be equally available in the body, therefore allowing them to have an equal effect). The OTA set up a Drug Bloequivalence Study Panel, and asked Dr. Robert M. Berliner, dean of the Vale University Medical School, to be its chairman. After months of intensive study, the panel released its report in July 1974. Among its findings were: "Current standards and regulatory practices do not assure drug bioequlvalence for drug prod. ucts." "Present. . . guidelines do not Insure quality and uniform bioavaiiability for drug products. Not only may the products of different manufacturers vary, but the product of a single manufacturer may vary from batch to batch or may change during stor- age." "The problem of bloinequlvalency in chemically equivalent products is a real one." The Food and Drug Administration has so far identified 193 cafegories of drug~, including thousands of different products, as having known or strongly suspected equivalence problems. The People Say They Don't Want Prescription Drug Substitution In a democracy what the people think counts. So it's important to know the findings of the national and two state surveys on the relative importance of drug cost, quality, effectiveness, safety, and bloequivalence. 2,532 people were surveyed all across America, and 1,149 people were questioned in California and Wisconsin. Seventy-one percent of the people questioned nationally believethe physician, not the pharmacist, should determine which drug product a patient takes. (In the state surveys, the percentage was 75.) In the state surveys, people placed far greater importance on effectiveness and safety of pre- *scription drugs than on their cost or speed of relief. In fact, cost was last by a decisive margin. Over 70% in the national poll said they didn't want substitution of generib drugs for those prescribed. (continued on page S-8) MARCH 1R7HIPRIVA1E PRACTICE ~.7 PAGENO="0231" COMPETITtVE PROBLEMS L~ THE DRUG INDUSTRY 14137 even if the substitution resulted in a cost savings. In California, people aged 55 and over oppose pharmacist drug-selection by a whopping margin of 83%. What it all boils down to is this: people don't want to take chances with their health to save a little money. If Substitution Were Allowed Imagine, for a moment, that the Oklahoma anti- substitution law has been repealed. You'reaick, and you go to your doctor. He examines you and pre- scribes a medication. But without his knowledge, the pharmacist substitutes a cheaper product. It doesn't work, but your doctor doesn't know why, since he doesn't know about the substitution. He knows how the drug he prescribed works, butyou're not taking it. Did the substitute drug deliver too little medication into your bloodstream? There's no telling, In the meartime, you're incurring additional expenses because of prolonged illness. Generic drugs may cost a little less in dollars and cents, but they can exact a high price in health. If your doctor is to do his best for you, he must be free to use his best judgment, in drug therapy and every other area. He must be free to choose the drug he knows will help you the most. If Oklahoma's anti-substitution l~w is repealed, you may be getting drugs from low-quality-control, no-research, minimum-distribution, fly-by-night companies. All for the sake of savings that will never materialize. How to Save Money on Medicine Right Now Carefully choose a reputable pharmacy, con- veniently located, that will serve you with quality drugs at reasonable prices. Make sure it has the services you want. C~n you get quick service on filling prescriptions? Is there free home delivery? These, of course, can affect prices. Talk to your doctor about the quality and price of your medication. Tell him you warrt the least ex- pensive product consistent with your medical needs. Make sure you got it by asking your doctor to specify that particular company's product on your prescription. If your condition requires longterm therapy,, ask your doctor to consider prescribing a larger supply. This will usually cut the cost per dosage. Keep a record of all your prescription drug pur- chases - or ask your pharmacist to do so. Around income tax time, this will be invaluable in computing your medical deduction. Oklahoma's anti-substitution law protects you and your family, whenever sickness threatens. What to Do.. Right Now Use the attached card to write to your State Rep- resentative or Senator. Tell him you object to the repeal of Oklahoma's strong anti-substitution law, bne of the best consumer protection laws we've got. Do it now. The alternative is enough to make you sick. If you are convinced Prescription Drug Substitu- tion (Generib Medicine) is bad for Oklahoma, please tell your Representative or Senator.. . just fill in the spaces on the card at right. Address it, sign it, stamp it. And send it. "I oppose Prescription Drug Substitution and as a concerned Oklahoman, I urge you to fight any pro- posed legislation that would bring such bad laws into our state." Name Address Signature Address the card to your appropriate Senator or Representative. POTTAWATOMIE COUNTY: Representative Charles Henry Representative James Townsend Senator Ralph Graves PONTOTOC COUNTY: Representative Lonnie Abbott Senator Wes Watkir~s PAGENO="0232" 14138 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY r' r' ~~r Ut~JL~UL ~ Published in the News-Star, Shawnee, Oklahoma, and the' Evening News, Ada, Oklahoma. t~7~%© S yzij'rin ftn~t~~t t\d `O(~ ~"~~:JJi~ llu~t Lately theft's bate a tot et noteeee Make yee tht,lkt Toj tot: he otto teetty 000et the eeoeoe'ee neet,tt b'y dtcg coot 1 neeeto dean tebttttett'oe cell oeeepae~ttttte1okteg. toeoyoeetoneyeenotteettooeee coo leget,aeo too ynee of A,td tow the nehtteaet hoot cone op eeed,oat'on eon 100 0', the acute. t'ettt eel lte,t~ cede" them: Petteit Note toy 0,0' Thote `ohooyee" ptetoentteetoallnototthobeattdeatete ehoe,to,,llyeqoolde,,gtaeeeteq~oel dtogt of foote ttte,e to be tiled wittt eithet beny,te the hooted ohetetoei tobot,tttet that teey cot be teyeodtetttt, the tllnht d,tteeoeooo it thetopeottoatiy cheat. to toot, they tot tttlett, eoohegt, toddy ted thootytion eeiythayeotoote yoe...ttteyetayeateiedtognnon,ttoktthe,etotolly potenhalty haemtotl ted eeoc total They toy pe000ephoet 1,11th ottey gteeeiotet000,etloel)eeteotloetho ekay,eoe'yetkyota~aie.whedoyee dtegt iettood of the btaed etetot eetlt tool eotth yoet Itte? nhete big yeoltteblo Thyy 0 d-5 te h rn_you 0 p11 Ct they'eo named - ate the tame thing. onowpitttdtegnghtnOattoma ho ha settee at alt this ohetodo that to itt ttttyetetlee that yeoo oetaeee the to eltetee, pelittea with coats gt000tton to yeoteett, and thee tot. ~ CvaeifiYI Oe-geteg eeteate h. Stetegeet geatuty ciaoaleiaia home hg f~Po~0i'~Wt3) (ittB (ttt7) iodbd h o1 d It y e It d em d d gh y S y ate ~a oltowed 1 nooold be tttt( eeytetetttatttit, 01 dade yoct Owe tettee onootiktteteoehteteohedooo:,~oe~~, ta~ Octet 0 tOO ~ The atternativets enough etodtoogo to It gnat ~ to make you sick. ff[b~ 31~aS L~©1lllit~cs r C17t91t I1I11~XO 01 Ktdltn nit I I 4 I,' It ~- I" BY Dccc? j r1~~~s PAGENO="0233" COMPETITrVE PROBLEMS IN THE DRUG INDUSTRY 14139 -- ~ ~ ~ ~ / t!cJ~L~ I! ~i~7 ~~inir c~~r or~ ~ ~`~Thfl~ ~ `~iL~ ¶90 6~) TI r~i 0 u~ ~ ~P ~ ~ ~ u~ t~u~ i~©r ~ TO Imyk ~dy ttettcctoc itt all tottits eshopt those pestditeg to the State Settate. It emsttd oaeketed by teputoblo besetete tao hOse aeless yoa act fact. phstmaoeattoal lois Call this ottmbet tot mote lototmatlco. Hoo scold ateyooe dtoaot ot spoosotteg yocte s1tcadyoeoooced tell us oahett sash att idiotic lasst Easy Its a lao that yoc call Well scoot a ptottst itt yost sac be made to cooed motto. Its a tees toots to the peoplo to Oklahoma Cdy too mooS tot Wags The bIg etate legisletoes Ot cede youe oes~t y tT w ;oat~h'&sOhot ~::~ Tb dp ~ dO~f~ ri~i bots atty mom atabold2p The alternative is enough pteceoam to pay tot yout f5, ç~ to make you sick ~1I~ ~ UCIIB~ t~ (diQ~1T~1~t kT~flL PAGENO="0234" 14140 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY ti7~7~ri 0 `~ç~T?7'~f~ (ji ~ flt ~ ń"fl) M / kL ~ \d~' ~1~Us L:~i~t ~EQt~ ~2t~IUII U flZi1KL~7 QXAI ¶90 0 r~~rv~n~ iP?7fl77flf~ thMLiSi~4a ~ 0 O(7~flri ~i 0n~1 rfaia ~ ~ I O~5$Li~ 1~C5~ ¶r~erfl~sg9r ~V ! a itI Ii ~t~cara ~ Y `éd Vi \~~Utj~ ~SALi L~U3 Lfl~flSUUC& ~ 0 /~<4c~a. `~d L[ ~:~z ::::t~:r~~, LI ~Zi~ ~ a:g~:'° t~g :~:a ~ sans ;ha0000roci 550 lob t~ill A ce quality cc~irci a pious )tti~ The alternative is enough ~o;~c Siia5 ~ to make you sick. rarradoga. ¶90 0 u'~""W~1 !L4!~ ~ 11b1kks ~ IThIIIIL Tlsis campaign to Stop Prescription Drug Substitution Legislatior is sponsored by the Puttawotomie cousty Medical Society ard Pharmaceutical Associatioo, auou ous.us,au ow, 1. 1 ii C a 10* ~0i pa - 01* 010 * lii Pu0 to 0 B PAGENO="0235" COMPETITIVE PROBL]~MS IN THE DRUG INDUSTRY 14141 t~O 0-my Ito Ot~ 0g~ 513 051) 355 ~btO 50 0 3 at The oihgeos of olooect stotec Dos haoo dootots aaho ace playIng Oagsian maCella eeth It's tot the fault of the dot'toes. Its the 1gw. Ce eleoect states, the politloaos haae petted ems that sound goom hot they to bad ntedcc,ne It you Oak beyond the pconnses They'te yelled geoetlc doug laws, ot ptesotiption dtag s.tbstituttytt laws. Atd they ptontise Comet peimes tot yout presotiptcoo dtugs. Its peamtlca, sItes they mayde is to pteoent yoa ~:9a5hm59 what yeas deotot masts you to And no one has yet pcocod that they oat saoe sacent study shoot that ps000tiphoct pctooo moot op art eoataga ot COO ott the dollec ottec the lao Geoecatly. the taos say that a dootoc mast otlte the gaoarig (ohttmioaly came at any dtug he macfe yoo to haoe. Not the beand came, to spIte speoiho btaod beoausa ho knows and cools So ooo may mlctd op oith mediotca made by some tly-by-mght oompany Chat appoats to be chemically equal bat sot. Sod that's ha oct00 that ceo kill yta: Th. eases petltlclass ohs say - with a sw - raqtolea ~ wetp~atslasts te~ka them squat. Tttese so-maIled genecio dtu sate toot cosopourdad dontioally. and they'te not wanatartated idOotically. And evety dootot mao toll you hottot stoties cheat patiaots ohm tound that out the hetd way: A f,u Po' 0" * b~f~ * - ~.. 0- l'leatt mod:otte that man supp050d to be equal to ho orignal but weoot't has oauaett lleatt attaoks d p AOtattytttoto~ysk yoo, dyotor it all geneelo ptotoot to yout oome to the people to Oklahoma COy who oatt stop tilts dloastuc -- yoct state logtclatots, Ot y~u can tatlte them yoycsolt but don't wait, now It the time to take aotton. WtteyouoownkCDat me The alternative Is enough to make you sick. IY. ¶~SG ~0'tt5t~ ~1řr~C Vt fte~ ~~x* This campaigh to Stop Prescription Drag Substitution Legislation is sp0050ted by the Pottawotomie County Medical Society and Pharmaceutical Association. aç.?o~.s.7;~..af~ ~ \jJJr~j~"i~J~ ~ ~~r' r~ ~T) - ~ ~ ~L~1C~ ~ PAGENO="0236" 14142 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY ~,~ci'c!7? \~ ~ ~ ~ i ~ ) t ~ ll~~1 ~ I ~ c~c~T1t2~rfllC ~ ti Soon, Oklahoma law may give you A the chance to test the equality of genenc medIc~neb for yourself Thbhttoodtotto~ssoO sootttittgty ho o&ttto It htd thy to sptt, ot hot ystisots togotod siOlsotty to ho sight )O~ ~ hod by Dot Its not los yot. Attd it ohoutdn't ho pt000d hot this too ttthI soon you toots hon shoot 25 ott dnugo soto sot oqsot. Ask yout deotot. Shots ate othoto. 500t ttoi hAs ho non in Cahtotttio sho touttd hot ~i gsnonioohty As so mid, thonos to too hot .sys oo hots to toss Shoot otttyiootly tonosod, glory sith ethos ot gsons ~ot It. Reotty. C~flll ~ ~©~ń The alternative is enough A to make you sick. ~J ~i©dt ~n~ix. This campaign to Stop Prescription Drug Substitution Legislation is spoosored by the Pontotoc Medicai Society god the Ada Pitarmacists Asoociation. PAGENO="0237" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14143 55 ti a. cy Ste nit ma tb' tQ5 tbtb ~bu 2)3 00 30 eC) 0 * ~ pfl7~tnrfrvc~ a. ~J &AL~s~LN LSaML~4~ 3 N C~.C\. "m~..! bee nest C petit enenoegh to eote tot hint. Cen eteke nec e ettete bet stoker: Like the D m~ tn ~ tn dg eheetd teken Second, the dtege cent be otnenp'en beepite When he decided bets ehet it meene, it's titnte gtend:eeo ole :nts oobody'e yneced thet Ce get Wetted. ptetntipt:en dnug ekbst:tttt:on ben eeoc yoe Like eeee,' mete then 20 en the delict en yoct ntbdte:ne. Seete et bent heee decided, they knee enough ~ e~on't d *hatmseinehe~~esb~ options cc to plus adttflibntet nnedic:ne, been you teetty eheed No ktddtng. bee sect eeoc et these peepte Ce dkteheme The peeposed tee tneetees peesetiptten dneg City Ce represent pee. dee It's time Ce glee sebst:totten, The setting point is bet genetic them 5 hend. (en ebemteet) neme dttigs etc eseetty sheepet Cett this numbet tot mote tntenmetion en the then beend neme medtoetten, preseript:nn dnug subottution tngietgtiun new And stsoe eti dtegs with the eeoc ehemloet pending. tt you're etteedy oondnoyd, sit us tents etc not the seme thetepeutteetty, ehy sehen you belt We'tt send e pnetest in yeun sheetds't yoee doeton be the one to bnnsenbe seine te youn Stete Senetot end Stete the msdtetne tie wents you tu get end bees bc Sepnotentettce. ot. you ben ente them younektt ssseeeses thet yeu'tt get it? Senetie dtugs etc hut dent we:t. bus is the tints to eke getton, eetsegntttsdtonteeteguetqueytyeentnet Writeyoeeteoetsee steodeeds tee eenty et pcoossstng, bet enty miotmsem geostement treeS, We're hess Cs tstt pee. And St pee estee ysm I~_,,,~ye2% hsssh sed yses messy, me esggset pee reed `eWS~ en * ~(`tttQ\ F "Cheetcetty sgusr' doee net, ecncur son, er' 5~ ~ms ;&e~ ~ me way the dog adsdyeet L)Ingie4~utd kuU bedy bittenenbes tn quetity eentnet, tittets, ` fl ~dtherntde:g~otnenyy ~: tn A The alternative is enough Nem Peek mite dIed beseess dittetest `~"rt. to make you sick. ; a:::: :: m d I ?s~i~;r ~ POssApb~oeL~ Sletitetiee ~ nb~tiL Isgietetiem is epennoted bp (ne Peote(etn Meditnet Society end tine Ado Ptngnntectnte Aenociettee. PAGENO="0238" 14144 COMPEPITWE PROBLEMS IN THE DRUG INDUSTRY r'~~ r~r"t [:iJ(?~(~' yi~-~ L) L~~~iUii (~3 ~r-~ fl ~ ~ ~\ii7[ ~C ir'~r U L~JLJ~ I) ~J L~1 )ULLJU [~ Radio Spot #1 Radio Soot #2 Announcer: You trust a politician enough to vote for him. Does that mean you trust him enough to dictate the conditions your pharmacist must follow in filling prescriptions? When he decides that's what his legislative position means, it's time to get worried. Like now. In eleven stat~s they've already. passed drug substitution laws that mean patients can't be sure they'll get the exact medicine their doctors prescribe. They may wind up with a similar but cheaper drug. That'd be fine if all the medicine was equal. But it's not. And the differences can make you a whole lot sicker than you already are . , , it has happened elsewhere, and it can happen here. If you don't act now, it's going tohappen. Right here in Oklahoma. You sent people to Oklahoma City to represent you in state government. On this issue you had better let your legislators know how you feel. Call (Shawnee: 273-8838) (Ada: 332-4116) and voice.a protest against prescription drug substitution. Do your part. . . medicine and politics don't mix. Announcer: Oklahoma, it's time to get worried. In eleven of our sister states, the politicians have decided they're as qualified as your doctor is to prescribe your medicine. So they've passed laws - drug substitution laws - that fly in the face of everything a doctor has spent years learning. If their law passes, all the doctor would be able to do would be to indicate a general type of medicine. . . not the specific. brand that he knows and trusts. That'd be fine if all the medicine was equal. But it's not. And the differences can kill you, can maim you, can make you a whole lot sicker than you already are. In documented instances it already has. Oklahoma, it's time to get worried `cause the first step in such a program has passed the House and is pending in the Senate. Stop pending drug substitution laws now. Call (Shawnee: 273-8838) (Ada: 332-4116), get the facts and voice a protest, because medicine and politics don't mix. Broadcast over radio stations KGFF, Shawnee, Oklahoma, and KIEN, KEOR, and KADA, Ada, Oklahoma. MARCH 1976/PRIvATE `95cr/cs 5.15 PAGENO="0239" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14145 Television Spot 1/1 Video: Three tablets of Digoxin displayed on counter, hands and shells come down to cover pills and shell game begins. Audio: Some politicians say these drugs are generically alike. Video: Shell game continues. Audio: Actually, because of the quality of their processing ~- or lack of It - one of these tablets may kill you, one may cure you and one may do nothing at all. Video: Shell game stops and shells are raised to look at tablets. Audio: Can you tell the difference? Your doctor can, if you let him. But he can't If drug substitution becomes law like it already has in Come states. Video: Fade to black. Video: Superimpose in white, upperthird of screen: Video: Don't let Drug Substitution become Ok- lahoma Law. Video: Superimpose phone number, centerscreen. Audio: Don't let it happen here. Call us now, (Ada 332-4116) (Shawnee 273.8838) we'll give you the facts. Video: Fade out upper third copy, leaving phone number. Fade in logo upper third. Superimpose: Medicine and politics don't mix. Audio: Medicine and politics don't mix. Video: Fade to black. Television Spot #2 Video: Extreme close.up of drug boxes lined up First one has been tipped and they fal' domino style, in slow motion, Audio: Some politicians said these drugs wer~ generically the same. Some New `Yorlt heart patients proved otherwise. Video: Last box falls. Audlot They died. Video: Dissolve to announcer seated on corner of desk where boxes lay. Picks up last box as he speaks. Audio: Prescription drug substitution supposedly gives you the same drugs for less money. Sounds good. Chemically the same yes, but therapeutically the way the body reacts toit some difference! Vicfeo: Superimpose this copy in white, upper third of screen. Audio: Don't let Drug Substitution become law here. Video: Superimpose phone rumbar, centerscröen. Audio: Call (Ada #332-41 16) (Shawnee #273-8838) now. We'll give you the facts. Video: Fade out upper third copy, leaving phone number. Fade in logotype upper third, "Medicine and politics don't mix." Lower third. Audio: Medicine and politics don't mix. Video: Fade to black. Television Spot #3 Video: Extreme closeup of large unmounted, cut diamond and piece of coal same size. Audio: A diamond. A chunk of coal. Both pure carbon - . . chemically equal - - - but therapeutically different - - . and some difference! - WOW! Video: Dissolve to announcer seated on corner of desk where diamond and coal are. Audio: Chemically equal medicines may be Just as dramatically different therapeutically - some difference! But you won't see it... you'll Just feel it - . , if prescription drug substitution beComes law in this state. Broadcast over television station KTEN, Ada, Oklahoma. Video: Fade to black. Video: Superimpose in upper third of screed: Don't Let Drug Substitution Become Law Here. Superimpose phone number center screen. Audio: Don't let it happen. Call this number flow, get the facts and then oppose any form of drug substitution legIslation - LQIJ$~LY - Video: Fade out upper third copy leaving phone number. Fade in logotype upper third. Audio: because medicine and politics don't mix. Video: Superimpose: Medicir~e .and politiQs don't mix. Lower third. Video: Fade to black, 5'16 PRIVATE pRacTicE/MARcH 1976 PAGENO="0240" 14146 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY PAGENO="0241" *COMPEPIPBJE PROBLEMS IN PEIE DRUG INDUS.~I'RY 14147 R5 forAcute Type III Aortic Dissection Found Arrested by Drug Regimen `I~'sOtNBURG5, SCOTLANn - Depression of oayo 12.,t cardial contractility, combioed with a re duction in systolic blood pressure, is the moss effective way to treat and control Type 555 acute aortic dissection, according so Dr. Rich. ard J. Cleveland, chairman of surgery at Tufts Univeesity School of Medicine in Bus. Reporting on site results of animal esapori' ments, Dr. Cleveland recommended the our of trimethaphan so peoduce the necessaey by- poteessian, noting that the effect of thit drug "maybe she critical factor in limiting dissec. Impliststiuns ASSCSS.d The implicationsof the study, be enplained, are that once initiated, aoetic dissection will progress in the face of a tignificant depres' sian of myacardial contractility alone, but can be halted by a combination of depressed mya- cardial contractility and moderate hypolco. In addition, Dr. Cleveland observed in his reporc so she recent meetllsg ham of the International CardioVascular Society, site fact that triweshaphan has been found to slow myocarcf?al contractility to tha same levels obtained with very large doses of pro~ pranolal indicates that trimeshaphan maybe the mare effactiv6 drug far contrast of acute Eepttim.sttaf Evident. Clout In theliaston experiments, he said, 80 mon- grel dags underwent left tltoracosonly and canssrncsian of a standardised intimal tear in site proximal descending aorta. They were divided into tfsree groups - IS untreated con trots and 10 each treatrd with peapranolul or with trimethapltan before development of the dissecting aneurysms. When the control animals were sacrificed after an hour, nine showed a progression of aortic dissection by an average of 81.5 percent of the distance from incision to celiac axis. One animal slsowed no progression, and in two cases the dissection covered only 50 and 65 percent of the distance. No statistically significant changelsad occurred in myocardiul coatractility, Dr. Cleveland noted, burasrend- ing uorsic systolic pressure in these animals had decreased from a mean of 174 mmHg to iriS mm FIg daring She observation period. In the propranalal-treated group, he coo tinned, nine animals showed aursic dissgction over a mean of 65 percent af the distance so the celiac axis. In four dogs, dissection had Continued on Page 6 * Important updated dosage information: LANOXIN® (digoxin) The recommended dosage has now been reduced. Lanovirt in Ihe original digoxin . . . the As a result of recent pharmacokipebc result of a research breakthrough by studies, 011ev nupporled by Burropghs burroughs Weilcome Co. over 40 years Weilcome Co., new lower doflage ago. If has been setting the standards recommendations have been adopted. everaince, They are Summariced in our rebised Through thff years, Lanoxin has prescribing InformatIon which appears henri distinguished by a reputation f~r on the following page. We urge you to consisteot effect. This is clinically signlfi- read thin important updated inform~tlon. cant because digooirf preparations which have the same digonin content d tte ad greatly in boa ailabllity `° 5 and consequent pharmacological effect. o,e,rxtaaei~ass, sD LA NOXIN~ TABLETS 0.125mg (yellow) 0.25 mp, scored (white) 0.5 mg, scored (green) CLINICAL TRENDS IN CARDIOL000/JAN1JARY.FEBRUARY 976 73-617 0 - `76 - 16 PAGENO="0242" n z z Q z 0 0 0 J ~.9. ~ Its PAGENO="0243" COMPETITIVE PROBLEMS fl~ THE DRUG INDUSTRY 14149 W Ii I ~ ufls EL~lRocA~OGkA t~: a S I~ PRE Et~T~ ~Y DR ;*N~ ~ LEEF LOW IN ~4RDt~LOGY. HE ~OO ~(W ~fo PtFA~ N W ~ ~ `:~: ~ ~ ~ . ~ I~ ~ `h . ~ ~ ~ ~` ~ ~ R ~ ~ ~ ~"*t~ ~ ~ ~ ~ ~ "~, ~ ` ~ ~ ~ ~ ~\ ~ ~ ~ ~ `~ ~ ~ : ~ ~ ~ ~ ~ ~ "~` ~ ~ "~~r ` ~ ~ ~ ~ ~fl I ~ Heparin Injected by Thrombophlebitics Info ~ ~ ~ Abdominal Fat Pad--20,000 Units Every Day ~ ~ Continued from Pag I e~'e~y-cI~y ~ched~de D~. ttt:tn whi C:t ~- rettop~ tit~tte ti ltc~tt:tt~tn t. ~ sign. Tltete lt~tiefltS .tre irsL ttit!(l on 1.2 to toot 1'RFNtt' IN CtRt too (.Y. * 11 ttttttc t.tpo A bleetlittg t1titodc one tttttt oIled i~ not 2.4 gtat n~o lenlert-coatttl otpititt Itilt. tlong it to ad fltitttttr ~ttiott tin da~ a week *~ ttta. dly ~ottaak tt( I ~ otttt .tittdlt.t ito to witlt ntccltoni:il ttte tattt at, Itot am atoitcltt d eli ttitn:t tug lltt' ttttt lot ittjctiott - tltott ftte ittg Jtcp.ti itt the tol)att him ~ (tacIt' tttotiitoting to otttpatiettt ltc1ntritt if tltt,~ do not rttpottd da)s a toec k then etct otloo do1. Allot thto. ,lotiitt~, to' Iit~t attd foto.t toti t, Do. otto, within too weckt. the hepar not oc toot, ~ ,t,dio- ott tin,, e,l ~ ~tt, I ,t rctt ti Stt,l at f,(t ofiter pottible he~atritt Tfte thir,I grottp, cltroiti thtotttltophlehi- tfte potietttt pot ((0 e,,terk-(,a(ed ,tpitin. * tide dlc,tt, Ito Bio,,klao tftytk `too ote,l otto tict. ftaoe Iong.etatdiog (`all twelling, tilcet, Sitoplt rcthotttg ,f.,ilt~ ,Io,;,~, ct(f(, tittg hc c;,c of ,ete,til,le tI opa .t otd te,'er,l fel,rilc lion changet in aigzncttttttiott and m1 nirn al ~ pcrit g p tio I i not or otictrial r,;, C 00, tot to ottec,f(ototi, po(tt. `Ifte phyticiattc lu Do toj~ tote tioto treat ~ lit. a l,le lotca,ttc Ito lhrot,tlto~t,j,et,i, or speuf o,otn pl ((.att 0 (tOt 1 ott gety to,l apply ~ itjtctioo ~ re tte- Eoclutlntg to', at,otoal not patictttt, otte of the ootpa tot, t ftc tttrtltro gtn *t(t,(( I~ tof,ett ~ ~ p.o kagtd. he oote,I. wI,oo, ha tecci,'c,l he tar, tt on an otlpatiett the cl,to nit,,, n,fitio,t fl:,t-ct "p .t((,I t,ecot,tct ~ .~Ito, t,e'e'c fottttd l,,ti, fat f,c ~`,t( II) vt trt,att, I tt,flott con- ocote. Dot-tog h, f~ tttyt- at-t of tf,eic tt,,,fv. t . tltt,t ftc effect f he1,- ~ rtttt-c I cc, tutu e of tfttotttf,ttphlc-Ititit when- the1- fottnd tltt,t lot ltcjt ttint ctttte ttwtts ~ . ~ ~ tittt- t. ott to I ct to, coet the,,j,, it tilted, Ito toac ,,oo,o petiod tnelfecttt-e ,~.,,tt,t cf,r,,t ,,,tttatt, fctt, totttt . ` t f ,(,,,(,,( tf,tee fact an)- of treato,-t,t f,,t Itte, t,f,',,tttf,tce ,tt,,_ Dt. DOs. R.dtn.d fo Son, Pntfnnts ~ OttO coften tt t ge-ct, Stilltt,,n told. If 11 fl's I ~ P ~ h ~ N Thp are c ott e,l to ttt~ect ltt~to ttti - tot :,fFt 20(1(0) D,. Stffltnnn Iltere', a f(tv(.lt((logk,l TIte iotpot tatttthitt g he otttin,,wI. it 0 (((C a day - tttf,, ,ttatteotttly two the ,bdom- odetntagc -d',it, g it 1 itt, ty. t fatet (itO reitt- tltOt (ft CfltttttCtt ((tt(( 0 ((((f(t (f (tt',ttttOpf(I(-- in,l fat pad. ~~SVe ttte tI todos e to ;(fl our pa- fore,o eto . Il,,- a.,tientt I ,, ~ ~ft~ tot t,-tt (ftt, bide t tttttO Ito ftreectttttt id, aC(tlC ptdtt in tietttt eoccpt tltote ct-ho a rec-eryt cf and frtol dad gc titt g lo~ tt-tthe, c ct-ill ft,_ tttw tf,v `tf ~ lt-g - tan ftc t,t-,u-tI e,tttitfe tI,e and tltt,ce tcegfnnc~ untfet- 10ff poottds Dr. ~ ~, corel often Itey lont Itace to witlta,,t inw,c',-to,tt Iterapt, antI Stdloian told Ct JNtCAt. Jnrnrs Ira Conococ.. stick tftat ttre,lf,- in the tt~r Ices. attcl thett Iota cotsrn,,lin which tc-rtoc to ttt to Iotttore (((to- For tftet,,, tcerec It,ce it to l0.f(00 ostttt dtyt. tltree day, tt,d ftntll~ four.' d tngerottt tftatt heparin. Ott the ftosi of o,tr datly.' ff,c Dc tw-,t t~(l,. -,ltoi,ia,, cet Iteit tcttiett~ enprrtettcc-. W (-cat( lte 70 percett ton e tlt,t The pattcntc art- also ,dwtr,l to ace means weekl, `oott 1 t lttttiug tint,, I too r tt:tl,lc teitftin nix tt,otttl,t of tltin tlteralty, tfte ptttient In keep tfteir feet elev,tttf tololt to ted. to let o,ttc- . tttttattt It O,,,c tl,c p: t,ie,tt - t,,~ will tltotc intpteccttent itotf, cytnptotuttitally swins or to walk at least a nttle a (lay if tf,ett stcitdtrd to ~ ,t1,ieio ~ tl,,-t tre crew twice a ttt(t 1 tt,(ttrOist ~.(tt~t plrdtc'cntcgraphy: coudttion petmitt, t(t tttke hydrotforapy - or tftttettto,ttl ti,,tt-rttt k, .tttd 1 ct, ,, ,,t, r ,tttl Tftis foes tnt tt,etst hot ftc c-ascular cyst(-tt( ot lettct a teatttt htttlt - tloilt, antI to wear (sco yrt,tt fo, clteth o l'~ ref t,rtt to itt ptctltrontltopftlehitit- eootlitiott. elasltcstothittg soerfttt .ttclrgnt-rops. Entended ftc dtlrcl. Or l(letl tvto, ograpftic w,ttliet bed rest is (tot p trot ifted. the Brooklyn s,tr- Pultttusuty Sytsspt.sss Wutshsd scent 0 sltoso tf,t,t all tltrw f(atiestts l,ace sotoc gross rts(pftostes(l. ft((t ftc pastents are tttld to Of c t,orsc- ~ if ftc- ,tti to tooftl (t((ttt f ~ persistettt tfotortttttlititt. otto, Il~ a tlet.,etttr in ueo,d prolongetl staodotg anti (o(ensise expo- poltoo tctr V 5Vttt~ ttttttttltttio g ttctt ,ttrstt . t-crtt vestoot filling titne. sure to sottltgltt. st-ftttft ,s t,rhesetl to lots-c a In- nliglt tt-tt ~ Itet gitt-o ~ ,t,i,,tttt,tl .~ tr,ftcc t Rr,ttrrcnces t,f actttt tltrottthophlct,iti sl(r((tof(O gence fOe, t ftv t- ((cots g 0 release of en. tttt ottiot. E(.G tI tltrct \-(tV ~ttt( d if tart tstt I ftrttt (0 (tt((( Ott- host-ener. Altttost serotossin. there .tttc trtts,t ((tttOtft t(( [at(ltttol(tt V tttt- tltrre ~ Vrters of the otttptticttts on It,- ftrpa- Tfte rrg(ttteo tt rttttt tst,( etl otttd the patirnt ftol usa Ittog w_ttt Dt .Stt lhttat, ttid. ritt rtgi to-u fttol so t ec(trtence. how' e,ther tt tlotttog tune of ocet 2ff ttsutu es TIte so, drnte of ttttoplico ions c;,uted ty At an added benefit, dtroscic progrensise antI symptotson ti((t(( ptwcrtt(rstt, (tt ( clotttttg ftc hep tittr egitoett sw resy small i nthrs- mo osin tofhtienc) ftdlowing tcttte tftossd,,,- time of ores 01 sn ttto t,-c scifto ((t(( titer ert- Do t(t(( tttte st-t iet, he rrlortetl. seitl ton ly sec-cit pldefdtit sttts ,ltnott totcdl) tf.arttt in the dencr of itnprosents-tw. At titis ~ront, Dr. Stdl- d ftc 107 fttUirt(tttltt c'lopitg tfinkafl ,foctt Dowmtate patiettt grotp. Stir l,asc- twtl seen mast nod Ins allrtgttes fttgtss tapeting tlte ttwnted pol tttttt, .trc et((ltofi - notte of shr,o tfte chrottically tsco lien tfnomfopldrlitic heparin fose. ft,tttl - a attv titoe (I toitt g or of er tlera~ty littth toe_re oftccrsrtf in oospt(tients orated tty "At the ltrgtttotng ((0 (reatsoent sorrr eto an Afanot,,tal ltlertlittg ftristg tfterttpy o (((((ret 1 otlter tc(l(oie f(o(,' ftc cooclittled. 4 CLINICAL TRENDS IN CARDIOLOGY/JANUARY-FEBRUARY 1976 PAGENO="0244" 14150 CO1~~ETITIVE PROBLEMS IN THE DRUG INDUSTRY PAGENO="0245" 9161 ~ NI SON~1 1YDINI1D P a~ ~ ~L6I `U~-~I I :8L u'~~ U! P~tI~II(Ifld ~! I~Od III; U~~L II S~~I 01 p.)ddOi1) ~~J- IW~ ~PI I)~A~ I ~-~---J ;u )I~fd ~U() .) I!fl11 l)U~IL~!~IU ~ I'I~~"~H A!I~~II!UI IJ!tI~t ~.u~ajd )!I)I~'~ n&oi~ nQ~-9i;P (~I~) I~~L ~(I()l AN ~OA~N pur * ~l *~iE:) `I I)~1II!M ~`(I *)1J~ tIO!II~! ~!J!1~ .c Io(I~~ 10I1J~~1) ~ ~!u~~' . 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I - 303 111)3)30)1)0! 0l30Ino)3l!d 1! 11)310)033) fl~3 ~1dWO) JO 3)U3p330i ~ IwO .003 030U0303 1S4UOQBd IVJ ~ JO~ fl33 aq~ JO~aJ~ 1 3131 UI P11)1331 311 - 30)! 3)31(1 JO 0031p3)!033 J~J~'J AHJ1~f1QNI OflUcI tEIHJ4 NI ~\It~E~IUO~Id c~IALLIJ1adJ'\TOD PAGENO="0246" 14152 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY W:0~Mt?~ s~q ~1Msta\ r I t*$Řte*a~ps* *~M~~st4 ~ :~:~~` ~ ~ <~p ~ ~ ~ s~: ~ ~ ~ ~ ~ ~ :~ ~ ~ ~ ~t~OQ~ fl ~ ~ ~Iiksp-.ne *,*~P~~at~a t~ ss ~ean~I-e ~ ~ ~ts .harn:flnhisteset ~a ~1fl$k*~S~tS 4flwb t t~ ~ .1~ ~ ~ ~ j ~tW*V~)bSa*%tO4V~P~SSY ,Ns;1*Itd$ qkn*SSrca~dkwS ~ ~ 1! WWW' WW~kP audte ř~s*ttn * *k$b t~ hIM th4fl *IStSb4k$hř~ ~ twwnp~nr4~ y4$$W ~ ~ gw*i~Ssaa~op~s* ftndMWt 9 thiS1~ S*AtWW~4~ *ts aa~a:atr't~rar~ r~r*4s*~~Sk ~r~t*_~ ~an%~w ~ b *~" ~t ~ ~ ~a SMS S'stt ~ -S .iNi c `;~ps~tetttg ~ ~ 4 ~ ~ tnltaer=t:t= ~ \~ ~ ~: ~ ~ ` ~ ~ ~ did ~* ~ ~e# t~ndd ~ ~ lMYfll&EMkC "` ~ ~`\" ~ ` `~ ~ ~% ~ ~ ~` ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~. ~ ~g*~~a~*$k I c&a1s$:bnss*p~pMEZ~tYssr%~~ ~ ~ ~ _ ~ ~ ~ 9 PAGENO="0247" COMPETITIVE PROBLEMS IN THE t)RUO INDUSTRY 14153 * M~i~t7~mâi* I ARDIOLOGY ~ ISSUE HIGHLIGHTS NemVa~k, N.Y. 10022 Managing Geriatric P Self-Help in Thrombophiebitis -Page ssraiglttened for introduction throu catheter. "We haveosed clover leaf and spiral filter designs and are now moving on ba fine mesh produced by crisscrossing wire loops. 1~he size of the mesls openings is only 2 mm square, small enougis to block ftc passage of even tiny emboli," Dr. Simon reported. Further animal experimessts wilt he con- ducted so establisit the alloys efficiency, as well as its Isiologic ellecss on 1)100(1 (1otting, liver function and other bodily fstnctions, he said. Tests on patients ne foreseen in one to two years if the present researds ptotocot con tinues to go well. Collaborating witls Dr. Sitsson on the nsesal. lnrgical aspects of. ftc filter js Professor Roy Kaplow of sise lsf,sssaclsstselts lnsfitute of `I'eclsnology, His cotlaisorators in clinical re searcls are Drs. F.dwin Saheotan nid David Penman of Harvard. "We believe,' c~nclndetl I)r. Suntan, "tlsat site filter represents only the first of many in vivo applications of sIte remsrkabtç thermal. memory alloys. i'bcre ate otlter instruments of complex shape tiost could Isenefit from this method of easy insertion and emglacemetst. inchstding devices for use itt arteries the Iseart, tise bronchi, use skeleton, ansi the uterus." of the vena s.sss. A Shepkr Appsoach If the wire proves safe in humans - it has so far been tested successfaslly in dogs - it would represent a much simpler approach to preventing emhoti from reaching the longs than the traditional lipation or clipping of the vena cava or its otastruction with a Mobin. Uddin umbrella, Ise noted. TIse former pro. cedure requires aladominal surgery, white the latter involves a cusdown in a jugular or fe moral vein. "The `memory' wire needs no other inlet titan the angiOgrlpisic casiseter already introduced fordiagnossic pnrpnses," Dr. Simon said. To prevent prematstre transformation dur. ing its passage tisrough tise catiseter, the wire is bathed in a coot solution below its trigger. sng tenaperatore wisile it is being introduced. Once in place an(l in its filter form, it "effee. tively sssbdividrs tise cross section of site vena cava nb a multitude of small openings that allow lalood to pass shsrougis, lasit not emiaohi risk of internal bleeditsg - sh -- suffered cerebral hemorrisages, undergone cc' cent surgery, or sststained fractures or other ~ `underlying metallurgical break. througls was achieved, at the ifS. Naval Ordnance Laboratory as a result of work by Dr. William Buehler on nickel/titanium al toys (Nitinot) in tisr mid.1960's. `I'be alloys were oesginally inuetsslrd for use in space an tennas. In addition to their unique nlsape memories, these alloys are 000snagnetic and are resistant to corrosion, oxidation and abra. sion - all distinct advantages in biological applications. In its straiglss.wice pisase, the alloy used by Dr. Simon has to he kept at a trtstpecatore of about 5O~F. Its transformation into the filter is completed at aiaout 9O~F, comfortably be' low hotly temperature. The filter shape is programed into the wire by winching it onto a jig at the lower temperature and ausneahing is its a furnace at about t,020'F. TIse nice is then cooled aod Rx For Acute Aortic Dissection - Page 2 Lithe U.S.A. PAGENO="0248" 14154 COMPETITIVE PROBLEMS IN TEE DRUG INDUSTRY The legal status and importance of medical records is changing, accord- ing to physician/legal expert Harold L. l{irsh. Consider, for instance, that medical evidence now plays a role in about 75% of all civil cases and in about 25% of criminal cases brought to suit. "Health care providers" such as private physicians or hospitals are re- sponsible for keeping a patient's medical records confidential; failure to do so may constitute legal grounds for negligence or invasion of privscy. In the past, medical records were considered the possession of the pri- vate physician, the hospital, or clinic. Since the courts have ruled that a patient has the right to a full and frank disclosure of all facts related to his physical condition, this gives the patient exclusive control over infor- mation pertaining to his health. And, although the health care provider has a right to keep the original record, the patient has an absolute legal right to the information contained. He is therefore entitled to a copy. Nurses, technicians, and orderlies whose work may be included in the patient's record also have a right to review records should they become "interested parties" in a legal case. In addition, insurance companies, attorneys, and health care providers have the right to inspect a patient's record with his permission. In ruling on medical records, the court recognizes two types of owner- ship: 1) the traditional ownership of physical materials that comprise the actual records and 2) ownership of * Records must be stored for the required statutory period. * Poorly kept or inadequate records may be considered a breach of the accepted standard of medical care. This would be a factor ins mal- practice case. The patient is responsible for the cost of duplicating his medical rec- ords. Nonpayment of a medical bill is not a legal reason for failing to reproduce the record on request. The court's decisions appear to be based on the legal principles that establish a patient's right to control his own body, his right to give informed consent to medical manage- ment, and his right to obtain complete medical information. The ultimate legal conclusion is that a patient bass "right of access" to his or her own records. Atthe same time, the courts have established the doctrine of profes- sional discretion regarding the prepa- New Computer in the Office You'll surely have no problem in scheduling patients' appointments- or in bffiing-now that a minicom- puter is being installed in your office, But B. Menkus, who understands the pitfalls, says there are several con- siderations. The first is whether your office computer will in fact do what's been promised by the salesman... then whetheryou can afford to have it work! Using a minicomputer requires more advance planning than most people realize. Furthermore, you'll probably need to be involved in the planning process more than you'd like. Then, various problems that your salesman cannot be expected to solve may develop only afterthe system is operating: * Dataerrors-'which often appear as billing mistakes. These are caused by minor typographical errors that occur in "feeding" information to the computer via typewriter. Be- cause of their likelihood, data errors are "almost impossible to prevent and difficult to correct." * Employee salary escalation-Suc- cessful computer operation requires a skilled operator familiar with the routine of your office. Trained indi- viduals are hard to find-and once you've trained such a person, expect to see them tempted by a higher salary in some other office. ration and dissemination of records. This means that a physician may decide to withhold psrt or all of the patient's record if he believes that the medical information will be detri- mental to the patient. Reasons for any such refusal should be documented in writing. RCcords are rightfully transferred to any physician who takes over the patient's care, in accordance with an AMA JudicialCoundil decree. (Hirsh HL: J Fam Pract 2:213, 1975) is reason Corrections, additions and deletions on medical charts and records should be made properly. Data should not be removed, tampered with or substituted once the record is made. * All changes ins patient's records are best made in chronological sequence with adequate explana- tions regarding the reason forthe change-again, without altering the original entry. * There should be no attempt to improve legibility of the original entries. PAGENO="0249" COMPEPIPBTE PROBLEMS IN THE DRUG INDUSTRY 14155 . Inability to handle exCeptions-A that Dr. Rizzone, a former pedia- Talkies Rated 4-Star in standard data processing system trician, now devotes his entire practice Educating Patients designed to handle only routine sit- to adolescent medicine. Sonic pedia- uations is provided by the salesman. tricians set aside one or two after- Machines that show films from behind if a patient's bill is paid by her son- noons a week treating adolescents the screen (so-called rear-projection in-law who has a different name and exclusively. Their assistants ssvitch devices) are helpful in educating a address, the computer is befuddled the Mickey Mouse/Bambi-typc deco- newly diagnosed heart patient, or per- unless it has been programmed (cx- rations and Sesame Street magazines haps a diabetic, about his disease. pensively) to deal with such unusual to something more suitable for tcen- Teaching devices also make your work situations. agers who are "too old" for the pedia- easier. During an office visit, the trician-but still "too young" for the newly diagnosed patient is escorted to Unanticipated expenses-Before internist (ie, patients between the ages the console; you select and insert the the minicomputer can operate, your of 12 and 2 1). So the adolescent stage appropriate film cartridge, seat the office may require expensive is an awkward one, even in medical patient in front of the screen, press changes in electrical sviring, in- practice! "on" and retreat until the film ends. creased storage space, and even . He will then usually have additional - How does adolescent medical care oc e ,spLua Y in u a ca inc d'ff-r fr, `diatrics't Primaril ou questions for you or the doctor. Try for tape cont~inin~ onhd ntiii di 1 with th y ung p nient nat the t( Ii in th patient n probt ins data on patients. parent. For instance, on the initial concretely to the points emphasized in On the other hand, using more visit, the patient and the parent may the him. You must be familiar with complex computer systems, pioneer- e , p - tient's problems... En one survey of ing family-practice groups have fully dential questionnaires, patient educational materials, a rear- computerized their patients' medical You must try ts) gain ttse confidence projection systens svas rated most records svith exciting results. Case his- and trust of difficult patients such as effective; next were written educa tories are read from a 1'V-type the withdrawn teenager with a tional materials (such a~ hip charts) screen. All records on file can be sprained wrist who is secretly devas. for "lecturing" a patient And al- checked by computer to find out which tated by aciie, asvkward physical though booklets are the simplest, patIents need a "reminder for a flu niovements, and conilicts about rated least effective are the booklets shot. The type of patient complaints emerging sexuality. That's why. be- distributed around the waiting room. reported can be periodically reviewed, sides treating the usual colds, sore In contrast, those you hand directly You can rapidly obtain printouts of throats, and sprains, Dr. Rizzone also to the patient are likely to be read. the patient's history for a consultation; counsels adolescent patients regard- (Neff 1: Physician's ft.'Iaitagement complete the morning's billing in OflC ing their problems of sexual adjust- 15[81'35-D 1975) hour: and even help to spot trouble- ment. Referral to a psychologist ntay in-the-making by reviewing trends on be necessary. Another major respon- a patient who has shown a steady sibility of the specialist in adolescent Does Prenatal Education rise in blood pressure over the past 6 medicine is family counseling, since Really Make Childbirth months. (Menhus B: P/isician's the biggest problem of the adolescent Easier? Manags'ment 15[71.59-GP. 1975; may tot be medical but rather the Patient Care 8151.68, 1974) struggle between parent and teenager Many educational progranas have for control. This conllict becomes been developed to improve the acute in,a patient with a chronic dis- expectant mottser's attitude toward _____________________________________________ ease such as diabetes; his parents childbirth and train her in the role may insist on supervising the admin- she can play during labor. One of the I istration of insulin, whereas he feels best known, based nit Pavlovian prin- competent to care for himself. If par- ciptes, was developed in Russiain cuts are afraid to gratit independence 1945. It was introduced by Dr. to the teenager with a chronic disease Fernand Lamaze to Frenchwomen in When a Teenager Phones, both the parents and the patient may 1951. The so-called Laniaze method, It's Important! deny the severity of illness, to the or variations of it, is widely taught in detriment of the patient. The plmysi- this country. So says George P. Rizzone, MD, clan and his assistant tire caught in pediatrician turned specialist in ado- the middle, The Lamaze method is aimed at lescent medicine. He finds that a lessening the anxiety of the prospec- phone call from an adolescent patient It's clear that the medical care of hive mother by providing information is rare unless something "very im- teenagers takes time and diplomacy, thatwill correct any misunderstand- portant is going on-either medically particularly because they mistrust ings about childbirth. It tries to or psychologically." You may have adults, it takes people like you to help develop more positive attitudes to- observed this in your own office. At them feel secure while they cope with ward pregnancy and thus, achieve a any rate, it's a good idea to give that medical and psychological problems, quicker, easier delivery. Since much adolescent priority, It's svorth noting (Campion EW: Pris,n 3181:41, 1975) of the anxiety surrounding childbirth PAGENO="0250" 14156 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY is thought to be related to the antici- pation of pain, the expectastt mother is taught how to relax so as to overcome physical tension that might produce pain. She is taught to copcentrate on complex breathing techr~iques syn- chronized to changing 6terine con- tractions. Thus, attention is shifted away from any pain associated with the contractions. Bodybuilding exer- cises are also recommended ass means of preparing for a comfortable delivery. Husbands are included in the program forboth emotional and practical support. They become an important part of the labor and delivery process by being present in the delivery room, Any anxiety-reducing effect of the Lamaze program could not be con- firmed by psychologic testing. The Lamaze-trained primiparas and mul- tiparas required less general anesthe- sia or nerve blocks than did multiparas who had not taken the course. Re- searchers conclude, therefore, that childbirth education courses such as the Lamaze program d6have objec- tive benefit. For more conclusive evidence, psychologic tests need to be targeted specifically toward the an- xiety provoked by pregnancy and concerns about delivery, according to this group of psychologists. (Zax M, et at: Am J-Obstet Gynecol 123:185,1975) ~~hN~ting Tlpster's Tips Bone upon those medicalterms-You may wish to consult the Manual of History Taking, Physical Examina- tions and Record Keeping, a text by EL. Raus, Philadelphia, J.B. Lippin- cottCo., 1974. (588 pp, $18.00). This will introduce you to numerous medical terms, and better still, it provides a glossary of medical terms plus their lay equivalents. Procedures described cequire anunderstanding of normal andpathologicanatomy and physiology. This text has been recom- mended for physician's assistant progcams. To crush a tablet-Place the unopened packet containing the pill between the jaws of ahemostat. Clamp down several times until the pill is reduced to a fine powder. "Most of these packets are made of strongpaper, and if care is taken, the patient will receive the entire dose." (Smith FM: RN 38 [71:53, 1975) About that Pap smear-Any sexually activewomanshouldhave Pap smears evaluated routinely; once a year is adequate for most women of child- bearing age. However, cancer patients should be tested every. 3 months dur- ing the first year, then every 6 months. Unless there are other risk factors, simply taking the pill or having an IUD does not necessitate semiannual examinations. (Patient Care 9[11J:112, 1975) Hold on to that slippery thermometer _Oldenoughforanoraltherltlometer * too young to keep it in the mouth? Famil$ physician, L.P. Lapin, takes the oral temperature of young chil- dren while they are lying down. If the thermometer does fallout, it drops only 2 or 3 inches to the examining table. What's more, children seem to keep a thermometer under the tongue more easily while lying down. (Patient Care 9[5]:96,1975) Learning Systems for Physician's Assistants The educational publishing division of Bobba-Merrill (4300 West 62nd Street, Indianapolis, IN 46206) has publIshed a series on Allied Health Occupations. These consist of soft- bound books with accompanying audio tapes, lab manuals and teachers guides (if needed) designedtoprovide the basics on 19 subjects such as medical office practice, medical rec- ords technology, physician's assistant techniques, patient-care techniques as well as the basics of anatomy, clinical chemistry and other important subjects. There are 19 core subjects; prices range from $4.95 to $7.95. now read even more body language N" Multisthi Read more, and you'll know more about your patients: hypertensive, cardiac, alcoholic, diabetic, bacteriuric.. .even perfectly healthy. America's foremost urine profile is now even more com- prehensive, providing 8 sensitive, specific checkpoints for more meaningful clinical evaluation-~in just 60 seconds. 3 impi~ved tests: more sensitive l3itirubin snd Occult Blood, a semi- quantitative Glucose determination. A brand-new test area, for Nitrite, demonstrates the presence of significant ba"~-riuria. 4 well.aCccnt Ketoneo, 1 p'.. - - tI Closeup of Detergent Hands When you examine cello obtained from the normal skin of palms and fingertips under a scanning dcc- Iron microscope, you see bristly, PAGENO="0251" COMPEPITIVE PROBLEMS LN THE DRUG INDUSTRY 14157 tentacle-like microvilli. One researcher reports that those bristles disappear in patients with housewives' dermatitis. Cell formation becomes flat ormisshapen after the hands are soaked in detergent. However, these cells seem to be normal in patients with psoriasit or eczema. A puzzling observation; soaking in Water pro- duces nearly the same destructive effectonthe stratum comeum asdeter- gent. It is believed that detergents exert a chemical effect 1) directly on keratin or 2) indirectly, by simply removing the normally protective oily film to expose the keratin. It seems that wearing rubber gloves for rinsing may be a good idea. (Earn Pract News 51111:31,1975) Airport X-ray Machines: How Much Radiation? Accordingto LaurenceE. Holder, MD, radiation has conjured up grotesque images of destruction ever since the atomic bombing of Hiroshima and Nagasaki.. .This may account for the emotional reaction some people have concerning x-ray machines installed aspart of airport security. The Bureau of Radiologic Health, a Division of the Food and Drug Administration, is responsible for keeping radiation exposure as low aspossible. Their gsideliues require that radiation emitted outside the system not exceed 0.5 millirosntgens (mE) in one hour at 5 cm from the equipment. And in reality, exposures are below detect- able limits... In the minute it takes you to'walk past the detector, the radi- ation intensity is about 0.0021 mR. (The roentgen is a measure of expo- sure in air, whereas a rem is a measure, of the amount of energy deposited in tissue.)The genetically significantdose of radiation is estimated as probably less than 20 mrem. Nonoccupation- ally exposed individuals should be limited to 170 mrem/yr. (HoklerLE:JAMA 233:1393,1975) Ames Company Division Miles Laboratories Inc. Elkharilndiana46bl4 PAGENO="0252" 14158 COMPEPIPIVE PROBLEMS IN THE DRUG INDUSTRY PAGENO="0253" COMPETITWE PROBLEMS IN THE DRUG INDUSTRY 14159 diagnostica Number 35/February 1976 ~ Aninternational journal decotedto the techniques and logicof diagnosis; published in English, French, German, Italian., Japanese, Portuguese, and Spanishand distributed quart erlyinl2il countries. Cover As many as 15-2Oro of the female population will develop bacteriuria atsome stage of lice, notably in the preschool and elementary-school years or during pregnancy. Furthermore, the female child is prone to develop ureteral reflux as evident in the cystourethrogrsm. These and other factors that predispose toward bacterisn-ia in females- together with the ultimate possibility of permanent renal damage and the indications for diagnostic monitoring-are evaluated by Morris Notelovitz, MD, on page 4. Articles 4 Bacteriuria in Females by Morris Notelovitz, MD(Rand),MBBCJ1. MRCOG 12 Amniotic Fluid Analysis in Diagnosing FetalAbnormalities by Takashi Wagatsuma, MD 19 Post-traumatic Ventilatory Disorders by William A. Cook, MD 16 Dry-Eye Syndrome by Marcia Spinak,MD, and Paul Henkind, MDPOD ~7 TheLady from Alabama by Richard D. Altick Harold Lastmas, MD, PhD, FACS (Chairman), Surgery, NewYork, NY, USA. Maurice Cloarec, MD, internal Medicine (Cardiovascular Disease), Paris, France Alvan It. Feinssein, MD, FACP, internal Medicine (Epidemiology), New Haven, CT, USA Khoo Oon Teik, MD., FRCP (Edin), FRACP, FRCP (Clas), internal Medicine, Lesn~rILLsvshin, MD, FACP, internal Medicine, Cleveland, OH, USA Morris Notelovitz, MD (Rand), MDBCH, MRCOG, Obstetrics and Gynecology, Durban, South Africa John Resdle-Slsort, MD, Pediatrics, Brisbane, Australia Bernardo Reyes-Leal, MD, FACP, internal Medicine (Endocrinology), BogotO, Colombia Robert VslpA, MD, FRCP (C), FACP, Endocrinology, Toronto, Canada Takashi Wagatsuma, MD, DMSc, Obstetrics and Gynecology, Tokyo, Japan J. M. Botero, MD (cx officio), Elkhart, IN, USA Published by Africa-P.O. Box 17479, }lillbrisw, Transvaal, Ssuth Africa Ames Company Canada-77 BelfielcI Road, Rexdale, Ontario ~ Division Miles Laboratories, Inc Europe-Stoke Court, StokePoges, Buckinghamshire, England FarEtt.st-P.O. Box 203, Springvale, Victoria3l7l, Australia Japan-Daiwa Honsha Building, 9-7, Cinza-1-chsme, Chuo-ku, Tokyo Latin America-Apartado Aereo 10472, Cult, Colombia United States-1127 Myrtle Street, Elkhart, Indiana 46514 Pictoclinic® Tales of MedicalDetection MedicalAdvisory Board PAGENO="0254" Bacteriuria is one of the most common bacterial infections to affect females.' Because of its cyclic pattern, the number of females who develop bacteriuria at some stage of life is at least three times greater thae the total who are bacteriuric at any one time.2 On this basis, it is estimated that 15-20% of females in the economically developed rountries may be affected at some stage of life.' Prevalence The prevalence of bacteriuria varies according to age, social background and ethnic group, as well as the clinical situation.' Screening surveys for bar- teriuria among preschool children have shown that 1-2% of girls tested had infected urine, whereas this finding is rare among boys.'5 The incidence of bee- teriuria decreases somewhat ih girls at the secondary- school level,6'7 An increased incidence is again observed during pregnancy, when 3-8% of pregnant women may be expected to develop significant urinary infections. The incidence of bacteriuria is also higher among hospital inpatients and outpatients than in the general population. Indwelling urethral cath~- tees are clearly implicated,' with females hav,ng a higher rate of catheter-associated barteriuria than Bacteriuria Defined Urtne, which is normally sterile, provides *an excellent culture medium for many microorgantsms. The clinical problem of differentiating a urine culture that is positive due to simple bacterial contamination from one that is referable to significant bacteriuria and clinical illness was resolved by Kass.'°"2 In pioneering studies, Kass found that patients with bacterial counts greater than 100,000. colonies per milliliter of urine usually had similar bacterial counts in subsequent specimens, and that the organisms presentwereknownucinarypathogens. Lowbacterial counts usually involved urethralcommensalsor mixed gram-negative and gram-positive organisms, sug- gesting that contamination had occurred. On re- examination, the urine usually proved negative for bacteria. The term significant bacteeiuria therefore means that bacteria are actively multiplying in bladder urine, and that `true" infection exists when the bacterial count reaches 100,000 or more colonies per milliliter of urine. This value may be expressed as 10~. Aaytnpfomatic beef eriuria- Covert or "asymp- tomatic" bacteriuria-which is extremely common- ref era to significant bacteriuria in the absence of any subjective urinary symptoms. Only two fifths of the bacteriuric schoolgirls who were recently surveyed had subjective symptoms.' In contrast, Mond et al'3 found that 50% of the female patients seen in general practice for urinary complaints had bacteriuria. Ob- viously, the presence or absence of dysuria, urinary frequency, or nocturia-symptoms typical of urinary tract infection-can be misleading. One can only rely upon the accurate bacteriologic examination of the urine f or accurate diagnostic information. CLINICAL SIGNIFICANCE OF BACTERIUBIA Pyelonephritia and renal failure. A major concern about bacteriuria is its potential role in the develop- 14160 co1~rPETI'rIvE PROBLEMS IN THE DRUG INDUSTRY Bacteriuria in Females Detection, Preva1en~e, Implications by Morris Notelovitz, Mi) (Ranit), MRBCH, MRCOC5 *gesearch FellowandClinicaltnStraCtOl, Departmentot Obstetrics and Gynecology. Universityof FloridaColfegeot Medicine. Gainesville. 4 Ames/Diagsos6ira PAGENO="0255" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14161 ment of chronic pyelonephritis and, thus, in renal failure. Follow-up studies of individuals who had documented bacteriuria at least ten years earlierwere rather inconclusive; although some of them dem- onstrated radiologic evidence of chronic pyelone- phritis with signs of renal malfunction and azotemia, the majority had no apparent renal defects. Incon- clusive results were mainly due to the small sample evaluated.' But to obtain evidence of whether the treatment of bacteriuria actually protects patients against a~qufred renal lesions, a controlled clinical trial involving some 100,000 patient-years would be Asymptomatic pyelonephritfs. There is increasing evidence that bacterial infection of the kidney need not be accompanied by the classic features of acute pyelonephritis, and that abnormal renalfunction may exist f or months before the symptoms of pyelone- phritis appear.'-" Beumfitt and Condie'4 referred to this as `asymptomatic" pyelonephritis. The wedge- shaped distribution of infection in thekidneysuggests that the most likely invasion route is via the collecting tubules as a consequence of infection ascending from the bladder and ureters."6 1-lematogenous infection can occur, but usually only when bacteremia is mani- fested.' Early detection of bacteriuria and asymp- tomaticpyelonephritis is clinically important, because renal functional abnormalities-evidenced by a deterioration of renal concentrating ability and the presence of specific antibodies to kidney tissue-can be reversed by appropriate therapy. Normal renal function is then restored.' Bacteriuria during pregnancy. The spontaneous cure rate of bacteriuria duringpregnancyis estimated as only 8%, compared to 20-25% per annum' in non- pregnant women. The difference is probably due to the dynamics of incomplete emptying of thebladder during pregnancy. Therefore, the incidence of symptomatic infection is high among pregnant women; an estimated 20-40% risk developing pye- lonephrltis later in pregnancy."4 The risk can be eliminated by treating a pregnant patient before clinical illness develops.' Perlnatal risk. Although maternal pyelonephritis is clearly associated with the occurrence of premature laborand perinatalloss, a possible contributory roleof asymptomatic bacteriuria is less certain. According to some researchers,' 10-25% of bacteriuric women deliver prematurely. However, variables such as race, socioeconomic background, smoking habits, and a history of reproductive loss (ie, abortion, stillbirth, or neonatal death) also play a tole. Women with bacteriuria who subsequently develop pyelone- phritis during pregnancy do have a high risk of delivering prematurely; the risk may be reduced by treatment. Thus, Condie et al'1 and Elderetal" found Prevalence of bacterlurla In females accordIng to age. 1:1 . - I 70 Age (years) Ames/Diagnootipa 5 PAGENO="0256" 14162 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY that a high rate of premature births in pregnant women with bacteriuria was limited to those whose bacteriuria either relapsed after treatment or proved unresponsive to therapy. Patients whose infections cleared completely usually did not have an excessive- ly high rate of premature delivery or othermorbidity. Because recurrent disease is frequently associated with evidence of renal involvement, it appears that renal involvement per se predisposes toward excess perinatal risk, rather than the persistent bacteriuria.° In short, since the early treatment of bacteriuria prevents symptomatic disease, its prevention should substantially decrease the incidence of premature births accompanying symptomatic pyelonephritis. Bacferlurla In schoolgirls Although bacteriuria is clearly prevalent among sthoolgirls, it is not known whether this may present an eventual health hazard. Screening surveys have shown that between 1-2% of schoolgirls have infected urine.3°'7 Approximately 30% also had vesicoureteral reflux, and 26% exhibited radiologic evidence of pyelonephritic scarring.4'7 Most had little or no history suggesting previous urinary tract infection. Pyelonepheitic changes are thought to develop from the combination of covert bacteriuria and vesicoureteral reflux. Pyelonephritic scarring is probably nonprogressive unless it is associated with severe vesicoureteral reflux.'° Most vulnerable in this respectarechildren under the ageof five,21 since renalscarringis morelikely to occurwhen the kidney is not fully grown. Persistent bacteriuria in children is associated with a genitourinary abnor- mality in 5-40% of cases.1 Bacterlurks and hypertension. Kass estimates that 10-20% of hypertensive females may have an associated bacteriuria, However, it is not clear whether the bacteriuria itself leads tohypertension, or whether the renal vascular disease and resulting kidney damage predispose toward setondary infec- tion. Available data favor the hypothesis that bacteriuria is associated with hypertension directly, rather than indirectly through secondary infection.' Cafheterlzaflon and bacferlurla, Urinary infec- tion acquired during the puerperium or after gyne- cologic surgery frequently is due to catheterization. Brumfitt et al" studied 320 women known to have had sterileurinebeforedeliveiY Ofwomenwhowere not catheterized, 4.7% developed infected urine during the puerperium. Incontrast,B.t% ofthewomen catheterized only once for specimen collection developed urinary infection. Of those in whom catheterization was performed for clinicd reasons, 22.8% developed bacteriuria. In women with urinary retention, the incidence rose to 40.6%. The majority remained asymptomatic, and the urinary infection either resolved spontaneously or cleared following one course of chemotherapy. Catheterization following gynecologic surgery is also associated with a high incidence of urinary infection, especially in thosewith indwellingcatheters andopen drainage. In contcastto therapidresponseof urinary infections during the puerperium, bacteriuria that develops atter pelvic surger~frequently persists. Simmons and Baker'3 studied 47 women who had undergonevaginoplasty six years previously; in3t.9%, significant bladder infection was distovered. In all instances, infection was attributable to operation and catheterization, Although such infections usually do not produce serious renal damage, the sequence of catheterization followed by bacteriuria, pyelone- phcitis, bacteremia and, ultimately, death hat been reported.' Such complications can be prevented by applying appropriate techniques in dlirrying out 6 Ames/Diagnostics PAGENO="0257" COMPETITIVE PROBLEMS IN THE DRUG I]SThTJSTRY 14168 catheterization and by using closed-circuit drainage systems.8 DIAGNOSIS OF BACTERIURIA Pour-plate technique. The accepted methodology for diagnosing a significant urinary tract infection is quantitative bacteriology; the standard procedure for counting bacterial colonies is the pour-plate tech- nique. According to this method, either blood agar or MacConkey's agar plates are inoculated with aliquots of undiluted urine obtained with standardired sterile loops or pipettes, preferably within minutes of voiding. Plates are incubated overnight at 372C, with blood agar in an atmosphere of increased CO2 tension. Colonies are counted the next day. It is recognized that this standard laboratory technique is liable to variation and error. This has led to the evaluation of other diagnostic methods, many of which provide accurate bacteriologic information and are also convenient and economical. Dip olldea. Brumfitt24 described a simplediagnostic method using a strip of sterile filter paper that is first dipped in urine, then placed on a small agarcontainer and incubated. This technique provides good results, but the differentiation between "doubtful" and "negative" findings is frequently difficult. The dip slide appears to provide the best approach to a fully quantitative method, Dip sliçles, now available from various manufacturers, have essentially the same design consisting of a glass or plastic slide coated on both sides with nutrient agar or an inhibitory selective agar. Slides are inoculated immediately after urine collection and incubated overnight in their sterile containers. Bacterial colony counts ace then estimated by comparing them with the colony density depicted on manufacturers' charts. Dip-slide testing has been extensively evaluated in adults and children; results compared favorably with the pour-plate technique used as control.327'27 A more recent innovation is the application of antibiotic sensitivity discs to the lower end of the dip slide prior to incubation.27 A zone of inhibition around the disc indicates that the organism is sensitive to that antibiotic. Thus, the practitioner may obtain both diagnostic and therapeutic informa- tion within 24 hssurs of urine collection. Chemical method: glucose oxidase test, Chemical methods have also been developed for diagnosing bacteriuria. Scherstén and Frit~28 used the fact that urinary glucose concentrations of less than 0.1 pmol/l Occur in the presence of significant bacteriuria provided that: a) the patient is fasting; b) the urinehas remained in the bladder for 4-6 hours. Loss' urinary glucose concentrations can be detected by a com- mercially available paper-strip test reagent (glucose oxidase) that reflects the small atisounts of sugar utilized durihg bacterial multiplication. A negative result is indicated by the blue color that develops within 10 minutes, while a positive result-equivalent to a urinary glucose concentration lower than 0.1 pmol/l -is indicated by the absence of a color change. This test's major drawback isthatitrequires a urine sample from a fastjng patient; failure to adhere to this requirement leads to false-negative resultt, undesirable in any screening device. For example, in one recent survey of schoolgirls screened for bat- teriuria,3 the glucose-oxidase test strip indicated a false-negative result in 20.8% while the dip-slide technique produced no false-negatives. Chemical method: nitrite test, Still another chemical test is based on the observation that the Criess reagent turns pink in the presence of nitrite formed during the reduction of urinary nitrate by certain gram-negative pathogens such as Eucheeic~tia coli. This commercially available test can detect 60-70% of cases of significant gram-negative bac- teriuria.25'3° Sensitivity is enhanced by withholding micturition for a few hours, and also by wailing at least nne minute before interpreting the test result.29 This method is far from ideal, as-in the author's experience-approximately 30-40% of false-negative results can be anticipated. False-positive results are infrequent.29 According to a recent report by Kunin,7' self-administration of the nitrite test by women ,vho participated in ascreeningprogram resulted inilO% de- tection of those with bacteriuria when three different Ames/Diagnostics 7 73-617 0 - 76 - 17 PAGENO="0258" 14164 cOi~tPET~VE PROBLEMS IN THE DRUG INDUSTRY morning specimens of urine were tested. The results were confirmed by quantitative urine culture. Combined nitrite test, colony counfing, and gram- negative reaction. More recently, a unique diagnostic test strip has been introduced which incorpru-ates a "nitrite-sensitive" pad for immediate identificatfoo of a gram-negative infection plus two culture pads3 one identifies the total bacterial colony count and the other, gram-negative pathogens. The test strip is presented ioasterileplastic envelope. After thestripis inoculated with urine, the nitrite reaction is read and the strip is replaced and sealed in its container, then incubated for24hours, Bacterialdensity is interpreted according to a chart provided by the manufacturer. Advantages provided by this test medium are a) an immediate result that is accurate in about 60% of significant gram-negative infections, and b) it dis- tinguishes gram-negative from gram-positive path- ogens. In a survey of 500 unselected female hospitaF' attendants,32 the author detected a 2.0% incidence of asymptomatic bacteriuria using this method, as compared to the 2.8% detected by a standard labora- tory pour-plate culture. Microscopic examination. Direct microscopic examination of the urineis frequently used as atest for bacteriuria. Its advantage is that smears of uncen- trifuged urine can be stained and examined within minutes. Comparing the Cram-stained urine smear with bacterial counts in urine, Norden and Kass° reported a 20% error by the Cram-stain technique. Pyuria, whichis defined astwoormorewhiteblood cells per microscopic field (centrifuged urine exam- med by high-power microscopy), is usually asso- ciated with urinary infection. Thirre are many other causes of pyuria besides infection, so that at com- pared to bacterial colony counts, this criterion yields an unacceptably high rate of false-negative results.2 Furthermore, the absence of pyuria is not a reliable criterion for excluding the presence of bacteriuria. COLLECTING URINE SPECIMENS Accuracy of any one of the diagnostic methods described is directly related to the manner of urine sampling. For example, urine retained in the bladder for approximately4-6 hours before collection enables any bacteria present to multiply, and thus greatly enhances test sensitivity. This is noticeable with the nitrite test in particular.3° An early-morning urinary specimen is therefore ideal, provided that the test reagent can be inoculated immediately or within one hour of collection. Alternatively, the specimen should be refrigerated at 4-6°C until cultured. The "casual" collection of urine or inadequate cleansing may produce contamination and unreliable results. While transabdominal bladder aspiration is possibly the ideal method of urine collection, it is clearly impractical for screening purposes. A clean- catch specimen is usually obtained easily~ All that is requiredis thatthepatientwashherhandsthoroughly, cleanse the introitus front to back using four sterile gauze swabs soaked in a 10% green-soap sotutiontand separate the labia widely while micturating. Edwards et at3 obtained excellent results among schoolgirls by requesting them to void upon awakening directly on both sides of a dip slide-the so-catted "dip stream." PREDICTING RENAL INVOLVEMENT Care must be exercised when assessing the significance of bacteriuria and deciding on the need for treatment,ronsidering thattherate of spontaneous disappearance of bacteriuria in nonpregnant women is about 20-25% per annum.2 Recurrence of bar- teriuria, appeurance of symptomatic disease, or demonstration of renal-tissue Invasion (especially if the patient is asymptomatic) will require careful assessment, treatment, and follow-up. With regurd to~ diagnosing renal involvement, it is known that patients with pyelonephritis areanabletoconrentrate the urine maximally. This also has been noted in bacteriuric patients who are asymptomatir.°'34 Patients unable to concentrate their urine above 700- 8 Ames/Diagnostics PAGENO="0259" ci 0 1 PAGENO="0260" 14166 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Amniotic Fluid Analysis in Diagnosing Fetal Abnormalities~ Some Clinical and Experimental Observations by Takashi Wagatsuma, MD5 Although the genesis and mechanisms leading to foemation of amniotic fluid have not yet been completely clarified, itis obvious that theananiotic sac and its fluid constitute a "fetal compartment" surrounded by the ch~rion and the placenta, both of which are products of conception. Although water, electrolytes and other solutes contained in the amniotic fluid may originate in part from the mother, the cells and macromolecules contained in this fluid are of fetal origin, and hence would logically reflect fetal properties. Therefore, sampling the amniotic fluid by amniocentesis would appear to be a useful means of detecting genetic disorders of the in- trauterine fetus. Clinical Applications of Amniocentesis The first systematic attempt to sample amniotic fluid for the purpose of obtaining information about the condition of the fetus was conducted in 1952 by Bevis.' This researcher determined the content of bile pigment in cases of erythroblastosis fetalie due to Rh isoimmuniration of the mother. Then, in 1960, Riis and Fuchs2 first applied the examination of amniotic fluid in their investigation of sex-linked hereditary During the past few years, amniocentesis (ie, removal of a sample of amniotic fluid by percu- taneous transabdominal puncture) has been gaining importance as a means of detecting genetic disorders and congenital abnormalities in ufeeo.°° Table 1 lists the indications and tests used in diagnosing various fetal conditions. Prenatal defection of chromosomal aberrations. The cytologic and cytogenetic study of cultured or uncultured amniotic-fluid cells has become estab- lished as a practical diagnostic technique. Inter' pretation of results helps in providing adequate genetic counsel to mothers having a high risk of bearing a child with chromosomal abnormalities. Down's syndrome (mongolism) is one of the many genetic diseases which may be diagnosed by cytogenetic techniques. Among theotherdiagnosable chromosomal abnormalities is 13-trisomy, acondition characterized by multiple coi'igenital anomalies. Enzymes in amniotic fluid. A new and çha(lcnging approach to the prenatal diagnosis of hereditary disease is the analysta of enzymes contained in cultivated or norideittvated cells collected from amoiotic fluid. Reviews of enzymaticstudies describe at least 15 enzymes isolated from cultivated cells. Numerous metabolic disorders have recently been diagnosed in the fetus by enzyme analysis. Sex-linked hereditary disease. The antenatal de- termination of sex is useful in preventing sex-linked hereditary disorders. Although th' --`~oachdoes not permit one to i ca direct diagi " ked diseases, it is ly useful sincer 5~rs fr-m these - ~` ~ ~`` cc be `Assoc,ote Profeosur, Deportment of Obstetr'cs aod Gyoecologt. Universjty or Tokyo, Japan. 12 Ames/Diagnostics PAGENO="0261" COMPETITIVE PROBLEMS TN THE DRUG INDUSTRY 14167 Consequently, this approach could present a serious medicotegal problem- at least in some countries. Congenital adrenal hyperplasla. Jeffcoate et al,9in 1968, successfully predicted the diagnosis of con- genital adrenal hypecplasia from levels of 17-keto- sterones and pregnanediol estimated in amniotic fluid; levels were markedly elevated as compared to those of four normal pregnancies. However, Fuchs and Cederqvist'° do not believe that one can predict congenital adrenal hyperplasia solely on the basis of hormonal levels in amniotic fluid. Amniography and fetogs-aphy. The ability to detect either hereditary or nonhereditary fetal malfor- mations would be extremely useful. Techniques directed toward this goal essentially rely upon visualization of the fetus. Four diagnostic approaches have been taken: roentgenogcaphy, amniography or fetography, ultrasonic scanning, and direct visual- ization, Amniography or fetography are modi- fications of the classic x-ray technique of visualizing the intrauterine fetus, Contrast medium is injected after amniocentesis is carried out. Soft-tissue abnor- malities in the fetus, suchas meningocele, displace the opacified amniotic fluid, permitting the intrauterine detection of abnormalities. Some results of fetog- raphy performed in our department are illustrated in Figures 1 and 2. The first shows a normal fetus; the second, anencephalus. Assessing fetal maturity. There are instances in which pregnancy must be terminated prematurely in te. see; Amnlc method' - ~------.. -~- - fluid v y amniocents tant in diagnosing hydramnios and o,~hydramnios. Clinical Experience with Amniocentesis in9l Women Between July 1966 and May 1973, 141 am- niocenteses were performed in 91 women at the Department of Obstetrics and Gynecology of the University of Tokyo. Indications for the procedure are listed in Table 2. Among these are genetic counseling, diagnosis of fetal anomalies, Rh i~com- patibility, and assessment of fetal maturity, which Ames/Diagnostics 13 PAGENO="0262" 14168 coMr~nPIv1~ PROflLEMS IN THE DRUG INDUSTRY lure. In a ~155~ tO ~e of group was Risk to the mother. There are severalpossible risks of amniocentesis that may affect the mother; however, only a few instances of maternal morbidity have been observed. These risks may include: * Amniotic- fluid embolism * Hemorrhage * Peritonitis * Abdominal pain * Abortion (premature labor) * Abruptio placentae * Premature rupture of membranes Risk to the fetus. Although fetal complications of amniocentesis are relatively more frequent than maternal complications, fetal effects attributable to the procedure ace rare. They have included: * Death due to disruption of fetomaternal circulation or amniOnitis * Injury to umbilical cord * Hemorrhage * Abortion or premature labor due to ruptured membranes * Fetomaternal transfusion * Possible teratogenic effect Experimental Studiei of Amniocentesis The possibility of a teratogenic effect of am- niocentesis recently attracted the attention of several investigators. In certain small experimental animals such as mice or rats, there occurs a phenomenon known as the "post-amniocentesis dysmelic syn- drome." Dr. Jimbo of our department performed amniocentesis unilaterally on a uterine horn of Wistac rats on day 15.5 of gestation. Fifty-four fetuses were delivered on day 21 and examined histologically; animals delivered from the opposite uterine horn served as controls. As shown in Table 4, in the experimental group 43 fetuses were aborted; 30% showed adhesions to the amniotic membrane. In the controlgroup, two fetuses died in utero and none of the 52 sucvivorsshowed any significant abnormalities. Ten of the 11 viable fetuses from the uterine horn subjected to amniocenteiis had ions forAmniocentesis in 91 Cases `Toe pct:ssts had ms,a this see :sd:satO~ is, ass:QCastas:S t obtained in ble 3). e entir: `Nusbass :s pa,estseses :sd:satasases :s as:ss d:sgsss:s ssud set bo t4 Ames/Dlagnostica PAGENO="0263" a z 1' I. PAGENO="0264" 14170 CO~flETITIVE PROBLEMS IN ~HE DRUG INDUSTRY PAGENO="0265" COMPEPIPIV1~ PROBLEMS IN THE DRUG INDUSTRY 14171 PAGENO="0266" 14172 CO~ETITIVE PROBLEMS IN THE DRt~G INDUSTRY PAGENO="0267" COMPETITIVE PROBLEMS IN THE DRUG TNDUS~RY 14173 Among the moSt completely undera is sudden pulmonary failure following surgery or trau- matic injury. Varlos~s post-traumatic ventilatory disorders may arise in severely injured patients Ex- amples are the so-cglled~"low flow"lungsyndromeor shock lung, pulmonary burns, wet-lung syndrome, pulmonary fat embolism, ventilator pneumonia, and hematogenous pneumoisja. Therapeutic diffitulties may arise from either a confused or an inadequate differential diagnossis, For clinical emphasis, therefore, these disorders will be discussed in the order in which their manifestations areseenclinically. Pulmonary burnoandwet lungareeachcausedbya direct injury to lung tissue so that their onset is immediate. Low-flow lung and fat embolism each have an intermediate onset, whereas ventilator pneu- monia and hematogenous pneumonia are the last to occur, and may become. superimposed on any pre- existing ventilatory disorder. IMMEDIATE ONSET Wet-Lung Syndrome This type of post-traumatic pulmonary disorder results fromaseverebruisetolungtissueltself. During World War II, Brewer and coworkers3 observed the post-traumatic wet-lung syndrome in casualties who were exposed to a blast or who had suffered a crushing blow to the thorax or abdomen. Ip such instances, compressive energy is transmitted via the chestwallordiaphragmtothelungcOnfined, asitts, in the thoracic cage. The sudden compression of lung tissue ruptures the small vessels and produces hem- orrhage and edema, both interstitial and intra- alveolar. Wetlung is suspected when there is ahistory of eothpressioainjury together with art early onsCf of pulmnnarysymptoms. Ordinarily thtsditordercaobe identified when the patient is admitted to the emergency department. In a patiAnt with the wet-lung syndrome, the chest x-ray shows diffuse haziness-either local or wide- spread-in one or both long fields. Upon physical examination, one finds rales and rhonchi; and, if the lung is badly injured, therg may be' evidence of consolidation. Hemothorax or pnenmothorax, or both, may be present (Fig. la) The bruised lungonay be identified byreexpandingthecollapsedlungthatis on the injured side of the body `(Fig. lb) Arterial blood-gas analysis reveals hypoxia whose severity is consistent with the severity of lung-tissue injury. fly- poxia is related to a loss of compliance that results from the exudation of plasma and which, conse- quently, interferes with surfactant function. Factors that contribute to hypoxia include: * Mechanical rCgtriction secondary to pulmonary- tissue edema * "Physiologic shunt" effect in perfused but nonaerated lung tissue * Restrictive effect of injury on the chest wall Fortunately, mostpatientswhosuffer from thewet- lung syndrome will respond well to appropriate treatment (Fig. ic) Pulmonary Bums Pulmonary bums are usually associated with facial bums or with bums sustained In a confined apace, and are therefore suspected in any patient who has suffered severe burnt under those conditions. Cytologic examination of the sputum (ie, exfoliative cytology) helps to pinpoint the diagnosis. Further- more, sucbpatientsoftenrequiretracheostorny;visual inspection of the airway at thattime may confirm the diagnosis by disclosing edema, erythema, Or actual scorching of the tracheal mucosa. Post-traumatk~ Venti~ `Associate Visiting Canical Professor in Surgery and History of Medicine, Albert Einstein College of Medicine, New York; Muto Thoracic CUnic, Lawrence, Massachusetts. Amra/Diagrasaatka 19 PAGENO="0268" 14174 Coi~~xrEPITIVE PROBLEMS IN THE DRUG INDUSTRY Early in the clinical course of a patient with pulmonary burns, the chest x-ray usually reveals a diffuse alveolar exudate with local areas of atelectasis due to thepresenceof edema fluidinthealveoliand to bronchial blockage byexfoliatedepithelialdebris. On arterial blood-gas analysis, one finds that the pH is lowered while Pco2 is increased. Hypoxiaiscaused by the inability of oxygen to diffuse into alveoli and across the edematous alveolar-capillary membrane. A "physiologic shunt" effect may ensue if the alveolar- capillary units are perfused adequately without being ventilated. A lack of oxygen diffusion and the resulting shunt effect can be identified on pulmonary function testing, iy, nitrogen orhelium"washout," and by determining the pulmonary diffusion capacity of carbon monoxide.5 In the presence of reduced ventilatory function, nitrogen or helium washout tests reveal a definite "slow space" effect related to those areas of alveolar hypoventilation. Diffusion capacity is reduced by interstitial and intra-alveolar edema. INTERMEDIATE ONSET Fat Embolism in Lung Following Injury Soon after a severe injury, fat may be liberated into the blood from fractured bones. Ithas beensuggested that fat globules may also be formed in blood by the aggregation of chylomicrons. Fat ernboli are en- trapped by small pulmonary vessels, leading to the fleas stage of pulmonary fat embolism which is characterized by the following: elevated pulmonary arterial pressures; right-axis deviation demonstrated on the electrocardiogram; decreased cardiac output and low arterial pressure; enlargement of the right heart and the right pulmonary artery (observed on x- ray, Fig. 2a); and an apparent increase in physiologic "dead space" detected by pulmonary function testing.'2 The latter is due to the lack of perfusion of alveoli, which may or may not be ventilated, At this stage, the diagnosis may beconfirmed either 20 Ames/Diagnostics PAGENO="0269" by detectiog free fat in the urine or increased activity of serum lipase. Early diagnosis may be lifesaving. Administration of heparin is recommended on the same basis as in thromboembolic disease.4 Besides increading blood flow through the pulmonary capil- laries, heparin may help to reduce the aggregation of chylomicrons and fat globules so that they can be transported through the pulmonary bed. As the fat embolism breaks down, It produces a oecond stage of pulmonary involvement in theform of exudative pneumonia. The latter results from a reaction of the pulmonary parenchyma to the products of lipid breakdown.2 Even though x-rays clearly reveal exudative pneumonia (Fig. 2b(, physical examination of the patient may be remarkably unrevealing, since the pulmonary involvement is primarily interstitial. Arterial hypox- emia usually is present and often progressive. Pul- nsonary function tests reveal a marked diffusion block, in, alveolar-capillary block dueto an inflamma- tory response. The latter may be controlled by ad- ministering massive doses of steroids which pur- portedly stabilize the cell membrane and thereby lessen the release of lysosomal enzymes. However, if the condition progresses, a decrease in pulmonary compliance and the closure of small airways leads to progressive hypoxia which, together with the oxygen- diffusion block, results in arterial oxygen desator- ation. This condition is extremely difficult to treat, even by controlled mechanical ventilation. Some benefit may be obtained by administering concen- trated oxygen and continuous positive end-expiratory pressure.12 Low-Flow Lung Syndrome During the Vietnamesewar, casualtieswererapidly evacuated from the battlefield to medical units at which they were given resuscitative as well as, definitive care by surgeons and paramedical per- sonnel. This led to the highest ratio of survivors to fatalities documented during wartime. But a new clinical problem then became apparent: after suc- cessful resuscitation from shock, some of the wound- ed died of pulmonary complications 4-7 days following injury-despite effettive ventilatory sup- port. Often patients without chest injuries-but with extensive injuries to other parts of the body-were affected. This lethal syndrome of post-traumatic pul- monary failure (shock lung or low-flow lung( is today well recognized as a potential complication of any severe injury that leads to shock. Moore and coworkers5 classified the pathophysio- logic phases of post-traumatic ventilatory failure as follows: Phase I: Injury; resuscitation, and alkalosis Phase II: Circulatory stabilization and beginning of respiratory difficulty Phase III: Progressive pulmonary insufficiency Phase IV: Terminal hypoxia with hypercarbia and asystole The lethal progression from injury through resuscitation to the state of terminal hypoxia is illus- trated in Figure 3. The most important diagnostic clue to low-flow lung is a history either of shock or low cardiac output following trauma. Pulmonary complications may follow any condition that leads to low cardiac outptrt, COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14175 Fig. 3-PathogerresiO of post-traumatic vent:Iatory tailare. 4= Decreased Adopted from Rogers, RM: Shock lang, or respirstory disrress syndrome of adults. Continuing Cdoc 3:26. f 975. Ames/Diagnostics 21 PAGENO="0270" 14176 co1\~n'EPIPIvE PROBLEMS iN `~iiE DRUG INDUSTRY tion of cardiogenic shock. In observed the onset of the salt only five minutes after - - i by hypovolemia. ..,,....sr events reveal the rnents of the blood- es-into progressively ggregates tend to settle in ret; . - g areas, while plasma streams toward the upper areas. Pulmonary capil- laries may then become blocked by the aggregates. If the patient is resuscitated in time, the aggregates will break up and reenter the circulation. However, platelet-fibrin thrombi may form behind the aggregates leading to a reactional edema of the perivascular tlssues;thisprocess goes on todestroy the endothelial and epithelial cells of the lung, producing exudation of plasma into alveoli, loss of surfactant function, decreased compliance, and atelectasis (Fig. 5). Occasionally, the process may act~ully be aggravated by resuscitative efforts.8 Experiments in our laboratory suggest that simply by administering large volumes of crystalloid solution (eg, glucose, saline), one can trigger the aggregation of erythro- cytes to cause interstitial edema of the lung. In addition to the cellular effects of the low-flow state described, It seems likely that a humoral com- ponent causes constriction of the small veins.11 The combination of all these factors produces a mal- distribution of air in the lung and progressive alve- olar-capillary block. As in patients with fat embolism, the clinical onset of post-traumatic pulmonary failure may be insidious because the initial pulmonary reactions are interstitial; few, if any, physical abnor- malities are apparent. Characteristically, the patient experiences arterial oxygen desaturation following an apparently successful resuscitation from the initial shock state (Fig. 6a), Hypoxia supervenes within hours, and even thoughonehears normalchestsounds on auscultation, the x-ray shows a diffuse infiltration of both lungs (Fig. 6b). The patient breathes deeply and rapidly; there is marked metabolic acidosis, arterial oxygen desaturation and, terminally, the carbon-dioxide level increases in arterial blood. The most prominent finding ishypoxiawhichissecondary to a severe diffusion block producedby intra-alveolar septal edema (see Fig. 5). As the process continues, atelectasis and pulmonary congestion become super- imposed. Fig. 4.-Microphotograph of animal lung)in vivo) following hypovolemic shock. Capillaries around the central alveolus are engorged with erythrocyte aggregates. Fig. 5.-Pathophysiology of low- 24 Ames/DiagnoSticti PAGENO="0271" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14177 LATE ONSET monary infiltration (Fig. lc( as compared to other . . respiratory syndromes. Physical examination reveals Ventilator Pneumonia the classic signs of consolidation and fluid in small A pulmonarl comphcatton obsers (d in sonic aiisvtvs. 11ypç~~~~ is Present; pulmonary function tests patients who have required assisted ~ entilation is best reveal abnormalities in ventilatory quotient, alveolar- known as *~s entilator l)nesimotiia.' lists is the last capillary bloc-k. and perfused nssnventilated lung l)ulinonarY complication to appear. ansl becomes tissue ssith l)hysitslogic shunting. It is at this advancccl superimposed spots the existing pulmonary disorder. stage that the patient nsa~' also develop hema- Ventilator pneunsoitia is caused by the inhalation of togenssus Isnetunonia warns, moist air which encourages a rapid prolif- eration of transient bacteria originating in either the Hematogenous Pneumonia device or the patients respiratory tract. Hematogenouu pneumonia. which may develop at Each stroke of the ventilator may drive bacteria a late stage of any septic disorder, is seen on x-ray as a deep into the lungs. Since the phenomenon of anti- patchy, disseminated infiltrate. Commonly it follows l)iotic resistaisce is notuncsnnmois in apatirntwho has massive bums, but may be associated with any septic, already receivrcl several cosirses of antibicstics, post'traumaticstate. During the early stages of hensa- treatnient (sf ventilator pnetimonia may be difficult. togenous pneumonia, the patient may present few Serial sputum cultsireshelp one to make ass earlydiag- significant physical fü~dings brcausr ofthe interstitial nods. Prophylactic measures should be ensployed to nature of thedisease. This typeof pneumonia ishighly help prevent ventilator pnesunssisia,such as the cleasi lethal; it responds-if at all--to therapy directed at maintenance sf snachinrcircuits togetherwith aseptic both the pnesimonia and the septic focus.7 care csf tlse tracheostomy svound.'4 Summary Typically, the chest x-ray of a l)tuc'sst who has Knowledge of the pathogenetic srquessce and time ventilator pneumonia shosux a naorr localiced Ptil. of clinical appearance of the various pulmonary disorders dr~c'rihed should help to clarify svhat has ~ problems; Rui.t.d R.f.r.nces: 1. Anbiuoagar M. Chalori J, Zargham Tracheb. ~~*~JIIPI~ ~fd~ normairat500haopehnrenratyproducedraienboiisn PrOcSocEopBiolMed Tt~~ 124 959. 1967 3. Brener L.A iii elai The net iuha iii aar _-asiialiioa. Anir Surg 123343 1946 4. Cobb CA Jr. etal Therapy of traumatic fatenbolism 4 W bbWr~ dSg :C:; b a conpiucation of he uniiaoenouus rfiuson of fluids Airir 0uurg132327 1950 FIg 6 -a Che t ay of f m I p t e t d y ft M F see in q C L 5 P W she fractured the pelvis ond leftfemur during afall inhaled heal Ont ear passages and usgs-an eapevnenual unoeshgation related toa hypotensive episode. The lungs are AmJPathol2l 311 1945 11. OadeniriA WebbW6 WaoOO trIcolor niural fly Cl b Che I ay of the me patiertt 16 Y IS hours later shows a diffuse infiltration of both lungs Surgery Aprii 15~4 12. Parker FB Jr of ii Tho henodynamucs dl eopari- During this period she becarre severely hypoo.uc but nienial fat embolusm and assvvuaisdiherapy Cheoi65545 1974 13. Pelers eohibited no signs of pulmonary d sease dr AM ci al Ohisvfuuslndlvaiuvnr. lvi rssp ably fhsrapy ft posi-irauna and It t D Pt m h I 11 t d m 4 P 5 p d 1 I p al yg wth m mb M 3 s 5 E 6 ooygenator, the patient died srrevisvrnonvrvravu frauuma J Trauurra.spevalussus 0625 1968 ,~ Amea/Diagnoafioa 25 PAGENO="0272" 14178 COMPEPITI~E PROBLEMS IN THE DRUG INDUSTRY TF1[ L~\DY [k~OM ~L~\BAM~\ by Richard D. Altick The case of Florence Maybrick tohimbysomeauthorities, and,asit offers, if anybody is disposed to turned out, the last according to look at it that way, a fortuitous anyone's count, was found on July conjunction of Jack the Ripper and 18, 1889, and Mrs. Maybrick's trial Henry James. The former's associa- opened in Liverpool thirteen days tion with Mrs. Maybrick is chrono- later. Henry James's association is logical; the sixth victim attributed of a very different, much subtler Reprintedfrom Victorian Studies in Scarlet, by Richord D.Altick,withlhepermtsoionOtthePxbllsftet. 01910 byW.W. Norton & Company, lnc,,for iS, Canada,ondopen'marketCcUntrieS ©1970by J. M. Dent & Sons, Ltd. in Commonwealth countnes except Canada. Originally titled Arsenic and the Lady from Alabama THE TRIAL OF MRS. Time: 1889 Place: Liverpool, England Category: Fact Ames/Dsaagnaotica 27 PAGENO="0273" COMPETIPtVE PROBTJEMS IN PHE DRUG INDUSTRY 14179 She was accused as a poisoner, even though her "victim's" prescriptions included arsenic, cascara, henbane, iridin, jaborandi, morphine, papain, prussic acid, and strychnine. sort, perhaps not really demon- strable: but one thinks of him because Mrs. Maybrick partic- ipated in that memorable exodus of marriageable young women from America to Europe between the end of theCivil War and turn of the century which so often hovers In the background of James's fiction. It is altogether too fanciful to see her as a small-scale, bour- geois replica of a Jamesian heroine-and yet... Mrs. Maybricic was born Florence Elizabeth Chandler, the daughter of a banker in Mobile, Alabama; herhusband,twenty-four years older than the, was a Liver- pool cotton merohant tempprarily resident in America, where they were married in 1881,* The story of the bjla.ybrick murder is a simple one, the com- plications in the trial record being almost exclusively due to the battle of the toxicologistobeingoncemore rejoined. On May 11, 1889, James Maybrick died "under mysterious circumstances" in hishome, afteran illness attendedbymany distressing symptoms. The principal evidence agsinst his wife was the presump- tion of motive. In March she had spent a few nights in London with another man, and later the same `There is delicious reverse snobbery in the statement ot James 53. Blame, the Secretary of State in Benjamin Harrison's cabinet, when he wrote in support of his countrywoman's reprieve: "That she may have been influenced by the foolish ambition of many American girls for a foreign marriage, and have descended from her own rank to that of her husband's family, which seems to have been somewhat vulgar, must be forgivento heryouth,since ohewasonly eighteen atthetime of her marriage." month, after their return from the Grand National Steeplechase, where they had happened to meet him, she and herhusband had had a violent argument,' in the course of which he had gives her multiple bruises and a black eye. Only the pleas of a servant and the family doctor dissuaded her from leaving him. Moreover, a month later, a week or so before her husband's final illness began, she had bought flypaper atachemist's,even though flies were not yet in season and there waS some flypaper left in the kitchen from last year. A servant saw her soaking the paper in her bedroom basin to remove the arsenic coating. Her explanation was that she wanted to make a cosmetic solution to clear her complexion, as'she was planning to accompany her hutband to a ball. At the trinl, some evidence was produced that arsenic was oc- casionally favored as a complexion aid or, alternatively, as a depilatory cream. Another chemist from whom Mrs. Maybrick had boughs a dozen flypapers in Aprilsaid, "I can speak to the fact that ladies came to buy flypapers when no flies were about." But the line of inquiry this statement invited-the possibility that certain other ladies' husbands subsequently died of violent gastric disturbances-was not pursued. Combined with this indisputable possession of arsenic was the fact that Maybrick"s nurses reported some apparent sleight-of.hand on his wife's part with the beef juice that the doctorhud ordered givento the patient. A search of the house after his death revealed the presence of arsenic in tiny or more significant amounts usa rag, is one of Mrs. Maybrick's handkerchiefs, in a bottle of aperient mixture, in a bottle of glycerine, in a packet marked `Poison for Cab" (ok-not "rats"), and elsewhere. All told, the analysts estimated that the arsenic found scattered about the house was enough to kill fifty people. But all this was circumstantial evi- dence, and in its totality it did not constitute a crushing case against the young woman. A comparison of this trial con- ducted in l889withthoseof 1856-65 reveals how far the Age of Science had progressed oince those remote days when toxicology and forensic medicine were in their hesitant, Inexperienced infancy. The medical evidence which occupies by far the greater pyrt of the Maybrick transcipt (the scene of virtually the whole reconstructed drama is the victim's sickroom) has a mychmorescientlficairaboutit,a greater assumption of authority. Home Office analysts were not forced Its admit, as one previous analyst had, that the poison re- vealed by their analysis was de- rived from their analytic tools. But the trouble was ,that along with heightened authority should have come consensus; and to such consensus was reached. The doe- furs disagreed as violently as ever. Was Maybrick's death veally caused by arsenic? Some expect witnesses testified that it was, while others,equally expert, testifiedwith. equal assurance that it was not. The defense labored mightily to show that Maybrick suffered from gastroenteritis. Certain it was that, despite a basically healthy constitu- tion, he was a hypochondriac of 28 Ameu/Disgnootics 73-617 0 -`76 - 18 PAGENO="0274" 14180 Coi\aETITIVE PROBLEMS IN THE DRUG INDUSPRY long standing, addicted to takingall kinds of medicines. Medicineswere a favorite topic of his in conversa- tion, and he eagerly followed the advice of his friends, sometimes doubling the recommended dose to be sure of good results. Evidence was brought from Norfolk, Virginia, where he had lived for a time, and from Liverpool itself, to the effect that he had sampled virtually the whole pharmaco- poeia, with special attention to sub- stances normally deemed lethal in sufficient quantity but including also such relatively benign items as quinine compound, cardamom pills, and Seidlitz powders. He was in the habit of dropping into a chemist's shop in downtown Liver- pool from two to five times a day for a "pick-me-up" laced with liquor arsenicalis, the quantity of which was steadily increased over ten years. If this suggests sheer aberration on'the part of the cotton broker, it must be noted that, as his chemist testified, many other level- headed businessmen he knew liked their daytime potations strengthen- ed with arsenic. Whatever the practice says about Maybrick per- tonally, it says a good deal more about the pressures of Liverpool business life. By May 1889, one would therefore assume, Maybrick had built up a high tolerance for a wide range of chemicals, phariasa- ceutical and nonpharmaceutical, against those last days when, as a letter to The Times after the trial put it, his stomach served as "a druggists' waste-pipe." For his malady, whatever it was, his doc- tors prescribed, in addition to measured doses of arsenic, avariety of substances including strychnine, jaborandi, cascara, henbane, morphia, prussic acid, papalne,and iridln,Itwasaformidableintakefor a patient of whom one physician testified, "He seemed to be suffer- ing from nervous dyspepsia. I should say that he was hypochon- driacal." But neither nervous dys' pepsin nor hypochrsndria would seem adequate to account for the voluminous and the disagreeable symptoms Maybrick suffered toward the end, except on the not unreasonable premise that the curative regimen was worse than the disease. In view of his well- attested appetite for those many drugs, one wonders why his wife should evenhave beensuspected of doing away with him, If she was intelligent enough to soak flypaper in a bgsin, she was also surely intelligent enough to realize that nature or ,the doctors, or both, would eventually do her work for her. Still, considering how long he had been ingesting those potions and powders without harm, she may be forgiven for doubting that, in his case, nature was to be much relied upon. The technical and contradictory nature, repetitiveness, and often the repulsiveness of the medical testimony do not recommend the trialrecordto thelayman's attentive reading. But It is lightened by occasional passages in which the atmosphere and action of the courtroom are vividly evoked. At one point, for example, an expert witness handed in as evidence a glass tube containing a "film" composed of arsenic crystals ob- tained from Maybrick's liver. The judge, James Fitzjames Stephen, tried two high-power magnifying ~asses but was unable to see she film and asked defense counsel to point it out to him. Counsel very properly admonished, "You must look for it yourself, my lord." Stephen tried again, this time with the court chaplain's slate hat as background. After apauseof some time, during which the court was silent, his lordship handed back the tube to the jury, with his two glasses, explaining that one was much more powerful than the other, but the more powerful one required to beso near to the eye on the one hand, and so close to the object on the other that It was very difficult to manage. The jury then proceeded to use the glasses of his lordship, the black coats of their fellow-jurymen being used as a background. That the judge had to be in- structed by counsel as to his proper conduct when presented with an exhibit is a small indication of what was, in fact, a governing cir- cumstance in the trial: his evident incompetence. James Fitzjames Stephen, a brilliant lawyer, legal historian, and man of letters, had become a judge of the high court in 1879. Butby nowitwasobviousthat his mental powers were no longer what they had been. H. B. Irving wrote of this disturbing state of affairs withexerhplary delicacy: "it Is Impossible forthe historian of fhe Maybrick case to ignore the statement, frequently made, that at the time of hertrlalthe judge's mind was suffering from the earlyattacks of an insidious disease which, two years later, compelled Sir James to retire from the bench. The judge Arnea/Diagsoatica 29 PAGENO="0275" COMPETITIVE PROBLEMS IN THE DRW.~ INDUSTRY 14181 just, at rOoster Perhaps it is unfair to cite the following excerpt from the judge's summing up as evidence of his failing intellect, but to most Englishmen it would be otherwise inexplicable: "The next date after that took place is the Grand National `something.' I don't-know whether it is a race, or a steeple- chase, ~but it is something called the `Gratsd National,' no if every' body knew what the substantive was-but the Grand National took place on the 29th March." Counsel at the bar and spectators must have mentally shaken their heads at such ignorance. In any case, Stephen's conduct of the trial called forth much sharp comment in both the press and thelegal profession and provided the chief basis for later t the s'as too small to h and that the torns observed during his last did not point to arsenic Pt ning; some of theclassic mani- festations were not present. Some members of Parliament signed the petitions. Public meetings in Mrs. Maybrick's support were held in London and Liverpool, and, since Mrs. Maybrick was American by birth, leading Officials and citizens of the United States alsopleaded in her behalf. Among the names subscribed to the petitions were those of Cardinal Gibbons, Vice- President Levi P. Morton, members of the cabinet in addition to Secretary of State James G. Blame, and high army olficers. At length, public opinion had its way to the extent that the con- demned woman's sentence was re- 30 Ameo/Dksgnostica PAGENO="0276" 14182 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY PAGENO="0277" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14183 Vol. 2 No. 3 March 1976 Primary Cardiology, Cardiovascular Medicine for the Primary Care Physician 10 Care of the Cardiac Surgical Patient Requires step-by-step planning 14 Current Status of Prosthetic Valves Which patients are candidates? 20 Diagnosis & Treatment with the Balloon Catheter Its use is being extended 26 DiagnostIc Sequence for Pulmonary Embolism Reducing that high mortality rate 30 Minor lnfarctions: What to Look For Are they benign or more serious? 38 Anticoagulant Drugs-When to Use, and How First of a series 42 Pulmonary Edema: Treatment Depends on Cause Replenishment of plasma volume is important 46 Should Digitalis Be Used in Treating Acute Myocardial Infarction? There are conflicting practices, opinions DEPARTMENTS 5 Editor's Page Is the lecture obsolete? Edward Gipstein, M.D. 8 Letters to the Editor 18 Photo Feature Internal heart functions are monitored by noninvasive technique 34 Case History SanfordS. Zevon, M.D. 48 ECG of the Month Atrioventricular block PUBLISHING STAFF Editor Design Director Executive Editor Edwin K. Zittell Frank DeMarco Robert V. A. Brown Managing Editor Associate Editor Associate Editor Lucy Kavaler Ann Terry Miriam Zwerin Art Editor Editortai Assistant Editorial Assistant Gary Monteferante Anita Cooke Sheila Martin Editoriai Coordinator Business Manager Production Manager Ginger Paulsuon Earl B. Geer, Jr. José Garcia PRIMARY CARDIOLOGY'rM publishes Publisher original articles by leading cardiol- Bruce Addison ogists to assist the primary care PRIMARY CARDlOLyGYv~it publIshed 10 lImes each year by PW CommunicatIons, Inc., 488 physician in the diagnosis and of PW Commu ndons d' Independent board oi edftors USV Pharmace bcal c~rporaiio~ treatment of cardiovascular and sponsors PRIMARY CARDIOLOGYIM as a continuing educational service to the practicing related illnesses frequently en~ ~ ~ ~ countered in his medical practice. $1.50 per copy. Annual subscription price $15.00. l$l7.50 canada and foreign) Application ______________________________________ to mall at controlled circulauon rates Is pending at Lancaster, Pa. Warren J. Taylor, M.D. Gordon K. Danielson, M.D. H.J.C. Swan, M.D. William Ganz, M.D. Arthur A. Sasahara, M.D. John J. Sampson, M.D. Louis M. Aledort, M.D. Max Harry Weil, M.D. Edgar Haber, M.D. PAGENO="0278" 14184 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Editor's P~iř~ Is the Lecture Obsolete? Pressures on the physician to update his knowledge come from many sides. The strongest motivation for continuing his education should, of course, come from the rapid proliferation of new medical findings, and the physician's desire to provide good medical care. But regardless of their personal drive to learn, all physicians will have to face the likeli- hood that mandatory continuing education-now legally required in a minority of states as a condition of relicensure and continuing hospital affiliation-will some day be required throughout the United States. Against this background it is disturbing to read the attacks by some writers in medical journalS on mandatory continuing education in gen- eral and on the lecture format in particular. These critics assert that the majority of continuing medical education programs rely heavily on the lecture method; that the flow of informa- tion is all one way-fromthe platform to the audience_discouragingthe active participation of the learner and fostering passivity and resent- ment; that compulsory attendance at such programs arouses resistance to learning; and that there is no evidence that phyticians render better patient care as a result of their attendance at these courses. Some critics say that mandatory continuing education and formal lectures should be replaced by a voluntary form of continuing self- education, in which the physicians could select problem-centered learn- ing opportunities directly related to his practice. Superficially, some of these arguments seem persuasive. There is no denying the destructive effect of a lecture delivered by a speaker who has little ability to hold the interest of a large audience; who has not organized his material well or simplified it appropriately for the occa- sion; and whose slides are so crowded with data printed in small, pale type that they cannot be read beyond the third row. But there is a right and a wrong'way to carry on any form of medical education, whether it is done through lectures, seminars, journal arti- cles, bedside teaching, or audiovisual teaching aids. Each of thesp methods, performed badly, wastes the physician's time. Each one, when it is performed well, makes a contribution to medical education which is unique to that method, and not replaceable by any other. Let us look at the advantages of the lecture when it is delivered at a highlevel of competence. A stimulating presentation by aspecialist who is also a gifted communicator can provide large audiences with a valu- able perspective-the result of his survey and crystallization of a tre- mendous amount of research. In an hour or less, a good speaker can illuminate what is known, what is new, and what is still to be explored, alerting the individual physician to developments that may have im- mediate bearing on his practice. This also helps the physician to focus his reading in a field crowded with more journals than he could ever survey and evaluate on his own. (continued page 6) MARCH 1970 EDITORIAL DIRZCrOR Richard Gorlin, M.D. Msrray M. Rosesberg Professor Chairman, Department of Medicine Mount Sinai School of Medicine Physician-is-Cl~ief The Mount Sinai Hospitsl New York, New York EDITORIAL ADVISORY BOARD John Somers Argue, M.D. Pamily Practice Pittsfield, N.H. Francis Layton Berqulst, M.D. Family Practice Laketand, Fla. Sidney Blumenthal, M.D. Professor of Pediatric Cardiology University of Miami School of Medicine Leonard A. Cobb, M.D. Professor of Medicine University of Washington Lawrence S. Cohen, M.D. Professor of Medicine and Chief of Cardioloey Yale University School of Medicine Jay N. Cohn, M.D. Professor of Medicine and Head Cardiovascular Division University of Minnesota Medical School Edward Glpsteln, M.D. Director of Medical Education Lawrence and Memorial Hospitals New London, Conn- Michael V. Herman, M.D. Chief of Cardiology The Mount Sinai Hospital New York, New York J. O'Neal Humphrles, M.D. Robert L. Levy Professor in Cardiology The Johns Hopkins University School of Medicine Hilliard J. Katz, M.D. Clinical Professor of Medicine University of California San Francisco William B. Kannel, M.D. Co.Direclor, Framingham Study, NHLI Marvin Moser, M.D. Clinical Professor of Medicine New York Medical College Louis K. Telchholz, M.D. Associate Chief of Cardiology The Mount Sinai Hospital New York, New York PAGENO="0279" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14185 Editor's Page (continued from page 5) This is the kind of educational experience we try to provide twice a month through the Medical Edu- cation Program at Lawrence and Memorial Hospi- tals in New London, Connecticut. For the past thir- teen years we have used the lecture format exten- sively. Participating physicians pay tuition, and they come voluntarily, in large numbers, from ovt-of- state as well as from the immediate area. Subject matter represents many disciplines, and physicians are offered course material closely related to prob- lems they face in their practices. At the end of each lecture, a question-and-answer period provides at least an adequate opportunity foraudience participa- tion andforresolution of points that maybe unclear. Since much of what can go wrong with lectures is due to the quality of the lecturer rather than to the lecture format itself, we screen our speakers care- fully. They are selected, not only for scholarship, but also for their ability to speak well, to make suita- ble slide and other visual presentations, and, in gen- eral, to have a strong impact on a large audience. At the end of each session, course participants are asked to fill out questionnaires evaluating the con- tent of the lecture, its value to them, and the effec- tiveness with which it was delivered. We share the results-bad or good- with the lecturers. Fortunately, many successful administrators, re- search scientists, and clinical specialists are also good communicators, and they are invited back again. But there are othef equally accomplished physicians who are brilliant in their specialties, or effective at directing large research projects or con- ducting intensive bedside teaching; and yet they do not have the special gifts required to organize or simplify their material into a good lecture and to present it with flair to alarge group. For their sakes, and in the interest of a successful educational pro- gfam, we feel Thattbey should knowhow they have been evaluated, and we do not ask theinback.-again. Response to our lectures suggests to us that this program, and many others like it in this country, constitute one of several possible forms of volun- tary, continuing self-education, in which physicians take responsibility for upgrading their knowledge. Despite their supposedly passive roles in a lecture situation, the participation of these physicians in question-and-answer periods, and their responses to evaluation questionnaires, indicate to us that they are involved in some form of learning and they find the courses rewarding. Of course, we cannot prove that these rewards are passed on in the form of changed physician behavior and better patient care. But we strongly doubt th~ validity of studies that clalm to measure the relation' ship between a medical education course and subse~ quent changes in patient care, To quote a writer o~i this subject in a recent issue of JAMA: There are many controlled factors that influ- ence physician behavior and treatment out- come that were not, and could not be, iden- t~f led or measured in such studies. While the studies fail to find a change, they also fail to prove that no charge occurred. Because our experience with the lecture format has been positive, we are interested in seeing tha( it is preserved as an effective instrument. To do this, more teaching talent must constantly be developed. Perhaps we can look for this talent among the ranks of medical school instructors and teaching fellows, many of whom are effective communicators. If they had more opportunities to represent their depsrt- metits on the lecture platform, we might see the rise of an important new group of medical lecturers. Since we can expect growing demands to-be made on the physician to engage in continuing education, all possible encouragement should be given to the de- velopment of such a corps of effective medical educators. 0 Edward Glpsteln, M.D. Director of Medical Education, Lawrence and Memorial Hospitals New L4'ndon, Conn. PRIMARY CARDIOLOGY PAGENO="0280" 14186 COMPETITIVE PROBLEMS IN THE DRUG INDUSTEY Letters to the: Editor___ We welcome comments, criticism, questions, and suggestions from our physician-readers and will occasionally print letters we receive. Please writeto Editor, PRIMARYCARDIOLOGY, 488 Madison Ave., New York, N.Y. 10022 D.O. Specialist You have made a slip in the October 1975 issue I would like to correct. Nextto each doctor's name, you indicate his area of specialization. If a physician is a D.O., itis takenforgranted he is apractitionerof osteopathic medicine. If a physician is an M.D.,it is taken for granted he is a practitioner of allopathic medicine. If you were to look up in the Directory of the American Osteopathic Association you will note there is no specialization called osteopathy. There are 54 types of specialization that osteopathic physi- cians are trained in. Your listing as Dr. Nash's spe- cialty "osteopathy" is an anachronism. For your information, Dr. Nash is certified in diagnostic roentgenology. I trust that in your future issues you will be more specific. Warren Wolfe, DO. Cherry Hill, New Jersey Aspirin's Role I have read with interest your note in Clinical Hori- zons entitled Two Studies Check Aspirin's Role in Stroke, Heart Attack Prevention, in Januarys issue of PRIMARY CARDIOLOGY. Aspirin has been consi- dered a drug potentially capable of preventing arter- ial thrombotic diseases. It has been studied in many places, and using varied clinical models. At present, however, it is not clear-cut that it will prevent thrombosis. Other drugs which can alter platelet function have also been studied for their ability to prevent arterial thrombosis. Persantine (dipyridamole), a drug long known as a coronary artery dilator, is capable of inhibiting platelet uptake of glucose and adenosine. In addition it inhibits platelet cyclic AMP phos- phodiesterase. Only in greaterthan physiologic con- centrations does this drug alter platelet aggregation. However, this drug is one of only a few which has clearly demonstrated its in-vivo ability to signifi- cantly inhibit valvular-induced embolic disease. In addition, in clinical settings which alter arterial vessel walls and lead to increased platelet turnover (decreased survival) dipyridamole alone or in com- bination with aspirin (thereby allowing a lower dose of dipyridamole) can return platelet survival to nor- mal. The PARIS. (Persantine Aspirin keinfarction 8 PRIMARY CARDIOLOGY PAGENO="0281" COMPETITIVE PROBLEMS IN TUE DRUG INDUSTRY 14187 Study), is now in progress. Twenty clinicalcenters have already entered more than eight hundred pa- tients with an aim for recruitment of two thousand. Patients will be randomized to aspirin alone, aspirin plus dipyridamole, orplacebo. These patients will be followed in similar fashion to those described in your article Eligibility is also similar, with a previous documented myocardial infarction being manda- tory. It is prospec Robert M. Jeresaty, M.D.). Lawrence S. Cohen, M.D. Professor of Medicine and Chief of Cardiology Yale University School of Medicine Dr. Cohen is, of course, quite correct. The film was ed, as was noted by several other e echocardiogram in its proper The Editor No Garbage I am happy with your subject matter and very happy with your conciSe, no garbage, presentation. Many thanks. MARCH 1976 PAGENO="0282" 14188 COMPETITIVE PROBLEMS IN THE DRUG INDTJSPRY Care oitbe The primary physician plays a vital part In the overall management of his cardiac patient un- dergoing elective surgery The history physical, basic laboratc'y data, and when indicated, test- ing, provide information that may be critical in the OR. Respiratory function, nutritional status, hepatic and renal functionJTWSt ill be optimal prior to surgery Consultation with the other physiciafls providing care during the patient's hospital stay is crucial. Yet one of the most im- portant contributions the primary physician can make is simply "being there" when his ap- prehensive cardiac patient is anesthetized. your cardiac patient is scheduled for an elec- tive or semi-elective procedure. What are the consequences of his cardiac condition for the overall surgical management? The operative stress coupled with the potential hazards of the anesthetic state may have a debilitating effect on an already over-strained heart. Careful attention to the following details will help your cardiac patient have as safe a hospital stay as possible. Basic Workup Primary prerequisites are a thorough history and physical exam, basic laboratory data, profile, elec- trolyte determination, prothrombin time and partial thromboplastin time, chest x-ray, and resting ECO. Stress testing may be helpful, in evaluating an indi- vidual with occult cardiac disease. It should not be considered as a routine, but when indicated it pro- vides a baseline on cardiac reserve that might prove to be a useful reference when the heart is stressed by the surgical procedure. Often, patients who exhibits normal resting ECO will, when stressed on a tread- mill orbicycle, show ECO changes or manifest chest pain, It is important that all clinicians involvçd inthe management of your patient_._anesthesiologists and surgeons -be informed of the results of the stress test and any other pertinent information derived from the history and physical. Cessation of Beta Blockade? The cardiac patient who regularly takes beta bloc- kers like propranolol may present a problem. There is recent convincing evidence that sudden cessation of propranolol can precipitate status anginosus or myocardial infarction. Yet having propranolol on By Warren J. Taylor, M.D. 10 PRIMARY CARDIOLOGY PAGENO="0283" COMPETITtVE PROBLEMS IN THE DRUG INDUSTRY 14189 Cardiac Surgical Patient board during surgery may be hazardous in that the drug may effectively prevent the patient from re- sponding to vasopressors should vasoconstriction be necessary perioperatively. Clearly a compromise course is indicated. It is advistsble to withdraw the drug gradually a week (some say two weeks).prior to surgery. This may be impossible in certain patients, and it may be neces- sáry to accept a degree of beta blockade during surgery, but the drug should be tapered to minimal levels preoperatively. If emergency surgery must be performed on the cardiac patient who regularly takes propranolol, the hypotension he may experience must bemanaged in light of the fact that many of the therapeutic agents which would normally be effective simply Will not work, Electrolyte and Fluid Balance The primary physician should be aware of electro- lyte imbalances in the presurgical cardiac patient. A low serum potassium or high sodium, for example, should be corrected with appropriate fluid therapy and judicious diuresis prior to surgery. Fluid balance is another key consideration. Hypovolemia may result in depletion of metabolic reserves and electrolyte imbalances. The "dried- out" patient maybe in relative good health preopera- tively, but the stress of surgery and fluid loss may make him hypovolemic very rapidly. This sets the stage for arrhythmias and an operative catastrophe. It is not good clinical practice to overly "dry out" your cardiac patients prior to elective surgery. In fact, many patients d~ better in the OR when they are a little on the "wet" side. However, hypervolemia caused by excess fluid replacement with crystalloids or colloids is also to be avoided, especially in the postoperative stage. Simi- larly, anemia should be corrected. Assessing Respiratory Function Baseline pulmonary function values must be as- certained so that any obstructive or restrictive re- spiratory defect can be identified. Measurement of vital capacity and maximum voluntary ventilation will suffice for initial screening. Any patient with demonstrated respiratory prob- lems should be çreparedfor surgery with chest phys- ical therapy and/or respiratory therapy, specifically intermittent, positive pressure breathing. Chest physical therapy entails teaching diaphragmatic breathing technics and other ways to optimize pul- monary fupction, i.e., effective coughing. In addi- tion to the pulnionary function tests previously men- tioned, baseline arterial blood gas values should also be obtained in these individuals, Smoking Absolutely Contraindicated Many physicians pay lip service to the idea that any patient, particularly a cardiac undergoing elec- tive surgery should abstain from smoking for at least three weeks preoperatively. I feel very strongly that this should be an absolute requirement. If a patient insists on smoking prior to elective surgery, the pro- cedure should be postponed. Nutritional Status The importance of nutritional status has recently been stressed by countless clinicians. It is now being recognized that proten calori.e malnutrition (PCM) may be, responsible for more postop morbidity/ mortality than has been previously identified, Itmay MARCH 1976 PAGENO="0284" 14190 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY be advisable to hyperaliment your cardiac cachectic patientpriorto an elective procedure since cachexia may cause defects in the immune response mechanism. There are several rather simple clues by which you can identify the cardiac cachectic. Many of these patients have albumin deficits and lym- phopenia. They are anergic and do not respond to skin testing with tuberculin or Candida albicans. If a patient doesn't react to these antigens, it can be assumed his host defenses have been severely com- promised. Anthropometric measurements such as compar- ing height/weight ratios, arm circumference, or triceps skin fold to established norms can also aid in the identification of these depleted patients. If the cardiac cachectic is relatively stable, you can afford the luxury of a few weeks of oral or parenteral byperalimentation prior to surgery. Ide- ally, one attempts to provide 40 calories and 1.7 grams of protein per kilogram of optimalbody weight per day. It is remarkable how well the majority of these patients respond to hyperalimentation. The change from a negative to positive protein balance and adequate caloric intake literally reignites their interest in living. These patients stopbeingargumen- tative, paranoid and lethargic. Preliminary data on one group of patients under- going multivalve replacement suggest that mortality and morbidity decrease significantly if the patient is properly nourished pre- and postoperatively. Ongo- ing investigation of this link in many cardiac syn- dromes will hopefully buttress this observation. Hyperalimentation is especially useful - even life-saving-in the interim between a majOr cardiac procedure and elactive or semi-elective surgery. Building the post cardiac surgery patient back up to near normal body weight and positive protein bal- ance is imperative before attempting lesser proce- dures. - Sedation Cardiac patients are probably the most apprehen- sive of all. There is a tendency on the part of physi- cians to combat this fear and its potential cardiovas- cular ramifications with heavy preop sedation. But this can cause hypoventilation and COs retenlion, which is much worse for these patients than the anxiety the sedation was supposed to relieve in the first place. I recommend that the cardiac patient be. trans- ported from his room to the OR with oxygen run- ning. If he has angina and nitroglycerin has been effective in controlling it, let him take nitroglycerin beforeleavinghis room andlethim carry his bottle of nitroglycerin with him. This can be tremendously reassuring, as well as being therapeutic. Use preoperative sedatives judiciously. One can always give more sedation, but you can't diminish a heavy dose once it has been administered. Induction Certain anesthetic techniques are contraindicated in cardiac patients. It behooves the primary physi- cian, if he is lobe a member of the surgical team, and the surgeon to discuss the anesthetic technique with the anesthesiologist well before the operation. It is well known that certain inhalational agents such as halothane sensitize the myocardium and can precipitate arrhythmias. Hence an anesthetic tech- nique for known cardiacs that seems to be gaining acceptance is IV. morphine, nitrous oxide, and high-flow oxygen. Though the nitrous oxide does have some cardiodepressive action, this combina- tion seems to present minimal hazards to the dis- eased myocardium. Whatever technique the anesthesiologist decides to use, a calm, sedate induction with pre- oxygenation is certainly to be desired, Too often, the surgical team forgets that the general commotion in the OR becomes amplified for the patient during induction. Soft noises seem to be very loud and disconcerting. There should be no talk and minimal background noise until the patient's level of con- sciousness descends below the auditory level. There is one exception to the edict against talking. We should never forget how terribly frightened these cardiac patients are immediately prior to surgery. It is important to stand by them-perhaps pat them on the shoulder-ortalk softly to them before they go to sleep. If the primary physician is to.be a member of the operative team, he can make a key contribution simply by being near his patient during induction. Seeing a familiar face can make all the difference. Intraoperative MonitorIng The basic minimal monitoring of a cardiac patient during surgery should include continuous ECO and measurements of arterial and central venous pres- sures, and urine output. Th~Swan'Ganz catheter is indicated in the unstable cardiac undergoing surgery. It can be used to measure not only right- but left-sided pressures during surgery and postopera- tively. However, since the use of the Swan~'Ganz has been associated with certain complications and morbidity, its routine use is not recommended, and when used, the technique should be supervised by someone thoroughly familiar with it. A gross buthelpful assessment of cardiac output is urine output. Low cardiac output will result in in- 12 PRIMARY CARDIOLOGY PAGENO="0285" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14191 CARDIAC SURGICAL PATIENT adequate r~nal perfusion and a concomitant drop in urine flow. Packed Cells Preferred When replacing blood lost during surgery, the use of packed cells should be considered. We should not be slaves to the notion that whole blood lost must be replaced by whole blood. The use of packed cells cafi lessen the hazard of hepatitis and other adverse transfusion reactions. In my view, packed cells, supplemented with plasma substitutes meet the patient's requirement for blood replacement with minimal risk. Frozen blood is even better if available in your institution. Initiating Postop Care Anesthesia may cause a very labile blood pressure in the immediate postop period. Sudden motion ac- centuates any instability that may exist. Hence it is critical that anesthetized patients - especially known cardiacs-be transported as gently as possi- ble to the RR, ICU, etc. Specific postop care is of course geared to the procedure the patient undergoes but two major therapeutic guidelines mustbe observed at all times. First, avoid hypervolemia. The cardiac patient is * unable to tolerate fluid overload. Secondly, be wary of pharmacologic support of the heart. While car- diotonic drugs such as dopamine or glucagon have a place in the postop armamentarium, excessive mo- tropic stimulation of the diseased myocarditim is very hazardous. Many patients will require mechanical ventilatory support. Although many clinicians contend that mechanical ventilation should be discontinued as soon as possible, continued use may be indicated in, the individual with marginal pulmonary function and labile blood pressure. These patients tend to do bet- ter if their work of breathing is reduced, especially if the postop pharmacologic management involves use of agents that will significantly depress respiratory drive. Analgesia in the postop phase may be associated with significant complications. It should be men- tioned that very young or very old patients tolerate potent analgesics - especially morphine - very poorly. Chronologic age, not apparent clinical con- dition should be the determining factor in morphine dotage. Once again, a good rule of thumb is: give small doses more often rather than a large dose ini- tially. This provides a wider margin of safety; Early Ambulation It is advisable to get your cardiac patient on his feet and moving about as soon as he is able. This prevents venous stagnation and lessens the possibil- ity of pulmonary embolism. An adjunct to early ambulation is low-dose hepa- rin therapy, i.e., 5000 units two times daily. This low dose doesn't cause full heparinization but does re- tard the thrombotic process. If one elects this therapy, a profile of the patient's bleeding and clot- ting factors should be available including prothrom- bin times and partial thromboplastin times. Prophylactic Antibiotics? Touching on what continues to be a controversial subject, prophylactic antibiotics, I suggest that the use of antibiotics for this purpose depends entirely on the extent of the procedure, the number of cathe- ters invading the patient and other operative factors. If the potential contamination time for a cardiac patient undergoing a relatively short procedure is minimal, it is probably not necessary to use prophylaxis. But for longer procedures, prophylactic antibio- tics are indicated immediately prior to surgery so that a blood tissue level exists at the time of possible contamination and for three days postoperatively. The drug should be discontinued at this time so that the normal flora are not suppressed and the road to secondary invasion remains closed. If sepsis de' velops, it should be identified, the organism isolated, the sensitivity determined, and the appropriate an- tibiotic utilized. U ~ Practice Procedures Steps for Managing Cardiac Surgical Patients Obtain baseline levels for cardiac reserve, pul- monary function and blood gases. Optimalize electrolyte balance, blood volume and fluid. The preoperative nutritional state of the patient may have a dramatic influence on the surgical outcome; hyperaliment when indicated. * Perioperatively, a morphine, nitrous oxide technique seems to be the least hazardous anesthetic. Minimal monitoring should include ECG, arterial pressure, central Venous pres- sure, and urine output. A Swan-Ganz is indi- cated in the unstable surgical cardiac. * Hypervolemia and undue pharmacolog- ic stimulation of the myocardium are to be avoided postoperatively. Ventilatory support may be necessary to reduce work. Early ambulation is a must; heparin therapy is op~ tional to prevent embolism. If prophylactic an- tibiotics are used, they should be discontinued on the third postoperative day. lJ I MARCH 1976 13 PAGENO="0286" 14192 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY By Gordon K. Danielson, M.D. Dr. Danielson is Professor of Surgery the Mayo Clinic Rochester, Mn. Although heart valve surgery has come of age, specialists are not yet ready to recommend the procedure for every potential candidate. With any progressive pathologic process, it is funda- mentally true that the earlier remedial measures can be instituted the less likely that serious tis- sue destruction will ensue. Nonetheless, except for some special circumstances, heart valve substitutes -whether of biologic or man-made origin-cannot yet be universally recommended for most patients until the disease process is quite well advanced, because of the remaining inherent risk of such substitutes over a span of years. In many patients for whom this life-saving measure is warranted, there is a remarkable im- provement in both the quality and the duration of their lIfe-spans. A ft8r more than a decade and a half of clinical experience with surgical replacement of heart valves, few physicians would question the basic soundness of this approach to the correction of mechanical malfunction of these car- Current Status diac structures. Nevertheless, and despite the im- pressive clinical results of surgical replacement, not all patients with damaged valves are automatically candidates for this type of restorative procedure. Theoretically, valvular heart disease would seem to be best treated by replacement of the diseased valve. This is an inherently rational copcept. But there are at least two majorlimiting factors: First, in terms of consideration of patient s~fety, there must be a valid possibility of replacing the diseased valve by a suitable substitute type in circumstances that carry an acceptable operative risk. Setond, the prosthetic valve must be free of intrinsic limitations; or, if it lacks this ideal attribute, it must have an established recordof performance far better than the prospect that otherwise awaits the patient based on the natural history of the valvular disease in ques- tion. Given these two conditions, and in the hands of a well-trained, experienced team, your patients with valvular disease, in most cases, can be greatly helped to attain an improved quality of life, as well as prolongation of life. This is compared to the clinical deterioration, long-drawn-out progressive disability and attendant emotional impact, or sudden death, that would be the alternative to surgical interven- tion. Our group at the Mayo Clinic recently undertook a reappraisal of the long-term results of 1,684 cases of aortic or mitral valve replacement with a Starr- Edwards type of ball valve prosthesis. We confirmed our impression that this measure does appreciably increase life expectancy over what would otherwise be expected in the natural course of valvular heart disease. Various studies have chronicled the natural course of mitral stenosis and have borne out that, without corrective surgery, the median survival time is only 6-7 years. In the last 5 years of our retrospec- tive survey we found that there had been an overall early operative mortality of 7 per cent; and over the entire survey span of 11 years, the operative tnortal- ity rate was 14 per cent. The early mortality rates noted in this survey were 6 per cent for aortic valve replacement and 9 per cent 14 PRIMARY CARDIOLOGY PAGENO="0287" COMPETITIVE PROBLEMS ]~ THE DRUG INDUSTRY 14193 of Prosthetic Valves with the Model 6120 mitral valve procedures. Since then even these rates have been lowered at our in- stitution. What is truly impressive is thatthe survival rate beyond 8 years after aortic valve replacement was 65 per cent compared with 85 per cent for the general population. Those who survived mitral valve replacement also had an appreciably greater likeli- hood of surviving 5 years or more postoperatively- a much better prospect than for those who receive only nonsurgical management. Indeed, for patients with mitral impairment, both early and late mortality arelikely to be reduced when surgicairelief is carried out early in the course of the disease. Actually, when correction of the aortic or mitral valve malfunction can be achieved early, before ad- vanced disease poses a limit on operative outcome, the surgical risk becomes ńiinimal-no more than about 2 per cent. Furthermore, the long-term results of surgery-even surgery performed years ago with early and less perfected types of substitute valves- are remarkably good in those patients corrected be- fore the onset of devastating secondary effects of the disease process. Thus, patients who undergo aortic valve replace- ment before there is significant cardiac enlargement cap expect about the same life-span as the general population of the same age and sex. The identical statement applies to mitral valve replacement if the procedure is carried out before the age of 50, and before there is marked enlargement of the left at- rium. When we add up all these pluses and minuses, we can hardly escape the conclusion that the poor re- sults of valve replacement encountered today fre- quently stem from the fact that surgical correction was delayed beyond the optimal period. Why is it, then, that few cardiologists recommend the radical step of earlier surgical intervention? For one simple reason: there is `still great uncertainty about the long-term function of the substitute valve in comparison to the known long-term function of even adiseased but natural valve at the early stage of the condition. Although valve replacement is now almost com- monplace, we still lack sufficient 5-year-follow-up data on most of the prostheses currently in use. Even those valves based on the traditional models have had some design modification. Unfortunately, as SCOREBOARD OF RELATIVE MERITS OF VARIOUS SUBSTITUTE VALVES Cloth-covered Tilting Viable Autogepous Ball salves ball valves disc valve homograft Heterograft graft Istentedl DUrability +++ ++* ++ ++ + 0 Hemodynamic characteristics + + ++ +++ +++ +++ Thromboembolism + ++ + +++ 4+-f Assurance of function ++ ++ ++ + + + Availability and choice of size +++ +++ +++ 0 ++ ++ Ease of insertion +++ +++ +++ + + ++ Record of survival ++ + + ++ + 0 TOTAL SCORE 16 14 14 12 12 11 Symbols: 0- unfavorable; + - fair; ++ - wed; +++ - eveellent. The durability of vhe metal ball in thi~ type of valve shvuld be excellent, but the voise created by such a prosthesis is sigvificaetly obiectionable. MARCH 1976 15 PAGENO="0288" 14194 COMPETITIVE PROBLEMS' IN THE DRtJG INDUSTRY experience has warned us, the slightest structural alteration of a valve carries the threat that it might in some unforeseen way contribute to a detrimental outcome, whether immediate or delayed. Admittedly, we do not now have at hand an ideal or near-ideal substitute for the natural heart valves, but there is every reason to be optimistic about even- tual achievement of this goal. Whetherthe scales will finally be tipped in favorofamechsnically passive or biologically active implant is still a matter of conjec- ture. Some specialists believe that in the long run the former will win out, because the man-made pros- thesis allows greater freedom in the modification of design. With further experience, the design that is mostlikely to approach the ultimate ideal, atleast for aortic valve replacement, will simulate the natural semilunar valve. Our ultimate goal will be attained, however, only with the development of a type of material that will be nonthrombogenic and at the same time as durable as a delicate semi-elastic mem- brane. What does this all add up to in terms of a rational policy of patient management? We cannot draw up inviolate guidelines to selection of a specific patient as a candidate for a specific type of substitute valve implantation. Each case must be considered mdi- vidually, `and the appropriate valve chosen by the surgeon in charge. Our group, for instanCe, con- tinues to use predominantly the ball valve for both aortic and mitral positions although trials of the Bjork-Shiley tilting disc and the Hancock hetero- graft valve are also in progress. Our basic criteriafor surgical intervention are to undertake correction of the significantly damaged sortie valve at the time of onset of secondary symptoms, or when the heart has appreciably enlarged (to a cardiothoracic ratio of about 0.57). We recommend replacement of a significantly damaged mitral valve when progressive' disability first carries the patient into the state designated as functional class III (according to New York Heart Association criteria). We also advise anoperation if theleft atrial or overall heart size is showing progres- sive enlargement beyond a moderate degree. For easy reference, here is a greatly simplified thumbnail sketch of the heart valves most commonly used at the present time: Central Flow-Type Valves Simulation of flow characteristics of human valves is generally considered desirable in any substitute. Central flow design tends to streamline entrance of blood into the aorta. thereby decreasing energy dis- sipation and turbulence (a source of trauma to blood components that probably impedes healing). At present this can be achieved only with biologic tissue such as: Autografts-The pulmonary valve is suitable for use in the sortie position because its con(iguration is nearly identical with that of the sortie valve. While autografts have the advantage of being fully viable and capable of regeneration and therefore theoreti- cally resistant to late valve failure, follow-up is not yet adequate to confirm this, Criteria for patient selection for this type of replacement are highly selective: it is restricted to individuals with isolated aortic valve disease and life expectancy'of 30 years or more. Viable Homografts-Fresh homogfaft valves are collected under sanitary conditions and then stored in antibiotic-containing physiologic solutions. Via- ble cells have been detected in such valves 5 years after implantation-though the total number begins to decrease sharply within 2-4 years. Whether these substitutes will remain viable and continue to func- tion without subsequent degeneration remains to be seen. Homografts mounted on struts have simplified surgical procedures, and allowed use of such im- plants in sites other than just the sortie position. An important advantage of the homograft is that anticoagulants are not needed for prevention of EIGHT YEARS-THREE VALVES A 48-year-old man underwent aortic homograft repiacementfor calcific aortic stenosis, with ex- cellent results for six years. He then developed severe shortness of breath on exertion and episodic, paroxysmal, nocturnal dyspnea. Ex- amination revealed severe sortie insufficiency plus gross cardiac failure, necessitating re- moval of the homograft and insertion of a Braunwald-Cutter valve, but without outpatient anticoagulant medication. About 18 months later, he was well but anemic, and showed schistocytes and burr cells in peripheral blood smears. One month later, hemoglobin count was slightly lower and ferrous sulfate therapy was started. When anemia failed to respond to therapy, patient was readmitted and tests con- firmed red cell fragmentation. Operation revealed that the implanted valve had cloth wear at the distal third of the struts, with retraction of the cloth and with easy dis- placement of the bail through the remaining struts and the inlet orifice. Substitution of a Bjork-Shiiey semicentrai flow-tilting valve has given this patient good recovery and an une- ventfui subsequent course. 16 PRIMARY CARDIOLOGY PAGENO="0289" COMPETIPtVE PROBLEMS IN THE DRUG INDUSThY 14195 th)~ombi. Nonviable Homografts-Freeze-drying, or potent sterilizing solutions, improve availability and stor- age of homograft valves, although they do destroy viable cells. Initial results were encouraging despite murmurs of aortic incompetence in nearly 45 per cent at the end of the first year postoperatively, but late results show a high failure rate. Heterografis (porcine)-Preservation is aimed at eliminating antigenic components of the valves which, therefore, become nonviable, with function dependent on their inherent elasticity and flexibility. The preservation methods appears critical to the long-term performance of these valves. Several re- cent reports indicate favorable results when glutar- aldehyde-preserved porcine valves (Hancock type) have been employed, with generally excellent func- tion, low rate of thromboembolus formation, and good durability (thus far up to 5-6 years). They are particularly suitable in patients for whom an- ticoagulant therapy is contraindicated or highly problematical. Since heterograft inner-to-outer- diameter ratio is less favorable than for prosthetic valves in the smaller aortic valve diameters, en- largement of the aortic root is advised for small aor- tic valve annuli, or use of a central flow prosthetic valve should be considered. Tissue Valves-Autologous, homologous, and het- erologous grafts of fascia lata, pericardium, rectus sheath, and dura mater have been used. As with a natural valve, preservation and storage must be ap- propriately employed, except for autologous grafts. In the sortie position these various types have func- tioned satisfactorily for 4-5 years. Synthetic Central FlowSubstitute Valves-Synthet- ic substitutes for duplicatingthe central flow orifice valve have been unsuccessful; relentless growth of fibroblasts soon produces a stiff, nonpliable valve with subsequent valve dysfunction. Lateral Flow Valves Ball Valve (simple)-Of all valves based on a lateral flow design, the ball valve has had the greatest clini- cal success. Originally constructed of a heavy acryl- ic cage with a metal poppet, this type was later refined to a lightweight metal cage with a Silastic poppet and with many subsequent signi~icant mod- ifications. The Starr-Edwards type, having gained greatest acceptance by surgeons, became a standard for comparison with other models. It, tQo, had un- dergone many modifications, including a change in the method of cure of the Silastic poppet which also affected all ball valves using such a poppet. Earlier Silastic produced swelling of the ball with conse- quent valve dysfunction or poppet fragmentation. Although ball variance has not been completely MARCH 1976 PROSTHETIC VALVES eliminated, it~ incidence is now nearly negligible in follow-ups of up to 7 years. The majorproblem witbthis type of prosthesis has been systemic thromboembolism (even with chronic anticoagulant therapy). This is a drawback with all prosthetic valves. Fortunately, the multiple modifi- cations in fabrication of this. valve have had a salu- tary effect on thromboembolism incidence. The cur- rent model (1260 aortic valve) appears to be as- sociated with only a 5 per cent, 3-year incidence, compared with a 20 per cent, 3-year incidence a decade ago. Cloth-Covered Prostheses-Since its introduction in 1967, the Starr-Edwards cloth-covered type of prosthesis has appeared to decrease thromboem- bolic episodes. But problems with cloth wear along the struts and at the seating ring necessitated many changes. and thereis a paucity of follow-up data on the current types. (A Braunwald-Cutter model, us- troduced in 1970, has recently been withdrawn frods the market because of heiholysis and accelerated poppet wear associated with poppet embolism.) Track Valves-A modified Starr-Edwards fabril~- covered modeldesignedto prevent cloth wearis now being assessed clinically. The new design protects the cloth atthe critical areas in contactwith the ball. Disc Valves-Integral to the design ofaball valve is a cage of sufficient length to permit adequate excur- sion of the ballfrom the inlet orifice. Although easily accommodated in the aortic position, it has been considered unsatisfactory for some atrioventricular valve replacements. To obviate its drawbacks~ a low-profile disc valve with aflatlens suspendedin an abbreviated cage was devised, but initial enthusiasm waned as the disc design failed to demonstrate any superiority in the atrioventricular position. Semicentral Flow-Tilting Disc Valve-This type re- tains the low-profile contour but approaches the cen- tral flow concept, and consists ofafree-floating lens ins partial Satellite cage. In the open position, it tilts 50 to 60~ in the direction of blood flow. With an ultralight disc, this valve has an extremely favorable orifice-to-mounting ring ratio and thus appears to be well suited for pediatric patients or those with a diminutive aortic valve annulus The semicentral flow-tilting valve (Bjork-Shiley. type) is also popular for use in adults and, to date, general problems have been few so far (except for thrombosis of the aortic valve prosthetis, which has occurred nearly exclusively in those with no or in- adequate anticoagulant prophylayis). Good control of long-term bflticoagulation is clearly essentisl in patients with this typeof valve implant andaltbough the wear characteristics thus far seem good, it re- mains to be seen if its performance will equal that of the ball-and-cage type. 0 17 73-617 0 - 76 - is PAGENO="0290" 14196 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Internal Heart Functions Are Mon precise and continuous monitoring of the of position by x-rays shown via "instant replay" ona heart's internal functioning without discom- TV screen. fort to the patient, has been made possible The new technique is being used at the Stanford by a technique that establishes mapping points in the University Medical Center to follow the progress of heart muscle, then records their subsequent changes patients after they have undergone surgery for heart transplants, coronary artery bypass graft, or valve replacement. Within an hour after x-rays are taken, physicians can determine how well each segment of the heart is working, how much blood the heart contains, how much blood it is pumping, and the length of contraction time. The first step in the system is taken while the patient is on the operating table: the surgeon im- plants minute metal coils at appropriate places in the muscle fiber. The coils are made of tantalum, a non- reactive substance that can last a lifetime. Later, x-rays taken in 3-second sequences are re- corded on a video disk-a magnetized, coated, 14-inch aluminum disk that can store high-resolution images and replay them at normal speed, in slow- motion, in reverse, or one frame at a time. Pulsed signals from angiogfams also can be played re- peatedly, making them available for prolonged analysis when a computer is linked to the disk. By comparing sets of x-rays with thosetaken later, researchers can determine if the heart is getting larger or smaller. They can also discover whether a transplanted heart is undergoing rejection, and how fast the heart is deteriorating or improving. In addition, the technique will be used to study the short-term recovery process after surgery, to inves- tigate the effects of drugs and exercise on the hearts of patients, and to examine the mechanisms by which the rejection process andanti-rejection drugs affect the transplanted heart. The system has been employed with considórable success for about two years on more than 50 heart- transplant, coronary artery-bypass, and valve- replacement patients at Stanford University Flospi- tal, by a research team composed of Dr. Neil `Ingels and engineer George Daughters of the Palo `Alto Medical Research Foundation, and Drs. Edward Stinson, Edwin Alderman, Lewis Wexler, Philip Oyer, Randall Griepp, Jack Copeland, and Norman Shumway of Stanford. The video disk, but not necessarily the metal tails, are alto used to analyze the blood-pumping effi- ciency of hearts of patients in the Mayo Clinic's cardiovascular research ward, 0 18 PRIMARY CARDIOLOGY PAGENO="0291" COMPETITIVE PROBLEMS J2'T THE DRUG INDUSTRY 14197 itored by Noninvasive Technique MARCH 1976 19 PAGENO="0292" 14198 coi~rn~mv~ PROBLEMS IN THE DRUG INDUSTRY Diagnosis and Treatment By H.J.C. Swan, M.D. and William Ganz, M.D. : The balloon flotation catheter, developed In re- cent years has greatly facilitated right heart and pulmonary artery catheterization It provides rn portant physiologic data for diagnosis and treatment of patients who are seriously ill not I ~ ~` only from myocardial infarction but from other D 5 D t J I ~ diseases as well tI Dj t t I I ________________________ Cd lg I Cd S Ml I Center. and Professot of alloon flotation catheters-now widely ac- M d U 1) cepted as reliable and relatively safe--are ~alifernia. Los Angeles. finding extended use for diagnosis and treat- ment of the critically ill, not only in larger institutions but also in the community hospital. They can be used at the bedside without fluoros- copy to provide highly relevant circulatory data, and to permit a rational selection of therapy with, at the im time is essment t patient iesponse The ap ~ ptic'itions of h-slloon fi )tation ath ters have come to in ludc tht c ui ste m sn igement of fluid volume Di G ~ - ~. ~ control in patients with bacteremia, acute pan- R / S te ititis ind severe blood loss I) p These Litheteis have found use -ilso in the coro C i 1 ~ nary care unit the medical intensiv ire unit the C i a ti i I ~ pstsuigis.al recovery unit the intraopeiative ar C t I P / / diovascular surgs..al suitt. the neuiosuigical md oh M 1 (1 t / ~ stetric areas and in anesth si)logy They sic of calif orals. Li's Angeles. ~ importance as well in the diagnostic cardiac catheterization laboratory. the pulmonary intensive care unit, and the pulmonary function laboratory. They have been of value in outpatient facilities in- cluding exercise laboratories and "noninvasive" laboratories. The Swan-Ganz catheter is relatively simple and does not require the special technical skill usually needed for manipulation of the traditional catheter. Further, it is a procedure of short duration and in- volves alow incidence of ventricular arrhythmias, as 20 . PRIMARY CARDIOLOGY PAGENO="0293" COMPETITIVE PEOBLEMS IN THE DRUG INDUSTRY 14199 With the Balloon Catheter MARCH 1976 21 PAGENO="0294" 14200 COi~ETIPIVE PROBLEMS IN THE DRUG INDUSTRY compared to traditional catheterization. Neverthe- less, its use does require training and practice. We recommend that every hospital prepare a small group of physicians, nurses, and technical personnel who will be truly familiar with use of the apparatus and ready to offer their services to other physicians on request. The results in information gained could help advance diagnosis and treatment on a broad front. We developed the flow-directed catheter in the late 1960s in connection with myocardial infarction studies in seriously ill patients. We sought a method for placement of catheters within the pulmonary ar- tery which would provide prompt and reliable pas- sage; would permit manipulation without use of the fluoroscope; and would not cause ventricular ar- rhythmias. A small inflatable balloon, mounted at the tip of a highly flexible cardiac catheter, was developed and tested, first in animal experiments and later in the clinical area. By 1970 we had re- ported on its use in 100 patients. The device consists of a double lumen catheter of about 1.5mm outside diameter. The smallerlumen is approximately 0.4 mm in diameter and is used to inflate a latex balloon at the catheter tip with either carbon dioxide or air. After the catheter has been introduced into the circulation by cutdown or per- cutaneous technique, the tip is positioned in the ECG LEAD FROM CATHETER TIP DURING INSERTION VC VC VC RA RA RV RV RV RA Catheter tip/n right atrium (note: larger amplitude and positive direction of "QRS'~ "P' may be larger than shown here, depending on position of catheter within atrium). RV Cathetertip lii right ventricle (note: small "P' withlarge negativedirection "QRS'~). Caution: Fort *elë ctrical safety, it is mandatory that these intracavlty ECQ's be monitored with suitably isolated, preferably battery powered, equip- ment. 22 PRIMARY CARDIOLOGY PAGENO="0295" COMPETITtVE PROBLEMS IN THE DRUG INDUSThY 14201 BALLOON CATHETER superior or inferior venacava orhigh right atrium. The balloon is then inflated, providing a relatively solid (isonliquid) element which is directed by the flowing stream of blood. The inflated balloon, with a diameter of about 11 mm, is flow-guided through the right atrium and tricuspid valve into the right ventri- cle. From there it finds its way into the main pulmo- nary artery and into a branch of the pulmonary ar- tery. When it reaches a pulmonary vessel slightly smaller in diameter than the inflated balloon it stops, much like a pulmonary embolus. When fluoroscopi- cally controlled, the balloon guidance system will flow from the right atrium to the pulmonary artery in about 10 to 20 seconds. When the balloon is deflated, the catheter shaft will recoil slightly into a larger pulmonary artery since the flowing blood now does not have the "mass" on which to act. When it is slowly and briefly inflated again, it has impact once more on a smaller artery and permits a wedge measurement- one of the most significant readings provided by the catheter. The balloon is important in avoiding endocardial irritation and arrhythmias: When it is inflated for passage through the right ventricle, the balloon pro- trudes over the catheter tip, which maintains its place in "the hole in the balloon doughnut." Pressure Tracings Needed The apparatus requires manometers and display units as well at electrocardiographic monitoring. A fluoroscope, although it can be dispensed with at the bedside, facilitates effective placement in some cases. Pressure tracings are needed, not only to as- sist in positioning the catheter tip, but to provide data useful in diagnosis. An increase in respiratory cycle pressure variations on the tracings indicates that the tip has reached the thorax. The balloon is then inflated and a recording made of the maximum and minimum pressures in the atrium. As it enters the tricuspid valve and passes into the right ventricle a similar recording is made. Pressure tracings then show the pulmonary artery pressure contour, and advancement is continued until a pressure is iden- tified which approximates pulmonary artery dias- tolic levels. The balloon is then deflated and phasic pulmonary artery pressure should reappear. The pressure levels in the pulmonary artery are then measured again. The balloon flotation catheter may be left in place up to a maximum of 48 hours in management of the critically ill, but re-use is questionable because cleaning and sterilization may cause deterioration of the latex balloon. The balloon must always be de- flated for withdrawal of the catheter. The flow-directed catheteris particularly useful in measuring the pressure in the pulmonary veins when wedged with its balloon. This reading is of critical importance in clinical practice in that it provides information on the level of pulmonary congestion and on the transferoffluidatthe pulmonary capillary level. In addition, pulmonary venous pressure re- lates closely to leftatrial pressure and, inthe absence of mitral valve disease, to left ventricular diastolic pressure. For clinical purposes the mean wedge pressure provides highly relevent data of practical significance. Most Valuable Parameter The principal data obtained from using the cathe- ter include the filling pressures of the right and left ventricle, ~ P/i~t T, and the cardiac output. Of these, left ventricular filling pressure appears to be a most valuable parameter of cardiovascular function on which to base therapeutic decisions and on which to evaluate their effectiveness, A knowledge of cardiac output as a basic compo- nent of cardiovascular function has always been ac- cepted as important by the cardiovascular physiologist. However, many clinicians have doubted the value of precise data on cardiac output levels and changes. Now that this variable can be measured with the balloon flotation catheter without particular difficulty or increased hazard to the pa- tient, the significance of such measurements in clini- cal practice is becoming recognized more widely. Several definable states of cardiovascular fur~c- tion can now be identifiedin pathophysiologic terms, and specific therapies can be indicated on a hemodynamic basis. For instance, normal cardiac output associated with a normal left ventricular ~il- ling pressure does not require specific cardiovascu- lar therapy, and indicates that abnormal symptoms or signs suggestive of cardiovascular dysfunction may have another basis. Changes may occur later, and the comparison of data can be significant. From the basic balloon flotation catheter have come other developments permitting more complex measurements. The thermodilution catheter incor- porates a thermistor which allows measurement of cardiac output by the thermodilution principle. Pediatric catheters have permitted catheterization of the heart with less risk of perforation or major arrhythmias in critically ill infants with congenital heart disease. And special balloon-tipped catheters are used for rapid bedside temporary pacing. Some surgeons have predicted that the balloon flotation catheter ushers in alt era in which monitoring of critically ill surgical patients will become accepted as being indispensable. 0 MARCH 1976 23 PAGENO="0296" 14202 COi~tIETITIVE PROBLEMS IN THE DRUG iNDUSTRY Diagnostic Sequence By Arthur A. Sasahara, M.D. Dr. Sasaha Del Medicine I Administration i..,~ West Roxbury, I Embolism Is the most common cause of pulmo- nary death among. hospitalized patients; and when Its secondary effects are also taken into account, It may well bethe most common cause of all deaths in the hospital. Untreated, pulmonary embolism isfatal in 25 to 35 per cent of cases. But the mortality rate plum- mets to between eight and ten percent with prompt diagnosis and effective treatment. Unfor- tunately, the diagnosis is not immediately appar- ent in many instances, because the clinical pic- ture of pulmonary emoblism Is largely non- specific. A practical diagnostic sequence can be formu- lated to assess patients with suspected emboli, even In situations wheredefinitlve, sophisticated diagnostic techniques are not readily available. It is a paradox that while medicine and surgery are taking great, if not giant steps forward, the mci- dence of thromboembolism is on the rise. Un- doubtedly, the increase is related to that progress, in that older and sicker patients are undergoing more complex operations and are confined to bed for longer periods. Thus, the stage is set for the forma- tion of thrombi and their release as emboli. Embolism is certainly regarded as the most com- mon cause of pulmonary deaths among hospital in- patients. In fact, if its secondary effects are taken into account, embolism may well be the most fre- quent cause of all in-hospital deaths. Each year, about 142,00 patients (four to five per 1,000 inpa- tients) die of pulmonary embolism in American hos- pitals. And another 568,000 (20 per 1,000 inpatients) suffer nonfatal embolic episodes. To some extent, the grim mortality figures are the result of slow or missed diagnosis. Without treat- ment, pulmonary embolism is fatal iii 25 to 35 per cent of cases. But with prompt diagnosis and effec- tive treatment, the mortality is considerably lower-eight to ten per cent. The obvious implication is that early diagnosis and immediate treatment greatly improve the prognosis. Early recognition is not always easy, however. Even in patients with segmental and larger vessel occlu- sion, pulmonary embolism is diagnosed infre- quently. One reason is that the symptoms and signs are usually nonspecific-attributable to any other car- diopulmonary problem. Another is that laboratory tests contribute little to diagnosis because they, too, are nonspecific for pulmonary entholism. Determi- nations that once seemed promising-serum LDH, GOT, and bilirubin-have been found to be of little use in diagnosing pulmonary embolism. Since neither clinical noilaboratory evidence points speci- fically to thromboembolic disease, appropriate diag- nostic studies often may be delayed until after another embolism occurs. As in so many clinical situations, the essential first 26 PRIMARY CARDIOLOOY PAGENO="0297" COMPETITIVE PROBLEMS L~T THE DRUG INDUSTRY 14203 step toward diagnosis is the physician's index of suspicion. Once he suspects that his patient has suf- fered pulmonary embolism, he can carry out a number of relatively simple tests to support the pre- sumptive diagnosis or rule it out At the same time, he can begin prophylactic treatment with low-dose heparin. One routine measure that yields valuable informa- tion is the plain chest x-ray. In a cooperative study conducted by the National Heart and Lung Institute (NHLI), the two most common features of chest films in patients with pulmonary embolism were high diaphragm on the side where the embolus was lodged, and pulmonary consolidation. Many of the patients had both. In the clinical context Of car- diopulmonary distress, then, either or both of thete featutes on the plain film should suggest the stropg possibility of pulmonary embolism, infarction, or both. To confirm the diagnosis, perfusioulung s~n- ning should be performed immediately. In the NHLI study, data were obtained from 14 institutions that followed a uniform study protocoL, in which the presence of pulmonary embolism was established by pulmonary angiography. Patients were grouped according to the extent of occlusiOn: Those who had two or more lObar arterial occlusions were classified as having suffered massive em- bolism; where there was lesser occlusion, the ~m- SUSPICION OF PULMONARY EMBOLISM 1 HE PA A IN -DVI J + DVI bPaO2 I ~PaO2 r LUNG SCAN 4-VIEW /1! ,`,` PULMONARY ANGIOGRAPHY ______ LTHROMBOLYICTHERAPY SURGERY I r Schema for deagnostic zz'orksp s/zen lung scanning and/or pulmonary angiography are not readily available. MARCH 1976 27 PAGENO="0298" 14204 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY bolism was classified as sub-masaive~ It must be pointed out that all the patients in the NHLI study had serious pulmonary vascular obstruction (aver- age, half of one lung), since the criteriafor eligibility excluded those with small pulmonary embolism. Massive or Submassive Embolism Symptoms such as pleural pain and syncope, and physical findings of tachypnea, rales, loud pulmo- nary second sound, and cyanosis were considered in relation to the massivity of the embolism. The only symptoms that could be used to distinguish between massive and sub-massive embolism were pleural pain (associated with sub-massive embolic occlu- sion) and syncope (indicating massive embolism). As for physical signs, only loud pulmonary second sound, Sa or S4 gallop sounds, and cyanosis were pertinent. These findings more often reflected mas- sive than sub-massive embolism. Only one-third of the patients had clinical evidence of thrombophle- bitis. The two definitive diagnostic procedures - perfusion lung scanning and selective pulmonary an- giography-often cannot be performed atthe critical time because most hospitals are not equipped to provide these services 24 hours a day, seven days a week. However, diagnostic evaluation for pulmo- nary embolism is incomplete without lung scanning, unless angiography has been performed. If the lung scan is abnormal, confirmation by pul- monary angiography is very desirable, especially in patients with prior cardiopulmonary disease. But in certain patients, treatment may be started without angiographic confirmation when thelung scan shows lesions that have a "high probability" of being due to pulmonary embolism. Such patientsare young per- sons without pre-existing cardiopulmonary disease, whose history and physical findings are compatible with the presence of pulmonary embolism. When scanning and angiography have to be de- layed, simpler tests may suffice for a provisional diagnosis. One such test is measurement of the arter- ial oxygen tension, which can be of value in exclud- ing pulmonary embolism provided that certain mod- ifications are adopted. First, the oxygen electrode must be calibrated with standard gas before each use. Second, the lower limit of normal for arterial oxygen tension should be established at 90 mm Hg, since higher tensions are rare among patients with pulmonary embolism. Therefore, if arterial oxygen tensions are to be used for diagnosis, calibration of the electrode prior to each measurement is essential to assure accuracy. NHLI UROKINASE PULMONARY EMBOLISMTRIAL Presenting Symptoms Prevalence (%) Symptom All Massive Submassive Dyspnea 81 79 83 Pleural pain 72 62 84* Apprehension 59 61 56 Cough 54 50 60 Hemoptysis 34 27 44 Sweats 26 27 24 Syncope 14 22* 4 eDifferences are significant. UPET: Presenting Signs Prevalence 1%) Signs All Massive Submassive Rales 53 50 57 tP2 53 60* 44 Phlebitis 33 42 21 S3,S4 34 47* 17 Sweating 34 41 24 Cyanosis 18 28* 6 tRespiration (>16) 87 tPulse (>100) 44 Fever (>37.8) 42 *Differences are significant. Laboratory Findings Test Per cent Patients LDHt 37 GOTt 26 HCT <35 per cent 23 BUN >20 18 Platelets (<200,000) 18 Bilirubin (>lmg/lOOmI) 10 Frequency of CXR Abnormalities Abnormality Per cent Patients Consolidation 41 High diaphragm 41 Pleural effusion 28 Plump pulmonary arteries 23 Atelectasis 20 LVt 16 Focal oligemia 15 RVt 5 28 PRIMARY CARDIOLOGY PAGENO="0299" COMPETITtVE PROBLEMS IN THE DRUG INDUSTRY 14205 Also useful as aids to the diaguosi~ of pulmonary embolisrt are various procedures for assessing the patency of the deep veins of the legs. A strong as- sociation between pulmonary embolism and deep vein thrombosis was documented recently by Sevitt, who found deep vein thrombosis in virtually all his patients who suffered fatal pulmonary embolism. Similarly, another physician, who assessed throm- bosis using the radioactive fibrinogen test, found pulmonary embolism to be present only when radioactive clots were detected in the deep veins. In the author's own experience, deep vein throm- bosis was detected in 95 per cent of patients with pulmonary embolism confirmed by selective pulmo- nary angiography. Contrastascendingphlebography is more definitive for detecting venous thrombosis than the simpler electrical impedance phlebography. However, its usefulness is limited because it is not readily available. Another limitation is thatcontrast ascending phlebography is an invasive test. There- fore, non-invasive procedures'.- electrical impe- ~lance pblebography and Doppler ultrasound-have been used with increasing frequency. For detecting deep vein thrombosis, impedance phlebography ap- pears to be more sensitive and more specific than Doppler ultrasound. Based on these non-invasive, readily available tests, a practical diagnostic sequence can be formu- lated to assess the many clinical situations in which perfusion lung scans and selective pulmonary an- giograms cannot be obtained immediately. If Pulmonary Embolism Is Suspected When pulmonary embolism is suspected, an im- mediate "covering dose" of 7,50010 10,000 units of heparin should be given intravenously; a routine chest x-ray and an electrocardiogram should be ob- tained; arterial oxygen tension should be measured; and patency of the deep veins should be assessed. If an accurately performed arterial oxygen tension measurement is normal (above 90 mm Hg), it is unlikely that pulmonary embolism is present. If phlebography shows the deep veins of the legs to be of normal patency, pulmonary embolism is also un- likely. Indeed, if the impedance measurement is normal in these suspected patients, our experience indicates a 90 per cent probability that pulmonary embolism does not exist. However, if the arterial oxygen tension is low or the deep veins are ob- structed, perfusion lung scanning should be per- formed to confirm the presence of an embolism. In this clinical setting, the impedance measure- ment is specific for detecting thrombosis in the deep PULMONARY EMBOUSM veins, where pulmonary emboli originate. There- fore, this test has far greater diagnostic value than the arterial oxygen tension measurement. In our group of patients, angiography confirmed the pres- ence of pulmonary embolism in 90 per cent of those whose impedance phlebograms indicated deep vein obstruction. Most patients should have angiographic confirma- tion of pulmonary emboli, particularly if some form of surgical intervention is contemplated. And in the vast majority of patients, intravenous heparin therapy should be continued, provided that an- ticoagulation. is not contraindicated. In the future, heparin will probably be replaced by thrombolytic agents. Because such compounds are superior to heparin in rapidity of action and com- pleteness of clot resolution, they are likely to be- come the preferred drugs fortreatment of pulmonary embolisp. However, since the thrombolytic agents are not yet available forgeneral use, heparin remains the drug of choice. o Practice Procedures Detecting Pulmonary Embolism Perfusion lung scanning and selective pul- monary anglography arethe definitive diagnos- tic procedures to confirm or rule out pulmonary embolism, but in many stuations, they are not Immediately available. When pulmonary em- bolism is suspected, the following diagnostic sequence is a practical means of prompt diag- nosis and successful management: * Give a `covering dose" of 7,500 to 10,000 units of heparin intravenously. * Obtain routine chest x-ray and ECG. * Measure arterial oxygen tension. When ten- sion is normal (90mm Hg or higher), pulmonary embolism is unlikely. * Assess deep veins for thrombi by contrast phlebography or impedance phiebography. If the impedance measurement is normal, the probability is 90 percent that thereis no pulmo- nary embolism, * Perform perfusion lupg scanning if arterial tension is reduced or deep veins are ob- structed. * Confirm the presence of pulmonary emboli by angiography. * Continue intravenous heparin therapy in pa- tients with confirmed pulmonary emboli, unless anticoagulation is contraindicated. MARCH 1976 29 PAGENO="0300" Minor Infarctions: dial infarction within a half-day to a month, despite restriction of their physical activity. At that time, it had already been well established that a number of anginal attacks may precede myocardial infarction. Many of the patients recovered spontaneously without ill effects, while others developed serious myocardial infarctions with a relatively high fatality rate.Still, the tendency has beets to label all such patietsts with one diagnosis~ intermediate coronary insufficiency syndrome.. Since myocardial revascularization, largely by aorto-coronary bypass, has come into widespread use, the challenge to the physician is to distinguish Dr. S'ampson to Clinical between the benign and the more serious forms of Professor of Medicine, such deviant anginal attacks. This distinction may University of California, . . San Fr c d indicate which patients might best benefit from sur- president of the gical revascularization, and which run the highest American Heart operative risks. Association Criteria Are Limited Unfortunately, prognostic criteria are few and diagnostic criteria are inadequately defined. Various degrees of coronary occlusion can develop asymp- tomatically. Even severe narrowing of all three coronary vessels may give no warning or may pro- duce only minor, stable angina until a serious myocardial infarction suddenly occurs. Conversely, coronary angiography may reveal relatively minor occlusive disease or no evident arterial narrowing in patients who have repeatedly required protective hospital admissions for severe `crescendo" spon- taneous angina or angina of effort. Patients with Prinzmetal's variant of angina often present such deviations from the expected occlusive disease, and this type of attack has been attributed to coronary arterial spasm. Different authors have offered different diagnos- tic criteria. To a large extent, these criteria depend on what statistical plan is to be used for analysis of a specific collection of cases. Another factor that in- fluences the specified diagnostic criteria is the physician's sphere of interest. For example, a car- diologist who is interested in the natural bistory of the disease, in noninvasive diagnostic study, and in "medical" care (i.e., rest during a presumptive criti- 14206 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY The Intermediate syndrome of acute coronary insufficiency has been described in ill-defined, imprecise terms. It encompasses a broad spec- trum of signs and symptoms, with wide varia- lions in prognosis. Distinction between the be- nign and more serious forms of this syndrome is Important in charting the course of therapy. Almost 40 years ago, two papers (one by Fed and the other by Eliaser and myself) were published describing the clinical patterns of patients who had experienced recurrences of angina pectoris that deviated from prior attacks. -Impor-' tance was attached to these new episodes because about half of the patients developed typical myocar- 30 PRIMARY CARDIOLOGY PAGENO="0301" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14207 What to Look For By John J. Sampson, M.D. cal period and treatment with anticoagulant drugs and beta-adrenergic-blocking agents) will not set the same criteria as a cardiovascular surgeon. The surgeon who is interested in revascularizing the myocardium by performing an aurto-coronary bypass will consider surgical mortality and post- operative benefits and complications. Still other criteria would be set by investigators who are study- ing the pathogenesisof the syndrome, or the pathol- ogy that can be foundat autopsy. The latter is espe- cially valuable when it is correlated with the as- sociated clinical patterns. The "intermediate syndrome" is generally recog- nized as coronary insufficiency of a severity inter- mediate between myocardial infarction and chronic angina pectoris with a consistent pattern. And there has been general agreement that the coronary circu- lation is insufficient to consistently meet the metabolic needs of the myocardium at rest, although it is generally sufficient so that myocardial infarction does not occur. However, evidence has accumulated that these neat definitions are not always entirely valid. For example, 20 years ago an autopsy study indicated `that when the onset of prolonged ru new paiti'points to an important new occlusion, the development of necrosis depends on both the degree and the dura- tion of myocardial ischemia. The intermediate syn- drome, then, may reflect a state of jeopardy that culminates in small or large areas of necrosis when the' compromised blood supply can no longer sup- port the vitality of the myocardium. - Syndrome Subgroup Sought Such necrosis, sometirtes called a "silent" infarc- tion, may not cause pain. However, it does produce the delayed rise of serum enzymes in 2 to 11 days, the electrocardiogram changes, the altered car- diodynaunics, and other Sighs that are characteristic of m~ocardial infarction. Because these changes occur with some frequency, it is necessary to ac- count for them by defining a more serious subgroup of the intermediate syndrome. One recent report indicated thatamong 84 patients who had typical prolonged infarction pain, only 26 had moderately elevated serum CPK-Ml3 levels, which presumably were detected because of fortui- tous timing of the determinations. However, their ECG patterns showed only S-T depressions or ele- vations and inverted T-waves, Another team of in- vestigators had previously reported similar eleva- tions of SOOT. Myocardial Scintigrams as Evidence The most recent evidence of minor jnfarctions, presented in several papers published over the pgst year, came from myocardial scintigrams taken on patients with the intermediate syndrome. In these studies, radioactive agents such as 99M-technetitum stannous pyrophosphate, 201-thallium, 43- potassium, 81-rubidium, and 129-cesium were either relatively concentrated or reduced in the infarcted areas and appeared on the scintigraphic image. Definition and identification of a more seriously threatened subgroup can pay off with a reducedsur- gical mortality rate. For example, in a study of Ill intermediate syndrome patients who haj the same pattern of pain and ECG changes in the S-T segment and T-wave, 16 patients had elevated serum levels of CPK-MB. These l6patients did not undergo bypass surgery, with the result that operative mortu~lity among the total study group was-reduced from the expected figure of more than 10 per cent to an actual death rate of only four per cent. In contrast, in another report, there was 80 per cent mortality in a small series of patients with impending or exteziding myocardial infarction who were subjected to emergency aorto-coronary bypass withoUt e*clu- sion of those at high risk. In patients who were followed for long periods, several reports have indicated that sudden dçath is not infrequent. In one group of 100 patients, 22 died suddenly in one year. It may be erroneous, then, to assume that "is- themic" ECO changes in T-waves and the S-T seg- ment are benign patterns. lndeed, a numberofinves- tigators have noted a tendency toward failure to recognize that these were the only I~tCO chan~es in autopsy-proven cases of myocatdial.infarction with one or more arteries occluded. MARCH 1976 31 PAGENO="0302" 14208 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Basically, the intermediate syndrome can be ac- cepted as a form of acute coronary insufficiency that does. not meet the criteria of a major myocardial infarction; but it is important to recognize the exis- tence of this syndrome as a subgroup with evidence of minor myocardial necrosis and a hazardous prog- nosis, NORMAL NO INSUF- FICIENCY WITH STRESS NORMAL INSUFFI- CIENCY WITH STRESS - Many terms have been used to describe the inter- mediate syndrome, and-some of them require corn- ment:~ * Acute coronary insufficiency (oracute myocar- dial ischernia and acute coronary heart attack). This term is probably accurate, but it requires further definition because it is too broad. It could include a spectrum of disease ranging from relatively new is- chemia without myocardial damage, through minor infarctions, to major infarctions. * intermediate coronary syndrome. This desig- nation encompasses the zone between chronic an- gina or no chest pain, through noninfarcted ischemic myocardium, to Sninor infarction as discussed ear- lier. Those patients with minor infarction must be classed as a subgroup with more serious prognosis. * Unstable angina has recently become apopular term. However, it has the shortcoming that many patients experience an almost continual fluctuation in the frequency. precipitating factors, and intensity of recurring pain, but they show no objective evi- dence of myocardial damage or myocardial infarc- tion over periods of many years. An example is a71-year-old mali who has suffered four mild myocardial infarctions. Over the past four years, he has had periods of one to three weeks with angina only on effort (e.g., rapid walking), inter- spersed with isolated spontaneous attacks lasting 30 to 45 minutes, recurring for four to five days, and HYPOTHETICAL INCREMENT OF CORONARY INSUFFICIENCY CORONARY INSUFFICIENCY ~AACUTE PECTORIS MYOCARD. INSUFFI' ISCHEMIA cIENCYWITH1 PMIN MOO. STRESS1 MYOC. INF. . SMALL MYOC. INF. ~ MYOCARDIAL INFARCTION MILD ~ ~- CORON'Y ~ CIRCULATION/MYOC._DE~ AND 1TTU ffl~I I~Bi~~HllI j PAIN E C G M. SHOCK &/OR HEART FAILURE SER ENZYMES MORTALJ~~~ T 3.5% ~ 1. 2. 3. 4. 5. Diagram shows proportion of the myocardial requirement to the local or general available supply ofoxygenated blood. Columns 2, 3 and part of 4 represent evidence of functional inadequacy - largely reversible. Column 3, angina pectoris is a dilnical term of variable functional and structural consequence. Columns 4 to 8 represent structural damage of the myocardium of increasing magnitude, dependent on the duration and degree of coronary insufficiency. 32 PRIMARY CARDIOLOGY PAGENO="0303" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14209 relieved only with repeated doses of nitroglycerine. Another patient-a 63-year-old woman-had three minor myocardial infarctions in six years. She has spontaneous episodes csf chest pain in the evening or night, lasting a half-hour to an hour despite the use of two to three sublingual nitroglycerine tablets. These attacks recur six to ten times a year. No changes are found in the ECO or serum enzymes, and she re- turns to moderate physical activity (e.g., climbing low hills) without discomfort. * Preinfarction angina is an inaccurate term in two respects: many of the attacks prove to be minor infarcts; and 50 to 80 per cent of patients never develop myocardial infarction. * Accelerated angina pectoris (or prolonged an- ginal pain) is agenerally descriptive term, but it does not cover the variations in clinical patterns. * Prodromata in acute myocardial infarction; premonitory period of myocardial infarction; let- pending myocardial infarction; impending coronary artery occlusion; and preliminary pain in coronary thrombosis. These five terms emphasize the hazard of an impending myocardial infarction, but they do not account f~r the many cases where immediate small infarctions have already occurred, and the many more in which infarction never develops. The duration of this premonitory, intermediate coronary syndrome is not given detailed attention in many reports. Four weeks would seem to be a ra- tional limit of duration of the acute episode, but the physician must take into account the dynamic mod- ifications that result from serial angiographic and scintigraphic studies, as well as the concentration and clearance of radioactive indicators in areas of infarction. A four-week duration of the syndrome is evident and expected after aorto-coronary bypass surgery, because of the alteration of collateral flow, and be- cause of the possibility of acute thrombotic and pre- sumably atherosclerotic advance of the arterial oc- clusion. A surprisingly rapid advance of athero- sclerosis has been observed on serial toronary angiograms and such progression is seen more fre- quently after aorto-coronary bypass than duriflg the course of medical therapy. Although many authors suggest a four-week duration of the intermediate syndrome, others believe the limit may be six weeks to two months. It is important to recognize that the acute coro- nary insufficiency is a labile process which may or may not advance to serious infarction. The clinical evidence may not indicate that a myocardial infarct, generally minor, often exists at the onset .of this syndrome. Therefore, it is the physician's responsi- bility to carry out without delay, diagnostic proce- MINOR INFARCTIONS dures (e.g. radioactive scinhigrams) that will reveal themyocardial lesion. In identifying these patients with suspected or proven minor infarct, the same care should be ap- plied as if they presented with the clinical and laboratory evidence of a major infarction. The importance of accurate diagnosis is that the presence of minor infarcts may modify the decision to perform an aorto-coronary bypass because of in- creased operative risk. 0 ~Practice Procedures Criteria for Diagnosis The criteria for diagnosis of intermediate coronary insufficiency have varied in extent, and to some degree in content,from one author to another. But all definitions include the ele- ments listed below: 1. New cardiac symptoms, or recurrence of symptoms after freedom from pain. The symp- tori-is may be anginal stain precipitated by effort or occurring spontaneously; episodes of spon- taneous dyspnea; fatigability; giddiness; dr faintness. 2. Worsening of symptoms: pain with in- creased severity, duration (over 15 or 30 min- utes), frequency, or spontaneity (nocturnal or during rest); br pain precipitated by less streSs than in previous attacks. Some authors classify patients within a more serious subgroup if they have spdntaneous pain recurring persistently after a day of bedrest. 3. Nitroglycerine or other nifrite~ have /ess ef- fect or give no relief from cheSt pain. In mostreports, the following objectiVe find- ings are considered pertinent: 1. Electrocardiogram showing depressed or elevated S-T segment; flattened or inverted T-wave (likelyto betransientfor 1-24 hours); no new Q deflections. 2. Serum enzymes not rising to `diagnostic' levels. The fallacy of this criterion-especIally with respect to CPK~M~ isoenzyme - is the transiency of theelevatiofl, sothat if blood is riot taken at the critical time, the peak level may be missed. CPK, SOOT, LDH (and LDH isoen- zymes 1 and 2) may rise frombase levels but remain within the customary maximum iimit~ (40 units). However, on daily testing forthree to five days, these enzymes may present a curve with over 10 percentvariation tothe peak level. 3. Coronary angiogram revealing greater than 50 per cent occlusion in one, two, or all three major coronary arteries, with rare exception. MARCH 1976 33 PAGENO="0304" 14210 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Cardiac Case History~ Tachyarrhythmia and the Wolff -Parkbison `White Syndrome By Sanford S. Zevon, M.D. A 22-year-old white male presented to the Emergency Room following the abrupt onset of pal- pitatiQn. Durisig the preceding three years, he had experienced two or three episodes which subsided spontaneously. There was no history of heart dis- ease, murmurs, or significant cardio-rçspiratory symptoms He had had no previous hospitalizations or operations. His parents and two siblings, ages 24 and 13, were alive and well, with no record of heart disease or palpitations. Review of systems was noncontributory. He did admit to using drugs (intravenous heroin and barbiturates) a few months prior to admission. On physical examination, he appeared to be a well-developed, well-nourished, thin white male in no distress. Blood pressure 110/80, pulse 215 per minute, temperature 100~, respirations 20 per mi- nute. The only pertinent finding involved the heart, which had a regular apical rate of 215 per minute. There were no murmurs, gallops, or rubs, and the lungs were clear. An electrocardiogram revealed a regular, sup- raventricular tachycardia with a ventricular rate of 215 per minute. Intravenous metaraminol raised the blood pressure to 210/100 but failed to convert the rhythm. Deslanoside (0.8 rug.) was then given in- travenously, and within 30 minutes he converted to normal sinus rhythm. A 12-lead electrocardiogram was being taken at the time of conversion, and normal sinus rhythm was recorded in leads V3-V6 (Fig.1). The postconver- sion 12-lead electrocardiogram revealed a short P-R. interval (0.11 sec. -0.12 sec.) and an inconspicuous but definite delta wave (Fig.. 2). In addition, achange in the direction of the initial QRS vector was~oted with the rhythm change. These findings supported the diagnosis of a pre-excitation phenomenon. Conversion to normal sinus rhythm was short- lived, and within 30 minutes he reverted to another tachyarrhytbmia, which had strikingly different electrocardiographic features (Fig. 3). The ventricu- lar rate was 240 to 300 per minute and irregular, and wide bizarre QRS complexes were observed. Blood pressure at this time was 95/60, and he was diaphore- tic. Although the rhythm resembled a ventricular tachycardia, the awareness of the existence of a Wolff-Parkinson-White syndrome led to the diag- nosis of atrial fibrillation with aberrant conduction. Intravenous propranolol(3 rug.) and edrophonium (10 mg.) were tried unsuccessfully, and he was fi- nally cardioverted with a DC electric shock of 60 watts-seconds. The post-conversion 12-lead elec- trocardiogram was identical to the ona taken after the initial conversion to sinus rhythm (Fig. 2). The increased frequency of tachyarrhythmia in the WPW syndrome is well known and is related to the presence of anomalous atrioventricular connec- tions. Paroxysmal atrial tachycatdia is the arrhyth- mia most often observed. Less frequently, atrial fib- rillation takes place. The occurrence of both tachyarrhythmias in the same patient illustrates the function of the anomal- ous pathway in this syndrome. During the atrial tachycardia, activation of the ventricle occurs ex- clusively via the normal A-V conduction system and in a retrograde direction via the anomalous pathway to complete a re-entrant circuit. During atrial fibril- lation, the ventricles are activated exclusively via the anomalous pathway resulting in a very rapid ventricular rate with wide QkS complexes that simulate ventricular tachycardia. The likelihood of misdiagnosis should be em- 34 PRIMARY CARDIOLOGY PAGENO="0305" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14~1 1 phasized. However, the combination of a very rapid (more than 240/mm), irregular ventricular arrhyth- mia, particularly in younger individuals, that is un- expectedly well tolerated should suggest the correct diagnosis. Although this arrhythmia is usually well tolerated7prolonged attacks may lead to adverse hemodynamic consequences, and ventricular fibril- lation and death may occur. Pharmacologic therapy to slow the ventricular rate using intravenous procainamide or lidocaine may be tried; however, the treatment of choice for atrial fibrillation in the WPW syndrome that presents with a "pseudoventricular tachycardia" is car- FIGURE dioversion with DC countershock. Digitalis should not be used in the presence of atrial fibrillation since it decreases conduction in the A-V node and enhances conduction through the ac- cessory pathway. It may also shorten the refractory period of the accessory pathway and result in an increase in the ventricular rate. For the treatment of atrial tachycardia, intra- venous propranolol is very useful, and procaina- mide or lidocaine may also be tried. To prevent recurrent atrial tachycardia, quinidine or propra- nolol, or the combination of these two agents, has been most useful. 0 35 13-617 0 - 76 - 20 PAGENO="0306" 14212 COMPETIT'~E PROBLEMS IN THE DRUG INDUSTRY Cardiac Case History~ FIGURE 2 36 PRIMARY CARDIOLOGY PAGENO="0307" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14213 PAGENO="0308" 14214 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Anticoagulant Drugs: By Louis M. Aledort, M.D. This overview of the complex subject of an- ~ ticoaguiant therapy introduces a series of arti- des that will explore the roles of various drugs in the treatment and possible prevention of throm- bosis. The modes of action of heparin, warfarin ~ derivatives, and the new antlplateiet compounds will be discussed in relation to their effect on ~ clotting mechanisms in the veins and arteries and also in relation to their use against a condi- tion that is receiving considerable attention - IIIDIVJWIIT2 diffuse, intravascular coagulation. The clinical IIIi~~J~JIIIIII' indications and contraindicatiOns for each drug ~ will be delineated, and the results of some of the Dr. Aledirt 5 Asocial latest research will be explained. Professor of Medicine. Mount Sinai Se/cool of ____________________________________________________ Medicine. - T hromhosis of arteries and veins is one of the foremost causes of disability and death. Perhaps the most effective way of treating and preventing these conditions is by the use of anticoagulants. And although heparin is effective and widely used, other drugs, such as the warfarin derivatives and compounds that act on the blood platelets tire coming into favor as more is learned about the seemingly endless complexities of blood coagulation. Highly important has been the discovery that thrombotic disease is in reality two diseases. or perhaps three. One must separately consider venous 38 PRIMARY CARDIOLOGY PAGENO="0309" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14215 When to Use-and How thrombotic disease and arterial thrombotic disease, because the pathogenesis of the two may be quite dissimilar. This is a critical distinction therapeuti- cally because they require different modes of treat- meńt and prevention. Clotting Leads to Bleeding There is, in addition, a relatively recent concept suggesting a third, basictype of coagulopathy, which is neither classical arterial disease nor venous dis- ease, but one that affects primarily the large vessels, small vessels, and capillaries. It is diffuse, intravas- cular coagulation, which is a complication attendant to many acute, subacute, and chronic diseases that lead to either overt thrombosis and/or what we call paradoxical hemorrhage in the face of thrombosis. Whatever triggers the coagulation uses up clotting factors in the blood, and bleeding results from the "consumption" of those factors, hence the term, consumption coagulopathy. Thus, paradoxically, a primary clotting problem leads to a bleeding prob- lem. Now as far as we know there are three elements that keep that body from bleeding, or blood from clotting. One is the integrity of the blood vessels, and this has been much underrated in the past. Very little has been written, until the last decade, about the role of the vessel itself in preventing either hemorrhage or thrombosis. The second element is the function of the platelet, a process that is being given more and more atten- tion. If the blood vessel is the first line of defense against coagulopathy, then the platelet is the second line. Platelets course through the blood, and wheti a vessel is injured they leave the mainstream and, through a series of complicated physical, biochethi- cal, and structural changes, form the primary hemos- tatic plug, which blocks the hole in the vessel. The third element in the control of hemorrhaging and clotting is a group of various coagulationfactors. For example, in order to maintain large blood vessel integrity during a surgical procedure, it is very im- portant to the clotting process that an entire chaiit of plasmatic factors are present, and that there is a working system of the checks and balances that aid or inhibit coagulation. Roles of Heparln and Warfarin For some time we have been aware that henlor- rhage is caused by lack of platelets or clotting fac- tors, or by abnormalities in blood vessels. We have not been so aware of how these same elements may be leading to clotting, even in the best-known type of thrombosis-that is, thrombophlebitis. It has been thought that this is a classical disorder in which the blood-clotting factors are in some way activated and the clots formed, and that the only way to treat the acute condition is with heparin. For long-term pre- vention, warfarin derivatives were the choice. We are nowfinding that there are people who have recurrent phlebitis or recurrent venous disease that may be resistant to those agents. We are beginning to MARCH 1976 39 PAGENO="0310" 14216 cOi~ri'ETITIvE PROBLEMS IN THE DRUG INDUSTRY ANTICOAGULANT DRUGS look at the elements of these clotting systems and at the platelets, and one can begin to dissect out the etiology of clotting in these vessels. In cases that are resistant, it may be that the initiating event is notlhe reaction of the blood coagulation factors per se but the response of the platelets, and that the heparins and warfarin derivatives do not inhibit this response. It is important, too, to keep in mind the role of antithrombin III, a co-factor for heparin. Without it there cannot be a balanced clotting mechanism. The recently recognized heparin co-factor may be defi- cient in some people, leaving them with a predisposi- tion to clotting. Such situations, if not identified, will lead to an inadequate response to heparin when it ordinarily would provide effective therapy. One must also consider the difficulties with arter- ial diseases. We recognize arterial thrombosis as either a blood clot in an artery that seems to have a normal surface, or a blood clot in a vessel in which the surface has been significantly altered by atherosclerosis. In the past there have been fads in the treatment and prevention of thrombotic diseases with the war- farm derivatives, which have been in and outoffavor for use in long-term prevention. Recent information suggests that some people who have changes in ves- sels may very well not have adequate coagulation mechanisms, and that their clots are not alone due to the conversion of fibrinogen to fibrin. Their thrombi may in some way be related to the alteration of fats, lipids, triglycerides, and other substances that may help initiate orperpetuate vessel-wall abnormalities. Platelets Alter Vessel Wall There seems to be a very intimate relationship between the platelets sticking to the blood vessel wall and an alteration in the vessel wall, all of which may perpetuate the system. There is even some very suggestive laboratory evidence that the platelets being sequestered near the surface walls of other platelets may actually promote changes in the vessel wall, and that this in turn makes it easier for the platelets to adhere to it. And remember, not all arteries are closed by clots. Some are blocked by pure atherosclerotic plaque. Evidence has been found that alteration of blood vessel walls in classical atherogenesis can be pro- duced by platelets releasing substances that act on the walls. Consequently, in the search for ways to prevent arterialvascular disease, one now may begin to investigate agents that eliminate or interfere with the platelet attaching itself to the vessel wall. We are beginning to get a handle on mechanisms that produce coagulation problems, by studying the causes. Is it the coagulation mechanism, together with various other interactions, that set riff the cas- cade of clotting factors that actively leads to thefinal deposition of fibrinogen as the main cause of the clot? Or is it the platelet-vessel wall interaction that initiates the formation of what we call "platelet plug," which is as effective a clot as the fibrinogen * plug in stopping blood flow? If one can answer these questions, one can give more rational therapy,'and that is the key to this whole question. Key to Thrombus PreventIon The heparin-like drugs are basically compounds that attack the final depositions and the conversion of fibrinogen to fibrin. If the clot was not formed by this pathway, those drugs will not work. On the other hand, if the platelet-vessel wall interaction is the initiating factor, we now have drugs that in vitro or in vivo can alter platelet responsiveness, and may be the key to the prevention of arterial and/or venous thrombus formation. Warfarin derivatives have been used for major prevention of venous and arterial clots because of their ease of administration and relatively low rate of complications. They slow the coagulation cascade to retard theformation of fibrin. They do not, however, affect platelet function, and cannot prevent fibrin- og~en conversion. In addition, in an age of multiple drug use, we are recognizing more and more drug-drug interactions that affect warfarin derivative metabolism, making the simple monitoring of these drugs by the familar prothrombin-time more difficult. An ideal, easy-to- administer, appropriate inhibitor of fibrinogen con- version is not available. However, more reports are appearing, suggesting that self-administered, low- dose, subcutaneous heparin may be an effective measure for the prevention of venous thromboem- bolic disease. There are arterial diseases and there are venous diseases. Major ones are caused by the coagulation mechanism; some are possibly caused by platelets. The arterial diseases look more and more as though they are influenced by the platelets. It is possible, in a highly sophisticated medical center, to do complex laboratory tests that might give an indication, but as yet we do not have appropriate methods widely available for the primary care physician. Investiga- tions are continuing, however, and one hopes they will lead to rational use of the heparin drugs and the anti-platelet drugs. 0 NEXT IN THE SERIES: Heparin-when and how It should be used, and when It should probably not be employed, based on what is proved, what appears probable, and what is Indicated by recent research. `` 40 PRIMARY CARDIOLOGY PAGENO="0311" PAGENO="0312" 14218 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Pulmonary Edema- Treatment By Max Harry Well, M.D. Dr. Weil is Director and Clinical Professor of Medicine and Biomedical Engineering, University of Southern California Center for the Critically Ill, Los Angeles. Pulmonary edema may foiiow shock, respIra- tory distress, lung injuries and infections, and a wide range of heart disorders. Although a com- mon condition, it Is not completely understood and should not be regarded as simply a result of pressure backed up from the left ventricle. Re- cent treatment of a specifIc group of patients shows that plasma collold osmotic pressure and Its relationship to pulmonary capillary pressure is intimately Involved in the development of pul- monary edema. The difference between the two pressures, determined by measuring each, may indicates leakage of plasma fluid intothe pulmo- nary interstltium. Following massive fluid loss, replenishing of plasma volume with albumin- containing fluids may restore colloid osmotic pressureto normal and thereby reducethe risk of pulmonary edema. pulmonary edema may seem simple enough to diagnose and perhaps equally simple to treat, but, in fact, it presents a dire threat to the pa- tient and a considerable challenge to the clinician. Multiple factors contribute to its cause, and they bear directly on the choice of therapy. Signs and symptoms don't always mean what they seem to mean, and can lead the physician astray. Mortality is high-a survival rate of lets than 50 per cent for patients who have pulmonary edema after active myocardial infarction. To successfully meet this combination of problems, the workup must be meticulous and management extremely selective. Pulmonary edema often develops in the seriously ill patient, particularly after acute myocardialinharc- tion. It can appear, too, after any type of left ven- tricular failure, aortic stenosis, myocardiopathy, mitral insufficiency, and congenital heart diseases. It may be related to lung injury (e.g., from aspi- ration), shock, or adult respiratory distress syn- drome; or it may be superimposed on pulmonary infections. The so-called hydrostatic pulmonary edema is caused by a rise in the left ventricular filling pressure, which in turn results from a decrease in the ability of theleftventricle to eject a sufficientvolume of blood. The pressure is retroconducted to the left atrium and then to the pulmonary veins, thereby increasing capillary hydrostatic pressure. Measure the Pressures In some patients, however, the problem stems from areduction in the plasma colloids and therefore a lowering of colloid osmotic pressure. Since it is the connection between colloid osmotic pressure and hydrostatic pressure which has recently been related to the appearance of pulmonary edema, colloid os- motic pressure should be measured. At the same time wedge pulmonary artery pressure or pulmonary diastolic pressure should be measured as an indica- tion of hydrostatic forces. In many cases, both de- creased colloid osmotic pressure and increased hy- drostatic pulmonary capillary pressure are involved. The chief sign of pulmonary edema may be the early appearance of moist rales or evidence of pul- monary interstitial and alveolar fluid accumulation on the chest radiograph. To this extent the chest x-ray is avery useful qualitative guide. Quantitative determination of conditions in which pulmonary edema develops, however, is best gauged by hemo- dynamic measurements -~- of left ventricular filling pressure and colloid osmotic pressure. The left ven- tricular pressure can be recorded in a hospital, by putting a catheter directly into the left ventricle re- trograde, from the axillary artery orfrom the femoral artery. The colloid osmotic pressure can be mea- 42 PRIMARY CARDIOLOGY PAGENO="0313" COMPETIP~VE PROBLEMS IN THE DRUG INDUSTRY 14219 Depends on Cause sured on a sample of plasma by a commercially available oncometer. Physical signs include disten- tion of the neck veins-which suggests an increase in right ventricular filling pressure - and alveolar edema, indicated by rales and generally confirmed by auscultation of the lungs. The clinician must, however, regard these signs with some caution, for several reasons. An increase in central venous pres- sure is contingent on right-sided failure, which is usually delayed following acute myocardial infarc- tion. This is the very reason why the Swan-Ganz catheter-the flotation pulmonary artery catheterby which wedge pressure is measured -~-. has been a boon. Failure Without the Signs The clinician should remember that right heart failure, although very common following left heart failure, follows only after substantial lag. Therefore, central venous pressure and neck veins may some- times be normal during the earlier stages of left heart failure. Thus, pulmonary edema may develop as a result of left heart failure without the patient having signs of left heart failure. Secondly, pulmonary edema in its earlier stages is interstitial edemas which doesn't involve the alveoli of the lungs. Consequently, the assumption that rales, heard inpatients afteronset ofalveolaredema, would be reliable as a clear indication has to be rejected. The clinician must use more sophisticated measurement. Now it may be that we have to accept the lesser efficiency of clinical signs and clinical measure- ments, under circumstances in which cost and vol- ume of patients present obstacles to the more sophis- ticated techniques. But it would be really quite wrong to even remotely imply that this is sufficient, if the physician waists to do the optimal job. For the management of these patients, the most effective drugs we have are a loop diuretic, furosemide, and ethacrynic acid. Occasionally, re- storing of fluid volume is indicated. It is important, under those circumstances, to be aware of the col- bid osmotic pressure in order not to dilute the vol- ume with noncolloid-containing fluids. Very often, volume buiidup is necessary f(r a patient who is in cardiogenic shock, but that volume probably should not be entirely made up of flon- colloid-containing fluids, but rather of albumin- containing fluids. Pulmonary edema is the end result of multiple factors. In earlier years, it was thought that the con- dition was caused by failure of the left ventricle, and the hydrostatic forces, which raise the pressure in the pulmonary capillaries, resulting in leakage of fluid. We now know that the colloid contained in the plasma is also an important variable, and may, in fact, greatly modify the extent to which fluid would or would not leak out in the presence or absence of left ventricular failure. The physician should keep in mind that in some patients following acute myocardial infarction, the colboid osmotic pressure is reduced and the left ven- tricular filling pressure may in fact be not very high. Under these conditions, the decrease in colloid ~s- motic pressure may be the primary cause of pul~o- nary edema. In these patients, not only the hydro- static pressure but also the colloid osmotic pressi~re must be consideredin efforts to reverse the edema.D Practice Procedures Pulmonary Edema- Osmotic Pressure--Hydrostatic Pressure Chief Signs: (Must be confirmed by more sophisticated measures) * Moist rales. * Pulmonary overload evident on chest x-ray. * Distention of neck veins. Measure: * Coioid osmotic pressure. * Pulmonary artery wedge pressure. Management: * If colloid osmotic presstire is critically re~ * duced in a volurne-deptefed patient, consider fluid volume buildup with 5 per cent human serum albumin. Be cautious In use of non- colloid-containing fluids. Loop diuretics in- crease colloid osmotic pressure. MARCH 1976 43 PAGENO="0314" 14220 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Should Digitlis Be Used In Treating `Acute Dr. Haber is Professor of Medicine i Department of Medicine, Harvard Medical School; Chief, Cardiac Unit Massachusetts General Hospital. Doston Confii4ting opinions and practices raise ques- tions about digitalis therapy In acute myocardiai infarction. Some clinicians feel its use Is con- traindicated; even when there is accompanying heartfaiiure, the use of digitalis is notuniversaliy accepted. Opinions also differ on its use in car- diogenic shock. Most agree, however, that it shouid be employed when acute myocardlai in- farction Is accompanied by atriai fibrillation. There are still many uncertainties about digitalis therapy, but so intensive Is current scientific in- vestigation that helpful data can be expected to appear in the near future. The role of digitalis therapy after acute myo- cardial infarction is still uncertain and, de- spite the magnitude of efforts by biomedical investigators in the study of digitalis glycosides, there are important unanswered questions in this clinical Situation. Some workers emphasize that there is little to be gained by administration of digitalis glycosides to patients who have uncomplicated infarction without cardiomegaly. There is also little clinical documen- tation of the drug's value in cardiogenic shock, a syndrome in which no pharmacologic agent has as yet been demonstrated to be very effective. Indeed, rapid digitalization may, on occasion, be harmful due to the vasoconstriCtor properties of the drug. Yet Karliner and Braunwald, for inst5nce, wrote in 1972 that until evidence to the contrary appears, digitalis should be continued in cardiogenic shock. They took this position on the basis of experience with experimental work and they presumption that this state, when observed clinically, is a form of extreme left ventriculat' failure. Typical of the findings that still project a confused picture to the clinician are results published in the Abstracts of the American Heart Association 48th (l975)Scientific Sessions. One group atNorth Shore and Cornell gathered data which "suggest that IV digoxin in certain patients with large predicted acute myocardial infarctions and high pulmonary wedge pressures results in salvage of ischemic nsyocar- dium." On the other hand, a joint Russian and American group. analyzing serum CPK in patients, concluded that digitalis appears to increase infarct size in patients with evolving myocardisl infarction. increases infarct Size This is an important question; and the finding that digitalis increased infarct size was supported by the 1971 observations of Maroko et al that a number of inotropic agents, including ouabain, increased the severity and extent of ischemic i~Ijury in experimen- tal coronary occlusion in the non.failing heart. When congestive heart failure complicates myocardial infarction, the use of digitalis is widely advocated. Yet, there are few studies in man that provide a solid basis for this recommendation. Kar- liner and Braunwald, noting the paucity of experi- mental and clinical evidence for such therapy, called for more clinical investigation into the question of whether the digitalis glycosides should continue to be used routinely in such cases. More recently, some benefits have been noted for 46 PRIMARY CARDIOLOGY PAGENO="0315" COMPETXPrVE PROBLEMS IN THE DRUG LNDUS~~R~ 14221 Myocardlal Infarction? By Edgar Haber, M.D. patients after digitalization to treat left ventricular failure following myocardial infarction. Others have found evidence of significant improvement from ouabain therapy in some indexes of left ventricular performance even though cardiac output was not affected. Nevertheless, it was felt that more study was needed of how digitalis acts on ventricle size and myocardial oxygen consumption. indication for Atrial Fibrillation The clearest indication for digitalis after acute myocardial infarction is in the treatment of atrial fibrillation with a rapid ventricular rate. Electrical cardioversion may be preferred in the treatment of other supraventricular tacbyarrhythmias. Animal experiments suggest that digitalis may induce ar- rhythmias at lower doses in cases of acute myocar- dial infarction, and that the toxic dose of digitalis glycosides is reduced as a result of rhythm distur- bances. Clinical evidence on this is not clear. The questions raised will certainly be studied in- tensively Since l9l2~ when Herrick advocated use of digitalis in all patiónts with acute myocardial in- farction, practice and techniques have changed. The magnitude of effort being expended by biomedical investigators in the study of digitalis can be judged from the listing of more than 600 citations in Index Medicus in 1972 alone. More than 300 compounds in the digitalis classification are known to exist, and the sources and structure-activity relations have been known in depth for more than ten years. But no compound has as yet been indentified with an im- proved therapeutic-toxic ratio. It isnow considered that the major action of di- gitalis is the augmentation of the force of myocardial contraction, although this appeared to have been generally overlooked by 19th century investigators, who stressed slowingof the heart as its major effect. Another myth that investigation has dispeUed in the past 25 years has been the belief that the inotropic action of digitalis was confined to the decompen- sated heart. It is now clear that the drug has this action in the normal, as well asfailing, heart mUscle. Yet the administration of cardiac glycosides re- sults in, no change, or a slight decline, in cardiac output in normal subjects. Cardiac output is deter- mined not only by the cardiac contractile state, but also by ventricular filling pressure, peripheral arter- ial resistance, and heart rate. It now appears that digitalis augments the contractile state of the normal myocardium in intact man, but that reflex adjust- ments in the other determinants of cardiac output prevent a ready appreciation of this inotropic effect. Is there such a thing as too much myocardia! con- tractility? Experimspfs have shown that th~ no- tropic action of digitalis increases progressively until toxic arrhythmias appear. The clinician's task is to determine the maximum dose consistent with an adequate margin of safety. 0 Debate Over Digitalis The Questions: * Is the drug useful for cardiogenic shock? * Does it increase the size of a myocardial Infarct? * Should digitalis be used routinely when cc~n- gestive heart failure complicates myocardial infarction? * Should it be used for left ventricular failyre following rnyocardlal Infarction? * Does digitalis induce arrhythmias in acute myocardial infarction? * Is there a possibility of tao much myocardial contractility? There are few, If any, clear-cut answers at present, but intensive investigation is continu- ing In the meantime, the physician must exert extreme care ~o determine the maximum dose of digitalis ttlat is ~ofisistent with an adequate margin of safety. Jit 11JiLJ ~1 T~J MARCH 1978 47 PAGENO="0316" 14222 CO1~ETIPIVE PROBLEMS IN THE DRUG INDUSTRY PRIMARY CARDIOLOGY PAGENO="0317" COMPEflTIVE PROBLEMS LN THE DRUG INDUSTRY 14223 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUSLIC HEALTH SERVICE FOOD AND DRUG ADMINISTRATION ROCKVILLE. MARYLAND 20852 M~Y 2? 1976 Honorable Gaylord Nelson Chairman, Subcommittee on Monopoly Select Committee on Small Business United States Senate Washington, D.C. 20510 Dear Senator Nelson: I wish to correct two errors in our testimony before your subcommittee on April 28, 1976. In discussing scientific exhibits, I referred to the written pr rams for scientific exhibits at two recent meetings of the~č~kan ca emy of Family Practice and the Pmerican College of Physicians and pointed out in each a listed exhibit on prazosin hydrochloride, an antihyper'~ tensive drug. I Indicated that the program did not note that the physician~~exhibitor was a full'~t1me employee of the manufacturer which had developed the drug. In addition,,! said that prazosin hydrochloride had not been approved for marketing at the time of either meeting, and that regulations did not permit pharmaceutical manufacturers to promote drugs prior to their approval for marketing. When asked about this by Mr. Gordon, I said that "this type of thing is a violation of the current regulations on drug labeling." I have subsequently learned that the manufacturer of prazosin hydrochloride (Pfizer) prepared the exhibits in anticipation 0f the approval of the drug but, when this approval was delayed, did not in fact display them at either meeting although they remained listed in the printed programs. I did not know this at the time of my testimony, and I regret that we did not check this point before preparing our testimony. Thus, no violation of FDA regulations occurred, and I extend my apologies to you and to Pfizer, Inc. for suggesting otherwise. Let me add, however, that this type of presentation remains a valid illustration of our concerns regarding the promotional aspects of scientific exhibits. As I testified, It is FDA's view, which we intend to incorporate into proposed regulations, that a scientifIc exhibit on a drug must be prepared independently of a drug manufacturer's control if It is to be exempt from drug labeling requirements. I believe the PAGENO="0318" 14224 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY planned Pfizer exhibit, if actually presented, would have properly been termed `drug labeling," by any reasonable description, and thus subject to the full disclosure and fair balance standards applicable to such labeling. The second error occurred during Dr. Rheinstein's testimony. In response to your question regarding the selection of the physician panels for the Pfizer-sponsored closed circuit television symposium on diabetes, Dr. Rheinstein replied that "Pfizer contracted with another company called Health Learning Systems to do the entire production." (Testimony at page 22.) Also in response to another question flr. Rheinstein indicated "And previous seminars sponsored by Health Learning Systems have said that they had up to 8,000 physicians seeing closed circuit broadcasts at one time." (Testimony at page 24.) Subsequent to this hearing, it was learned that Pfizer did not contract with any outside company but made all arrangements including the selection of physician panels staff itself. Health Learning Systems produces multi-city closed circuit TV programs on medical subjects, but was not involved in this program. Sincerely yours, J. Richard Crout, M.D. Director Bureau of Drugs cc: Pfizer, Inc. Health Learnina Systems PAGENO="0319" COMPE~IP~VE PROBLEMS ]~ PHE DRUG INDUSTRY 14225 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE FOOD AND DRUG ADMINISTRATION WASHINGTON. D.C. 20204 JUN 181976 Paul Cutler, M.D. Professor of Medicine The University of Texas Health Science Center at San Antonio 7703 Floyd Cuv'l Drive San Antonio, Texas 78284 Dear Dr. Cutler: Thank you for your letter of May 17 commenting on the text of my statement before the Subcommittee on Monopoly of the Senate Select Committee on Small Business. I am pleased that you share my concern regarding the influence of the pharmaceutical industry on the continuing education of physicians. My concern is with our system of continuing education, a system that is supported in growing ~nea~,ure by an industry with a particular interest. It is not with specific articles or their authors. I tried to point out In my testimony that the quality of the articles in controlled-circylation journals is often high and that these journals emphasize practical patient care information often neglected by the scholarly" journal~. Further, I certainly agree with your feeling that investigational therapies should be considered in the medical literature. I have never argued that the FDA-approved package insert should in any way limit discussions about drugs by independent physicians. The migraine article was used simply as an example of material presented in an industry-supported pubiicatioi which a drug company .~ould be prohibited from saying in its own labeling or advertisements~ Regardless of the merit of the article and de9ree of review, this situation is properly open to discussion by reasonable men without such discussion being taken as reflecting on the integrity of individuals. If you reel that Current Prescribing has methods of subject selection and internal review currently unknown to the public which protect the independence of scientific content and yet permit industry funding, please let us know of these in greater detail. In preparing testimony for Senator Nelson, I felt my broad discussion of post-graduate medical education had to include a fair number of examples of the educational materials I was talking about~ A number of the editors and authors of these examples have felt that their motives a~nd integrity were questioned. I specifically tried to avoid any such PAGENO="0320" 14226 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY suggestion but obviously did not convey my feeling fully. My examples were intended to show only that controlled-circulation journals (or educational cassettes, or seminars) were regularly concerned with subject matter that is of crucial interest to the drug industry. If I understand your letter correctly, you would not disagree with me in feeling that control over the content of educational materials should be in the hands of independent physicians and educators. At the present time, with medical educational materials of all kinds increasingly funded'by drug manufacturers, there is, i believe, a growing burden on controlled circulation journals to show this is the case. Please take this as a challenge to our current system and certain policies, not as a comment on anyone's persor~al honesty. According to information supplied by the publishers ofCurrent Prescrjjp~ and appearing in the May 24, 1976 issue of Standard Rate and Service, the circulation of Current Prescribing is entirely non-paid. Although many physicians may have returned to the publishers business reply cards supplied by the publisher and stating that these physicians would like to receive or continue tb receive Current Prescribin~g, this does not change the publication's status as a controlled circulation journal or its financial support. Once again t appreciate your letter and the opportunity to exchange views. Sincerely yours, J. Richard Crout, M.D. Director Bureau of Drugs cc: Senator Gaylord Nelson PAGENO="0321" COMPETITWE PROBLEMS ThT THE DRUG INDUSTRY 14227 STATEMENT OF THE AMERICAN ACADEMY OF FAMILY PHYSICIANS BY JOHN C, KELLY, M.D. SUBCOMMITTEE ON MONOPOLY SELECT COMMITTEE ON SMALL BUSINESS UNITED STATES SENATE MAY 2Lt, 1976 MR CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE, I AM JOHN C, KELLY, A PRACTICING FAMILY PHYSICIAN FROM RENO, NEVADA. I CURRENTLY SERVE AS CHAIRMAN OF THE BOARD OF DIRECTORS OF THE AME~ICAN ACADEMY OF FAMILY PHYSICIANS, WHICH IS THE LARGEST MEDICAL SPECIALTY ORGANIZA- TION IN THE UNITED STATES) WITH OVER 37,000 MEMBERS. SEATED WITH ME IS LESLIE HUFFMAN, WHO IS A PRACTICING FAMILY PHYSICIAN FROM GRAND RAPIDS, Oi-iio. DR. HUFFMAN IS THE SPEAKER OF THE ACADEMY'S CONGRESS OF DELEGATES AND FORMERLY SERVED AS CHAIRMAN OF OUR COMMITTEE ON SCIENTIFIC PROGRAM. WE ARE PLEASED TO BE PRESENT TODAY TO PROVIDE INFORMATION TO THE SUBCOMMITTEE REGARDING COMMERCIAL AND SCIENTIFIC EXHIBITS AS THEY RELATE TO THE ACADEMY'S LONG-STANDING CONCERN FOR INSURING THE CONTINUING EDUCATION OF PHYSICIANS. I WOULD LIKE TO POINT OUT THAT THE ACADEMY IS RECOGNIZED AS A PIONEER IN THE AREA OF CONTINUING EDUCATION. WE ARE PROUD TO SAY THAT, AMONG ALL ORGANIZATIONS REPRESENTING PHYSICIANS, WE WERE THE FIRST TO REQUIRE A SPECIFIC NUMBER OF HOURS OF CONTINUING EDUCATION IN ORDER ro RETAIN MEMBERSHIP. 73-6~? 0 - 76 - 21 PAGENO="0322" 14228 COMPEPITIVE PROBLEMS IN PIlE DRUG INDUSThY THE ACADEMY'S ANNUAL SCIENTIFIC ASSEMBLY PROVIDES A WIDE CHOICE OF CONTINUING EDUCATION OPPORTUNITIES FOR FAMILY PHYSICIANS. PRACTICAL DIDACTIC LECTURES BY NATIONALLY KNOWN SPEAKERS ARE AN ASSEMBLY HIGHLIGHT OTHER PROGRAM ELEMENTS ALSO EMPHASIZE THE PRACTICAL: COURSESCOMPLETE WITH SYLLABI) SMALL GROUP DISCUSSIONS) DEMONSTRATIONS OF TECHNIQUES AND PROCEDURES WHICH FAMILY PHYSI- CIANS CAN USE IN THEIR DAY-TO-DAY PRACTICES. SCIENTIFIC AND TECHNICAL EXHIBITS PROVIDE A GREAT SOURCE OF INFORMATION ON RE- SEARCH PROJECTS, NEW EQUIPMENT, SERVICES, AND PHARMACEUTICALS. PHYSICIANS EARN ONE HOUR OF PRESCRIBED AAFP CONTINUING ED- UCATION CREDIT FOR EACH HOUR OF PARTICIPATION IN ANY ELEMENT OF THE SCIENTIFIC PROGRAM, EXCEPT FOR THE VIEWING OF EXHIBITS. BY CAREFULLY SCHEDULING HIS TIME, A PHYSICIAN CAM EARN 31 CREDIT HOURS DURING THE 3˝ DAYS OF THE ASSEMBLY. PHYSICIAN REGISTRATION AT THE 197'4 ASSEMBLY IN LOS ANGELES WAS `4,978--AN ALL-TIME HIGH CLINICAL SEMINARS--THE SMALL GROUP DISCUSSIONS-PROVED TO BE MOST POPULAR, IN 19Th, 518 SEMINARS or~ `40 DIFFERENT TOPICS WERE PRESENTED. WITH ATTENDANCE IN EACH SEMINAR LIMITED TO 15 REGISTRANTS, 7,770 INDIVIDUAL OPENINGS WERE AVAILABLE. IN 19Th, MORE THAT 600 EDUCATIONAL PRESENTATIONS WERE SCHEDULED IN THE VARIOUS PROGRAM ELEMENTS. OUR 1975 ASSEMBLY IN CHICAGO REGISTERED 3,622 PHYSICIANS. THE NUMBER OF EDUCATIONAL PRESENTATIONS SCHEDULED IN THE VARIOUS PROGRAM ELEMENTS WAS APPROXIMATELY 300, -2- PAGENO="0323" COMPETIPXVE PROBLEMS IN TUE DRUG INDVSTRY 14229 ALTHOUGH THE SCOPE OF THE SUBCOMMITTEE'S HEARINGS HAS COVERED MANY ASPECTS OF THE ROLE OF PHARMACEUTICAL COMPANIES IN PtWVIDINt3 CONTINUING MEDICAL EDUCATION.. WE HAVE BEEN REQUESTED TO CONFINE OUR STATEMENT TO COMMERCIAL AND SCIENTIFIC EXHIBITS. ACCORDINGLY, OUR TESTIMONY WILL BE LIMITED TO THAT TOPIC. WE WERE SPECIFICALLY REQUESTED TO COVER THE FOLLOWING POINTS: THE CONTENT AND PURPOSE OF COMMERCIAL AND SCIENTIFIC EXHIBITS AND WHAT DISTINGUISHES ONE FROM THE OTHER; WHO SPONSORS THEM; WHO PREPARES THEM) WHAT KIND OF EDITORIAL REVIEW IS EXERCISED; ARE ANY EXHIBITS REJECTED; AND THE EXTENT TO WHICH CONVENTIONS ARE DEPENDENT ON DRUG COMPANY SUPPORT. WE WILL DISCUSS THESE POINTS IN THE ORDER IN WHICH THEY HAVE BEEN LISTED. THE FIRST QUESTION CONCERNS THE CONTENT AND PURPOSE OF COMMERCIAL AND SCIENTIFIC EXHIBITS. ALTHOUGH WE CONSIDER BOTH TYPES OF EXHIBITS TO BE VALUABLE MECHANISMS FOR PROVIDING CURRENT MEDICAL INFORMATION TO OUR MEMBERS, WE RECOGNIZE THAT THE PRIMARY PURPOSE OF COMMERCIAL EXHIBITS IS TO PROMOTE THE PRODUCTS OF THOSE PURCHASING THE EXHIBIT SPACE. ON THE OTHER HAND, THE PRIMARY PURPOSE OF SCIENTIFIC EXHIBITS IS TO PROVIDE INFORMATION TO PHYSICIANS THROUGH THE DISSEMINATION OF THE RESULTS OF SCIENTIFIC RESEARCH. UNLIKE COMMERCIAL EXHIBIT SPACE, SCIENTIFIC EXHIBIT SPACE AT OUR ANNUAL MEETING CANNOT B~ PURCHASED. RATHER, IT IS AWARDED ON THE BASIS OF THE EXHIBIT'S RELEVANCE TO FAMILY PRACTICE AS WELL AS QUALITY, LEGIBILITY, SCIENTIFIC ACCURACY AND ETHICAL CONTENT. WHEREAS A PROSPECTUS IS SENT TO POTENTIAL COMMERCIAL EXHIBITORS, THE ACADEMY DOES NOT SOLICIT SCIENTIFIC EXHIBITS EXCEPT IN THOSE INSTANCES IN WHICH THE EXHIBIT HAS BEEN VIEWED BY A MEMBER OF OUR SCIENTIFIC PROGRAM COMMITTEE - 3~ - PAGENO="0324" 14230 COMPEPITIVE PROBLEMS IN PHE DRUG INDUSPEY AT SOME OTHER MEDICAL MEETING AND HAS BEEN RECOMMENDED FOR PRE- SENTATION AT OUR MEETING ON THE BASIS OF FULFILLING THE CRITERIA PREVIOUSLY MENTIONED. UNSOLICITED EXHIBITS ARE ACCEPTED OR REJECTED FOLLOWING A REVIEW OF II~(FoRMATION SUBMITTED BY THE PROS- PECTIVE EXHIBITOR IN THE SCIENTIFIC EXHIBIT APPLICATION FORM WHICH IS ATTACHED TO THIS TESTIMONY AS EXHIBIT A. A REVIEW OF THIS APPLICATION FORM BRINGS OUT SEVERAL ADDITIONAL DIFFERENCES BETWEEN COMMERCIAL AND SCIENTIFIC EXHIBITS. WHEREAS ONE OF THE PURPOSES OF COMMERCIAL EXHIBITS IS ADMITTEDLY THE PROMOTION OF PARTICULAR PRODUCTS, THERE IS A STRICT PROHIBITION AGAINST SELLING OR OFFERING FOR SALE ANY COMMERCIAL ITEM IN CONJUNCTION WITH A SCIENTIFIC EXHIBIT. WHEREAS SALES REPRESENTATIVES OF PHARMACEUTICAL COMPANIES CAN AND DO STAFF COMMERCIAL EXHIBITS,. THERE IS A STRICT PROHIBITION AGAINST SUCH REPRESENTATIVES PERFOR WING A SIMILAR FUNCTION IN CONJUNCTION WITH A SCIENTIFIC EXHIBIT. WHEREAS COMMERCIAL EXHIBITS DO PROMOTE DRUG PRODUCTS BY TRADE NAME) ONLY GENERIC NAMES MAY BE USED IN THE BODY OF SCIENTIFIC EXHIBITS AND ANY REFERENCES TO SUCH GENERIC DESIGNATIONS MUST BE AFFORDED EQUAL EMPHASIS. IN TESTIMONY PRESENTED BEFORE THIS SUBCOMMITTEE ON APRIL 28TH BY DR RICHARD CROUTJ DIRECTOR OF THE FooD AND DRUG ADMINISTRATION'S BUREAU OF DRUGS) EMPHASIS IS GIVEN TO THE FACT THAT MATERIAL CONTAINED IN SCIENTIFIC EXHIBITS USUALLY IS NOT SUBJECT TO THE SAME RESTRICTIONS PLACED ON DRUG LABELING. THE THRUST OF DI~, CROUT'S TESTIMONY SEEMED TO BE THAT ALTHOUGH COMMERICAL EXHIBITS CAN BE REGULATED ADEQUATELY, SCIENTIFIC EXHIBITS PROVIDE A MECHANISM WHEREBY DRUG COMPANIES CAN PROMOTE THEIR PRODUCTS WITHOUT BEING SUBJECT TO THE USUAL REQUIREMENTS FOR DRUG LABELING AND ADVERTISING. - 4 - PAGENO="0325" COMPETIPXVE PROBLEMS IN THE DRUG INDUSTRY 14231 HOWEVER, BECAUSE THERE IS A DIFFERENCE BETWEEN COMMERCIAL EXHIBITS AND SCIENTIFIC EXHIBITS, WE BELIEVE THERE MAY BE GOOD REASON THEY SHOULD NOT BE SUBJECT TO THE SAME RESTRICTIONS. AGAIN, LET ME EMPHASIZE THE POINT THAT THE PRIMARY PURPOSE OF SCIENTIFIC EXHIBITS IS EDUCATION WHEREAS THE PRIMARY PURPOSE OF COMMERCIAL EXHIBITS IS PROMOTION I DON'T BELIEVE THAT PHYSICIANS VIEWING A SCIENTIFIC EXHIBIT WILL ACCEPT IT FOR ANY MORE THAN WHAT IT IS, THE RESEARCH FINDINGS OF A PARTICULAR EXHIBITOR NOR DO I BE- LIEVE THAT THE DISSEMINATION OF INFORMATION THROUGH A SCIENTIFIC EXHIBIT WILL ENCOURAGE PHYSICIANS TO USE DRUGS IN A MANNER OR FOR A PURPOSE FOR WHICH THEY ARE NOT APPROVED1 THE FDA STILL HAS THE FINAL ATUHORITY TO DETERMINE THE PROPER USE OF A PARTICULAR DRUG AND THE APPLICATION OF THE FINDINGS OF A PARTICULAR RESEARCHER ARE LIMITED BY THIS AUTHORITY. ON THE OTHER HAND, AS LONG AS A RESEARCH EFFORT REPRESENTS THE LEGITIMATE FINDINGS OF THE RE- SEARCHER AND THE RESULTS ARE OBJEC11VELY PRESENTED, WE DON'T BELIEVE THE MATERIAL SHOULD BE WITHHELD FROM THE M~DICAL COMMUNITY SOLEY ON THE BASIS OF THE FACT THAT IT MAY BE FAVORABLE TO A PARTICULAR DRUG As A REVIEW OF THE ATTACHED SCIENTIFIC EXHIBIT APPLICATION FORM WILL SHOW, THE ACADEMY'S REQUIREMENTS FOR SCIENTIFIC EXHIBITS HAVE BEEN ESTAGLISHED FOR THE PURPOSE OF INSURING THAT THESE EXHIBITS ARE NOT IMPROPER OR UNETHICAL AND THAT THEY SERVE AN EDUCATIONAL FUNCTION. IN RESPONSE TO THE QUESTION OF WHO SPONSORS THESE EXHIBIJS A LARGE PERCENTAGE OF COMMERCIAL EXHIBITS AFE SPONSORED BY PHARMACEUTICAL COMPANIES. THESE ARE READILY IDENTIFIABLE SINCE THE EXHIBIT SPACE IS PURCHASED BY THE COMPANY WISHING TO UTILIZE IT, -5 PAGENO="0326" 14232 coi~n~rrriv~ PROBLEMS IN THE DItUG INDUSThS~ IN THE CASE OF SCIENTIFIC EXHIBITS THE SPONSORS MAY INCLUDE PUBLIC AND PRIVATE NON-PROFIT ORGANIZATIONS., SUCH AS PROFESSIONAL AND LAY HEALTH ORGANIZATIONS AND MEDICAL SCHOOLS, AS WELL AS GOVERNMENTAL AGENCIES AND THE ARMED SERVICES. IN ADDITION, A LARGE NUMBER OF SCIENTIFIC EXHIBITS ARE SUPPORTED BY PAHRMACEUTICAL COMPANIES TO ONE DEGREE OR ANTOEHR. IN REVIEWING THE SCIENTIFIC EXHIBITS RE- CEIVING DRUG COMPANY SUPPORt AT PAST ACADEMY MEETINGS, IT APPEARS THAT THE FIGURE OF 80% CITED IN DR. CROUT'S EARLIER TESTIMONY IS REASONABLE. IT IS ACCURATE TO SUGGEST THAT DRUG COMPAt~IIES ARE LIKELY TO SUPPORT THOSE EXHIBITS WHICH ARE FAVORABLE TO A PARTICULAR PRODUCT OF THE COMPANY, CERTAINLY, IT WOULD BE DIFFICULT IF NOT IMPOSSIBLE TO ENVISION A SITUATION IN WHICH A DRUG COMPANY WOULD SUPPORT AN EXHIBIT WHICH WAS UNFAVORABLE TO A PRODUCT OF THAT COMPANY. HOWEVER, IF THE MAtERIAL CONTAINED IN AN EXHIBIT PRESENTS LEGITIMATE FINb INGS BASED ON SCIENTIFIC INVESTIGATION, WE BELIEVE IT SERVES A VALUABLE EDUCATIONAL FUNCTION, REGARDLESS OF SPONSORSHIP. SHOULD ORGANIZATIONS SUCH AS THE ACADEMY FIND THEMSELVES IN THE POSITION OF NOT HAVING SCIENTIFIC EXHIBITS SUPPORTED BY DRUG COMPANIES, THE RESULT WOULD NOT BE BETTER SCIENTIFIC EXHIBITS BUT THE PROBABLE ABSENCE OF SCIENTIFIC EXHIBITS ALTOGETHER. WE WERE ASKED TO PROVIDE INFORMATION ON WHO PREPARES COMMERCIAL AND SCIENTIFIC EXHIBITS. IN THE CASE OF COMMERCFAL EXHIBITS, THE EXHIBIT IS PREPAREI) BY THE PHARMACEUTICAL COMPANY OR OTHER ORGANIZA TION PURCHASING THE EXHIBIT SPACE. PRESUMABLY, THE ACTUAL CON- STRUCTION OF THE EXHIBIT MAY BE `DONE IN-HOUSE OR BY AN EXHIBIT FIRM RETAINED BY THE COMPANY. IN ANY EVENT, THE FORMAT AND CONTENTS. WOULD BE PRESENTED IN ACCORDANCE WITH THE SPECIFICATIONS OF THE PAGENO="0327" c0MPE'PIPrVE PROBLEMS tN THE DRUG INDUSTRY 14233 PURCHASER OF THE EXHIBIT SPACE SCIENTIFIC EXHIBITS WHICH ARE SUPPORTED BY DRUG COMPANIES MAY BE PREPARED BY DRUG COMPANIES, BY THE INDIVIDUAL OR INDIVIDUALS WHO CONDUCTED THE RESEARCH OR BY AN EXHIBIT FIRM RETAINED DIRECTLY BY THE INVESTIGATOR AND REIMBURSED BY THE DRUG COMPANY ALTHOUGH THE DRUG COMPANY MAY EXERCISE SOME CONTROL OVER THE FORMAT USED FOR EXHIBITS WHICH IT SPONSORS) THE DATA AND CONCLUSIONS WHICH ARE THE BASIS OF THE EXHIBIT WOULD REMAIN THE RESPONSIBILITY OF THE INVESTIGATOR. IN THIS CONNECTION, I SHOULD MENTION THAT ALTHOUGH A DRUG COMPANY MIGHT EXERCISE CONTROL OVER THE EXHIBIT FORMAT IN ORDER TO INSURE EFFECTIVE VISUAL PRESENTATION OF THE MATERIAL THE ACADEMY PLACES RESTRICTIONS ON THE FORMAT OF EX- HIBITS PRESENTED AT OUR MEETING IN ORDER TO INSURE THAT THIS MATERIAL IS NOT PRESENTED IN A BIASED MANNER WHICH WOULD GIVE SPECIAL EMPHASIS TO A PARTICULAR DRUG.. FOR EXAMPLE, THE ACADEMY'S RE- GULATIONS STATE "COMPARISONS OF EFFICACY,CONTRAINDICATIONS, NODES OF ADMINISTRATION, ET CETERA,BETWEEN COMPETITIVE DRUGS SHALL BE FULLY PRESENTED. EDITORIAL CONCLUSIONS SHOULD BE MADE WITH ETHICAL RESTRAINT" OUR REGULATIONS FURTHER PROVIDE THAT "ALL GENERIC DESIGNATIONS OF COMPETITIVE DRUGS SHALL BE USED WITH EQUAL EMHASIS ON HEIGHT,WEIGHT, COLOR OR TYPE FACE OF LETTERING." SCIENTIFIC EXHIBITS OTHER THAN THOSE SUPPORTED BY DRUG COM- PANIES WOULD BE PREPARED BY THE INVESTIGATOR OR THE INSTITUTION OR AGENCY INVOLVED. FOR EXAMPLE, ONE OF THE EXHIBITS WHICH WON AN AWARD FOR EXCELLENCE AT OUR 1975 SCIENTIFIC ASSEMBLY WAS PRE- PARED SOLEY BY THE INVESTIGATOR, WHO HAND-PRINTED HIS DATA ON POSTER BOARD. -7- PAGENO="0328" 14234 COMPETITIVE PROBLEMS IN THE DRTJG INDUSTRY WE WERE REQUESTED TO INDICATE THE TYPE OF EDITORIAL REVIEW WHICH IS EXERCISED OVER THE CONTENT OF EXHIBITS AS WELL AS WHETHER OR NOT EXHIBITS ARE REJECTED. BECAUSE THESE QUESTIONS ARE INTER- RELATED) I WOULD LIKE TO RESPOND TO BOTH OF THEN TOGETHER. AS I PREVIOUSLY MENTIONED, BEFORE A SCIENTIFIC EXHIBIT IS ACCEPTED FOR PRESENTATION AT OUR ANNUAL MEETING, THE PROSPECTIVE EXHIBITOR MUST SUB~4IT A SCIENTIFIC EXHIBIT APPLICATION FORM TO THE ACADEMY. THE FORM MUST BE ACCOMPANIED BY A TRANSCRIPT OF ALL COPY APPEARING IN THE EXHIBIT TOGETHER WITH A PHOTOGRAPH OR SKETCH, OR THE EXHIBIT MUST BE FULLY OUTLINLD. THIS APPLICATION IS FOR- WARDED TO THE CHAIRMAN OF THE SUBCOMMITTEE ON SCIENTIFIC EXHIBITS FOR HIS REVIEW, IF, ON THE BASIS OF THE MATERIAL CONTAINED IN THE APPLICATION1 THE CHAIRMAN OF THIS SUBCOMMITTEE DETERMINES THAT THE EXHIBIT DOES NOT CONFORM TO THE REGULATIONS, THE EXHIBIT IS REJECTED OR THE EXHIBITOR MAY BE REQUESTED TO MAKE APPROPRIATE CHANGES TO CONFORM TO THE REGULATIONS. IN ADDITION) THE EXHIBIT MAY BE REJECTED--AND THEY HAVE IN THE PAST--IF THE MATERIAL IS NOT RELEVANT TO FAMILY PRACTICE OR THE EXHIBIT APPEARS TO BE OF POOR QUALITY. IN REQUESTING AM EXHIBITOR TO MAKE MODIFICATIONS IN THE EXHIBIT, OBVIOUSLY THE ACADEMY WOULD NOT REQUEST THAT THE DATA OR CONCLUSIONS BE CHANGED. HOWEVER, IF--FOR EXAMPLE--AN EXHIBIT CON- TAINED REFERENCETO A SPECIFIC DRUG COMPANY, THIS MOULD BE A VIO- LATION OF OUR REGULATIONS AND THE EXHIBIT WOULD HAVE TO BE MODIFIED OR REJECTED. IN THE PAST, SOME PROBLEMS HAVE EXISTED IN EXERCISING EDITORIAL REVIEW OVER SCIENTIFIC EXHIBITS ONCE THEY HAVE BEEN SET UP AT OUR SCIENTIFIC ASSEMBLY. LAST NOVEMBER, THE ACADEMY REQUESTED THE PMA -8- PAGENO="0329" COMPETITtVE PROBLEMS tN TUE DRUG INDUSTRY 14235 LIAISON COMMITTEE ON SCIENTIFIC EXHIBITS TO WORK WITH US AT OUR NEXT SCIENTIFIC ASSEMBLY IN BOSTON IN ORDER TO IMPROVE OUR ABILITY TO EX- ERCISE THIS ON-THE-SPOT REVIEW. THE FUNCTION OF THIS LIAISON COMMITTEE IS TO REVIEW ALL SCIENTIFIC EXHIBITS AFTER THEY HAVE BEEN ASSEMBLED AND PRIOR TO THEIR OPENING IN ORDER TO REPORT ANY INFRACTIONS OF OUR EXHIBIT REGULATIONS. EXHIBITORS RESPONSIBLE FOR THOSE EXHIBITS IN VIOLATION OF THE REGULATIONS WILL BE REQUESTED TO CORRECT THE VIOLATIONS PRIOR TO THE OPENING OF THE EXHIBITS. SUCH CORRECTIONS WILL BE AC- COMPLISHED BY MASKING IMPROPER OR INAPPROPRIATE MATERIAL, AGAIN, THE ACADEMY WOULD NOT ATTEMPT TO CHANGE THE DATA OR CONCLUSIONS, BUT RATHER CORRECT IMPROPER PRESENTATIONS) SUCH AS REFERENCE TO A SPECIFIC COMMERCIAL PRODUCT. ALTHOUGH THE LIAISON COMMITTEE ON SCIENTIFIC EXHIBITS IS A BODY OF THE PHARMACEUTICAL MANUFACTURERS ASSOCIATION, WE HAVE EVERY REASON 10 EXPECI THAT THEIR INPUT WILL DO MUCH TO INSURE THE HIGHEST ETHICAL AND SCIENTIFIC STANDARDS FOR THESE EXHIBITS SINCE THE MEMBERSHIP OF THE PMA IS BROADLY REPRESENTATIVE OF THE DRUG INDUSTRY, IT SEEMS APPARENT THAT THIS COMMITTEE WILL HAVE AN INTEREST IN INSURING THAT EXHIBITS SPONSORED BY PARTICULAR DRUG FIRMS NOT PRESENT BIASED OR UNETHICAL MATERIAL AND, I SHOULD REITERATE THE POINT THAT THE LIAISON COMMITTEE WILL NOT BE REVIEWING THE EXHIBIT AGAINST A SET OF CRITERIA ESTABLISHED BY THE INDUSTRY--BUT AGAINST THOSE ESTABLISHED BY THE ACADEMY. ONE FURThER COMMENT WHICH I WOULD LIKE TO MAKE REGARDING THE REJECTION OF EXHIBITS IS THAT EACH SCIENTIFIC EXHIBIT IS EVALUATED AT THE TIME OF THE SCIENTIFIC ASSEMBLY IN TERMS OF ITS VALUE TO FAMILY PRACTICEJ EDUCATIONAL VALUE, APPEARANCE OR FORMAT AND SCIENTIFIC CONTENT. I HAVE ATTACHED A COPY OF THIS EVALUATION FORM AS APPENDIX B. THE FORM IS USED TO DETERMINE THOSE EXHIBITS DE- SERVING RECOGNITION AS OUTSTANDING EXHIBITS, AND IT IS COMPLETED -9- PAGENO="0330" 14236 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY BY MEMBERS OF TIlE ACADEMY'S COMMITTEE ON SCIENTIFIC PROGRAM. FURTHERMORE, THE COMPLETED EVALUATION FORMS PROVIDE AN ADDITIONAL CRITERIA TO BE USED IN DETERMINING WHETHER A PARTICULAR EXHIBIT SHOULD BE ASSIGNED SPACE IN FUTURE YEARS, IF THE EXHIBITOR INVOLVED SUBMITS AN APPLICATION FOR SUCH SPACE AS REGARDS EDITORIAL REVIEW AND REJECTION OF COMMERCIAL EXHIBITS) FOR THE MOST PART, SUCH EXHIBITS ARE ACCEPTED UNLESS THEY ARE DEEMED INAPPROPRIATE TO A MEETING OF THIS TYPE OR UNLESS THERE HAS BEEN A PREVIOUS INSTANCE OF IMPROPER OR UNETHICAL CONDUCT BY THE EXHIBITOR INVOLVED. THERE HAS BEEN AT LEAST ONE INSTANCE IN WHICH A COMMERCIAL EXHIBITOR WAS BODILY REMO'/ED FROM THE EXHIBIT FLOOR EECAUSE HE ENGAGED IN SIDE-SHOWTYPE TACTICS. THE FINAL AREA WHICH WE WERE REQUESTED TO COVER IS THE EXTENT TO WHICH CONVENTIONS ARE DEPENDENT ON DRUG COMPANY SUPPORT. As I HAVE PREVIOUSLY STATED, SCIENTIFIC EXHIBITS ARE AWARDED SPACE AT OUR CONVENTION ON THE BASIS OF THEIR EDUCATIONAL VALUE. SINCE SUCH EXHIBITS DO NOT PRODUCE INCOME, DRUG COMPANY SUPPORT OF THEN DOES NOT EFFECT THE ACADEMY'S OVERALL ABILITY TO STAGE ITS SCIENTIFIC ASSEMBLY. HOWEVER, BECAUSE A SIGNIFICANT NUMBER OF THESE EXHIBITS ARE SUPPORTED BY DRUG COMPANIES, SUCH SUPPORT IS ESSENTIAL TO INSURE THAT THIS PARTICULAR ELEMENT OF THE SCIENTIFIC PROGRAM IS POSSIBLE. WE DO BELIEVE SCIENTIFIC EXHIBITS ARE AN IMPORTANT ELEMENT OF CONTINUING EDUCATION, AND AS I HAVE MENTIONED, THE ABSENCE OF DRUG COMPANY SUPPORT WOULD NOT MEAN BETTER SCIENTIFIC EXHIBITS BUT A PROBABLE ABSENCE OF SCIENTIFIC EXHIBITS ALTOGETHER. ON THE OTHER HAND, THE INCOME WHICH IS DERIVED FROM THE SALE OF COMMERCIAL EXHIBIT SPACE IS AN IMPORTANT FACTOR IN THE ACADEMY'S -10 - PAGENO="0331" COMPETiP]VE PROBLEMS IN PH~E DRUG INDUSThY 14237 ABILITY TO STAGE ITS ANNUAL MEETING. IN PAST YEARS) THE TOTAL COST OF HOLDING OUR ANNUAL MEETING HAS SIGNIFICANTLY EXCEEDED THE INCOME WHICH IT PRODUCES FROM ALL SOURCES FOR EXAMPLE, IN THE YEAR 1975, TOTAL INCOME WAS $1475,463 AND TOTAL EXPENSES WERE $579,031 EXPENSES EXCEEDED INCOME BY $103,569, O~ THE INCOME WHICH WAS RECEIVED, $2147,000--ovER 50%--WAs RECEIVED FROM THE SALE OF. TECHNICAL EXHIBIT SPACE. SINCE A LARGE PART OF THIS EX- HIBIT SPACE WAS SOLD TO DRUG COMPANIES, IT IS OBVIOUS THAT THEIR PARTICIPATION IS IMPORTANT IN INSURING THAT IT IS ECONOMIC'\LLY POSSIBLE TO HOLD OUR ANNUAL MEETING. BEFORE CONCLUDING, I WOULD LIKE TO MAKE ONE ADDITIONAL POINT. ALTHOUGH DRUG COMPANY SUPPORT OF SCIENTIFIC AND COMMERCIAL EX- HIBITS HAS BEEN AN IMPORTANT FACIOR IN THE ACADEMY'S ABILITY TO PROVIDE HIGH QUALITY, CONTINUING EDUCATION TO OUR MEMDERS, IT HAS NOT PRODUCED THE RESULT THAT THE TOTAL EDUCATIONAL CONTENT IS CONTROLLED BY THE DRUG INDUSTRY, SCIENTIFIC EXHIBITS ARE BUT ONE OF NINE ELEMENTS IN OUR SCIENTIFIC PROGRAM ATTACHED TO THIS STATEMENT AS EXHIBIT C IS A LIST OF THESE NINE PROGRAM ELEMENTS WHILE IT IS TRUE THAT THE INCOME DERIVED FROM THE SALE OF COM- MERCIAL EXHIBIT SPACE TO PHARMACEUTICAL COMPANIES HAS PROVIDED FINANCIAL SUPPORT FOR THE ENTIRE SCIENTIFIC ASSEMBLY, IT IS ALSO TRUE THAT THE PURCHASE OF EXHIBIT SPACE DOES NOT GIVE SUCH PHAR MACEUTICAL COMPANIES ANY CONTROL OVER THE EDUCATIONAL CONTENT OF THE NINE PROGRAM ELEMENTS WHICH COMPRISE THE SCIENTIFIC PRO- GRAM. MR. CHAIRMAN, WE HAVE ATTEMPTED TO COVER EACH OF THE AREAS OUTLINED II~I YOUR INVITATION TO APPEAR BEFORE THIS SUBCOMMITTEE -ii- PAGENO="0332" 14238 coi~t i~rriv~ PROBLEMS ]N THE DRTJG INDtISTRY WE HOPE THAT THE INFORMATION WHICH WE HAVE PRESENTED WILL BE OF BENEFIT TO YOU IN YOUR DELIBERATIONS. AT THIS TIMEJ DR. HUFFMAN AND I WILL BE HAPPY TO ANSWER ANY ADDITIONAL QUESTIONS WHICH YOU MIGHT HAVE. -12- * * * PAGENO="0333" COMPETIP~VE PROBLEMS IN PRE DRUG INDUS~FRY LX~E~L11.IL_A AMERICAN ACADEMY OF FAMILY PHYSICIANS THE SCIENTIFIC EXHIBIT for the Twenty-eighth Annual Scientific Assembly-- September 20-23, 1976 BOSTON FOREWORD 14239 bach year, the scientific exhibits acquire increasing stature as a teaching discipline at our Assettshly. Members are SOXIOUS to learn about new developments in medicine, and the Assembly program provtclcs ttoncontiict' iri~t hours for exhibit study. Hence, the scientific exhibitor, if selected for the Academy Assembly, hns a ttrtique opportitnity to tench. In order to select the most suitable exhibits, certain criteria have been develtigeil, includkxi~ `ttpplication to itintily practice as well as the usual standards of quality, legibility, scientific accttmacy anti ethical content. Regrettably. it svill be itnpossible to ttccept every exhibit offered to us, The store information SF00 give on the attached application form, the easier it will be for us to select those exhibits of the greatest vaitte to family lsltysiciats. We appreciitte your desire to join us itt Boston. If we are ttttable to accept yottr exhibit, we encourage you to apply ayai it its hit are years. If ytnir exhibit is selected is e look forward to fleeting you We will make an cattiest effort to provide a plcasattt and worthwhile experience. .lA M ES M BURLEY, M.D., C/tai,'mwz St,bc'oi,i,ni(tee on Sci~nti/Yc Exhibits UEf\l)LINE FOR APPLICATION -May .1. 1976 PAGENO="0334" 14240 COi~~IflVE PROBLEMS IN THE DRUG INDUSTRY ACADEMY REGULATIONS FOR SCIENTIFIC EXHIBITS I. Tb.~ author or authors of the exhibit shall be fully responsible for the content, arrangement and presentis- (ion of all data in the exhibit. 2. 1~xect)t in `are emergency situations. one of the authors of the scientific exhibit is expected to be present at he Assembly and itt charge of the exhibit, If this is not possible lie applicant (exhibitor) is expected to infortu lie Academy promptly. The exhibit itziist be staffed by a qualified demonstrator during the open" hours of he Assembly. .1. An exact Iranscript of all copy to appear in the exhibit together with a photograph or sketch, must be sal)Iuilicd before any favorable action nay be taken ott the application. If this catinot he tlone, a full out~ line ansi be given in the attached application. 4. Accurate, well'documentect and up-to-date pharmaceutical research provides needed medical inforntalion. Exhibjts based on such data are welcome; however, they mast be presented in an ethical manner. Conipar' isons of efficacy. contraindications. modes of administration, et cetera, between competitive drugs shall be fully presented. Editorial conclusions should be made with ethicol restraint. 5. Only generic names of drugs and other products may be used in the body of the exhibit. The first appear- ance of the geileric muse may be marked by an ash. isk, svitli the brand name of the l)roctuct as a footnote at the bottom of the exhibit, not exceeding ˝" its height. (When a number of dilferent products appear in the exhibit copy, exception to this rule stay be granted at the discretion of the committee.) Commercial pro~lact names are not pernsitted in the title of an exhibit. 6. All generic designations of conspetitive drugs shall be used with equal emphasis on height, weight. color or type face of lettering. 7. l)es'ices designed only to attract attention, through the use of motion, sound, excessive illumination or flagrant use of color shoi.uld be avoided. This does riot imply that an exhibit may not be attractive or employ ausy legitimate device to emphasize or clarify its data, S. Sound movies or recordings may be used only if they do not detract from adjoining exhibits, and tire located in the exhibit to avoid blocking the aisle. Intent to use such devices should be clearly stated at the ti sic applictstion is made. A No reference to or credif for financial aid shall he indicated its Use exhibit. 1(1. Sales representatives of commercial firms tire not permitted to staff a scientific exhibit at any time. 11, Exhibitors tire encouraged to discuss their svork with visiting physicians, both singly and in groups. It is expected that these dieciissionis like the exhibit itself, svill be marked by etlsical restraint and that pm' sentationts will be mmdc in a manner that in no svay disrupts or detracts frons adjoining presentations. 2 PAGENO="0335" COMPETITIVE PROBLEMS tN THE DRUG INDUSTRY 14241 Scientific Exhibit Application AMERICAN ACADEMY OF FAMILY PHYSICIANS TWENTY-EIGHTH ANNUAL SCIENTIFIC ASSEMBLY BOSTON, SEPTEMBER 2O~23, 1976 h c fat a sv n g information is necessary to guide the Subcommittee on Scientific Exhibits in its selections aIl(t to assure adequata physical facilities at the AssensbLy for accepted exhibits. Please read carefully, fill in cimpteicly (type if t)ossttc). and return, in duplicate (see address on last page) no later than May 1 1976. 1. EXACT EXHl8lTTlTLE....~ ______*_________ ______ ______________ 2. PERSONNEL (highest degree attained) A. Senior Exhibitor_______________________ ____________ Title Organization etephotie ~ *______________________ ________ B. List all other physicians and senior scientists who conducted the research on which the exhibit is based; only these names will appear in the printed program: ~ -*--________________ Tttle~~ - --__________ _____________ C. Contact (Individual to whom correspondence should be addressed, it not the senior exhibitor) Name ____________________________________________ tolephone_.~_--~__-_~~ 3. [300TH DESCRIPTION FOR PROGRAM-Please describe the exhibit in 50 words, as you would like to have it appear in the printed Official Program. The Academy reserves the right to edit your CO~~ it nucessary. Please type double-spaced. This application must he returned in duplicate 3 PAGENO="0336" 14242 COMPETITIVE PROBLEMS ]N THE DRUG INDUSTRY 4. EXHII3IT INCLUDES: Charts. ~Posters_______ Photos Microphotos_..-~ X-rays_..__._Other Transparendes__ -~ -- Machines-_-.------- Specimens~.~ Movie~.._......____ View Boxes____________ Other Equipment 5. BOOTH SIZE: Scientific booths are divided by drapery hung on pipes; side walls are 6 feet deep; all walls are 8 feet high. Floor space is limited-please be accurate in giving your exhibit dimensions. Exhibits exceeding 8 feet in height or 6 feet in depth are not accepted by special ruling. MAXIMUM LINEAR BOOTH LENGTH desired __feet Can use MINIMUM LINEAR LENGTH of -feet Is this a pre-built exhibit? Yes D No 0 6. COMMERCIAL PRODUCTS: In determining the educational value of an exhibit, it is helpful to the committee to know if branded pharmaceuticals were used in the clinical work on which the exhibit is based (see Academy regulations 5 and 6 on page 2 of this application). Copy concerning drug research must be presented in an ethical manner without commercial emphasis on the brand name and without deliberate disparagement of commercial products. Failure to abide by this ethical restriCtion, in spirit as well as letter, will be considered cause for removal of the exhibit from the audi torium. is Brand Product Brand Name Name Used Manufacturer (Generic Name) fl Ex~ibit? Name of sponsor__.__-~__~- ~_--------~ -~ 7. 1 I1STORY: I-las this exhibit been presented in whole or in part at any previous Assembly of the Acadeiny? Yes [1 No LI If yes, when?_._---.----------------- Has it been presented at any other medical society 4- PAGENO="0337" COMPETIPtVE PROBLEMS N THE DRUG INDUSTRY 14243 8. EXHIBIT COPY: Please enclose, in duplicate, booklet or folder giving copy as it will app~ar in the exhibit. If not available, detailed information must be given in the space below concerning the research on which this exhibit will be based or the teaching material to be presented. It complete exhibit copy is submitted, it is not necessary to fill in the space below. Exhibit Description A. OBJECTIVES B. FINDINGS 5 73-617 0 - 76 - 22 PAGENO="0338" 14244 COMPETITIVE PROELEMS J~ THE `DRUG INDUSTRY C. CONCLUSIONS The undersigned agrees that (1) this exhibit will be staffed by qualified demonstrators during the "open" hours of the Assembly. (2) that all demonstrations svill be conducted in an ethical, professional manner, and (3) that no commercial item will be sold or offered for sale by exhibitor or other personnel in the Scientific Exhibit Section. This form, when completed, shall be forwarded promptly to Mr. Edward IL Daleske, Secretary, Committee on Scientific Program, American Academy of Family Physicians, 1740 W. 92nd St., Kansas City, Missouri MI 14 6 PAGENO="0339" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14245 E_XH I B IT p American Academy of Family Physicians SCIENTIFIC EXHIBIT EVALUATION FORM Senior Exhibitor Exhibit Title Meeting Exhibit Number Excellent (8) Good (6) Fair (4) Poor (2) I. Value to Family Practice -- - - Eiccellent (4) Good (3) FaIr (2) Poor (1) II. Educational Value - (purpose conclusions) Excellent (4) Good (3) FaIr (2) Poor (1) III. Appearance or Format (clarify dcsign, esthetic value) Excellent (4) Good (3) FaIr (2) PoOr (1) LV. Scientific Content - - - (valid, properly structured, timely) Subtotals __________ - - TOTAL: points out of a possible 20 points. Exhibitor olaf flog: Needed _________ Not Needed __Exhibitoe present: Yes _No - (Evaluator's name) PAGENO="0340" 14246 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY LXJLI B I I ~ ~ HYNES VETERANS AUDITORIUM, BOSTON CARE WITH CARING SCENE OF EXPANDED MEDICAL EDUCATION OPPORTUN IT! ES The 1976 Scientific Assembly program offers nine diverse modalities and more than 100 practical sut~et.t~ to suit your learning needs asd prefer' unce~. You CAfl build a personalized curriculum around the rillowing elements planned by fellow ph'sicirns who serve on the Conrrnittee on Sci' s'ntilic Program: * c:liiricrl Seminars * Continuing Education Courses * Dislogue * I sn lurching Denioristrations * longrainirneci Instruction * I dlii rig and Strapping l)t'monstrsntions Inn tures l)emonstral uris * Su i('n)tifiC Exhibits * I ditties inn tin 1.nli tsp p1 rysicians can i'urrn otto hour of lire' .scrilsd .\\l I' credit for E'~CIi tour spent in any portion of the scientific program (exckrd'rtig the viewing of scientific exhibits). l3y carefully sclre' clulisg your time (that is, from 0:00 am to 5:00 p.m. MoncLny, Tuesday anti Wednesday of tire ,\sscmbly and 0:t)0 am. to noon oil Thursday) it wonnkl be possible to earn moo.. than 30 approved continuing medical education hours. Each of tIre nine program elements is tlescritted below. Advance registration is advised for the first two) which also involve a tee. The other seven elemOnts are free of charge. The Committee on Scientific Program suggests that you register inirmurdiately for airy Sennuinr,tr~ or Continuing Edo' cation Courses you tiny wish to partidil)ate in. Ilavinig received 111)1 ilication thsit yotir registra' lion is complete, yost will then be able to plan the rest of your time to host advantage. 3 PAGENO="0341" COMPEflPIVE PROBLEMS IN THE DRUG INDUSTRY 14247 STATEMENT BY: Mr. J. E. Raeben, President, Visual Information Systems, Division of Republic CorporaHon before Subcommittee on Monopoly, U. S. Senate, Small Business Committee, May 10, 1976 PAGENO="0342" 14248 COMPETITIVE PROBLEMS IN TEE DRTJG INDUSTRY Summary The following statement identifies Visual Information Systems (VIS) activities. I briefly describe those concerned with medical communication or education and, at greater length, deal with those likely to be of special interest to the Subcommittee. As each activity is discussed, an effort is made to respond in that section to the Subcommittee's concerns as suggested in ifs invitation letter of April 6. 1. About VIS Our company was formed in October 1962 and became part of Republic Corporation in 1969. Its first activities were in closed circuit television at conventions. Since then we have provided business and university instruction on videotape and made smaller forays into sports and entertainment. VIS' principal activities and those of interest to the Subcommittee are in medicine and this statement is limited to them. 2. VIS medical activities are: Convention Television, begun in 1962; The Network For Continuing Medical Education (NCME), begun in 1965; Audio Visual Education in Neurosurgery (AVENS), begun in 1969; Amercian Academy of Ophthalmology And Otolaryngology Continuing Education on Television, begun in 1971; Physicians Radio Network (PRN) begun in 1974 3. Convention Television Convention T.V. began in 1962 at a meeting of the American Dental Association. The service, to which we attach the trade name Hotelevision, enabled PAGENO="0343" COM?ETITtVE PROBLEMS IN THE DRUG INDUSTRY 14249 dentists in their own hotel rooms to watch programs on dentistry prepared by the Associetion. Since that date, Hotelevision and other Forms of convention television have been supplied by us to about 70 Association meetings, predominately for physicians. All programming is developed under the direction of the Association and the service has been supported by perhaps a dozen pharmaceutical companies in all. When product messages accompany the telecast, they are always unrelated to the content of the program. To my knowledge, no studies have been done to measure the impact on physicians prescribing practices. 4. NCME The Network For Continuing Medical Education (NCME) was established in 1965 with the support of Roche Laboratories. This was the first effort in any field to use the emerging video technology for publishing. We employ a journal" concept with three "articles" or programs in each reel. Unlike the way motion pictures had been used, we put forward the then un-usual notion that an audience as small as a single viewer was adequate and that viewing should take place at the convenience of the viewer, not the exhibitor. These ideas today seem commonplace. In 1972, with the introduction of the videocassette machine, a cassette subscription plan was developed. This has enabled hospitals to build their own videocassette libraries and offer them as community resources. Today all 700 NCME hospitals subscribe, paying $1,200 to $1,600 yearly. The remainder of the cost Is borne by Roche Laboratories. About 145,000 physicians have regular access to NCME programs. -2- PAGENO="0344" 14250 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 5. In 1965, when the Network began, we hoped the programs would be produced either by medical schools, just then acquiring videotape equipment, or by government facilities, such as, for example, the National Naval Medical Center, or Walter Reed Army Medical Center. In short, we expected to vest responsibility for producing the programs in the academic medical community. That programming, however, proved to be, too often, not suitable for distribution for technical or production reasons. It became more effective for NCME to provide direct production assistance to the physicians, at those same medical centers, whose work was to be the subject of the programs. (Programs produced by medical centers are, however, still occasionally distributed on NCME.) The Network presently distributes each year 69 different programs. These are assembled onto 23 one-hour reels, and are sent out one reel every-other-week, except monthly in summer. I would like to put into the record now this catalog which lists NCME's programs and their participants. 6. Program subjects and their content are determined through the following process: First of all, we have a National Board of physicians concerned with education. That Board includes such persons as Lowell Coggeshali, formerly Vice President at the University of Chicago and the nation's first Assistant Secretary for Medical Affairs at Heelth, Education and Welfare , George Aagaard, one of the nof ion's first deans of continuing medical education, now Professor at Washington University School of Medicine and Edmund Peilegrino, Chairman of the Board, Yale- New Haven Medical Center. A complete list is provided in an appendix to this statement. This Board -~-"~4~c overall direction to the Network. For example, at the Board's meeting -3- PAGENO="0345" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14251 later this May, it will discuss steps NCME must take to meet the accreditation requirements of various accrediting bodies; another group, the Medical Advisory Committee, is made up of physicians, also listed in the appendix, who meet regularly to select specific program subjects and often to suggest participants for them. The participant himself then determines the specific content of hs program, although NCME staff guide him on ways to make programs more visual. The staff also sometimes recommends for or against programs based on their suitability for television. The sponsor does not ask us and we do not volunteer to produce particular programs or to treat programs in any particular way. As with any publisher or broadcaster, our goal is to provide subjects likely to be of interest and value to large audiences, because if they are not, doctors will not watch, hospitals will not subscribe and our sponsor will cease his own support. If one were to view.these programs - and they are the silent witnesses here - he would Find that large numbers of them do not deal with drugs and that when they do, it may be as much against as for their greater use. 7. Product Messages appear preceding each program on the reel. The schedule of product messages is prepared months in advance by the sponsor without knowledge of the programs they are to accompany. However, when the reel is assembled, our staff takes care to avoid even the accidental juxtaposing of product messages with programs dealing with the same clinical subject. No study has ever been done to determine the extent to which product messages on NCME affect drug prescribing -4- PAGENO="0346" 14252 COi~tPEPIPIVE PROBLEMS IN TRE~ DRUG INDUSTRY practices. And, of course, no studies have been done on the influence of the programs themselves on drug prescribing. Few of these programs, if any, would lend themselves to such study. Surveys are done to determine if physicians watch our programs and find them useful. But although our audience attendance figures appear to us gratifyingly high, the sincerest form of flattery is the fact that 700 hospitals, Including many of the nation's important clinical centers, pay their own money to subscribe. Perhaps I should add here that NCME has rendered assistance to the National Library of Medicine, has disseminat~d information to physicians at the request of the National Center for Disease Control and for many years supplied programs without cost to VA and other government hospitals and institutions. 8. AVENS Audio Visual Education In Neurosurgery (AVENS) is a videocassette, monograph, and slide service, in popular terms, a multi-m~dia system. Subjects and their presenters are chosen by the Society of Neurological Surgeons which began the project with the support of a grant from the John and Mary R. Markle Foundation. The programs are sold to neurosurgical training centers and to individual neurosurgeons. But as the number of subscribers is small (about 125 have bought the first series of 10 programs), the project is far from self-sustaining. Because the distribution and production apparatus constructed for NCME is available to us, we can continue AVENS at our own expense and we are doing so. Some of the programs are said to be among the better teaching of any sort ever done in neurosurgery. Without foundation support, however, AVENS could not have been begun and without our own assistance, I am not sure it could continue. PAGENO="0347" COMPETITtVE PROBLEMS IN THE DRUG INDUSTRY 14253 9. MOO The American Academy Of Ophthalmology And Otolaryngology established in 1971 a continuing education series in videocassette form. We act as the Academy's video publisher. Production monies have been provided by the Academy. Program subjects and presenters are selected by the Academy, and the majority of programs are produced by the presenter, often with university television facilities. The programs are sold to ophthalmologists and otolaryngologists. About 200 subscriptions have been sold to each group. The cost to duplicate, market and distribute these programs is borne by VIS. The service will require a very substantial increase in sales to be self-s~ustaining. As with AVENS, we are pleased to be associated with the project because, in the long-run, it should enhance our position as a publisher of good medical education in televigion form. As with AVENS, however, it raises tke question, can such education exist, at present, and in there forms, without subsidization? 10. PRN Physicians Radio Network, or PRN, is a 24-hour a day, lday a week medical news, information and education service for physicians. It is transmitted over special FM freqt~ncies. It requires a special receiver provided by us without charge to the doctor. Research on the technical feasibility of PRN was begun by us in 1965. Over a period of several years I tried unsuccessfully to interest both the federal health establishment and major medic~1 associations either in supporting this project, or in joining me in a common search for support. In April, 1974 broadcasting was started in two cities to test whether physicians would listen and whether~~ might pay for the -6- PAGENO="0348" 14254 cO1~?nETITIVE PROBLEMS IN THE DRUG INDUSTRY service. We learned that a physician~subscription approach was impractical. However, listenership was quite high and it encouraged us to go to industry for support. We offered PRN both as a new advertising medium and one with high prospective social utility. Today, 5 companies advertise on PRN. They are: CIBA Pharmaceutical Company, Merck Sharp & Dohme, Pfizer Laboratories Division, Roche Laboratories, Smith Kline & French Laboratories and S.K. & F. Company. We hope to have more sponsors in time. There are eight one-minute advertising messages in each hour. These fall in a strict rotation planned weeks ahead, clearly with no knowledge of the news items they will eventually be adjacent to. The service now broadcasts in 23 cities to about 21,000 physicians. By year end we should be on-the-air in 30 cities, rea~hing 75,000 physicians. Our longer term goal is about 150,000 physicians, half the nations doctor population but far more than half of those active in patient care. At present, PRN programming is a single hdur, repeated 24 times and changed each day. In each city, local medical news is also broadcast every hour, generally with the cooperation of the local medical society. This summer we expect to begin updating the programming twice each day and we can broadcast an important bulletin anytime. Although PRN has been primarily a news service, we are now beginning a continuing education Series as well. This is a program, 15 minutes or so long, and repeated 20 to 30 times in the week. It is accompanied by printed self-assessment forms mailed to the physician. If our audience finds this programming useful, we think it should be a regular part of the radio service. If practicable, we may offer blocks of time for teaching purposes to the general and special medical assocations which presently have the training and education responsibility -7-. PAGENO="0349" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14255 for their constituencies. It seems to us surprising that until PRN, medicine had no medium to transmit important information quickly. If regional or national health crises threatened, there was no way, except in sometimes inappropriate public media, for medicine to communicate about it. Setting aside the matter of emergencies, if a scientific advance of any importance takes place, many months normally elapse from authorship to publication. Many more months elapse before confirmation or rebuttal by others. Our hope is that by accelerating this process, by telescoping into a few months, or even weeks, a dialogue that now may take years, PRN can have a genuine impact on medical progress not achievable in any other way. PRN news is reported by medical correspondents throughout the United States and by a permanent office staff of experienced medical journalists. Decisions on which 25 or 30 stories make up the daily broadcast are made solely by the editorial staff. Advertisers play no part. We have made a considerable effort to determine how much physicians listen to PRN and I believe we have excellent information on this, better perhaps than that possessed by many other media used for medical communication or education. We assume also, that sponsors will ultimately try to employ advertising measurement techniques on PRN messages. 11. It is certainly important to protect education from undue bias, And, it is always reasonable to fear that he who pays the piper may call the tune. That, however, has not been our experience and I hope that my presentation bears this out. Thank you. PAGENO="0350" 14256 COMPETrt~IVE PROBLEMS IN THE DRUG INDUSTRY Appendix A NCME BOARD OF CONSULTANTS George N. Aagaard, M.D. (Chairman) Professor of Medicine University of Washington School of Medicine Richard M. Bergland, M.D. Chairman, Neurosurgery Department The Milton S. Hershey Medical Center Edward Bird, M.D. Division Cancer Control National Cancer Institute Lowell T. Coggeshall, M.D. Trustee and Vice-President Emeritus University of Chicago Marvin Johnson, M.D. St. Joseph Hospital Medical Education Department Denver, Colorado Attallah Kappas, M.D. Professor and Physician-In-Chief Rockefeller University New York, N.Y. Robert Moseley, M.D. Professor and Chairman Department of Radiology University of New Mexico School of Medicine PAGENO="0351" COMPETITJVE PROBLEMS IN THE DRUG INDUSTRY 14257 MEDICAL ADVISORY COMMFfTEE James J. Bulger, M.D. Family Physician 115 College Park Medical Center Great Falls, Montana Dr. Bulger is a practicing family physician with a special interest in cardiology. He represents our viewing audience in Montana. He advises us on topics that hold interest at his hospital in Great Falls and tells us of presenters who are good on camera. He is also asked, at times, to review scripts prior to production to make certain that all points are covered. George Eckert, D. 0. Doctor's Hospital Columbus, Ohio Dr. Eckert is the single osteopathic physician on our medical advisory committee. He has a private practice and recommends topics of interest to himself as well as his colleagues. In addition, he reports to us on the reception of NCME programs at Doctor's Hospital in Columbus, Ohio. P. R. Garver, M.D. Diplomate, Board of Family Practice Medical-Dental Building Show Low, Arizona Dr. Garver has a large general practice in Arizona and is constantly on the look-out for continuing medical education opportunities. We depend on him for advice as he uses NCME as a primary source of postgraduate education for himself and the other physicians and paramedics in the community. Alan L. Goldberg, M.D. Family Physician 2805 Grand Concourse Bronx, New York Assistant Visiting Physician, Department of Medicine Bronx Lebanon; Department of Electrocardiology Dr. Goldberg is a family physician with a large, busy practice and is active with the state chapter of the American Academy of Family Physicians. He represents our audience and advises us on the appropriateness of material we present. He frequently screens programs prior to distribution. PAGENO="0352" 14258 COMPETITIVE PROBLEMS IN TUE DRUG INDUSTRY Marvin Johnson, M.D. Director of Medical Education St. Joseph Hospital Denver, Colorado Dr. Johnson wears severaj hats on the medical advisory committee. He is a practicing surgeon and a director of medical education at his hospital in Denver. In addition, he is a member of the AMA's Council on Scientific Assembly and the Committee on Continuing Medical Education. Dr. Johnson provides us with topics that appeal to his hospital staff, names of presenters considered very good in the western United States, and advice on improving NCME programs to meet the requirements for continuing medical education credit of the AMA. Mortimer J. Lacher, M.D. Attending Physician, Medical Oncology Service Memorial Hospital for Cancer and Allied Diseases Dr. Lacher is NCMEs resource for developments and presenters in the field of cancer. Richard D. Levere, M.D. Professor of Medicine Chief of the Hematology Division Vice Chairman, Department of Medicine Assistant to the Dean for Interdisciplinary Programs State University Hospital, Downstate Medical Center Dr. Levere provides the NCME staff with program ideas and teachers in the field of internal medicine and hematology. He frequently screens the programs prior to distribution. Harold C. Neu, M.D. Associate Professor of Medicine Associate Professor, Pharmacology Head of Infectious Diseases Columbia University College of Physicians and Surgeons Dr. Neu, as an academic physician with a small private practice, has wide-ranging contacts with specialists in many fields; has on interest in continuing medical education by' videotape c~'nd first-hand experience with it, and has an ability to choose on-camera talent--that is experts in their. medical field with a flare for on-camera presentation. PAGENO="0353" COMPETITXVE PROBLEMS IN THE DRUG INDUSTRY 14259 Edmund D. Pellegrino, M.D. Chairman of the Board Yale-New Haven Medical Center Dr. Pellegrino, as on educator and practicing physician, has a special interest in the use of videotape for postgraduate education of physicians. He frequently r~commends topics for use on NCME as well as appropriate teachers. Charles Plotz, M.D. Director, Office of Continuing Medical Education Professor of Medicine Chairmoh of the Department of Family Practice Downstate Medical Center Dr. Plotz has a unique role on our advisory committee. As a director of continuing medical education and chairman of the department of family practice, he advises us on the kinds of programs that appeal to practicing physicians at his instituton and often acts as a sponsor for special continuing medical education credit. He is an authority in the field of rheumatoid arthritis and provides us with program topics and experts in the field as teachers for N~ME. lsadore Rossman, M.D. Medlcal:Director of the Home Care Department Associate Professor of Community Medicine Albert Einstein Medical College Dr. Rossman was selected for the committee because he has a private internal medicine practice and an interest in geriatric medicine. He advises us on topics in his area of interest. Rafael C. Sanchez, M.D. Associate Dean Louisiana State University School of Medicine New Orleans, Louisiana Dr. Sanchez, as a former practicing internist and family physician, and as a current dir~ctor of continuing medicdl education for LSU School of Medicine, advises us on topic selectien, presenters, and developments in the field of continuing medical education. LSU produce~ its own continuing medical education videotapes and provides them and NCME videotapes to a network of hospitals in and around New Orleans. Dr. Sanchez is a key source of information on the appropriateness of topics for our NCME audience. Travis Smith, M.D., Chief of Staff Hendrick Memorial Hospital, Abilene, Texas Dr. Smith advises us on the reception of programs by community hospital MD1s. 7~-617 0 - 76 - 23 PAGENO="0354" 14260 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY PAGENO="0355" COMPETITtVE PROBL1I~MS IN THE DRUG INDUSTRY 14261 THE NCME MASTER LIBRARY The NCME Master Videocassette Library, with approximately 700 medical education pro. grams is the most extensive collectiřn of telecasts available to hospitals and medical schools. Presented by leading physicians and medical researchers many of these programs were produced at medical centers and are available to NCME subscribers to supplement their basic regularly scheduled service. This catalog also includes listings from the Ameri- can Medical Students Association (AMSA) Video Journal and the American Cdllege of Physicians Television Hospital Clinics. Code letters AMSA and ACP before the catalog numbers identify these programs. HOW TO ORDER Requests for programs may be submitted on order forms in the back of the catalog. Please allow six weeks for an order to be delivered. Videocassettes are shipped at library rate. (Faster delivery can be made by airshipment, provided the borrower agrees in writing to assume the additional cost.) Tapes may be returned library rate and should be insured for $50. Subscribers to NCME's videocassette service may purchase individual titles for addition to their own Cassette Resource Center. Rentals are for a two-week period. (A modest fee is charged for master library videocassettes to defray the cost of tape stock, duplication, shipping and inspection.) NON-CASSETTE EQUIPMENT If the equipment to which you have access uses tape in any form other than the video. cassette and you want information on how to use NCME, please write or phone. PROGRAM REVIEW CARD A program review card accompanies each Master Library videocassette. NCME asks that the person for whom the order was placed fill out the program review card after using the program. As re.evaluation of these programs is a continuous process, your return of the program review card is essential to helping NCME maintain this important source Of tale. vised medical information. Whenever a program, in the opinion of the reviewer, has some important inadequacy, there will be no charge. However, the reWewer must state the reason on the program review card, and return it within two weeks after receipt of the videocassette. PROGRAM SUBMISSIONS INVITED Should you wish NCME to consider a program produced by your institution for Inclusion In the catalog, NCME will arrange to scr9en it for possible national distribution. In making your programs available, you increase t~ie ef. fectiveness of videocassettes in continuing medical education. Tape library services are made possible by Roche Laboratories through its support of the production and regular distribution of all NCME telecasts. Duplication or reproduction in any form of all or any portion of the videotape programs [~sted in this Catalog without the express written consent of NCME is not permitted. The Network for Continuing Medical Education 15 Columbus Circle New York, New York 10023 (212) 541-8088 © 1976 NCME PAGENO="0356" 14262 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY USE OF NCME FOR CONTINUING EDUCATION CREDIT Increasing numbers of professional organiza- tions, state medical associations and specialty groups are encouraging-and in some cases requiring-their members to participate in continuing education activities. The use of NCME programs is widely acceptable toward partially meeting the requirements of these various organizations. A review of some pro- fessional CME requirements may be useful. To earn the Physician's Recognition Award of the American Medical Association, physicians must participate in 150 hours of continuing medical education during a three-year period. The AMA divides CME activities into six cate- gories and five sub-categories. NCME pro- grams are routinely accepted in category 5A which has a limit of 22 hours. Once category 5A is filled, they are acceptable in category 2 up to a limit of 45 hours. Specially designated NCME programs are acceptable for category 1 credit under provisions governing the indi- vidual use of audio visual materials. Credit of this type is limited to 45 hours in total. The American Academy of Family Physicians requires 150 hours in a three-year period and divides its activities into two categories: Pre- scribed and Elective. Prescribed refers to ac- tivities specifically produced for the field of Family Practice while Elective comprehends all other programs. NCME programs are us- ually accepted as Elective but sometimes as Prescribed. Total hours required by other pro- fessional societies may vary. The American Osteopathic Association con- tinuing medical education program specifies that a particular category of credit be deter- mined by the Director of Medical Education at the osteopathic hospital or school where the activity is conducted. The DME also for- wards attendance rosters to AOA headquar- ters, and participation is entered on the com- puter record of the members involved. NCME programs are most often accfedlted under category 2A or 20 at the recommendations of the IDME. NCME's service includes a self-assessment quiz which physicians use to evaluate their knowledge of teaching points made in NCME programs. Upon completion of the quiz, it may be retained for the physician's own record or, if desired, sent to NCME for confidential filing. To receive credit, the quiz must be returned to NCME. The quiz can be mailed directly to NCME or given to the Director of Medical Education, the Medical Staff Secretary, Chair- man of the Education Committee or another appropriate person who collects all quizzes and sends them in bulk to NCME every two weeks. Physicians may request their NCME activity records at anytime. Not all NCME programs have self-assess- ment quizzes. When those programs which do are ordered from the cata- log, one copy of the self-assessment quiz will be enclosed. You may dupli- cate the quiz as your needs require. Please make sure' the Social Security number is clearly written if the quiz Is returned for credit. If there are subsequent questions, please phone NCME at (212) 541-8088. PAGENO="0357" COMPETITtVE PROBLEMS IN THE DRUG INDUS~EY 14263 TABLE OF CONTENTS Adolescent Medicine 4 Allergy 5 Anesthesiology 6 Biochemistry 8 Cardiology and Cardiovascular Disease 9 Dermatology 17 Drug Abuse 19 Embryology 21 Emergency Medicine and Trauma 22 Endocrinology 27 Family Practice 30 Gastroenterology 30 Genetics 34 Geriatrics 37 Hematology 37 Hospital Medicine 41 Infectious and Parasitic Disease 43 Instrumentation and Computers 47 Intensive Care 51 Internal Medicine 53 Legal Medicine 58 Musculoskeletal and Connective Tissue Disorders 60 Nephrology 62 Neurology 63 Nursing and Paramedical Programs 69 Nutritional and Metabolic Disorders 73 Obstetrics and Gynecology 75 Oncology 80 Ophthalmology 83 Orthopedics ... 84 otolaryngology 88 Pathology 89 Pediatrics 90 Pharmacology 98 Physiology 102 Practice Management and Medical Economics 102 Psychiatry 104 Public Health 112 Pulmonary Disease 116 Radiology 11~ Rehabilitation and Physical Medicine ~122 Reproduction, Fertility and Sexuality . 125 Space Medicir~e 128 Surgery (includes general abdóm~nal, cardiovascular, orthopedic, neurologic, pediatric, plastic, thoracic, etc.) . 129 Topical and Historical Programs 134 Urology 138 Virology 140 3 PAGENO="0358" 14264 COMPETITIVE PROBI4EMS IN THE DRUG INDUSTRY ADOLESCENT MEDICINE A NEW HOSPITAL APPROACH TO ADOLESCENT CARE, with Michael I. Cohen, M.D., Director of the Division of Adolescent Medicine; and Iris Litt, MD., Assistant Director. The division is part of the Department of Pediatrics, Montefiore Hos. pital in New York City. What advantages are there to an adolescent cen ter within a hospital? With the help of young patients, Dr. Cohen and Dr. Litt show many benefits of establishing an adolescent unit as a distinct service of a general hospital. (17 minutes) (in color) 1411107 DEALING WITH EPILEPSY: THE SOCIAL PROB- LEM, with Mary Louise Scholl, M.D., Associate Pediatrician, Massachusetts General Hospital, and Assistant Professor of Pediatrics, Harvard Medical School, Boston, Massachusetts. With proper physician guidance, epileptics can live nearly normal lives. Dr. Scholl reviews typical problems with three patients and explains what physicians can do to help. (21 minutes) (in color) 0415130 DRUG ABUSE: RECOGNIZING AND TREATING ACUTE REACTION TO AMPHETAMINES AND SEDATIVE HYPNOTICS, with David E. Smith, M.D., Instructor, Department of Pharmacology, University of California School of Medicine, San Francisco; and Medical Director, Haight'Ashbury Medical Clinic. Why do most young drug users avoid family physicians when their drug experiences get them in trouble? Dr. Smith discusses this problem with several drug users. He also gleans detailed descriptions from the young users of drug "trips" and "bad trips." Finally, Dr. Smith de- scribes the kinds of adverse reactions to am- phetamines and sedative hypnotics, and out- lines suggested therapy. (19 minutes). 0411822 DRUG ABUSE: RECOGNIZING AND TREATING ACUTE REACTIONS TO HALLUCINOGENS, with David E. Smith, M.D., Instructor, Department of Pharmacology, University of California School of Medicine, San Francisco; Medical Director, Haight-Ashbury Medical Clinic. In this telecast, experienced young people can- didly discuss "bad trips" and other adverse symptoms conected with drug abuse. The pro- gram concludes with a concise rundown of recommended therapy. (19 minuteS). 0411923 GETTING A FIX ON HEROIN. Treatment of heroin-addicted patients is clouded by popular misconceptions and mythologies about heroin use and treatment. SAMA cameras take you to drug abuse treatment facilities in New York and San Francisco to explore the problems of the drug addict and the problems of treating him. Speaking for SAMA is Dahlia Kirkpatrick, a third. year student at Yale who discusses the issues with Dr Herbert Kleber, Director of the Drug Abuse Unit of the Connecticut Mental Health Center. (34 minutes) (in color) SAMA 2810453 INFECTIOUS MOF'IONUCLEOSIS, with James C. Niederman, M.D., Associate Clinical Professor of Epidemiology and Medicine, Yale University School of Medicine, New Haven, Conn. Diag- nosis and treatment of an important clinical entity-plus some of the burgeoning research implications. (16 minutes) (in color) 0919525 INSIDE THE DOOR: A FREE CLINIC. What't free about a free clinic besides the medical care? The spirit is. And the- cooperation between pro- fessionals and students of all disciplines. SAMA cameras take you to The Door, a free clinic in New York City, that offers adolescents full medi- cal care as well as legal,' social and educational counseling. Medical students and physicians at The Door talk about how they believe free clinics can help humanize medical treatment. (23 minutes) (in color) SAMA 2810149 MANAGEMENT OF ADOLESCENT SYMPTOMS. Methods of dealing with the problems of ado- lescents - particularly experimentation with sex and drugs - are demonstrated with groups of teenagers, by Steven R. Homel, M.D., Depart- ment of Pediatrics, Jefferson Medical College and Hospital of Philadelphia, Pa, (18 minutes). ` 1308004 MEDICAL PROBLEMS 6F ADOLESCENT HEROIN ABUSE, with Michael I, Coften, M.D., Director of the Division of Adolescent Medicine; and Iris ,Litt, MD,, Assistant Director. The Division is `part of the Department pf Pediatrics, Montefiore Hospit~l in New York City. An in-depth interview is conducted with a 14- year-old heroin addict- under treatment. The youth describes his life with drugs followed by comments on the interview by the physicians. (14 minuteS) (in color) 1311025 4 PAGENO="0359" COMPETIPIVE PROBLEMS IN THE DRUG INDUSTRY 14265 REACHING THE ADOLESCENT PATIENT. How can the physician "communicate" with the ado- lescent patient whose physical problems so often are linked to his emotional state? Using groups of youngsters at different age levels, Steven R. Homel, M.D., Department of Pediatrics, Jefferson Medical College and Hospital of Philadelphia, demonstrates techniques and methods that can be applied to general practice. (18 minutes). 1807905 RECOGNIZING ROLES IN JUVENILE DIABETES, with Donnell D. Etzwiler, M.D., Director, Diabetes Education Center, and Pediatrician, St. Louis Park Medical Center, Minneapolis. A pediatrician gives guidelines for early diagnosis and manage- ment of juvenile diabetes and shows which responsibilities of good control should be as- signed to physician, health professional, and pa- tient. This presentation was produced with the cooperation of the Council on Scientific Assem- bly of the American Medical Association. (16 minutes) un color) 1822934 SCOLIOSIS: SIGNIFICANCE OF EARLY DETEC- TION, with Hugo A. Keim, M.D., Director of the Scoliosis Clinic, New York Orthopaedic Hospital; and David B. Levine, M.D., Associate Attending Orthopaedic Surgeon, Hospital for Special Sur- gery, and Cliniral Associate Professor, Cornell University Medical College, New York City. Approximately one adolescent in 10 has idio- pathic scoliosis, which too often is not recog- nized until the curvature has become debilitat- ing. Two orthopedists show what to look for on x-rays and how to conduct a simple office exami- nation that makes earlier diagnosis and treat- ment easier. (15 minutes) ho color) 1914726 THE DOCTOR-ADOLESCENT RELATIONSHIP. The adolescent frequently needs an outlet to express his doubts and concerns. How the physician can serve as this outlet during a clinical visit is demonstrated by Steven R. Homel, M.D., of the Department of Pediatrico, Jefferson Medical Col- lege and Hospital, Philadelphia, Pa. (30 minutes). 0408319 THE NEW HEROIN SCENE: A PFRSPECTIVE FOR PHYSICIANS, with George R, Gay, M.D., Chief of the Medical Section and Director of the Heroin Clinic of the Haight-Ashbury Clinic, and Instructor in Toxicology at the University of California at San Francisco. A new group of drug abusers appears to be growing in numbers across the country - the "middle-class jun- kies" who are "dropping out" of society on heroin. The dimensions of the problem are explored by Dr. Gay. He also outlines treatment for the young abusers who are consumed by the chemical aspects of life rather than the human aspects. (22 minutes) 1413530 THE THREAT OF SUICIDE. Those who ~ommit suicide frequently attempt to communicate their desperation to their physicians. How can we be sensitive to these warnings, either open or covert, and how can we help a patient once his Suicidal intentions are known? Two medical students dis- cuss this issue with Harvey Resnik, M.D., Chief of the Mental Health Emergencies Sectio~i, Na- tional Institute of Mental Health and Clinical Professor of Psychiatry, George Washington Uni- versity School of Medicine. (27 minutes) (In color) SAMA 2810757 THRESHOLD TO ADDICTION, with Steven R. Homel, M.D., Department of Pediatrics, Jefferson Medical College and Hospital of Philadelphia. Dr. Homel discusses the reasons for drug addic- tion with two teen-agers and a young medical student. Their answers are candid, and offer in- sight into the attitudes of young people today. (23 minutes) (in color) 2610206 THE TREATMENT OF ACNE, with Paul Lazar, M. D., Associate Professor of Dermatology, North- western University Medical School, Chicago. When an adolescent with acne doesn't respond to topical therapy and a year of tetracycline treatment do you consider steroid therapy, topical or systemic, or acne surgery? Dr~ Lazar recommends the progression to follow in treating acne. (19 mInutes) (in color) 2020133 ALLERGY A CURRENT APPROACH TO POISON OAK! POISON IVY DERMATITIS, with William L. Ep- stein. M.D., Professor and Chairman, Depart- ment of Dermatology, University of California, San Francisco. Dr. Epstein demonstrates vari- ous treatments for severe and mild cases of poison oak and poison ivy dermatitIs, along with the problems of re-exposure, cross-sensitiv- ity with other substances and other dermatologi- cal complications. He also describes vartous de-sensitizlng and hypo-sensitizing agents. This program will benefit the non-dermatologist. (15 minutes) (in color) 0313364 ANAPHYLACTIC REACTIONS TO DRUGS. Drug allergies in various degrees of severity have been found to occur in as many as 10 to 15 p~r cent of patients. But the one feared most by physi- cians because it can lead to death is the ana- phylactic reaction. Bernard B. Levine, M.D., Associate Professor of Medicine, Department of Internal Medicine, New York University Medical Center, points out the clinical and pathologic signs of anaphylaxis and makes recommenda- tion on treatment. (15 minutes). 0106312 5 PAGENO="0360" 14266 COi~~fl'ETIPIVE PROBLEMS IN PIlE DRUG INDUSTRY A PRACTICAL APPROACH TO ALLERGIC DERMA- TOSES IN CHILDREN, with Vincent J. Fontana, M.D., Professor of Clinical Pediatrics, New York University College of Medicine, New York City Dr. Fontana demonstrates ways in which the general physician can arrive at positive diagnoses of both common and less-frequently encountered allergic dermatoses in children. He follows each diagnosis with its recommended treatment. (18 minutes) (in color) 1614937 ASTHMA - PART I - ETIOLOGY AND DIAG- NOSIS. A new and more active differentiation between Asthma of known and unknown origin has been established by Irving H. Itkin, MD., Chief, Department of Asthma Allergy, National Jewish Hospital and Research Center and Assist- ant Professor of Medicine, University of Colorado Medical Center. Dr. ltkin demonstrates the Quan- titative Inhalation Challenge Apparatus, a new tool useful in distinguishing between Asthfrta of known and unknown origin, and explains how this differentiation is useful in the management of the disease. (18 minutes). 0107418 ASTHMA - PART II - MANAGEMENT AND RE- HABILITATION. Treatment of the acute attack of asthma as well as a program directed towards long term management is illustrated by Irving H. ltkin, M.D., Chief, Department of Asthma Allergy National Jewish Hospital and Research Center and Assistant Professor of Medicine, Uni- versity of Colorado Medical Center, Denver, Colorado. (18 minutes). 0107519 CHILDHOOD ALLERGY: THE GREAT MASQUER- ADER, with Roland B. Scott, M.D., Professor of Pediatrics and Child Health, Howard Univer- sity School of Medicine, Washington, D.C. Dem- onstration of the subtle early signs and symp- toms of allergy which may eventually lead to serious, debilitating disease. Emphasis is on the child with "too many colds." (20 minutes) (in color) 0321280 HOW I APPROACH ATOPIC DERMATITIS, with Marion B. Sulzberger, M.D., Professor Emeritus, New York University School of Medicine, and Clinical Professor of Dermatology, University of California in San Francisco. Atopic eczema is a perplexing problem for the dermatologist and the general practitioner. Dr. Sulzberger describes the "chain multiple factor" approach to the disease in terms of occurrence and treatment. (15 minutes) (in color) 0813419 MANAGEMENT OF THE AMBULATORY ASTHMAT- IC CHILD, with Vincent J. Fontana, M.D., Direc- tor of the Department of Pediatrics, St. Vincent's Hospital; and Medical Director, New York Found- ling Hospital, both in New York City. Dr. Fontana describes the steps that a general practitioner can take to alleviate the symptomatology of asthma, the prevention of future episodes andthe avoidance of complications of bronchial asthma. (16 minutes) (In color) 1314139 PREDICTION OF PENICILLIN ANAPHYLAXIS BY SKIN TESTS. Screening patients to determine the presence of an allergy to penicillin by a simple test is shown by Be nard B. Levine, M.D., Associate Professor of Medicine, Depart- ment of Internal Medicine, New York University Medical Center. (18 minutes). 0607719 THE TREATMENT OF BRONCHIAL ASTHMA, with Frank Penman, M.D., Clinical Professor of Medicine, University of Oregon School of Medi- cine, Portland. How to treat the asthmatic po- tient early tQ avoid a potential respiratory crisis. (16 minutes) (in color) 2020032 WHAT'S CAUSING THE INCREASED INCIDENCE OF PHOTOSENSITIVE REACTIONS?, with John H. Epstein, M.D., Associate Clinical Professor of Dermatology, University of California at San Francisco, and Chief of Dermatology at Mount Zion Hospital and Medical Center in San Fran- cisco. Increased public obsession with sunbath- ing and an ever increasing number of photo- sensitizers in our environment are reaching the stage where almost every physician can expect to see patients exhibiting phototoxic or photo- allergic reactions. Diagnosis and treatment of the following are explored in this telecast: phototoxicity, photoallergy, exogenous photo- sensitizers, therapeutic and antibacterial agent reactions and plant-induced photosensitivity. (15 minutes) (in color) 2313502 ANESTHESIOLOGY ACUPUNCTURE ANAESTHESIA AS PERFORMED IN THE PEOPLE'S REPUBLIC OF CHINA, with Samuel Rosen, M.D., Clinical Professor of Otol- ogy Emeritus, Mt. Sinai School of Medicine, and Consulting Otologist, New York Eye and Ear Infirmary, and Ben Park, Director of Program- ming, NCME. Films of major surgery under acupuncture anaesthesia, received from main- land China, provide the basis of Dr. Rosen's observations about acupuncture anaesthesia and how it works. His comments carry the added weight of his personal experience in witnessing 15 such operations in China late in 1971. (21 minutes) (in color) 0115528 6 PAGENO="0361" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14267 ACUPUNCTURE IN WESTERN MEDICINE. Sung J. Liao, M.D., Associate Professor of Rehabilita- tive Medicine at Boston University School of Medicine, shows two medical students how he performs acupuncture therapy for the relief of pain and discusses the integration of this treat- ment into his practice of medicine. (19 minUtes) (in color) SAMA 2810758 THE ASPHYXIATING PATIENT: HOW AND WHY I INTUBATE, with Richard J. Ward, Professor, Department of Anesthesiology, University of Washington School of Medicine, Seattle. The steps involved in endotracheal intubation are reviewed and the procedure then performed on a surgical candidate. (13 minutes) (in color) 0117933 BIOMEDICAL ANALYSIS: SPEED, ACCURACY, SENSITIVITY The uses of gas chromatography in the analysis of anesthetic effects, in blood studies and in obstetrics is shown by Harold B. White, Ph.D., Professor of Biochemistry; Leonard Fabian, M.D., Chairman, Department of Anesthesiology; and Winf red L. Wiser, M.D., Professor of Obstetrics and Gynecology, University of Mississippi Med- ical Center, Jackson, Miss. (18 minutes). 0208405 EPIDURAL BLOCK. Utilization of this procedure on a patient about to undergo cesarean section is demonstrated by Irving M. Pallin, M.D., Direc- tor of Anesthesiology, The Jewish Hospital of Brooklyn, New York. (17 minutes). 0502911 LOCAL ANESTHESIA: THREE EFFECTIVE TECH- NIQUES, with William C. North, M.D., Professor and Chairman of the Department of Anesthesi- ology, the University of Tennessee College of Medicine, Memphis. When and how to use three methods of local anesthesia for most minor office procedures. Includes: field block, digital block, intravenous regional block. (14 minutes) (in color) 1220720 MAINTAINING THE AIRWAY, with Richard Zeper- nick, M.D., Instructor in Anesthesiology, Depart- ment of Surgery, Tulane University School of Medicine. How to keep the patient breathing in an emergency. 16 minutes). 1301201 SIM ONE ANESTHESIOLOGICAL TRAINING SIMULATOR: PART I, DEVELOPMENT An electromechanical, computer-controlled man- ikin has been developed to train physicians in anesthesiologic procedures at the University of Southern California School of Medicine. Describ- ing this life-like device are J. S. Denson, M.D., Professor, Chairman, Division of Anesthesiology, and Stephen Abrahamson, Ph.D., Director, Divi- sion of Research in Medical Education, along with two engineers from the Aerojet Corporation, Azusa, California, the firm which built Sim One. (25 mInutes). 1904708 SIM ONE - ANESTHESIOLOGICAL TRAINING `SIMULATOR: PART II, APPLICATION A resident physician performs an endotracheal intubation on Sim One, an electro-mechanical manikin built to duplicate human cardiopulmo- nary functions and used as a teaching tool at the University of Southern California School of Medi- cine. J. S. Denson, M.D., and Stephen Abraham- son, Ph.D., members of the school's faculty, conduct the program. (17 minutes). 1904809 THE TEAM APPROACH TO CHRONIC PAIN, from the Pain Control Center of Temple Ur~iversity Hospital, Philadelphia. With Mary E. Moore, M.D., Ph.D., Assistant Professor of Medicine, Section of Rheumatology, and psychologist; Edward J. Resnick, M.D., Associate Professor of Orthopedic Surgery, and coordinator, Pain Control Center; Richard 01cr, M.D., Associate Professor of Anes- thesiology; Shavarsh Chrissian, M.D., Assistant Professor of Rehabilitation Medicine; and Marc Flitter, M.D., Assistant Professor of Neurosurgery. Current theories of pain are leading ~o new methods for treatment. The techniques 1iemon- ctrated here can work for you and your patients. This program was produced with the cooperation of the Department of Continuing Medical Educa- tion, Temple University. (16 minutes) (in color) 2023841 THERAPEUTIC ANESTHESIA FOR LOCALIZED PAIN, with William C. North, M.D., ProfesSor and Chairman, Department of Anesthesiology, Uni- versity of Tennessee School of Medicine~ Mem- phis. A demonstration of two anesthetic tech- niques for localized pain: intercostal nerve block and myofascial block. The emphasis is op tech- nique, risks, and complications. (13 minutes) (in color) 2020934 U.S. ACUPUNCTURE: STATUS REPORT 1973, with physicians and scientists from Boston; Cin- cinnati; Los Angeles and Canoga Park, California; New York City; St. Louis; and Washington, D.C. - . . moderated by-John J. Bonica, M.D., blrector of the Anesthesia Research Center, University of Washington, Seattle. and Chairman of tt!e NIH ad hoc Committee on Acupuncture. NCME explores the state of acupuncture research and practice in the U.S. with visits to acupunc- ture clinics, classrooms, and research labs and interviews with acupuncture researchers. (30 mInutes) (In color) 211.8608 7 PAGENO="0362" 14268 COMPETITIVE PROBLEMS IN THE DRUG INDU~PRY BIOCHEMISTRY BIOMEDICAL ANALYSIS: SPEED, ACCURACY, SENSITIVITY The uses of gas chromatography in the analysis of anesthetic effects, in blood studies and in obstetrics is shown by Harold B. White, Ph.D., Professor of Biochemistry; Leonard Fabian, M.D., Chairman, Department of Anesthesiology; and Winfred L. Wiser, M.D., Professor of Obstetrics and Gynecology, University of Misslssippin Med ical Center, Jackson, Miss. (18 minutes). 0208405 CANCER MANAGEMENT: THE FUTURE OF CEA, with E. Douglas Holyoke, M.D., Chief of the Gen- eral Surgery Service at Roswell Park Hospital, Buffalo, N. Y., interviewed by Alan L Goldberg, M.D., family physician in private practice in the Bronx, N. Y. A look at the possible future of carcinoembryonic antigen as a diagnostic aid, a prognostic indicator, and as a monitoring test for patients with cancer. Dr. Holyoke uses case histories to illustrate the various uses of the antigen. (18 minuses) (in Color) 0317875 CELLULAR DISTURBANCES: A NEW CONCEPT OF OBESITY Some extremely obese patients may be incapable of losing weight and maintaining the loss because they may have acquired an excessive number of fat cells early in life. This is one of the findings of Jules Hirsch, M.D., Professor and Senior Physi- cian to The Hospital, Rockefeller University, New York. (19 minutes). 0308704 FINGERPRINTING MYOCARDIAL INFARCTION SERUM ENZYMES. How serum enzyme analysis is used to increase diagnostic accuracy and what prognostic data are furnished are demon- strated by John S. Ladue, M.D., Ph.D., As- sistant Professor of Clinical Medicine, Cornell University School of. Medicine, New York. (15 xinutes). 0608104 GASTROINTESTINAL CYTOLOGY A VALUABLE DIAGNOSTIC PROCEDURE: PART I "Application and Results." Confirming a diagno- sis without surgery through the use of Papanico- laou staining of cells from the gastrointestinal tract - with Charles Norland, M.D., Assistant Professor of Medicine, University of Chicago School of Medicine. (16 mInutes). 0703303 GROSS SYNOVIANALYSIS, a discussion of joint fluid analysis for the practicing physician, pre- sented by Daniel J. McCarty, M.D., Associate Professor of Medicine, and Head of Rheumatol- ogy Section, Hahnemann Medical College and Hospital. (13 minutes). 0700411 IMMUNOLOGY: FRONTIERS OF THERAPY, with Robert A. Good, M.D., PhD., Professor and Head, Department of Pathology, University of Minnesota School of Medicine, Minneapolis. Research meets clinical medicine as Dr. Good explains a "new kind of cellular engineering." The application of this new therapy is demon- strated in patients, and, in a look at the future, Good speaks of giving cancer patients "an im proved immunity system" to help the `host look at cancer as the foreigner it really is." (22 minutes) (In color) 0916519 IMMUNOLOGY: THE FUTURE, with Robert A. Good, M.D., Ph.D., Professor and Head, Depart- ment of Pathology, University of Minnesota School of Medicine, Minneapolis. "The next few years are really bright for im- munobiology," says Dr. Good. He and his col- leagues review the informxtion already in hand which will eventually open the doors to the transplantation era and facilitate treatment and prevention of cancer. The program's emphatiS is on coming immunologic tools for the clinician. (19 mInutes) (In color) 0916621 IMMUNOLOGY: THE NEW PATHOLOGY, with Robert Good, M.D., Professor and Head, Depart- ment of Pathology, University of Minnesota School of Medicine. In a wide-ranging discussion of recent discov' cries in immunology, Dr. Good describes the function of T-cell and beta-cell systems and their meaning for clinicians. (19 minutes) (in color) 0916418 SPHINGOLIPIDOSIS: GENETICS The increasing incidence of sphingollpicl disease, such as Tay-Sachs, Gaucher's, and Niemann' Pick, is examined genetically by Staniey M. Aron- son, M.D., Professor of Pathology, State Univer- sity of New York Downstate Medical Center, and Attending Neuropathologist, Isaac Albert Re- search Institute, Jewish Chronic Disease Hos~ pital, Brooklyn. (15 minutes). 1904914 SPHINGOLIPIDOSIS - PART I - BIOCHEMICAL ASPECTS. The chemical compositions of ganglio- sides, sphingomyelins, sulfatides, glycolipids, and cerebrosides, as they are found in the vari- ous sphingolipid diseases, are analyzed by Abra- ham Saifer, Ph.D., Chief of the Biochemistry Department, Isaac Albert Research Institute of the Jewish Chronic Disease Hospital, Brooklyn. (21 minutes). 1905015 8 PAGENO="0363" COMPETITIVE PROBLEMS 1~ THE DRUG INDUSTRY 14269 SPHINGOLIPIDOSIS - PART II - PATHOLOGY. Several pathologic manifestations - such as amaurotic family idiocy (Tay-Sachs disease), hep. atosplenomegaly (Niemann-Pick disease), and others - grouped under the general category of sphingolipidosis, are examined and defined by Bruno W. Volk, M.D., Director of the Isaac Albert Research Institute, of the Jewish Chronic Disease Hospital, and Clinical Professor of Pathology, State University of New York Downstate Medical Center, Brooklyn. 121 minutes). 1905016 SPHINGOLIPIDOSIS - PART Ill - CLINICAL ASPECTS. The specific physiologic manifests. tions of the Tay-Sachs and Niemann-Pick dix eases and amaurotic idiocy-such as cherry red macula, clonus, severe contractions, the frog" position of the legs, and lack of macrocephaly - are demonstrated with young patients by Larry Schneck, M.D., of the Albert Isaac Research Institute of the Jewish Chronic Disease Hospi. tal, Downstate Medical Center, Brooklyn, New York. (13 minutes). 1905217 STEROIDS, HORMONES AND INFLAMMATORY DISEASE, with Gerald Weissman, M.D., Associate Professor of Medicine, New York University Medi- cal Center. Steroids, hormones, and chloro. quin have been shown to counteract inflamma- tion and tissue injury by virtue of their stabili- zation of lysosomes. (14 minutes). 1900318 THE MECHANISM OF ACTION OF POLYENE AN- TIBIOTICS, with Gerald Weissman, M.D., Asso- ciate Professor of Medicine, New York University Medical Center. Aniphotericin B disrupts mam- malian fungal membranes. (17 minutes). 1302816 THE MEMBRANES OF CELLS AND ORGAN- ELLES, with Gerald Weissman, M.D., Associate Professor of Medicine, New York University Medical Center. (20 mlnutns). 1302730 CARDIOLOGY & CARDIOVASCULAR DISEASE A COMPREHENSIVE INTENSIVE CARE UNiT IN A GENERAL HOSPITAL - PART I - "History and Organization" - with Albert H. Douglas, M. D., Director, Department of Medicine, and Erwin Lear, M.D., Director, Department of Anesthesiology, Queens Hospital Center; Edward Meilman, M.D., Physician-in-Chief of Medicine, and Charles Trey, M.D., Attending Physician, The Long Island Jewish Hospital. (17 minutes). 0301931 A COMPREHENSIVE INTENSIVE CARE UNIT IN A GENERAL HOSPITAL - PART II - "Clinical Applications" - with Albert H. Douglas, M.D., Director, Department of MedIcine, and Erwin Lear, M.D., Director, Department of Anesthesi- ology, Queens Hospital Center; Edward Meilman, M.D., Physician.in'Chief of Medicine, and eharles Trey, M.D., Attending Physician, The Long Island Jewish Hospital. (16 minutes). 0302032 CARDIAC TRANSPLANTATION. With Denton A. Cooley, M.D., Professor of Surgery; Robert D. Bloodwell, M.D., Assistant Professor of Surgery; Grady L Hailman, M.D., Associate Professor of Surgery; and Robert D. Leachman, M.D~, Pro fessor of Cardiology, Baylor University c~ollege of Medicine. Cardiac transplantation deserves now to be ac- cepted in the vast armamentarium of treatment of the coronary patient, according to Dr. Cooley. Noting this, he points out that the problems sur- rounding rejection of the donor heart are being met with increasingly good results. Thus, he adds, the major drawback to increased use of cardiac transplantation is the availability of donor hearts. The implications of this - the need for a new definition of death as well as possible pro- cedures for storing donor hearts - are dis- cussed by Dr. Cooley and his colleagues. The film for this presentation was taken during the first transplantation, While the procedure has not changed radically in transplantations that followed this one, the attitudes ot the physicians have. No longer is the ttandplant patient treated like a "cardiac cripple," they contend. Rather, where possible, every attempt is made to handle him as any other postopera- tive case with ambulation after 48 hourC the goal. (30 minutes) (In colur) 2007014 CEREBRO-VASCULAR INSUFFICIENCY - DI- AGNOSIS AND MANAGEMENT, The diagnostic workup of the patient t~ith evidence of cerebro- vascular insufficiency as well *as medical man- agement of this individual is demonstrated in PART I of this two-part series, The second pro- gram concerns itself with indications for sur- gical referral for transient ischemic attacks, with a discussion of risks and results. Charles A. Kape, M.D., Chief, Division of Neurology, The Permanents Medical Group, Hayward, California, emphasizes diagnostic considerations and medi- cal management, while Edwin J. Wylie, M.D., Professor of Surgery, University of California Medical Center, San Francisco, focuses on sur- gical problems. The exchange between the au- thorities provides an opportunity to examine the multifaceted sides of this common clinical prob- lem. (PART 1,18 minutes). 0307805 PART ii, 18 mwuten). 0307806 9 PAGENO="0364" 14270 cOlltnETIPWE PROBLEMS IN THE DRUG INDUSTRY CLINICAL PATHWAYS OF CARDIOMYOPATHY, with John F. Stapleton, M.D., Professor of Medi- cine, Georgetown University Medical Center, Washington, D. C. Drawing on 17 years of ex- perience with the Cardiomyopathy Study Unit, a distinguished cardiologist presents steps for earlier recognition of this condition in your pa- tients. This program was produced with the co- operation of Georgetown University School of Medicine in Washington, D. C. (16 minutes) (in color) 0323385 CLUES TO CONGESTIVE HEART FAILURE, with Herbert J. Levine, M.D., cardiologist, Tufts-New England Medical Center, Boston, Massachusetts- Fully developed congestive heart failure is easily recognized. Precursor signs and symptoms are not as easily diagnosed. Dr. Levine describes his office procedure for detecting congestive heart failure at its earliest stages. Careful history taking is essential to Dr. Levine's approach. Sev- eral patients are shown to demonstrate his tech- nique (16 minutes) (in color) 0311727 COMMON PITFALLS IN ECG RECORDING, with Nanette K. Wenger, M.D., Professor of Medicine (Cardiology), Emory University School of Medi- cine, and Director of the Cardiac Clinics, l~rady Memorial Hospital, Atlanta, Electrical interfer- ence, machine malfunction, and improper patient preparation and ECG recording technique can give you tracings which are impossible to inter- pret properly. Dr. Wenger shows how to help your office assistant avoid these pitfalls. (11 minutes) tIn color) 0317574 CONGESTIVE HEART FAILURE - PATHOPHYSI- OLOGY AND TREATMENT, with Albert N. Brest, M.D., Head, Section of Vascular Disease and Renology, Hahnemann Medical College and Hos- pital. (15 minutes). 0302545 CONGESTIVE HEART FAILURE: PRECISION DI- AGNOSIS, with Jamos E. Doherty, M.D., Professor of Medicine and Pharmacology, University of Arkansas College of Medicine and ~irector, Di- vision of Cardiology, V.A.-University Medical Center Hospitals, Little Rock. Improve your skills as a diagnostician. Learn how to focus on the often-missed, early, subtle clues to congestive heart disease. (11 minutes) (in color) 0323687 CONGESTIVE HEART FAILURE: SUCCESSFUL MANAGEMENT, with James E. Doherty, M.D., Professor of Medicine and Pharmacology, Uni- versity of Arkansas College of Medicine, and Di- rector, Division of Cardiology, V.A-University Medical Center Hospitals, Little Rock. Digitalis, Diet, Diuretics, Rest and Vasodilators. When and how to prescribe most effectively- (12 minutes) (in color) 0323788 CORONARY ARTERY DISEASE IN MAN - PART I - PRACTICAL CONSIDERATIONS AT THE BEDSIDE. Robert J. Boucek, M.D., Professor of Medicine, University of Miami School of Medi- cine, describes how the clinician can improve his diagnosis of the site and degree of coronary artery disease. (22 minutes). 0305149 CORONARY ARTERY DISEASE IN MAN - PART II - STRUCTURE AND FUNCTION OF THE COR- ONARY ARTERIES IN THE LOCALIZATION OF ATHEROSCLEROSIS. How the structure of the coronary artery wall, the arterial musculature, and the action of the heart felate to the specific, predetermined sites of coronary artery disease are described by Robert J. Boucek, M.D., Profes- sor of Medicine, University of Miami School of Medicine. (19 minutes). 0305250 CURABLE HYPERTENSION, with Ralph E. Peter- son, M.D., Professor of Medicine and Director, Division of Endocrinology, New York Hospital- Cornell University Medical Center, New York City. Forty million adult Americans have blood pres- sures higher than 150/90; in half of them, hyper- tension is secondary to another disease process. Among this latter group, surgery to remove the underlying cause is effective in five per cent or one million cases. Dr. Peterson shows how to de- termine if a hypertensive patient is among the curable million. (16 minutes) (in color) 0315270 THE DIAGNOSTIC CHALLENGE OF CHEST PAIN, with moderator Alfred Soffer, M.D., Professor of Cardiology at the University of Health Sciences- Chicago Medical School, Chicago, and Editor-in- Chief of Chesf, the Journal of the American Col- (ege of Chest Physicians. Participants are: R. D. Henderson, M.B., F.R.C.S. (C)., Staff Surgeon, Toronto General Hospital and Assistant Professor of the Department of Surgery at the University of Toronto, Canada; Barry William Levine M.D., Assistant Professor of Medicine, Harvard Medi- cal School, and Chief, Outpatient Pulmonary Services, Massachusetts General Hospital, Bos- ton; Linda D. Lewis, M.D., Assistant Professor of Neurology, College of Physicians and Surgeons of Columbia University, and Chief of the Neu- rology Clinic, Neurological Institute of Columbia Presbyterian Medical Center, New York City; Morton E. Tavel, M.D., Associate Professor of Medicine at the Indiana University School of Medicine, Indianapolis. Pinpointing the cause of your patient's chest pain poses an urgent diagnostic challenge. Join Dr. Soffer and four specialists on these clinical grand rounds as they reach a diagnosis on five patients. (32 minutes) (in color) 0423362 10 PAGENO="0365" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14271 DIET FOR THE CA1tDIAC PATIENT, with W. Jann Brown, M.D., Professor and Acting Chairman, Department of Pathology, UCLA, School of Med- icine. A major problem with most low-sodium, lowS calory diets is that they are monotonous and tasteless; patients are prone to "cheat" on them. Dr. Brown, from his own kitchen, shows that the cardiac patient can enjoy near-gourmet menus. (16 minutes) (in color) 0411913 DIGITALIS: FRIEND OR FOE? with James E. Doherty, M.D., Professor of Medicine and Direc- tor of Cardiology, University of Arkansas School of Medicine aid The Little Rock Veterans Ad- ministration Hospital. Dr. Doherty points out the signs and symptoms of digitalis toxicity and provides guidelines for adjusting dosage to pro- vide maximum benefit without adverse reactions. (This program was part of the Drug Spotlight Program of the American Society for Clinical Pharmacology and Therapeutics,) (13 minutes) (in color) 0420152 DOES TYPE A PERSONALITY AFFECT YOUR HEART?, with Ray H. Rosenman, M.D., Associate Director of the Harold Brunn Institute and Asso- ciate Chief of the Department of Medicine, Mount Zion Hospital and Medical Center, San Francisco; William B. Kannel, M.D- Medical Director of the Framingham Heart Study in Massachusetts; and Campbell Moses, M.D., Vice-President of Medicus Communications in New York City, Is stressful behavior a coronary risk factor? Doctor Moses moderates a lively discussion. 1)8 mInutes) (in color) 0421858 ECHOcARDIQGRAPHY: SOUNDING THE HEART, with Fred Winsberg, M.D,, Director of the Division of DiagnOstic Ultrasound, Montreal General Hos- pital, and Associate Professor of Radiology, Mc- Gill University, Montreal, Quebec. When and how to use a non-invasive diagnostic procedure for yOur cardiac patients, (14 minutes) (in color) 0521629 EMERGENCY CARDIAC CARE, with William J, Grace, M.D., Department of Medicine, New York University School of Medicine, and Joseph G. Hayes, M.D., Cornell University Medical College, New York City; Costas T, Lambrew, MD., De- partment of Me9icine, Meadowbrook Hospital, East Meadow, New York; and Joseph Schluger, M.D., Department of Medicine, Lbng Island Col- lege Hospital, Brooklyn, New York. A personal plan of action is proposed to help the physician deal with pa)ients showing early signs of myo- cardial infarction, Optional emergency cardiac care systems adaptable to different community needs are described, and recently modified CPR techniques are demonstrated. A Television Clinic of thg Americart College or Physicians, 1974. Please inquire for special rental information. (60 minutes) (in color) ACP 2867482 EMERGENCY TRANSVENOUS CARD1AC PACING, with Doris J, W, Escher, M.D., Attending Physi. mait in the Division of Medicine and Physician. in-Charge of Cä1'cttac-Catheterization, Montefiore Hospital and Medical Center, Bronx, New York. The technique for emergency transvenous car. diac pacemaker insertion at the patient's bed. side is shown. Intracardiac electrogram patterns are correlated with catheter position, from high right atrium to the target position at the apex of the ventricle, (19 minutes) un color) 0520426 EVALUATING CARDIAC CATHETERIZATION IN AORTIC VALVE DISEASE, with Adolph Hutter, M,D., Associate Ditector of the Coronar~' Care Unit and Assistant In Medicine at Massachusetts General Hospital, and Instructor in MediCine at Harvard Medical School; and Peter Block1 M.D, Assistant In Medicine at MassachusettS General, and Instructor in MediCine atHarvard, Boston. Two members of the Harvard faculty demon. strafe when cardiac catheterization shovld be performed, They show the complications asso- ciated with the operation. And, they rnalfe the distinction in the problems of catheterizing children and adults, (16 minules), 05)2916 EVALUATING CARDIAC CATHETERIZATION IN MITRAL VALVE DISEASE, with Adolph Hutter, M.D., Associate Director of the CoronaryCare Unit and Assistant in Medicine at Massachusetts General Hospital, and Instructor in Medicine at Harvard Medical School; and Peter Block, M~D., Assistant in Medicine at Massachusetts General, and Instructor in Medicine at Harvayd, BOston. Two physicians on the Harvard faculty pre- sent their second N1~ME program on c~rdiac catheterization, In this telecast, they describe the indications and advantages of a generally benign right heart. catheterization to determine the severity of a mitral valve lesion. (15 minutes) (in color) 0513017 THE EXERCISE TEST, with Elliott M. Stein, M.D., Assistant Professor of Medicine, the New Jersey College of Medicine and Dentistry; Chief of the Exercise Laboratory and Cardiac Rehabilitation, Saint Michael's Medical Center, Newark. A fresh and comprehensive look at the real value of the dynamic exercise test. Indications, cop' traindications, and how a multifactorial analysis of your patient's response rtan help in both diag- nosis and treatment of cardiovagcular disease. (16 mInutes) (in color) 0523530 FINGERPRINTING MYOCARDIAL INFARCIION SERUM ENZYMES. How serum enzyme analysis is used to Increase diagnostic accuracy and what prognostic data are furnished are demon- strated by John ~. Ladue, M.D., Ph.D., Assistant Professor of Clinical Medicing, Cornell Univergity School of Medicine, New York. (15 mInutes). 0608~04 11 PAGENO="0366" 14272 coi~n'EPITwE PROBLEMS IN TItE DRUG INDUSTRY FRAMINGHAM'S CORONARY CANDIDATE: IDENTIFICATION AND PROPHYLAXIS William B. Kannel, M.D., Thomas R. Dawber, M.D., and William P. Castelli, M.D., from the Heart Disease Epidemiology Study of the Na- tional Heart Institute, National Institutes of Health, Framingham, Massachusetts, demon- strate, with patients, the objectives and the apparent successes of the Study. (21 mInutes) (ln color) 0609711 GAS ENDARTERECTOMY - PART I - PERIPH- ERAL ARTERIES. The injection of CO2 into the media of an occluded artery and the subsequent removal of the media, intima and arteriosclerotic material are shown by one of the originators of the procedure, Philip N. Sawyer, M.D., Profes- sor of Surgery, and Head of the Vascular Sur- gical Service. Downstate Medical Center, State University of New York, Brooklyn. (14 minutes). 0704701 GAS ENDARTERECTOMY - PART II CORO- NARY ARTERIES. The injection of CO2 into a grossly occluded coronary artery separates the media, intima, and atheromatous substance from the adventitia, a procedure which greatly simplifies endarterectomy, in the view of Philip N. Sawyer, M.D., Professor of Surgery, and Head of the Vascular Surgical Service, Downstate Med- ical Center, State University of New York, Brook- lyti. (18 minutes). 0704802 HEMODYNAMICS - AN INSTRUCTIONAL DE- VICE. A mechanical model of the cardiovascular system is demonstrated and discussed by Simon Rodbard, M.D., Chief of Cardiology, City of Hope Medical Center, Duarte, California. Designed by Dr. Rodbard as a teaching aid, the machine simulates normal blood flow, and, by opening or closing the appropriate valves, demonstrates cardiovascular dysfunction, as well, (15 minutes). 0805303 HOW I DOSUBCLAVJAN VENIPUNCTURE, with Josef E. Fischer, M.D., Assistant Professor of Surgery, Harvard Medical School, and Instructor in Surgery at Massachusetts General Hospital, Boston. Dr. Ilscher demonstrates catheter place- ment in the subclavian vein and outlines Indica- tions and contraifldications for the procedure. (17 minutes) (in color) 0817830 HOW I TREAT VARICOSE VEINS, 4~ith RObert~ A. Nabatoff, M.D., Chief of the Vascular Clinic, Mount Sinai Hospital and Medical Center, New York City. Injection or surgery? Dl~ Nabatoff's outpatient stripping procedure, which hedem- orlsti'ates, answers a number of the practi~al objections to surgical therapy. (20 mInutes) (in color) 0818231 IMPLANTED PACEMAKERS: LONG-TERM FOL- LOWUP, with Doris J. W. Escher, M.D., Attending Physician, Department of Medicine, Cardiology Division; and Seymour Furman, M.D., Associate Attending Surgeon, Department of Surgery, Car- diothoracic Surgery Division, Montefiore Hospital and Medical Center, Bronx, New York. How to avoid unnecessary implanted pacemaker failure. Specific teSts to evaluate pa.:emaker function are demonstrated and the results interpreted. (21 minutes) (in color) 0920528 INFLUENCE OF THE EMOTIONS 014 THE OUT- COME OF CARDIAC SURGERY: DIAGNOSIS AND DECISION with Janet A. Kennedy, M.D., Assist- ant Professor of Psychiatry; and Hyman Bakst, M.D., Assistant Clinical Professor of Medicine; both of tf~e Albert Einstein College of Medicine in New York City. Eight distinct emotional stages have been observed in 148 cardiac surgery pa- tients in a nine-year. study. The anxieties and reactions of patients are shown for each of these stages. (20 minuteS). 0910506 INFLUENCE OF THE EMOTIONS ON THE OUT- COME OF CARDIAC SURGERY: PSYCHOLOGICAL CATEGORIES, with Dr. Kennedy and Dr. Bakst in a separate program from the one above. In this one they clasdify cardiac surgery patients into six groups with their distinguishing defense characteristics. Understanding these groupings during an interview with a patient can aid in predicting how the patient will be affected by surgery, whether he will accept surgery, survive it, and avail himself of the benefits of restored cardiac function. (24 misused. 0910507 INNOCENT HEART MURMURS IN CHILDREN, with Bernard L: Segal, M.D., Clinical Professor of Medicine, Hahnemann Medical College and Hos- pital, Philadelphia. Perhaps a third of all children have heart murmurs, but they are often inno- cent. Cardiologist Segal demonstrates an ex- amination to differentiate innocent from organic murmurs and uses audio recordings to point out the characteristics of several common murmurs. (13 minuteS) (In color) 0917624 INTERPRETING EKGs: A MOt~EL FOR NORMAI SEQUENCE OF ACTIVATION AND INTRA-VENTR1C- ULAR CONDUCtION DEFECTS, with Peter Block, M.D., Assistant in Medicine at Massachusetts General Hospital, and Instructor In Meditine at Harvard Medical School, Boston, Massachtisetts. Physicians in general 3ractice will be able to up- date their knowledge of reading EKGs ln this first of two telecasts on the subject. In this program, Dr. Block shows how references to normal heart function can be used to solve problems in diagnosing right anti left bundle-branch block. lit minuteul (in colon 0913209 12 PAGENO="0367" COMPETITIVE PROBLEMS IN TILE DRUG INDUSTRY 14273 INTERPRETING EKG5: CURRENT CONCEPTS OF HEART BLOCK, with Adolph M. Hutter, Jr., M.D., Instructor in Medicine, Harvard Medical School, Boston. Some heart block `patients are emergen- cies, some are not. Some should be treated, some should not. Dr. Hutter presents a schematic re view of heart block. . . and what to do - about it. (18 minutes) (in color) 0914917 INTERPRETING EKGs: INFARCT PATTERNS IN PRESENCE OF BUNDLE.BRANCH BLOCK, with Adolph Hutter, Jr., M.D., Associate Director of the Coronary Care Unit and Assistant in Med icine at Massachusetts General Hospital, and In structor n Medicine at Harvard Medical School. The elec rocardiographic diagnosis of myocardial infarctio is difficult with the presence of bundle branch block. Dr. Hutter will show the general physician how to recognize right and left bundle. branch block on EKGs and how to read myocar- dial infarctions in the presence of conduction defects. (18 minutes) (in color) 0913315 INTERPRETING EKGs: RECOGNITION AND TREATMENT OF SUPRAVENTRICULAR AR- RHYTHMIAS - ATRIAL FIBRILLATION, ATRIAL FLUTTER AND PAROXYSMAL ATRIAL TACHYCAR- DIA, with Adolph M. Hutter, Jr., M.D., Associate Director of the Coronary Care Unit and Assistant in Medicine at Massachusetts General Hospital and Assistant Professor of Medicine, Harvard Medical School, Boston. With the aid of dia- grams and sample EKG5, Dr. Hutter explains the mechanisms involved in supraventricular arrhyth- mias and the therapeutic maneuvers to coun teract them. Emphasis is given to differentiating the arrhythmias; to the use of' digitalis, its effects and signs of toxicity; and to the appro~ priate use of cardioversion. (18 minutes) (in color) 0916520 INTERPRETING EKGs: RECOGNITION AND TREATMENT OF SUPRA-VENTRICULAR AR- RHYTHMIAS-SINUS BRADYCARDIA AND SICK SINUS SYNDROME, with Peter Block, MD., As- sistant in Medicine at Massachusetts General Hospital, and Assistant Professor of Medicine, Harvard Medical School, Boston. Tgts for the differentiation and management of sinus brady. cardia, wandering atrial pacemaker, multifocal atrial tachycardia, and sick sinus syndrome (sinus bradycardia alternating with rapid tachyarrhyth- mias). (13 minutes) (in color) 0916722 Master Library services are made possible through the support by Roche Labora- tories of the production and regular distri- bution of all NCME telecasts. INTERPRETING EKGs: VENTRICULAR ARRYTH- MIAS, with Peter Block, M.D., Assistant in Medi~ cine, Massachusetts General Hospital, and instruc- tor in Medicine, Harvard Medical School, Boston. Ventricular premature beats (VPB) and their complications are now known to produce altera tions in hemodynamics - . cardiac deterid~ration - and even sudden death. Dr. Block graphical. ly demonstrates the differential diagnosis of VPBs, for the general physician. (20 minutes) (in color) 0914816 MANAGEMENT OF STROKE - PART I. Rudolph Kaelbling, M.D., Associate Professor o~ Psy. chiatry, Ohio State University College of Medi- cine, examines the common types of strolçe and their effects on consciousness, mental acuity, speech, and physical coordination~ as well as the impact of stroke on the patient's f~miIy. Rehabilitation is discussed also, and a speech therapist is shown working with patients. (14 minutes). 13ó5506 MANAGEMENT OF STROKE - PART II The physical rehabilitation of the stroke patie~it - including rehabilitative appliances, exercise, and physiotherapy - is discussed and demonstrated by Ernest W. Johnson, M.D., Chairman, Depart- ment of Physical Medicine, Ohio State University College of Medicine. (17 minutes). 1305607 MEDICAL ASPECTS OF CONSTANT CORONARY CARE UNITS IN A GENERAL HOSPITAt The problem of the rhythm death following myo cordial infarction has provided the stimulus for development of cardiac resuscitation and cardiac monitoring units. The required equipment and techniques are discussed and demonstrated by Richard Watts, M.D,, Head, Cardiovascular Sec- tion, Department of Medicine, Fairview Geperal Hospital, Cleveland, Ohio. (14 minutes). 1303923 MILD-TO-SEVERE HYPERTENSION: TIPS FOR TREATMENT, with George N. Aagaard, M.D., Pro- fessor of Medicine and Head of the Division of Clinical Pharmacology, University of Washington School of Medicine, Seattle. As part of the na- tional `Drug Spotlight Program", Dr. Aagaard pre- sents a simple approach to treating patients with hypertension. He outlines the basic ton- pharmacologic approach, the way in which to use oral diuretics, adrenergic inhibitors and smooth muscle dilators, and his method of handling refractory hypertension. (14 minutes) (in color) 13j7749 13 PAGENO="0368" 14274 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY THE NATIONAL HYPERTENSION TEST, with Har- riet P. Dustan, M.D., Vice-Chairman, Research Division The Cleveland Clinic; Edward D. Froh- lich, M.D., George Lynn Cross, Research Profes- sor and Director, Division of Hypertension, Uni- versity of Oklahoma Health Sciences Center, Oklahoma City; Curtis G. Hames, M.D., Chairman, Evans County Health Department, Claxton, Geor- gia; Morton H. Maxwell, M.D., Clinical Professor of Medicine, UCLA, and Director, Hypertension Division, Cedars-Sinai Medical Center, Los Ange- les; and Gerald E. Thomson, M.D., Professor of Medicine, Columbia University, and Director of Medicine, Harlem Hospital, New York City. How skilled are you in the diagnosis and treatment of various types of hypertension? How much do you know about the pathophysiology of this disease? Find out by taking this self-assessment test, produced in cooperation with the Americat Heart Association. The test considers hypertension as a hemodynamic abnormality and as a disease. Pan- elists present 8 patients with hypertension and ask questions to challenge your skills. You will learn the answer to each question and hear a discus- sion of the "right and wrong" alternatives of patient management during the test. To keep track of your score, an answer sheet is provided with the test. (65 minutes) (in color) 1422536 PAUL D. WHITE: CARDIOLOGY IN MY TIME No physician is better equipped to describe the development of cardiology as a specialty than one of its pioneers. The telecast is filled with anecdotes from Dr. White's many associations through his many years of medical practice. (Courtesy, Eli Lilly and Company) (28 minutes) (In color) 1608602 PEDIATRIC CARDIOLOGY - PART I - CATHE- TERIZATION IN INFANTS. Donald R. Sperling, M.D., Assistant Professor of Pediatrics, Califor- nia College of Medicine, University of California, explains the indications and technique for diag- nosing congenital heart disease by means of the cardiac catheter. (14 mInutes). 1605003 PEDIATRIC CARDIOLOGY - PART II - DIVI- SION OF PATENT DUCTUS ARTERIOSUS. Joseph J. Verska, M.D., Associate Clinical Professor of Surgery, University of California, the California College of Medicine, and Director of Cardiac Surgery, White Memorial Medical Center, Los Angeles, operates to correct this congenital cardiac defect. The patent ductus in this infant patient was diagnosed (in PART I) by Donald R. Sperling, M.D., also of the California College of Medicine, using cardiac catheterization. (19 minutes). 1605104 PRE-HOSPITAL CORONARY CARE - A MODEL FOR YOUR COMMUNITY, with Eugene Nagel, M.D., Associate Professor, Department of Anes- thesiology, University of Miami School of Medi- cine, and Clinical Director, Department of Anes- thesiology, Jackson Memorial Hospital, Miami, Florida. How quickly can your community get optimum coronary care facilities to a patient in cardiac arrest or ventricular fibrillation? Dr. Nagel shows how the Miami Emergency Rescue Service is set up, demonstrates how quickly it works in a simulated rescue, and shows what is needed to implement a complete mobile emer- gency health care system. (21 minutes) (in color) 1615438 PHYSICAL MEASURES FOR ARTHRITIS, STROKE AND CARDIOVASCULAR REHABILITATION, with John A. Faulkner, Ph.D., Department of Physi- ology and Robert L. Joynt, M.D., George H. Koepke, M.D., Barry Miller, M.D., and Edwin M. Smith, M.D., all of the Department of Physical Medicine and Rehabilitation, University of Michi- gan Medical School, Ann Arbor, Mich. The panel discusses and demonstrates physical measures for treating arthritis, techniques to prevent con- tractures following stroke and methods to use In preserving maximal function of unaffected ex- tremities, and also presents the basics for pre- scribing exertise for the patient with coronary heart disease. A Television Clinic of the Ameri- can College of Physicians, 1973. Please inquire for special rental information. (60 minutes) (in color) ACP 2867370 PRINCIPLES OF CORONARY CARE. Early surveil- lance and continuous monitoring of patients with acute myocardial infarction greatly enhance re- suscitation probability in the event of arrhythmia or fibrillation. Stephen Wittenberg, M.D., In- structor in Medicine, and Roger Hand, M.D., Chief Medical Resident, New York University Medical Center, demonstrate monitoring and resuscitation procedures in the Intensive Care Unit of University Hospital. (11 minutes). 1605920 PROBLEMS AND PITFALLS IN PSYCHOSOMATIC MEDICINE: HYPERTENSION, with Roy R. Grinker, M.D., Associate Professor of Psychiatry and Neu- rology, and F. Theodore Reid, M.D., Associate Professor of Psychiatry and Neurology, both from the Michael Reese Hospital in Chicago, Illinois. Doctors Grinker and Reid take up the problem of a young woman suffering from hypertension. Dr. Grinker analyzes the cause of the hyperten- sion in interviews with the woman. (15 mInutes) (in color) 1612621 14 PAGENO="0369" COMPETITIVE PROBLEMS IN PflE t)~RUG INI)TIS~RY 14275 PULMONARY EMBOLISM: A RATIONAL AP- PROACH TO MANAGEMENT, with William Hall, M.D., Director of the Pulmonary Function Unit at Strong Memorial Hospital, and Assistant Pro- fessor of Medicine, University of Rochester School of Medicine, Rochester, New York. The mortality rate for untreated pulmonary embolism patients is between 25 and 50 percent. Doctor Hall demonstrates that such gloomy results can be avoided through prompt and effective management, which includes anticoagulant ther- apy and the treatment of hyŘoxia. (This pEo~ram is part of the Drug Spotlight Program of the American Society for Clinical Pharmacology and Therapeutics.) (17 minutes) (in color) 1619744 RADIOISOTOPE ARTERIOGRAPHY Richard Janeway, M.D., and C. Douglas Maynard, M.D., of the Departments of Neurology and Radi- ology at the Bowman Gray School of Medicine present a new aid to ce~ebrovascular disease. (20 minutes). 1809503 REPAIR OF A RUPTURED VENTRICULAR SEPTUM A rupture of the ventricular septum is a com- paratively uncommon phenomenon, most often occurring in patients who have suffered an oc- clusion, particularly of the left coronary artery involving the septal branch. The technique for repairing the rupture is demonstrated by Adrian Kantrowitz, M.D., Director of Surgery, Maimo- nides Medical Center, Brooklyn, and Professor of Surgery, State University of New York, Col lege of Medicine, ~ie minStes), 1803810 RESECTING AN ANEURYSM OF THE ASCEND- ING AORTA The demonstration illustrates the standard tech- niques for resection of an ascending aorta using pump oxygenator by-pass, continuous coronary perfusion, and replacement with dacron pros. thesiS - with Adrian Kantrowitz, M.D., Director of Surgery, M2imonides Medical Center and Pro- fessor of Surgery, State University of New York, College of Medicine. (15 minutes). 1803313 SELECTION OF PATIENTS AND DRUGS FOR TREATMENT OF HYPERTENSION, with Albert N. Brest, M.D., Associate Professor of Medicine and Head, Section of Vascular Disease and Re- nology, Hahnemann Medical College and Hos- pital. (17 minutes). 1902801 STASIS ULCERS OF THE ANKLE, with Robert A. Nabatoff, M.D., Chief, Vascular Surgery, Depart- ment of Obstetrics and Gynecology, at Mount Sinai Medical Center, New York City. How to treat these common, yet often puzzling, symp- toms before surgery for the underlying vascular insufficiency. (14 minutes) (in color) 1918430 SURGICAL TREATMENT OF HEART BLOCK Robert Schrarne), M.D., Associate Professor of Surgery, Tulane University School of Medicine, discusses and demonstrates surgical use of electronic pacemakers. (15 minut5s). 1902823 THE EXERCISE PRESCRIPTION, with Nanette K. Wenger, M.D., Professor of Medicine, Division of Cardiology, Emory University Sthool of Medicine, Atlanta; and William L. Haskell, Ph.D., Co. Director of the Stanford University Cardiac Re- habilitation Program, Palo Alto, Calif. You can prescribe exercise as precisely as you do drugs. Here's how the results of an exercise stress test can guide you. (22 minutes) (in color) 0519324 THE HEART. One in a series of Anatomical Re- lationships from Duke University Medical Center. The surface anatomy of the heart, presented by John L. Dobson, M.D., Department Of Anatomy. (19 minutes). 0800401 THE MASTER TWO-STEP TEST * PART I. Arthur M. Master, M.D., Consulting Qardiologist, Mount Sinai Hospital, demonstrates the ultilization of the two-step test. (12 minutes). 1302312 THE MASTER TWO-STEP TEST - PART II. Arthur M. Master, M.D., Consulting Cardiologist, Mount Sinai Hospital, presents patient data on nega- tive and positive two-step tests. (23 minutes). 1302413 THE MASTER TWO-STEP: A REAPPRAISAL Arthur M. Master, M.D., cardiologist and Erneri- tus Professor of Medicine at Mt. Sinai HoSpital and Medical Center in New York, discUsses the three major uses of the streSs imposed by the doUble two-step test in conjunction with EDO tracings. US minsteu). 1~08914 THE PRESENT STATUS OF CORONARY ARTERY BYPASS SURGERY, with RoIf M. Gunnar, M.D., Department of Medicine, Loyola University of Chicago, Stritch School of Medicine, Maywctod, Ill. a~d Veterans Administration Hospital, Hines, Ill.; John M. Moran, M.D., Department of Sur- gery, I~limgaudas Nemickas, M.D., Deparment of Medicine, Roque Pifarré, M.D., Department of Surgery, and Patrick Scanlon, M.D., Department of Medicine, all of Loyola University of Chicago, Stritch School of Medicine, Maywood, I~l. The indications, contraindications, and ways to assess the prognosis of coronary artery surgery, including vein grafts, endarterectomy, and In- ternal mammary artery grafts, are illustrated and discussed, In addition, postoperative com- plications are put in perspective and weys to evaluation postoperative resultS are discussed. A Television Clinic of the American College of Physicians, 1973. Please inquire for special rental information. (50 minutes) (in color) ACP 28~37367 15 73-617 0 - 76 - 24 PAGENO="0370" 14276 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY TIME BORROWERS IN SHOCK, with Leon I. Gold- berg, Ph.D., M.D., Professor of Medicine and Pharmacology, and Director of Clinical Pharma- cology, Emory University School. of Medicine in Atlanta Georgia. When the physician needs to `borrow time" while treating the underlying causes of shock, a cautious use of sympathomi- metic amines is often a worthwhile temporary solution. (14 minutes) (in color) 2020737 TRANSIENT ISCHEMIC ATTACK: PART I - THE HISTORY (13 minutes) (in color) 2018829 TRANSIENT ISCHEMIC ATTACK: PART II - THE PHYSICAL, with Clark H. Millikan, M.D., Senior Consultant and Professor of Neurology, The Mayo Clinic, Rochester, Minn. During this two-part program, you'll take a close look at how to make a diagnosis of TIA - - - an important challenge, as three of five major strokes may be preventable through proper diagnosis of TIA's and their subsequent treatment. (21 minutes) (in color) 2018830 TREATMENT OF CORONARY HEART DISEASE- ISCHEMIC HEART DISEASE. How can the phy- sician in general practice determine if medical management of ischemic heart disease is no longer necessary and surgery is indicated? This program on coronary insufficiency is concerned with differential diagnosis of the patient afflicted for the first time with coronary heart disease. Surgical procedures for chronic occlusive disease are shown by Denton A. Cooley, M.D., Professor of Surgery; Grady L Hallman, M.D., Associate Professor of Surgery; Robert D. Bloodwell, M.D., Assistant Professor of Surgery; and Robert D. Leachman, M.D., Professor of Cardiology, Baylor University College of Medicine, Houston, Texas. (19 minutes) (In color) 2007215 TREATMENT OF CORONARY HEART DISEASE - POSTINFARCTION COMPLICATIONS. Aortic aneurysm, ventricular septal defect, heart block - . - these complications to recovery of coronary patients are treatable, but require prompt evalu- ation and advanced surgical techniques. Denton A. Cooley, M.D., Professor of Surgery; Grady L. Hallman, M.D., Associate Professor of Surgery; Robert D. Bloodwell, M.D., Assistant Professor of Surgery; and Robert D. Leachman, M.D., Pro- fessor of Cardiology, Baylor University College of Medicine, delineate the management of these conditions. (21 mInutes) (In color) 2007116 TREATMENT OF SEVERE CORONARY ARTERY DISEASE: A TOTAL SURGICAL APPROACH W. Dudley Johnson, M.D., Department of Cardio- vascular and Thoracic Surgery and the Division of Surgery, Marquette School of Medicine, Mil- waukee, Wisconsin, discusses and vividly de- scribes the pedicle system of indirect revascular- ization, the vein by.pass technique in direct coronary surgery, and resection of aneurism9. (19 minutes) (In color) 2009318 U. C. GRAND ROUNDS: THE HAND AND THE HEART Mark E. Silverman, M.D., with the David Grant Hospital-Travis Air Force Base, California, pre. cents visual evidence of the hand as a source of diagnosing cardiovascular disorders. (20 minutes). 2108901 UNCOVERING WHAT'S RIGHT WITH THE STROKE PATIENT, with Paul J. Corcoran, M.D., Associate Professor of Rehabilitation Medicine, Boston University Medical Center, Boston. Dr. Corcoran shows the non-rehabilitation special- ist how to examine and evaluate the stroke patient during his first post-CVA days. Unlike most exams, attention is given to ability rather than disability. (22 mInutes) (in color) 2117007 VENOUS THROMBOSIS AND PULMONARY EM- BOLISM PREVENTION, RECOGNITION, AND TREATMENT, with Harold A. Baltaxe, M.D., De- partment of Radiology; William Gay, MD., De- partment of Surgery; James W. Hurley, M.D., andSusan A. Kline, M.D., Department of Medi- cine; all of Cornell University Medical College, New York City. Among topics considered: key signs and symptoms of venous thtombosis; pre- ventive measures, including mini-heparinlzation; screening tests for the presence of emboli; and therapy, both surgical and medical, with special attention given to fibrinolytic agents. (60 minutes) (in color) ACP 2857481 WHAT CAROTID ARTERIOGRAPHY CAN TELL YOU, with Michael D. F. Deck, M.D., Associate Attending Radiologist, Memorial Sloan-Kettering Cancer Center, and Associate Professor of Radi- ology, Cornell University Medical Center, New York City. Skull films and brain scans show bone metastases in a patient with inoperable lung cancer. Following Irradiation, she has progres- sively severe headaches and slight dementia. Does she have additional metastases in the brain? Should she have more irradiation? With this patient, Dr, Deck demonstrates carotid ar- teriography and the value of the procedure. (17 mInutes) (In color) 2318909 16 PAGENO="0371" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14277 WHAT YOU AND YOUR PATIENT SHOULD KNOW ABOUT CORONARY ARIERIOGRAPHY, with F. Mason Sones, Jr., Director of the Department of Cardiovascular Disease and Cardiac Laboratory; and Donald B. Effler, M.D., Director of the De- partment of Cardiovascular and Thoracic Sur- gery, The Cleveland Clinic. What is coronary ar- teriography? Which patients are candidates? Which patients are not? What information does the consultant need? What happens during the procedure? These questions are answered during this program which includes a demonstration of coronary arteriography. (24 minutes) (In color) 2318708 WHEN SHOULD HYPERTENSION BE TREATED? with Edward Fries, M.D., Senior Medical Investi- gator, VA Hospital, Washington, D.C.; and Ray W, Gifford, Jr., M.D., Department of Nephrology, Cleveland Clinic. Or, Fries, winner of the Lasker Award, and Dr. Gifford review, through patient interviews, the recent changes in criteria for intervention In hypertension. (19 minutes) (In color) 2316203 DERMATOLOGY A CURRENT APPROACH TO POISON OAK! POISON IVY DERMATITIS, with William L. Ep- stein, M.D., Professor and Chairman, Depart- ment of Dermatology, University of California, San Francisco. Dr. Epstein will demonstrate various treatments for severe and mild cases of poison oak and poison ivy dermatitis, along with the problems of re-exposure, cross-sensitiv- ity with other substances and other dermatologi- cal complications. He will also describe various desensitizing and hypo~sensitizing agents. This program will benefit the non-dermatologist. (15 minutes) (In color) 0313364 A PRACTICAL APPROACH TO ALLERGIC DERMA. TOSES IN CHILDREN, with Vincent J. Fontana, M.D., Professor of Clinical Pediatrics, New York University College of Medicine, New York City. Dr, Fontana demonstrates ways in which the general physician can arrive at positive diagnoses of both common and less-frequently encountered allergic dermatoses in children, He follows each diagnosis with its recommended treatment, (18 minutes) (In color) 1614937 ALL ABOUT WARTS, With Silas E. O'Qulnn, M.D., Dermatologist and Dean of Medicine, Louisiana State University School of Medicine, New Orleans. Identification and three quick office techniques for removing these benign but unsightly growths are demonstrated, (13 minutes) (in color) 0120539 ALOPECIA IN DIAGNOSIS, with Norman Oren- treich, M.D., Professor of Dermatology and Syphilology, New York University Sčhool of Medicine, New York City. Hair loss: an insult to vanity or a sign of systemic disease? this pro- gram shows how to recognize those cases that are more than just a cosmetic embarrassment. (18 minutes) (in color) 0119938 AN EFFECTIVE WAY TO CONTROL PSORIASIS, with Paul Lazar, M.D., Associate ProfCssor of Dermatology, Northwestern University School of Medicine, Chicago. The treatment most likely to control psoriasis with emphasis on variations to suit patient age, motivation, occupation, and body area involvement. (18 minutes) (in color) 0519825 BURN: TREATMENT - PART I The course of treatment of the burn patient is demonstrated by Charles L Fox, Jr., M~D., Pro- fessor of Microbiology, Columbia Univerelty Col- lege of Physicians and Surgeons. (15 mInutes) (in color) 0207312 COMMON SKIN DISORDERS IN THE FIR~T YEAR OF LIFE, with David L. Cram, M.D., Chief of the Dermatology Clinic, University of Calift~rnia at San Francisco. How to distinguish amdng the variety of skin eruptions you may see in infants. (15 mInutes) (in color) 0322383 CUTANEOUS SIGNS OF INTERNAL MALIGk'IANCY, with Irwin M. Braverman, M.D., Profe~sor of Dermatology, Yale University School of Medicine, New Haven, Connecticut. The signs can help-/f you can read them. A dermatologist demonstrates the workup for a patient with a suspected underlying maIi~nancy. (16 minutes) (in color) 0323586 DIAGNOSING COMMON SMALL SKIN LESIONS, with Robert Auerbach, M.D., Assistant Clinical Professor of Dermatology, New York University School of Medicine, New York City. Bef9re the biopsy Dr. Auerbach shows you the subtle clinical differences between nevi and melanomas, and helps you sort out benign seborrheic keratoses premaligriant keratoses, and carcinoma. (16 mlnuteo) (in color~ 0418345 THE DIAGNOSIS OF SYSTEMIC LUPUS ERYTHE- MATOSUS, with Naomi Rothfield, M.D., Profes- sor of Medicine, and Chief, Arthritis Section. University of Connecticut School of Medicine, Farrnington, Connecticut. Demonstrating the early detection of S.L.E. through clinical and lab- oratory findings. (19 minutes) (in color) 0419951 17 PAGENO="0372" 14278 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY DIAGNOSTIC CUTANEOUS SIGNS OF SYSTEMIC DISEASE, with Denny L Tuffanelli, M.D., Assist- ant Clinical Professor of Dermatology, University of California at San Francisco. A noted derma- tologist uses 13 examples to show how observa- tion of the skin can lead to diagnosis of severe systemic disease. (19 minutes) (in color) 0413926 DIAGNOSTIC DIFFICULTIES ON BLACK SKIN, with Betty Fischmann, MB., B.S., M.R.C.P.Ed., Chief of Dermatology, Medical Service, Veterans Administration Hospital and Dermatologist at Howard University and Georgetown University, Skin signs, particularly erythema, are hard to see on black patients. Further, black patients experience disorders of pigmentation, keloid formation and problems of hair growth more often than whites do. Using two patients and a number of slides, Dr. Fischmann shows the viewer how to reach a diagnosis based on skin signs in the black patient. (19 minutes) (in color) 0417338 THE HAND AS AN INDICATOR OF SYSTEMIC DISEASE, with Marguerite Lerner, M.D., Clinical Professor of Dermatology, Yale University School of Medicine, New Haven, Conhecticut. Doctor Lerner investigates the cause of several hand complaints, incl~iding Raynaud's phenomenon, xanthomas, and telangiectasia. (19 minutes) (In color) 0821337 HERPES SIMPLEX: VIRAL DILEMMA, with Richard C. Gibbs, M.D., Associate Professor of Clinical Dermatology, New York University Medical Cen- ter, New York City. A clinical presentation, stressing some precautions in the differential diagnosis and treatment of the herpes simplex virus, Types I and II. 113 minutes) (in color) 0820135 HEXACHLOROPHENE: OPEN TO DEBATE, with Harold C. Neu, M.D., Associate Professor of Medicine and Chief, Division of Infectious Dis. eases; Stanley James, M.D., Professor of Pedi- atrics and Chairman of the American Academy of Pediatrics Committee on the Fetus and New- born); Carl Nelson, M.D., Professor of Derma- tology and President of the American Derrna- tological Association. All of the participants are on the faculty of the Columbia University Col- lege of Physicians and Surgeons, New York City. Since December 15, 1971, bathing newborns with hexachlorophene, routine in most nur- series, has been banned by the F.D.A. and the American Academy of Pediatrics-or has it? Our panel looks at this problem from several angles and comes up with some interesting conclusions. (16 minuteo) (in color) 0815520 HOW I APPROACH ATOPIC DERMATITIS, with Marion B. Sulzberg~r, M.D., Professor Emeritus, New York University School of Medicine, and Clinical Professor of Dermatology, University of California in San Francisco. Atopic eczema is a perplexing problem for the dermatologist and the general practitioner. Dr. Sulzberger describes the `chain multiple factor" approach to the disease in terms of occurrence and treatment. (15 minutes) (in color) 0813419 LONG-TERM MANAGEMENT OF S.L.E., with Naomi F. Rothfield, M.D., Professor of Medicine and Chief, Arthritis Division, University of Con. necticut School of Medicine, Farmington, Conn. Specific drugs and general life adjustments are important to the treatment course of systemic lupus erythematosus. However, the key to manS aging S.L.E., demonstrated here, is to identify symptoms and signs of impending flare-ups. (17 minutes) (in color) 1220019 OFFICE TREATMENT OF SKIN CANCER, with Rex A. Amonette, M.D., Chemosurgeon, DepartS mont of Dermatology, University of Tennessee College of Medicine, Memphis. Diagnosis and treatment of potential malignancy and skin can- cer are demonstrated. Includes the use of fluoro~ uracil, biopsy, curettage and electrodesiccation, total excision, cryosurgery, irradiation, and chemosurgery. (19 minutes) (in color) 1521010 PARASITIC INFESTATION: LOOK FOR LICE, with Silas E. O'Quinn, MD,, Professor of Dermatology and Dean of Medicine; and Harold Trapido, Ph.D., Professor of Tropical Medicine and Medical Parasitology, both at Louisiana State University School of Medicine in New Orleans. A compre- hensive look at what may be causing that tern ble itch. Knowledge of your patients' hygiene does not rule out lice. (11 minutes) (in color) 1620645 PARASITIC INFESTATION: SCABIES, with Silas E. O'Quinn, M.D., Professof of Dermatology and Dean of Medicine; and Harold Trapido, Ph.D., Professor of Tropical Medicine and Medical Parasitology, both at Louisiana State University School of Medicine in New Orleans. Everything you always wanted to know about mites but (were too busy) (forgot) to ask. (14 minutes) (in colon 1621348 SKIN ERUPTIONS: DUE TO DRUGS?, with David L. Cram, M.D., Chief of the Dermatology Clinic, Uni~ versity of California at San Francisco. Is your pa- tient's skin reaction due to drugs? Is it dangerous enough to warrant removing a necessary medica- tion? Which of several drugs is the culprit? (16 minutes) (in color) 192~Z40 18 PAGENO="0373" COMPETITtVE PROBLEMS IN THE DRUG INDUSTRY 14279 STASIS ULCERS OF THE ANKLE, with Robert A. Nabatoff, M.D., Chief, Vascular Surgery, Depart- ment of Obstetrics and Gynecology, at Mount Sinai Medical Center, New York City. How to treat these common, yet often puzzling, symp- tows before surgery for the underlying vascular Insufficiency. (14 minutes) (in colur) 1918430 SYSTEMIC LUPUS ERYTHEMATOSUS, with Wer- ner F. Barth, M.D., Department of Medicine; and Harry M. Robinson, M.D., Department of Derma- tology; both of University of Maryland School of Medicine; and Donald T. Lewers, M.D., Divi- sion of Nephrology, Maryland General Hospital. Three patients illustrate the clinical variability of systemic lupus erythematosus, as well as differences in therapy. The immunopathology is discussed, with particular attention to recent concepts of pathogenesis. Factors adversely affecting prognosis and those warranting more aggressive therapy are underscored. Also dis- cussed are recent developments using immuno- fluorescent examination of skin biopsy to dis- tinguish systemic lupus erythematosus from discoid lupus and other connective tissue dis- eases. A Television Hospital Clinic of the Ameri- can College of Physicians, 1972. Please inquire for special rental information. (50 minutes) (in color) ACP 2837247 THE TREATMENT OF ACNE, with Paul Lazar, M. D., Associate Professor of Dermatology, North- western University Medical School, Chicago. When an adolescent with acne doesn't respond to topical therapy and a year of tetracycline treatment do you consider steroid therapy, topical or systemic, or acne surgery? Dr. Lazar recommends the progression to follow in treating acne. (19 minutes) (in color) 2020133 WHAT'S CAUSING THE INCREASED INCIDENCE OF PHOTOSENSITIVE REACTIONS?, with John H. Epstein, M.D., Associate Clinical Professor of Dermatology, University of California at San Francisco, and Chief of Dermatology at Mount Zion Hospital and Medical Center in San Fran- cisco. Increased public obsession with sunbath- ing and an ever increasing number of photo- sensitizers in our environment are reaching the stage where almost every physician can expect to see patients exhibiting phototoxic or photo- allergic reactions. Diagnosis and treatment of the following are explored in this telecast: phototoxicity, photoallergy, exogenous photo- sensitizers, therapeutic and antibacterial agent reactions and plant-induced photosensitivity, (15 minutes) un color) 2313502 ZOSTER: ITS COURSE AND TREATMENT, with Richard C. Gibbs, M.D., Associate Professor of Clinical Dermatology, and Philip A. Brunell, M.D., Director, Laboratory of Infectious Disease, Pedi- atrics Department; both of New York University Medical Center in New York City. Recommends treatment for the severe pain of this generally one-time, but unforgettable, illness. (9 minutes) (in color) 2620201 DRUG ABUSE DOWN AND OUT IN THE ER. Barbiturate over- dose, accidental or intentional, is the number one drug abuse problem presenting in Emer- gency Rooms. Dr. George Gay of the Haight- Ashbury Free Medical Clinic in San Francisco and Dr. Eric Comstock, director of the Institute of Toxicology at Baylor University, join medical student John Rose of Baylor to demonstrate recommended procedures for the diagnosis and treatment of a barbiturate overdose crisis. (26 minutes) (in color) SAMA ~810859 DRUG ABUSE: RECOGNIZING AND TREATING ACUTE REACTION TO AMPHETAMINES AND SEDATIVE HYPNOTICS, with David E. Smith, M.D., Instructor, Department of Pharmacology, University of California School of Medicite, San Francisco; and Medical Director, Haight-~\shbury Medical Clinic. Why do most young drug users avoid family physicians when their drug experiences get them in trouble? Dr. Smith discusses this problem with several drug users. He also gleans detailed descriptions from the young users of drug trips" and "bad trips." Finally, Dr. Smith- de- scribes the kinds of adverse reactions to am phetamines and sedative hypnotics, and out- lines suggested therapy. 119 munuteol. 0411822 DRUG ABUSE: RECOGNIZING AND TREATING ACUTE REACTIONS TO HALLUC1NOGEN$. with David E. Smith, M.D., Instructor, Department of Pharmacology, University of California School of Medicine, San Francisco; Medical Director, Haight-Ashbury Medical Clinic. In this telecast, experienced young people can- didly discuss "bad trips" and other adverse symptoms connected with drug abuse. The pro- gram concludes with a concise rundown of rec- ommended therapy. (19 minutesl. 0411923 19 PAGENO="0374" 14280 cOi~nwrITIvE PROBLEMS IN THE DRUG INDUSTRY EARLY DIAGNOSIS OF ALCOHOLISM, with Mar- vin A. Block, M.D., Vice President of the AMA Society on Alcoholism, and Associate Professor, State University of New York at Buffalo. `There are all kinds of alcoholisms and all kinds of alcoholics." Dr. Block provides specific criteria by which you may judge the kind of alcoholism and the stage of the disease. 124 mInutes) (In coior( 0516820 GETTING A FIX ON HROIN. Treatment of heroin-addicted patients is clouded by popular misconceptions and mythologies about heroin use and treatment. SAMA cameras take you to drug abuse treatment facilities in New York and San Francisco to explore the problems of the drug addict and the problems of treating him. Speaking for SAMA is Dahlia Kirkpatrick, a third- year student at Yale who discusses the issues with Dr. Herbert Kieber, Director of the Drug Abuse Unit of the Connecticut Mental Health Center. (34 mInutes) (in color) SAMA 2810453 IF THE DOCTOR'S INTO DRUGS . . . Studies show the incidence of drug abuse and alcohol- ism to be much higher among physicians than among th.e general population. Should this prob- lem be chalked off as an occupational hazard? Or can it be controlled? What might one do for a colleague developing dependence on drugs or alcohol? How does one avoid such dependence himself? Three psy- chiatrists who have studied and treated drug dependent and alcoholic physicians discuss these issues. (17 minutes) (in color) SAMA 2810555 MANAGEMENT OF ADOLESCENT SYMPTOMS. Methods of dealing with the problems of ado' l~scents - particularly experimentation with sex and drugs - are demonstrated with groups of teenagers, by Steven R. Homel, M.D., Depart- ment of Pediatrics, Jefferson Medical College and Hospital of Philadelphia, Pa. 118 minutes). 1308004 MEDICAL PROBLEMS OF ADOLESCENT HEROIN ABUSE, with Michael I. Cohen, M.D., Director of the Division of Adolescent Medicine; and Iris Litt, M.D., Assistant Director. The Division is part of the Department of Pediatrics, Montefiore Hospital in New York City. An in-depth interview is conducted with a 14' year-old heroin addict under treatment. The youth describes his life with drugs followed by comments on the interview by the physicians. 114 mInutes) fn colon 1311025 METHADONE MAINTENANCE FOR THE HARD CORE HEROIN ADDICT, with Ray E. Trussell, M.D., Director of Beth Israel Medical Center in New York City; Harvey Gollance, M.D., Associate Director; and Harold L. Trigg, M.D., Unit Director, Methadone Maintenance Treatment Program at the Morris J. Bernstein Institute of Beth Israel. For the acute heroin addict, Methadone may be the only answer to a normal existence. Physi- cians at the Beth Israel clinic describe their Methadone therapeutic program. The effective- ness of their program is dramatized by an inter- view with an addict in the program. The information in this telecast will interest general physicians and specialists. (21 minutes). 1311231 NAME YOUR POISON: ALCOHOL. Many physI- cians and medical students still treat alcoholics as second-class patients, Because of ingrown cultural attitudes, early alcoholism often goes undetected and untreated. Med students meet with a recovered alcoholic, with Dr. Marvin Block of the State University of New York at Buffalo, and Dr, Frank Seixas, Medical Director of the National Council on Alcoholism, to discuss ways to detect and help incipient alcoholics using science to replace serendipity. (37 minutes) (in color) SAMA 2810251 THE MULTIPHASIC TREATMENT OF ALCOHOL- ISM, with Albert N. Brown-Mayers, M.D., Director of the Alcoholic Service; Edward E. Seelye, M.D., Unit Administrator of the Alcoholic Service; and Leonard R. Sillman, M.D., Attending Psychiatrist, all of the Westchester Division of the New York Hospital-Cornell Medical Center, White Plains, NY. A new, formalized approach to the treat- ment of alcohOlism Is suggested. Presenters show how residential alcoholic treatment works and outline a complete program, many elements of which you'll find practical and effective in your own practice. (29 minutes) (In color) 1316946 THE NEW HEROIN SCENE: A PERSPECTIVE FOR PHYSICIANS, with George R. Gay, M.D. Chief of the Medical Section and Director of the Heroin Clinic of the Haight-Ashbury Clinic, and Instructor in Toxicology at the University of California at San Francisco. A new group of drug abusers appears to be growing in numbers across the country - the "middle-class jun- kies" who are "dropping out" of society on heroin. The dimensions of the problem are ex- plored by an authority on drug abuse. Dr. Gay also outlines treatment for the young abusers who are consumed by the chemical aspects of life rather than the human aspects. 122 mlnuteu(. 1413530 20 PAGENO="0375" COMPETITtVE PROBLEMS IN THE DRUG INDUSTRY 14281 THRESHOLD TO ADDICTION, with Steven R. Homel, M.D., Department of Pediatrics. Jefferson Medical College and Hospital of Philadelphia. Dr. Homel discusses the reasons for drug addic- tion with two teen.agers and a young medical student. Their answers are candid, and offer in~ sight into the attitudes of young people today. (23 minutes) (in color) 2010206 TREATMENT OF ACUTE HEROIN TOXICITY, with David E. Smith, M.D., Director and Founder of the Haight-Ashbury Free Medical Clinic and Assistant Clinical Professor of Toxicology at the University of California in San Francisco; and George R. Gay, M.D., Chief of the Medical Sec. tion and Director of the Heroin Clinic with the Haight~Ashbury Clinic and Instructor in Toxi- cology at the University of California, San Fran. cisco. With growing numbers of heroin abusers in middle-class America, physicians increasingly are going to face the problem of acute heroin overdose - a medical emergency. Two physi- cian-experts put this problem into perspective through patient interviews, describe the street" treatments that are in use - adding to risk of the complications - and finally present the treatment procedure they employ. (20 mInutes). 2013422 EMBRYOLOGY EGG TRANSPORT IN MAMMALS, with Richard J. Blandau, M.D., Professor of Biological Struc. tures, University of Washington School of Medi- cine. Discussion and cinemicrographic visuali~ zation of egg transport in rabbits, rats, and humans. (15 minutes). 0501404 CLINICAL MANAGEMENT OF HUMAN REPRO. DUCTIVE PROBLEMS: PART I. Alvin F. Goldfarb, M.D., Assistant Professor of Obstetrics and Gynecology, Jefferson Medical College and Hos- pital, presents `Evaluating the Infertile Couple." (19 mInutes). 0303118 CLINICAL MANAGEMENT OF HUMAN REPRODUCTIVE PROBLEMS: PART II `The Physio-Anatomic Basis of Fallopian Tube Function." The second program in this continu- ing series - with Luigi Mastroianni, Jr., M.D., Professor of Obstetrics and Gynecology, Univer- sity of Pennsylvania School of Medicine. (17 minutes). 0303319 CLINICAL MANAGEMENT OF HUMAN REPRODUCTIVE PROBLEMS: PART Ill "Tubal Factor Treatment." Correcting distortion of the tubal ovarian relationships. With Celso- Ramon Garcia, M.D., Associate Professor of Ob- stetrics and Gynecology, University of Pennsyl- vania School of Medicine. (16 minutes). 0303620 CLINICAL MANAGEMENT OF HUMAN REPRODUCTIVE PROBLEMS; PART IV "The Cervix in Infertility." Evaluation of the cervical factor in cases of female infertility - with Kamran S. Moghissi, M.D., Associate Profes- sor of Obstetrics and Gynecology, Wayne State University School of Medicine. (17 minutes). 0304421 THE CLINICAL MANAGEMENT OF HUMAN REPRODUCTIVE PROBLEMS: PART V "New R6search," a discussion and derrionstra- tion of the use of frozen sperm for artificial in- semination; irfimuriologic aspects of infertility; and new laparoscopic techniques. (18 minutes), 0304622 CLINICAL MANAGEMENT OF HUMAN REPROdUCTIVE PROBLEMS: PART VI - INDICES OF OVULATION The tests which are available to determine the absence or occurrence of ovulation are described by Howard Balm, M.D., Chief, Gynecic Research Unit, Pennsylvania Hospital, Philadelphia. (26 minutes). 0~04923 CLINICAL MANAGEMENT OF HUMAN REPRO- DUCTIVE PROBLEMS * PART VII - NOUC- TION OF OVULATION. The several n~ethods available for treating the anovulatory, infertile female are evaluated by Alvin F. Goldfarb, M.D., Assistant Professor of Obstetrics and G~~necol- ogy, and Abraham E. Rakoff, M.D., Professor of Obstetrics and Gynecology, Jefferson Medical College and Hospital, and Howard Balm1 M.D., Chief, Gynecic Research Unit, Pennsylvania Hospital. (15 minutes). 0305024 CLINICAL MANAGEMENT OF HUMAN REPRO- DUCTIVE PROBLEMS - FINAL PROGRAM -- THE SUMMATION. Alvin F. Goldfarb, M.D., As- sistant Professor of Obstetrics and Gynecology, Jefferson Medical College and Hospital, pre- sents a review and a summation of the seven programs in the series on human reproductive problems. (20 mInutes). 0~05325 21 PAGENO="0376" 14282 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY EMERGENCY MEDICINE AND TRAUMA ACID-BASE IMBALANCE: THREE PROGRAMS. "For decades, acid-base metabolism with its cabalistic terminology has intrigued and, inci- dentally, terrorized many clinicians. Actually, the whole subject of acid-base metabolism and its clinical application is just another facet of medi- cal science that, once understood, presents itself in a straightforward, logical manner . . ." Hugh J. Carroll, M.D. The following three programs were produced In cooperation with the Office of Continuing Educa- tion of the State University of New York, Down- state Medical Center, Brooklyn, New York. ACID-BASE IMBALANCE: PATHOGENESIS, with Hugh J. Carroll, M.D., Associate Professor of Medicine, Director of the Electrolyte and Hy- pertension Section, Department of Medicine, Downstate Medical Center. A presentation of the primary disturbances in metabolic and respiratory acid-base Imbalances, their mech- anisms of compensation, and the clinical situ- ations in which they may occur. (22 minutes) (in color( 0122444 ACID-BASE IMBAFANCE: RECOGNITION AND MANAGEMENT, with Hugh J. Carroll, M.D., As- sociate Professor of Medicine, Director of the Electrolyte and Hypertension Section, Depart- ment of Medicine, Downstate Medical Center. When blood gases and other clinical studies confirm the presence of an acid-base disturb- ance, it is the physician's part to reverse the imbalance directly or to treat the underlying disease so that the patient's own corrective mechanisms can restore the normal state. (15 minutes) (in color) 0122445 KETOTIC AND NONKETOTIC COMA: MECH- ANISMS AND TREATMENT, with Hugh J. Car- roll, M.D., Associate Professor of Medicine, Director of the Electrolyte and Hypertension Section, Department of Medicine, Downstate Medical Center. Pathophysiology, diagnosis, and management in diabetic ketoacidosis and hyperosmolar, hyperglycemic, nonketotic coma. (18 minutes) (in color) 1122406 APPROACH TO GASTROINTESTINAL PAIN, with Howard M. Spiro, M.D., Chief of Gastroenterology, Yale-New Haven Hospital, and Professor of Medi- cine, Yale University School of Medicine, New Haven, Connecticut. Three carefully coached actors appear as patients seeking diagnoses. In this program Dr Spiro deals with abdominal emergencies. The viewer is invited to exercise his diagnostic skills alongside a leading gastro- enterologist. (19 minutes) (in color) 0115226 BEDSIDE PULMONARY ARTERY CATH ETERIZA- TION, with T. Crawford McAslan, M.D., Associate Clinical Director, Maryland Institute for Emer- gency Medicine, and Professor of Anesthesiology, University of Maryland School of Medicine, Balti- more. An introduction to the Swan-Ganz flow-directed, balloon-tipped catheter. Indications, method of insertion at bedside, and techniques for avoiding complications. (55 minutes) (in color) 0223621 BURN - PART I. The course of treatment of the burn patient is demonstrated by Charles L. Fox, Jr., M.D., Professor of Microbiology, College of Physicians and Surgeons, Columbia University. (15 minutes) (in color) 0207312 BURN-PART Il-SYSTEMIC TREATMENT. The guidelines for treatment of burns and the need for constant review of the physiologic status of the patient are presented by Charles L. Fox, Jr., M.D., Professor of Microbiology, College of Phy- sicians and Surgeons, Columbia University. Dr. Fox also demonstrates results of topical treat- ment and grafting procedures. (16 mInutes) (in color) 0207413 THE COMATOSE PATIENT: IMMEDIATE MAN- AGEMENT AND EVALUATION, with Jerome S. Resnick, M.D., Director of Neurology, Stamford Hospital, Stamford, Connecticut, and Clinical As- sociate Professor of Neurology, New York Medi- cal College. Problem: coma. History: unknown. Dr. Resnick shows how to find the cause of coma using your eyes and nose, a flashlight, ophthalmoscope, pin and blood pressure cuff. This progthm was pro- duced in cooperation with the Department of Continuing Medical Education, New York Medical College. (16 minutes) (in color) 0323990 THE COMATOSE PATIENT: PATHOPHYSIOLOGY, with Jerome S. Resnick, M.D., Director of Neu- rology, Stamford Hospital, Stamford, Connecti- cut, and Clinical Associate Professor of Neurol- ogy, New York Medical College. Definition, etiologies, and mechanisms of pro- longed unconsciousness, presented in cogent, organized and practical style. ThiS program was produced with the cooperation of the Depart-, ment of Continuing Medical Education, New York Medical College. (16 minutes) (in color) 0323889 COMMON PROFESSIONAL FOOTBALL INJURIES, MECHANICS AND EFFECTS, with James A. Nicholas, M.D., Associate Professor of Clinical Surgery (Orthopedic), Cornell University Medical College atd Team Physician, the New York Jets. (18 minutes). 0302330 22 PAGENO="0377" DIAGNOSING THE MALTREATMENT SYNDROME IN CHILDREN, with Vincent J. Fontana, M.D., Di' rector of the Department of Pediatrics, St. Vin- cent's Hospital; and Medical Director, New York Foundling Hospital, both in New York City. In full agreement with a JAMA editorial stating that the `maltreated or battered child could be the leading cause of death in infants and children," Dr. Fon- tana describes the presenting signs that should make any physician suspect battered child or maltreatment syndrome - a diagnosis that may prevent future trauma to the child and may even save its life. (14 minutes) (in caior) 0414329 DIAGNOSIS AND TREATMENT OF HAND IN- JURIES. A key hint in making repairs of badly crushed hands is that if any connection exists at all, the injured part should not be severed, in the view of Ronald B. Berggren, M.D., Assist- ant Professor of Surgery and Director, Division of Plastic Surgery at Ohio State University College of Medicine. This and other aspects of hand injury are discussed among Dr. Serggren, and Robert J. Duran, M.D., Assistant Professor of Surgery, Division of Plastic Surgery and Co. Director, Hand Clinic, and Carl R. Coleman, M.D., Clinical Assistant Professor of Surgery, Division of Orthopedics, and Co-Director, Hand Clinic, Ohio State University College of Medicine. (20 minutes). 0406808 DIAGNOSTIC THORACENTESIS, with James W. Kilman, M.D., Associate Professor of Surgery, and Thomas E. Williams, Jr., M.D., Assistant Pro' féssor of Surgery, Ohio State University College of Medicine, Columbus. Thoracentesis for both diagnosis and emergency therapy is performed following a discussion of the tauses, signs, and symptoms of pleural effusion. 119 minutes) (in ca(or( 0419248 DOWN AND OUT IN THE E.R. Barbiturate over- dose, accidental or intentional, is the number one drug abuse problem presenting in Emer- gency Rooms. Dr. George clay of the Haight- Ashbury Free Medical Clinic in San Francisco and Dr. Eric Comstock, director of the Institute of Toxicology at Baylor University, join medical student John Rose of Baylor to demonstrate recommended procedures for the diagnosis and treatment of a barbiturate overdose crisis. (26 minutes) (in coior). SAMA 2810859 DRINKERS IN CRISIS, with Henry D. Abraham, M.D., Harvard Medical School, and Chief, Marl- borough.Westborough Unit, Westborough State Hospital, Westborough, Massachusetts; and John A. Renner, M.D., Director of the Alcoholism Clinic, Massachusetts General Hospital, Boston. The Scene: The psychiatric emergency depart- ment at Mass. General. The Players: Walk-in alcoholics seeking help. The P)otr How to use an alcoholic's time of crisis to set the stage for short- and long-term care. (16 minutes) (in color) 0421255 EMERGENCY CARDIAC CARE, with William J. Grace, M.D., Department of Medicine, New York University School of Medicine, and Joseph G. Hayes, M.D., Cornell University Medical College, New York City; Costas T. Lambrew, M.D., De- partment of Medicine, Meadowbrook Hospital, East Meadow, New York; and Joseph $chlug4r, M.D., Department of Medicine, Long Island aol- lege Hospital, Brooklyn, New York. A personal plan of action is proposed to help the physician deal with patients showing early signs of myo- cardial infarction. Optional emergency cardiac care systems adaptable to different community needs are described, and recently modified CPR techniques are demonstrated. A TeIevisii~n Clinic of the American College of Physicians, 1974. Please inquire for special rental information. (60 minutes) (in color) ACP 2867482 EMERGENCY CLOSED TUBE THORACOSTOMY, with James W. Kilman, M.D., Associate Professor of Surgery, and Thomas E. Williams, M.D., As- sistant Professor of Surgery, Ohio State Uni- versity College of Medicine, Columbqs. The causes, consequences, symptoms, and signs of pneumothorax are reviewed and an emergency closed tube thoracostomy is performed. (20 minutes) (In coior) 0519123 EMERGENCY ORTHOPEDIC MANAGEMENT, Paul R. Meyer, Jr., M.D., Department of Orthopedics, Tulane University School of Medicine, demon- strates emergency splinting at the scene of an accident. 17 minutes). 0501308 EMERGENCY TRANSVENOUS CARDIAC PACING, with Doris J. W. .Escher, M.D., Attending Physi- cian in the Division of Medicine and Physician- in-Charge of Cardiac Catheterization, Montefiore Hospital and Medical Center, Bronx, New York. The technique for emergency transvenous car- diac pacemaker insertion at the patient'~ bed- side is shown. Intracardiac electrogram patterns are correlated with catheter position, from high right atrium to the target position at the apex of the ventricle. (19 minutes) (in coior) 0520426 FRACTURED FACES - THE LOWER FACE. From the First Annual Symposium on Maxillofacial Trauma, Washington, D.C., Lester M. Cramer, M.D., Professor and Chairman, Section of Plastic Surgery, Teniple Ur~iversity Health Sciences Center, demonstrates operative and fixatioh pro- cedures for fractures of the m9ndible. (15 minutes). 0605608 FRACTURED FACES - THE MIDDLE PACE. Lester M. Cramer, M.D., Professor and Chairman of the Section of Plastic Surgery, Temple Uni- versity Health Sciences Center, reviews the structure of the middle face, the types of frac- tures which occur in that area, and the various forms of treatment including internal fixation. (18 minutes). 0605509 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14283 23 PAGENO="0378" 14284 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY INTERNAL JUGULAR VEIN CATHETERIZATION, with T. Crawford McAslan, M.D., Associate Clini- cal Director, Maryland Institute for Emergency Medicine, and Professor of Anesthesiology, Uni versity of Maryland School of Medicine, Balti- more, The internal jugular vein . . . an attractive alternative to the basilic with its high failure rate and the subclavian with its high incidence of pneumothorax. (11 minutes) (in color) 0923735 LEGAL PROBLEMS IN THE EMERGENCY ROOM. When can a minor be treated without parental consent? What special precautions should be taken with victims of criminal violence? Points to know about the law to protect a patient's rights and safeguard physician liability are discussed by William Mangold, M.D., J.D., resident in sur- gery at Bexar County Hospital, San Antonio, and member of the Texas bar; and Crawford Morris, Esq., trial lawyer specializing in medical mal- practice cases for Arter & Hadden Associates, Cleveland. (18 minutes) (in color) SAMA 2811063 MAINTAINING THE AIRWAY, with Richard Zeper- nick, M.D., Instructor in Anesthesiology, Depart- ment of Surgery, Tulane University School of Medicine. How to keep the patient breathing in an emergency. is mInutes). 1301201 MANAGEMENT OF ACUTE HEAD INJURIES, with William E. Hunt, M.D., Professor and Director of the Division of Neurosurgery; and W. George Bingham, Jr., M.D., Assistant Professor, Division of Neurosurgery, both with the Ohio State Uni- versity College of Medicine, in Columbus. Two neurosurgeons demonstrate the diagnostic pro~ cedurethey follow in cases of acute head in- juries. They also show the complications that can arise during the hours immediately after the injuries, and the neurosurgical emergencies that can develop. tu minutes) 1314140 MANAGEMENT OF ACUTE POISONINfI, with Jay M. Arena, M.D., Director, Poison Control Center of the Duke University Medical Center, Durham, NC., and former President, American Academy of Pediatrics. Dr. Arena shows how to treat com- mon and uncommon poisoning episodes on an emergency basis. (22 minutes) (in color) 1317648 MANAGEMENT OF ACUTE SPINAL INJURIES, with William E. Hunt, M.D., Professor and Director of the Division of Neurosurgery; W. George Bing- ham, Jr., M.D., Assistant Professor, Division of Neurosurgery; and Stephen Natelson, M.D., Sen- ior Resident in Neurosurgery; all with the Ohio State University College of Medicine in Columbus. Three specialists describe the precautions that are necessary in handling patients with spinal injuries through the stages in the emergency room, in radiology and during the period of re- habilitation. us minutes) (in color) 1314038 MANAGEMENT OF ASPIRIN POISONING, with Jay M. Arena, M.D., Director, Poison Control Center, Duke University Medical Center, Durham, N. C., and former President, American Academy of Pediatrics. Dr. Arena draws on 35 years' experience to give a practical approach to handling the most com- mon cause of poisoning in children. (13 minutes) (in color) 1317347 MANAGEMENT OF THE BATTERED CHILD SYN- DROME, with C. Henry Kempe, M.D., Professor and Chairman of Pediatrics; Brandt F. Steele, M.D., Professor of Psychiatry; and Helen Alex- ander, Medical Social Worker, Supervisor of Lay Therapists, Battered Child Program. All three are with the University of Colorado Medical Center. The reasons for abuse become apparent in an unrehearsed conversation with the mother of a patient. Three experts offer some practical advice on coping with parents once child abuse has been diagnosed and the underlying problems identified. (18 minutes) (in color) 1314441 MANAGEMENT TIPS FOR SOFT TISSUE INJU- RIES IN CHILDREN, with Thomas S. Morse, MD., Associate Professor of Surgery, Ohio State Uni- versity College of Medicine, Columbus, Ohio, The surgical technique for repairing a laceration in a child is about the same as that used for adults, but there are ways to make it easier. In this program, speclalattention is given to dress- ings, restraints and slings, as Dr. Morse shares his "little tricks" that help make it easier to deal with children. (18 minutes) (ii, color) 1319552 MEDICAL PROBLEMS ENCOUNTERED WITH BASEBALL PLAYERS, with Joseph T. Coyle, M.D., Clinical Associate, Bone and Joint Sur~ gery, Stritch School of Medicine, Loyola Uni- versity and Team Physician, the Chicago White Sox. 114 minutes). 1302426 THE MILITARY DOCTOR, with Commander Richard M. Esca~eda, M.D. Report from Vietnam on military and Civilian care (21 minuses). 1302133 24 PAGENO="0379" COMPETITIVE PROBLEMS IN THE I)RUG INDUSTRY 14285 NEAR DROWNING: WATCH THE BLOOD GASES, with Norman L Fine, MD., Chief, Respiratory Services, The Griffin Hospital, Derby, Conn., and Assistant Clinical Professor of Medicine, Yale University Medical School, New Haven. The model of the fatally-drowned person is no longer relevant in treating the survivor of near drown- ing. This program brings you up to date. (15 minutes) (in color) 1422940 OFFICE ORTHOPAEDICS: AFTER THE FALL, with Robert E. Leach, M.D., Professor and Chairman, Department of Orthcepaedic Surgery, Boston University Medical Center, Boston. Dr. Leach demonstrates casting and wrapping procedures for common orthopaedic injuries- dislocated shoulder, tibia and fibula fractures, ankle sprains and fractures. (18 minutes) (in color) 1517208 PRE-HOSPITAL CORONARY CARE - A MODEL FOR YOUR COMMUNITY, with Eugene Nage), M.D., Associate Professor, Department of An- esthesiology, University of Miami School of Medicine, and Ci)nical Director, Department of Anesthesiology, Jackson Memorial Hospital, Mi- ami, Florida. How quickly can your community get opt)mum coronary care facilities to a patient in cardiac arrest or ventricular fibrillation? Dr. Nagel shows how the Miami Emergency Rescue Service is set up, demonstrates how quickly it works in a simulated rescue, and shows what is needed to implement a complete mobile emergency health care system. (21 mInutes) (in color) 1615438 PRIMARY EVALUATION OF THE MULTIPLY IN. JURED PATIENT from the Ohio State University College of Medicine, with Larry C. Carey, M.D., Professor and Chairman of the Department of Surgery, and William E. Hunt, M.D., Professor and Director of the Division of Neurologic Sur- gery. The first 90 seconds in the emergency room are crucial. Evaluating the nature and extent of the patient's injuries in a proper sequence greatly increases the patient's chances for survival. This program was produced in cooperation with the Center for Continuing Medical Education, Ohio State UniversIty. (18 minutes) (in color) 1623049 PRIMARY TREATMENT OF SOFT TISSUE IN- JURIES, with Ronald B. Berggren, M.D., Pro- fessor and Director, Division of Plastic Surgery, Ohio State University College of Medicine, Co- lumbus. The three Ds of Sound management, Diagnosis, Debridement and Definitive Care, are demonstrated. Special emphasis is given to ways to avoid particular deformities. (19 mInutes) (in color) 1619443 RESPIRATORY DISTRESS SYNDROME OF THE ADULT: TREATMENT WITH PEEP, with Robert M. Rogers, M.D., Professor of Medicine, Msociate Professor of Physiology, and Chief of the Pul- monary Disease Section, University of Oklahoma Health Sciences Center, Oklahoma City. How a reasonable therapeutic program can significantly reduce high mortality from RDSA, the major pulmonary complication from trauma, hemor- rhage, surgery, septicemia, and shock. (16 minutes) (in colOr) 1821131 SAVING LIVES: IMMEDIATE CARE FOR COMMON EMERGENCIES. Could you save a life If your neighbor's baby was choking? Could yoU effec- tively stop massive bleeding? When accidents happen, friends of victims are likely to turn to you assuming you know more about emergency medical treatment. Do you? Hugh Hill of Medi- cal College of Virginia and Marcia Silver of Johns Hopkins join David Pilcher, M.D., Associate Pro- fessor of Surgery at the University of Vermont School of Medicine, and C. Earl Gettinger, Co- ordinator of Emergency Medical Services for the Vermont State Health Department, to discuss and demonstrate emergency treatment in cases of respiratory failure, massive bleeding ançi com- mon household poisonings. (23 mInutes) (in color) SAMA 2811461 SECONDARY AND TERTIARY EVALUATII~N OF THE MULTIPLY INJURED PATIENT, from the Ohio State University College of Medicine, with Larry C. Carey, M.D., Professor and Chairman, Department of Surgery, and William E. Hunt, M.D., Professor and Director, Division of Neu- rologic Surgery, Columbus. When the multiply injured patient arrives in the emergency room, various examinations help identify the exfent of injury. This program outlines each examination. The program was produced in cooperation with the Center for Continuing Medical Education, Ohic State University. (14 minutes) (in color) 1923142 SKELETAL TRACTION - THE TEAM APPROACH - PART I ADMISSION AND EMERGENCY CARE. The emergency management of a fractured femur is demonstrated by William McCloud, M.D., Resident in Orthopedic Surgery, Ohio State Uni- versity Center for Continuing Medical Education, for his departmental team, which includes an R.N., orthopedic orderly, physiotherapist, and occupational therapist. Discussing the rationale for the procedures, he reviews the structnre of the femur and the surrounding muscles and how the anatomy and type of fracture dictate the ap- propriate management. (25 minutes). 2701332 25 PAGENO="0380" 14286 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY SNAKEBITE, with Findlay E. Russell, M.D., Ph.D., Professor of Neurology, Physiology and Biology, and Director, Laboratory of Neurological Re- search, University of Southern California School of Medicine, Los Angeles. How to distinguish the dangerous bites, recommend first aid, and apply emergency and supportive treatment. (24 minutes) (in color) 1920636 SPECIAL PROBLEMS OF FACIAL TRAUMA SURGERY - PART I. Examination and repair of lacerations of the soft tissue of the face are discussed and demonstrated by Ross H. Mus- grave, M.D., Clinical Associate Professor of Sur- gery (Plastic), University of Pittsburg School of Medicine. (26 minUtes) (in color) 1905412 TECHNIQUES IN EMERGENCY CARE, with Stephen E. Goldfinger, M.D., Director of Com- munity Programs, Department of Continuing Ed- ucation and James Dineen, M.D., Fellow in Con tinuing Education, Harvard Medical School and Massachusetts General Hospital, Boston, Massa- chusetts. The procedures and armamentarium of the com munity hospital emergency room are constantly improving. Physicians who have not served as house officers recently will benefit from this pro- gram. Current emergency care is demonstrated with a patient in coma, another with unexplained fever, a third with trauma and, finally, several malingerers and depressives. (16 minutes) (in cslor) 2010904 THE ASPHYXIATING PATIENT: HOW AND WHY I INTUBATE, with Richard J. Ward, Professor, Department of Anesthesiology, University of Washington School of Medicine, Seattle. The steps involved in endotracheal intubation are reviewed and the procedure then performed on a surgical candidate, (13 mInutes) (in color) 0117933 THE EMERGENCY ROOM: A GROWING PUBLIC UTILITY, with Stephen E. Goldfinger, M.D., Di- rector of Community Programs, Department of Continuing Education; and James Dineen, M.D., Fellow in Continuing Education, Harvard Medical School and Massachusetts General Hospital, Bos- ton, Massachusetts. Physicians have trained their pati6nts to seek medical attention from emergency rooms after office hours. This common practice has placed staggering demands on hospital emergency fa- cilities. How can the hospital meet these de- mands? Who will staff the emergency facilities? What technical advances have been introduced to assist ER personnel? Doctors Goldfinger and Dineen present answers to these dilemmas. (19 minutes) (in color) 0511009 THERMAL INJURIES: MEDICAL, SURGICAL, AND PSYCHIATRIC CARE, wifh an introduction by T. 0. Blocker, Jr., M.D., Professor of Surgery and Pres- ident Emerif us, The University of Texas Medical Branch af Galveston. The following three programs were produced under the supervision of Stephen R. Lewis, M.D., Chief of Plastic Surgery and Di- rector of Continuing Education, UTMB-Galveston. KEEPING THE BURN PATIENT ALIVE, with Duane L. Larson, M.D., Professor of Plastic Sur- gery, UTMB-Galveston, and Director, Shriners Burns Institute, Galveston. A 1-2-3 approach to emergency care for critically-burned patients plus the steps to take in assuring the patient's survival during transportation to a hospital. (16 minutes( (in color) 1122205 HOSPITAL BURN CARE: MINIMIZING DE- FORMITIES AND OTHER COMPLICATIONS, with Hugo Carvajal, M.D., Pediatric Nephrol- ogist, Shriners Burns Institute, and Assistant Professor of Pediatrics, UTMB-Galveston; and Duane L. Larson, M.D., Director, Shriners Burns Institute, and Professor of Plastic Surgery, UTMB-Galveston. The definitive care of burn patients. Emphasis is placed on daily wound care, fluid replacement and nutrition, and pro- cedures to minimize contracture and hyper- trophic scarring before and after grafting. (22 minutes) (in colon 0822239 THERMAL INJURY: EMOTIONAL AND PHYSI- CAL STRESS, with Mary S. Knudson, Ph.D., Chief, Division of Behavioral Sciences, Shriners Burns Institute; Duane L. Larson, M.D., Pro- fessor of Plastic Surgery, UTMB-Galveston, and Director, Shriners Burns Institute; and Robert B. White, M.D., Professor of Psychiatry, UTMB-Galveston. Practical methods to combat the physical pain, toxic delirium, helplessness, and regression seen in patients with major burns. (12 minutes( (In color) 2022240 TIME BORROWERS IN SHOCK, with Leon I. Gold- berg, Ph.D., M.D., Professor of Medicine and Pharmacology, and Director of Clinical Pharma- cology, Emory University School of Medicine in Atlanta, Georgia. When the physician needs to "borrow time" while treating the underlying causes of shock, a cautious use of sympathomi- metic amines is often a worthwhile temporary solution. (14 minutesl (in color) 2020737 TRANSFUSION THERAPY: THE GROWING IMPACT OF FROZEN BLOOD, with Charles Huggins, M.D., Director of the Blood Bank and Transfusion Serv- ice, Massachusetts General Hospital, Boston. Blood transfusion therapy as it is practiced in a major medical center, with guidelines to the use of fresh and freshly frozen components. (14 minutes) lie color) 2022139 26 PAGENO="0381" COMPETIPIVE PROBLEMS IN THE DRUG INDUSTRY 14287 TRAUMA TO THE LIVER: PRIMARY CARE AND DIAGNOSIS, with Gordon F. Madding, M.D., Asso ciated Clinical Professor of Surgery, University of California School of Medicine, and Associate in Surgery, Stanford University School of Medicine; and Paul A. Kennedy, M.D., Assistant Clinical Professor of Surgery, Stanford University School of Medicine. In the opinion of Drs. Madding and Kennedy, there are ten specific steps that should be taken when a patient presents with traumatic injury to the abdomen. These measures lead most rapidly to effective therapeutic actions. (18 mInutes) (in color) 2014924 TRAUMA TO THE LIVER: OPERATIVE APPROACH AND SURGICAL PROCEDURE, with Gordon F. Madding, M.D., Associate Clinical Professor of Surgery, University of California School of Medi- cine and Associate in Surgery, Stanford University School of Medicine; and Paul A. Kennedy, M.D., Assistant Clinical Professor of Surgery, Stanford University School of Medicine. Anatomically and surgically this large, vital organ is not widely un derstood. Drs. Madding and Kennedy demon- strafe a few basic principles which can make emergency treatment of damaged liver s~fer and surer. (17 minutes) (in color) 2015025 TRAUMATIC HAND INJURIES: ASSESSMENT AND EMERGENCY MANAGEMENT, with Martin A. Posner, M.D., hand surgeon and Chairman of the Hand Service, Hospital for Joint Diseases, New York City. An organized approach to the evaluation and care of patients with lacerations, crushing wounds, and other traumatic hand injuries. its minutes) (in color) 2021535 TREATMENT OF ACUTE HEROIN TOXICITY, with David E. Smith, M.D., Director and Founder of the Haight-Ashbury Free Medical Clinic and Assistant Clinical Professor of Toxicology at the University of California in San Francisco; and George R. Gay, M.D., Chief of the Medical Sec- tion and Director of the Heroin Clinic with the Haight-Ashbury Clinic and Instructor in Toxi- cology at the University of California, San Fran- cisco. With growing numbers of heroin abusers in middle-class America, physicians increasingly are going to face the problem of acute heroin overdose - a medical emergency. Two physi- cian-experts put this problem into perspective through patient interviews, describe the `street" treatments that are in use - adding to risk of the complications - and finally present the treatment procedure they employ. (20 minutes). 2013422 TREATMENT OF RESPIRATORY FAILURE, with Robert M. Rogers, M.D., Assistant Professor of Medicine, and Director of the Respiratory Inten- sive Care Unit, Hospital of the University of Penn- sylvania. The selection and application of appropriate emergency procedures in treating respiratory failure are fully explored. (19 minutes) (in color) 2010217 ENDOCRINOLOGY ADULT DIABETES: OUTGUESSING THE NEXT 24 HOURS, with Leo P. Krall, M.D., Director, Educa- tiOn Division, and Lecturer in Medicine, Joslin Diabetes Foundation, Inc., and New England Deaconess Hospital, and Lecturer, Harvard Medi- cal School, Boston. Management of diabetes mellitus starts with defining treatment goals and understanding why they are often difficult to ob- tain. Dr. Krall discusses the general management of different types of patients. This program was produced with the cooperation of the Cguncil on Scientific Assembly of the American Medical As- sociation. (25 minutes) (in c&or( 0123046 CAN YOU TREAT OBESITY IN CHILDR~N? with Platon J. Collipp, M.D., Chief Pediatrici~n, Nas- sau County Medical Center, and Professor of Pediatrics, State University of New York, Stony Brook, Long Island, N, Y. Lçing-standing obesity, a health hazard in later life, can be stemmed in childhood and adolescence, Dr. CoIlIpp shows how diet, group treatment, challenge and support have successfully removed "60 tons gf Long Island baby fat." (18 minutes) (in color) 0318076 CELLULAR DISTURBANCES: A NEW CONCEPT OF OBESITY Some extremely obese patients may be incapa- ble of losing weight and maintaining the loss because they may have acquired an excessive number of fat cells early in life. This is one of the findings of Jules Hirsch, M.D., Professor and Senior Physician to The Hospital, Rockefeller University, New York. iv minutes). 0~08704 CLINICAL MANAGEMENT OF HUMAN REPRO- DUCTIVE PROBLEMS: PART I. Alvin F. Gbldfarb, M.D., Assistant Professor of Obstetrics and Gynecology, Jefferson Medical College add Hos- pital, presents "Evsluating the Infertile Couple." (19 minutes). 0303U8 CLINICAL MANAGEMENT OF HUMAN REPRODUCTIVE PROBLEMS: PART II "The Physlo-Anatomic Basis of Fallopian Tube Function." The second program in this continu- ing series - with Luigi Mastroianni, Jr., M.D., Professor of Obstetrics and Gynecology, Univer- sity of Pennsylvania School of Medicine. (17 minutes). 0303319 CLINICAL MANAGEMENT OF HUMAN REPRODUCTIVE PROBLEMS: PART II "Tubal Factor Treatment." Correcting distortion of the tubal ovarian relationships. With Celso- Ramon Garcia, M.D., Associate Professor of Ob- stetrics and Gynecology, University of Pennsyl- vania School of Medicine. its minutes). 0303620 27 PAGENO="0382" 14288 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY CLINICAL MANAGEMENT OF HUMAN REPRODUCTIVE PROBLEMS: PART IV `The Cervix in Infertility." Evaluation of the cervical factor in cases of femate infertility - with Kamran S. Moghissi, M.D., Associate Pro- fessor of Obstetrics and Gynecology, Wayne State University School of Medicine. (17 minutes) 0304421 CLINICAL MANAGEMENT OF HUMAN REPRODUCTIVE PROBLEMS: PART V "New Research," a discussion and demonstra- tion of the use of frozen sperm for artificial In. semination; immunologic aspects of infertility; and new laparoscopic techniques. (18 minutes). 0304622 CLINICAL MANAGEMENT OF HUMAN REPRO- DUCTIVE PROBLEMS: PART VI - INDICES OF OVULATION The tests which are available to determine the absence or occurrence of ovulation are de- scribed by Howard Balm, M.D., Chief, Gynecic Research Unit, Pennsylvania Hospital, Philadel. phia. (26 mInutes). 0304923 CURABLE HYPERTENSION with Ralph E. Peter- son, M.D., Professor of Medicine and Director, Division of Endocrinology, New York Hospital- Cornell University Medical Center, New York City. Forty million adult Americans have blood pres- sures higher than 150/90; in half of them, hyper- tension is secondary to another disease process. Among this latter group, surgery to remove the underlying cause is effective in five per cent, or one million cases. Dr. Peterson shows how to de- termine if a hypertensive patient is among the curable million. ~ie minutes) (in color) 0315270 CURRENT DIAGNOSTIC AND TREATMENT PROBLEMS IN THYROID DISEASE, with Gerald Burke, M.D., Department of Medicine; Leslie J. DeGroot, M.D., Department of Medicine; Alex. ander Gottschalk, M.D., Department of Radiology; Edward Paloyan, M.D., Department of Surgery; and Samuel Refetoff, M.D., Department of Medi- cine, all of the Pritzker School of Medicine of the University of Chicago. In a clinic setting, the panelists discuss diagnostic and therapeutic problems including management of possible thyroid carcinoma, clinical thyrotoxocosis with "normal" lab data, exophthalmos, and congen- ital goiter. Clinical physiology and related re- search are emphasized. A Television Clinic of the American College of Physicians, 1973. Please inquire for special rental Information. (60 minutes) (in color) ACP 2827366 CURRENT MANAGEMENT OF THE ADULT DIABETIC, with Peter H. Forsham, M.D~, Director of Metabolic Research Unit, University of Cali- fornia School of Medicine, San Francisco. Dr. Forsham outlines the treatment of adult dia- betes. In addition to explaining his use of diet and insulin therapy, he thoroughly examines the oral hypoglycemic agents, including phenformin hydrochloride and the sulfonylureas, explaining how they work, their side-effects, and the most effective regimen. (22 minutes) (In color) 0316673 CUSHING'S SYNDROME: FORTY YEARS LATER, with Ralph Peterson, M.D., Professor of Medicine ançl Director, Division of Endocrinology, New York Hospital-Cornell Medical Center, New York City. Today physicians know much more than did Har- vey Cushing about the syndrome that bears his name. Dr. Peterson reviews and updates its mechanisms and diagnosis. (19 minutes) (In color) 0315069 DIABETIC ACIDOSIS. Practical rules of thumb for the treatment of diabetic acidosis, with Daniel B. Stone, M.D., and Joseph D. Brown, M.D., Department of Internal Medicine, Univer- sity Hospital, University of Iowa College of Medicine. (29 minutes). 0400403 THE DIABETIC FOOT: HANDLE WITH CARE, with H. Howard Goldstein, M.D., Senior Physician, The Joslin Clinic, Division of the Joslin Diabetes Foundation, and the New England Deaconess Hospital, Boston. Once problems occur in the diabetic foot, they tend to be progressive. Dr. Goldstein teaches how to examine the feet of the diabetic patient and recommends appro- priate preventive care and treatment. This pro- gram was produced in cooperation with the Council on Scientific Assembly of the American Medical Association. (17 minutesl (in color) 0423261 DIABETIC RETINOPATHY: ATTEMPTS TO HOLD THE IMAGE, with Raymond Pilkerton, M.D., As- sociate Professor of Ophthalmology and Direc- tor, Retina Service, Georgetown University Med- ical Center, Washington, D.C. The relationship between the duration of diabetes and the stages of diabetic retinopathy. How treatment may tem- porarily stop the advance of this complication. This presentation was produced in cooperation with the Council on Scientific Assembly of the American Medical Association. (16 minuteS) (in color) 0423160 28 PAGENO="0383" COMPETIPWE PROBLEMS IN THE DRTJG IN1~USTRY 14289 INBORN ERRORS OF METABOLISM: TREATMENT Charles R. Scriver, M.D., of the DeBelle Labora tory for Biochemical Genetics at the Montreal Children's Hospital in Montreal, Canada, places the problems of hereditary disorders in their proper perspective. Dr. Scriver divides his ther- apeutic discussion into "genetic engineering" and "environmental engineering." (15 minutes) (In color) 0909605 INBORN ERRORS OF METABOLISM: MECHANISM AND DIAGNOSIS Charles R. Scriver, M.D., of the DeBelle Labors' tory for Biochemical Genetics at Montreal Chil. dren's Hospital in Montreal, P.Q., Canada, de. scribes the current techniques for managing genetic diseases. (13 minutes) (in color) 0909804 HOW I EVALUATE THE THYROID, with W. Lester Henry, Jr., M.D., Professor and Chairman of the Department of Medicine, Howard University School of Medicine, Washington, D.C. How to examine the thyroid from the anterior position (instead of the more usual posterior) with tips on the diagnosis of thyroId enlargement, Henry emphasizes the physical exam as well an the use of radioactive scans. (14 minutes) (in color) 0816827 HYPERCALCEMIA: A DIFFERENTIAL DIAGNOSIS, with John T. Potts, Jr., M.D., Chief of Endocrinol. ogy, Massachusetts General Hospital, and Asso- ciate Professor of Medicine, Harvard Medical School, Boston, Massachusetts, Hypercalcemia can be a life~threatening situation. Dr. Potts shows how a diagnosis of hypercalcemia can be established, and what action can be taken for the various possible causes. (16 minutes) (in color) 0813218 NEWEST DIAGNOSTIC AND THERAPEUTIC AP. PROACHES TO THYROID DI$EASE, with Manfred Blum, M.D., Charles S. Ho)lander, M.D., Herbert H. Samuels, M.D., and Louis Shenkman, M.D., all of the Department of Medicine, New York University Medical Center School of Medicine, New York City. Recent diagnostic and therapeu. tic approaches to thyroid disease are examined in the context of clinical case presentations of T3 toxicosis, hypothalamic hypothyroidism, and autonomous adenoma. Topics discussed include the clinical usefulness of radioassay procedures for thyroxine, triiodothyronine, thyrotropin, free thyroxine, the value of thyrotropln.releasing hor- mone in thyroid diagnosis, and the diagnostic utility of thyroid echography. A Television Clinic of the American College of Physicians, 1974. Please inquire for special rental information. (60 minutes) (in color) ACP 2837479 RECOGNIZING ROLES IN JUVENILE DIABETES, with Donnell D. Etzwiler, M.D., Director, Diabetes Education Center, and Pediatrician, St. Louis Park Medical Center, Minneapolis. A pediatrician gives guidelines for early diagnosis and manage ment of juvenile diabetes and show~ which responsibilities of good control should be as. signed to physician, health professional, and pa. tient. This presentation was produced with the cooperation of the Council on Scientific Assem- bly of the American Medical Association, (16 minutes) (in color) 1822934 SHORT STATURE IN CHILDREN, with Maurice D. Kogut, M.D., Director, Clinical Research Cen. ter, Children's Hospital of Los Angeles, Los Angeles, California. Three standard growth deviations are defined, and those conditions which are responsible for growth retardation - where no obvious disease is present * are described by Dr. Kbgut. (17 minutes) (in color) 1911705 SOME ORGANIC CAUSES OF CHILDHOOD OBE~ SITY, witti Platon J. Collipp, M.D., Chief 9f Pedi~ atrics, Nassau County Medical Center, and Pro. festor of Pediatrics, State University c~f New York, Stony Brook, Long Island, N. Y, Don't dis- count `glandular" causes of obesity without a long, hard look. Dr. Collipp presents patients with the more common of these rare diseases associated with overweight. (15 minutes) (in color) 1518209 THE DIABETES PUZZLE: A PRACTiCAL AP- PROACH, with Rachmiel Levine, M.D., Pr~fessor and Chairman of the Department of Medicine at New York Medical College in New York City. Most of the three million cases of diabetes In the U.S. are considered niild from the metabolic viewpoint. However, because of the link to many forms of cardiovascular, renal and other di. ceases it becomes important to discov~r and treat the mild forms. Dr. Levine describes the classical symptoms of diabetes and wl~en to suspect the disease in the absence of the typi. cal signs. He classifies therapy, relates diabetes to other diseases and describes its pathogénesis and Inherited factors. (17 minutes). 04~L0805 THE DIABETIC IN COMA/BRITTLE DIABETES! THE YOUNG DIABETIC, with Rachmiel Levine, M.D., Professor and Chairman of the Depart- ment of Medicine at New York Medical College in New York City. Coma may occur in a person with diabetes for the same reasons as it would occur in the non- diabetic. For that reason it is important to dif- ferentiate between the two comas. Dr. Levine describes ketoacidosis, hyperglycemic coma, lactacidosis, hypoglycemia. Dr. Levine als9 dis- cusses "brittle" diabetes and the prognosis of childhood dIabetes. (20 minutes). 0410904 29 PAGENO="0384" 14290 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY TREATMENT OF INSULIN-DEFICIENT DIABETES, with Peter H. Forsham, M.D., Director, Metabolic Research Unit, University of California School of Medicine, San Francisco. Insulin has been avail- able for 50 years, but its use in diabetic therapy can be improved. To achieve better results, says Dr. Forsham, physicians must simqjate as closely as possible the release of insulin by normal persons. (21 minutes) (In color) 2016427 FAMILY PRACTICE AFTER THE SPONTANEOUS ABORTION: COUN- SELING BY THE FAMILY PHYSICIAN, with William C. Rigsby, M.D., Assistant Professor, Department of Obstetrics and Gynecology, and Adolph Hats, M.D., Clinical Associate Professor, Department of Psychiatry, Ohio State University School of Medicine. Using an actual case of spontaneous abortion in a much wanted preg- nancy, Drs. Rigsby and Hans - and the patient in question - delineate areas in which the physician can support and reassure his patient in the time of crisis. (19 minutes) (in color) 0116129 FAMILY PRACTICE: A NEW SPECIALTY FOR THE GENERALIST, with Eugene S. Farley, M.D., M.P.H., Director of Family Medicine Program, Highland Hospital, University of Rochester, Ro- chester, N.Y. The formalization of Family Prac- tice as a medical specialty raises questions: What is thiS specialist's role in the community? What training does he require? Answering these questions and others, Dr. Fancy-a pioneer in this growing new specialty-shows us a modern family practice and describes the type of para- medical assistance required for its efficient operation. (20 minutes) (in color) 0614413 FAMILY PRACTICE AND COMMUNITY HEALTH, with Eugene S. Fancy, Jr., M.D., M.P.H, Director of Family Medicine Program, Highland HospItal, University of Rochester, Rochester, N. Y. Family Practice is distinguished from general practice by its emphasis on prevention, a bridge with the community and, often, group structure. Dr. Fancy takes us into his family practice to show how it serves the community as well as the changing needs of the practice's staff. iie minutes) (in color). 0614514 THE GENERAL PRACTITIONER AND COMMUNITY RESOURCES AVAILABLE FOR THE DEVELOPMEN- TALLY DELAYED, with William Gibson, M.D., Di- rector, the Ohio State University Hirschel W. Nisonger Center for Mental Retardation, and As- sociate Professor of Physical Medicine at the Ohio State University College of Medicine; Cary W. Perkins, with the Ohio Association for Re- tarded Children, Inc.; and Donald Cavin, Ed.D., Chief of Special Education at the Nisonger Center in Columbus, Ohio. The general practitioner can play an invaluable role in guiding families of the mentally retarded and the developmentally dis- abled to community resources and treatment cen- ters. This telecast acquaints the physician with recent federal legislation providing for new re- sources, and how he can learn of their availability in his commdrlity. (le minutes) (In color) 0714015 GASTROENTEROLOGY ABDOMINAL ARTERIOGRAPHY, with Robin Caird Watson, M.D., Chairman of the Department of Diagnostic Radiology, Memorial Sloan-Kettering Cancer Center, and Associate Professor of Radi- ology, Cornell University Medical Center, New York City. When to order an arteriognam and what it can tell you. Dr. Watson demonstrates the tech- nique he uses to investigate a patient with a mass in the area of the pancreas, vague upper GI symp- toms and equivocal X-rays. (20 m(nutes) ((n color) 0118435 ACUTE REGIONAL ENTERITIS: A CLINICAL PATH- OLOGICAL CONFERENCE, with Floyd M. Beman, M.D., Professor of Medicine; J, David Dunbar, M. D., Assistant Professor of Radiology; Dante G. Scarpelli, M.D., Professor of Pathology; and William Pace, M.D., Assistant Dean of the Col- (ego of Medicine; all from the Ohio State Uni- versity College of Medicine in Columbus, Ohio. Four physician-educators critically explore a case of severe, progressive regional enteritis. (23 minutes). 0110703 ADVANCES IN GASTROSCOPY The value of gastroscopy IS discussed by Charles S. Winans, M.D., Instructor in the Department of Medicine at the University of Chicago Pritlker School of Mediëine, and demonstrated by Selbi Kobayashi, M.D., Research Fellow at the same institution. (19 minutes) (In color) 0108905 30 PAGENO="0385" APPLICATION OF DIAGNOSTIC CYTOLOGIC TECHNIQUES TO GASTROINTESTINAL ENDOS- COPY AND LIVER BIOPSY, with Sidney J. Winawer, M.D., Director, Diggnostic Gastrointes- tinal Laboratory, Memorial Sloan-Kettering Can- cer Center and Clinical Associate Professor of Medicine, Cornell University Medical College; and and Paul Sherlock, M.D., Chief, Gastroenterology Service, Memorial Sloan-Kettering Cancer Center and Associate Professor of Medicine, Cornell University Medical College. Directed brush cy- tology and directed pulsatile lavage cytology through the upper GaStrointestinal Panendo- scope and Colonoacope are demonstrated. Pul- satile lavage through the standard sigmoido- scope for rectocolonic cytology is also shown. This presentation was made at the 1973 annual meeting of the American Society for Gastroin- testinal Endoscopy. Please inquire for special rental information. (41 minutes) (in color) ASGE 2800976 APPROACH TO GASTROINTESTINAL PAIN: CASES I & II, with Howard M. Spiro, M.D., Profes- sor of Medicine, Yale University School of Medi- cine, New Haven, Connecticut. Dr. Spiro is con- fronted by two "patients-actors who have been carefully coached by another physician In symptoms and histories of particular gastroin- testinal disorders. The "patients" do not know their diagnoses, nor does Dr. Spiro who arrives at his conculsions on camera. An opportunity to match diagnostic skills with a leading gastro- enterologist. (18 minutes) (in color) 0115024 APPROACH TO GASTROINTESTINAL PAIN: CASES Ill & IV, with Howard M. Spiro, MD., Pro- fessor of Medicine, Yale University School of Medicine, New Haven, Connecticut. Dr. Spiro en- counters "patients" unknown to him who have been carefully coached in symptoms of specific G.I. disorders. You can match diagnosis with him as he reaches his conclusions on camera, (14 minutes) (in color) 0115125 APPROACH TO GASTROINTESTINAL PAIN: CASES V, VI & VII, with Howard M. Spiro, M.D., Chief of Gastroertterology, Yale-New Haven Hos- pital, and Professor of Medicine, Yale University School of Medicine, New Haven Connecticut. Three carefully coached actors appear as patients seeking diagnosis. In this program Dr. Spiro deals with abdominal emergencies. The viewer is in- vited to exercise his diagnostic skills alongside a leading gastroenterologist. (19 mlnutesi (in color) 0115226 APPROACH TO GASTROINTESTINAL PAIN: CASES VIII & IX, with Howard M. Spiro, M.D., Professor of.Medicine, Yale University ~chool of Medicine, and Chief of Gastroenterolo~y, Yale- New Haven Hospital, New Haven, Conn. lwo "pa- tient" actors present with radiating pain. Dr. Spiro listens to their stories and elucicttptes: one rare but not difficult to diagnose, the other fairly common but not easy. Compare your own find- ings. (14 minutes) (in color) 0115327 APPROACH TO UPPER GI BLEEDING, With Robert M. Lowman, M.D., Professor and Acting Chairman, Department of Radiology; and Howard M. Spiro, M.D., Chief of Gastroenterology Divi- sion, Department of Medicine, Yale University School of Medicine, New Haven, Conn. Endos- copy - . . selective arteriography , . con- trast media studies - - - gastric aspIration Which of these aids should you emplny and in what order for a patient with upper GI bleeding? Drs. Spiro and Lowman review the relevant his- tory of two patients and then show the results of several examinations including arteriography and endoscopy used for the diagnoses. 119 minutes) lit color) 0118234 CROHN'S DISEASE: ONCE YOU HAVE TI-~E DIAG- NOSIS, with Henry D. Janowitz, M.D., Clinical Professor of Medicine and Head of the Division of Gastroenterology at Mt. Sinai Hospital and School of Medicine, New York City. Surgery or medicine - - - the critical decision in treating patients with Crohn's disease. Doctor ~Anowitz offers a rational approach to selecting the ap- propriate therapy. (16 minutes) (In color) 0322082 DIAGNOSING DYSPHAGIA, with Robert M. Low- man, M.D., Department of Radiology, and Howard M. Spiro, M.D., Chiefof the Gastroenterology Divi- sion, Department of Medicine, Yale University School of Medicin6, New Haven, Conn. Drs. Low- man and Spiro outline the order in which to use barium swallow X-rays, esophagoscepy bougi- nage and motility studies to differentiate psycho- genic, obstructional and physiological dySphagia. They. illustrate their discussion with barium swal- low X-rays and films of esophagoscopy. (20 minutes) (In color) 0417741 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14291 All programs in this catalog are copyright by the Network for Continuing Medical Education. Duplication, reproduction, or distribution in any form of all or any part of the programs is prohibited without the express written consent of NCME. 31 73-6)7 0 - 76 - 25 PAGENO="0386" 14292 COMPETITIVE PROBLuEMS IN THE DRTJG INDUSTRY DIAGNOSIS OF OCCULT INTRA-ABDOMINAL NEOPLASMS, with Herbert B. Greenlee, M.D., Department of Surgery, Loyola University of Chi- cago, Stritch School of Medicine, Maywood, Ill,, and Veterans Administration Hospital, Hines, Ill.; Erwin M. Kammerling, M.D., Department of Medi- cine, University of Health Sciences, The Chicago Medical Scthool, and Louis Weiss Memorial Hos- pital, Chicago; Sumner C. Kraft, M.D., Depart- ment of Medicine, University of Chicago; and Armand Littman, M.D., Department of Medicine, University of Illinois, College of Medicine, Chi- cago, and Veterans Administration Hospital, Hines1 Ill. The panel presents cases illustrating some of the difficulties and solutions involved in tracking down a diagnosis of intra-abdominal neoplasms. Emphasis is given to the tests (some old some new, some under-utilized) which are helpful in deciding to perform exploratory laps- rotomy. A Television Clinic of the American Col- lege of Physicians, 1973. Please inquire for special rental information. (60 minutes) (In color) ACP 2847368 DIAGNOSING PEPTIC ESOPHAGITIS, with Robert M. Lowman, M.D., Professor and Acting Chair- man, Department of Radiology, and Howard M. Spiro, M.D., Chief of the Gastroenterology Divi- sion, Department of Medicine, Yale University School of Medicine, New Haven, Conn. Drs. Low- man and Spiro demonstrate how to determine the cause of heartburn and to reveal related serious diseases using barium swallow X-rays endoscopy and the Bernstein acid perfusion test. (16 minutes) (in color) 0417842 DIAGNOSING THE INFLAMED BOWEL, with Mar- vin M. Schuster, M.D., Director of Gastroenterol- ogy, Baltimore City Hospitals, Associate Profes- sor of Medicine and Assistant Professor of Psychiatry, Johns Hopkins University School of Medicine, Baltimore. When the signs point to inflammatory bowel disease, here Is the four- stage wo~kup recommended to differentiate Ul- cerative colitis from granulomataus disease of the colon. (17 minutes) (in color) 0419449 For more information about NCME's Master Videocassette Library or bi-weekly videocassette service, write: NCME/15 Columbus Circle/New York, N.Y. 10023; or phone: (212) 541-8088. THE DIAGNOSTIC CHALLENGE OF CHEST PAIN~ with moderator Alfred Softer, M.D., Professor of Cardiology at the University of Health Sciences- Chicago Medical School, Chicago, and Editor-in- Chief of Chest, the Journal of the American Col- lege of Chest Physicians. Participants are: R. D. Henderson, MB., F.R.C.S. (C)., Staff Surgeon, Toronto General Hospital and Assisthnt Professor of the Department of Surgery at the University of Toronto, Canada; Barry William Levine, M.D., Assistant Professor of Medicine, Harvard Medi- cal School, and Chief, Outpatient Pulmonary Services, Massachusetts General Hospital, Bos- ton; Linda D. Lewis, M.D., Assistant Professor of Neurology, College of Physicians and Surgeons of Columbia University, attd Chief of the Neu- rology Clinic, Neurological Institute of Columbia Presbyterian Medical Center, New York City, Morton E. Tavel, M.D., Associate Professor of Medicine at the Indiana University School of Medicine, Indianapolis. Pinpointing the cause of your patient's chest pain poses an urgent diagnostic challenge. Join Dr. Soffer and four specialists on these clinical grand rounds as they reach a diagnosis on five patients. (32 minutes( (in color) 0423362 DIFFERENTIAL DIAGNOSIS OF DISEASES OF THE ILEUM AND COLON. The dilemma of differ- entiating between regional ileitis, ulcerative co- litis and granulomatous colitis may be no more than a confusion of terms, yet may lead to im- proper management of these diseases, In this presentation, Burrill B. Crohn, M.D., Professor Emeritus, Department of Gastroente~ology, Mount Sinai Hospital and Medical Center, New York, illustrates his own diagnostic techniques and methods of handling these clinical entities. (16 minutes). 0407915 Many NCME programs have self -assess- ment quizzes, one copy of which will ac- company each videocassette. You may duplicate the quiz as your needs require. Upon completion, return the quizzes to NCME, and we will maintain a record of participation (not the score) for each phy- sician. These records are keyed to the phy- sician's Social Security numbers: please take care that the numbers are clearly written. Physicians may request their NCME activity records at any time. 32 PAGENO="0387" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14293 ESOPHAGEAL DISORDERS AND CHEST PAIN- (EVALUATION AND MANAGEMENT OF ESOPHA- GEAL REFLUX), with Thomas R. Hendrix, M.D Department of Medicine; Theodore M. Bayless, M.D., Department of Medicine, Martin W. Don~ ncr, M.D., Department of Radiology; Francis El. Milligan, M.D., Department of Medicine; and David B. Skinner, M.D., Department of Surgery: all of the Johns Hopkins University School of Medicine. Clinical, radiologic, and special procedures used in evaluation of gastroesophageal reflux are presented, including acid perfusion, esQpha- goscopy, cine radiology, esophageal motility, and pH probe measurement. The relation of reflux to esophagitis and to reflux symptoms are defined. Among topics discussed: medical therapy for reflux; surgical options; relation of hiatal hernia to reflux; and management of complications of reflux, stricture, and esopha- geal ulcer. A Television Hospital Clinic of the American College of Physicians, 1972. Please inquire for special rental information. 159 minutes) (In color) ACP 2817243 FROM TOP TO BOTTOM: A FIBEROPTIC VIEW OF THE BODY, with Howard J. Eddy, M.D., At tending Surgeon, Community Hospital, Doctors Hospital and St. John's Hospital, Long Island, New York; and Richard S. McCray, M.D., Asso- ciate Director of the Clinical Gastrointestinal Unit, St. Luke's Hospital, and Associate in Med- icine, Columbia UniversIty College of Physicians and Surgeons, New York City. Fiberoptic Instruments now available permit the clinician to inspect, biopsy, and even treat lesions in the esophagus, stomach, duodenum and colon. Dr. McCray, a gastroenterologist, takes viewers on a trip through the upper GI tract. Dr. Eddy, a colon and rectal surgeon, shows lesions of the lower tract and removes a benign polyp using the instrument. 130 minUtes) (in color) 0616715 GASTROINTESTINAL CYTOLOGY - A VALUABLE DIAGNOSTIC PROCEDURE: PART I "Application and Results." Confirming a diagno. sic without surgery through the use of Papanico. laou staining of cells from the gastrointestinal tract - with Charles Norland, M.D., Assistant Professor of Medicine, University of Chicago School of Medicine. (16 minutes). 0703303 GASTROINTESTINAL CYTOLOGY: PART II "Techniques and Methods of Interpretation." Demonstration of the techniques of tubular in- tubation, stomach washing, and slide staining utilized in this diagnostic procedure - with Charles Norland, M.D., Assistant Professor of Medicine, University of Chicago School of Med. icine. (17 minutes). 0703404 HANDLING THE GALLSTONE PATIENT, With J. L Thistle, M.D., Gastroenterologist, Depaitment of Gastroenterology, Mayo Clinic, Rochester, Min- nesota. Deciding which of your patients will benefit from surgery is not always easy. Dr. Thistle looks at two patients and points out the important elements in making that decision. (15 minutes) (in color) 0823043 HOW I DO SIGMOIDOSCOPY, with Ralph E. L. Hertz, M.D., Associate Attending Surgeon, De~ partment of Co~on arid Rectal Surgery, Me morial Hospital for Cancer and Allied Diseases, New York City. Dr. Hertz demonstrates the steps involved in inspection of the perianal tissues, sigmoidoscopy and anoscopy, and provides tips for making the procedure easier for you and more comfortable for the patient. (21 minutes) (In color) 0817329 IMMUNOLOGIC TESTS FOR VIRAL HEPATITIS, with Carroll M. Leevy, M.D., Professor of Medi- cine and Director, Division of Hepatology and Nutrition, College of Medicine and Dehtistry of New Jersey, Newark. The tests for Hepatitis A and B and what they can do for you in practice. (16 minutes) (in color) 0923132 JAUNDICE: IS IT MEDICAL OR SURGICAL?, with Carroll M. Leevy, M.D., Professor of Medicine and Director, Division of Hepatology and Nutri- tion, the College of Medicine and Dentistry of New Jersey, Newark. An uptodate look at this diagnostic puzzle. (15 minutes) (in color) 1023202 MALABSORPTION SYNDROME Victor W. Groisser, M.D., Clinical Professor of Medicine, New Jersey College of Medicine, and Director of Gastroertterology, MountainSide Hos- pital, Montclair, New Jersey, comments on the frequency of malabsorption syndrome~ on the possibility of misdlagnosis and the need for clearing up the confusion surrounding malab- sorption. (19 minuteS). 1309602 PROBLEMS AND PITFALLS IN PSYCHOSOMATIC MEDICINE: PEPTIC ULCER, with Roy R. Grinker, M.D., Associate Professor of Psychiatry Snd Neu- rology; and F. Theodore Reid, M.D., Associate Professor of Psychiatry and Neurology, both from the Michael Reese Hospital in Chicago, IllinoIs. Most physicians are confronted with patients suffering from psychosomatic illnesses. Many of these patients are treated as "second class citi- zens," largely because of the frustrations in treating them, This program shows the non. psychiatric physician the way to handle psycho- somatic conditions by citing a peptic ~ilcer pa- tient as an example. Particular attention is given to differentiating illnesses with etiologic origins and emotional disturbances. 116 minutes) (in color) 1,612522 33 PAGENO="0388" 14294 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY RADIOLOGIC DIAGNOSIS OF THE ACUTE ABDOMEN Several radiological techniques are available in diagnosing patients presenting with acute abdom- inal pain. Robert D. Moseley, Jr., M.D., Professor and Chairman of the Department of Radiology, University of Chicago Pritzker School of Medicine, summarizes these techniques and considers their importance in clinical findings. (15 minstes) (in color) 1808804 RECTAL BLEEDING: FINDING THE CAUSE, with Robert M. Lowman, M.D., Professor and Acting Chairman, Department of Radiology, and How- ard M. Spiro, M.D., Chief of Gastroenterology Division, Department of Medicine, Yale Univer- sity School of Medicine, New Haven, Conn. Drs. Lowman and Spiro review the procedures in- volved in diagnosing minimal, moderate and massive rectal bleeding and outline the order in which sigmoidoscopy, colonoscopy, barium ene- ma and selective arteriography should be em- ployed. (18 minutes) (in color) 1817927 A TELEVISION DISCUSSION BY THE CLINICAL PATHOLOGICAL FACULTY. Featured are Floyd M. Beman, M.D., Professor of Medicine, J. David Dunbar, M.D., Assistant Professor of Pathology, Dante G. Scarpelli, M.D., Professor of Pathology, and William Pace, Assistant Dean, Ohio State University College of Medicine, who discuss a case of severe, progressive regional enteritis, the causes of death, and the steps that might have been taken to prolong the patient's life. isa minutes). 2800006 TRAUMA TO THE LIVER: OPERATIVE APPROACH AND SURGICAL PROCEDURE, with Gordon F. Madding, M.D., Associate Clinical Professor of Surgery, University of California School of Medi- cine; and Associate in Surgery, Stanford Univer- sity School of Medicine; and Paul A. Kennedy, -M.D., Assistant Clinical Professor of Surgery, Stanford University School of Medicine. Anatomi- cally and surgically this large, vital organ is not widely understood. Drs. Madding and Kennedy demonstrate a few basic principles which can make emergency treatment of damaged liver safer and surer. (19 minutes) (in color) 2015025 TRAUMA TO THE LIVER: PRIMARY CARE AND DIAGNOSIS, with Gordon F. Madding, M.D., Asso- ciated Clinical Professor of Surgery, University of California School of Medicine, and Associate in Surgery, Stanford University School of Medicine; and Paul A. Kennedy, M.D., Assistant Clinical Professor of Surgery, Stanford University School of Medicine. In the opinion of Drs. Madding and Kennedy, there are ten specific steps that should be taken when a patient presents with traumatic injury to the abdomen. These measures lead most rapidly to effective therapeutic actions, (18 minutes) (In color) 2014924 GENETICS ABNORMAL SEX DIFFERENTIATION, with Mau- rice D. Kogut, M.D., Director, Clinical Research Center; and Jordan J. Weitzman, M.D., pediatric surgeon, both of Children's Hospital of Los An- geles. The factors of determining sexual ambiguities in the newborn are clearly demonstrated in this telecast. Emphasis is also placed on early treat- ment and establishing an unambiguous sex of rearing. (17 minutes) (in color) 0111601 AN OUTLINE OF CYTOGENETICS A survey of the field of human cytogenetics, covering the development of the techniques which make chromosome studies practical - with LCDR Thomas R. Birdwell, MC, U.S.N., Head, Cytogenetics Division, Department of Pa- thology, U.S. Naval Hospital, San Diego, Calif. (18 minutes). 1503403 CHROMOSOMES BY MAIL As an alternative to the time-consuming and costly practice of transporting the patient to the testing center, there is now a practical method for shipping blood specimens over long dis- tances for the leukocyte chromosome culture and chromosome analysis. LCDR Thomas R. Birdwell, MC, U.S.N., Head, Cytogenetics Divi- sion, U.S. Naval Hospital, San Diego, Calif., demonstrates the technique. (11 minutes). 0303810 CYSTIC FIBROSIS: DIAGNOSIS AND MANAGE- MENT, with Paul R. Patterson, M.D., Director, Cystic Fibrosis Unit, Albany Medical Center, Al- bany Medical College, Union University, New York, Attention is drawn to cystic fil?rosis as a model genetin disease. Dr. Patterson describes, with many examples, C/Fs mode of inheritance, in- cidence, symptoms, differential diagnosis, detec- tion of carrier state, current status of manage- ability and prospects for palliative or corrective therapy. (19 minutes) (in color) 0310961 DIAGNOSIS AND MANAGEMENT OF HUNTING- TON'S CHOREA, with Charles Markham, M.D., Professor of Neurology, University of California, Los Angoles School of Medicine, and Milton Wex- ler, Ph.D., President, California Chapterof The Committee to Combat Huntington's Disease. Huntington's Chorea - an invariably fatal dis- order -is transmitted by a dominant gene; thus the carriers' children have a 50 percent chance of inheriting it. There are thought to be more than 100,000 people afflicted with Huntington's Chorea in the U.S. and Canada - most of them undiagnosed or mis-diagnosed. Unless physi- cians can detect the disease in these unknown thousands and effectively counsel them, a ge- netic time-bomb is being fused against future generations. (17 minutes) (in color) 0415331 34 PAGENO="0389" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14295 EPIDEMIC GENETIC DISEASE, with Claude La- berge, M.D., of the Human Genetics Laboratory, Universite Laval, Quebec. Tyrosinemia is an hereditary disease which can be traced back to a French couple who migrated to North America more than 300 years ago. One in 24 to one in 41 in a particular region in Quebec are carriers of the disease trait, and this is spreading. (No trace of the disease has been recorded in the United States.) Dr. La- berge charts the diagnosis and treatment of this disease to describe the dynamics of ge- netic diseases, how the diseases are approached today and how they may be overcome in the future. (16 minutes) (in color) - 0512310 GENETIC COUNSELING FOR CHROMOSOME ABNORMALITIES: AUTOSOMAL CHROMOSOMES, with Frederick Hecht, M.D., Associate Professor of Medical Genetics and Pediatrics, Crippled Children's Division, University of Oregon Medical Center, Portland, Oregon. The parents of children with non-sexual chromo- somal abnormalities ar4 interviewed by sev- eral people who are involved in training physi- clans in genetic counseling at the University of Oregon. This program is of particular value to general physicians. (13 minutes) (in color) 0712706 GENETIC COUNSELING FOR CHROMOSOME ABNORMALITIES: SEX CHROMOSOMES, with Frederick Hecht, M.D., Associate Professor of Medical Genetics and Pediatrics, Crippled Chil- dren's Division, University of Oregon Medical Center, Portland, Oregon. The general physician learns eight character- istics of effective genetic counseling from this telecast, Particular attention is given to several different sex chromosomal abnormalities. (17 mInutes) (in color) 0712605 GENETIC MEDICINE: A MEDICAL FACILITY OF THE FUTURE, with Claude Laberge, M.D., Hu- man Genetics Laboratory, Faculte de Medecine, Universite Loyal, Quebec. Dr. Laberge shows the steps that are now being taken to use the advances in molecular biology and biochemical genetics for curing human hereditary diseases. The advances in- clude determining the structure of genetic material, understanding protein synthesIs and de- ciphering the genetic code. Dr. Laberge demon- strates how this information will lead to a new branch of medicine; and how it will' go far be- yond the present use of merely counseling pa- tients, (16 mInutes) (in color) 0712407 GROWTH AND DIFFERENTIATION OF HUMAN LYMPHOCYTES: PART I "Nucleic Acid Synthesis." Arnold D. RuI~in, M.D., Associate in Medicine, Mount Sinai School of Medicine, demonstrates the technique~ for ex- tracting nucleic acid from lymphocytes, focus- ing on RNA metabolism. (19 minutes). 0703912 GROWTH AND DIFFERENTIATION OF HUMAN LYMPHOCYTES: PART II, ABNORMAL NUCLEIC ACID SYNTHESIS IN LEUKEMIA Arnold D. Rubin, M.D., Associate in Medicine, Mount Sinai School of Medicine, New Ybrk, con- ducts an investigation of abnormal growth pat- terns of lymphocytes taken from patients with lymphoproliferative disorders. (20 minutes). 0704713 HUMAN CYTOGENETICS "Indications for Cytogenetic Testing" - LCDR Thomas R. Birdwell, MC, U.S.N., Head, Cyto- genetics Division, U.S. Naval Hospital, San Diego, Calif., presents some of the indications for primary amenorrhea, investigation of female and male sterility, differential diagnosis of con- genital defects in the newborn, differential diag- nosis of chronic myelocytic leukemia, investiga- tion of intersex, family counseling, and genetic prognosis. (14 minutes). 0803707 INDENTIFICATION AND GROUPING OF CHROMOSOMES LCDR Thomas R. Birdwell, MC, U.S.N.i Head, Cytogenetics Division, Department of Pathology, U.S. Naval Hospital, San Diego, Calif., ditcusses the features of the model chromosome and then demonstrates the technique of identifying and grouping chromosomes in karyotypes. (16 minutes). 0903501 INBORN ERRORS OF METABOLISM: MECHANISM AND DIAGNOSIS Charles R. Scriver, MD., of the DeBelle Labora- tory for Biochemical Genetics at Montreal Chil- dren's Hospital in Montreal, P.Q., Cana~1a, de- scribes the current techniques for managing genetic diseases. (13 minutes) (in color) 0909804 INBORN ERRORS OF METABOLISM: TREATMENT Charles R. Scriver, M.D., of the DeBelle Labora- tory for Biochemical Genetics at the Montreal Children's Hospital in Montreal, Canada, places the problems of hereditary disorders in their proper perspective. Dr. Scriver divides his ther- apeutic discussion into "genetic engineering" and "environmental engineering." (15 minutes) (in color) 0909605 35 PAGENO="0390" 14296 COMPETITIVE PROBLEMS IN THE DRUG INIYLJSTRY NEW GENETIC COUNSELING FOR THE 70s, with Carlo Valenti, M.D., Associate Professor, Depart ment of Obstetrics and Gynecology, Downstate Medical Center In Brooklyn, New York. New uses of amniocentesis give the physician greater opportunities for genetic counseling. Dr. Valenti shows how the procedure can be used to define chromosomal aberrations, effects of drugs - specifically LSD - and how it can be employed to identify se~ and define fetal ma- turity. (17 minutes) (in color) 1410806 NEW TECHNIQUES IN AMNIOCENTESIS, with Carlo Valenti, M.D., Associate Professor, Depart- ment of Obstetrics and Gynecology, State Uni- versity of New York, Downstate Medical Center in Brooklyn, New York, Removing amniotic fluid from a pregnant woman to determine Rh abnormalities is one of the major advances in obstetrics and gynecology during the past 10 years. Amniocentesis is now successfully used at early stages of pregnancy to predict other fetal anomalies. The procedure, with sonograms and instruments, is illustrated in detail. (16 minuteS) (in color) 1410728 OBTAINING AND CULTURING LEUKOCYTES FOR CHROMOSOME ANALYSIS Demonstrating a simple method of obtaining chromosomes for study and analysis - with LCDR Thomas R. Birdwell, MC, U.S.F'4., Head, Cytogenetics Division, Department of Pathology, U.S. Naval Hospital, San Diego, Calif. (15 minutes). 1503402 PRENATAL DIAGNOSIS OF HEREDITARY DIS- ORDERS, with Carlo Valenti, M.D., Professor of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, Brooklyn, New York. A practical look at the indications for amniocentesis. Dr. Valenti demonstrates the pro- cedure, which many primary care physicians are performing themselves, (21 mihUtes) (in color) 1617942 SICKLE-CELL ANEMIA: MANAGEMENT, with Ro- land B, Scott, M.D., Professor and Head of the Department of Pediatrics, Howard University, and Chief Pediatrician at Freedmen's Hospital in Washington, D.C. There is no curative treatment for sickle-cell anemia, according to Dr. Scott, However, early diagnosis of the disease, which afflicts more than 50,000 black Americans, can ameliorate the most disturbing symptoms. Dr. Scott de- scribes the therapeutic program he follows to enhance survival until the patient reaches puberty - when the natural course of the dis- ease process appears to become attenuated.. (14 minutes) (in color) 1911506 SICKLECELL ANEMIA: SUSPICION AND DIAG- NOSIS IN INFANTS AND CHILDREN, with Roland B, Scott, M.D., Professor and Head of the De- partment of Pediatrics, Howard University, and Chief Pediatrician at Freemen' a Hospital in Washington, D.C Also V. Bushan Bhardwai, M.D., Assistant Professor of Pediatrics, Howard University, and Pediatric Hematologist, Freed- men's Hospital. Sickle-cell anemia afflicts more than 50,000 Americans of African descent. Perhaps another two million Americans carry the trait, Until recently, it was believed that little could be done for the disease. Now relief from the symptoms and a prolonging of life are possible. This telecast features the characteristics of the disease, and the laboratory procedure followed to establish a conclusive diagnosis, (20 mInutes) (in colon 1911407 SPH1NGOLIPIDOS1S: GENETICS The increasing incidence of sphingolipid disease, such as Tay-Sschs, Gaucher's, and Niemann-Pick, is examined genetically by Stanley M. Aronson, M.D., Professor of Pathology, State University of New York Downstate Medical Center, and Attend- ing Neuropathologist, Isaac Albert Research insti- tute, Jewish Chronic Disease Hospital, Brooklyn. (15 minutes). 1904914 SPHINGOLIPIDOSIS - PART I - BIOCHEMICAL ASPECTS. The chemical compositions of ganglio- sides, sphingomyelins, sulfatides, glycolipids, and cerebrosides, as they are found in the vari- ous sphingolipid diceasec, are analyzed by Abra- ham Saifer, Ph.D., Chief of the Biochemistry Department, Isaac Albert Research Institute of the Jewish Chronic Disease Hospital, Brooklyn. (21 minutes). 1905015 SPHINGOLIPIDOSIS - PART Ii - PATHOLOGY, Several pathologic manifestations - such as amaurotic family idiocy (Tay-Sachs disease), hep- atosplenomegaly (Niemann.Pick disease), and others - grouped under the general pategory of sphingolipidosis, are examined and defined by Bruno W. Volk, M.D., Director of the Isaac Albert Research Institute, of the Jewish Chronic Disease Hospital, and Clinical P~ofossor of Pathology, State University of New York Downstate Medical Center, Brooklyn. (21 minunesl. 1905016 SPHINGOLIPIDOSIS - PART III - CLINICAL ASPECTS. The specific physiologic manifesta- tions of the Tay-Sachs and Niemann-Pick dis- eases and amaurotic idiocy-such as cherry red macula, clonus, severe contractions, the "frog" position of the legs, and lack of macrocephaly - are demonstrated with young patients by Larry Schneck, M.D., of the Albert Isaac Research Institute of the Jewish Chronic Disease Hospi- tal, Downstate Medical Center, Brooklyn, New York, (13 minutes). 1905217 36 PAGENO="0391" COMPETITIVE PROBLEMS IN THE DRUG ItJSTi~ 14297 WHO SPEAKS FOR THE BABY? A baby is born mongoloid, with a defective heart and duodenal atresia. The parents, with three other children at home, ask that lifesaving intestinal surgery not be performed. The pediatrician, trained to preserve life, seeks a court order to operate. Is such a decision within the physician's province? Should this child live or die? A presentation by physicians and medical students of points of view on infant euthanasia. (20 minutes) (In color) SAMA 2810352 GERIATRICS AGING AS A FACTOR IN DIFFERENTIAL DIAG- NOSIS, with Isadore Rossman, M.D., Medical Director, Home Care Department, Montefiore Hospital, and Associate Professor of Community Medicine, Albert Einstein College of Medicine, in New York City. Normal changes in the geri- atric patient modify usual considerations in do. ing differential diagnosis. The changes that pro duce the involutional phenomena are indicated, and their effect on a true diagnosis is em- phasized. (14 minutes). 0110306 ARTHRITIS: SURGICAL INDICATIONS, PART I - EARLY, PROPHYLACTIC John L. Sbarbaro, Jr., M.D., Assistant Professor of Orthopedic Surgery at the University Qf Penn- sylvania School of Medicine in Philadelphia, Pa., indicates that if suppressive drug and physical therapy cannot control advancing arthritis, ex- tirpation might. (19 minutes) (in color) 0108416 ARTHRITIS: SURGICAL INDICATIONS, PART II - LATE, RECONSTRUCTIVE The development of non-reactive metals, im- proved design of molds and prosthesis and im- proved surgical techniques have caused a recent resurgence of interest in the surgical reconstruc- tion of deformed arthritic joints. John L. Sbar- bare, Jr., M.D., Assistant Professor of Orthopedic Surgery, University of Pennsylvania School of Medicine, demonstrate some of the new tech- niques and shows the results of surgical repair. (16 minutes) (in color) 0108517 DEALING WITH THE TERMINALLY ILL PATIENT Elizabeth Kubler-Ross, M.D., Assistant Professor of Psychiatry University of Chicago, demon- strates the stages a patient goes through once he becomes aware he is dying. Dr. Ross also dis- cusses the reaction of people around the patient. (16 minutes) 0409401 LEARNING TO LIVE WITH DYING. Dying is per- haps the most difficult and least understood phase of life. Terminail y ill patients and their families turn to their physicians for support and guidance that goes beyond clinical care. Medical students Sam Cullison and Mike O'NeaI join The Reverend Barry Wood, M.D. and Wil- liam Fischer, M.D., both of Roosevelt Hospital, New York City, and Robert Neale, Th.D., of Union Theological Seminary, New York City, to discuss the management of terminally III patients and their families. (39 mInutes) (In color) SAMA 2810656 MANAGEMENT OF THE TERMINALLY ILL: THE FAMILY Elizabeth KublerRoss, M.D., Assistant F~rofessor of Psychiatry at the University of Chicago, offers practical help to physicians in dealing with the dying patient and his family. (16 minutes). 1309708 PRACTICAL MANAGEMENT OF DISABILITY IN THE AGED. Geriatric patients with n~urômus- cular and orthopedic disabilities denionstrate that, when properly motivated and emotionally supported, they can adapt to their physical dis- abilities as mechanical obstacles to be over- come. Leo Dobrin, M.D., Clinical Instructor, Re- habilitative Medicine, New York University Med- ical Center, and Director of Physical bledicine and Rehabilitation, The Jewish Home and Hos- pital for Aged, and Frederic Zeman, M.D., Chief of Medical Services at The Jewish Home and Hospital for Aged, offer clinical commentary. (18 mInutes). 1605918 TOTAL HIP REPLACEMENT, with John J. Gartland, M.D., James Edwards Professor of Orthopaecllc Surgery, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania. Since the mid-sixties thousands of American men and women have obtained relief from crippling hip disease through the implantation of total hip arthroplastles. Dr. Gartland employs the tech- nique advanced by Charriley and Muller to replace the right hip of a middle-aged man who had his left hip similarly replaced five months previously. (19 minutes) (in color) 2015126 `HEMATOLOGY I ACUTE MYELOGENOUS LEUKEMIA: THE DIAG- NOSIS, with Monroe Dowling, Jr., M.D., Assistant Attending Phy~ician, Hematology Servife, Me- morial Sloan-Kettering Cancer Center, New York City. Tips for making an earlier diagnosiC in pa- tients suspected of having acute leukemia. (13 minutes) (in color) 0Z21941 37 PAGENO="0392" 14298 COMPETITIVE PROBLEMS IN TITE DRUG ThTDUSTRY ACUTE MYELOGENOUS LEUKEMIA: THE TREAT- MENT, with Monroe Dowling, Jr., M.D., Assistant Attending Physician, Hematology Service, Me- morial Sloan-Kettering Cancer Center, New York City. Treating the patient with acute leukemia can be difficult and dangerous. To enable you to han- dle your patients more safely, Doctor Dowling outlines the principles and precautions of the management of this disease. (21 minutes) (in color) 0121942 AN OUTLINE OF CYTOGENETICS A survey of the field of human cytogenetics, covering the development of the techniques which make chromosome studies practical - with LCDR Thomas R. Birdwell, MC, U.S.N., Head, Cytogenetics Division, Department of Pa- thology, U.S. Naval Hospital, San Diego, Calif. (16 minutes). 1503403 ANTIBODY AFFINITY AND BIOLOGICAL ACTIVITY: PART I "Measurement of Antibody Affinity." A discus- sion of the binding affinity of antibodies for the antigenic determinant, and a description of the two methods used for measuring affinity: equili- brium dialysis and fluorescence quenching. With Gregory W. Siskind, M.D., Assistant Professor of Medicine, New York University Medical Center. (15 minutes). 0103613 ANTIBODY AFFINITY AND BIOLOGICAL ACTIVITY: PART II "Measurement of Antibody Affinity." Gre~Qry W. Siskind, M.D., Assistant Professor of Medicine, New York University Medicine Center, discusses fluorescence quenching for measuring the bind- ing affinity for antibodies for the antigenic determinant. (14 minutes). 0103714 ANTIBODY AFFINITY AND BIOLOGICAL ACTIVITY: PART III "Biological Significance of Antibody Affinity." Gregory W. Siskind, M.D., Assistant Professor of Medicine, New York University Medical Center, discusses the heterogeneity of the immune response with respect to antibody affinity and the effects of affinity on in vivo antibody activity. (16 minutes). 0103815 All programs in this catalOg are copyright by the Network for Continuing Medical Education. Duplication, reproduction, or distribution in any form of all or any part of the programs is prohibited without the express written consent of NCME. BLOOD CELL NEOMORPHOLOGY IN HEMATO- LOGIC DISEASE, with Wallace N. Jensen, M.D., Lawrence S. Lessin, M.1~., and Dennis S. O'Leary, M.D., all of the Dspartment of Mcdi. cine, George Washington University School of Medicine, Washington, D.C. Advanced micro- scopic and cinematographic techniques have allowed reinterpretations of sort e older morpho- logic findings and afforded new observations concerning the reasons for changes in shapes and size of blood cells. The panel reviews the newer findings and offers a current interpre- tation of their significance. A Television Clinic of the American College of Physicians, 1974. Please inquire for special rental information. (60 minutes) (in color) ACP 2847480 BLOOD COMPONENT THERAPY - FACTOR VIII - RICH CRYOPRECIPITATE. The rational treat- ment of classical hemophilia using cryoprecipi- tate is discussed in this presentation by Carol Kasper, M.D., and Judith Pool, Ph.D., of the American Association of Blood Banks Compo- nent Therapy Workshop Program. The discovery of cryoprecipitate, dosage schedules, and clin- ical effectiveness are among the topics covered. (20 minutes). 0206106 BLOOD COMPONENT THERAPY - PLATELETS FOR TRANSFUSION. The importance of platelet transfusions in leukemia, in intensive cancer chemotherapy, and their usefulness In other dis- ease states: a report by Gerald S. Gilchrist, M.B., M.C.H., Assistant Professor of Pediatrics, Uni- versity of Southern California School of Medi- cine, and Director of the Platelet Donor Center, Children's Hospital of Los Angeles. (16 minutes). 0206408 BLOOD COMPONENT THERAPY - THE CLINI- CAL USE OF GAMMA GLOBULIN. Although safe and effective in many situations, gamma globulin may be contraindicated in others. Both of these areas are discussed by Paul Wehrle, M.D., Hast- ings Professor of Pediatrics, University of South- ern California, and Chief Physician, Children's Division of Los Angeles County General Hospital; Frans Peetoom, M.D., Director of Immunology, Hyland Laboratories; and E. R. Jennings, M.D., Clinical Professor of Pathology, University of California at Irvine, and Director of Pathology, Memorial Hospital of Long Beach. (20 minutes). 0206307 38 PAGENO="0393" COMPETITWE PROBLEMS IN THE DRUG INDUSTRY 14299 CHROMOSOMES BY MAIL As an alternative to the time-consuming and costly practice of transporting the patient to the testing center, there is now a practical method for shipping blood specimens Over long dis- tances for the )eukocyte chromosome culture and chromosome analysis. LCDR Thomas P. Birdwell, MC, U.S.N., Head, Cytogenetics Divi- sion, U.S. Naval Hpspital, San Diego, Calif., demonstrates the technique. (11 minutes). 0303810 CONTROL OF HEMOGLOBIN SYNTHESIS IN THE CHICK BLASTODERM - PART I - Preparation of the experimental model with Richard D. Le- vere, M.D., Assistant Professor of Medicine, Downstate Medical Center, State University of New York. (17 minutes). 0302946 CONTROL OF HEMOGLOBIN SYNTHESIS IN THE CHICK BLASTODERM - PART II - "The Effect of Delta Aminolevulinic AcId" - with Richard D. Levere, M.D., Assistant Professor of Medicine, Downstate Medical Center, State University of New York. (15 minutes). 0303047 CONVERSATION WITH GEORGES MATHE: IM- MUNOLOGICAL APPROACH TO THE TREATMENT OF LEUKEMIA, with Professor Georges Mathé, Director, Institut de Cancérlogie et d'lmmuno- genétique, Hopital Paul-Brousse, Villejuif, France; and Ernest H. Rosenbaum, M.D., Director Medical Cancer Service, and Director, Immuno. logical Research of Mt. Zion Hospital in San Francisco. NCME has videotaped several hours of candid conversation with French professor Georges Mathé, noted for his innovatiobs in treating leukemia. In this telecast, Professor Mathé `de- scribes how his active immunotherapy differs from. conventional leukemic therapy. (17 minutes). 031294.8 FINGERPRINTING MYOCARDIAL INFARCTION SERUM ENZYMES. How serum enayme analysis is used to increaSe diagnostic accuracy and what prognostic data are furnished are demon- strated by John S. Ladue, M.D., Ph.D., Assistant Professor of Clinical Medicihe, Cornell University School of Medicine, New York. (15 minutes). 0608104 GROWTH AND DIFFERENTIATION OF HUMAN LYMPHOCYTES~ PART I "Nucleic Acid Synthesis." A~flold D. Rubin, M.D., Associate in Medicine, Mount Sinai School of Medicine, demonstrates the techniques for ex- tracting nucleic acid from lymphocytes, focus- ing on RNA metabolism. (19 minutes). 0703912 GROWTH AND DIFFERENTIATION OF HUMAN LYMPHOCYTES: PART II, ABNORMAL NUCLEIC ACID SYNTHESIS IN LEUKEMIA Arnold 0. Ruhin, M.D., Associate in Medicine, Mount Sinai School of Medicine, New York, con- ducts an investigation of abnormal growth pat terns of lymphocytes taken from patients. with lymphoproliferative disorders. (20 minute$). 0704713 HEMODYNAMICS - AN INSTRUCTIONAL DE- VICE. A mechanical model of the Cardiovascular `system is demonstrated and discussed by Simon Rodbard, M.D., Chief of Cardiology, City of Hope Medical Center, Duarte, California. Designed by Dr. Rodbard as a teaching aid, the machine simulates normal blood flow, and, by opening or closing the appropriate valves, demonstrates cardiovascular dysfunction, as well. (15 minutes). 0~08303 HOME TRANSFIJ$.ION FOR HEMOPHI~JA PA- TIENTS, with S. Frederick Rabiner, M,D.., I~irSctor of the Clinical Hematology Unit, Michael Reese Hospital and Medical Center, Chicago; and Asso- ciate Professor of Medicine at the University of Chicago Pritzker School of Medicine. Hemophilia patients can be administered anti-hemophiliac factor by trained~ relatives in the home, on vaca- tion - almost anywhere. This is the experience of a three-year program at Michael Reese Hospi- tal. The program, the training for relatives and the results are discussed and shown In this telecast. (20 minutes) (in color) 0813117 HUMAN CYTOGENETICS "Indications for Cytogenetic Testing" ~ LCDR Thomas R. Birdwell, MC, U.S.N., Head, Cyto- genetics bivisiop, U.S Naval Hospital, San Diego, Calif., presents some of the indications for primary amenorrhea, investigation of female and male sterility, differential diagnosis of con- genital defects in the newborn, differential diag- riosis of chronic myelocytic leukemia, investiga- tion of intersex, family counseling, and 8enetic prognosis. (14 minutes). 0803707 IDENTIFICATION AND GROUPING OF CHROMOSOMES LCDR Thomas R, Birdwell, MC, U.S.N., Head, Cytogenetics Divlsion, Department of Pat~iology, U.S. Naval Hospital, San Diego, Calif., discusses the features of the model chromosome and then demonstrates the technique of identifying and grouping chromosomes in karyotypes. (16 minute~). 0903501 IN VITRO STUDIES OF HUMAN LYMPHOCYtES - PART I - "Lymphocyte Culture and Re~ponse to Antigens" - with Kurt Hirschhorn, M.D., Pro- fessor of Pediatrics and Chief, Division o~ Medi- cal Genetics, Mount Sinai School of Medicine, (19 minutes). 0903112 39 PAGENO="0394" 14300 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY IN VITRO STUDIES OF HUMAN LYMPHOCYTES: PART II "Mixed Lymphocyte Culture and Histocompati- bility" -~-- with Kurt Hirschhorn, MD., Professor of Pediatrics and Chief, Division of Medical Genetics, Mount Sinai School of Medicine (15 mInutes). 0903213 MULTIPLE MYELOMA: A CONTROLLABLE DIS- EASE, with Raymond Alexanian, M.D., Associate Professor of Medicine, University of Texas, M.D. Anderson Hospital and Tumor Institute, Houston. In three patients, Doctor Alexanian points out the clinical and laboratory abnormalities in multi" pIe myeloma along with the tests needed to con- firm the diagnosis. (17 minutes) (in color) 1322055 OBTAINING AND CULTURING LEUKOCYTES FOR CHROMOSOME ANALYSIS Demonstrating a simple method of obtaining chrolnosomes for study and analysis - with LCDR Thomas R. Birdwell, MC, U.S.N., Head, Cytogenetics Division, Department of Pathology. U.S. Naval Hospital, San Diego, Calif. (15 minutes). 1503402 REGULATION OF BLOOD FLOW BY THE CAPIL- LARY. A challenge to the theory that blood flow is regulated by the smooth muscle of the ar- terioles is presented by Simon Rodbard, M.D., Chief of Cardiology, City of Hope Medical Center, Duarte, California. By means of the "capillaron," a mechanical device that he has constructed to show a `packet" of cells supplied by one or more capillaries, he offers the point of view that regulation of blood flow and perfusion of the tissues are controlled at the capillary level. (13 minutes). 1805208 RH DISEASE - PART I - PREVENTION, Anti D gamma globulin, an antigen which has proved successful in preventing Rh sensitization in pregnant women, is described by Edward T. Bowe, M.D., Instructor, Obstetrics and Gyne- cology, College of Physicians and Surgeons, Co- lumbia University, New York. (15 minutes). 1805618 RH DISEASE - PART II - MANAGEMENT - AMNIOCENTESIS. Edward T. Bowe, M.D., In- structor, Obstetrics and GynecoIog~, College of Physicians and Surgeons, Columbia University, discusses the etiology, incidence, and diagno- sis of Rh immunization, with particular empha- sis on the usefulness of amniocentesis in man- agement of the disease. (15 minutes). 1805719 RH DISEASE - PART III - MANAGEMENT - INTRAUTERINE TRANSFUSION. The intraperi- toneal infusion of 0 neg. red cells to an Rh positive fetus is `not an occasional procedure" and demands an obstetric team skilled in the technique, according to Edward T. Bowe, M.D., Instructor, Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia Univer- sity. The intrauterine procedure is demonstrated in this telecast, and Dr. Bowe also covers the criteria for selecting patients, the risk to the fetus, and the over-all rates of success of the procedure compiled from several U.S. hospitals. (10 minutes). 1805820 SICKLE-CELL ANEMIA: MANAGEMENT, with Ro- land B. Scott, M.D., Professor and Head of the Department of Pediatrics, Howard University, and Chief Pediatrician at Freedmen's Hospital in Washington, D.C. There is no curative treatment for sickle-cell anemia, according to Dr. Scott. However, early diagnosis of the disease, which afflicts more than 50,000 black Americans, can ameliorate the most disturbing symptoms. Dr. Scott de- scribes the therapeutic program he follows to enhance Survival until the patient reaches puberty - when the natural course of the dis- ease process appears to become attenuated. (14 minutes) (In color) 1911506 SICKLE-CELL ANEMIA: SUSPICION AND DIAG- NOSIS IN INFANTS AND CHILDREN, with Roland B. Scott, M.D., Professor and Head of the De- partment of Pediatrics, Howard University, and Chief Pediatrician at Freedmen's Hospital in Washington, D.C. Also V. Bushan Bhardwaj, M.D., Assistant Professor of Pediatrics, Howard University, and Pediatric Hematologist, Freed- men's Hospital. Sickle-cell anemia afflicts more than 50,000 Americans of African descent. Perhaps another two million Americans carry the trait. Until recently, it was believed that little could be done for the disease. Now relief from the symptoms and a prolonging of life are possible. This telecast featureC the characteristics of the disease, and the laboratory procedure followed to establish a conclusive diagnosis. (20 minutes) (in color) 1911407 STRUCTURE AND FUNCTION OF IMMUNOGLOB- ULINS, with Edward C. Franklin, M.D., Assistant Professor of Medicine, New York University Medical Center. (15 minutes). 1900919 40 PAGENO="0395" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY j4301 THE SYMPTOM, ANEMIA: A DIFFERENTIAL DIAG~ NOSIS, with Herbert C. Lichtman, M.D., Pro. fessor of Medicine at the Downstate Medical Center, Brooklyn, New York. Dr. Lichtman and two third-year medical students participate In a teaching session in which one patient case hIs- tory is traced. Anemia is a concern in this proS gram only as it pertains to the process of arriving at a differential diagnosis. Dr. Lichtman offers the pattern he follows in arriving at a diagnosis and warns against approaches that will void a diagnosis. (21 mInutes). 1910624 TRANSFUSION THERAPY: THE GROWING IMPACT OF FROZEN BLOOD, with Charles Huggins, M.D., Director of the Blood Bank and Transfusion Serv- ice, Massachusetts General Hospital, Boston, Blood transfusion therapy as it is practiced in a major medical center, with guidelines to the use of fresh and freshly frozen components. (14 minutes) (in color) 2022139 HOSPITAL MEDICINE A NEW HOSPITAL APPROACH TO ADOLESCENT CARE, with Michael I. Cohen, M.D., Director of the Division of Adolescent Medicine; and Iris Litt, M.D., Assistant Director. The division is part of the Department of Pediatrics, Montefiore Hos- pital in New York City. What advantages are there to an adolescent cen- ter within a hospital? With the help of young patient, Dr. Cohen and Dr. Lift show many benefits of establishing an adolescent unit as a distinct service of a general hospital. (17 mInutes) (in color) 1411107 CLINICAL PHARMACY: THE PHYSICIAN'S VIEW. POINT, with Padraig Carney, M.D., Chief of Staff, Memorial Hospital Center of Long Beach, Cali- fornia, and William E. Smith, Jr., `harm. D., Director, Pharmacy and Central Services, Memorial Hospital Center of Long Beach, Cali- fornia. Although Clinical Pharmacy has only recently gained wide attention, it has been oper- ating at Long Beach since 1959. Dr. Carney gives a candid evaluation of the Clinical Pharma. cist as a member of the patient-care team, against a background of specific demonstrations provided by Dr. Smith and his staff. (21 mInutes) (In ColOr) 0315672 LEGAL PROBLEMS ON THE WARDS. What conS stitutes a proper informed consent for medical treatment? In what circumstances can informa- tion be legally withheld from a patient? What are the consequences of altering a patient's medical record? Points to know about the law to protect a patient's rights, and safeguard physician li- ability are discussed by William Mangold, M.D., J.D., resident in surgery at Bexar County Hos- pital, San Antonio, and columnist for The New Physician; and Crawford Morris, Esq., trial lawyer specializing in medical malpractice cases for Arter & Hadden Associates, Cleveland. (23 mInutes) (In color) ` SAMA 2810962 MEDICAL ADVANCES INSTITUTE: AN NCME RE- PORT. MAI, an organization of physicians in Ohio advocating a system of health care review, is providing guidance to physicians in that state who are attempting to establish Professional Standards Review Organizations. Neither the MAI system nor any other has yet been totally accepted by HEW as a model system for PSRO. 17 mInutes) (in color) 1321454 MEDICAL ASPECTS OF CONSTANT CORONARY CARE UNITS IN A GENERAL HOSPITAL The problem of the rhythm death following myo- cardial infarction has provided the stimulus for development of cardiac resuscitation and cardiac monitoring units. The required equipment and techniques are discussed and demonstrated by Richard Watts, M.D., Head, Cardiovascular Sec- tion, Department of Medicine, FairvleW General Hospital, Cleveland, Ohio. (14 minutes)- 1303923 NEW IV. TECHNIQUE FOR TOTAL NUTRITIONAL SUPPORT. Maintaining patients on IV feeding for long periods of time with satisfactoI~y results can now be accomplished with an indwelling catheter. The technique and its use on patients are demonstrated by Stanley J. Dudri~k, M.D., and Douglas W. Wilmore, M.D., Department of Surgery, and Harrison Department of Surgical Research, University of Pennsylvania School of Medicine, Philadelphia, Pa. (20 mInutes). ~406708 PREVENTION OF HOSPITAL INFECTIONS, with Harold C. Neu, M.D., Associate Professor of Med- icine and Chief, Division of Infectious Diseases, Columbia University College of Physicians and Surgeons, New York City. Dr. Neu takes us into an intensive care unit to demonstrate not only the physician's role in preventing nosocomial infections but also his sometimes unwitting role in causing them. (19 minutes) (in color) 1615840 41 PAGENO="0396" 14302 COMPETrTIVE PROBLE~tS IN THE DRUG INDUSTRY PSRO: THE ISSUE OF 1974, with Senator Wal- lace F. Bennett (R.Utah); James L. Henry, M.D., President, Ohio State Medical Association; Robert B. Hunter, M.D., member, AMA Board of Trustees; and J. Lewis Schricker, Jr., M.D., Pres. ident, Utah State Medical Association. Edmund D. Pellegrino, M.D., Chancellor for Health Sciences, University of Tennessee, is moderator. Senator Bennett's controversial PSRO amend- ment to Public Law 92-603, the Social Security Act, is outlined and examined. Dr. Pellegrino challenges panelists with major questions sur- rounding the legislation. Topics include PSRO's cost, effect on malpractice liability, and possible interference in the practice of medicine. 122 minutes) (in coler) 1620947 THE IMPORTANCE OF PEER REVIEW, with Ralph S. Emerson, M.D., Chairman, Ad Hoc Committee on peer review, Medical Society of the State of New York. Peer review is no longer a professional persuasion, it is a government mandate under the Medicare and Medicaid laws. Dr. Emerson points out the benefits of a properly established and executed peer review committee. He dis- cusses the benefit of review committees to the public; and to physicians as an organized voice in policy making. 113 minutes). 0910603 THE PROBLEMORIENTED MEDICAL RECORD, with Paul Y. Ertel, M.D., Associate Professor of Pediatrics, Ohio State University College of Medicine, Columbus, Ohio. This Special Workshop offers a comprehensive picture of what physicians and other health professionals need to know to initiate and main- tain Problem-Oriented Medical Records. This unique interactive Workshop combines tele- vision instruction arId workbooks which include POMR forms for the participants to use as they work along with the videotape. Please inquire for special rental information. (50 minutes) (in color) 2800048 UNDERSTANDING STATISTICS - PART I. Dr. Vernon E. Weckwerth, Associate Professor, Pro- gram in Hospital Administration, University of Minnesota, shows how the probability distribu- tions used by the statistician are directly analo~ gous to the use of experience by administrators as a guide in making decisions. (15 minutes). 2700103 UNDERSTANDING STATISTICS - PART II. "Ac- counting." Robert E. Linde, Director of Finance, American Hospital Association, explains the sig- nificance of reports prepared by the accountant to assist the administrator in declsion~making. (15 minutes). 2700204 A Workshop Conference on Computer Applica- tions to Hospital Dietetic Information A series of 11 lectures, demonstrations, and discussions taped during two workshops cosponsored by Ohio State University, Division of Medical Die- tetics, College of Medicine, and the Health Facil- ities Planning and Construction Service (Hill. Burton Program), United States Public Health Service, Department of Health, Education, and Welfare, and held at Columbus, Ohio, during the summer of 1967. Although not produced by NCME the Network makes these tapes available through special arrangements with the Public Health Service. Please note that these are not conventional tele- vision programs, but rather videotape recordings made at portions of a live workshop. Because of the value placed on the videotapes by the Pub- lic Health Service, NCME has agreed to make these programs available through its library, A WORKSHOP CONFERENCE ON COMPUTER APPLICATIONS TO HOSPITAL DIETETIC INFOR. MATION - PART A. John P. Casbergue, Asso- ciate Professor, Ohio State University. Co- lumbus, Ohio. Introduction and Orientation to the Conference and Evolution of Electronic Data Processing. Mr. Casbergue sets the scene for the four.day conference. 2800015 A WORKSHOP CONFERENCE ON COMPUTER APPLICATIONS TO HOSPITAL DIETETIC INFOR- MATION - PART B. George Christakis, M.D., Associate Professor, Community Medicine (Nu- trition), Mt. Sinai School of Medicine, New York. Dietetics and Computers, Their Role in Com- munity Health, Dr. Christakis presents the ra- tionale for the marriage of dietetics and com- puters for community health. 2800016 A WORKSHOP CONFERENCE ON COMPUTER APPLICATIONS TO HOSPITAL DIETETIC INFOR- MATION - PART C. John P. Casbergue, and James Griesen, Systems Analyst, School of Al- lied Medical Services, Ohio State University. Basic Computer Concepts in Review. The lec- turers describe what is meant by electronic data processing and systems design, using rele~ vant dietary concepts. 2800017 A WORKSHOP CONFERENCE ON COMPUTER APPLICATIONS TO HOSPITAL DIETETIC INFOR- MATION - PART ID. Jordan Baruch, D.Sc., Director, MEDINET, Watertown, Massachusetts. Medical Information Systems and Their Impli- cations for Patient Medical and Dietetic Care. Dr. Baruch discusses medical information sys~ tems and their implications for patient, medical,, and dietetic care. 2800018 42 PAGENO="0397" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14303 A WORKSHOP CONFERENCE ON COMPUTER APPLICATIONS TO HOSPITAL DIETETIC INFOR- MATION - PART E. James Griesen. Systems Analysis and the Role of the Dietitian in Plan- ning the Use of Electronic Data Processing. Mr. Griesen answers the question, What does elec- tronic data processing mean to the hospital die- titian?" 2800019 APPLICATIONS TO HOSPITAL DIETETIC INFOR- A WORKSHOP CONFERENCE ON COMPUTER MATION - PART F. John P. Casbergue. Plan ning a Dietary Information System: Goals and Data Requirements. Mr. Casbergue lists the kinds of information required to meet pre established system goals. 2800020 A WORKSHOP CONFERENCE ON COMPUTER APPLICATIONS TO HOSPITAL DIETETIC INFOR- MATION - PART G. John P. Casbergue. Demon. stration of a Model Dietary Information System. Data are put into the computer and information is printed out in this live demonstration. 2800021 A WORKSHOP CONFERENCE ON COMPUTER APPLICATIONS TO HOSPITAL DIETETIC INFOR- MATION - PART H. Paul Konnersman, Con~ sultant, MEDINET, Watertown, Mass. Planning Considerations in the Use of Electronic Data Processing Systems. A discussion and demon. stration of the mathematical foundations of computer-assisted menu planning and how C.A.M.P. assists in writing the menu. This lec. ture supplements that given by Dr. Baruch in PART D. 2800022 A WORKSHOP CONFERENCE ON COMPUTER APPLICATIONS TO HOSPITAL DIETETIC INFOR. MATION PART I. John P. Casbergue. The Role of Education for the Professional and Non- professional in Planning the Use of Electronic Data Processing. The need for in~service educa- tion is stressed. 2800023 A WORKSHOP CORFERENCE ON COMPUTER APPLICATIONS TO HOSPITAL DIETETIC INFOR- MATION - PART J. Joseph L. Balinfly, D.Eng., Professor, Computer System Research, School of Business Administration, Tulane University; and Ronald L. Gue, Ph.D., Director of Research Division, Center for Health and Administration, University of Florida. A Demonstration and Dis- cussion of Computer-Assisted Menu Planning. A discussion and demonstration showing how the computer can assist in writing the menu. 2800024 A WORKSHOP CONFEREF'(CE ON COMPUTER APPLICATIONS TO HOSPITAL DIETETIC INFOR- MATION - PART K. John P. Casbergue. Second Conference: Final Discussion and Summary. A lively and varied topic discussion among the participants and the staff of the second confer- ence. Each conference group stressed different needs-in their discussion. 2800025 INFECTIOUS AND PARASITIC DISEASE ANTIBIOTIC MISADVENTURE: "THE CASE OF OVERKILL," with Harold C. Nec, M.D., Chief of Infectious Diseases, Columbia University College of Physicians and Surgeons, New York City. Test your prescribing ability by following the day- by-day reports on a 70-year-old male patient ad- mitted to the hospital with shaking chills, pleuri- tic pain, headache, fever, rapid respiratIons and pulse. This program is part of the "Drug Spot- light Program" sponsored by the American So- ciety for Clinical Pharmacology and Therapeutics. (8 minutes) (in color) 0118636 ANTIBIOTIC MISADVENTURE: "THE CASE OF SUPERINFECTION, PAR EXCELLENCE,'~ with Harold C. Neu, M.D., Chief of Infectious Dis- eases, Columbia University College of Physicians and Surgeons, New York City. See if you c~n find all of the prescribing mistakes made in this case, which started as a relatively sim~l~ prob- lem-a 71-year-old woman complaining of fa- tigue and nausea, with abdominal mass, e'evated body temperature and white count. (This pro- gram was presented as part of the American Society for Clinical Pharmacology and Therapeu- tics' Drug Spotlight Program.) (13 minutes) (in color) 0118737 ANTIMICROBIAL TOXICITIES: FROM OFFICE TO 1-IOSPITAL, with Harold C. Neu, M.D., Associate Professor of Medicine and Head, Division of In- fectious Diseases, Columbia University College of Physicians and Surgeons, New York City. Help manage a patient with chronic urinary tract in- fection. As the case unfolds, you select the most effective drug, manage various unexpected com- plications, and alter or stay with your choice given a variety of clinical situations. (20 minutesl (in color) 0122343 ANTIMICROBIAL TOXICITIES: THE INNOCUOUS SETTING, with Harold C. Neu, M.D., Associate Professor of Medicine and Head, Division of In- fectious Diseases, Columbia University College of Physicians and Surgeons, New York City. Which antibiotics are effective and least toxic for the patient who has staphylococcal cellulitis - - - vaginitis - - - otitis media and externa? To test your skills in prescribing, help manage a patient with these problems. (13 wioutes) (in color) 0121840 43 PAGENO="0398" 14304 COMPETfl~WE PROBLEMS IN THE DRUG INDUSTRY BACTERIAL MENINGITIS: RAPID ASSESSMENT AND TREATMENT, with Paul F. Wehrle, M.D., Professor of Pediatrics, University of Southern California School of Medicine, and Allen W. Mathies, Jr., M.D., Professor of Pediatrics, Uni' versity of Southern California School of Mcdi. cine, Los Angeles. An estimated 15,000 Amen. cans contract acute bacterial meningitis every year. Between 10 and 15 percent of these die, almost always within twenty-four hours of the onset of symptoms. Drs. Wehrle and Mathies review what the physician must know and do to institute therapy with the speed and precision which can beat the 24.hour deadline. (18 minutes) (in color) 0215315 BUGS vs. DRUGS: CAN WE COMBAT BACTE- RIAL RESISTANCE?, with Harold C. Neu, M.D., Associate Professor of Medicine and Chief, Divi- sion of Infectious Diseases, Columbia University College of Physicians and Surgeons. Dr. Neu employs semi-animated graphic art to answer the title's question with a qualified `Yes." He illustrates several of the mechanisms by which bacteria develop resistance and suggests ways in which knowledge of those mechanisms can be used against resistant strains. (15 minutes) (in color) 0215716 CHOLERA, 1971: RISK, DIAGNOSIS AND MAN- AGEMENT, with David J. Sencer, M.D., Director of the Center for Disease Control, Department of Health, Education and Welfare in Atlanta, Geor- gia; Philip S. Brachman, M.D., Chief of the CDC Epideminology Program; and EugeneJ. Gangarosa, M.D., Deputy Chief, Bacterial Diseases Branch, CDC Epidemiology Program. Cholera, feared since biblical times, is spreading throughout the world. As more tourists travel abroad, concern grows over contacting the disease and infecting the American continent. Three experts from CDC discuss the very small risk to America, and describe the simple steps that can be taken to diagnose and treat cholera among returning travelers. (17 minutes) (in color) 0312909 COUNSELLING THE VD PATIENT. The sexual overtones of venereal disease expose VP patients to a special complication . . . a value judgment of their behavior. Such judgment, however un- intentional, can detract from the treatment of the disease. Dr. Mary Howell of the Somerville Women's Health Project in Somerville, Massa- chusetts, Rev. Thomas Mauer of the University of Minnesota Human Sexuality Program and three medical students use role playing to il- lustrate these difficulties and discuss their solu- tion. (22 minutes) (in color) SAMA 2810860 CURRENT STATUS OF TF~ PROBLEM OF VE- NEREAL DISEASE, with Frank M. Calia, M.D., Department of Medicine, and R. C. Vail Robin- son, M.D., Division of Dermatology, both of University of Maryland School of Medicine; and Richard Hahn, M.D., Department of Medicine, the Johns Hopkins University School of Medi- cine. The panelists discuss the epidemiology, diagnosis and treatment of syphilis and gonor' rhea. Special emphasis given to methods of diagnosis in asymptomatic infections, extra- genital manifestations of gonorrhea, increasing penicillin resistance of the gonococcus, use of single dose therapy in gonorrhea, dermatologic manifestations of syphilis, and problems related to the serologic diagnosis of syphilis. A Television Hospital Clinic of the American College of Surg~ons, 1972. Please inquire for special rental information. (57 mInutes) (in colur) ACP 2857242 DID YOUR PATIENT GET HIS DISEASE ABROAD? with Kevin M. Cahill, M.D., D.T.M. & H. (Lond.), Director of the Tropical Disease Center at Lenox Hill Hospital, New York, and Professor of Tropi- cal Medicine, Royal College of Surgeons in Ire- land. Your patients may present you with ame- biasis or malaria if they travel, have been in Vietnam, have had contact with those who have been abroad or if they experiment with drugs. Dr. Cahill shows you how to diagnose and treat these diseases, and offers advice on prevention. (19 minutes) (in color) 0417540 DRUG INTERACTION: "THE CASE OF THE PUSHY ANTIBIOTIC," with Harold C. Neu, M.D., Head of Infectious Diseases, and Associate Professor of Medicine, Columbia University College of Physi- cians and Surgeons, New York City. When can the right selection of antibiotics be wrong? In four clinical situations, says Dr. Neu in this "Drug Spotlight Program," presented in cooper' ation with the American Society for Clinical Pharmacology and Therapeutics. (9 minutes) (in color) 0419146 DRUGS vs. BUGS: CHOOSING THE RIGHT ANTI' BIOTIC, with Harold C. Neu, M.D., Associate Professor of Medicine and Chief, Division of In- fectious Diseases, Columbia University College of Physicians & Surgeons, New York. The best way to choose an antibiotic is to match its antibacterial action to the organism's suscepti- bility. Dr. Neu uses lively graphics to demon' strate the metabolic effects of several commonly used antibiotics, and offers some practical ad- vice on choosing the right drug for the bug. (15 minutes) (in color) 0415632 44 PAGENO="0399" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14305 GONORRHEA: ELUSIVE EPIDEMIC, with Frank M. Calia, M.D., Chief Qf Infectious Diseases, Loch Raven Veterans Administration Hospital, and Associate Professor of Medicine, University of Maryland School of Medicine, Baltimore, Maryland. An aggressive approach to this seemingly Un. beatable venereal disease. Shows screening procedure for catching the silent carrier, and how to handle new oriental strains of DC. (20 mInutes) (In color) 0717417 GONORRHEA: A PLAGUE OUT OF CONTROL The incidence of gonorrhea is increasing at a rate of 10 to 15 per cent a year. Although many people jump to the conclusion that this is due to relaxed morals and increased liberality in sex, the National Communicable Disease Center in Atlanta, Ga., feels differently. Discussing the problem, new diagnostic techniques and ways to eradicate the disease are William J. Brown, M.D., and Leslie C. Norms, M.D., Chief of the Center's Venereal Disease Research Laboratory. (12 mInutes) (In color) 0709909 HERPES SIMPLEX: VIRAL DILEMMA, with Richard C. Gibbs, M.D., Associate Professor of Clinical Dermatology, New York University Medical Can- tar, New York City. A clinical presentation, stressing some precautions in the differential diagnosis and treatment of the herpes simplex virus, Types I and II. (13 minutes) (in color) 0820135 HEXACHLIIROPHENE: OPEN TO DEBATE, wIth Harold C. Neu, M.D., Associate Professor of Medicine and Chief, Division of Infectious Dis- eases; Stanley James, MD., Professor of Pediat- rics and Chairman of the American Academy of Pediatrics Committee on the Fetus and New- born) Carl Nelson, M.D., Professor of Dermatol- ogy and President of the American Dermatolog- ical Association. All of the participants are on the faculty of the Columbia University College of Physicians and Surgeons, New York City. Since December 15, 1971 bathing newborns with hexachiorophene, routine in most nurseries, has been banned by the F.D.A. and the American Academy of Pediatrics-or has it? Our panel looks at this new problem from several angles and comes up with some interesting conclusions. (Se minutes) (in color) 0815520 IMMUNIZATION FOR FOREIGN TRAVEL. Al- though Federal law requires certain immuniza- tion shots for Americans going abroad, physi- cians can recommend additional protection for their traveling patients by knowing what major diseases are endemic to particular areas of the world and prescribing the appropriate shots. Discussing this proposal is E. L. Buescher, M.D., Chief, Department of Virus Diseases, Walter Reed Army Institute of Research, Washington, D.C. (15 minutes) 0905702 INFECTIOUS MONONUCLEOUS, with James C. Niederman, M.D., Associate Clinical Professor of Epidemiology and Medicine, Yale University School of Medicine, New Haven, Conn. Diag- nosis and treatment of an important clinical entity-plus some of the burgeoning research implications. 116 minutes) (In Color) 0919525 KEEPING UP ON IMMUNIZATIONS, with ~aniuel L Katz, M.D., Prbfeos~r and Chairman of the Department of Pediatrics, Duke University Medi- cal School, and Chairman of the Commimtee on Infectious Disease of the American Academy of Pediatrics, Durham, North Carolina. Here's a quiz on preventive practice. Six cases point up some problems in "routine" office immunization. (18 minutes) (in color) 1121804 THE LABORATORY IN DIAGNOSIS OF PNEU- MONIA. Pneumonia continues to acc&int for 45,000 deaths each year. Treating a patient with drugs which may suppress but fail to eradicate the infecting organism may place him in jeop- ardy, and provides less than optimal care. Dis- covery of the etiologic agent is determined in the laboratory by such efforts as microscopic, cultural, serological and antimicrobial selisltivity tests, according to Robert Austrian, M.D., John Herr Musser Professor and Chairman, Depart- ment of Research Medicine, University of Penn- sylvania School of Medicine. 116 minutes). 1207201 `THE NATIONAL ANTIBIOTIC THERAPY TE~T." The National Antibiotic Therapy Test con*ists of a seventy-five minute videotape worksh~p with the objective of self-assessment and l~arning aboUt the proper use of antibiotics in medical practice. The practicing physician is confronted with patient problems requiring decision on the use or non~se of antibiotics. NATT was also designed for a broad range of medical specialties including the family phy- sician, the internist, the pediatrician, the oto- laryngologist, the urologist, the obstetrician! gynecologist, and the general surgeon. The test scores of the participating physician can be com- pared with those of other physicians throughout the country. The test is self-administered, and self-scored. Please call NCME for special price infOrmation which includes scoring folders. (70 minUtes) (in color) 2800075 Master Library services are made possilile through the support by Roche Labora- tories of the production and regular distri- bution of all NCME telecasts. 45 PAGENO="0400" 14306 COMPE.PrnVE PROBLEMS IN THE DRUG IN~DUSPRY THE NATIONAL ANTIBIOTIC THERAPY TEST: FIRST RESULTS, with Alan L. Goldberg, M.D., family physician Bronx, New York; Harold C. Neu, M.D., Head, Infectious Diseases, Columbia University College of Physicians and Surgeons, New York City; and Edmund D. Pellegrino, M.D., Prnfessor of Medicine and Chancellor for Health Sciences, University of Tennessee. `First Re suits on the National Antibiotic Therapy Test include 4,513 scores of physicians taking the examination. The national averages and how various specialty groups scored are among the results presented on this program. Five of the questions, the most difficult on the test, are reviewed. (17 minutes) (in color) 1420834 PARASITIC INFESTATION: LOOK FOR LICE, with Silas E. O'Quinn, M.D., Professor of Dermatology and Dean of Medicine; and Harold Trapido, Ph.D., Professor of Tropical Medicine and Medical Parasitology, both at Louisiana State University School of Medicine in New Orleans. A conipre- hensive look at what may be causing that tern ble itch. Knowledge of your patients' hygiene does not rule out lice. (1.1 minutes) (in color) 1620645 PARASITIC INFESTATION: SCABIES, with Silas E. O'Quinn, M.D., Professor of Dermatology and Dean of Medicine; and Harold Trapido, Ph.D., Professor of Tropical Medicine and Medical Parasitology, both at Louisiana State University SchOol of Medicine in New Orleans. Everything you a(ways wanted to know about mites but (were too busy) (forgot) to ask. (14 minutes) (in color) 1621348 PREVENTION OF HOSPITAL INFECTIONS, with Harold C. Neu, M.D., Associate Professor of Med- icine and Chief, Division of Infectious Diseases, Columbia University College of Physicians and Surgeons, New York City. Dr. Neu takes us into an intensive care unit to demonstrate not only the physician's role in preventing nosocomial infections but also his sometimes unwitting role in causing them. (19 minutes) (in color) 1615840 Each program is accompanied by a review card. NCME asks that the person for whom the program was ordered fill out and return this card. Because reevaluation of MasterLibrary videocassettes is a contin- ual process, return of the program review card is essential in helping NCME deter- mine which programs remain useful as re- sources for continuing medical education. PROBLEMS OF BACTERIAL INFECTION - PART I. With David H. Smith, M.D., Assistant Professor of Pediatrics, Harvard Medical School, and Children's Hospital Medical Center, Boston, Massachusetts. How do bacteria become resistant to antibiotics and what does this mean to physicians in the care of their patients? This problem is becoming increasingly difficult for physicians whose patients may suddenly cease to respond to a medication or may sud- denly develop "hospital-based" infections. In this presentation, Dr. Smith shows how these problems are being met. He demonstrates the selection process of drug resistance develop- ment in bacteria) populations and illustrates hospital-by-hospital, ward-by-ward differences in resistant pathogens. Dr. Smith emphasizes the need to determine the pattern of multiple in- fectious drug resistance of bacteria in a hospital environment, so that the most appropriate and effective drug can be prescribed. (16 minutes). 1607025 PROBLEMS OF BACTERIAL INFECTION - PART II. The need for physicians to understand the pattern of drug resistance that exists in hospital wards - . - and what to do with these vital data - . - is pointed up by David H. Smith, M.D., As- sistant Professor of Pediatrics, Harvard Medical School, and Children's Hospital Medical Center, Boston, Massachusetts. (16 mioutet). 1607126 ROCKY MOUNTAIN SPOTTED FEVER, with Theo- dore E. Woodward, M.D., Professor and Head, Department of Medicine, University of Maryland School of Medicine and Hospital, Baltimore. Using three patients with diagnoses in doubt, Doctor Woodward helps you arrive at the proper diagnosis, noting the distinguishing features of spotted fever and its mimicking diseases. (19 minutes) (in color) 1820329 RUBELLA. Albert McKee, M.D., Department of Microbiology, University of Iowa School of Medi- cine, discusses the isolation of the rubella virus and the problems that the disease causes in pregnancy. (26 minutes) 2800002 Master Library services are made possible through the support by Roche Labora- tories of the production and regular distri- bution of all NCME telecasts. 46 PAGENO="0401" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14307 THE RUBELLA IMMUNIZATION PROGRAM: A PROGRESS REPORT, with Saul Kmgman, M.D., Professor and Chairman of the Department of Pediatrics; and Louis Z. Cooper, M.D., Associate Professor of Pediatrics and Director of the Ru- bella Birth Defect Evaluating Project - both physicians from the New York University Medical Center, Bellevue Hospital, New York City; and John J. Witte, M.D., Chief of the Immunization Branch of the Center for Disease Control, Depart- ment of Health, Education and Welfare, Atlanta, Georgia. The Rubella Immunization Program has been in widespread use since the Summer of 1969. Three authorities on rubella report the findings of the Immunization Program and offer advice to practicing physicians based on the findings. (23 mInutes) (In cSlor) 1812823 SKIN TESTING FOR TB, with John A. Crocco, M.D., Director of Pulmonary Disease Section, St. Vincent's Hospital and Medical Center, New York; and Downstate Medical Center, Brooklyn, New York. A demonstration of the correct way to administer two types of TB skin tests, with guide- lines for their interpretation. (12 minutes) (In color) 1920637 A SPECIAL REPORT: RUBELLA IMMUNIZATION A timely program containing the latest informa. tion about the Rubella Vaccine, its development and its recommended administration is presented by H. Bruce Dull, M.D., Assistant Director of the National Communicable Disease Center in At- lanta, Ga. (22 minutes) (in color) 1908815 SYPHILIS: AN ERADICABLE PUBLIC HEALTH PROBLEM William J. Brown, M.D., Chief of the Venereal Disease Program at the National Communicable Disease Center in Atlanta, Ga., warns physicians of a false sense of security in dealing with syphilis because of recent development of drugs. The need for recognizing the various stages of syphilis is stressed with clear examples. (8 mInutes) (in color) 1909525 SYPHILIS: BE SUSPICIOUS, with Frank M. Caila, M.D., Chief, Infectious Diseases, Loch Raven Veterans Hospital, and Associate Professor of Medicine, University of Maryland School of Medicine, both in Baltimore. A new look at an old enemy, with emphasis on the pms and cons of a variety of serologic tests. (15 minutes) (in color) 1917628 TUBERCULOSIS: A NEW MEDICAL CHALLENGE FOR THE SEVENTIES, with Vernon N. Houk, M.D., and Phyllis Edwards, M.D., of the TuberS culosis Section of the National Communicable Disease Center; and William W. Stead, M.D., Professor of Medicine at Marquette School of Medicine in Milwaukee. Tb is frequently diag- nosed as pulmonary fibrosis. The epidemiology of the disease in the U.S. today is shown, along with the current approach to its eradication. (17 minutes) (In color) 2010419 ZOSTER: ITS COURSE AND TREATMENT, with Richard C. Gibbs, M.D., Associate Professor of Clinical Dermatology, and Philip A. Brunch, M.D., birector, Laboratoryof Infectious Disease, Pedi- atrics Department; both of New York University Medical Center In New York City. Recommends treatment for the severe pain of this generally one-time, but unforgettable, illness. (9 minutes) (in color) 2620201 INSTRUMENTATION AND COMPUTERS A COMPREHENSIVE INTENSIVE CARE UNIT IN A GENERAL HOSPITAL- PART I - "History and Organization" - with Albert H. Dougl5s, M.D., Director, Department of Medicine, and Erwin Lear, M.D., Director, Departthent of Anesthesiology, Queens Hospital Center; Edward Meilman, M.D., Physician-in-Chief of Medicine, and Charles Trey, M.D., Attending Physician, The Long Is- land Jewish Hospital. (17 minutes). 0301931 A COMPREHENSIVE INTENSIVE CARE UNIT IN A GENERAL HOSPITAL - PART II - `Clinical Applications" - with Albert H. Douglas, M.D., Director, Department of Medicine, and Erwin Lear, M.D., Director, Department of Anesthesi- ology, Queens Hospital Center: Edward Meilman, M.D., Physician-in-Chief of Medicine, and Charles Trey, M.D., Attending Physician, The Long Is~ land Jewish Ho~,pital. ~16 mInutes). `0302032 ADVANCES IN GASTROSCOPY The value of gastroscopy is discussed by Charles S. Winans, M.D., Instructor in the Department of Medicine at the University of Chicago Pritzker School of MedicinC, and demonstrated by Selbi Kobayashi, M.D., Research Fellow at the same institution. (59 mInutes) (In color) 0108905 AUTOMATIC ELECTROCARDIOGRAPHIC SCREEN- ING. A portable digital~anaIogue computer is being tested as an electrocardiographic screenS ing device, Weldon J. Walker, M.D., Director, Cardiopulmonary Laboratory, White Memorial Medical Center, Los Angeles, demonstrates the equipment and discusses its~future. 111 mInutes). 0105522 47 73-617 0 - 76 - 26 PAGENO="0402" 14308 COMPETITIVE PROBLEMS IN THE DRUG IN'DUSTRY CARE OF THE CRITICALLY ILL. How new tech- niques of monitoring and computers are con- tributing to the care of the acutely ill patient are demonstrated by Paul K. Hanashire, M.D., Assistant Prpfessor of Medicine, University of Southern California School of Medicine. (16 mInutes). 0307603 COMMON PITFALLS IN ECG RECORDING, with Nanette K. Wenger, M.D., ProfessOr of Medicine (Cardiology), Emory University School of Medi- cine, and Director of the Cardiac Clinics, Grady Memorial Hospital, Atlanta. Electrical interfer- ence, machine malfunction, and improper patient preparation and ECG recording technique can give you tracings which are impossible to inter- pret properly. Dr. Wenger shows how to help your office assistant avoid these pitfalls. (11 minutes) (in color) 0317574 COMPUTER ANALYSIS OF THE ELECTROEN- CEPHALOGRAPH Demonstrating the unique suitability of the computer for quantitating the large amount of information recorded by the electroencephalo- graph and for comparing findings and removing artifacts - with Julius Korein, M.D., Assistant Professor of Neurology, New York University Medical Center and Bellevue Hospital Center. (16 mInutes). 0303333 COMPUTER TECHNIQUES AS AN ADJUNCT TO CLINICAL IMPRESSIONS IN THE EVALUATION OF DRUG RESPONSE - PART I - "The First Five Weeks." Burton J. Goldstein, M.D., Chief, Division of Research, Department of Psychiatry, University of Miami School of Medicine, presents the design of a research project and a demon- stration of computerized patient tests. (14 minutes). 0302136 COMPUTER TECHNIQUES AS AN ADJUNCT TO CLINICAL IMPRESSIONS IN THE EVALUATION OF DRUG RESPONSE PART II - "Clinical Evaluation." John Caidwell, M.D., Professor of Psychiatry and Head, Department of Psychiatry, Burton J, Goldstein, M.D., Chief, Division of Re- search, Department of Psychiatry, and the Psy- chiatric staff, University of Miami School of Medicine, evaluate a patient's progress under specific drug therapy. (25 minutes). 0302237 COMPUTER TECHNIQUES AS AN ADJUNCT TO CLINICAL IMPRESSIONS IN THE EVALUATION OF DRUG RESPONSE - PART Ill - Conclu- sions." Burton J. Goldstein, M.D., Chief, Division of Research, Department of Psychiatry, Univer- sity of Miami School of Medicine, and Dean J. Clyde, Ph.D., Director, Computer Center, Univer- sity of Miami, demonstrate the usefulness of a computer in evaluating patient data. (15 minutes). 0302338 CRYOSURGERY A demonstration of the treatment of chronic en- docervicitis with cryosurgery, and a discussion of its advantages in other gynecologic proce- dures. With Sidney Lefkovics, M.D., Chief, Sec- tion of Obstetrics and Gynecology, St. Barnabas Hospital, Livingston, New Jersey. (16 minutes). 0303556 CRYOSURGERY, A CATARACT PROCEDURE The special indications and technique for utiliz- ing the cryostylet in cataract surgery are demon- strated and discussed by Gerald Fonda, M.D., Director, Ophthalmology Division, Department of Medicine, St. Barnabas Medical Center, Living- ston, New Jersey. (13 minutes). 0303957 DIAGNOSTIC ULTRASOUND--PART I-ULTRA- SONOGRAPHY OF THE HEART, The use of ultra- sound in diagnosing pericardial effusion as well as for the study of the motion of prosthetic heart valves is demonstrated by Joseph H. Homes M.D., Professor of Medicine and Head of the Division of Renal Disease, University of Colorado Medical Center, Denver, Colorado. (19 minutes). 0408110 DIAGNOSTIC ULTRASOUND-PART Il-CLINI- CAL ULTRASONOGRAPHY IN OBSTETRICS AND GYNECOLOGY. The use of sound waves to mon- itor the fetus In utero'is illustrated by Horace E. Thompson, M.D., Associate Professor of Ob- stetrics and Gynecology, University of Colorado Medical Center, Denver, Colorado. (16 minutes). 0408211 DIFFERENTIAL DIAGNOSIS OF EARLY CERVICAL LESIONS, with Albert B. Lorincz, M.D.. Professor of Obstetrics and Gynecology; George L. Weld, M.D., Professor of Obstetrics and Gynecology and Director of the School of Cytotechnology; and Jester D. O'Dell, M.D., Clinical Associate in Obstetrics and Gynecology. All are affiliated with the University of Chicago Pritzker School of Medicine and the Chicago Lying-In HoSpital. These three physicians resolve some of the *prob~ lems of evaluating borderline cervical smears and offer guidance to the timeliness of surgery. They also diScuss colposcopy and offer alter- natives to the physician who does not have access to a colposcope. (19 minutes) (in color) 0410816 ECHOENCEPHALOGRAPHY: A NEW, SAFE, SIMPLE, AND PRACTICAL DIAGNOSTIC AID William M. McKinney, M.D., of the. Department of Neurology, Bowman Gray School of Medicine and North Carolina Baptist Hospital in WInston- Salem, North Carolina, and Frederick L. Thur- stone, Ph.D., of the Biomedical Engineering De- partment of Duke University, Durham, North Carolina, illustrate the unique value of echoen- cephalography in determining brain pathology. (15 mInutes). 0509403 48 PAGENO="0403" COMPEPIPWE PROBLEMS IN THE DRUG INDUSTRY j4309 EVALUATING CARDIAC CATHETERIZATION IN AORTIC VALVE DISEASE, with Adolph Hutter, M.D., Associate Director of the Coronary Care Unit and Assistant in Medicine at Massachusetts General Hospital, and Instructor in Medicine at Harvard Medical School; and Peter Block, M.D., Assistant in Medicine at Massachusetts General and Instructor in Medicine at Harvard, Boston. Two members of the Harvard faculty demon- strate when cardiac catheterization should be performed. They show the complications asso- ciated with the operation. And, they make the distinction in the problems of catheterizing children and adults. (16 minutes). 0512916 EVALUATING CARDIAC CATHETERIZATION IN MITRAL VALVE DISEASE, with Adolph Hutter, M.D., Associate Director of the Coronary Care Unit and Assistant in Medicine at Massachusetts General Hospital, and Instructor in Medicine at Harvard Medical School; and Peter Block, M.D., Assistant in Medicine at Massachusetts General and Instructor in Medicine at Harvard, Boston. Two physicians on the Harvard faculty present their second NCME program on cardiac cathe. terization. In this telecast, they describe the in- dications and advantages of a generally benign right heart catheterization to determine the severity of a mitral valve lesion. (15 minutes) (in color) 0513017 EXCHANGE TRANSFUSION FOR LIVER FAILURE The use of exchange transfusion to reverse the path toward acute hepatic failure Is demon- strated by Joseph C. Darin, M.D., Professor of Medicine at Marcluette School of Medicine In Milwaukee, Wisconsin. (17 minutes) (in color) 0509813 FROM TOP TO BOTTOM: A FIBEROPTIC VIEW OF THE BODY, with Howard J. Eddy, M.D., At- tending Surgeon, Community Hospital, Doctors Hospital and St. John's Hospital, Long Island, New York; and Richard S. McCray, M.D., Asso~ ciate Director of the Clinical Gastrointestinal Unit, St. Luke's Hospital, and Associate in Mcdi. cine, Columbia University College of Physicians and Surgeons, New York City. Fiberoptic instru- ments now available permit the clincian to in- spect, biopsy, and even treat lesions in the esophagus, stomach, duodenum and colon. Dr. McCray, a gastroenterologist, takes viewers on a trip through the upper GI tract. Dr. Eddy, a colon and rectal surgeon, shows lesions of the lower tract and removes a benign polyp using the instrument. (30 minutes) (In color) 0616715 GASTROINTESTINAL CYTOLOGY - A VALUABLE DIAGNOSTIC PROCEDURE: PART I Application and Results." Confirming ~ diagno- sis without surgery through the use of Papanico~ laou staining of cells from the gastrointestinal tract - with Charles Norland, M.D., Assistant Professor of Medicine, University of Chicago. (16 mInutes). 0703303 GASTROINTESTINAL CYTOLOGY: PART II `Techniques and Methods of Interpretation." Demonstration of the techniques of tubular in- tubation, stomach washing, and slide staining utilized in. this diagnostic prQcedure - with Charles Norland, M.D., Assistant Professor of Medicine, University of Chicago School of Mcdi. CiflO. (17 minutes). 0703404 LARYNGOGRAPHY: PART I Procedures and Normal Findings." A demon- stration of the technique for performing the laryngogram, and a discussion of the normal structures of the larynx - with George Stassa, M.D., Assistant Professor of Radiology, New York Hospital - Cornell Medical Center. (18 mInutes) (In color) ~203704 LARYNGOGRAPHY: PART II `Some Abnormal Findings." Contrast laryngog- raphy enables the radiologist to evaluate the various disease processes occurring in the larynx. George Stassa, M.D., Assistant Professor of Radiology, New York Hospital - Cornell Medical Center, reviews the abnormal findings that might be detected with this technique. 114 minutes). 1203905 MEDICAL ASPECTS OF CONSTANT CORONARY CARE UNITS IN A GENERAL HOSPITAL The problem of the rhythm death following my- ocardial infarction has provided the stimulus for development of cardiac resuscitation and cardiac monitoring units. The required equip- ment and techniques are discussed and dem- onstrated by Richard Watts, M.D., H~ad Cardio- vascular Section, Department of Medicine, Fair- view General Hospital, Cleveland, Ohio. (14 minutes). 1303923 NEONATAL INTENSIVE CARE. `Mini~instru~ ments" are providing physicians in this special unit with ways of carefully monitoring infants in critical condition. The instruments and tech- niques are shown by John C. Sinclair, M.D., De- partment of Pediatrics, and Edward )~, Bowe, M.D., Department of Obstetrics and GynecQlogy, Columbia Presbyterian Medical Center, New York. ~ie mInutes). 1407902 49 PAGENO="0404" 14310 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY NEW LIGHT FROM HEAT - THERMOGRAPHY - PART I. The current status of thermography - methods as well as clinical applications - is described by Jacob Gershon-Cohen, M.D., D.Sc.M. Emeritus Director, Division of Radiol- ogy, Albert Einstein Medical Center, and Profes- sor of Research Radiology, Temple University Medical School. (19 minutes). 1406409 NEW LIGHT FROM HEAT - THERMOGRAPHY- PART II. Clinical applications of this infrared scan device are demonstrated by Jacob Gershon- Cohen, M.D., D.Sc.M., Emeritus Director, Divi- sion of Radiology, Albert Einstein Medical Cen. ter, and Professor of Research Radiology, Tern. pIe University Medical School. (16 minutes). 1406510 NUCLEAR MEDICINE AND THE COMMUNITY HOSPITAL, with Alexander D. Crosett, M.D., Di- rector of Nuclear Medicine and Radiotherapy, Overlook Hospital, Summit, N. J. Can the com- munity hospital justify use of the expensive and sophisticated machinery of nuclear medicine? Yes, says Dr. Crosett, and he shows how his de. partrnent does. (17 minutes) (in color) 1419033 PEDIATRIC CARDIOLOGY - PART I - CATHE- TERIZATION IN INFANTS. Donald R. Sperling, M.D., Assistant Professor of Pediatrics, Califor- nia College of Medicine, University of California, explains the indications and techniques for diag- nosing congenital heart disease by means of the cardiac catheter. (14 minutes). 1605003 PRINCIPLES OF CORONARY CARE. Early sur- veillance and continuous monitoring of patients with acute myocardial infarction greatly enhance resuscitation probability in the event of arrhyth- mia or fibrillation. Stephen Wittenberg, M.D., In- structor in Medicine, and Roger Hand, M.D., Chief Medical Resident, New York University Medical Center demonstrate monitoring and resuscitation procedures In the Intensive Care Unit of University Hospital. (11 minutes). 1605920 SELECTIVE RENAL ARTERIOGRAPHY: PART I The technique for visualizing the intrarenal vas- cular system, utilizing the opaque catheter and serial roentgenography, is demonstrated by Klaus Ranniger, M.D., Associate Professor of Radiology, University of Chicago School of Med- icine. iii minutes). 1903802 SELECTIVE RENAL ARTERIOGRAPHY: PART II Klaus Ranniger, M.D., Associate Professor of Radiology, University of Chicago School of Med- icine, demonstrates a technique for examining the intrarenal vascular system using the opaque catheter and serial roentgenography. (11 minutes). 1904703 SIM ONE - ANESTHESIOLOGICAL TRAINING SIMULATOR: PART I-DEVELOPMENT An electro-mechanical, computer-controlled manikin has beet-i developed to train physicians in anesthesiologic procedures at the University of Southern California School of Medicine. De- scribing this life-like device are J. S. Denson, M.D., Professor, Chairman, Division of Anes- thesiology, and Stephen Abrahamson, Ph.D., Di- rector, Division of Research In Medical Educa- tion, along with two engineers from the Aerojet Corporation, Azusa, California, the firm which built Sim One. (25 minutes). 1904708 SIM ONE - ANESTHESIOLOGICAL TRAINING SIMULATOR: PART Il-APPLICATION A resident physician performs an endotracheal intubation on Sim One, an electro-mechanical manikin built to duplicate human cardiopulmo- nary functions and used as a teaching tool at the University of Southern California School of Medicine. J. S. Denson, M.D., and Stephen Abrahamson, Ph.D., members of the school's faculty, conduct the program, (17 minutes). 1904809 THE LASER IN OPHTHALMOLOGY - - - AND BEYOND. Film of the actual effects of laser beams on mice melanoma, as well as demon- strations of its use in various eye conditions in humans, is presented by Francis A. L'Esperance, M.D,, Associate in Ophthalmology, Eye Institute, Columbia Presbyterian Medical Center, New York. (17 mInutes) (In color) 1207706 THE MASTER TWO-STEP: A REAPPRAISAL Arthur M. Master, M.D., cardiologist and Emeri- tus Professor of Medicine at Mt. Sinai Hospital and Medical Center in New York, discusses the three major uses of the stress imposed by the double two-step test in conjunction with ECG tracings. (16 minutes). 1308914 THE MASTER TWO-STEP TEST - Part I. Arthur M. Master, M.D., Consulting Cardiologist, Mount Sinai Hospital, demonstrates the utilization of the two-step test. (12 minutes). 1302312 THE MASTER TWO-STEP TEST - PART II. Arthur M. Master, M.D., Consulting Cardiologist, Mount Sinai Hospital, presents patient data on nega- tive and positive two-step tests. (23 mInutes). 1302413 YOU CAN TAKE BETTER PHOTOGRAPHS, DOC- TOR, with Louis Z. Cooper, M.D., Director of the Rubella Project, New York University Medical Center, New York City; and Herb Flatow, Photo- graphic Consultant. Physicians who use still photography as a "tool" in their practices will benefit from this telecast. Aside from seeing new equipment, the viewer will learn to solve framing, lighting and camera setting problems in the hospital and in the office. (18 mInutes) (In color) 2413801 50 PAGENO="0405" COMPETITIVE PROBLEMS IN THE DRUQ INDUSTRY 14311 WHAT ARE WE LEARNING IN SPACE MEDICINE? (HUMAN ADAPTATION TO SPACE), with Charles A. Berry, M.D., Director of Medical Research and Operations, NASA, Houston, Texas. Dr. Berry reveals how he and his team of physicians have answered the question: What is the worSt thing that can happen to the astronauts during a flight?" Such considerations as prophylactic surgery and medication aboard the flight are disclosed. (14 minutes) (In color). 2313705 WHAT ARE WE LEARNING IN SPACE MEDICINE? (IN-FLIGHT CONCERNS), with Charles A. Berry, M.D., Director of Medical Research and Opera tions, NASA, Houston, Texas. Dr. Berry takes us through the countdown of medical activity during a rocket launch. He offers anecdotes, supplemented with official NASA film - such as the implications of losing Alan Shepard, Jr.'s EKG sensor prior to Apollo 14 liftoff. (28 mInutes) (In color) 2313704 WHAT ARE WE LEARNING IN SPACE MEDICINE? (THE PHYSIOLOGICAL ENVIRONMENT), with Charles A. Berry, M.D., Director of Medical Re. search and Operations, NASA, Houston, Texas. Among the many medical problems Dr. Berry highlights in this telecast are loss of red cell mass on long flights and new monitoring leads for various bodily functions with a suggestion of how they might be used in "conventional" pa. tient practice. (13 minutes) (in color) 2313703 WHAT IS A COMPUTER? A tour through a computer laboratory with dem. onstrations of the computer's use in medicine - with Leo Joseph Tick, M.D., Research Pro. fessor of Geophysical Statistics, New York Uni- versity School of Engineering and Science. (19 minutes). 2303201 INTENSIVE CARE A COMPREHENSIVE INTENSIVE CARE UNIT IN A GENERAL HOSPITAL - PART I - "History and Organization" - with Albert H. Douglas, M.D., Director, Department of Medicine, and Erwin Lear, M.D., Director, Department of Anesthesiology, Queens Hospital Center; Edward Meilman, M.D., Physician-in-Chief of Medicine, and Charles Trey, M.D., Attending Physician, The Long Island Jewish Hospital. (17 minutes). 0301931 A COMPREHENSIVE INTENSIVE CARE UNIT IN A GENERAL HOSPITAL - PART II - "Clinical Applications" - with Albert H. Douglas, M.D., Director, Department of Medicine, and Erwin Lear, M.D., Director, Department of Anesthesi. ology, Queens Hospital Center; Edward Meilman, M.D., Physician.in.Chief of Medicine, and Charles Trey, M.D., Attending Physician, The Long Island Jewish Hospital. (16 mInutes). 0302032 ACUTE RESPIRATORY INSUFFlCIENC't~: MECH. ANISMS AND DIAGNOSIS, with Alfred P. FIsh. man, M.D., Associate Dean of the University of Pennsylvania School of Medicine and Director of the Cardiovascular Pulmonary Division; and Robert M. Rogers, M.D., Assistant Professor of Medicine and Director of the Respiratory Inten- sive. Care Unit. The general principles of diag- nosing respiratory failure are presented ~or physi- cians unfamiliar with the recent advances in pulmonary physiology and respiratory intensive care. (18 mInutes) (in color) 0110104 BEDSIDE PULMONARY ARTERY CATHETERIZA. TION, with T. Crawford McAslan, M.D., Associate Clinical Director, Maryland Institute for Emer. gency Medicine, and Professor of Anesthesiology, University of Maryland School of Medicine, Balti- more. An introduction to the Swan.Ganz flow-directed, balloon-tipped catheter. Indications, method of insertion at bedside, and techniques for avoiding complications. (15 minutes) (in color) 0223621 CARE OF THE CRITICALLY ILL How new tech- niques of monitoring and computers are con- tributing to the care of the acutely III patient are demonstrated by Paul K. Hanashire, M.D., Assistant Professor of Medicine, University of Southern California School of Medicine. 116 minutes). 0307603 CONTAMINATION OF INTRAVENOUS INFUSIONS, with Richard J. Duma, M.D., Chairman, Division of Infectious Diseases and Immunology, and As- sociate Professor of Medicine, The Medical Col~ lege of Virginia, Richmond, and President-Elect of the National Foundation for Infectious Diseases. How to recognize and prevent contamination of intravenous infusions. (A Drug Spotlight Pro- gram, presented in cooperation with the Ameri- can Society for Clinical Pharmacology and Thera- peutics) (17 minutes) (in color) 0321781 INTERNAL JUGULAR VEIN CATHETERIZATION, with T. Crawford McAslan, M.D., Associate Clini. cal Director, Maryland Institute for Emergency Medicine, and Professor of Anesthesiology, Uni- versity of Maryland School of Medicine, Balti- more. The internal jugular vein - . - an attractive alternative to the basilic with its high failure rate and the subclavian with its high incidence of pneumothorax. (11 minutes) (In color) 0923735 51 PAGENO="0406" 14312 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY MEDICAL ASPECTS OF CONSTANT CORONARY CARE UNITS IN A GENERAL HOSPITAL The problem of the rhythm death following myo- cardial infarction has provided the stimulus for development of cardiac resuscitation and cardiac monitoring units. The required equipment and techniques are discussed and demonstrated by Richard Watts, M.D., Head, Cardiovascular Sec- tion, Department of Medicine, Fairview General Hospital, Cleveland, Ohio. (14 mInutes). 1303923 NEONATAL INTENSIVE CARE. "Mini-Instru- ments" are providing physicians in this special unit with ways of carefully monitoring Infants in critical condition. The instruments and tech- niques are shown by John C. Sinclair, M.D., Department of Pediatrics, and Edward T. Bowe, M.D., Department of Obstetrics and Gynecology, Columbia Presbyterian Medical Center, New York. (16 minutes). 1407902 NEUROSURGICAL INTENSIVE CARE, A specially designed five-patient neurosurgical intensive care unit is providing a new kind of acute care for patients with central nervous system dis- orders. Patients are admitted to the unit prior to surgery and returned there postoperatively - a geographical convenience that has proven of great value both to patients and staff. The important role of the unit in n-service train- ing is described by Joseph Ransohoff, M.D., Professor and Chairman, Department of Neuro- surgery, New York University-Bellevue Medical Center. Demonstrating the special equipment in the unit, Dr. Ransohoff also takes note of its limitations: Even highly sophisticated monitoring devices cannot replace the continuity of care that can be provided by a well-trained staff. (26 minutes). 2701525 NURSING ASPECTS OF CONSTANT CORONARY CARE UNITS - PART I. The expanding use of electronic and mechanical equipment in the hos- pital and in medicine generally is having an increasing impact on the nursing profession. Diane Eddy, R.N., Head Nurse, Constant Coronary Care Unit, Fairview General Hospital, Cleveland, Ohio, discusses current technology from the nurse's point of view and demonstrates modern electronic devices, including the EKG monitor and defibrillator. (22 minutes). 2700319 NURSING ASPECTS OF CON$TANT CORONARY CARE - PART II. An illustration of the nurse's role in coronary care. Unique admission pro- cedures such as placing leads on the coronary patient and taking an EKG strip are shown. Diane Eddy, RN., Head Nurse, Constant Coronary Care Unit at Fairview General Hospital, Cleve- land, Ohio, shows how to recognize changes in a patient's condition, employ emergency equip. ment, and assist the physician in an emergency. Moving the patient to the "step down unit" and educating his family for home care are also dis- cussed. (19 minutes). 2700420 PRINCIPLES OF CORONARY CARE. Early surveil- lance and c,ntjnuoüs monitoeing of patients with acute myocardial infarction greatly enhance re- suscitation probability in the event of arrhythmia or fibrillation. Stephen Wittenberg, M.D., In- structor in Medicine, and Roger Hand, M.D., Chief Medical Resident, New York University Medical Center, demonstrate monitoring and resuscitation procedures in the Intensive Care Unit of University Hospital. (11 minutes). 1605920 TRANSFUSION THERAPY: THE GROWING IMPACT OF FROZEN BLOOD, with Charles Huggins, M.D., Director of the Blood Bank and Transfusion Serv- ice, Massachusetts General Hospital, Boston. Blood transfusion therapy as it is practiced in a major medical center, with guidelines to the use of fresh and freshly frozen components. (14 minutes) (in colur) 2022139 Many NCM.E programs have self -assess- ment quizzes, one copy of which will ac- company each videocassette. You may duplicate the quiz as your needs require. Upon completion, return the quizzes to NCME, and we will maintain a record of participation (not the score) for each phy- sician. These records are keyed to the phy- sician's Social Security numbers: please take care that the numbers are clearly written. Physicians may request their NCME activity records at any time. 52 PAGENO="0407" COMPETITIVE PROBLEMS IN THE DRUG INDTSSTflY 14313 INTERNAL MEDICINE ACID-BASE IMBALANCE: THREE PROGRAMS. "For decades, acid-base metabolism with its cabalistic terminology has intrigued and IncI- dentally, terrorized many clinicians. Actually, the whole subject of acid-base metabolism and Its clinical application is just another facet of medI- cal science that, once understood, presents Itself in a straightforward, logical manner ." Hugh J. Carroll, MO. The following three programs were produced in cooperation with the Office of Continuing Educa- tion of the State University of New York, Down- state Medical Center, Brooklyn, New York. ACID-BASE IMBALANCE: PATHOGENESIS, with Hugh J. Carroll, M.D., Associate Professor of Medicine, Director of the Electrolyte and Hy- pertension Section, Department of Medicine, Downstate Medical Center. A presentation of the primary disturbances in metabolic and respiratory acid-base imbalances, their mech- anisms of compensation, and the clinical situ- ations in which they may occur. (22 minutes) (in color) 0122444 ACID-BASE IMBALANCE: RECOGNITION AND MANAGEMENT, with Hugh J. Carroll, M.D., As- sociate Professor of Medicine, Director of the Electrolyte ~nd Hypertension Section, Depart- ment of Medicine, Downstate Medical Center. When blood gases and other clinical studies confirm the presence of an acid-base disturb- ance, it is the physician's part to reverse the imbalance directly or to treat the underlying disease so that the patient's own corrective mechanisms can restore the normal state. (15 minutes) (in color) 0122445 KETOTIC AND NONKETOTIC COMA: MECH- ANISMS AND TREATMENT, with Hugh J. Car- roll, M.D., Associate Professor of Medicine. Director of the Electrolyte and Hypertension Section, t~epartment of Medicine, Downstate Medical Center. Pathophysiology, diagnosis, and management in diabetic ketOacidosis and hyperosmolar, hyperglycemic, nonketotic coma. (18 minutes) (in color) 1122406 ACUTE REGIONAL ENTERITIS: A CLINICAL PATHOLOGICAL CONFERENCE, with Floyd M. Beman, M.D., Professor of Medicine; J. David Dunbar, M.D., Assistant Professor of Radiology; Dante G. Scarpe(li, M.D., Professor of Pathology; and William Pace, M.D., Assistant Dean of the College of Medicine; all from the Ohio State Uni- versity College of Medicine in Columbus, Ohio. Four physician-educators critically explore a case of severe, progressive regional enteritis. (23 mInutes). 0110703 ADULT DIABETES: OUTGUESSING THE NEXT 24 HOURS, with Leo P. KraII, M.D., Director, Educa- tion Division, and Lecturer in Medicine, Joslin Diabetes Foundation, Inc., and New England Deaconess Hospital, and Letturer, Harvard Medi- cal School, Boston. Management of diabetes mellitus starts with defining treatment gŕals and understanding why they are often difficult to ob- tain. Dr. KraII discusses the general management of different types of patients. This program was produced with the cooperation of the Council on Scientific Assembly of the American MedIcal As- sociation. (25 minutes) (in color) 0123046 APPLICATION OF DIAGNOSTIC CYTOLOGIC TECHNIQUES TO GASTROINTESTINAL ENDOS- COPY AND LIVER BIOPSY, with Sidney J. Winawer, M.D., Director, Diagnostic Gastrointes' tinal Laboratory, Memorial Sloan-Kettering Can- cer Center and Clinical Associate Professor of Medicine, Cornell University Medical CoII~ge: and Paul Sherlock, M.D., Chief, Gastroenterology Serv- ice, Memorial Sloan-Kettering Cancer Center and Associate Professor of Medicine, Cornell Univer- sity Medical College. Directed brush cytology and directed pulsatile lavage cytology through the upper Gastrointestinal Panendoscope and Colon- oscope are demonstrated. Pulsatile lavage through the standard sigmoidoscope fOr recto- colonic cytology Is also shown. This presentation was made at the 1973 annual meeting of the American Society for Gastrointestinal Endoscopy. Please inqUire for special rental Information. (41 minutes) (In color) ASGE 2800076 AN ANATOMICAL APPROACH TO LOW BACK PAIN, with Peter Marchisello, M.D., Attending Orthopedic Surgeon. The Hospital for Special Surgery, Cornell University Medical Center, New York City. Modern life seems to breed back pain. As more and more patients come to physicians with this complaint, Dr. Marchicello demon- strates, it becomes increasingly important to review and understand the anatomy of the spine to make differential diagnoses. (20 mInutes) (in color) 0116230 BEDSIDE ROUNDS: EVALUATING THE NEED FOR FLUID THERAPY, with Cecil H. Coggins, M.D., Assistant Professor of Medicine, Harvard Medical School, Boston, Massachusetts. Recent views and techniques for evaluating the adequacy of the patient's blood volume and his extra cell interfluld volume are presented with the use of case studies. (20 mInutes) (in color) 0212003 53 PAGENO="0408" 14314 co~n~.~rrivi~ PROBLEMS IN THE DRUG INDUSTRY CELLULAR DISTURBANCES: A NEW CONCEPT OF OBESITY Some extremely obese patients may be incapa- ble of losing weight and maintaining the loss because they may have acquired an excessive number of fat cells early in life. This is one of the findings of Jules Hirsch, M.D., Professor and Senior Physician to The Hospital, Rockefeller University, New York (19 minutes) 0308704 CLINICAL CLUES FOR EARLY DETECTION OF DIABETES. Normal glucose tolerance test re- sults may not mean the absence of diabetes, but merely the absence of currently detectable diabetes, according to 0. Peter Schumacher, M.D,. Consultant in Endocrinology and Metabol- ism, Cleveland Clinic Education Foundation. Dr. Schumacher recommends that in the routine of caring for patients with a family history of dia- betes, physicians should continually be on the lookout for clues, such as postprandial reactive hypoglycemia, dermatitis gangrenosa, psoriasis, gout, vaginal moniliasis, renal glycosuria, hyper- lipemia retinalis, thyrotoxicosis, and Dupuytren's contracture. (19 minutes). 0306115 COMPUTER TECHNIQUES AS AN ADJUNCT TO CLINICAL IMPRESSIONS IN THE EVALUATION OF DRUG RESPONSE - PART I - "The First Five Weeks." Burton J. Goldstein, M.D., Chief, Division of Research, Department of Psychiatry, University of Miami School of Medicine, presents the design of a research project and a demon- stration of computerized patient tests. (14 minutes). 0302136 CORTICOSTEROIDS: Rx FOR THREE CONNECTIVE TISSUE DISEASES, with Richard H. Ferguson, M.D., Associate Professor of Medicine and Head of a Section of Rheumatology, The Mayo Clinic and Mayo Foundation, Rochester, Minnesota. Three successful therapeutic plans using corti- costeroids to control certain problems in tem- poral arteritis, polymyositis, and lupus nephritis are outlined. (This program was presented as part of the American Society for Clinical Phar- macology and Therapeutics' Drug Spotlight Pro. gram.) (20 minutes) (in color) 0321079 All programs in this catalog are copyright by the Network for Continuing Medical Education. Duplication, reproduction, or distribution in any form of all or any part of the programs is prohibited without the express written consent of NCME. CURRENT DIAGNOSTIC AND TREATMENT PROBLEMS IN THYROID DISEASE, with Gerald Burke, M.D., Department of Medicine; Leslie J. DeGroot, M.D., Department of Medicine; Alex- ander Gottschalk, M.D., Department of Radiology; Edward Paloyan, M.D., Department of Surgery; and Samuel Refetoff, M.D., Department of Medi- cine, all of the Pritzker School of Medicine of the University of Chicago. In a clinic setting, the panelists discuss diagnostic and therapeutic problems including management of possible thyroid carcinoma, clinical thyrotoxocosis with `normal" lab data, exophthalmos, and congen- ital goiter. Clinical physiology and related re- search are emphasized. A Television Clinic of the American College of Physicians, 1973. Please inquire for special rental information. (50 minutes) (in color) ACP 2827366 CURRENT MANAGEMENT OF THE ADULT DIABETIC, with Peter H. Forsham, M.D., Director of Metabolic Research Unit, University of Cali. fornia School of Medicine, San Francisco. Dr. Forsham outlines the treatment of adult dia betes. In addition to explaining his use of diet and insulin therapy, he thoroughly examines the oral hypoglycemic agents, including phenformin hydrochloride and the sulfonyltireas, explaining how they work, their side-effects, and the most effective regimen. (22 minutes) (in color) 0316673 DIABETIC ACIDOSIS. Practical rules of thumb for the treatment of diabetic acidosis, with Daniel B. Stone, M.D., and Joseph D. Brown, M.D., Department of Internal Medicine, Univer- sity Hospital, University of Iowa College of Medicine. (29 minutes). 0400403 DIAGNOSIS OF OCCULT INTRA-ABDOMINAL NEOPLASMS, with Herbert B. Greenlee, M.D., Department of Surgery, Loyola University of Chi- cago, Stritch School of Medicine, Maywood, III., and Veterans Administration Hospital, Hines, Ill; Erwin M. Kammerling, M.D., Department of Medi- cine, University of Health Sciences, The Chicago Medical School, and Louis Weiss Memorial Hos- pital, Chicago; Sumner C. Kraft, M.D., Depart- ment of Medicine, University of Chicago; and Armand Llttman, M.D., Department of Medicine, University of Illinois, College of Medicine, Chi- cago, and Veterans Administration Hospital, Hines, Ill. The panel presents~cases illustrating some of the difficulties and solutions involved in tracking down a diagnosis of intra-abdominal neoplasms. Emphasis is given to the tests (some old, some new, some under-utilized) which are helpful in deciding to perform exploratory lapa- rotomy. A Television Clinic of the American Col- lege of Physicians, 1973. Please inquire for special rental information. 50 minutes) (in color) ACP 2847368 54 PAGENO="0409" COMPETITIVE PROBLEMS IN PEE DRUG INDtJSTRY 14315 THE DIAGNOSIS OF SYSTEMIC LUPUS ERYTHE- Iv1ATOSUS, with Naomi Rothfield, M.D., Profes- sor of Medicine, and Chief, Arthritis Section, University of Connecticut School of Medicine, Parmlngton, Connecticut. Demonstrating the early detection of S.L.E. through clinical and lab- oratory findings. (19 minutes) (in color) 0419951 DIAGNOSTIC CUTANEOUS SIGNS OF SYSTEMIC DISEASE, with Denny L, Tuffanelli, M.D., Assist- ant Clinical Professor of Dermatology, University of California at San ~rancisco. A noted derma- tologist uses 13 examples to show how observa- tion of the skin can lead to diagnosis of severe systemic disease. (19 minuteS) (in color) 0413926 DIGITALIS: FRIEND OR FOE? with James E. Doherty, M.D., Professor of Medicine and Direc- tor of Cardiology, University of Arkansas School of Medicine and The Little Rock Veterans Ad- ministration Hospital. Dr. Doherty points out the signs and symptoms of digitalis toxicity and provides guidelines for adjusting dosage to pro- vide maximum benefit without adverse reactiots. (This program was part of the Drug Spotlight Program of the American Society for Clinical Pharmacology and Therapeutics-) (13 minutes) (in color) 0420152 ESOPHAGEAL DISORDERS AND CHEST PAIN - (EVALUATION AND MANAGEMENT OF ESOPHA- GEAL REFLUX), with Thomas R. Hendrix, M.D., Department of Medicine; Theodore M. Bayless, M.D., Department of Medicine; Martin W. Don- ncr, M.D., Department of Radiology; Francis D. Milligan, M.D., Department of Medicine; and David B. Skinner, M.D., Department of Surgery; all of the Johns Hopkins University School of Medicine. Clinical, radiologic, and special pro. cedures used In evaluation pf gastroesophageal reflux are presented, ináludlng acid perfusion, esophagoscopy, cine radiology, esophageal mo- tility, and pH probe measurement. The relation of reflux to esophagitis and to reflux symptoms are defined. Among topics discussed:' medical therapy for reflux; surgical options; relation of hiatal hernia to reflux; and management of complications of reflux, stricture, and esopha- geal ulcer. A Te(evision Hospital Clinic of the American College of Physicians, 1972. Please inquire for special rental information. (59 minutes) (in color) ACP 2817243 EXCHANGE TRANSFUSION FOR LIVER FAILURE The use of exchange transfusion to reverse the path toward acute hepatic failure is demonstrated by Joseph C. Darin, Mb., Professor of sledicine at Marquette School of Medicine in Milwaukee, Wisconsin. (17 mInutes) (in color) 0509813 THE EYE AND SYSTEMIC DISEASE:' AN INTER- CHANGE, with Eleador Faye, MD., Attending Surgeon, Manhattan Eye, Ear, and Throat Hos- pital, and Medical Director, Low Vision Clinic New York Association for the Blind; and Isadore Rossman, M.D., Medical Directcir, Home Care Department, Montefiore Hospital and Medical Center, and Associate Professor, Albert Einstein Medical College, New York City. Two physicians interact in the management of three patients with vision problems. Focus is on shared responsi- bility and communication. (13 mInutes) (in cOlor) 0521228 GASTROINTESTINAL CYTOLOGY- A VALUABLE DIAGNOSTIC PROOEDURE: PART I Application and Results." Confirming a diagilo- sin without surgery through the use of Papanico- laou staining of cells from the gastrointestinal tract - with Charles Norland, M.D., Assistant Professor of Medicine, University of Chicago School of Medicine. (16 minutes). 0703303 GOUT: A CURRENT VIEW, with Stanley L Wal- lace, M.D., Associate Director of Medicine, Jew- ish Hospital and Medical Center of Brooklyn, and Clinical Professor of Medicine, Downstate Medical Center in Brooklyn, Gout is frequently misdiagnosed because the patient does not fit the stereotype - a fat, middle.aged man With a red, swollen b(g toe. Five important fadtors to consider in identifying acute gout are carefully detailed - with special emphasis on treatment and prevention of the disease, (18 mInutes) (in color) 0714.816 THE HAND AS AN INDICATOR OF SYSTEMIC DISEASE, with Marguerite Lerner, M,D,, Clinical Professor of Dermatology, Yale University School of Medicine, New Haven, Connecticut. Doctor Lerner investigates the cause of several hand complaints, including Raynaud's phenotnenon, xanthomas, and telangiectasia. (19 mInutes) (In color) 0821337 HEADACHE: MIGRAINE AND HISTAMINIC CE- PHALGIA, with William G.' Speed, III, M.D.ç'De- partment of Medicine; and Leonard J, ~alIant, M.D., Department Of Psychiatry; both of the Johns Hopkins University School of Medicine. This program deals predominantly with the management of the more chronic forms of mi- graine, emphasizing pharmacotherapeutic tech- niques and touching on those aspects of psy- chotherapy that might be useful to internists, Histaminic cephalgia (also known as cluster head- ache, cycle headache, or migraine variant) and methods of managing it are discussed. Adapted from a Television Hospital Clinic of the Ameri- can College of Physicians, 1972. Please inquire for special rental information, (60 minutes) (in color) ACP 2867244 `55 PAGENO="0410" 14316 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY HOW I DO A BONE MARROW ASPIRATION, with Mortimer J. Lacher, M.D., Assistant Attending Physician, Department of Medicine, Memorial Hospital for Cancer and Allied Diseases, New York City. Another in NCME's new series of demonstrations by experts of how they do prac tical, frequently performed procedures. (10 minutes) (In color) 08~6322 HOW I DO A BONE MARROW BIOPSY, with Mortimer J. Lacher, M.D., Assistant Attending Physician, Department of Medicine Memorial Hospital for Cancer and Allied Diseases, New York City. Dr. Lacher describes the necessary equipment and then demonstrates, step-by-step, the procedure for obtaining and preparing a bone marrow specimen. Highlighting the pro- gram is Lacher's procedure for quickly and ac- curately finding the target area for biopsy on the posterior iliac crest. (9 mInutes) (in color) 0816524 HYPERBARIC OXYGEN - A NEW ADJUNCT TO THERAPY. The increased use of hyperbaric oxy- gen in a variety of diseases and in emergency as well as daily care is discussed by Theobold Reich, M.D., Associate Professor of Clinical Sur- gery and Director of the Hyperbaric Facility at New York University Medical Center; and Myron Youdin, Research Scientist and Chief Engineer of the Hyperbaric Facility. (19 minutes). 0806509 HYPERBARIC OXYGEN TOXICITY. Hyperbaric oxygenation is being used more frequently In clinical situations, but its use is restricted by the toxic effects of ox~igen itself. Donald R. Sperling, M.D., Assistant Professor of Pediatrics and ~Head of the Division of Pediatric Cardiology, University of California at Irvine, California Col- lege of Medicine, demonstrates studies on the toxicity of oxygen and its prevention under high pressure in newborn and adult mice. (13 minutes). 0805410 LIPIDS AND DIABETES. An understanding of the variations in the serum lipids can give the physician greater freedom in prescribing for the diabetic patient, according to George F. Cahill, Jr., M.D., Associate Professor of Medicine, Har- vard Medical School. Dr. Cahill describes a simple system for separating lipid components in the blood and suggests that fats and carbohy- drates need not be eliminated from diabetic diets. (20 minutes). 1206007 LONG-TERM MANAGEMENT OF S.L.E., with Naomi F. Rothfield, M.D., Professor of Medicine and Chief, Arthritis Division, University of Con- necticut School of Medicine, Farmington, Conn. Specific drugs and general life adjustments are important to the treatment course of systemic lupus erythematosus. However, the key to man- aging S.L.E., demonstrated here, is to identify symptoms and signs of impending flare-ups. 1)7 minutes) (in color) 1220019 MALABSORPTION SYNDROME Victor W. Groisser, M.D., Clinical `Professor of Medicine, New Jersey College of Medicine, and Director of Gastroenterology, Mountainside Hos' pital, Montclair, New Jersey, comments on the frequency of ma)absorption syndrome, on the possibility of misdiagnosis and the need f~r clear- ing up the confusion surrounding malabsorption. (19 minutes). 1309602 THE MEDICAL MANAGEMENT OF METASTATIC BREAST CANCER, with Justin J. Stein, M.D., Professor of Radiology, UCLA School of Medicine, and a past President of the American Cancer Society. Advanced breast cancer: a bleak future for the patient and a difficult management prob- 1cm for the physician. This program provides a step-by-step approach to improve the quality of survival for your patient. (19 minutes) (in toter) 1319953 NEUROMUSCULAR DISORDERS OF INTEREST TO PHYSICIANS, with Andrew G. Engel, M.D., Department of Neurology; Peter James Dyck, M.D., Department of Neurology; a~d E. H. Lambert, M.D., Department of Medicine, all of the Mayo Clinic, Mayo Graduate School of Medi- cine, Rochester. Mjpn. The clinical state of patients with uremic neuropathy, the myasthenic syndrome, and adult acid maltase deficiency is shown and correlated with histologic, physio- logic, and biochemical abnormalities. A Televi- sion Clinic of The American College of Physicians, 1973. Please inquire for special rental informa- tlon. (60 minutes) (In color) ACP 2817365 NEW IV. TECHNIQUE FOR TOTAL NUTRITIONAL SVPPORT. Maintaining patients on IV. feeding for long periods of time with satisfactory results can now be accomplished with an indwelling catheter. The technique and its use on patients are demonstrated by Stanley J. Dudrick, MD, and Douglas W. Wilmore, M.D., Department of ~urgery and Harrison Department of Surgical Research, University of Pennsylvania School of Medicine, Philadelphia, Pa. (20 minutes). 1406708 56 PAGENO="0411" COMPETITWE PROBLEMS IN THE DRUG INDUS']~RY 14317 RADIOLOGIC DIAGNOSIS OF THE ACUTE ABDOMEN Several radiological techniques are available in diagnosing patients presenting with acute ab- dominal pain. Robert D. Moseley, Jr., M.D., Professor and Chairman of the Department of Radiology, University of Chicago Pritzker School of Medicine, summarizes these techniques and considers their importance in clinical findings. (15 minutes) (In color) 1808804 RENAL ARTERIAL HYPERTENSION AND TREAT. MENT, with Albert N. Brest, M.D., Associate Professor of Medicine and Head, Section of Vascular Disease and Renology, Hahnemann Medical College and Hospital. (12 minutes). 1802609 RETAINED COMMON DUCT STONES. George M. Saypol, M.D., Associate Professor of Clinical Surgery, New York University Medical School, and Director of Surgery, The Long Island Jewish/ Queens Hospital Center, discusses the manage- ment of stones left in the bile ducts following cholecystectomy. 1)9 minutes). 1801117 SKIN TESTING FOR TB, with John A. Crocco, M.D., Director of Pulmonary Disease Section, St. Vincent's Hospital and Medical Center, New York; and Downstate Medical Center, Brooklyn, New York. A demonstration of the correct way to administer two types of TB skin tests, with guide. lines for their interpretation. (12 minutes) (in color) 1920637 THE DIABETES PUZZLE: A PRACTICAL AP. PROACH, with Rachmiel Levine, M.D., Professor and Chairman of the Department of Medicine at New York Medical College in New York City. Most of the three million cases of diabetes in the U.S. are considered mild from the metabolic viewpoint, However, because of the link to many forms of cardiovascular, renal and other diseases it becomes important to discover and treat the mild forms. Pr. Levine describes the classical symptoms of diabetes and when to suspect the disease In the absence of the typical signs. He classifies therapy, relates diabetes to other dis. eases and describes its pathogenesis and in~ herited factors. (17 minutes). 0410805 THE DIABETIC IN COMA/BRITTLE DIABETES/ THE YOUNG DIABETIC, with Rachmiel Levine, M.D., Professor and Chairman of the Department of Medicine at New York Medical College in New York City. Coma may occur in a person with diabetes for the same reasons as it would occur in the non- diabetic. For that reason It is Important to dif. ferentiate between the two comas. Dr Levine describes ketoacidosis, hypergycemic coma, act' acidosis, hypoglycemia. Dr. Levine also discusses "brittle" diabetes and the prognosis of childhood dIabetes. (20 mInutes). 0410904 THE VALUE OF RENAL BIOPSIES IN THE MAN. AGEMENT OF PATIENTS, with Kent Armbruster, M.D., Department of MedIcine, Rush MedIcal College, Chicago; David P. Earle, M.D., Depart. ment of Medicine, Northwestern UniversIty MedI. cal School, Chicago; Robert Jennings, MD., De- partment of Pathology, Northwestern University Medical School, Chicago; Robert M. Kark, M.D., Department of Medicine, Rush Medical ~olIege, Rush.Presbyterlan-St. Luke's Medical Center, Chicago; Robert C. Muehrcke, M.D., Department of Medicine, Rush Medical College, Rush. Presbyterian-St. Luke's Medical Center, Chicago; Conrad Pirani, M.D., Department of Pathology, Columbia University College of Physicians and Surgeons, New York City; and Hock H. Yeoh, M.D., Department of Medicine, Northwestern University Medical School, Chicago. To illustrate the usefulness of renal biopsy in the manage- ment of certain patients with renal disease, both pathologists and clinicians discuss particular patient problems along with the corresponding history, clinical and laboratory findings, and renal biopsy results for each patient. A Television Clinic of the American College of Physicians, 1973. Please inquire for special rental inforrn matlon. (60 minutes) (In color) ACP 2857369 THE TREATMENT OF BRONCHIAL ASTHMA, with Frank Penman, M.D., Clinical Professor of Medicine, University of Oregon School of MedI. cine, Portland. HOw to treat the asthmatic pa- tient early to avoid a potential respiratory crisis. (16 minutes) (in color) 2020032 TREATMENT OF INSULIN.DEFICIENT DIABETES, with Peter H. Forsham, M.D., Director, Metabolic Research Unit, University of California School of Medicine, Son Francisco. Insulin has been avail able for 50 years, but its use in diabetic therapy can be improved. To achieve better results, says Dr. Forsham, physicians must simulate as close- ly as possible the release of insulin by normal persons. (21 mlnttes) (in color) 2016427 TUBERCULOSIS: A NEW MEDICAL CHALLENGE FOR THE SEVENTIES, with Vernon N. Houk, M.D., and Phyllis Edwards, M.D., of the TuberS culosis Section of the National Communicable Disease Center; and William W. Stead, M.D., Professor of Medicine at Marquette School of Medicine in Milwaukee. TB is frequently diag- nosed as pulmonary fibrosis. The epidemiology of the disease in the U.S. today is shown, along with the ~urrent approach to Its eradication. (17 minutes) (In color) 2010419 57 PAGENO="0412" 14318 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY WHEN SHOULD HYPERTENSION BE TREATED? with Edward Fries, M.D., Senior Medical Investi- gator, VA Hospital, Washington, D.C.; and Ray W. Gifford, Jr., M.D., Department of Nephrology, Cleveland Clinic. Dr. Fries, winner of the Lasker Award, and Dr. Gifford review, through patient interviews, the recent changes in criteria for intervention in hypertension. (19 minutes). 2316203 ZOSTER: ITS COURSE AND TREATMENT, with Richard C. Gibbs, M.D., Associate Professor of Clinical Dermatology, and Philip A. Brunch, M.D., Director, Laboratory of Infectious Disease, Pedi. atrics Department; both of New York University Medical Center in New York City. Recommends treatment for the severe pain of this generally one-time, but unforgettable, illness. (9 minutes) (in color) 2620201 LEGAL MEDICINE A FORENSIC AUTOPSY WITH DR. MILTON HEL. PERN, Chief Medical Examiner for the City of New York, and Professor and Chairman of the Department of Forensic Medicine, New York University School of Medicine; and John F. Dcv- un, M.D., Deputy Chief Medical Examiner, City of New York, and Associate Professor of Foren- sic Medicine, N~w York University School of Medicine. A 32-year-old stockbroker, known to be a heavy drinker, depressed and with a recent prescription for sleeping pills, is found dead In bed. Although he was treated for diabetes in childhood, he has not seen a physician recently. What would you write on the death certificate? Suicide? Accident? Natural causes? Dr. Helpern the noted forensic pathologist, takes you through the autopsy to determine the cause of death. (21 minutes) (in color) 0617518 A GUIDELINE FOR CONSENT: THE UNIFORM ANATOMICAL GIFT ACT, with Alfred M. Sadler, Jr., M.D., and Blair Sadler, LL.B., of the Na. tional Institutes of Health, the Vanderbilt Univer- sity School of Law and the Duke University School of Medicine. A thorough and timely dis- cussion of the medicolegal ramifications of organ transplantation is offered by the consul- tants to the National Conference of Commis- sioners on Uniform State Laws, which drafted the law. (18 minutes). 0710114 CONCEPTS IN IATROGENIC MEDICINE: PART I David M. Spain, M.D., Director of Pathology at the Brookdale Hospital Center in Brooklyn, New York and Clinical Professor of Pathology at Co- lumbia University; and Alan F. Lyon, M.D., Chief of Cardiology and Associate Clinical Professor at the State University of New York Downstate Med- ical Center in Brooklyn, New York, observe that iatrogenic disorders are increasing as a conse- quence of the growing complexity of the `Med- ical Environment." Control, they demonstrate, is absolutely essential because latrogenesis has reached epidemic proportions. (18 minutes). 0308740 CONCEPTS IN IATROGENIC MEDICINE: PART II David M. Spain, M.D., Director of Pathology at the Brookdale Hospital Center in Brooklyn, New York, and Clinical Professor of Pathology at Co- lumbia University; and Alan F. Lyon, M.D., Chief of Cardiology and Associate Clinical Professor at the State University of New York Downstate Medical Center in Brooklyn, New York, suggest the ease by which physicians can be reduced to "push-button technicians" with the growing number of diagnostic and therapeutic agents and devices. They demonstrate, with specific examples, the ways in which the physician can "become the artful clinical scientist." (18 minutes). 0308841 COPING WITH THE INCREASED RISK OF PHYSI- CIAN'S MALPRACTICE LIABILITY, with David S. Rubsamen, M.D., LL.B., Editor, "Professional Liability Newsletter," and lecturer, University of California, San Francisco. The prospects of changes and reforms in legal proceedings involv- ing malpractice are explored in this telecast. (19 mInutes). 0313163 IATROGENIC DRUG PROBLEMS, with Leighton E. Cluff, M.D., Chairman and Professor, Depart- ment of Medicine, University of Florida College of Medicine, Gainesville. Dr. Cluff presents patient cases illustrating com- mon physician errors in drug administration and shows how to avoid them. (14 minutes) (in color) 0923734 For more information about NCME's Master Videocassette Library or bi-weekly videocassette service, write: NCME/15 * Columbus Circle/New York, N.Y. 10023; or phone: (212) 541-8088. 58 PAGENO="0413" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14319 INFORMED CONSENT: PREVENTING THE MAL- PRACTICE SUIT, with Henry B. Alsobrook, Jr., general counsel to the Louisiana State Medical Society, affiliated member of the American Med- ical Association, and senior partner, Adams and Reese, New Orleans; and Alan L Goldberg, M.D., family physician, Bronx, New York, and member of NCME's Medical Advisory Committee. How much do you have to tell a patient? How can you be sure the patient understands what you've said? How can you protect yourself from a mal- practice suit? A clinician and an attorney con- front these and other questions surrounding the issue of informed consent. (15 minutes) (in color) 0922931 LEGAL PROBLEMS IN THE EMERGENCY ROOM. When can a minor be treated without parental consent? What special precautions should be taken with victims of criminal violence? Points to. know about the law to protect a patient's rights and safeguard physician liability are discussed by William Mangold, M.D., J.D., resident in sur- gery at Bexar County Hospital, San Antonio, and member of the Texas bar; and Crawford Morris, Esq., trial lawyer specializing in medical mal- practice cases for Arter & Hadden Associates, Cleveland. (18 minutes) (in color) SAMA 2811063 LEGAL PROBLEMS ON THE WARDS. What con- stitutes a proper informed consent for medical treatment? In what circumstances can informa- tion be legally withheld from a patient? What are the consequences of altering a patient's medical record? Points to know aboUt the law to protect a patient's rights and safeguard physician li- ability are discussed by William Mangold, M.D., iD., resident in surgery at Bexar County Hos- pital, San Antonio, and columnist for The New Physician; and Crawford Morris, Esq., trial lawyer specializing in medical malpractice cases for Arter & Hadden Associates, Cleveland. (23 minutes) (in color) SAMA 2810962 PHYSICIAN'S MALPRACTICE LIABILITY IN THE SOCIAL CONTEXT, with David S. Rubsamen, M.D., LL.B., on the faculty of the University of Califor- nia, San Diego. Doctors are not being singled out for legal actions; they are being swept up in a social change. This is only one of many conclu- sions Dr. Rubsamen will make as he describes the dimensions of the malpractice liability problem. (18 minutes). 1613033 PILLS, PRISONERS AND PROGRESS. In the U.S., much of the controlled study drUg research done among norm~l" human beings is conducted among prisoner volunteers. Four disparate views of drug research using such human subjects are presented to medical student moderator, John Trowbridge, by: Gilbert McMahon, M.D., head of Therapeutics Section, Department of Medicine, Tulane University Medical School; Mr. Willy Hol- der, an es-convict and President of the California Prisoner's Union; Mr. Michael Mills, a research ~associate for the Center for Criminal Justice at the University of Chicago Law School; and Alan Varley, M.D., Medical Director of the Up~ohn Company. (19 mInutes) (In color) SAMA 2811064 SiMPLIFYING THE MEDICOLEGAL REPORT, with Robert M. Fox, an attorney and author of the book, The Medicoiegal Report: Theory and Prac- tice. This telecast will be helpful to physicans who have problems composing a medical-legal report for attorneys or insurance carriers - particu- larly when injuries are involved. (17 minutes) (in color) 1912010 THE GOOD SAMARITAN: RISKS AND RESPON- SIBILITIES, with Alfred M. Sadler, Jr., M.D., and Blair Sadler, LL.B., of the National Institutes of Health in Bethesda, Maryland. How can the physician perform emerge~cy care without facing the danger of law suits? What is the standard of care that is expectec~ of the physician-good samaritan? The answer~ offered by Dr. Sadler and Mr. Sadler are of importance to every physician in active practice. (le minutes). 0710710 THE IMPORTANCE OF PEER REVIEW, with Ralph S. Emerson, M.D., Chairman, Ad Hoc Committee on peer review, Medical Society of the State of New York. Peer review is no longer a professional persuasion, it is a government mandate under the Medicare and Medicaid laws. Dr. Emerson points out the benefits of a properly established and executed peer review committee. He dis- cusses the benefit of review committees to the public and to physicians as an organized voice in policy making. (13 mInutes). 0910603 THE PHYSICIAN AS AN EXPERT WITNESS - PART I. Professor Ronald Carison, College of Law, Reginald Cooper, Assistant Professor, Rbbert C. Porter, M.D., Department of Orthopedic Surgery, College of Medicine, University of Iowa and attorneys Wayne C. Collins and Thomas Daley. Re-enactment of actual case with patient, phy- sician, and legai counsel. (21 minutes). 1601512 59 PAGENO="0414" 14320 COMPET]1~IVE PROBLEMS IN THE DRUG II'~DUSTRY THE PHYSICIAN AS AN EXPERT WITNESS - PART II - "The Trial" - with Professor Ronald Carison, College of Law, Dr. Reginald Cooper, Assistant Professor, Robert C. Porter, M.D., De- partment of Orthopedic Surgery, College of M~di- cine, University of Iowa and attorneys Wayne C. Collins and Thomas Daley. Re-enactment of actual case with patient, physician, and legal counsel. (24 minutes). 1601613 THE PHYSICIAN AS AN EXPERT WITNESS - PART III - "The Conclusion" - with Professor Ronald Carlson, College of Law, Dr. Reginald Cooper, Assistant Professor, Robert C. Porter, M.D., Department of Orthopedic Surgery, College of Medicine, University of Iowa and attorneys Wayne C. Collins and Thomas Daley, Re-enact- ment of actual case with patient, physician, and legal counsel, (59 minutes). 1601814 THE UNIFORM DONOR CARD, with Alfred M. Sadler, Jr., M.D., and Blair Sadler, LL.B., of the National Institutes of Health, Bethesda, Mary- land. Another NCME program explained how the Uniform Anatomical Gift Act affects the practic- ing physician. This program shows a related de- velopment that has occurred in the form of a newly approved Uniform Donor Card. (9 minutes). 2110502 MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS CERVICAL SPINE: DISPLACEMENT OR DISEASE? with P. W. Haake, M.D., Assistant Professor of Orthopedics, University of Rochester School of Medicine and Dentistry, Rochester, New York. The patient with sudden acute neck pain: Is it a disc-a tumor-arthritis-whiplash? Compare your approach to this common problem with that of an orthopedist. This program was produced with the cooperation of the Council on Scientific Assembly of the American Medical Association. (15 minutes) (in color) 0323891 CORTICOSTEROIDS: Rx FOR THREE CONNECTIVE TISSUE DISEASES, with Richard H. Ferguson, M.D., Associate Professor of Medicine and Head of a Section of Rheumatology, The Mayo Clinic and Mayo Foundation, Rochester, Minnesota. Three successful therapeutic plans using corti- costeroids to control certain problems in tem- poral arteritis, polymyositis, and lupus nephritis are outlined. (This program was presented as part of the American Society for Clinical Phar- macology and Therapeutics' Drug Spotlight Pro- gram.) (20 minutes) (in color) 0321079 DIAGNOSIS AND TREATMENT OF PAGET'S DIS. EASE, with John T. Potts, Jr., M.D., Chief of Endocrinology, Massachusetts General Hospital; and Associate Professor of Medicine, Harvard Medical School, Boston. Paget's disease of the bone is seen with increasing frequency in the population over 40. Dr. Potts reviews the present information about the cause of the disease, its pathophysiology and the new approaches to therapy which give promise for controlling the disease. (58 minutes) (in color) 0413124 THE DIAGNOSIS OF SYSTEMIC LUPUS ERYTHE- MATOSIJS, with Naomi Rothfield, M.D., Profes. sor of Medicine, and Chief, Arthritis Section, University of Connecticut School of Medicine, Farmington, Connecticut. Demonstrating the early detection of S.L.E. through clinical and lab' oratory findings. (19 minutes) (In cOlor) 0419951 "DOCTOR, I PUT MY BACK OUTI": MANIPULA- TIVE THERAPY, with Philip E. Greenman, DO., Chairman and Professor, Department of Bio- mechanics, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan. Low back pain - . - a common problem seen through the eyes of an osteopathic physician. Evaluation and treatment are demonstrated. (23 minutes) (in color) 0421757 EARLY SURGERY FOR THE ARTHRITIC HAND, with Alan H. Wilde, M.D., Head of the Rheuma- toid Surgery Section, Department of Orthopaedic Surgery, The Cleveland Clinic Foundation. When six months of intensive medical management fail to help the patient with rheumatoid arthritis of the hand, synovectomy may preserve useful function and relieve pain. In this program: * the rationale for synovectomy; * the history and physical exam used to disclose indications for surgery; and * the operative procedure and the postoperative results. (20 minutes) (In color) 0518522 GROSS SYNOVIANALYSIS, a discussion of joint fluid analysis for the practicing physician, pre- sented by Daniel J. McCarty, M.D., Associate Professor of Medicine, and Head of Rheumatol- ogy Section, Hahnemann Medical Cojlege and Hospital. (13 minutes). 0700411 HOME MANAGEMENT OF ARTHRI'I'IS, with John J. Calabro, M.D., Chief of Medicine and Director of Rheumatology, Worcester City Hospital, Wor- cester, Mass. A rheumatologist demonstrates how patients with arthritis can actively partici- pate in a lifelong program of comprehensive home care. The value of exercises and paraffin treatments are also considered. (16 minutes) (In color) 0820236 60 PAGENO="0415" COMPETITIVE PROBLEiMS IN THE DRUG INDUSTRY 14321 JUVENILE RHEUMATOID ARTHRITIS. A series of patients are presented, and diagnosis and treatment are discussed by staff members at Duke University Medical Center. H. M. Carpenter, M.D., is conference coordinator; Madison Spock, M.D., leads the discussiot. (33 minutes). SAMA 2800001 LABORATORY STUDIES IN CONNECTIVE TIS- SUE DISORDERS. PART III in a series with Edward C. Franklin, M.D., Associate Professor of Medicine, New York University Medical Cen. ter. (16 minutes). 1201203 LONG-TERM MANAGEMENT OF S.L.E,, with Naomi F. Rothfieid, M.D., Professor of Medicine and Chief, Arthritis Division, University of Con- necticut School of Medicine, Farmington, Conn. Specific drugs and general life adjustments are important to the treatment course of systemic lupus erythematosus. However, the key to man- aging S.L.E., demonstrated here, is to identify symptoms and signs of impending flare-ups. (17 minutes) (in color) 1220019 MICROSCOPIC SYNOVIANALYSIS, the use of phase microscopy for joint fluid analysis, with Daniel J. McCarty, M.D., Associate Professor of Medicine, and Head of Rheumatology Section, Hahnemann Medical College and Hospital. (24 minutes). 1300532 SELECTING PATIENTS FOR TOTAL KNEE RE- PLACEMENT, With John A. Lynch, M.D., Ortho- pedic Surgeon, Topeka, Kansas, and Associate Professor of Clinical Orthopedics, University of Kansas School of Medicine, Kansas City, Kansas. Which of your patients with arthritic knees is a candidate for a knee prosthesis? Here are the guidelines plus new information on this con- stantly changing solution to severe knee pain. (17 minutes) (In color) 1921639 STEROIDS, HORMONES AND INFLAMMATORY DISEASE, with Gerald Weissman, M.D., Associ- ate Professor of Medicine, New York University Medical Center. Steroids, hormones, and chloro- quin have been shown to counteract inflam- mation and tissue injury by virtue of their stabili- zation of lysosomes. (14 minutes). 1900318 STRUCTURE AND FUNCTION OF IMMUNO- GLOBULINS, with Edward C. Franklin, M.D., As- sistant Professor of Medicine, New York Uni- versity Medical Center. tss minutes). 1900915 THE TEAM APPROACH TO CHRONIC PAI~'1, from the Pain Control Center of Temple University Hospital, Philadelphia. With Mary E. Moore, M.D., Ph.D., Assistant Professor of Medicine, Section of RheumatoloRy, and psychologist: Edward J. Resnick, M.D., Associate Professor of Orthopedic Surgery, and coordinator, Pain Control Center; Richard Eiler, M.D., Associate Professor Qf Anes- thesiology; Shavarsh Chrissian, M.D., Assistant Professor of Rehabilitation Medicine; arid Marc Flitter, M.D., Assistant Professor of Neurosurgery. Current theories of pain are leading to new methods for treatment. The techniques demon- strated here can work for you and your patients. This program was produced with the cooperation of the Department of Continuing Medical Educa- tion, Temple University. (16 minutes) (ir) color) ~0~3841 THE FIVE-MINUTE JOINT EXAM, with John J. Calabro, M.D., Chief of Rheumatology, Worces- ter City Hospital, and Professor of Medicine, University of Massachusetts - Medical School, Worcester, Massachusetts. Here's a five-minute joint exam, with pointers on how to distinguish degenerative joint disease from such other con- ditions as ankylosing spondylitis and rheumatoid arthritis. (17 rninuteo) (in color) 0619721 THE PROBLEM OF POLYARTHRITIS, with Mary Betty Stevens, M.D., Department of Medicine; Martin W. Donner, M.D., Department of Radi- ology; Lawrence E. Shulman, M.D., Department of Medicine; Alexander S. Townes, M.D., Depart- ment of Medicine; and Thomas M. Zizic, M.D., Department of Medicine; all of the Johns Hop- kins University School of Medicine. A pnisenta- tion-with patients-of clinical arid Ia~oratory features of significance to the differential diag- nosis of acute polyarthritis. The value and limi- tations of serologic findings, synovial fluid analysis, and radiographic findings, are em- ~3hasized, and the role of arthrography in diag- nosis and management is evaluated. ~lsO dis- cussed are management programs and prob- lems relating to rheumatoid arthritis and its variants: ankylosing spondylitis, microcrystalline synovitis, and articular sepsis. A Television Hospital Clinic of The bmerican College of Physicians, 1972. Please inquire for special rental information. (60 minutes) (In color) ACP ~847246 Master Library services are made possible through the support by Roche Labora- tories of the production and regular distri- bution of all NCME telecasts. 61 PAGENO="0416" 14322 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY SYSTEMIC LUPUS ERYTHEMATQSUS, with Wer- ner F. Barth, M.D., Department of Medicine; and Harry M. Robinson, M.D., Department of Derma- tology; both of University of Maryland School of Medicine; and Donald 1. Lewers, M.D., Division of Nephrology, Maryland General Hospital. Three patients illustrate the clinical variability of systemic lupus erythematosus, as well as dif- ferences in therapy. The immunopathology is discussed, with particular attention to recent concepts of pathogenesis. Factors adversely affecting prognosis and those warranting more aggressive therapy are underscored. Also dis- cussed are recent developments using immuno- fluorescent examination of skin biopsy to dis- tinguish systemic lupus erythematosus from discoid lupus and other connective tissue diseases. A Television Hospital Clinic of the American College of Physicians, 1972. Please inquire for special rental information. (60 minutes) (in color) ACP 2837247 THREE ORTHOPEDIC EXAMINATIONS FOR NON- ORTHOPEDISTS HOW I EXAMINE THE SPINE (19 minutes) (in color) 0822742 HOW I EXAMINE THE HIP (15 minutes) (in culor) 0822641 HOW I EXAMINE THE KNEE (16 minutes) (in color) 0822540 With A. Graham Apley, F.R.C.S., Honorary Direc- tor of the Department of Orthopedics, St. Thom- as' Hospital, London; and Consulting Orthopedic Surgeon, Rowley.Bristow Orthopedic Hospital, Pyrfcid, England; Visiting Professor of Ortho- pedics, Albert Einstein Hospital in New York City. Authoritative demonstrations of pormal and ab- normal findings in three orthopedic problem areas-for the generalist. These programs were produced in cooperation with the Department of Orthopedic Surgery and the Office of Continuing Medical Education, Albert Einstein College of Medicine in New York City. TREATMENT OF RHEUMATOID ARTHRITIS: WHEN ASPIRIN FAILS, with Charles M. Plotz, M.D., Professor of Medicine, and Director, Sec- tion on Rheumatic Diseases, Downstate Medical Center, Brooklyn, N.Y. Demonstration of a simple evaluation roubne for arthritis patients when aspirin is no longer effective. How to select the best therapy, with precautions to remember about corticosteroids, cytotoxic and immunologic agents. (20 minutes) (In color) 2017428 NEPHROLOGY BEDSIDE ROUNDS: DIAGNOSTIC TECHNIQUES IN ACuTE RENAL FAILURE, wih Cecil H. Cog- gins, M.D., Assistant Professor of Medicine, Har- vard Medical School. This telecast aims to provide the primary care physician with a practical approach to speedy detection of the underlying cause of renal failure. (18 minutes) (in color) 0211902 CLINICAL PHARMACOLOGY OF DIURETIC DRUGS, with Albert N. Brest, M.D., Associate Professor of Medicine and Head, Section of Vas- cular Disease and Renology, Hahnemann Mcdi. cal College and Hospital. (15 minutes). 0302726 HEMATURIA: DON'T STOP THE WORKUP TOO SOON, with Vincent J. O'Conor, Jr., M.D.,. Chair- man of the Department of Urology at North- western Memorial Hospital, and Professor of Urol- ogy at Northwestern University Medical School, Chicago. A urologist shows his method of evaluat- ing patients with hematuria which is always a danger signal of underlying urologic or renal disease. (15 minuteu) (in color) 0821938 KIDNEY TRANSPLANTATION The following physicians from Cedars-Sinai Med- ical Center in Los Angeles, Calif., discuss renal transplantation with the general physician in mind: Stanley S. Franklin, M.D., Medical Director of the Transplantation Program; Charles R. Klee- man, M.D., Director of Medicine; Morton H. Max- well, M.D., Chief of Nephrology and Hypertension Service; Paul Teraski, M.D., Professor of Surgery at the UCLA School of Medicine; Richard L. Treiman, M.D., and HarQld G. Kudish, M.D., both vascular surgeons. (19 mInutes) (in color) 1109003 RENAL ARTERIAL HYPERTENSION AND TREAT- MENT, with Albert N. Brest, M.D., Head, Sec- tion of Vascular Disease and Renology, Hahne- mann Medical College and Hospital. (11 minutes). 1802609 RENAL BIOPSY: WHEN WILL IT HELP THE CHILD? with Shane Roy, III, M.D., pediatric nephrologist and Associate Professor of Pedi- atrics, University of Tennessee College of Medi- cine, Memphis. Using four detailed patient cases, Doctor Roy illustrates the use of renal biopsy, The program includes an actual biopsy pro- cedure. (15 minutes) (in color) 1820830 62 PAGENO="0417" COMPETITIVE PROBLEMS IN DUE I~RUG INDUSTRY 14323 SELECTIVE RENAL ARTERIOGRAPHY: PART I The technique for visualizing the intrarenal vas- cular system, utilizing the opaque catheter and serial roentgenography is demonstrated by Klaus Ranniger, M.D., Associate Professor of Radiol- ogy, University of Chicago School of Medicine. 117 minutes). 1903802 SELECTIVE RENAL ARTERIOGRAPHY: PART II Klaus Ranniger, M.D., Associate Professor of Ra~ diology, University of Chicago School of Medi- cine, demonstrates a technique for examining the intrarenal vascular system using the opaque catheter and serial roentgenography. (11 minutes). 1904703 THE VALUE OF RENAL BIOPSIES IN THE MAN- AGEMENT OF PATIENTS, with Kent Armbruster, M.D., Department of Medicine, Rush Medical College, Chicago; David P. Earle, M.D., Depart- ment of Medicine, Northwestern University Medi- cal School, Chicago; Robert Jennings, M.D., De- partment of Pathology, Northwestern University Medical School, Chicago; Robert M. Kark,. M.D., Department of Medicine, Rush Medical College, Rush-Presbyterian-St. Luke's Medical Center, Chicago; Robert C. Muehrcke, M.D., Department of Medicine, Rush Medical College, Rush- Presbyterian-St. Luke's Medical Center, Chicago; Conrad Pirani, M.D., Department of Pathology, Columbia University College of Physicians and Surgeons, New York City; and Hock H. Yeoh, M.D., Department of Medicine, Northwestern University Medical School, Chicago. To illustrate the usefulness of renal biopsy in the manage- ment of certain patients with renal disease, both pathologists and clinicians discuss particular patient problems along with the corresponding history, clinical and laboratory findings, and renal biopsy results for each patientA Television Clinic of the American College of Physiolans, 1973. Please inquire for special rental Infor- mation. (60 minutes) (in color) ACP 2857369 TREATMENT OF CHRONIC UREMIA: CONSERVATIVE THERAPY This is the second program on kidney disease produced at the Cedars-Sinai Medical Center in Los Angeles, Calif., with Morton H. Maxwell, M.D., Director of the Kidney and Hypertension ServIce; Charles R. Kleeman, M.D., Director of Medicine; Arthur Gordon, M.D., Assistant Chief of the Kid- ney and Hypertension Service; and Stanley S. Franklin, M.D., Medical Director of the Trans- plantation Program, (20 mInutes). 2010012 TREATMENT OF CHRONIC UREMIA: HEMODIALYSIS This program was produced at the Cedars-Sinai Medical Center in Los Angeles, Calif., With Mor- ton H. Maxwell, M.D., Director of the Kidney and Hypertension Service; Arthur Gordon, M.D., As- sistant Chief of the Kidney and Hypertension Service; John R. DePalma, M.D., Director of Hemodialysis; and Thomas R. Gral, M.D., Asso- ciate ~irector of Hemodialysis. They describe the re)atively new modality of therapy for patients with the types of uremia that were formerly terminal. (18 minuteS). 2009913 NEUROLOGY AN ANATOMICAL APPROACH TO LOW BACK PAIN: SPONDYLOLISTHESIS AND ANKYLOSING SPONDYLITIS, with Peter Marchisell~, M.D Attending Orthopedic Surgeon, The Hospital for Special Surgery, Cornell University Medical Cen- ter, New York City. A firm review of the anat- omy, backed by x-rays and physical examina- tion, is essential to arrive at a definite diagnosis of the cause of low back pain. Dr. Marchisello defines anatomical deviation in two patients, only one of whom may benefit from surgery. (18 minutes) (in color) 0116331 A SINGLE PATIENT-ORIENTED NEUROP$Y,CHO- PHARMACOLOGY. An objective method of evalu- ating the effects of drug therapy in neuro- psychiatric disease is demonstrated by Walter Knopp, M.D., Associate Professor of Psychiatry, Ohio State Un)versity College of Medicine. In his discussion of l3ilIes de Ia Tourette's disease, Dr. Knopp gives particular emphasis to sympto- matic treatment of a neuropsychiatric disorder. (18 minutes). 1906511 A TELEVISION DISCUSSION OF THE ~`iEURO' LOGICAL EXAMINATION, Conducting the pro- gram, which includes questions from th~ studio audience, are Wilson E. Hunt, M.D., Professor of Surgery, and W. C. Wiederholt, M.D., Assistant Professor of Medicine, Ohio State University College of Medicine. The program, telecast to 12 Ohio hospitals, was produced by the Ohio Medical Education Network. (56 minutes). 2800004 CARPAL TUNNEL SYNDROME, with Frank M. Howard, M.D., Neurolo~ist, Mayo School of Medicine, Rochester, Minn. During this program, you'll follow a patient's complaint of tingling hand to the diagnosis of carpal tunnel syndrome, and find out how to determine whether this is a primary or secondary condition. 117 minutes) (in color) 0319578 63 73-6)7 0 - 76 - 27 PAGENO="0418" 14324 COMPETITIVE PROBLEMS IN THE DRUG IN~DUSTRY CEREBRO-VASCULAR IN~UI~FICIENCY - DI- AGNOSIS AND MANAGEMENT. The diagnostic workup of the patient with evidence of cerebro- vascular insufficiency as well as medical man agement of this individual is demonstrated in PART I of this two-part series. The second pro- gram concerns Itself with indications for sur- gical referral for transient ischemic attatks, with a discussion of risks and results. Charles A. Kane, M.D., Chief, Division of Neurology, The Permanente Medical Group, Hayward, California, emphasizes diagnostic considerations and medi- cal management, while Edwin J. Wylie, M.D., Professor of Surgery, University of California Medical Center, San Francisco, focuses on sur- gical problems. The exchange between the au- thorities provides an opportunity to examine the multifaceted sides of this common clinical prob- lem. (PART I: 18 mInutes). 0307805 (PART II, 18 mInutes). 0307806 CLINICAL PROBLEMS IN NEUROLOGY: PARALY- TIC BRACHIAL NEURITIS AND CARPAL TUNNEL SYNDROME, with Gene K. Lasater, M.D.; MIchael Cherington, M.D.; and Sidney Duman, M.D.; all neurologists from the Department of Medicine at the University of Colorado Medical Center. This telecast highlights several cases of paralytic bra- chial neuritis and carpal tunnel syndrome origin- ally presented at the 52nd annual session of the American College of Physicians. (20 minutes) (in color) 0314368 CLINICAL PROBLEMS IN NEUROLOGY: THORAC. IC OUTLET SYNDROME AND CERVICAL ROOT LESION, with Gene K. Lasater, M.D,; Michael Cherington, M.D.; and Sidney Duman, M.D.; all neurologists from the Department of Medicine at the University of Colorado Medical Center. Three neurologists presented several cases of thoracic outlet syndrome and cervical root lesions at the 52nd annual session of the American College of Physicians. This telecast highlights their pre- sentation. (20 mInutes) (In color) 0314267 THE COMATOSE PATIENT: IMMEDIATE MAN. AGEMENT AND EVALUATION, with Jerome S. Resnick, M.D., Director of Neurology, Stamford Hospital, Stamford, Connecticut, and Clinical As- sociate Professor of Neurology, New York Medi- cal College. Problem: coma. History: unknown, Dr. Resnick shows how to find the cause of coma using your eyes and nose, a flashlight, optithalmoscope, pin and blood pressure cuff. This program was pro- duced in cooperation with the Department of Continuing Medical Education, New York Medical College. (16 minutes) (in color) 0323990 THE COMATOSE PATIENT: PATHOPHYSIOLOGY, with Jerome S. Resnick, M.D., Directorof Neu- rology, Stamford Hospital, Stamford, Connecti- cut, and Clinical Associate Professor of Neurol- ogy, New York Medical College. Definition, etiologies, and mechanisms of pro- longed unconsciousness, presented in cogent, organized and practical style. This program was produced with the cooperation of the Depart- ment of Continuing Medical Education, New York Medical College. (16 minutes) (in color) 0323889 COMPUTER ANALYSIS OF THE ELECTROEN- CEPHALOGRAPH Demonstrating the unique suitability of the computer for quantitating the large amount of information recorded by the electroencephalo- graph and for comparing findings and removing artifacts - with Julius Korien, M.D., Assistant Professor of Neurology, New York University Medical Center and Bellevue Hospital Center. (16 minutes). 0303333 CURRENT MANAGEMENT OF PARKINSONISM AND OTHER MOVEMENT DISORDERS, with George C. Cotzias, M.D., Medical Department, Brookhaven National Laboratories, Upton, Long Island, New York and Fletcher H. McDowell, M.D., Fred Plum, M.D., and Richard D. Sweet, M.D., all of the Department of Neurology, Cor- nell University Medical College, New York City. Recent approaches to management of Parkin- son's disease include use of Dopa decarboxy- lase inhibitors, apomorphine, and piribdil as alternatives to L-Dopa. These are discl,ssed, together with possible future therapies involving polypeptides with dopamine-like effects. Use of proprano)oI for essential tremors and catechola- mine antagonists for chorea, torticollis, oral fa- cial dyskinesia, and tics are also considered. A Television Clinic of the American College of Physicians, 1974. Please inquire, for special rental information. (60 minutes) (in color) ACP 2827478 DEALING WITH EPILEPSY: THE SOCIAL PROB- LEM, with Mary Louise Scholl, M.D., Associate Pediatrician, Massachusetts General Hospital, and Assistant Professor of Pediatrics, Harvard Medical School, Boston, Massachusetts. With proper physician guidance, epileptics can live nearly normal lives - Dr, Scholl reviews typical problems with three patients and explains what physicians can do to help. (21 minutes) (in color) 0415130 64 PAGENO="0419" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14325 DETECTION AND DIAGNOSIS OF EDUCATION- ALLY/NEUROLOGICALLY HANDICAPPED CHIL' DREN, with Henry S. Richanbach, M.D., Assist- ant Clinical Professor of Pediatrics at Stanford University School of Medicine. Millions of children cannot succeed in school despite adequate intelligence and eagerness to learn. By evaluating the variations of their be- havior and their ability to perform, these chil- dren can have a good chance In fulfilling their learning potential. Dr. Richanbach demonstrates basic office pro. cedures for detecting, diagnosing and treating school failure in children before the children are caught up in a cycle of failure. The telecast concentrates on the effort of the individual general physician, and not the multi- discipline approach. (17 minutes) (In color) 0412702 DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS OF MIGRAINE AND MUSCLE CONTRACTION HEAD. ACHES -c- PART I - The Migraine Headache" -with Arnold P. Friedman, M.D., Associate Clini- cal P~ofessor of Neurology and Director, Head- ache Unit, Montefiore Hospital. (11 mInutes). 0402706 DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS OF MIGRAINE AND MUSCLE CONTRACTION HEAD- ACHES - PART II - `Muscle Contraction and Other Headaches that Mimic Migraine" - with Arnold P. Friedman, M.D., Associate Clinical Professor of Neurology and Director, Headache Unit, Montefiore Hospital. (14 minutes). 0402907 DIAGNOSIS AND MANAGEMENT OF HUNTING- TON'S CHOREA, with Charles Markham, M.D., Professor of Neurology, University of CalifornIa, Los Angeles School of Medicine, and Milton Wex- er, Ph.D., President, California Chapter of The Committee to Combat Huntingdon's Disease. Huntingdon's Chorea - an invariably fatal dis- order - is transmitted by a dominant gene; thus the carriers' children have a 50 percent chance of inheriting it. There are thought to be more than 100,000 people afflicted with Huntingdon's Chorea in the U.S. and Canada - most of them undiagnosed or mis-diagnosed. Unless physi- cians can detect the disease in these unknown thousands and effectively counsel them, a ge- netic time-bomb is being fused against future generations. (17 mInutes) (in color) 0415331 All programs in this catalog are copyright by the Network for Continuing Medical Education. Duplication, reproduction, or distribution in any form of all or any part of the programs is prohibited without the express written consent of NCME. THE DIAGNOSTIC CHALLENGE OF CI-tE~T PAIN, with moderator Alfred Soffer, M.D., Professor of Cardiology at the University of Health Sciences- Chicago ~Aedical School, Chicago, and Editor-in- Chief of Chest, the Journal of the American Col- lege of Chest Physicians. Participants are: R. D. Henderson, MB., F.R.C.S. (C)., Staff Surgeon, Toronto General Hospital and Assistant `rofessor of the Department of Surgery at the University of Toronto, Canada; Barry William Levine, M.D., Assistant Professor of Medicine, Harvard Medi- cal School, and Chief, Outpatient Pulmonary Services, Massachusetts General Hospital, Bos- ton; Linda D. Lewis, M.D., Assistant Professor of Neurology, College of Physicians and Surgeons of Columbia University, and Chief of the Neu. rology Clinic, Neurological Institute of Columbia Presbyterian Medical Center, New Yprk City, Morton E. Tavel, M.D., Associate Professor of Medicine at the Indiana University School of Medicine, Indianapolis. Pinpointing the cause of your patient's chest pain poses an urgent diagnostic challenge. Join Dr. Soffer and four specialists on these clinical grand rounds as they reach a diagnosis on five patients. (32 minutes) (in color) 0423362 DIZZINESS AND VERTIGO. The differential diag- nosis of these common presenting cQmplaints is demonstrated by Alfred D. Weiss, M.D., De- partments of Neurology and Otolar~ingology, Massachusetts General Hospital and Massachu- setts Eye and Ear Infirmary. (18 minutes). 0408318 ECHOENCEPHALOGRAPHY A NEW, SAFE, SIMPLE, AND PRACTICAL DIAGNOSIS AID William M. McKinney, M.D., of the Department of Neurology, Bowman Gray School of MedIcine and North Carolina Baptist Hospital in Winston- Salem, North Carolina, and Frederick L Thur- stone, Ph.D., of the Biomedical Engineering De- partment of Duke University, Durham, North Carolina, illustrate the unique value of echoen- cephalography In determining brain pathology, (15 minutes). 0509403 HEADACHE: MIGRAINE AND HISTAMINIC CE- PHALGIA, with William G. Speed, III, M.D., De- partment of Medicine; and Leonard J. Gallant, M.D., Department of Psychiatry; both of the Johns Hopkins University School of Medicine. This program deals predominantly with the management of the more chronic forms of mi- graine, emphasizing pharmacotherapeutic tech- niques and touching on those aspects of psy. chotherapy that might be useful to internists. Histaminic Cephalgia (also known as cluster head- ache, cycle headache, or migraine variant) and methods of managing it are discussed. Adapted from a Television Hospital Clinic of the Ameri- can College of Physicians, 1972. Pleate inquire for special rental information. (60 minutes) (In color) ACP 2867244 65 PAGENO="0420" 14g26 COMPETITIVJ~ PROBLEMS IN THE DRUG IN~DTJSTRY HOW I DO A LUMBAR PUNCTURE, with Jerome Posner, M.D., Chief of Neuropsychiatry, Memo. rial Hospital for C~ncer & Allied Diseases, New York City. One of an NCME series of demon- strations by experts of practical, every-day procedures in medicine. (12 minutes) (in color) 0816221 INTRACTABLE PAIN: SURGICAL RELIEF THROUGH STEREO-TAXIC CORDOTOMY A stereo-taxic cordotomy is demonstrated in de- tail by James A. Taren, M.D., Professor of Sur. gory, Section of Neurosurgery, University of Michigan Medical Center, (23 minutes) (in color) 0909510 IRREVERSIBLE COMA. The increased frequency of transplantation raises the question: Is heart beat, alone, sufficient grounds for defining death, or should the parameters of clinical death be expanded? This topic is discussed by Robert S. Schwab, M.D., Director, Brain Wave Laboratory, Massachusetts General Hospital, and Associate Clinical Professor of Neurology, Har- vard Medical School, and Robert R. Young, M.D., Associate Director, Brain Wave Laboratory and Associate Professor of Neurology, Massachusetts General Hospital. (16 minutes). 0906914 LABORATORY PARAMETERS OF MUSCLE DIS- EASE. Laboratory studies can help the physician to differentiate subtle patterns of muscular weakness. Raymond D. Adams, M.D., Bullard Professor of Neuropathology, Harvard Medical School, and Chief of the Neurology Service, Massachusetts General Hospital, explores dis- ease states that may be uncovered through biochemical tests. The use of the electromyo- graph, which offers a more sophisticated meas- ure of muscle response through electrical activity, is demonstrated by Robert R. Young, M.D,. Associate Director Brain Wave Laboratory and Associate Professor of Neurology, Massa- chusetts General Hospital. (16 minutes). 1206202 1~: L-DOPA, with Melvin D. Yahr, M.D., Professor of Neurology, Columbia University College of Physicians & Surgeons, Columbia Presbyterian Medical Center, New York City, and Executive Director, Parkinson's Disease Foundation; and Fletcher McDowell, M.D., Professor of Neurology and Associate Dean, Cornell University Medical College, New York City. For the first time since Parkinson's disease was described more than 150 years ago, a substan- tial number of Parkinsonism patients can be effectively treated by a drug. The drug gives functional improvement and prac- tical relief in a majority of Parkinson cases. L-DOPA is described in terms of its effective- ness, side effects and indicated dosages. (19 minutes). 1811624 MANAGEMENT OF ACUTE HEAD INJURIES, with William E. Hunt, M.D., Professor and Director of the Division of Neurosurgery; and W. George Bingham, Jr., M.D., Assistant Professor, Division of Neurosurgery, both with the Ohio State Uni- versity College of Medicine, in Columbus. Two neurosurgeons demonstrate the diagnostic pro- cedure they follow in cases of acute head in- iuries. They also show the complications that can arise during the hours immediately after the injuries, and the neurosurgical emergencies that can develop. (15 minutes). 1314140 MANAGEMENT OF ACUTE SPINAL INJURIES, with William E. Hunt, M.D., Professor and Director of the Division of Neurosurgery; W. George Bing- ham, Jr., M.D., Assistant Professor, Division of Neurosurgery; and Stephen Natelson, M.D., Sen- ior Resident in Neurosurgery; all with the Ohio State University Collegeof Medicine in Columbus. Three specialists describe the precautions that are necessary in handling patients with spinal injuries through the stages in the emergency room, in radiology and during the period of re- habilitation. (18 minutes) (In color) 1314038 MANAGEMENT OF STROKE - PART I. Rudolph Kaelbling, M.D., Associate professor of Psy- chiatry, Ohio State University College of Medi- cine, examines the common types of stroke and their effects on consciousness, mental acuity, speech, and physical coordination, as well as the impact of stroke on the patient's family. Rehabilitation is discussed also, and a speech therapist is shown working with patients. (14 minutes). 1305506 MANAGEMENT OF STROKE - PART II. The physical rehabilitation of the stroke patient - including rehabilitative appliances, exercise, and physiotherapy - is discussed and demonstrated by Ernest W. Johnson, M.D., Chairman, Depart- ment of Physical Medicine; Ohio State Univer- city College of Medicine. )17 minutes). 1305607 MANAGING THE HYPERACTIVE CHILD, with Gerald Erenberg, M.D., Pediatric Neurologist, Montefiore Medical Center and Morrisania Hos- pital, Bronx, N. Y. Amphetamines are no pana- cea, nor need they be your first plan of attack. A structured approach to treatment is outlined and illustrated. (12 mInutes) (in colsri 1318651 MECHANISMS OF TREMORS AND FITS, with John N. Meagner, M.D., Associate Professor of Neurosurgery; and George W. Paulson, M.D., As- sociate Professor of Neurology; both of the Ohio State University College of Medicine in Columbus, Ohio. A variety of common and un- common tremors and fits are vividly demon- strated. The emphasis of this program is on causes and diagnoses. (17 minutes). 1310420 66 PAGENO="0421" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14327 MENIERE'S DISEASE: DIFFERENTIAL Dx, with James R. Tabor, M.D., Otologist and Assistant Professor of Surgery, University of Colorado Medical Center, Denver. By comparing two pa- tients, an otologist demonstrates how to rec- ognize the patient with Meniere's disease, and how to rule out other disorders. (16 minutes) (in color) 1322356 MIGRAI NE: DIFFERENTIAL DIAGNOSIS, with Arnold Friedman, M.D., Clinical Professor of Neurology, Columbid University College of Physi- cians and Surgeons, Physician in Charge of Headache Unit, Montefiore Hospital and Medical Center, Consultant to National Institute of Neu- rological Diseases, Division of National Institutes of Health. At least nine disorders, some of them potentially fatal, may mimic migraine. Dr. Fried- man demonstrates anatomical clues to their dif- ferential diagnosis. (12 minutes) (in color). 1314743 MIGRAINE: ITS DIAGNOSIS AND TREATMENT, with Arnold Friedman, M.D., Clinical Professor of Neurology, Columbia University College of Physi- cians and Surgeons; Physician in Charge, The Headache Unit, Montefiore Hospital and Medical Center; and Consultant to the National Institute of Neurological Disease and Stroke of the Na- tional Institutes of Health. Dr. Friedman presents a highly visual and prac- tical approach to diagnosing the five common types of migraine and how best to treat them. Heavy emphasis is placed on the individuality of migraine patients. (17 minutes) (in celor). 1314642 NEUROMUSCULAR DISORDERS OF INTEREST TO PHYSICIANS, with Andrew G. Engel, M.D., Department of Neurology; Peter James Dyck, M.D., Department of Neurology; and E. H. Lambert, M.D., Department of Medicine, all of the Mayo Clinic, Mayo Graduate School of Medi- cine, Rocnester, Minn. The clinical state of patients with uremic neuropathy, the myasthenic syndrome, and adult acid maltase deficiency is shown and correlated with histologic, physio- logic, and biochemical abnormalities. A Televi- sion Clinic of The American College of Physicians, 1973. Please inquire for special rental informa tion. (60 minutes) (in color) ACP 2817365 Master Library seroices are made possible through the support by Roche Labora- tories of the production and regular distri- bution of all NGME telecasts. PEDIATRIC NEUROMUSCULAR PROBLEMS. De- termining the existence and extent of brain damage in the very young child requires not only attention to every movement and response made by the child, but a knowledge of how to interpret them for treatment. Examination of the hypotonic infant as well ss observation of the abnormalities associated with cerebral palsy are explored, using actuci child patients, by William C. Earl, M.D., Assistant Professor, Department of Physical Medicine, and Robert A. Wehe, M.D., Instructor, Department of Pediatrics, Ohio State University College of Medicine. (17 minutes). 1607606 PEDIATRIC PROGRESS: SUBDURAL FLUID COL- LECTIONS, with Richard J. Pellegrino, M.D., Di- rector of Pediatric Neurology, University of Nebraska Medical Center, Omaha. Subdural fluid collection in a very young child is not the same problem encountered iii older children and adults. Here are the differences in signs and symptoms, diagnosis and treatment. (15 minutes) (iv color) 1623651 PHENOMENA OF CLINICAL MYOLOGY. Much in- formation about a patient's muscle fiber can be elicited by a thorough examination of each muscle group, from head to toe. Raymond D. Adams, M.D., Chief of Neurology ServicŘ, Mas- sachusetts General Hospital, and Bullafd Pro- fessor of Neuropathology, Harvard Medical School, demonstrates the systematic examina- tion of a dystrophic patient. (56 minutes). 1606111 SCANNING THE BRAIN IN CROSS SECTIOtiI, with Paul F. J. New, M.D., Chief of Neuroradiology at Massachusetts General Hospital and AsSociate Professor of Radiology at Harvard Medical School. Demonstration of the new radiological technique of computerized tomography, a non- invaSive method of investigating and analyzing the brain in detail that may be the most im- portant single advance in radiological diagnosis in 50 years. (16 minutes) (in color( 1920435 SCOLIOSIS: SIGNIFICANCE OF EARLY DETEC- TION, with Hugo A. Keim, M.D., Director of the Scoliosis Clinic, New York Orthopaedic Hospital; and David B. Levine, M.D., Associate Attending Orthopaedic Surgeon, Hospital for Special Sur- gery, and Clinical Associate Professor, Cornell University Medi0al College, New York City. Approximately one adolescent in 10 ha~ idio- pathic scoliosis, which too often iS not recog- nized until the curvature has become debilitat- ing. Two orthopedists show what to look for on x-rays and how to conduct a simple office exami- nation that makes earlier diagnosis and treat- ment easier. (15 minutes) (in color) 1914726 67 PAGENO="0422" 14328 COMPETITIVE PROBLEMS IN THE DRtG INDUSTRY SCItLENING PRESCHOOLERS FOR NEUROLOGI- CAL DEFICITS, with N. Paul Rosman, M.D., Pro- fessor of Pediatrics and Neurology, and Director of Pediatric Neurology at Boston University School of Medicine, and Boston City Hospital. A 15-minute exam can head off possible learning difficulties. Dr. Rosman tests an apparently nor- mal five-year-old for neurological problems and analyzes his results. (20 minutes) (in color) 1918443 SENSORY FEEDBACK THERAPY, with Joseph Brudny, MD., Project Director, Sensory Feed- back Unit, Institute for Crippled and Disabled (lCD.), Bellevue Hospital Center; Julius Korein, MD, Professor of Neurology, New York Univer- sity Medical Center; Bruce Grynbaum, M.D., Professor of Rehabilitation Medicine, NYU Medi- cal Center; Lawrence W. Friedman. MD, Medical Director, lCD., Bellevue Hospital Center; and Ms. Lucie Levidow, Research Assistant, lCD., all in New York City. `Biofeedback" techniques have been applied to diverse medical, psycho- logical, and functional conditions. One thera- peutic application, shown on this program, offers no-risk help for certain neuromuscular disorders. 1)8 minutes) (in color) 1920232 SNAKEBITE, with Findlay E. Russell, M.D., Ph.D., Professor of Neurology, Physiology and Biology, and Director, Laboratory of Neurological Re- search, University of Southern California School of Medicine, Los Angeles. How to distinguish the dangerous bites, recommend first aid, and apply emergency and supportive treatment. (24 minutes) (in color) 1920636 SOME PATHOLOGIES OF SLEEP, with Julius Se- gal, Ph.D., of the National Institute for Mental Health, and Professor of Psychology, George Washington University Washington, D.C. Dr. Se- gal describes the various stages of normal sleep and then relates disorders in REM and deep sleep to enuresis, somnambulism, night terrors and other patient problems. Special emphasis is given to the diagnosis and treatment of narcolep- sy, which affects half a million people in the U.S. (19 minutes) (in color) 1917729 SORTING OUT SEIZURES IN CHILDREN, with Gilbert H. Glaser, M.D., Chairman and Professor, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, and President of the American Academy of Neurol- ogy. This program provides a quick and thorough evaluation of the seizure patient from initial ob- servation to mandatory laboratory and radiologic tests for a prompt diagnosis. (16 minutes) (in color) 1920334 SPHINGOLIPIDOSIS: GENETICS The increasing incidence of sphingolipid dIs- ease, such as Tay-Sachs, Gaucher's, and Nie- rnann~Pick, is examined genetically by Stanley M. Aronson, MD., Professor of Pathology, State University of New York Downstate Medical Cen- ter, and Attending Neuropathologist, Isaac Al- bert Research Institute, Jewish Chronic Disease Hospital, Brooklyn. (55 minutes). 1904914 SPHINGOLIPIDOSIS - PART I - BIOCHEMICAL ASPECTS. The chemical compositions of ganglio. sides, sphingomyelins, sulfatides, glycolipids, and cerebrosides, as they are found in the vari- ous sphingolipid diseases, are analyzed by Abra' ham Saifer, Ph.D., Chief of the Biochemistry Departrrient, Isaac Albert Research Institute of the Jewish Chronic DiseaSe Hospital, Brooklyn. (21 minutes). 1905015 SPHINGOLIPIDOSIS - PART II - PATHOLOGY Several pathologic manifestations - such as amaurotic family idiocy (Tay-Sachs disease), hep. atosplenomegaly (Niemann-Pick disease), and others - grouped under the general category of sphingolipidosis, are examined and defined by Bruno W. Volk, M.D., Director of the Isaac Albert Research Institute, of the Jewish Chronic Disease Hospital, and Clinical Professor of Pathology, State University of New York Downstate Medical Center, Brooklyn. (21 minutes). 1905016 SPHINGOLIPIDOSIS - PART Ill - CLINICAL ASPECTS. The specific physiologic manife~ta- tions of the Tay-Sachs and .Niemann-Pick dis- eases and amaurotic idiocy-such as cherry red macula, clonus, severe contractions, the "frog" position of the legs, and lack of macrocephaly - are demonstrated with young patients by Larry Schneck, M.D., of the Albert Isaac Research Institute of the Jewish Chronic Disease Hospi- tal, Downstate Medical Center, Brooklyn, New York. (13 mInutes). 1905217 THE TEAM APPROACH TO CHRONIC PAIN, from the Pain Control Center of Temple University Hospital, Philadelphia. With Mary E. Moore, M.D., Ph.D., Assistant Professor of Medicine, Section of Rheumatology, and psychologist; Edward J. Resnick, M.D., Associate Professor of Orthopedic Surgery, and coordinator, Pain Control Center; Richard Eller, M.D., Associate Professor of Anes- thesiology~ Shavarsh Chrissian, M.D., Assistant Professor of Rehabilitation Medicine; and Marc Flitter, M.D., Assistant Professor of Neurosurgery. Current theories of pain are leading to new methods for treatment. The techniques demon- strated here can work for you and your patients. This program was produced with the cooperation of the Department of Continuing Medical Educa- tion, Temple University. (16 minutes) (in color) 2023841 68 PAGENO="0423" COMPETITIVE PROBLEMS ik THE DRUG INDUSTRY 14329 THE DIFFERENTIAL DIAGNOSIS OF DIZZINESS, with Rosalie Burns, M.D., Professor and Head of the Department of Neurology; and Robert Wolfson, M.D., Professor and Head of the Division of Oto- laryngology, The Medical College of Pennsyl- vania, Philadelphia. The patient who complains of dizziness may be suffering from one of many. maladies. Two experts, presenting three such pa- tients, demonstrate how the primary care physi- cian can question and examine his way to a cOn- clusive diagnosis. 120 minutes) (in color) 0418344 THE HYPERACTIVE CHILD: FINDING THE CAUSE, with Gerald Erenberg, M.D., Pediatric Neurologist, Montefiore and Morrisania Hos- pitals, Bronx, N. Y. The child is out of control at school or at home. You are asked to diag- nose or rule out minimal brain damage. This program shows you how - simply and quickly. 118 minutes) (in color) 0818532 THE NEUROLOGICAL EXAMINATION. Careful analysis of the subjective complaints of the pa- tient is the key in the neurological examination where the doctor will never have an "ihsidë view." Diagnosis of central nervous system com- plaints and demonstrations of the most helpful procedures are done by WillIam E. Hunt, M.D., Professor of Surgery and Director, Division of Neurological Surgery, end W, C. Wiederholt, M.D., Assistant Professor of Medicine, Division of Neurology, Ohio State University College of Medicine. (16 minutes). 1407803 THE NEUROLOGICAL EXAMINATION FOR THE NEWBORN, with N. Paul Rosman, M.D., Profes- sor of Pediatrics and Neurology and Director of Pediatric Neurology, Boston University School of Medicine. Here are Dr. ROsrńan's reasons and techniques for this exam - an important few minutes in the first days of a newborn's life. (19 mInutes) (In color) 1418131 TRANSIENT ISCHEMIC ATTACK: PART I - THE HISTORY (13 mInutes) (in Color) 2018829 TRANSIENT ISCHEMIC ATTACK: PART Ii - THE PHYSICAL, with Clark H. Millikan, M.D., Senior Consultant and Professor of Neurology, The Mayo Clinic, Rochester, Minn. During this two-part program, you'll take a close look at how to make a diagnosis of TIA . . an important challenge, as three of five major strokes may be preventable through proper diagnosis of TIA's and their subsequent treatment. (21 minutes) (in color) 2018830 A TELEVISION DISCUSSION OF THE MANAGE. MENT OF STROKE PATIENTS. From the Ohio Medical Education Network, the etiology and management of stroke is covered In a distussion led by Rudolph Kaelbllng, M.D., Assistant Pro- fessor of Psychiatry, and Ernest W. Johnson, Chairman, Department of Physical Medicine, Ohio State UnIversity College of Medicine. (50 minutes). 2800005 TREATING EDUCATIONALLY/NEUROLOGICALLY HANDICAPPED CHILDREN, with Henry S. Rich' anbaOh, M.D., Assistant Clinical Professor of Pedi- atrics, Stanford University School of Medicine; and Lester Tarnapol, SoD., Past Pre~ident of the California Association for Neurologically Handicapped - both from Stanford, California. The general physician will learn about the drugs that are being administered cautiously to educa- tionally handicapped children, and th~ special educational programs that have been developed to assist them in daily living. (17 minutes) (in color) 2012811 WI-IAT CAROTID ARTERIOGRAPHY CAN TELL YOlI, with Michael D, F. Deck, M.D., Associate Attending Radiologist, Memorial $loan-Kettering Cancer Center, and Associate Professor of Radi' ology, Cornell University Medical Center, New York City. Skull films and brain scans show bone metastases in a patient with inoperable lung cancer. Following irradiation, she has progres- sively severe headaches and slight dementia. Does she have additional metastases in the brain? Should she have more irradiatll?n? With this patient, Dr. Deck demonstrates carotid ar- teriography and the value of the procedure. (17 minutes) (in color) 2318909 NURSING AND PARAMEDICAL A DREAM COME TRUE. This program for recruit. ing nurses ~hows the areas of responsibility filled by the RN. and the student nurse, From the University of MisslCslppi Medical Centet. 116 minutes). 2800003 BASIC TERMINOLOGY FOR REHABILITATION APPLIANCES. Produced by the Institute of Phys- ical Medicine and Rehabilitation. A unique dem- onstration of basic rehabilitation appliances and how they ean be utilized. (24 mInutes), *700701 69 PAGENO="0424" 14330 COMPETITIVE PRffBLEMS IN THE DRUG IN1)USTRY CARDIO-RESPIRATORY RESUSCITATION - RN.- M.D. COOPERATION. The critical need for con- tlnuous surveillance and expeditious deploy- meet of personnel and equipment in cases of cardiac or respiratory arrest underscoves the in- terdependence of the nurse and physician. Grace Davidson, R.N., Director of Nursing, New York University Medical Center, discusses the nurses responsibilities and opportunities. The uses of 24-hour EKO monitoring and spe- cialized resuscitatory equipment are demon- strated by Stephen Wittenberg, M.D., Instructor in Medicine, and Roger Hand, M.D., Chief Med ical Resident, New York University Medical Cen- ter. Airway team procedures, the components of the airway cart, and results obtained through their effective use are demonstrated and dis- cussed by Noel Cohen, M.D., Assistant Professor of Otolaryngology, (22 minutes). 2701418 DEVELOPING A PLAN FOR NURSING CARE - PART I AND PART II. How a plan for nursing care is evolved when the patient first enters the hospital. Emphasis is on the nurse's activities end the knowledge that she must employ. Par- ticipants include Gladys Sorenson, Professor. of Nursing; Betsy Linn Ray and Donna M. Knapp, Instructors; and others from the staff and stu- dent body of the University of Arizona College of Nursing. (PART I: 25 minutes). 2700207 (PART II: 16 minutes). 2700308 HEART TRANSPLANTS AND THE OPERATING ROOM NURSE. Five key participants in major heart transplant operations describe their ex- periences. Each explains the part She played during surgery, how it differed from a normal surgical schedule, advance preparations needed, and the extra precautions taken, The nurses: Ludmila Davis, R.N., Director of the OR, and Peggy Ann Hartin, R.N., Assistant Head Nurse, Palo Alto-Stanford Hospital; Grace M. Ray, RN., Supervisor of the OR, and Enid E. Collymore, R.N., OR Staff Nurse, Maimonides Hospital, Brooklyn, N. Y.; and Peggy Jordaan, Senior Theatre Sister in charge of the Cardlo- thoracic Unit, Groote Schuur Hospital, Capetown, South Africa. Moderator: Kathryn L. O'Donnell, R.N., Overlook Thoracic Clinic, Boston. (24 minutes). 2701515 Master Library services are made possible through the support by Roche Labora- tories of the production and regular distri- bution of all NCME telecasts. NEUROSURGICAL INTENSIVE CARE. A specially designed five-patient neurosurgical intensive care unit is providing a new kind of acute care for patients with cehtral nervous system dis- orders, Patients are admitted to the unit prior to surgery and returned there postoperatively - a geographical convenience that has proven of great value both to patients and staff. The important role of The unit in inservice train- ing is described by Joseph Ransohoff, M.D., Professor and Chairman, Department of Neuro. surgery, New York University-Bellevue Medical Center. Demonstrating the special equipment in the unit, Dr. Ransohoff also takes note of Its limitations: Even highly sophisticated monitoring devices cannot replace the continuity of care that can be provided by a well-trained staff. (26 minutes). 2701525 NURSING ASPECTS OF CONSTANT CORONARY CARE UNITS - PART I. The expanding use of electronic and mechanical equipment iii the hos- pital and in medicine generally is having an increasing impact on the nursing profession. Diane Eddy, RN., Head Nurse, Constant Coronary Care Unit, Fairview General Hospital, Cleveland, Ohio, discusses current technology from the nurse's point of view and demonstrates modern electronic devices, including the EKG monitor and defibrIllator. (22 minutes). 2700319 NURSING ASPECTS OF CONSTANT CORONARY CARE - PART II. An illustration of the nurse's role in coronary care. Unique admission pro- cedures such as placing leads on the corollary patient and taking an EKG strip are shown. Diane Eddy, RN., Head Nurse, Constant Coro- nary Care Unit at Fairview General H~~pital, Cleveland, Ohio, shows how to recognize changes in a patient's condition, employ emerge~jcy equip- ment, and assist the physician In an emergency. Moving the patient to the "step down unit" and educating his family for home care are also dis- cussed. ~sg minutes). 2700420 NURSING'S ROLE IN PATIENT AND FAMILY ANXIETY. Responding to a real need to ease the anxiety of the patient and his family upon com- ing into the hospital, a special program has been organized at Memorial Hospital of Long Beach. In this presentation, Clue Gunter, RN., Staff Assistant, Department of Nursing, demonstrates how communication by the nurse of a personal interest in the patient and his fears can help ease him through even the most critical situa- tions, Explaining their oWn roles in the program are Senior Clinical Nurse Karen Sorensen, RN., Staff Nurses Bronwynn Jones, RN., and Eleanor Barr, RN., and Clinical Nurse Jean Maffel, RN. (29 minutes). 2701623 70 PAGENO="0425" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14331 THE PEDIATRIC NURSE PRACTITIONER: AN EVOLVING ROLE IN PATIENT CARE, with Henry K. Silver, M.D., Professor of Pediatrics, University of Colorado Medical Center, Denver; and Loretta C. Ford, RN., Ed.D., Professor and Chairman of Community Health Nursing, University qf Colo- rado School of Nursing, Denver, If your pediatric practice is about one-half well-child supervision and one-fifth minor respiratory infections man- agement, then your office could be a candidate for a pediatric nurse practitioner (PNP). A group with six years' experience in the PNP program helps you understand this new role and the PNP-doctor relationship with vignettes of a PNP on-the-job. Although this telecast concerns pedi- atric practice, other physicians, too, can benefit from this look at the PNP experience, (20 minutes) (in color) 1614535 THE PEDIATRIC NURSE PRACTITIONER IN YOUR OFFICE, with Henry K. Silver, M.D., Professor of Pediatrics, University of Colorado Medical Cen- ter, Denver; Donald Cook, M.D,, Lewis R. Day, MD, and Robert Schiff, M.D., all pediatricians practicing with PNPs; and Loretta C. Ford, RN., Ed.D., Professor and Chairman of Community Health. Nursing, University Colorado School of Nursing, Denver, In six years' experience with over 80 PNPs, there have been no legal problems. Three physicians and their PNP associates describe their own enthusiastic reactions and those of their col- leagues to this innovative, patient-accepted pro- gram that provides security and a lighter work load for physicians as well as professional grati- fication for PNPs. (18 mInutes) (in cslor) 1614636 PSYCHODRAMA - THE PROLOGUE - PART I. This workshop in psychodrama, with patients and staff of the Hennepin County General Hos- pital, demonstrates the methods used to ini- tiate and stage psychodrama. Presented by James Enneis, Director of Psychodrama, St. EliZ- abeth's Hospital and U.S. Department of Health, Education, and Welfare. (26 mInutes). 2700829 PSYCHODRAMA - THE PLAY - PART II. In this section of a special three-part series, psy- chiatric patients at Hennepin County General Hospital participate in an actual psychodrama, conducted by James Enneis, Psychodramatist from St. Elizabeth's Hospital, Washington, DC. The patients act out Inner conflicts, Impossible to express in their daily lives, and the reactions of the other patients in the audience are shown (29 mInutes). 2701130 PSYCHODRAMA - THE CRITIQUE - PART III. Members of the medical and nursing staffs dis- cuss their impressions after having observed and participated in a psychodrama. Conducting the critique i~ James Ennels, Supervisory Psy- chodramatist, St. Elizabeth's Hospital, Wash- ington, DC. (14 mInutes). 2701231 SKELETAL TRACTION - THE TEAM APPROACH - PART I - ADMISSION AND EMEI~GENCY CARE. The emergency management of a frac- tured femur is demonstrated by William McCloud, M.D., Resident in Orthopedic Surgery Ohio State University Center for Continuing Medical Educa- tion, for his departmental team, which includes an R.N., orthopedic orderly, physiotherapist, and occupational therapist. Discussing the rationale for the procedures, he reviews the structure of the femur and the surrounding muscles and how the anatomy and type of fracture dictate the ap- propriate management. (25 mInutes). 2701332 SKELETAL TRACTION - THE TEAM APPROACH - PART II * IN TRACTION. How the patient in traction benefits from the attention of a well- organized team of specialists is demonstrated by William McCloud, M.D., Resident In Otho- pedic Surgery, Ohto State University Center for Continuing Medical Education, and a depart- mental team caring for a patient with a frac- tured femur. The occupational therapist helps the patIent to adjust to the discomfort and anxiety df pro- longed hospitalization and to prepare for limi- tations of activity during home convalescence. The physiotherapist shows the kinds of exer- cises best suited to the patient in leg traction. The orthopedic nurse evaluates the patient's con- dition, particularly skin color, circulation in the fractured leg, and any signs of infection. The im- portance of hygiene is stressed as she demon- strates the proper method for bathing the patient in skeletal traction. (24 minutes). 2701433 STROKE - FOCUS ON INDEPENDENCE. Help- ing the stroke patient to become self-sufficient poses a challenge to the nurse In the general hospital. Elizabeth Pliskoff, R.N., works with stroke patients at Good Samaritan Hospital in Phoenix, Arizona, and demonstrates how patients can be taught seIf~exercise, feeding themselves, and the natureof their illness. (30 minutes). 2701028 71 PAGENO="0426" 14332 COMPETITIVE PROBLEMS IN ~HE DRUG INI)USTRY THE CLINICAL NURSING SPECIALIST. This new approach frees the nurse from a structural assignment and allows her to work anytime and anywhere in the hospital, depending on the status of her patient. She follows the patient from admission through post-operative care and is trained to deal with emotional and cultural factors as well as the physical and medical re- quirements of her patient Presenting this con- cept are Miss Laura L Slmms, RN., Department Head of Surgical Nursing, and Miss Virginia DerrickC, RN., Clinical Nursing Specialist and Associate Professor of Nursing Education, Cor- nell University, New York Hospital. (30 minutes), 2702002 THE HEAD NURSE - HER ROLE AS A CLINICAL RESOURCE PERSON. The head nurse can serve as a key person in creating a therapeutic en- vironment for patient care, As a clinIcal resource person, she creates a setting of continuing edu- cation and communication within the hospital. Miss Grace Davidson, Director of Nursing, New York University Medical Center, Illustrates the role of the head nurse in giving priority and focus to individual nursing care, problem solv- ing, and the needs of patients. The point Is made that the head nurse, In guiding her staff to initiate and obtain goals of nursing care, must rely on self-perception, a philosophy of nursing, and her hospital's organizational structure. - (26 minutes). 2701814 THE IMPACT OF TECHNOLOGY IN THE NURS- ING PROFESSION - Program 2. "NursIng As- pects of Constant Coronary Care Units - Part I." A discussion and demonstration of modern electronic equipment including the EKG monitor and defibrillator - from the nurse's point of view. With Diane Eddy, R.N., Head Nurse. Con- stant Coronary Care Unit, Fairview General Hos- pital, Cleveland, Ohio. (22 minutes). 2700309 THE IMPACT OF TECHNOLOGY IN THE NURS- ING PROFESSION - Program 3. Nursing As- pects of Constant Coronary Care Units - Part II." A presentation of the nurse's duties and responsibilities in a constant coronary monitor- ing unit - from the time of patient admission to transfer to the "step down unit" to "patient education at discharge." With Diane Eddy, R.N., Head Nurse, Constant Coronary Care Unit, Fair- view General Hospital, Cleveland, Ohio. (19 minutes). 2700410 THE IMPACT OF TECHNOLOGY IN THE OPERAT- ING ROOM - "CRYOSURGERY." Dorothy Paul- son, RN., Operating Room Supervisor, and Pa- tricia Partridge, RN., St. Barnabas Medical Cen- ter, Livingston, New Jersey, discuss the techno- logical changes now taking place In the operat- ing room and explain the nurse's responsibilities for cryosurgical equipment during both setup and surgery. Gerald Fonda, M.D., Director, Oph- thalmology Division, demonstrates cataract cryo- surgery and Sidney Lefkovics, Chief, Seótlon of Obstetrics and Gynecology, shows how cryo- surgery is utilized in a gynecologic procedure. (36 minutes). 2700117 THE NURSE -~-`- HER EXPANDED ROLE IN CHILD CARE. Nurses can provide comprehensive well- child care and identify, appraise and temporarily manage some acute and chronic childhood con- ditions, Henry K. Silver, M.D., Professor of Pediatrics, University of Colorado Medical Center, describes how the Pediatric Nurse-Practitioner Program at Colorado prepares nurses to assume this In- creased role in total child health care. Developed with the cooperation of Loretta C. Ford, R.N,, Ed.D., Departntent of Nursing, the program has resulted in a realignment of functions per- formed by ~ihysicians and nurses so that each can atsume those aspects of child care he can perform best. The result is Improved patient care and more effective use of the skills and time of both physicians and nurse. (21 mInutes). 2701826 THE NURSING TEAM CONFERENCE - PART I. A concise explanation of the theory and makeup of the nursing team conference, utilizing an ac- tual team conference to illustrate the principles involved. Participants include Eleanor C. Lam. bertsen, R. N., EdO., Professor of Nursing Edu- cation and Dliector, DIvision of Nursing Educa- tion, Teachers College, Columbia University; Ellen Fahy, R.N., Ed.D., Associate Professor of Nursing Education, Teachers College, Columbia University; Barbara Friedman, R.N., Team Leader, and members of the Mount Sinai Hospital Nurs- ing staff. (30 minutes). 2700421 THE NURSING TEAM CONFERENCE - PART II. "Practice" demonstrates how the nursing team conference operates to provide a working tool for greatly improved patient care. Participants Include Eleanor C. Lambertsen, R.N., Ed.D., Pro- fessor of Nursing Education, Teachers College, Columbia University; Ellen Fahy, R.N., Ed.D., As- sociate Professor of Nursing Education, Teachers College, Columbia University; Barbara Friedman, RN., Team Leader, and members of the Mount Sinai Hospital Nursing Staff. (30 minutes). 2700522 72 PAGENO="0427" COMPETITtVE PROBLEMS IN THE DRUG INDUSTRY 14333 THE PROBLEM'ORIEN'IED MEDICAL RECORD, with Paul V. Ertel, M.D., Associate Professor of Pediatrics, Ohio State University College of Medicine, Columbus, Ohio. This Special Work. shop offers a comprehensive picture of what physicians and other health professionals need to know to initiate and maintain Problem' Oriented Medical Records. This unique inter' active Workshop combines television instruction and workbooks which include POMR forms for the participants to use as they work along with the videotape. Please inquire for special rental information. (50 minutes) (in color) 280004.8 THE USE OF COMPUTERS IN A GENERAL HOS PITAL. Dean J. Clyde, Ph.D., Director of the Bio-Metrics Laboratory at the University of Mi- ami, demonstrates and discusses how a com- puter records patient history and retrieves the data, monitors various aspects of the patient's condition, and performs bookkeeping. This use qf computers in a general hospital frees nurses, paramedical personnel, and administrators for more effective use of skills and time, (15 mInutes). 2700906 UNIT DOSE. A revised system of dispensing drugs in the hospital - transferring certain responsibilities from the nursing staff to the pharmacy - has been implemented at the Uni- versity of Kentucky Medical Center. By way of comparison, the system of drug distribution currently practiced in most hospitals is reviewed, emphasizing those places where errors are most likely to occur. Revising such a system requires, of course, that a number of modifications be made in equipment and packaging; how these alterations have been made and integrated into the new system at the University is demon- strated. (30 minutes), 2701005 Rental and purchase prices cover the actual costs of duplication; therefore, no provision is made for the previewing of catalog programs. If, in the opinion of the person for whom it was ordered, a pro- gram contains any significant flaw or in- adequacy, no charge will be made. The reviewer is, however, requested to state the reason on the program review card that accompanies each Master Library videocassette. NUTRITIONAL AND METABOLIC DISORDERS ACID-BASE IMBALANCE: THREE PROGRAMS. "For decades, acid-base metabolism with Its cabalistic terminology has intrigued and, Inci- dentally, terrorized many clinicians. Actually, the whole sub!ect of acid-base metabolism and Its clinical application is just another facet ~f medi- cal science that, once understood, presents Itself in a straightforward, logical manner. . :" Hugh J. Carroll, M.D. The following three programs were produced In cooperation with the Office of Continuing Educa- tion of the State University of New York, Down- state Medical Center, Brooklyn, New York. ACID-BASE IMBALANCE: PATHOGENESIS, with Hugh J. Carroll, M.D., Associate Professor of Medicine, Director of the Electrolyte and Hy- pertension Section, Department of k~edicine, Downstate Medical Center. A presentation of the primary disturbances in metabolic and respiratory acid'base imbalances, their mech' anisms of compensation, and the clinical situ~ ations in which they may occur. (22 minutes) (In color) 0122444 ACID-BASE IMBALANCE: RECOGNITION AND MANAGEMENT, with Hugh J. Carroll, M.D., As~ sociate Professor of Medicine, Director of the Electrolyte and Hypertension Section, Depart. ment of Medicine, Downstate Medical Center. When blood gases and other clinical studies confirm the presence of an acid-base disturb' ance, it is the physician's part to reverse the imbalance directly or to treat the underI~'ing dis- ease so that the patient's own corrective mech- anisms can restore the normal state. (15 minUtes) (in color) 0122445 KETOTIC AND NONKETOTIC COMA: MECH- ANISMS AND TREATMENT, with Hugh J. Car- roll, M.D., Associate Professor of Medicine, Director of the Electrolyte and HypertensIon Section, Department of Medicine, Downstate Medical Center. Pathophysiology, diagnosis, and management in diabetic ketoacid~sis and hyperosmolar, hyperglycemic, nonketot~c coma. (18 minutes) (In color) 1122406 73 PAGENO="0428" 14334 COMPETITIVE PROBLEMS IN THE DRUG IN~DUSTRY ADULT DIABETES: OUTGUESSING THE NEXT 24 HOURS, with Leo P. Krall, M.D., Director, Educa. tion Division, and Lecturer in Medicine, Joslin Diabetes Foundation, Inc., and New England Deaconess Hospital, and Lecturer, Harvard Mcdi. cal School Boston. Management of diabetes mellitus starts with defining treatment goals and understanding why they are often difficult to ob~ tam. Dr. Krall discusses the general management of different types of patients. This program was produced with the cooperation of the Council on Scientific Assembly of the American Medical As~ sociation. (25 mInutes) (in color) 0123046 CAN YOU TREAT OBESITY IN CHILDREN? with Piston J. Collipp, M.D., Chief Pediatrician, Nas' sau County Medical Center, and Professor of Pediatrics, State University of New York, Stony Brook, Long Island, N.Y. Long-standing obesity, a health hazard in later life, can be stemmed in childhood and adoles~ cence. Dr. Col(ipp shows how diet, group treat~ ment, challenge and support have successfully removed "60 tons of Long Island baby fat." (18 minutes) (in color) 0318076 CURRENT MANAGEMENT OF THE ADULT DIA~ BETIC, with Peter H. Forsham, M.D., Director of Metabolic Research Unit, University of California School of Medicine, San Francisco. Dr. Forsham outlines the treatment of adult dia' betes. In addition to explaining his use of diet and insulin therapy, he thoroughly examines the oral hypoglycemic agents, including phenformin hydrochloride and the sulfonylureaa, explaining how they work, their side-effects, and the most effective regimen. (22 minutes) (in color) 0316673 THE DIABETES PUZZLE: A PRACTICAL AP. PROACH, with Rachmiel Levine, M.D., Professor and Chairman of the Department of Medicine at New York Medical College in New York City. Most of the three million cases of diabetes in the U.S. are considered mild from the metabolic viewpoint. However, because of the link to many forms of cardiovascular, renal and other diseases it becomes important to discover and treat the mild forms. Dr. Levine describes the classical symptoms of diabetes and when to suspect the disease in the absence of the typical signs. He classifies therapy, relates diabetes to other dis- eases and describes its pathogenesis and in~ herited factors. (17 minutes) 0410805 THE DIABETIC IN COMA/BRITTLE DIABETES! THE YOUNG DIABETIC, with Rachmiel Levine, M.D., Professor and Chairman of the Depart. ment of Medicine at New York Medical College in New York City. Coma may occur in a person with diabetes for the same rea~ons as it would occur in the non diabetic. For that reason It is important to dif. ferentiate between the two comas, Dr. Levine describes ketoacidosis, hyperglycemic coma, lactic acidosis, hypoglycemia. Dr. Levine also discusses "brittle" diabetes and the prognosis of childhood diabetes. (20 minutes) 0410904 HYPERCALCEMIA: A DIFFERENTIAL DIAGNOSIS, with John T. Potts, Jr., M.D., Chief of Endocrinol' ogy, Massachusetts General Hospital, and Asso date Professor of Medicine, Harvard Medical School, Boston, Massachusetts. Hypercalcemla can be a life-threatening situation. Dr. Potts will show how a diagnosis of hypercalcemia can be established, and what action can be taken for the various possible causes. (16 minutes) (in color) 0813218 RECOGNIZING ROLES IN JUVENILE DIABETES, with Donnell D. Etzwiler, M.D., Director, Diabetes Education Center, and Pediatrician, St. Louis Park Medical Center, Minneapolis. A pediatrician gives guidelines for early diagnosis and manage- ment of juvenile diabetes and shows which responsibilities of good control should be as- signed to physician, health professional, and pa' tient. This presentation was produced with the cooperation of the Council on Scientific Assem- bly of the American Medical Association. (16 minutes) (in color) 1822934 SOME ORGANIC CAUSES OF CHILDHOOD OBE- SITY, with Platon J. Collipp, M.D., Chief of Pedi- atrics, Nassau County Medical Center, and Pro- fessor of Pediatrics, State University of New York, Stony Brook, Long Island, N.Y. Don't dis- count "glandular" causes of obesity without a long, hard look. Dr. Collipp presents patients with the more common of these rare diseases associated with overweight. (15 minutes) in color) 1518209 TREATMENT OF INSULIN-DEFICIENT DIABETES, with Peter H. Forsham, M.D., Director, Metabolic Research Unit, University of California School of Medicine, San Francisco. Insulin has been avail- able for 50 years, but its use in diabetic therapy can be improved. To achieve better results, says Dr. Forsham, physicians must simulate as closeS ly as possible the release of insulin by normal persons. (21 minutes) (in color) 2016427 74 PAGENO="0429" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14335 OBSTETRICS AND GYNECOLOGY AFTER THE SPONTANEOUS ABORTION: COUN- SELING BY THE FAMILY PHYSICIAN, with Wil- liam C. Rigsby, M.D., Assistant Professor, De- partment of Obstetrics end Gynecology, and Adolph Hess, M.D., Clinical Associate Professor, Department of Psychiatry, Ohio State University School of Medicine. Using an actual case of spontaneous abortion in a much wanted preg- nancy, Drs. Rigsby and Hess - and the patient in question-delineate areas in which the physi- cian can support and reassure his patient in the time of crisis. (19 minutes) (in color) 0116129 ALCOHOL IN PREVENTION OF PREMATURE DELIVERY. The premature baby is generally bet- ter off in utero than he wou~d be if born. Fritz Fuchs, M.D., Professor of Obstetrics and Gyne- cology, Cornell Medical College, and Anna-Riitta Fuchs, Research Associate, The Population Council, describe how the infusion of alcohol can be used to delay premature delivery. (20 minutes). 0106608 BIOMEDICAL ANALYSIS: SPEED, ACCURACY, SENSITIVITY The uses of gas chromatography in the analysis of anesthetic effects, in blood studies and in obstetrics is shown by Harold B. White, Ph.D., Professor of Biochemistry; Leonard Fabian, M.D., Chairman, Department of Anesthesiology; and Winfred L. Wiser, M.D., Professor of Obstetrics and Gynecology, University of Mississippi Med ical Center, Jackson, Miss. (18 minutes). 0208405 THE BREAST EXAMINATION, with Angelo J. DePalo, M.D., Assistant Attending Surgeon, Memorial Hospital for Cancer and Allied Dis- eases, New York City. Earlier detection of breast tumors through a complete and simple breast exam. (21 minutes) (in color) 0219818 CESAREAN BIRTH Delivery by Cesarean Section - with Stanley H. Tischler, M.D., Associate Obstetrician and Gyn- ecologist of The Jewish Hospital of Brooklyn. (8 minutes). 0303201 CLINICAL MANAGEMENT OF HUMAN REPRO. DUCTIVE PROBLEMS: PART I. Alvin F. Goldfarb, M.D., Assistant Professor of Obstetrics and Gyn- ecology, Jefferson Medical College and Hospital, presents "Evaluating the Infertile Couple." (19 mInutes). 0303118 CLINICAL MANAGEMENT OF HUMAN REPRODUCTIVE PROBLEMS; PART II "The Physio-Anatomic Basis of Fallopian Tube Function." The second program in a series - with Luigi Mastroianni, Jr., M.D., Professor of Ob- stetrics and Gynecology, University of Pennsyl- vania School of Medicine. (17 mInutes). 0303319 CLINICAL MANAGEMENT OF HUMAN REPRODUCTIVE PROBLEMS: PART III "Tubal Factor Treatment." Correcting distortion of the tubal ovarian relationships. With Celso- Ramon Garcia, M.D., Associate Professor of Ob- stetrics and Gynecology, University of Pennsyl- vania School of Medicine. (16 mInutes). 0303620 CLINICAL MANAGEMENT OF HUMAN REPRODUCTIVE PROBLEMS: PART IV "The Cervix in Infertility." Evaluation of the cervical factor in cases of female Infertility - with Kamran S. Moghissi, M.D., Associate f'rofes- sor of Obstetrics and Gynecology, Wayne State University School of Medicine. (17 minutes). 0304421 CLINICAL MANAGEMENT OF HUMAN REPRODUCTIVE PROBLEMS: PART V "New Research," a discussion and demclnstra- tion of the use of frozen sperm for artificial in semination; immunologic aspects of infertility; and new laparoscopic techniques. (18 minutes). 0304622 CLINICAL MANAGEMENT OF HUMAN REPRODUCTIVE PROBLEMS: PART VI- INDICES OF OVULATION The tests which are available to determine the absence or occurrence of ovulation are described by Howard Balm, M. D., Chief, Gynecic Research Unit, Pennsylvania Hospital, Philadelphia. (26 minutes). 0304923 CLINICAL MANAGEMENT OF HUMAN REPRO- DUCTIVE PROBLEMS - PART VII - INDUC. TION OF OVULATION. The several methods available for treating the anovulatory, infertile - female are evaluated by Alvin F. Goldfarb, M.D., Assistant Professor of Obstetrics and Gynecol~ ogy, and Abraham E Rakoff, M.D., Professor of Obstetrics and Gynecology, Jefferson Medical College and Hospital, and Howard Balm, M.D., Chief, Gynecic Research Unit, Pennsylvania Hospital. (15 minutes). 0305024 CLINICAL MANAGEMENT OF HUMAN REPRO DUCTIVE PROBLEMS - FINAL PROGRAM - THE SUMMATION. Alvin F. Goldfarb, M.D., As- sistant Professor of Obstetrics and Gynecology, Jefferson Medical College and Hospital, pre~ sents a review and a summation of the seven programs in the series on human reproductive problems. (20 minutes). 0305325 75- PAGENO="0430" 14336 COMPETITIVE PROBLEMS IN THE DRUG IN1YrJSTRY COUNSELING FOR VOLUNTARY STERILIZATION: TUBAL LIGATION, with Ronald J. Pion, M.D., Associate Professor of Obstetrics and Gynecol' ogy, University of Washington, Seattle. Sterilization as a form of birth control was rarely performed in this country. Now it is increasing with growing concern toward `the pill," increas- ing Interest in overpopulation and changing sexual attitudes. Dr. Pion is seen with several couples who have decided on sterilization for the wife, and their reasons and attitudes are explored. (17 minutes) (in color) 0312352 COUNSELING THE CANDIDATE FOR ABORTION, with Ronald J. Pion, M.D., Associate Professor of Obstetrics and Gynecology, and Director of Divi- sion of Family Planning, University of Washing' ton School of Medicine, Seattle. Dr. Pion interviews 3 patients. In each conver- sation, he concentrates on providing the patient seeking a termination to her pregnancy with options and alternatives to reach a rational decision to her crisis. (17 mInutes) (in color) 0312454 COUNSELING THE POST-ABORTION PATIENT, with Ronald J. Pion, M.D., Associate Professor, Department of Obstetrics and Gynecology, and Director of the Division of Family Planning; and Nathaniel N. Wagner, Ph.D., Associate Professor of Psychiatry and Obstetrics and Gynecology, both from the University of Washington School of Medicine, Seattle, Washington. Post~abortion patients are interviewed in an at tempt to show physicians the opportunities that exist for helping patients beyond a period of crisis. (18 minutes) (in color) 0312555 CRYOSURGERY A demonstration of the treatment of chronic endocervicitis with cryosurgery, and a discussion of its advantages in other gynecologic proce- dures. With Sidney Lefkovics, M.D., Chief, Sec- tion of Obstetrics and Gynecology, St. Barnabas Hospital, Livingston, New Jersey. (16 minutes). 0303556 DIAGNOSTIC ULTRASOUND-PART Il-CLINI. CAL ULTRASONOGRAPHY IN OBSTETRICS AND GYNECOLOGY. The use of sound waves to mon itor the fetus in utero is illustrated by Horace E. Thompson, M.D., Associate Professor of Ob. stetrics and Gynecology, University of Colorado Medical Cenfer, Denver, Colorado. (16 minutes). 0408211 DIFFERENTIAL DIAGNOSIS OF EARLY CERVICAL LESIONS, with Albert B. Lorincz, M.D., Professor of Obstetrics and Gynecology; George L. Weld, M.D., Professor of Obstetrics and Gynecology and Director of the School of Cytotechnology; and Lester D. O'Dell, M.D., Clinical Associate in Ob- stetrics and Gynecology. All are affiliated with the University of Chicago Pritzker School of Medicine and the Chicago Lying-In Hospital. These three physicians resolve some of the prob iems of evaluating borderline cervical smears and offer guidance to the timeliness of surgery. They also discuss colposcopy and offer alternatives to the physician who does not have access to a colposcope. (19 minutes) (in color) 0410816 DIFFERENTIAL DIAGNOSIS OF PELVIC INFLAM~ MATORY DISEASE, with Charles H. Debrovner, M.D., Director of Obstetrics and Gynecology, French and Polyclinic Medical School and Med. ical Center, New York City. The acute abdomen as seen from the special viewpoint of an expert on pelvic inflammatory processes. (20 minutes) (in color) 0421556 EGG TRANSPORT IN MAMMALS, with Richard J. Biandau, M.D., Professor of Biological Struc~ tures, University of Washington School of Med. icine. Discussion and cinemicrographic visuali~ zation of egg transport in rabbits, rats, and humans. (15 minutes). 0501404 ENDOAMNIOSCOPY: INSIDE THE FUTURE, with Carlo Valenti, M.D., Professor of Obstetrics and Gynecology, Downstate Medical Center of the State University of New York, Brooklyn. An ex~ perimental technique, demonstrated on this pro- gram, allows you to see the fetus and offers a host of therapeutic possibilities, from transfusion to correcting birth defects under direct vision, in ufero. (9 minutes) (in coior) 0518521 EPIDURAL BLOCK. Utilization of this procedure on a patient about to undergo cesarean section is demonstrated by Irving M. Pallin, M.D., Di- rector of Anesthesiology, The Jewish Hospital of Brooklyn, New York. (17 minutes). 0502911 EXTRACORPOREAL CIRCULATION IN THE HU~ MAN PLACENTA, with Kermit Krantz, M.D., Pro. fessor of Obstetrics and Gynecology, University of Kansas School of Medicine. A presentation of human placenta research and some clinical applicatIons. (24 minutes). 0501414 76 PAGENO="0431" COMPETITIVE PROBLEMS IJ~ THE DRUG INDUSTRY 14337 FEEDBACK: SEX EDUCATION The provocative subject of `Sex E~ducation" is Introduced by Alvin F. Goldfarb, M.D., Assistant Professor of Obstetrics and Gynecology, Jefferson Medical College and Hospital, Philadelphia. Participants in the panel are: Moderator: Hubert L. Allen, M.D., Instructor in Clinical Obstetrics and Gyne. cology, Washington University School of Medi- cine, St. LOuis, Mlssourj. Clay Burchell, M.D., Associate Professor of Obstetrics and Gynecol. ogy, University of Illinois College of Medicine, Chicago. John W. Huffman, M.D., Professor of Obstetrics and Gynecology, Northwestern Uni. versity Medical School, Chicago. Capt. James P. Semmens, MC, USN, Chief of Obstetrics and Gynecology, U.S. Naval HospItal, Oakland, CalI- fornia. Don W. Oakes, AM. MA., Qirector of Secondary Education, Hayward Unified School District, Hayward, California. (50 minutes). 0604001 FITTING A DIAPHRAGM - ARE YOU MAKING ANY M1STAKES?, with Alfred Tanz, M.D., Attend- ing Physician in Obstetrics and Gynecology, Lenox Hill Hospital, and Assistant Clinical Pro- fessor of Obstetrics and Gynecology, New York Medical College, New York City. The failure rate with diaphragi'ns is not always patient error, asserts Dr. Tanz who demonstrates proper fitting techniques and patient instructions. (9 minutes) (In color) 0616916 GONORRHEA: ELUSIVE EPIDEMIC, with Frank M. Calia, M.D., Chief of Infectious Diseases, Loch Raven Veterans Administration Hospital, and Associate Professor of Medicine, University of Maryland School of Medicine, Baltimore, Maryland. An aggressive approach to this seem- ingly unbeatable venereal disease. Shows screening procedure for catching the silent carrier, and how tcr handle new oriental strains of GQ. (20 mInutes) (In color) 0717417 HOW I DO A COMPLETE CERVICAL BIOPSY, with Ralph M. Richart, M.D., Director of Ob-Gyn Pathology, Columbia University College of Physi- cians and Surgeons, New York City. Dr. Richart demonstrates techniques for endocervical curet- tage and punch biopsy. He points out how to locate the transformation zone from which all punch biopsy specimens should be taken, thus avoiding any need to biopsy all four quadrants. 11 minutes (in color) 0816625 HOW I DO A PAP SMEAR, with Ralph Richart, M.D., Director of Ob-Gyn Pathology, Columbia University College of Physicians and Surgeons. Another in NCME's current series of demonstra- tions by experts of practical, day-to-day pro- cedures in medicine. Dr. Richart outlines steps whIch will make taking a Pap smear more effi- cient and the results more reliable, 8 mInutes (in color) 0816423 HOW I DO ELECTROCAUTERY OF THE f~IERVIX, with Ralph M. Richart, M.D.,, Director of Ob- Gyn Pathology, Columbia University College of Physicians and Surgeons, New York City. Dr. Richart demonstrates electrocoagulation of the cervix, points out the pitfalls to be avoided in performing the technique and presents advice on follow-up patient counseling. (8 minutes) (In color) 0~16726 HOW I INSERT AN IUD, with Alfred Tans, M.D., Attending Physician in Obstetrics and Gynecol- ogy, Lennox Hill Hospital, and Assistant Clinical Professor of Obstetrics and Gynecology, New York Medical College, New York City. lnd~catlons and contraindications for the IUD are reviewed and the proper procedure for lnsertifg the de- vice is shown. (10 minutes) (In color) 0817028 LAPAROSCOPIC STERILIZATION, with Thomas F. Dillon, M.D., Director of Obstetrics and Gynecol- ogy, Roosevelt Hospital, and Professor of Ob- stetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York City. Endoscopic film sequences taken during laparoscopic tubal sterilization accompany a demonstration of the procedure. (20 mInutes) (in color) 1218817 LARGE SCALE PREGNANCY `TESTING FOR THE `70s, with Elizabeth Connell, M.D., A$soclate Professor of Obstetrics and Gynecology, College of Physicians and Strrgeons, Columbia University in New York, and Director, Family Life Services, International Institute for Study of Human Re- production; Ralph W, Gause, M.D., Obstetrical Consultant, National Foundation-March of Dimes; and Donald P. Swartz, MD., Clinical Professor of Obstetrics and Gynecology, College of ~hysiclans and Surgeons and Director of Obstetrics and Gynecology, Harlem Hospital in New york. Three physicians demonstrate the ease Of adn'tinistra- tion and reliability of new inexpensive pregnancy tests. The doctors also identify situations in which wider pregnancy testing may now be indi- cated, and consider issues raised by the simpli- city and accessibility of pregnancy testing kits. (19 mInutes) (In color) 1213914 MANAGEMENT OF THE PATIENT WITH AN IN- TRAUTERINE DEVICE, with Don Sloan, M.D., Assistant Clinical Professor and Director, Divi- sion of Psychosomatic Medicine, Dept. of Ob- stetrics and Gynecology, New York Medii~aI Col- lege, Tbe intrauterine device is now established as a standard contraceptIve option. By means of typical patient interviews, Dr. Sloan reviews indications for prescribing the IUD and out- lines points to be made in counsellIng the pa- tient at time Of insertion. (17 minutes) (in color) 1315645 77 PAGENO="0432" 14338 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY THE MEDICAL MANAGEMENT OF METASTATIC BREAST CANCER, with Justin J. Stein, M.D., Professor of Radiology, UCLA School of Medicine, and a past President of the American Cancer Society. Advanced breast cancer~ a bleak future for the patient and a difficult management prob- lem for the physician. This program provides a step-by-step approach to improve the quality of survival for your patient. (19 minutes) (in cOlor) 1319953 NATURAL CHILDBIRTH: THE PHYSICIAN'S ROLE, with Alfred Tanz, M.D., obstetrician and gynecol- ogist, Lenox Hill Hospital, and Assistant Clinical Professor of Obstetrics and Gynecology, New York Medical College, New York City. Far from relieving the physician of his responsibility in childbirth, this increasingly popular approach to labor and delivery emphasizes his role at the times he is really needed. (15 mInutes) (in color) 1418932 A NEW APPROACH TO THE PELVIC EXAM, with Philip Sarrel, M.D., Associate Professor of Ob- stetrics and Gynecology at the Yale University Medical School and Co-director of the Human Sexuality Program at Yale University, New Haven, Connecticut. A method is shown which will enable you to examine the `atypical" patient (the anxious, the arthritic, the obese, the bed- ridden) and which will also make your examina- tion of the typical patient more comfortable and informative. (19 minutes) (in color) 1420735 NEW GENETIC COUNSELING FOR THE `7Os, with Carlo Valenti, M.D. Associate Professor, Depart- ment to Obstetrics and Gynecology, Downstate Medical Center in Brooklyn, New York, New uses in amniocentesis give the physician greater opportunities for genetic counseling. Dr. Valenti shows how the procedure can be used to define chromosomal aberrations, effects of drugs -specifically LSD-and how It can be employed to Identify sex and define fetal maturity. (17 mInutes) (in color) 1410806 NEW TECHNIQUES IN AMNIOCENTESIS, with Carlo Valenti, M.D. Associate ProfessoY, Depart- ment of Obstetrics and Gynecology, State Uni- versity of New York, Downstate Medical Center in Brooklyn, New York. Removing amniotic fluid from a pregnant woman to determine Rh abnormalities is one of the major adVances in obstetrics and gynecology during the past 10 years. Amniocentesis is now successfully used at early stages Of pregnancy to predict other fetal anomalies. The procedure with sonograms and instruments, is illustrated in detail. (16 mInutes) (In color) 1410728 OFFICE APPROACH TO DELAYED MENARCHE, with Paul G. McDonough, M.D., Associate Pro- fessor of Obstetrics and Gynecology, and Chief of the Reproductive-Endocrine-Genetics Unit, the Medical College of Georgia, Augusta, Georgia. The office management of delayed menarche carries with it physical or psychiatric hazard. Dr. McDonough demonstrates how to avoid pitfalls in anatomic and endocrine amenorrhea, and gives advice on handling the "late bloomer" and her mother. (15 mInutes) (In color) 1515507 PEDIATRIC GYNECOLOGY. John W. Huffman M.D., Professor of Obstetrics and Gynecology, Northwestern University Medical School, and Dorothy M. Barbo, M.D., Instructor of Obstetrics and Gynecology, Marquette University School of Medicine, discuss obstetric problems In chil- dren and demonstrate special Instruments made for the young patient. (15 minutes). 1601405 THE PILL AND THE INFORMED PATIENT, With Louis fJL Heliman, M.D., Deputy Assistant Secre- tary `for Population Affairs, U. S. Department of Health, Education and Welfare, Washington, D. C., Professor and Chairman Emeritus, De- partment of Obstetrics and Gynecology, State University of New York Downstate Medical Cen- ter, in New York City. An update on oral contra- ceptives and how to counsel patients for in- formed consent. Dr. Heilman interviews a healthy young patient, beginning contraception, and an older patient with complications related to oral contraceptive drugs. This program is presented as part of the American Society for Clinical Pharmacology and Therapeutics Drug Spotlight Program. (29 mInutes) (In color) 1623450 PRENATAL DIAGNOSIS OF HEREDITARY DIS' ORDERS. with Carlo Valeflti, M.D., Professor of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, Brooklyn, New York. A practical look at the indications for amniocentesis. Dr. Valenti demonstrates the pro- cedure, which many primary care physicians are performing themselves. (21 minutes) (in color) 1617942 RESPIRATORY DISTRESS IN THE NEWBORN: MEDICAL CONDITIONS, with Alexander J. Schaf- fer, M.D., Associate Professor Emeritus of Pedi- atrics, Johns Hopkins UniversIty School of Med- icine, and Assistant Commissioner of Health of the City of Baltimore, Md. Indications of respire' tory distress In the newborn can be detected prior to labor, in labor and in delivery. The alerting signs are clearly illustrated. Dr. Schaffer also summarizes the general principles of treat- ment. (22 minutes) (In color) 1810415 78 PAGENO="0433" COMPETITIVE PROBLEMS IN THE DRUG I)~'DUBTRY 14~39 RH DISEASE - PART I * PREVENTION. Anti D gamma globulin, an antigen which has proved successful in preventing Rh sensitization in pregnant women, is described by Edward T. Bows, M.D., Instructor, Obstetrics and Gyne- cology, College of Physicians and S~irgeons, Co- lumbia University, New York. (15 minutes). 1805618 RI-I DISEASE - PART II - MANAGEMENT - AMNIOCENTESIS. Edward 1. Bowe, M.D., In- structor, Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, discugses the etiology, Incidence, and diagno- sis of Rh immunization, with particular empha- sis on the usefulness of amniocentesis in man- agement of the dIsease. (15 minutes) 1805719 RH DISEASE - PART Ill - MANAGEMENT - INTRAUTERINE TRANSFUSION. The Intraperi- toneal infusion of 0 neg. red cells to an Rh positive fetus is `not an occasional procedure" and demands an obstetric team skilled in the technique, according to Edward T. Bowe, M.D., Instructor, Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia Univer- sity. The intrauterine procedure is demonstrated in this telecast, and Dr. Bowe also covers the criteria for selecting patients, the risk to the fetus, and the over-all rates of success of the procedure compiled from several U.S. hospitals. (10 minutes). 1805820 RUBELLA. Albert McKee, M.D., Department of Microbiology, University of Iowa School of Medi- cine, discusses the isolation of the rubella virus and the problems that the disease causes In pregnancy. (26 mInutes) 2800002 SEX IN AGING AND DISEASE, with Philip A. Sarrel, M.D., Associate Professor of Obstetrics and Gynecology at Yale University Medical School; and Lonia Sarrel, Co-Director of the Human Sexuality Program at the Yale University Student Mental Hygiene Department in New Haven, Connecticut, Sexual development of healthy aging persons, as well as patients with the more common geriatric disorders, is dis- cussed. (19 minutes) (in COlor) 1921438 TECHNIQUES OF FETAL MONITORING, Pointing up the need for a more rational approach, to the management of fetal distress, Edward T. Bowe, M.D., Assistant Professor of Obstetrics and Gynecology, and John C. Sinclair, M.D., AssIstant Professor of Pediatrics, Columbia Presbyterian Medical Center New York, demonstrate a spe- cial' test for mothers and babies at risk~ (18 minutes). 2008003 THE LACTATING' MOTHER, with J, bouglas Veach, M.D., CilnicalInstructor, Departmedtof Ob- stetrics and Gyne~ology;'Wliiard B. Eernol~I, M.D., ClinicaF Associate Professor of Ped1'atrics~ James G. Good, MD, Clinical Instructor, Department of Preventive Medicine, all of Ohio State University College of Medicine, Columbus. How and when to acquaint expectant mothers with the rationale for breast-feeding; demonstration of proper care of the breasts before and after baby ha~ begun to nurse; diagnosis and treatment of Infection in the lactating breast. (16 mInutes) (In color) 1215815 THE PILL: CLINICAL ASPECTS. Perhaps no other group of drugs has elicited such tontinu ing concern on the part of physicians and patients as have the oral contraceptives. In this presentation, a!i available data on the or- ganic effects of the pill ~re brought together by Celso Ramon Garcia, M.D., Professor of Ob- stetrics and Gynecology, Edward E. Wallach, M.D., Assistant Professor of Obstetrics and Gynecology, and Harold I. LIef, M.D., Professor of Psychiatry, University of Pennsylvania School of Medicine. In spite of possible risks associated with the pill, they point out that `physicians must consider it in the light of fear of pregndhcy, of unwanted pregnahcy or of illegal abortion. (21 minutes). ` 1607517 THE PILL: COUNSELING FOR AND AGAINST ITS USE, with Don Sloan, M,D., Assistant Clinical Professor and Director, Division of `Psychoso. matic Medicine, Department of Obstetrics and Gynecology, New York Medical College, New York, N.Y. One patient wants the pill and shouldn't have It, another wants an lU.D. but should use the pill. Dr. Sloan, in interviews With teaching-assistant "patients," demonstrates how to obtain relevant information about medical history and sexual activity, and how to steer the patient toward the appropriate contraceptive. (15 minuteS) `(In color) i~6~5739 TREATING THE INFERTILE COUPLE: NITIAL WORKUP AND DETERMINATION OF OVULATION, with Melvin R. Cohen, M.D., of the Michael Reese Hospital and Medical Center and the Chicago Fer- tility Institute, Chicago, ill. Dr. Cohen côndu~ts an Interview with an infertile couple to ~lemon- strate the gathering of a marital and medical history, to ascertain abnormalities in the wife and to determine the fertility of the husband. (16 minutes) (In color) 2013220 79 73-617 0 - 76 - 28 PAGENO="0434" 14340 COMPETITIVE PROBLEMS IN THE DRUG IN5DUSTRY TREATING THE INFERTILE COUPLE: DIFFICULT DIAGNOSES AND MANAGEMENT with Melvin R. Cohen MD, of the Michael Reese Hospital and Medical Center and the Chicago Fertility Insti- tute, Chicago, Ill, When medical and marital histories, interviews and fertility tests fail to reveal the reasons for infertility, a series of sophisticated tests can be performed. Such techniques as the Rubin Gas Test or hysterosal- pingography, culdoscopy and laparoscopy are among those that Dr. Cohen describes during this program. (17 mInutes) (in color) 2013321 THE VAGINA AND FEMALE SEXUAL DYSFUNC- TION, with Philip A. Sarrel, M.D., Associate Pro- fessor of Obstetrics and Gynecology at Yale University Medical School; and Lorna Sarrel, Co- Director of the Human Sexuality Program at the Yale University Student Mental Hygiene~ Depart- ment, in New Haven, Connecticut. Vaginitis and the resulting vaginismus are diagnosed and treated. Medical and sex-counseling protocols are set forth. (18 mInutes) (in color) 2220802 WHAT MAMMOGRAPHY CAN TELL YOU, with Ruth Snyder, M.D., Associate Radiologist, Mem- orial Sloan-Kettering Cancer Center, and Clinical Assistant Professor of Radiology, Cornell Univer- sity Medical Center, New York City. Mammography detects early cancerous changes in the breast: should it be done as routinely as a Pap smear? Dr. Snyder explains the indications and demon- strates what the technique reveals. (17 minutes) (in color) 2318007 WHO SPEAKS FOR THE BABY? A baby Is born mongoloid, with a defective heart and duo denal atresia. The parents, with three other children at home, ask that lifesaving Intestinal surgery not be performed. The pediatrician, trained to preserve life, seeks a court order to operate, Is such a decision within the physi- cian's province? Should this child live or die? A presentation by physicians and medical stu- dents of points of view on infant euthanasia.. (20 minutes) (In color) SAMA 2810352 ONCOLOGY ACUTE MYELOGENOUS LEUKEMIA: THE DIAG- NOSIS, with Monroe Dowling, Jr., M.D., Assistant Attending Physician, Hematology Service, Me. morial Sloan-Kettering Cancer Center, New York City. Tips for making an earlier diagnosis in pa- tients suspected of having acute leukemia. (13 minutes) (In color) 0121941 ACUTE MYELOGENOUS LEUKEMIA: THE TREAT- MENT, with Monroe Dowling, Jr., M.D., Assistant Attending Physician, Hematology Service, Me- morial Sloan-Kettering Cancer Center, New York City. Treating the patient with acute leukemia can be difficult and dangerous. To enable you to han die your patients more safely, Doctor Dowling outlines the principles and precautions of the management of this disease. (21 minutes) (In color) 0121942 BONE NEOPLASMS IN CHILDREN: EARLY DE- TECTION, with Joseph H. Kushner, M.D., pedi- atrician and Co-Chairman of the `Department of Pediatric Oncology, University of California, San Francisco. Three symptomatic patients. Is the lesion benign or malignant? Here, concisely, are keys to ac curate-and early-diagnosis. (17 minutes) (in color) 0223520 THE BREAST EXAMINATION, with Angelo J. DePalo, M.D., Assistant Attending Surgeon, Memorial Hospital for Cancer and Allied Dis- eases, New York City. Earlier detection of breast tumOrs through a complete and simple breast exam. (21 minutes)(ifl color) 0219818 QANCER MANAGEMENT: THE FUTURE OF CEA, with E. Douglas Holyoke, M.D., Chief of the Gen- iral Surgery Service at Roswell Park Hospital, Buffalo, N. V., interviewed by Alan L Goldberg, M.D., family physician in private practice in the Bronx, N. Y. A look at the possible future of carcinoembryonic antigen as a diagnostic aid, a prognostic indicator, and as a monitoring test for patients with cancer. Dr. Holyoke uses case histories to illustrate the various uses of the antigen. (18 minutes) (in color) 0317875 CONVERSATION WITH GEORGES MATHE: BONE- MARROW TRANSPLANT, with Professor Georges Mathé, Director, Institut de Cancerlogie et dIm- .munogénétique, Hôpital Paul-Brousse, Villejuif, France; and Ernest H. Rosenbaum, M.D., Director, Medical Cancer Service, and Director, Immunolog- ical Research of Mt. Zion Hospital in San Fran- cisco. Prof Mathé will offer the current indications for successful marrow transplantation. Prof. Mathé performed the first successful bone- marrow transplantation in man in 1958. (13 mInutes). 0313062 CONVERSATION WITH GEORGES MATHE: CAN- CER CHEMOTHERAPHY, with ProfeSseur Geor- ges Mathé, Directeur, Institut de Cancerologie et dImmunogénetique, Hôpital Paul-Brousse, Ville- juif, France; and Ernest H. Rosenbaum, M.D., Di- rector, Medical Cancer Service, and Director, Im- `muno)ogical Research of Mt. Zion Hospital, San Francisco. Professor Mathé, who is one of the pioneers in the field, concisely sets forth an ap- proach to understanding the relatively new mo- dality Qf cancer chemotherapy. (17 mInutes). 0315271 80 PAGENO="0435" COMPETITIVE PROBLEMS IN THE DRtIG INDtYSTRt 14341 CONVERSATION WITH GEORGES MATH~: IM- MUNOLOGICAL APPROACH TO THE TREATMENT OF LEUKEMIA, with Professor Georges Mathé, Director, Institut de Cancérlogie et d'Immuno- génetique, Hhpital PauIBrousse, Villejuif, France; and Ernest H. Rosenbaum, M.D., Director Medical Cancer Service, and Director, Immunological Re- search of Mt. Zion Hospital in San Francisco. NCME has videotaped several hours of candid conversation with French professor Georges Mathé, noted for his innovations in treating leukemia. Professor Mathé describes how his active immunotherapy differs from conventional leukemic therapy. 117 minutes), 0312948 CONVERSATION WITH GEORGES MATHE: TREAT. MENT OF HODGKIN'S DISEASE, with Professor Georges Mathé, Director, Institut de Cancerlogie et d'lmmuriogénetique, Hópital Paul-Brousse, Villejuif, France; and Ernest H. Rosenbaum, M.D., Director, Medical Cancer Service, and Director, Immunological Research of Mt. Zion Hospital in San Francisco. Prof. Mathé, known internationally for his work in cancer therapy, offers a candid view of current treatment of Hodgkin's Disease. (13 mInutes). 0313966 CURRENT DIAGNOSTIC AND TREATMENT PROBLEMS IN THYROID DISEASE, with Gerald Burke, M.D., Department ~f Medicine; Leslie .1. DeGroot, M.D., Department of Medicine; Alex~ ander Gottschalk, M.D., Department of Radiology; Edward Paloyan, M.D., Department of Surgery; and Samuel Refetoff, M.D., Department of Medi- cine, all of the Pritzker School of Medicine of the University of Chicago. In a clinic setting, the panelists discuss diagnostic and therapeutic problems including management of possIble thyroid carcinoma, clinical thyrotoxocosis with `normal" lab data, exophthalmos, and congen- ital goiter. Clinical physiology and related re- search are emphasized. A Television Clinic ~`f the American College of Physicians, 1~3. Please inquire for special ~entaI information. (60 mInutes) (In color) ACP 2827366 CUTANEOUS SIGNS OF INTERNAL MALIGNANCY, with Irwin M. Bravern~n, M.D., Professor, of Dermatology, Yale University School of Medicine, New Haven, Connecticut. The signs can help-if you can read them. A dermatologist demonstrates the workup for a patient with a suspected underlying malignancy. (16 minutes) (in color) 0323586 DIAGNOSING COMMON SMALL SKIN LESIONS, with Robert Auerbach, M.D., Assistant Clinical Professor. of Dermatology, New York University School of Medicine, New York City. Before the biopsy Dr. Auerbach shows you the subtle clinical differences between nevi and melanomas, anti helps you sort out benign seborrheic keratoses, pre.malignsnt keratoses, and carcinoma. (16 minutes) (in color) 0418345 DIAGNOSIS OF OCCULT INTRA-ABDOMINAL NEOPLASMS, with Herbert B. Greenlee, M.D., Department of Surgery, Loyola University cif Chi- cago, Stritch School of Medicine, Maywood, Ill., and Veterans Administration Hospital, Hines, Ill.; Erwin M. Kammerling, M.D., Department of Mcdi' cine, University of Health Sciences, The Chicago Medical School, and Louis Weiss Memorial Hos- pital, Chicago; Sumner C. Kraft, M.D., Depart- ment of. Medicine, University of Chicago; and Armand Littman, M.D., Department of Medicine, University of Illinois, College of Medicine, Chi. cago, and Veterans Administration Hospital, Hines, Ill. The panel presents cases-illustrating some of the difficulties and solutions involved in tracking down a diagnosis of intra~abd~minal neoplasms. Emphasis is given to the tests (some old, some new, some under.utilized) which are helpful in deciding to perform exploratory lapa. rotomy. A Television Clinic of the Americ~n Col- lege of Physicians, 1973. Please inquire for special rental information. (60 minutes) (In color) ACP 2847368 DIFFERENTIAL DIAGNOSIS OF EARLY CERVICAL LESIONS, with Albert B. Lorincz, M.D., Professor of Obstetrics and Gynecology~ George L Weid, M.D., Professor of Obstetrics ~fld Gynecology and Director of the School of Cytotechnology; and Lester D. O'Dell, M.D., Clinical Associate in Ob- stetrics and Gynecology. All are affiliated with the University of Chicago Pritzker Sch~iol of Medicine and the Chicago Lying-In Hospital. These three physicians resolve some of the prob lems of evaluating borderline cervical sme~rs and offer guidance to the timeliness of surger~l. They also discuss colposcopy and offer alternatives to the physician who does not have accesS to a colposcope. (19 `minutes) (in color) 0410816 EWING'S SARCOMA. Case presentations- of un~ suspected Ewing's Sarcoma, their diagnosis and prognosis, .with Gordon B. McFarland, Jr., M.D., Tulane University and Mary Sherman Orthopedic Laboratories, Alton Ochsner Medical Foundation. (10 minuteS). 0501212 GUIDELINES FOR STAGING AND MANAGEMENT OF HODGKIN'S DISEASE, with Mortimer J. Lacher, - M.D., Assistant Attending Physician, Medical Oncology Service, Department of Medi- cine, Memorial Hospital, New York City. The Promise: Longer survival for most Hodgkin's disease patients. Here are the latest recommen- dations for the staging of Hodgkin's disea~e and the current treatment plan that fulfillS that promise. (18 minutes) (In color) 0718118 81 PAGENO="0436" 14342 COMPETITIVE PROBLEMS IN TUE DRUG IN~DUSTRY HOW DO A BONE MARROW ASPIRATION, with Mortimer J. Lacher, M.D., Assistant Attending Physician, Department of Medicine, Memorial Hospital for Cancer and Allied Diseases, New York City. Another in NCME's new series of demonstrations by experts of how they do practical, frequently performed procedures. (10 minutes) (In color) 0816322 HOW I DO A BONE MARROW BIOPSY, with Mortimer J. Lacher, M.D., Assistant Attending Physician, Department of Medicine, Memorial Hospital for Cancer and Allied Diseases, New York -City. Dr. Lacher describes the necessary equipment and then demonstrates, step~by-step, the - procedure for obtaining and -preparing a bone marrow specimen. Highlighting the pro gram is Lacher's procedure for quickly and ac curately finding the target area for biopsy on the posterior iliac crest. - (9 minutes) (in color) 0816524 HOW I DO A COMPLETE CERVICAL BIOPSY, wHi Ralph M. Richart, M.D., Director of Ob-Gyn Pathology, Columbia University College of Physi cians and Surgeons, New York City. Dr. Richart demonstrates techniques for endocervical curet~ tage and punch biopsy. He points out how -to locate the transformation zone from which all punch biopsy specimens should be taken, thus avoiding any need to biopsy all four quadrants.. (11 minutes) (In color) 0816625 ILIAC MARROW ASPIRATION, with Mortimer J. Lacher, M.D., Assistant Attending Medical On- cologist, Memorial Hospital for Cancer and Allied Diseases, New York City. Dr. Lacher dem- onstrates the procedure for obtaining and pre- paring a bone marrow specimen from the pos- tenor iliac crest. (9 mInutes) (in color) 0917123 IMMUNOLOGY: FRONTIERS OF THERAPY, with Robert A. Good, M.D., Ph.D., Professor and Head, Department of Pathology, University of Minnesota School of Medicine, Minneapolis. Re- search meets clinical medicine as Dr. Good explains a "new kind of cellular engineering." The application of this new therapy is detton. strated in patients, and, in a look at the future, Good speaks of giving cancer patients "an im- proved immunity system" to help the "host look at cancer as the foreigner It really is." (22 mInutes) (In color)- 0916519 IMMUNOLOGY: THE FUTURE, with Robert A. Good, M.D., Ph.D., Professor and Head, Depart- ment of Pathology, University of Minnesota SchQol of Medicine, Minneapolis. "The next few years are really bright for immunobiology," says Dr. Good. He and his colleagues review the in- formation already in hand which will eventually open the doors to the transplantation era and facilitate treatment and prevention of cancer. The program's emphasis is on coming im- munologic tools for the clinician. (19 mInutes) (In color) 0916621 IMMUNOLOGY: THE NEW PATHOLOGY, with Robert Good, M.D., Professor and Head, Depart- ment of Pathology, University of Minnesota School of Medicine. In a wide-ranging discussion of recent discoveries in immunology, Dr. Good describes the function of T-cell and beta-cell systems and their meaning for c~linicians. - (19 minutes) (in color) 0916418 LYMPHANGIOGRAPHY IN DIAGNOSIS AND THER- APY, with Robin Caird Watson, MD., Chairman of the Department of Diagnostic Radiology, Memorial Sloan-Kettering Cancer Center, and Associate Professor of Radiology, Cornell Uni- versity Medical Center, New York City. When is lymphangiography useful? What happens to your patient when you order it? The technique and the interpretation of several lymphangiograms illus- trate the procedure's place in your practice. (17 minutes) (in color) 1219218 MEDIASTINOSCOPY IN STAGING CARCINOMA OF THE LUNG, with Edward H. Goldberg, M.D., Department of Surgery and Oncology Council, Michael Reese Hospital and Medical Center, Chicago, Illinois. - Lung cancer can be the most frustrating prob- lem for a physician. Techniques are available for a definite diagnosis, but uncertainty exists on how to proceed with the patient. Thoracotomies have high operative mortality~and extensive mor- bidity. In addition, the procedure proves to be unnecessary in about 50 per cent of the cases. Through the use of the mediastinoscope, it is possible to view and photograph the mediasti- num, This has resulted in a new method of stag- ing lung cancer, and an improved approach to - treatment. A mediastinoscopy Is demonstrated, and the staging method Is shown in detail. (14 mInutes) (In color) 1312021 THE MEDICAL MANAGEMENT OF , METASTATIC BREAST CANCER, with Justip J. Stein, M.D., Professor of Radiology, UCLA School of Medicine, and a past President of the American Cancer Society. Advanced breast cancer: a bleak future for the patient and a difficult management prob- lem for the physician. This program provides a step-by-step approach to improve the quality of survival for your patient. (19 minutes) (in colors 1319953 - MULTIPLE MYELOMA: A CONTROLLABLE DIS', EASE with Raymond Alexanian, M.D., Associate Professor of Medicine, University of Texas, M.D. Anderson Hospital and Tumor lnS~titute, Houstoń In three patients, Doctor Alexanian points out the clinical and laboratory abnorttalities in multi- ple myeloma along with the tests needed to con- firm the diagnosis. (1~ minutes) (it, color) 1322055 82 PAGENO="0437" COMPETITIVE PROBI4EMS IN THE DRUG INDUSTRY 14343 OFFICE TREATMENT OF SKIN CANCER, with Rex A. Amonette, M.D., Chemosurgeon, Dep~rt. ment of Dermatology, University of Tennessee College of Medicine, Memphis. Diagnosis and treatment of potential malignancy and skin can- cer are demonstrated. Includes the use of fluoro- liracil, biopsy, curettage and electrodesiccation, total excision, cryosurgery, irradiation, and chemosurgery. (19 minutes) (in color) 1521010 PROSTATE CANCER: CHOOSE YOUR WEAPONS, with Harry Grabstald, M.D., Urologic Surgeon; Basil 5, Hilaris, M.D., Radiologist; and Charles W. Young, M.D., Medical Oncologist; all from Memorial Hospital for Cancer and Allied Dis eases, New York City. What happens after the primary care physician and the hospital pathol- ogist diagnose prostate cancer? Drs.~ Grabstald, Hilaris and Young discuss the effective treat- ment alternatives and the grading and staging Involved in therapeutic decisions. A look at the therapeutic alternatives and the controversies surrounding this common and often curable form of cancer, (20 minutes) (in color) 1617241 RADIOCURABLE CANCERS IN ADULTS - PART I. The principal group of tumors known to be curable by radiotherapy is demonstrated by Sir Brian Windeyer, F.R.C.P., F.R.C.S., Professor of Therapeutic Radiology, The Middlesex Hospital, University of London, England. (12 minutes). 1806201 RADIOCURABLE CANCERS IN ADULTS - PART II. Selecting the most effective treatment for a cancer patient is a constant problem. In this presentation, Sir Bryan Windeyer, F.R.C.P., F.R.C.S., Professor of Therapeutic Radiology, The Middlesex Hospital, University of London, England, evaluates the alternatives of surgery or radiation therapy-or a combination of both- in squamous cell carcinoma of the tongue, can- cer of the larynx, and breast cancer. (14 mInutes). 1806302 RADIOLOGIC MANAGEMENT OF EARLY CANCER OF THE LARYNX, with Alexander D. Crosett, M.D., Director, Radiation Therapy and Nuclear Medicins, and Charles E. Langgaard, M.D., oto- laryngologist, both at Overlook Hospital, Sum- mit, N. J. How the radiation department of a cOmmunity hospital approaches early laryngeal cancer and provides the patient with an excel- lent prognosis. (12 minutes) (In color) 1818928 WHAT MAMMOGRAPHY CAN TELL YOU, with Ruth Snyder, M.D., Associate Radiologist, Mem- orial Sloan-Kettering Cancer Center, and Clinical Assistant Professor of Radiology, Cornell Univer- sity Medical Center, New York City. Mammography detects early cancerous changes in the breast: should it be done as routinely as a Pap smear? Dr. Snyder explains the indications and demon- strates what the technique reveals. (17 minutes) (in color) 2318007 OPHTHALMOLOGY CHILDHOOD STRABISMUS: AN APPROACH FOR NON~OPHTHALMOLOGlSTS, with Virginia Lubkin, M.D., Assistant Clinical Professor and Head of the Ophthalmic Plastic Surgery Clinic, Mount Sinai School of Medicine, and Attending Ophthal mologist at the New York Eye and Ear Infirmary. Monocular vision - - - absence of depth percep tion - - - and a cosmetic defect-consequences of a missed strabismus. Here are eight tests, performable in 10 minutes, to screen for eye muscle imbalance. Both normal and abnormal test responses are demonstrated. (23 minutes) (in color) 0319177 CLINICAL APPLICATIONS OF ELECTRICAL AC- TIVITY OF THE RETINA AND VISUAL QORIEX, presented by Jerry Hart Jacobson, M.D., Clinicol Assistant Prof5ssor of Surgery (Ophthallnology), Cornell University - New York Hospital - Cor- nell Medical Center. us minutes). 0300914 CRYOSURGERY, A CATARACT PROCEDURE The special indications and technique for utiliz- ing the cryostylet in cataract surgery arn~ demon- strtted and discusssed by Gerald Fonda, M.D., Director, Ophthalmology Division, Department of Medicine, St. Barnabas Medical Center, Living- ston, New Jersey. (13 minutes). 0303957 DIABETIC RETlNOPAT~'I~v': ATTEMPTS TO HOLD THE IMAGE, with Raymond Pilkerton, M.D., As- sociate Professor of Ophthalmology aild Direc- tor, Retina Service, Georgetown University Med- ical Center, Washington, D.C. The relationship between the duration of diabetes and the stages of diabetic retinopathy. How treatment nay tem- porarily stop the advance of this complication. This presentation was produced in coqperation with the Council on Scientific Assembly of the American Medical Association. lie minutes) (in color) 0423160 DIAGNOSING COMMON EYE INFLAMMATIONS, with Virginia Lubkln, M.D., attending ophthal- mologist at New York Eye and Ear Infirn~ary, and Clinical Assistant Professor of Ophthalmology, Mt. Sinai School of Medicine, New York City. On this program valuable diagnostic clues to help save the vision of patients with eye In' flammations. Dr. Lubkin demonstrates a quick and thorough examination of the eye I~o differ- entiate among conjunctivitis, herpes simplex, iridocyclitis and acute glaucoma. (15 minutes) (in color) 0419247 ELECTRICAL ACTIVITY OF THE RETINA AND VISUAL CORTEX, presented by Jerry Hart Jacob- son, M.D., Clinical Assistant Professor of Surgery (Opthalmology), Cornell University - F~ew York Hospital - Cornell Medical Center. lie minutes). 0500805 83 PAGENO="0438" 14344 COMPETITIVE PROBLEMS IN TEE DRt7(~ IN1)USTRY THE EYE AND SYSTEMIC DISEASE: AN INTER- CHANGE, with Eleanor Faye, MD., Attending Surgeon, Manhattan Eye, Ear, and Throat Hos- pital, and Medical Director, Low Vision Clinic, New York Association for the Blind; and Isadore Rossman, M.D., Medical Director, Home Care Department, Montefiore Hospital and Medical Center, and Associate Professor, Albert Einstein Medical College, New York City. Two physicians interact in the management of three patients with vision prOblems. Focus is on shared responsi- bility and communication. (13 mInutes) (in color) 0521228 FLASHES AND FLOATERS: SUSPECT A RET- INAL TEAR, with Morton L. Rosenthal, MD,, Surgeon-Director and Director of the Retina Service, New York Eye and Ear Infirmary, New York City, How to diagnose tears in the retina before retinal detachment occurs, when the damage can be repaired without major surgery (14 minutes) (in color) 0622223 GLAUCOMA DETECTION IN THE NON-OPHTHAL- MOLOGIST'S OFFICE, with Jerome N. Goldman, MD, Attending Ophthalmologist at the Wash- ington Hospital Center~ and Clinical Assistant Professor of Ophthalmology at HoWard Univer- sity Medical School, Washington, DC. Not all ocular hypertensives lose their sight or need treatment, So, when does a patient have glau- coma? High ocular pressure in combination with certain changes in the optic disc demonstrated in this program will help you reach a firm dIag- nosis, (17 minutes) (in color) 0719719 GLAUCOMA - SCREENING, DIAGNOSIS, MED- ICAL MANAGEMENT Drug therapy or corrective surgery can arrest or eliminate the effects of glaucoma. This is possible when an early diag- nosis Is made. Dan M- Gordon, M.D., F,A.CS, of New York Hospital-Cornell Medical Center, New York, demonstrates tonometry in diagnosing glaucoma and discusses the types of therapy available in correcting the condijion. (16 minutes). 0708208 HOW TO APPROACH THE EYE Dan M. Gordon, M.D., of New York Hospital- Cornell University Medical Center in New York discusses and describes the instruments, the procedures and the medications that a general physician can use in treating ocular emergen- cies, Dr, Gordon shows - with great detail - the techniques of everting and controlling the eye for examination and removing foreign bodies from the eyelid and the cornea. His basic mes- sage in the telecast is that many ocular problems can be managed or classified by the non-ophthal- mologist who learns a few simple procedures and is not afraid to apply them. (18 minutes) (in color) 0808606 THE IRRITATED EYE, with Jerome N. Goldman, M.D., Attending Ophthalmologist, Washington Hospital Center, Washington, D.C. How far to go and how much to do in diagnosing and treating an eye that hurts or has the foreign body sen- sation-" (18 minutes) (in color) 0920027 THE LASER IN OPHTHALMOLOGY - . . AND BEYOND. Film of the actual effects of laser beams on mice melanoma, as well as demon- strations of its usein various eye conditions in humans, is presented by Frances A. L5Esperance, M.D., Assobiate in Ophthalmology, Eye Institute, Columbia Presbyterian Medical Center, New York. (17 minutes) (in color) 1207706 THERAPEUTIC LAMELLAR KERATOPLASTY, with A. Benedict Rizzuti, M.D., Director of Corneal Service, Brooklyn Eye and Ear Hospital. A demon stration of specialized corneal surgery. (15 minutes). 2003005 ORTHOPEDICS AN ANATOMICAL APPROACH TO LOW BACK PAIN: SPONDYLOLISTHESIS AND ANKYLOSING SPONDYLITIS, with Peter Marchisello, M.D., At- tending Orthopedic Surgeon, The Hospital for Special Surgery, Cornell University Medical Cen ter, New York City. A firm review of the anat- omy, backed by x-rays and physical examina~ tion, is essential to arrive at a definitive diag- nosis of the cause of low back pain. Dr. Mar- chisello defines anatomical deviations in two patients, only one of whom may benefit from surgery. (18 minutes) (in color) .0116331 AN ANATOMICAL APPROACH TO LOW BACK PAIN: POSTURAL PAIN AND HERNIATED DISC, with Peter Marchisello, M.D., Attending Ortho~ pedic Surgeon, The Hospital for Special Sur- gery, Cornell University Medical Center, New York City. Modern life seems to breed back pain. As more and more patients come to physi- cians with this complaint, Dr. Marchisello dem- onstrates, it becomes -increasingly important to review and understand the anatomy of the spine to make differential diagnoses. (20 minuten) (In color) 0116230 ARTHRITIS: SURGICAL INDICATIONS, PART I - EARLY, PROPHYLACTIC John L. Sbarbaro, Jr., M.D., Assistant Professor of Orthopedic Surgery at the University of Penn- sylvania School of Medicine in Philadelphia, Pa., indicates that if suppressive drugs and physical therapy cannot control advancing arthritis, ex- tirpation might. (19 mInutes) (in color) 0108416 84 PAGENO="0439" COMPETITIVE PROBLEMS IN THE DRUG INDUSTET 14345 ARTHRITIS; SURGICAL INDICATIONS, PART II - LATE, RECONSTRUCTIVE The development of non-reactive metals, im proved design of molds and prosthesis and im- proved surgical techniques have caused a recent resurgence of interest in the surgical reconstrut~ tion of deformed arthritic joints. John L. Sbar- baro, Jr., M.D., Assistant Professor of Orthopedic Surgery, University of Pennsylvania School of Medicine, demonstrate some of the new tech- niques and shows the results of surgical repair. 16 minutes) (In color) 0108517 ATHLETIC INJURIES: DIAGNOSIS WITHOUT DE- LAY, with Robert E. Leach, M.D., Professor and Chairman, Department of Orthopaedic Surgery, Boston University Medical Center, and Consult- ant, Boston Celtics basketball team, Boston. Dr. Letch emphasizes on-the-spot diagnosis of knee and ankle injuries and demonstrates diag- nostic tests which can help you pinpoint the extent of injury quickly, thus avoiding delay In rehabilitation. (19 minutes) fin color) 0117132 CERVICAL SPINE: DISPLACEMENT OR DISEASE? with P. W. Haake, M.D., Assistant Professor of Orthopedics, University of Rochester School of Medicine and Dentistry, Rochester, New York. The patient with sudden acute neck pain: Is it a disc-a tumor-arthritis-whiplash? Compare your approach to this common problem with that of an orthopedist. This program was produced with the cooperation of the Council on Scientific Assembly of the American Medical Association. (16 minutes) (in color) 0323891 COMMON COMPLICATIONS OF FRACTURES: MALUNIONS, VASCULAR AND NEURAL, with Paul H. Curtiss, M.D., Professor and Director of the Division of Orthopedics, Department of Sur- gery; and Paul R. Miller,, M.D., Clinical Associate Professor of Orthopedic Surgery, both at Ohio State University College of Medicine, Columbus, Ohio. How to avoid fracture complications, and how to treat them when they ariSe are discussed and demonstratecL Complications in both children and adults are considered with numerous case studies. (17 minutes). 0311829 COMMON COMPLICATIONS OF FRACTURES: SOFT TISSUE, with Paul H. Curtiss, Jr., M.D., Professor and Director of the Division of Ortho- pedics, Department of Surgery; and Paul R. Miller, M.D., Clinical Assotlate Professor of Orthopedic Surgery, both at Ohio State University College of Medicine. Several patients and a number of X-rays are used to describe common fracture complications and the course of treatment followed in each In- stance. (15 minutes). 0311628 COMMON PROFESSIONAL FOOTBALL INJURIES, MECHANICS AND EFFECTS, with Jan~es A. Nicholas, M.D., Associate Professor of Clinical Surgery (Orthopedic), Cornell University Medical College and Teact Physican, the New York Jets. (18 mInutes). 0302330 CONGENITAL HIP DISLOCATION IN CHILDREN - PART I. Cases of congenital dislocation of the hip- have the most successful outcome if diag- nosis and treatment are~done before the child has learned to walk (or before two years of age). Paul H. Curtis, Jr., M.D., Professor of Surgery, Department of Orthopedics, Ohio State Univer- sity College of Medicine, demonstrates some of the simple diagnostic procedures for Infants with hip dislocation. These include abduction of the hips, observation of the skin fQlds of the thigh, and the placing together and flexion of the legs. These procedures, aided by x-rays, and the subsequent application Of the proper cast, usually will restore proper hip function without resorting to an operation. (9 mihutes). 0~5243 CONGENITAL HIP DISLOCATION IN CHILDREN - PART Il-SURGICAL CORRECTION. The oper- ative techniques available to restore hip function are presented by Henry B. Lacey, M.D., Clinical Associate Professor, Division of Orthopedics, Ohio State University College of Medicine, using patients who were not diagnosed until after the age of two years. ~ia minutes). 0$5344 DIAGNOSIS AND TREATMENT OF PAGET'S DIS- EASE, with John T. Potts, Jr., M~D., Chief of Endocrinology, Massachusetts General Hospital; and Associate Professor of Medicine, Harvard Medical School, Boston. Paget's Disease of the bone is seen with increasing frequency in the population over 40. Dr. Potts reviews the pres- ent Information about the cause of the áiseasa, its patho-physiology and the new appi-oathes to therapy which give promise for controlling the disease. (18 mInutes) (In Color) 0413124 "DOCTOR, I PUT MY BACK OUTI": MANIPULA- TIVE THERAPY, with Philip E. Greenman, DO., Chairman and Professor, Department ~f Bio- mechanics, College of Osteopathic Medicine, Michigan State University, East Lansing Michigan Low back pain - . - a common problem seen through the eyes of an osteopathic physician. Evaluation and treatment are demonstrated. (2~ minutes) (in colOr) 0421757 85 PAGENO="0440" 14346 COMPETITIVE PROBLEMS IN THE DRTJG IN'DUSTRY EARLY PROSTHETIC FITTING FOR CONGENITAL DEFECTS OF THE EXTREMITIES, with Charles H. Epps, Jr., M.D., Department of Orthopedics, Howard University School of Medicine, and Chief, Juvenile Amputee Clinic, D.C. General Hospital, Washington, D.C. Several patients from the Juvenile Amputee Clinic demonstrate differences between early and late prosthetic fitting for congenital extremity defects. Which conditions require surgical amputation and early prosthetic fitting? How do you approach parents of chil- dren with congenital defects? Epps answers these questions. (14 mInutes) (in Color) 0521027 EARLY SURGERY FOR THE ARTHRITIC HAND, with Alan H. Wilde, M.D., Head of the Rheuma toid Surgery Section, Department of Orthopaedic Surgery, The Cleveland Clinic Foundation. When six months of intensive medical management fall to help the patient with rheumatoid arthritis of the hand, synovectomy may preserve useful function and relieve pain. In this program: * the rationale for synovectomy; * the history and physical exam used to disclose indications for surgery; and * the operative procedure and the postoperative results. (20 mInutes) (In color) 0518522 ELECTRICITY AND BONE HEALING, with Leroy S. Lavine, M.D., Professor and Head of the Divi- sion of Orthopedic Surgery, Downstate Medical Center, Brooklyn, N.Y., and Attending In Charge of Orthopedic Surgery, Long Island Jewish Medi- cal Center, New Hyde Park, N.Y. Congenital pseudoarthrosis of the tibia failed to respond to conventional treatment, but when electric cur- rent was passed across the defect, beginning bone union was apparent after four months. Dr. Lavine briefly reviews the attendant biophysical phenomena and illustrates the highlights of his case. (15 minutes) (In color) 0515718 EMERGENCY ORTHOPEDIC MANAGEMENT. Paul R. Meyer, Jr., M.D., Department of Orthopedics, Tulane University SOhool of Medicine, demon- strates emergency splinting at the scene of an accident. (7 mInutes). 0501308 EWING'S SARCOMA. CaSe presentations of un- suspected Ewing's Sarcoma, their diagnosis and pr6gnosis, with Gordon B. McFarland, Jr., M.D., Tulane University and Mary Sherman Orthopedic Laboratories, Alton Ochsner Medical Foundation. (10 mInutes). 0501212 THE FIVE-MINUTE JOINT EXAM, with John J. Calabro, M.D., Chief of Rheumatology, Worcester City Hospital, and Professor of Medicine, Uni- versity of Massachusetts Medical School, Wor- cester, Massachusetts. Here's a five-minute joint exam, with pointers on how to distinguish degen- erative joint disease from such other conditions as ankylosing spondylitis and rheumatoid arth- ritis. (17 minutes) (in color) 0619721 FOR THE NEWBORN: A MINUTE'S WORTH OF ORTHOPAEDICS, with Robert S. Siffert, M.D., Professor and Chairman, Department of Ortho paedics, Mount Sinai School of Medicine of City University of NewYork, and Orthopaedic Sur- geon and Chiet, Mount Sinai Hospital, New York City, Is the baby abnormal, or has the intrau- terine position caused a defect which is only temporary? Dr. Siffert offers a checklist exami- nation for the newborn, which con be com- pleted in about a minute, and which should give you the answer. (24 minutes) (in color) 0617117 FRACTURES OF THE LOWER EXTREMITIES. Se- lected cases and principles of management of lower extremity fractures are presented by Ed- ward J. Eyring, M.D., Assistant Professor of Or- thopedics and Physiological Chemrstry, and John B. Roberts, M.D., Assistant Professor of Ortho- pedics, Ohio State University College of Med- icine. (14 minutes). 0607510 FUNCTIONAL EXAMINATION OF THE LOCO- MOTOR SYSTEM, with Denys Jobin, M.D., of the Faculte de Medecine, Universite Laval, Quebec, P.Q. Dr. Jobin demonstrates a number of tests which can offer clues to (nuscular and skeletal appara- tus problems. The tests can be performed quick- )y and simply. These tests are not meant to produce exhaustive information. Rather, they are valuable as an initial diagnosis in more than 80 per cent of the cases examined. (14 minutes) (in color) 0612112 GOOD TENNIS IS GOOD MEDICINE, with Robert Nirschl, M.D., Chairman, Committee on Medical Aspects of Sports of the Medical Society of Virginia; and Chief, Orthopedic Surgery, North- ern Virginia Doctors Hospital, Arlington, Virginia. Epicondylitis, a common complaint of tennis players, and ordinary folk, is analyzed and treated with practical methods. (15 minutes) (In Color) 0720420 MANAGEMENT OF ACUTE SPiNAL INJURIES, with William E. Hunt, M.D., Professorand Director of the Division of Neurosurgery; W. George Bing- ham, Jr., M.D., Assistant Professor, Division of Neurosurgery; and Stephen Natelson, M.D., Sen- ior Resident in Neurosurgery; all with the Ohio State University College of Medicine in Columbus. Three specialists describe the precautions that are necessary in handling patients with spinal injuries through the stages in the emergency room, in radiology and during the period of re- habilitation. ~ia minutes) (in color) 1314038 86 PAGENO="0441" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14347 MANAGEMENT OF AMPUTEES: P}~OSTH~SIS, with Ernest W. Johnson, MD., Professor and Chairman of Physical Medicine; and William G. Pace, M.D., Professor of Surgery and Assistant Dean of Ohio State University College of Medi- cine. There is a great variety of prosthetic devices available today. The range of devices for in- fants through geriatric patients - is illustrated with emphasis on their habilitative and re- habilitative effects. (15 minutes). 1311305 MEDICAL PROBLEMS ENCOUNTERED WITH BASEBALL PLAYERS, with Joseph T. Coyle, M.D., Clinical Associate, Bone and Joint Surgery, Stritch School of Medicine, Loyola University and Team Physician, the Chicago White Sox. (14 mInutes). 1302426 OFFICE ORTHOPAEDICS: AFTER THE FALL, with Robert E. Leach, M.D., Professor and Chairman, Department of Orthopaedic Surgery, Boston University Medical Center, Boston- Dr. Leach demonstrates casting and wrapping procedures for common orthopaedic injuries - dislocated shoulder, tibia and fibula fractures, ankle sprains and fractures. (18 minutes) (in color) 1517208 ORTHOPEDIC INJURIES AND THEIR TREAT- MENT, Paul R. Meyer, Jr., M.D., Department of Orthopedics, TulaneUniverslty School of Medi- cine, presents a series of patients with uncom- mon orthopedic injuries including a surgical repair of torn ligaments. (15 minutes). 150Z303 PROBLEMS IN THE MANAGEMENT OF AMPU- TEES, with Ernest W. Johnson, M.D., Professor and Chairman of the Department of Physical Medicine; and William G. Pace, M.D., Professor of Surgery and Assistant Dean of the College of Medicine, Ohio State University, Columbus, Ohio. Current surgical techniques both for above-knee and below-knee amputations are shown and dis- cussed. Also, part of this telecast is devoted to a technique for immediate post-operative fitting of a prosthetic leg after above-knee amputation. (16 )ninutet). 1611224 RECONSTRUCTIVE HAND SURGERY, with Leo A. Keoshian, M.D., Clinital Instructor of Surgery, Stanford University School of Medicine, Stan- ford, California. Highlights of surgical procedures carried out in Viet Nam are detailed. The reconstructive hand surgery necessitated by war injuries is related to similar civilian injuries (ie., a firecracker in- jury). (21 minutes) (in color) 1811707 ROTARY INSTABILITY OF THE KNEE: PART I A new diagnostic technique for rotary knee In. stability is demonstrated by Donald B. Slocum, M.D., and Robert L. Larson M.D., Department of Orthopaedics, Sacred Heart General Hospital, Eugene, Ore. (17 mInutes) (in color) 1808421 ROTARY INSTABILITY OF THE-KNEE: `ART II * REHABILITATION AND MANAGEMENT In this telecast, Donald B. Slocum, M.D., and Robert L. Larson, M.D. Department of Ortho- paedics, Sacred Heart General Hospital, Eugene, Ore., continue their discussion by showing cor- rective surgery and demonstrating the therapeutic programs that follow. (18 minutes) (in color) 1808522 SCOLIOSIS: SIGNIFICANCE OF EARLY DETEC- TION, with Hugo A. Keim, M.D., Director of fhe Scoliosis Clinic, New York Orthopaedic Hospital; and David B. Levine, M.D., Associate Attending Orthopaedic Surgeon, Hospital for Special Sur- gery, and Clinical Associate Professor, Cornell University Medical College, New York City. Approximately one adolescent in 10 has idio- pathic scoliosis, which too often is not recog- nized until the curvature has become debilitat- ing. Two orthópaedists show what to look for on x-rays and how to conduct a simple office exam- ination that makes earlier diagnosis and treat- ment easier. (15 minutes) (In color) 1914726 SCOLIOSIS: WHEN TO OPERATE, with Hugo A. Keim, M,D., Director ~f the Scoliosis Clitlic, New York Orthopaedic Hospital of the Colunibia l,Ini- versity Medical Center; and David . B. Levine, M;D., Associate Attending Orthopaedic Surgeon, Hospital for Special Surgery, and Clinital Asso- ciate Professor, Cornell University Medical Cal- lege, New York City. The choice between brac- ing and surgery for scollosis may pose a dilem- ma. Doctors Levine and Keim demonstrate when surgery is indicated, and offer the referring physician insight into the whys and the hows of current surgical and bracing techniques. (it minutes) (in color) 1914.827 SELECTING PATIENTS FOR TOTAL KNEE RE- PLACEMENT, with John A. Lynch, M.D., Ortho- pedic Surgeon, Topeka, Kansas, and Associate Professor of Clinical Orthopedics, Uniidersity of Kansas School of Medicine, Kansas City, Kansas. Which of your patients with arthritic knees IS a candidate for a knee prosthesis? Here are the guidelines plus new information on this con- stantly changing solution to severe kneq pain. (17 mInutes) (In color) 1921639 THE LOWER BACK PAIN SYNDROME - PART I. The physical findings in a typical L-5 disc proW trusion, and the pathological anatomical mech- anisms for these findings, are examined by James 0. Johnston, M.D., Chief of Orthopedics, Kaiser Foundation Hospital of Oakland, California. The various types of lumbar disc syndrome.s are il- luotrated by Dr. Johnston, to help to correlate the classical neurologic deficits found in. route compression disorders. (iS minuses)- ~208008 87 PAGENO="0442" 14348 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY THE LOWER BACK PAIN SYNDROME - PART II. The most effective management of low back pain is considered by James 0. Johnston, M.D., Chief of Orthopedics, Kaiser Foundation Hospital, Oakland, California. Dr. Johnston estimates that some 95 percent of these patients recover with an uncomplicated treatment program highlighted by rest and moist heat. (19 mInutes). 1208109 THE MILITARY DOCTOR, with- Commander Rich. ard M. Escajeda, M.D. Report from Vietnam on military and civilian care. (21 mInutes). 1302133 THREE ORTHOPEDIC EXAMINATIONS FOR NON. ORTHOPEDISTS HOW I EXAMINE THE SPINE (19 mInutes) (In color) 0822742 HOW I EXAMINE THE HIP (15 minutes) (in color) 0822641 HOW I EXAMINE THE~KNEE- - - (se minutes) (in color) 0822540 With A. Graham Apley, F.R.C.S., Honorary Direc- tor of the Department of Orthopedics, St. Thom- as' Hospital, London; and Consulting Orthopedic Surgeon, Rowley-Bristow Orthopedic Hospital, Pyrfod, England; Visiting Professor of Ortho. pedics, Albert Einstein Hospital in New York City. Authoritative demonstrations of normal and ab. normal findings in three orthopedic problem areas-for the generalist. These programs were produced in cooperation with the Department of Orthopedic Surgery and the Office of Continuing Medical Education, Albert Einstein College of Medicine in New York City. TOTAL HIP REPLACEMENT, with John J. Gart- land, M.D., James Edwards Professor of Ortho- paedic Surgery, Jefferson Medital College of Thomas Jefferson University, Philadelphia, Pennsylvania. Since the mid-sixties thousands of American men and women have obtained relief from crippling hip disease through the im- plantation of total hip arthroplasties. Dr. Gart. land employs the technique advanced by Charn. Icy and Muller to replace the right hip of a middle-aged man who had his left hip similarly replaced five months previously. (19 minutes) (in color) 2015126 All programs in this catalog are copyright by the Network for Continuing Medical Education. Duplication, reproduction, or distribution in any form of all or any part of the programs is prohi6ited without the expreis written consent of NCME. OTOLARYNGOLOGY THE DIFFERENTIAL DIAGNOSIS OF DIZZINESS, with Rosalie Burns, M.D., Professor and Head of the Department of Neurology; and Robert Wolfson, M.D., Professor and Head of the Division of Oto. laryngology, The Medical College of Pennsyl- vania, Philadelphia. The patient who complains of dizziness may be suffering from one of many maladies. Two experts, presenting three such pa- tients, demonstrate how the primary care physi. cian can question and examine his way to a con clusive diagnosis. (20 minutes) (in color) 0418344 DIFFERENTIAL DIAGNOSIS OF HOARSENESS. Treatment of hoarseness without determining Its cause can result In the dangerous masking of a common signal to problems. In this presentation, Dr. Wilbur J~ Gould, Director of Otolaryngology, Lehox Hill Hospital, New York,ç onstrasjha ~ in early identificatIon and treatment of disorders of the larynx. (15 minutes). 0408217 EARLY DETECTION OF ACOUSTIC NEUROMAS. Newly developed surgicll procedures for remov- ing acoustic neuromas have produced good re- sults. Alfred WeIss, M.D., Director of Otoneurol- ogy, Massachusetts Eye and Ear Infirmary, and Instructor in Otolaryngology, Harvard Medical School, emphasizes the need and discusses the techniques of early diagnosis. (20 mInutes). 0508501 FINDING AND RECOGNIZING ORAL LESIONS, with Elliot W. Strong, M.D., Chief of the Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York City. Dr. Strong dem- onstrates how to convert a routine oral cavity examination Into a procedure with better identi- fication of early, curable lesions. (19 minutes) (in color) 0618019 HEARING LOSS: A THREAT AT ANY AGE, with Merrill Goodman, M.D., Director of Otolaryngol- ogy, Long Island Jewish-Hillside Medical Center, and Medical Director, Long Island Hearing and Speech Center, New Hyde Park, Long Island, New York. 20 million Americans have an undiscovered but measurable hearing loss. Here's how you can uncover and often treat hearing loss in children and adults. (18 minutes) (in color) 0819034 IS IT SINUSITIS? With Melvin E. Sigel, M.D., Clinical Associate Professor of Otolaryngology, University of Minnesota Medical School, and AssiStant Chief, Department of Otolaryngolagy, Hennepin County General Hospital, Minneâ~olis. Physical examination and x-ray pointers for dis- tinguishing Sinusitis, an easy "wastebasket" diagnosis, from other diseases. (13 minutes) (it color) 0919826 88 PAGENO="0443" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14349 LARYNGOGRAPHY: PART 1 `Procedures and Normal Findings.' A demon stration of the technique for performing the laryngogram, and a discussion of the normal structures of the larynx - with George Stassa M.D., Assistant Professor of Radiology, New York HospitalCornell Medl~al Center. (18 mInutes). 1203704 LARYNGOGRAPHY: PART II `Some Abnormal Finding~." Contrast laryngog. raphy enables the radiologist to evaluate the various disease processes occurring in the larynx. George Stassa, M.D., Assistant Professor of Radi- ology, New York Hospital-cornell Medical Cen- ter, reviews the abnormal findings that might be detected with this technique. (14 minutes) 1203905 MENIERE'S DISEASE: DIFFERENTIAL Dx, with James R. Tabor, M.D., Otologist and Assistant Professor of Surgery, University of Colorado Medical Center, Denver. By comparing two pa- tients, an otologist demonstrates how to rec- ognize the patient with Meniere's disease, and how to rule out other disorders. (16 minutes) (in celor) 1322356 RADIOLOGIC MANAGEMENT OF EARLY CANCER OF THE LARYNX, with Alexander 0, Crosett, M.D., Director, Radiation Therapy and Nuclear Medicine, and Charles E. Langgaard, M.D., oto. laryngologist, both at Overlook Hospital, Sum- mit, N. J. How the radiation department of a community hospital approaches early laryngeal cancer and provides the patient with an excel- lent prognosis. (12 mJnutes) (in celer) 1818928 T & A: PANACEA OR PLACEBO?, with Melvin E. Sigel, M.D., Clinical Associate Professor, Dc- partrnent of Otolaryngology, University of Min- nesota Medical School, Minneapolis. The oldest surgical therapy still in use . . . when is it in order today? (16 minutes) (in euler) 2022038 Each program is accompanied by a review card. NCME asks that the person for whom the program was ordered fill out and return this card. Because reevaluation of MasterLibrary videocassettes isa contin- ual process, return of the program review card is essential in helping NCME deter- mine which programs remain useful as re- sources for continuing medical education. PATHOLOGY A FORENSIC AUTOPSY WITH DR. MILTON HEL- PERN, Chief Medical Examiner for the City of New York, and Professor and Chairman of the Department of Forensic Medicine, New York University School of Medicine; and John F.. Dcv- un, M.D., Deputy Chief Medical Examiner, City of New York, and Associate Professor of Foren- sic Medicine, New York University School of Medicine. A 32-year-old stockbroker, known to be a heavy drinker, depressed and with a recent prescription for sleeping pills, is found dead in bed. Although he was treated for diabetes In childhood, he has not seen a physician recently. What would you write on the death certificate? Suicide? Accident? Natural causes? Dr. Helpern, the noted forensic pathologist takes you through the autopsy to determine the cause of death. (21 minutes) (in color) 0617518 ACUTE REGIONAL ENTERITIS: A CUNICAL PATHOLOGICAL CONFERENCE, with FIdyd M. Beman, M.D., Professor of Medicine; J. David Dunbar, M.D., Assistant Professor of Radiology; Dante G, Scarpelli, M.D., Professor of Pathology; and William Pace, M.D., Assistant Dean of the College of Medicine; all from the Ohio State Uni- versity College of Medicine in Columbus, Ohio, Four physician- educators critically explore a case of severe, progressive regional enteritis. (23 minutes). 0110703 CLIT'IICAL LABORATORIES: PH1i'SICIAN ~VALU- ATION AND UTILiZATION, with Randolph M. Chase, Jr., M.D., Director, Microbiology Depart- ment, New York University Hospital; Joseph H. Boutwell, M.D, Chief of Licerisure and Develop- ment Branch, Laboratory Division of the k~ational Communicable Disease Center in Atlanta, Georgia; and Edward Cavanaugh, M.D., Chief of Laboratory Training Section of the NCDC, An overvieW of clinical laboratories In the U.S. today, Including costs, range of tests, quality of work and selecting a lab, Is presented in this program produced at the National Communicable Disease Center. (17 minutes) (In color) 0310317 CONGESTIVE HEART FAILURE - PATHOPHYSI- OLOGY AND TREATMENT, with Albert N~ Brest, M.D., Head, Section of Vascular Disease and Renology, Hahnemann Medical College and Hos- pital. (15 mInutes). 0302545 EXTRACORPOREAL CIRCULATION IN THE HU~ MAN PLACENTA with Kermit Krantz, M.D., Pro- fessor of Obstetrics and Gynecology, Unhversity of Kansas School of Medicine. A presentation of human placenta research and some clinical applications. (24 minutes), 0501414 89 PAGENO="0444" 14350 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY GASTROINTESTINAL CYTOLOGY: PART I - A VALUABLE DIAGNOSTIC PROCEDURE `Application and Results" Confirming a diagno- sis without surgery through the use of Papanico- laou staining of cells from the gastroin,testinal tract - with Charles Norland, M.D., Assistant Professor of Medicine, University of Chicago School of Medicine. (16 minutes). 0703303 GASTROINTESTINAL CYTOLOGY: PART II "Techniques and Methods of Interpretation." Demonstration of the techniques of tubular intu- bation, stomach washing, and slide staining utilized in this diagnostic procedure - with Charles Norland, M.D., Assistant Professor of Medicine, and Director, Gastrointestinal Cytology Laboratory, University of Chicago School of Medicine. (17 minutes). 0703404 GROSS SYNOVIANALYSIS, a discussion of joint fluid analysis for the practicing physician, pre- sented by Daniel J. McCarty, M.D., Associate Professor of Medicine, and Head of Rheumatology Section, Hahnemann Medical College and Hos- pital. (13 mInutes). 0700411 MICROSCOPIC SYNOVIANALYSIS, the use of phase microscopy for joint fluid analysis, With Daniel J. McCarty, M.D., Associate Professor of Medicine and Head of Rheumatology Section, Hahnemann Medical College and Hospital. (24 minutes). 1300532 SPHINGOLIPIDOSIS: GENETICS The increasing incidence of sphingolipid dis- ease, such as Tay'Sachs, Gaucher's, and Nie- mann.Fick, is examined genetically by Stanley M. Aronson, M.D., Professor of Pathology, State University of New York Downstate Medical Cen. ter, and Attending Neuropathologist, Issac Al- bert Research Institute, Jewish Chronic Disease Hospital, Brooklyn. (15 minutes). 1904914 SPHINGOLIPIDOSIS - PART I - BIOCHEMICAL ASPECTS. The chemical compositions of ganglio- sides, sphingomyelins, sulfatides, glycolipids, and cerebrosides, as they are found in the vari- ous sphingolipid diseases, are analyzed by Abra- ham Saifer, Ph.D., Chief of the Biochemistry Department, Isaac Albert Research Institute of the Jewish Chronic Disease Hospital, Brooklyn. (21 minutes). 1905015 SPHINGOLIPIDOSIS - PART II- PATHOLOGY. Several pathologic manifestations - such as amaurotic family idiocy (Tay-Sachs disease), hep- átosplenomegaly (Niemann-Plck disease), and others - grouped under the general category of sphingolipidosis, are examined and defined by Bruno W. Volk, M.D., Director of the Isaac Albert Research Institute, of the Jewish Chronif Disease Hospital, and Clinical Professor of Pathology, State University of New York Downstate Medioal Center, Brooklyn. (21 minutes). 1905016 SPHINGOLIPIDOSIS - PART Ill - CLINICAL ASPECTS. The specific physiologic manifesta- tions of the Tay-Sachs and Niemann-Pick dis- eases and amaurotic idiocy-such as cherry red macula, clonus, severe contractions, the "frog" position of the legs, and lack of macrocephaly - are demonstrated with young patients by Larry Schneck, M.D., of the Albert Isaac Research Institute of the Jewish Chronic Disease Hospi- tal, Downstate Medical Center, Brooklyn, New York. (13 minutes). 1905217 STEROIDS, HORMONES AND INFLAMMATORY DISEASE, with Gerald Weissmah, M.D., Associate Professor of Medicine, New York University Medical Center. Steroids, hormones, and chioro- quin have been shown to ábunteract inflam- mation and tissue injury by virtue of their stabiliIation of lysosomes. (14 minutes). 1900318 THE LABORATORY IN DIAGNOSIS OF PNEU- MONIA. Pneumonia continues to account for 45,000 deaths each year. Treating a patient with drugs which may suppress but fail to eradicate the infecting organism may place him in jeop- ardy, and provides less than optimal care. Dis- covery of the etiologic agent is determined in the laboratory by such efforts as microscopic, cultural, serological and antimicrobial sensitivity tests, according to Robert Austrian, M.D., John Herr Musser Professor and Chairman, Depart- ment of Research Medicjne, University of Penn' sylvania ~chooI of Medicine. - (16 minutes). 1207201 PEDIATRICS ABNORMAL SEX DIFFERENTIATION, with Mau- rice D. Kogut, M.D., Director, Clinical Research Center; and Jordan J. Weitzman, M.D., pediatric surgeon, both of Children's Hospital of Los An- geles. The factors of determining sexual ambiguities in the newborn are clea~Iy demonstrated in this telecast. Emphasis is also placed on early treat- ment and establishing an unambiguous sex of rearing. (17 minutes) (In color) 0111601 A PRACTICAL APPROAQH TO ALLERGIC DERMA- TOSES IN CHILDREN, with Vincent J. Fontana, M.D., Professor of Clinical Pediatrics, New York University College of Medicine, New York City. Dr. Fontana demonstrates ways in which the general physician can arrive at positive diagnoses of both common and less-frequently encountered allergic dermatoses in children. He followS each diagnosis with its recommended treatment. (18 mInutes) (In color) 1614937 90 PAGENO="0445" COMPETITtVE PROBLEMS IN THE DRUG INDUSTRY 14351 BABY . ARE YOU MINE? ARE YOU REALLY ALIVE? Medical treatment was successful, but the mother couldn't care for her premature baby. Why? Did hospital care interfere with the mother's attachment to her baby? Marshall H. Klaus, M.D., Professor of Pediatrics and Director of the Neonatal Nurseries `at Case Western Reserve University of Medicine in Cleve. land, Ohio, presents the highlights of studies on maternal attachment. In addition, there are pos- itive clinical hints on how to strengthen and support parental attachment. (26 minutes) (in color) SAMA 2811774 BONE NEOPLASMS IN CHILDREN: EARLY DE- TECTION, with Joseph H. Kushner, M.D., pedi- atrician and Co-Chairman of the Department of Pediatric Oncology, University of California, San Francisco. Three symptomatic patients. Is the lesion benign or malignant? Here, concisely, are keys to ac- curate-and early-diagnosis, (17 minutes) (In color) 0223520 CAN YOU TREAT OBESITY IN CHILDREN? with Platon J. Collipp, M.D., Chief Pediatrician, Nas- sau County Medical Center, and Professor of Pediatrics, State University of New York, Stony Brook, Long Island, N. Y. Long-standing obesity, a health hazard in later life, can be stemmed in childhood and adolescence. Dr. Collipp shows how diet, group treatment, challenge and support have successfully removed "60 tons of Long Island baby fat." (18 mInutes) (In color) 0318076 CHILD DEVELOPMENT PROBLEMS with Pearl L Rosser, M.D., Director, Child Development Cen- ter, Department of Pediatrics, Howard University School of Medicine, Washington, D. C. Develop- mental differences in children are not always benign. Dr. Rosser outlines ways to differentiate problems of socioeconomic origin from those which are clinically significant. (15 mInutes) (In color) 0323284 CHILDHOOD ALLERGY: THE GREAT MASQUER- ADER, with Roland B. Scott, M.D., Professor of Pediatrics and Child Health, Howard Univer- sity School of Medicine, Washington, D.C. Dem- onstration of the subtle early signs and symp- toms of allergy which may eventually lead to serious, debilitating disease. Emphasis is on the child with "too many colds." (20 mInutes) (in color) 0321280 CHILDHOOD STRABISMUS: AN APPROACH FOR NON-OPHTHALMOLOGISTS, with Virginia Lubkin, M.D., Assistant Clinical Professor and Head of the Ophthalmic Plastic Surgery Clinic, Mount Sinai School of Medicine, and Attending Ophthal- mologist at the New York Eye and Ear Infirmary. Monocular vision - . - absence of depth percep- tion - . - and a- cosmetic defect-consequences of a missed strabismus. Here are eight tests, performable in 10 minutes, to screen for eye muscle imbalance. Both normal and abnormal test responses are demonstrated. (23 minutes) (in color) 0319177 COMMON SKIN DISORDERS IN THE FIRST YEAR OF LIFE, with David L Cram, M.D., Chief of the Dermatology Clinic, University of California at San Francisco. How to distinguish among the variety of skin eruptions you may see In infants. (15 minutes) (in color) 0322383 CONGENITAL HIP DISLOCATION IN CHILDREN - PART I. Cases of congenital dIslocatIOn of the hip have the most successful outcome if diag- nosis and treatment are done before the child has learned to walk (or before two years of age). Paul H. Curtiss, Jr., M.D., Professor of Surgery, Department of Orthopedics, OhIo State Univer- sity College of Medicine, demonstrates some of the simple diagnostic procedures for Infants with hip dislocation. These Include abductiOn of the hips, observatIon of the skin folds of the thigh, and the placing together and flexion of the legs. These procedures, aided by x-rays, and the sub- sequent application of the proper cast~ usually will restore proper hip function withoUt resort- ing to an operatIon. (9 minutes). 0305243 CONGENITAL HIP DISLOCATION IN CHiLDREN - PART II - SURGICAL CORRECTION.. The operative techniques available to restore hip function are presented by Henry B. Lacey, M.D., Clinical Associate Professor, Division Of Ortho- pedics, Ohio State University College of Medicine, using patients who were not diagnosed Until after the age of two years. fl3 mInutes). 0305344 CYSTIC FIBROSIS: DiAGNOSIS AND MANAGE- MENT, with Paul R. Patterson, M.D., Director, Cystic Fibrosis Unit, Albany Medical Center, Al- bany Medical College, Union University, New York. Attention is drawn to cystic fibrosis as a model genetic disease. Dr. Patterson describes, with many examples, C/F's mode of inheritance, inci- dence, symptoms, differential diagnosis, detec- tion of carrier state, current status of manage- ability and prospects for palliative or Corrective therapy. (19 mInutes) (In color) 0310961 91 PAGENO="0446" 14352 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY DEALING WITH EPILEPSY: THE SOCIAL PROB- LEM, with Mary Louise Scholl, M.D., Associate Pediatrician, Massachusetts General Hospital, and Assistant Professor of Pediatrics, Harvard Medical School, Boston, Massachusetts. With proper physician guidance, epileptics can live nearly normal lives - Dr. Scholl reviews typical problems with three patients and explains what physicians can do to help. (21 minutes) (In color) 0415130 DEATH OF A SIBLING, with Thomas S. Morse, M.D., Associate Professor, Surgery, Ohio State University College of Medicine, and Thomas E. Schaffer, M.D., Professor of Pediatrics, Ohio State University College of Medicine. In a time of crisis for parents and surviving chil- dren, the family physician can assume an essen- tial role in support of both. Drs. Morse and Schaffer focus on specific problems that result from the death of a sibling: questions to expect, *points to emphasize; emotions to look for; how to use your medical authority to smooth the way. (19 mInutes) (In color) 0416035 DETECTION AND DIAGNOSIS OF EDUCATION- ALLY/NEUROLOGICALLY HANDICAPPED CHIL- DREN, with Henry S. Richanbach, M.D., Assis- tant Clinical Professor of Pediatrics at Stanford University School of Medicine. Millions of children cannot succeed in school de- spite adequate intelligence and eagerness to learn. By evaluating the variations of their be- havior and their ability to perform, these chil- dren can have a good chance in fulfillIng theIr learning potential. Dr. Richanbach demonstrates basic office proce- dures for detecting. diagnosing and treating school failure in children before the children are caught up in a cycle of failure. The program concentrates on the effort of the individual general physician, and not the multi discipline approach. (17 mInutes) (in color) 0412702 DEVELOPMENTAL DISABILITY AND THE GEN- ERAL PRACTITIONER, with Geoffrey Woo-ming, M.D., Chief of Pediatrics, Ohio State University Center for Mental Retardation, and Assistant Pro- fessor of Pediatrics, OSU College ci Medicine; Marian Chase, MA., Chief of Physical Therapy, OSU Center for Mental Retardation, and Assistant Professor of Physical Therapy, School of Allied Medical Professions, OSU College of Medicine; and Henry Leland, Ph.D., Chief of Psychology, OSU Center for Mental Retardation, and Associate Pro- fessor of Psychology, College of Social and Behav- ioral Sciences, OSU, Columbus Ohio. A multi- disciplinary approach is used on this telecast to show the general physician how he can help fami- lies with mentally retarded children. (15 mInutes), 0414228 DIA1~NOSING THE MALTREATMENT SYNDROME IN CHILDREN, with Vincent J. Fontana, M.D., Di~ rector of the Department of Pediatrics, St. Vin- cent's Hospital; and Medical Director, New York Foundling Hospital, both in New York City. in full agreement with a JAMA editorial stating that the "maltreated or battered child could be the leading cause of death in infants and children," Dr. Fon- tana describes the presenting signs that should make any physician suspect battered child or maltreatment syndrome - a diagnosis that may prevent future trauma to the child and may even save its life. (14 minutes) (In color) 0414329 DIAGNOSIS OF LEARNING DISABILITIES, with Dorothy L. DeBoer, Ph.D., Director, Learning Disabilities Center, Mercy Hospital and Medical Center, Chicago; and Lowell M. Zollar, M.D., Pediatrician and Pediatric Consultant to the Learning Disabilities Center, Mercy Hospital and Medical Center, Chicago. What is the best way to care for the patient with a specific learning disability? This program follows a child through a learning disabilities center, and shows not only how to recognize these patients, but what can be done to help them. (16 minutes) (In color) 0421154 EARLY PROSTHETIC FITTING FOR CONGENITAL DEFECTS OF THE EXTREMITIES, with Charles H. Epps, Jr., M.D., Department of Orthopedics, Howard University School of Medicine, and Chief, Juvenile Amputee Clinic, D.C. General Hospital, Washington, D.C. Several patients from the Juvenile Amputee Clinic demonstrate differences between early and late prosthetic fitting for congenital extremity defects. Which conditions require surgical amputation and early prosthetic fitting? How do you approach parents of chii~ dren with congenital defects? Epps answers these questions. 114 minutes) (in color) 0521027 FAILURE TO THRIVE, with Aaron R. Rausen, M.D., Director of Pediatrics, Beth Israel Medical Center, and Professor of Pediatrics, Mount Sinai School of Medicine, New York City. Suddenly, or gradually, the child fails to thrive. There's no obvious cause. Here's how to examine your patient systematically, to sift through hundreds of possible clues and to solve this massive medical mystery. (16 minutes) (in color) 0619420 For more information about NCME's Master Videocassette Library or bi-weekly videocassette service, write: NCME/15 Columbus Circle/New York, N.Y. 10023; or phone: (212) 541-8088. 92 PAGENO="0447" COMPETITIVE ?ROELtMS IN THE DETJG iuserw~ 14353 FOR THE NEWBORN: A MINUTES WORTH OF ORTHOPAEDICS, with Bobert S. Siffert, M.D., Pro fessor and Chairman, Department of Orthopae. dice, Mount Sinai School of Medicine of City Un) versity of New York, and Orthopaedic Surgeon and Chief, Mount Sinai Hospital, New York City. is the baby abnormal, or has the intrauterine position caused a defect which is only tern' porary? Dr. Siffert offers a checKlist examination for the newborn, which can be completed in about a minute and which should give you tht answer. (24 minutes) (in coler) 0617117 HEXACHLOROPHENE: OPEN TO DEBATE, with Harold C. Neu, M.D., Associate Professor of Medicine and Chief, Division of Infectious Dis- eases; Stanley James, M.D., Professor of Pediat. rica and Chairman of the American Academy of Pediatrics Committee on the Fetus and New- born; Carl Nelson, M.D., Professor of Dermatol- ogy and President of the American Dermatolog- ical Association. Al) of the participants are on the faculty of the Columbia University College of Physicians and Surgeons, New York City. Since December 15, 1971 bathing newborns with hexachiorophene, routine in most nurseries, has been banned by the F.D.A. and thk American Academy of Pediatrics-or has it? Our panel looks at this new problem from several angles and comes up with some interesting conclusions. (leminutes) (In color) 0815520 HOME TRANSFUSiON FOR HEMOPHILIA PA- TIENTS, with S. Frederick Rabiner, M.D., Director of the Clinical Hematology Unit, Michael Reese Hospital and Medical Center, Chicago; and Asso- ciate Professor of Medicine at the University of Chicago Pritzker School of Medicine. Hemophilia patients can be administered anti-hemophiliac factor by trained relatives in the home, on vaca- tion - almost anywhere. This is the experience of a three-year program at Michael Reese Hospi- tal. The program, the training for relatives and the results are discussed and shown in this telecast. (20 minutes) (in color) 0813117 HYPERBARIC OXYGEN TOXICITY. Hyperbaric oxygenation is being used more frequently in clinical situations, but its use is restricted by the toxic effects of oxygen itself. Donald R. Sperling, M.D., Assistant Professor of Pediatrics and Head of the DivisiOn of Pediatric Cardi- ology, University of California at Irvine, Cali- fornia College of Medicine, demonstrates studies on the toxicity of oxygen and its prevention un- der high pressure in newborn and adult mice. (13 mInutes). 0805410 INBORN ERRORS OF' METABOLISM: MECHANISM AND DIAGNOSIS Charles R. Scriver, M.D., of the DeBei)e Labora- tory for Biochemical Genetics at Montreal Chil- dren's Hospital in Montreal, P.Q., Canada, dc sôribes the current techniques for managing genetic diseases. (13 minutes) (In Color) 0909804 INNOCENT HEART MURMURS IN CHII~DREN, with Bernard L. Segal, M.D., Clinical ProfeSsor of Medicine, Hahnemann Medical College and Hos- pital, Philadelphia. Perhaps a third of all children have heart murmurs, but they are often inno- cent. Cardiologist Segal demonstrates an ex- amination to differentiate innocent from ~rganic murmurs and uses audio recordings to point out the characteristics of several common murmurs. (13 mInutes) (In colOr) 0917624 KEEPING UP ON IMMUNIZATIONS, with Samuel L. Katz, M.D., Professor and Chairman of the Department of Pediatrics, Duke University Medi- cal School, and Chairman of the Committee on Infeitious Disease of the American Academy of Pediatrics, Durham, North Carolina. Here's a quiz on preventive practice. Six cases point u~ same problems in `routine" office immunization. Ut minutes) (in co)or) 1~218O4 LOOK OUT FOR LEAD, with Jay M. Arena, M.D., Director, Duke University Poison Control Cen- ter, Durham, N.C., and former President, Amer icon Academy of Pediatrics. There are poten- tially more lethal sources of lead poisoning than old paint in city slums, says Dr. Arena. He pre- sents tips for diagnosis and treatment In your suburban and rural patients. (10 minutes) (in color) 1217216 MANAGEMENT OF ADOLESCENT SYMPTOMS Methods of dealing with the problems of adoles- cents - particularly experimentation with sex and drugs - are demonstrated with grbups of teenagers by Steven R. Homel, MID., Depart- ment of Pediatrics. Jefferson Medical College and Hospital, Philadelphia, Pa. (18 mInutes). 1308004 MANAGEMENT OF ASPIRIN POISONING, with Jay M. Arena, M.D., Director, Poison Control Center, Duke University Medical Center, Durham, N. C., and former President, American Academy of Pediatrics Dr. Arena draws on 35 ye~rs' ex- perience to give a practical approach to handling the most common cause of poisoning in chil- dren. (13 mInutes) (in color) 1317347 93 PAGENO="0448" 14354 COMPETITIVE PROBLoEMS IN THE DRUG INDUSTRY MANAGEMENT OF THE AMBULATORY ASTHMAT- IC CHILD, with Vincent J. Fontana, M.D., Direc- tor of the Department of Pediatrics, St. Vincent's Hospital; and Medical Director New York Found- ling Hospital, both in New York City. Dr. Fontana describes the steps that a general practitioner can take to alleviate the symptomatology of asthma, the prevention of future episodes and the avoidance of complications of bronchial asthma, (16 minutes) (in color) 1314139 MANAGEMENT OF THE BATTERED CHILD SYN- DROME, with C. Henry Kernpe, M.D., Professor and Chairman of Pediatdcs; Brandt F. Steele, M.D., Professor of Psychiatry; and Helen Alex- ander, Medical Social Worker, Supervisor of Lay Therapists, Battered Child Program. All three are with the University of Colorado Medical Center. The reasons for abuse become apparent in an unrehearsed conversation with the mother of a patient. Three experts offer some practical advice on coping with parents once child abuse has been diagnosed and the underlying problems identified. (18 minutes) (in color) 1314441 MANAGEMENT TIPS FOR SOFT TISSUE INJU- RIES IN CHILDREN, with Thomas S. Morse, M.D., Associate Professor of Surgery, Ohio State Uni- versity College of Medicine, Columbus, Ohio. The surgical technique for repairing a laceration in a child is about the same as that used for adults, but there are ways to make it easier. In this program, special attention is given to dress. ings, restraints and slings, as Dr. Morse shares his "little tricks" that help make it ealser to deal with children. (18 minutes) (in color) 1319552 MANAGING THE HYPERACTIVE CHILD, with Gerald Erenberg, M.D., Pediatric Neurologist, Montefiore Medical Center and Morrisania Hos- pi~aI, Bronx, N. Y. Amphetamines are no pana- cea, nor need they be your first plan of attack. A structured approach to treatment is outlined and illustrated. (12 mini~tes) (in color) 1318651 PEDIATRIC CARDIOLOGY - PART I - CATHE- TERIZATION IN INFANTS. Donald R. Sperling, M.D., Assistant Professor of Pediatrics, Califor- nia College of Medicine, University of California, explains the indications and techniques for diag- nosing congenital heart disease by means of the cardiac catheter. (14 mInutes). 1605003 PEDIATRIC CARDIOLOGY- PART II - DIVISION OF PATENT DUCTUS ARTERIOSUS. Joseph J. Verska, M.D., Associate Clinical Professor of Surgery, University of California, the CalIfornia College of Medicine, and Director of Cardiac Sur- gery, White Memorial Medical Center, Los An- geles, operates to correct this congenItal cardiac defect. The patent ductus in this infant patIent was diagnosed (in PART I) by Donald R. Sperling, M.D., also of the California College of MedIcIne, using cardiac catheterization. (19 mInutes). 1605104 PEDIATRIC GYNECOLOGY. John W. Huffman, M.D., Professor of Obstetrics and Gynecology, Northwestern University Medical School, and Dorothy M. Barbo, M.D., instructor of ObstetrIcs and Gynecology, Marquette University School of Medicine, discuss obstetric problems in children and demonstrate special Instruments made for the young patient. (15 minutes). 1601405 PEDIATRIC NEUROMUSCULAR PROBLEMS. De- termining the existence and extent of brain dam- age in the very young child requires not only attention to every movement and response made by the child, but a knowledge of how to interpret them for treatment. Examination of the hypo- tonic infant as well as observation of the abnor- malities associated with cerebral palsy are ex- plored, using actual child patients, by William C. Earl, M.D., Assistant Professor Department of Physical Medicine, and Robert A. Wehe, M.D., Instructor, Department of Pediatrics, Ohio State University College of Medicine. (17 minutes). 1607607 PEDIATRIC PROGRESS: SUBDURAL FLUID COL- LECTIONS, with Richard J. Pellegrino, M.D., Di- rector of Pediatric Neurology, University of Nebraska Medical Center, Omaha. Subdural fluidi collection in a very young child is not the same problem encountered in older children and adults, Here are the differences in signs and symptoms, diagnosis and treatment. (15 minutes) (in color) 1623651 PERSISTENT OR RECURRENT FEVER IN IN- FANTS AND CHILDREN, with Sydney S. Gellis, M.D., Pediatrician-In-Chief, Tufts-New England Medital Center, Boston, Massachusetts. Dr. Gellis shows the physical findings which should most arouse suspicion In the physician of the eight leading non-infectious causes of "fever of unknown origin." (18 mInutes). 1611209 PROBLEMS OF BACTERIAL INFECTION - PART I, David H. Smith, M.D. Assistant Professor of Pediatrics, Harvard Medical School, and Chil- dren's Hospital Medical Center, Boston, Massa- chusetts, poses the following question and an- swers it in detail: How do bacteria become re- sistant to antibiotics and what does this mean to physicians in the care of their patients? This problem is becoming increasingly difficult for physicians whose patients may suddenly cease to respond to a medication or may saddenly develop "hospital-based" infections. (17 mInutes). 1607025 94 PAGENO="0449" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14355 REACHING THE ADOLESCENT PATIENT. How can the physician communicate with the ado- lescent patient whose physical problems so of- ten are linked to his emotional state? Using groups of youngsters at different age levels, Steven R. Homel, M.D.1 Department of Pedia- trics, Jefferson Medical College and Hospital of Philadelphia, demonstrates techniques and methods that can be applied to general prac- tice. (18 minutes). 1807905 RECOGNIZING ROLES IN JUVENILE DIABETES, with Donnell D. Etzwiler, M.D., Director, Diabetes Edutation Center, and Pediatrician, St. Louis Park Medical Center, Minneapolis. A pediatrician gives guidelines for early diagdosis and manage- ment of juvenile diabetes and shows which responsibilities of good control should be as- signed to physician, health prçfessional, and pa- tient. This presentation was produced with the cooperation of the Council on Scientific Assem- bly of the American Medical Association. (16 mInutes) (In color) 1822934 RECURRENT URINARY TRACT INFECTIONS IN CHILDREN, with A. Barry Belman, M.D., Attend- ing Pediatric Urologist, Children's Memorial Hos- pital, and Assistant Professor of Urology, North- western University Medical School, Chicago. How should you evaluate a child with recurrent U.T.l.? Compare your routine with that of a pediatric urologist. (14 minutes) (in colon 1821632 RENAL BIOPSY: WHEN WILL IT HELP THE CHILD? with Shane Roy, Ill, M.D., pediatric nephrologist and AssocWte Professor of Pedi- atrics, University of Tennessee College of Medi- cine, Memphis. Using four detailed patient cases, Doctor Roy illustrates the use of renal biopsy. The program includes an actual biopsy pro- cedure. (15 minutes) (in color) 1820830 RESPIRATORY DISTRESS IN THE NEWBORN: INDICATIONS FOR SURGERY, with Alexander J. Schaffer, M.D., Associate Professor Emeritus of Pediatrics Johns Hopkins UniversIty School of Medicine, and Assistant CommissIoner of Health of the City of Baltimore, Maryland. The clinical signs of respiratory distress are shown, along with examples of anomalies. Special attention is given to the approach of arriving at a specific diagnosis. (25 mInutes) (In color) 1810314 RESPIRATORY DISTRESS IN THE NEWBORN: MEDiCAL CONDITIONS, with Alexander J. Schaf- fer, M.D., Associate Professor Emeritus of Pedi- atrics, Johns Hopkins University School of Med~ icine, and Assistant Commissioner of Health of the City of Baltimore, Md. Indications of respira- tory distress in the newborn can be detected prior to labor, in labor and in delivery. The alerting signs are clearly illustrated. Dr. Schaffer also summarizes the general principles of treat- ment. (22 minutes) (In color) 1810415 SCREENING PRE-SCHOOLERS FOR NEUROLOGI- CAL DEFICITS, with N Paul Rosman, MO., Pro- fegsor of Pediatrics and Neurology, and Director of Pediatric Neurology at Boston University School of Madicine, and Boston City Hospital. A 15-niinute exam can head off possible learning difficulties. Dr. Rosrnan tests an apparently nor- mal five-year-old for neurological problems end analyzes his results. (20 minutes) (in color) 1918443 SICKLE-CELL ANEMIA: MANAGEMENT, with Ro- land B. Scott, M.D., Professor and Head of the Department of Pediatrics, Howard University, and ChIef PediatrIcian at Freedmens Hospital in Washington, D.C. There is np curative treatment for sickle-cell anernid, accbrding to Or. Scott. However, early diagnosis of the diseas~e, which afflicts mOre than 50,000 lack Americans, can ameliorate the most disturbing symptoms. Dr. Scott describes the therapeutic program he follows to enhance survival until the patient reaches puberty - when the natural course of the disease process appears to become attenuated. (14 minutes) (in color) 1911506 SICKLE-QELL ANEMIA: SUSPICION AND DIAG- NOSIS IN INFANTS AND CHILDREN, with Roland B. Scott, M.D., Professor and Head of the De- partment of Pediatrics, Howard University, and Chief Pediatrician at Freedmen's Hos~itaI in Washington, D.C. Also V. Bushan Bhardw~j, M.D,, Assistant Professor of Pediatrics, Howard Uni- versity, and Pediatric Hematologist, Freedmen's Hospital. Sickle-cell anemia afflicts more than 50,OQO Americans of African descent. Perhaps another two million black Americans carry the t!alt. Until recently, it was believed that little could be done for the disease. Now relief from the symptoms and a prolonging of life are possible. This telecast features the characteristics of the disease, and the Iabocatory procedure followed to establish a conclusive diagnosis. (20 mInutes) (In color) i911407 SHORT STATURE IN CHILDREN, with Maurice D. Kogut, M.D., Director, Clinical Research Center, Children's Hospital of Los Angeles, Los Angeles, Califo?nia. Three standard growth deviations are defined, and those conditions which are responsible for growth retardation - where no obvious disease is present - are described by Dr. Kogut. 117 minutes) (in color) 1911705 95 73-617 0 - 76 - 29 PAGENO="0450" 14356 COMPEPITIVE PROBLEMS IN T~E DEUG INDUSTRY SOME ORGANIC CAUSES OF CHiLDHOOD OBE- SITY, with Platon J. Collipp, MD., Chief of Pedi- atrics, Nassau County Medical Center, and Pro. fessor of Pediatrics, State University of New York, Stçtny Brook, Long Island, N. Y. Don't dis- count `glandular" causes of obesity without a long, hard look, Dr. ColIlpp presents patients with the more common of these rare diseases associated with overweight. (15 minutes) (in color) 1518209 SOME PATHOLOGIES OF SLEEP, with Julius Se- gal, Ph.D., of the National Institute for Mental Health, and Professor of Psychology, George Washington University, Washington, D.C. Dr. Se- gal describes the various stages of normal sleep and then relates disorders in REM and deep sleep to enuresis, somnambulism, night terrors and other patient problems. Special emphasis is given to the diagnosis and treatment of narcolep~ sy, which affects half a million people in the U.S. (19 mInutes) (In sslsr) 1917729 SORTING OUT SEIZURES IN CHILDREN, with Gilbert H. Glaser, M.D., Chairman and Professor, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, and Presidentof the American Academy of Neurol- ogy. This program provides a quick and thorough evaluation of the seizure patient from Initial ob- servation to mandatory laboratory and radiologic. tests for a prompt diagnosis. (16 minutes) (in color) 1920334 A SI°ECIAL REPORT: RUBELLA IMMUNIZATION A timely program containing the latest informa- tion about the Rubella Vaccine, its development and its recommended administration is presented by H. Bruce Dull, M.D., Assistant Director of the National Communicable Disease Center in At- lanta, Ga. (22 minutes). 1908815 SPHINGOLIPIDOSIS: GENETICS The increasing incidence of sphingolipid disease, such as Tay-Sachs, Gaucher's, and Niemann-Plck, is examined genetically by Stanley M. Aronson, M.D., Professor of Pathology, State University of New York Downstate Medical Center, and Attending Neuropathologist, Isaac Albert Re- search Institute, Jewish Chronic Disease Hospl~al, Brooklyn. (15 minutes). 1904914 SPI-IINGOLIPIDOSIS - PART I - BIOCHEMICAL ASPECTS. The chemical compositions of ganglio- sides, sphingomyelins, sulfatides, glycolipids, and cerebrosides, as they are found in the vari~ ous sphingolipid diseases, are analyzed by Abra- ham Saifer, Ph.D., Chief of the Biochemistry Department, Isaac Albert Research Institute of the Jewish Chronic Disease Hospital, Brooklyn. (21 minutes). 1905015 SPHINGOLIPIDOSIS -` PART II- PATHOLOGY. Several pathologic manifestations - such as amaurotic family Idiocy (Tay.Sachs disease), hep- atosplenomegaly lNiemann'Pick disease), and others - grouped under the general category of sphingolipidosis, are examined and defined by Bruno W. Volk, M.D., Director of the Isaac Albert Research Institute, of the Jewish Chronic Disease Hospital, and Clinical Professor of Pathology, State University of New York Downstate Medical Center, Brooklyn. (21 minutes). 1905016 SPHINGOLIPIDOSIS - PART Ill - CLII'&ICAL ASPECTS. The specific physiologic manifesta. tions of the Tay-Sachs and Niemann~Pick dis- eases and amaurotic idiocy-such as cherry red macula, clonus, severe contractions, the "frog" position of the legs, and lack of macrocephaly - are demonstrated with young patients by Larry Schneck, M.D., of the Albert Isaac Research Institute of the Jewish Chronic Disease Hospi- tal, Downstate Medical Center, Brooklyn, New York. (13 mlnsten). 1905217 THE DIABETIC IN COMA/BRITTLE DIABETES! THE YOUNG DIABETIC, with Rachmiel Levine, M.D., Professor and Chairman of the Depart- ment of Medicine at New York Medical College in New York City. Coma may occur in a person with diabetes for the same reasons as it would occur in the non- diabetic. For that reason it is important to dif- ferentiate between the two comas. Dr. Levine describes ketoacidosis, hyperglycemic coma, lactacidosis, hypoglycemia. Dr. Levine also dis- cusses "brittle" diabetes and the prognosis of childhood diabetes. (20 minutes). 0410904 THE DISTRESSED NEWBORN: THE FIRST 30 MiNUTES, with Peter A. M. Auld, M.D., Director, Neonatal Intensive Care Unit, and Professor of Pediatrics, New York Hospital-Cornell Medical Center, New York, Your newborn's Apgar score is low. Here's how to manage the immediate emergencies-.---and how to decide whether them- fant needs intensive care, lie minutes) (In color) 0419650 THE DOCTOR-ADOLESCENT RELATIONSHIP. The adolescent frequently needs an outlet to express his doubts and concerns. How the physIcian can serve as this Outlet durIng a clinical visIt is dem- onstrated by Steven R. Homel, M.D., of the De- partment of Pediatrics, Jefferson MedIcal College and Hospital, PhIladelphia, Pa. (30 minutes). 0408319 96 PAGENO="0451" COMPETIPtVE PROBLEMS IN THE DRUG INDUSTRY 14357 THE GENERAL PRACTITIONER AND COMMUN- ITY RESOURCES AVAILABLE FOR THE DEVEL- OPMENTALLY DELAYED, with William Gibson, M.D., Director, the Ohio State University Hirschel W. Nisonger Center for Mental Retarda- tion, and Associate Professor of Physical Med- icine at the Ohio State University College of Medicine; Cary W. Perkins, with the Ohio Asso- ciation for Retarded Children, Inc.; and Donald Cavin, Ed.D., Chief of Special Education at the Nisonger Center In Columbus, Ohio. The general practitioner can play an invaluable role in guid- ing families of the mentally retarded and the developmentally disabled to community re- sources and treatment centers. This telecast acquaints the physician with federal legislation providing for new resources, and how he can learn of their availability in his community. (16 minutes) (In color) 0714015 THE HYPERACTIVE CHILD: FINDING THE CAUSE, with Gerald Erenberg, M.D., Pediatric Neurologist, Montefiore and Morrisanla Hos- pitals, Bronx, N. Y. The child Is out of control at school or at home. You are asked to diag- nose or rule out minimal brain damage. This program shows you how - simply and quickly. (18 mInutes) (in color) 0818532 THE NEUROLOGICAL EXAMINATION FOR THE NEWBORN, with N. Paul Rosman, M.D., Profes- sor of Pediatrics and Neurology and Director of Pediatric Neurology, Boston University School of Medicine. Here are Dr. Rosman's reasons and techniques for this exam - an important few minutes in the first days of a newborn's life, (19 mInutes) (in color) 1418131 THE PEDIATRIC NURSE PRACTITIONER: AN EVOLVING ROLE IN PATIENT CAREm with Henry K. Silver, M.D,, Professor of Pediatrics, Univer- sity of Colorado Medical Center, Denver; and Loretta C. Ford, Ed.D., Professor and Chairman of Community Health Nursing, University of Colorado School of Nursing, Denver. If your pediatric practice is about one-half well- child supervision and one-fifth minor respiratory infections management, then your office could be a candidate for a pediatric nurse practitioner (PNP). A group with six years' experience in the PNP program helps you understand this new role and the PNP-doctor relationship with vig. nettes of a PNP řn-the.job. Although this tele- cast concerns pediatric practice, other physi- cians, too, can benefit from this look at the PNP experience. (20 minutes) (in coloY) 1614535 THE PEDIATRIC NURSE PRACTITIONER IN YOUR OFFICE, with Henry K. Silver, M.D., Uni- versity of Colorado Medical Center, Denv!r; Don- ald Cook, M.D., Lewis R. Day, M.D., and Robert Schiff, M,D., all pediatricians practicing with PNP5; and Loretta C. Ford, RN., Ed.D., Profes- sor and Chairman of Community Health Nursing, University of Colorado School of Nursing, Denver- In six years' experience with over 80 PNPS, there have been no legal problems. Three physi- cians and their PNP assocIates describe their own enthusiastic reactions and those of their col- leagues to this innovative, patient-accepted pro- gram that provides security and a lighter work load for physicians as well as professional grati- fication for PNPs. (18 minuteS) (in color) 1614636 THE RUBELLA IMMUNIZATION PROGRAM: A PROGRESS REPORT, with Saul Krugman, M.D., Professor and Chairman of the Department of Pediatrics; and Louis Z. Cooper, M.D., Associate Professor of Pediatrics and Director of the Ru- bella Birth Defect Evaluating Project both physicians from the New York University1Medical Center, Bellevue Hospital, New York City; and John J. Witte, MD., Chief of the Immunization Branch of the Center for Disease Control, Depart- ment of Health, Education and Welfare, Atlanta, Georgia. The Rubella Immunization Program has been in widespread use since the Summer of 196~. Three authorities on rubella report the findings of the Immunization Program and offer advice to practicing physicians based on the findings. (23 mInutes) (In color) 2812823 THE TEAM APPROACH TO THE CLE1~T PALATE: HABILITATON Members of the staff at the Lancaster Cleft Palate Clinic in Lancaster, Pa., along with H. K. Cooper, Sr., D.D.S., founder and Director Emeritus of the clinic, demonstrate their approach to a birth defect found in every 700 births. (18 minutes) (in color) ~010001 THE TEAM APPROACH TO THE CLEFT PALATE: REHABILITATION, with ~Robert T. Millard, Chief Speech Pathologist, and Mohammed Mazaheri, D.D.S., Chief Prosthodontlst, both of the Lancas- ter (Pa.) Cleft Palate Clinic. A variety of cases Is explored with the team approaches to each'prob- 1cm described in detail. (15 mInutes) (In color) ~010102 Master Library services are made possible through the support by Roche L4bora- tories of the production and regular ~iistri- bution of all NCME telecasts. 97 PAGENO="0452" 14358 COMPETITIVE PROBLrE~S IN THE DRUG INDUSTRY TREATING EDUCATIONALLY/NEUROLOG1CALLY HANDICAPPED CHILDREN, with Henry S. Richan. bach, M.D., Assistant Clinical Professor of Pedi- atrics, Stanford University School of Medicine; anc~ Lester Tarnapol, Sc,D., Past President of the California Association for Neurologica)ly Handicapped - both from Stanford, California. The general physician will learn about the drugs that are being administered cautiously to educa- tionally handicapped children, and the special educational programs that have been developed to assist them in daily living. (17 minutes) (in color) 2012811 THE TREATMENT OF BRONCHIAL ASTHMA, with Frank Perlman, M.D., Clinical Professor of Medicine, University of Oregon School of Medi- cine, Portland. How to treat the asthmatic pa- tient early to avoid a potential respiratory crisis. (16 minutes) (in color) 2020032 VESICOURETERAL REFLUX IN CHILDREN, with A. Barry Belman, M.D., Attending Pediatric Urologist, Children's Memorial Hospital, and As- sistant Professor of Urology, Northwestern Uni- versity Medical School, Chicago. How to find the congenital anomaly that can cause renal damage in children with recurrent U.T.l,s. (9 minutes) (in color) 2221703 WHO SPEAKS FOR THE BABY? A baby is born mongoloid, with a defective heart and duodenal atresia. The parents, with three other children at home, ask that lifesaving intestinal surgery not be performed. The pedintrician, trained to preserve life, seeks a ëourt order to operate. Is such a decision within the physician's prov- )nce? Should this child live or die? A presenta- tion by physlcians and medical students of points of view on infant euthanasia. (20 mInutes) (in color) SAMA 2810352 PHARMACOLOGY ANAPHYLACTIC REACTIONS TO DRUGS. Drug allergies in various degrees of severity have been found to occur in as many as 10 to 15 pci' cent of patients. But the one feared most by physi~ clans because it can lead to death is the ana- phylactic reaction. Bernard B. Levine, M.D., Associate Professor of Medicine, Department of Internal Medicine, New York University Medical Center, points out the clinical and pathologic signs of anaphylaxis and makes recommenda- tion on treatment. (15 minutes). 0106312 ANTIBIOTIC MISADVENTURE: "THE CASE OF OVERKILL," with Harold C. Neu, M.D., Chief of Infectious Diseases, Columbia University College of Physicians and Surgeons, New York City. Test your prescribing ability by following the day~ by-day reports on a 7O.year.old male patient ad. mitted to the hospital with shaking chills, pleuri- tic pain, headache, fever, rapid respirations and pulse. This program is part of the "Drug Spot- light Program" sponsored by the American So- ciety for Clinical Pharmacology and Therapeutics. (8 minutes) (in color) 0118636 ANTIBIOTIC MISADVENTURE: "THE CASE OF SUPERINFECTION, PAR EXCELLENCE," with Harold C. Neu, M.D., Chief of Infectious Dis- eases, Columbia University College of Physicians and Surgeons, New York City. See if you can find all of the prescribing mistakes made in this case, which started as a relatively simple prob~ 1cm-a 71-year-old woman complaining of fa- tigue and nausea, with abdominal mass, elevated body temperature and white count. (This pro. gram was presented as part of the American Society for Clinical Pharmacology and Therapeu. tics' Drug Spotlight Program.) (13 minutes) (In color) 0118737 ANTIMICROBIAL TOXICITIES: FROM OFFICE TO HOSPITAL, with Harold C. Neu, MD, Associate Professor of Medicine and Head, Division of ln~ fectious Diseases, Columbia University College of Physicians and Surgeons, New York City. Help manage a patient with chronic urinary tract in~ fection. As the.case unfolds, you select the most effective drug, manage various unexpected com- plications, and alter or stay with your choice given a variety of clinical situations. (20 minutes) (In color) 0122343 ANTIMICROBIAL TOXICITIES: THE INNOCUOUS SETTING, with Harold C. Neu, M.D., Associate Professor of Medicine and Head, Division of In- fectious Diseases, Columbia University College of Physicians and Surgeons, New York City. Which antibiotics are effective and least toxic for the patient who has staphylococcal cellulitis vaginitis . . - otitis media and externa? To test your skills in prescribing, help manage a patient with these problems. (13 minutes) (in color) 012184-0 BUGS vs. DRUGS: CAN WE COMBAT BACTERIAL RESISTANCE?, with Harold C. Neu, M.D., Asso~ ciate Professor of Medicine and Chief, Division of Infectious Diseases, Columbia University CoI~ lege of Physicians and Surgeons. Dr. Neu em- ploys semi-animated graphic art to answer the title's question with a qualified "Yes." He illus- trates several of the mechanisms by which bac- teria develops resistance and suggests ways In which knowledge of those mechanisms can be used against resistant strains. (15 minutes) (in color) 0215716 98 PAGENO="0453" COMPETITrVE PROBLEMS IN THE DRUG INDUSTRY ~4359 CLINICAL PHARMACOLOGY OF DIURETIC DRUGS, with Albert N. Brest, M.D., Associate Professor of Medicine and Head, Section af Vas- cular Disease and Renology, Hahnemann Medi. cal College and Hospital. (15 mInutes). 0302726 CLINICAL PHARMACY: THE PHYSICIAN'S VIEW. POINT, with Padraig Carney, M.D., Chief of Staff, Memorial Hospital Center of Long Beach, Cali- fornia, and William E. Smith, Jr., Pharm. D., Director, Pharmacy and Central Services, Me- morial Hospital Center of Long Beach, Cali- fornia, Although Clinical Pharmacy has only recently gained wide attention, It has been operating at Long Beach since 1959. Dr. Carney gives a candid evaluation of the Clinical Phar- macist as a member of the patient-care team, against a background of specific demonstra- tions provided by Dr Smith and his staff. (21 mInutes) (In color) 0315672 CONGESTIVE HEART FAILURE: SUCCESSFUL MANAGEMENT, with James E. Doherty, M.D., Professor of Medicine and Pharmacology, Uni- versity of Arkansas College of Medicine, and Di- rector, Division of Cardiology V.A-University Medical Center Hospitals Little Rock. Digitalis, Diet, Diuretics, Rest and Vasodilators. When and how to prescribe most effectively. (12 minutes) (In Color) 0323788 CONTAMINATION OF INTRAVENOUS INFUSIONS, with Richard J. Duma, M.D., Chairman, Division of Infectious Diseases and Immunology, and As- sociate Professor of Medicine, The Medical Col- lege of Virginia, Richmond, and President-Elect of the National Foundation for Infectious piseases. How to recognize and prevent cpntamination of intravenous infusions (A Drug Spotlight Pro- gram, presented in cooperation with the Ameri- can Society for Clinical Pharmacology and Thera- peutics) (17 minuteS) (in color) 0~21781 CORTICOSTEROIDS: Rx FOR THREE CONNECTIVE TISSUE DISEASES, with Richard H, Ferguson, M.D., Associate Professor of Medicine and Head of a Section of Rheumatology, The Mayo Clinic and Mayo Foundatioli, Rochester, Minnesota. Three successful therapeutic plans using corti- costeroidt to control certain problems in tem- poral arteritis, polymyositis, and lupus nephritls are outlined. (This program was presented as part of the American Society for Clinical Phar- macology and Therapeutics' Drug Spotlight Pro- gram.) (20 minutes) (in color) 0321079 THE DIAGNOSIS AND TREATMENT OF DE- PRESSION. These programs were produced with the cooperation of the Council on Sclefltlflc As- sembly of the American Medical Association. MASKED DEPRESSION: THE INTERVIEW AND THE RECOGNITION AND DELINEATION OF DEPRESSION, with Thomas P. Hackett, M.D., Acting Chief, Department of PsychIatry~ Massa- chusetts General Hospital and Associate Pro- fessor of Psychiatry, Harvard Medical School, Boston. A comprehensive look at depression for the non-psychiatrist. Interview techniques are demonstrated and explained for one of the most common, yet hidden, forms this illness can take. (30 mInutes) (In color). 2322759 BIOGENIC AMINE THEORIES OF bEPRESSION, with Ross J. Baldessarini, M.D., Chief, Neuro- pharmacology Laboratory, Massachusetts Gen- eral Hospital, and Associate Professor of Psy- chiatry, Harvard Medical School, Boston. This program concerns management, which may be based on theories of metabolic etiology as well as on traditional psychiatric tenets. Dr. Baldessarini presents the biological theory. (54 minutes) (In color) 0222822 MANAGING THE DEPRESSED PATIENT, with Gerald L Kierman, M.D., Superintendent, Erich Lindemann Mental I-tealth Center, and Profes- sor of Psychiatry, Harvard Medical School, Bos- ton. Dr. Klerman presents the treatment of six common types of depressed patients. (34 minutes) (In color) 1322857 DIGITALIS: FRIEND OR FOE? with Jdmes E. Doherty, M.D., Professor of Medicine and Direc- tor of Cardiology, University of ArkansaS School of Medicine ~nd The Little Rock Veterans Ad- ministration Hospital. Dr. Doherty poi~t~ out the signs and symptoms of digitalis toxidty and provides guidelInes for adjusting dosag~ to pro- vide maximum benefit without adverse reactions. (This program was part of the Drug Spotlight Program of the American Society for Clinical Pharmacology and TherapeutIcs.) (13 mInuteS) (In color) 0420152 DOWN AND OUT IN THE ER Barbiturate over- dose, accidental or intentional, is the number one drug abuse problem presenting i~s Emer- gency Rooms. Dr. George Gay. of the Haight- Ashbury Free Medical Clinic in San I~rancisco and Dr. Eric Comstock, Director of the Institute of Toxicology at Baylor University, join medical student~ Jotir~ Rose of Baylor to demonstrate recommended procedures~for the diagnosis and treatment of a barbiturate overdose crisis. (26 mInutes) (In color). SAMA 1810859 99 PAGENO="0454" 14360 COMPEP~TIVE PROBLEMS IN THE DRUG IN~DUSTR.Y DRUG INTERACTION:"THE CASE OF THE PUSHY ANTIBIOTIC" with Harold C. Neu, M.D., Head of Infectious Diseases, and Associate Professor of Medicjne, Columbia University College of Physi- clans and Surgeons, New York City. When can the right selection of antibiotics be wrong? In four clinical situations, says Dr. Neu In this Drug Spoflight Program," presented in cooper- ation with the American Society for Clinical Pharmacology and Therapeutics. (9 mInutes) (In color) 0419146 DRUG INT~RACT1ONS, with George N. Aagaard, M.D., Professor of Medicine and Head of the Division of Clinical Pharmacology, University of Washington, Seattle, Washington. A leading pharmacologist presents the several interac- tions that can occur and should be anticipated whenever a multiple-drug regimen is altered. Specific and common examples are offered. (17 mInutes) (In color). 0413625 DRUGS vs. BUGS: CHOOSING THE RIGHT AN. TIBIOTIC, with Harold C. Neu, M.D., Associate Professor of Medicine and Chief, Division of In- fectious Diseases, Columbia University College of Physicians & Surgeons, New York. The best way to choose an antibiotic is to match its antibacterial action to the organism's suscepti- bility. Dr. Neu uses lively graphics to demon. strate the metabolic effects of several com- monly used antibiotics, and offers some practi cal advice on choosing the right drug for the bug. (15 minutes) (In color) 0415632 IATROGENIC DRUG PROBLEMS, with Leighton E. Cluff, M.D., Chairman and Professor, Depart- ment of Medicine, University of `Florida College of Medicine, Gainesville. Dr. Cluff presents patient cases'illustratlng com- mon physician errors in drUg administration and shcl~Vs how to avoid them. (14 minUtes) (In color) 0923734 LONG-TERM MANAGEMENT OF S.L.E., wIth Naomi F. Rothfleld, M.D., Professor of Medicine and Chief, Arthritis Division, University of Con- necticut School of Medicine, Farmlngton, Conn. Specific drugs and general life adjustments are important to the treatment course of systemic lupus erythematosus. However, the key to man- aging S.L.E., demonstrated here, is to identify symptoms and signs of impending flare-ups. (17 mInutes) fin color) 1220019 MANAGEMENT OF ACUTE POISONING, with Jay M. Arena, M.D., Director, Poison Control Center of the Duke University Medical Center, Durham, N.C., and former President, American Academy of Pediatrics. Dr. Arena shows how to treat com- mon and uncommon poisoning episodes on an emergency basis. (22 mInutes) (In color) 1317648 MANAGEMENT OF ASPIRIN POISONING, with Jay M. Arena, M.D., Director, Poison Control Center, Duke University Medical Center, Dur- ham, N. C., and former President, American Academy of Pediatrics. Dr. Arena draws on 35 years' experience to give a practical approach to handling the most common cause of poison. ing in children. (13 mInutes) (In color) 1317347 MILD-TO-SEVERE HYPERTENSION: TIPS FOR TREATMENT, with George N. Aagaard, M.D., Pro- fessor of Medicine and Head of the Division of Clinical Pharmacology, University of Washington School of Medicine, Seattle. As part of the na- tional "Drug Spotlight Program", Dr. Aagaard pre. sents a simple approach to treating patients with hypertension. He outlines the basic non- pharmacologic approach, the way in which to use oral diuretics, adrenergic inhibitors and smooth muscle dilators, and his method of handling refractory hypertensiOn. (14 minutes) (In color) 1317749 MOOD.ALTERING DRUGS: STOP, THINK, PRE- SCRIBE, with W. J. Russell Taylor, M.D., Ph.D., Director of Clinical Pharmacology Philadelphia General Hospital, Philadelphia. Anxiety, depres- sion and over a hundred available drugs are the subject of this "Drug Spotlight Program" feature. Two patients who need drug therapy present their complaints, and Dr. Taylor Identifies by brand the drugs he would and would not prescribe. (18 mInutes) (In color) 1318350 "THE NATIONAL ANTIBIOTIC THERAPY TEST." The National Antibiotic Therapy Test consists of a seventy-five minute videotape workshop with th~ objective of self-assessment and learning about the proper use of antibiotics in medical practice. The practlcinç physician is confronted with patient problems requiring aecisions on the use or non-use of antibiotics. NATI' was also designed for a broad range of medical specialties including the family phy- sician, the internist, the pediatrician, the oto- laryngologist, the urologist, the obstetrician! gynecologist, and the general surgeon. The test scores of the participating physician can be com- pared with those of other physicians throughout the country, The test is self-administered, and self-scored. Please call NCME for special price Information which includes scoring folders. (75 minutes) (In color) 2800075 100 PAGENO="0455" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14361 THE NATIONAL ANTIBIOTIC THERAPY TEST: FIRST RESULTS, with Alan L. Goldberg, MD., family physician, Bronx, New York; Harold C. Neu, M.D., Head, Infectious Diseases, Columbia University College of Physicians and Surgeons, New York City; and Edmund D. Pellegrino, M.D., Professor of Medicine and Chancellor for Health Sciences. University of Tennessee. "First Re. suits" on the National Antibiotic Therapy TeSt include 4,513 scores of physicians taking the examination. The national averages and how various specialty groups scored are among the results presented on this program. Five of the questions, the most difficult on the test, are reviewed. (17 minutes) (in color) 1420834 PHARMACOLOGY OF BARBITURATES, with Ga. briel L. Plaa, M.D., Associate Professor, De- partment of Pharmacology, University of Iowa College of Medicine. A discussion of the phar- ~iacoIogic action of barbiturates. (28 minuteS). 1601310 THE PILL AND THE INFORMED PATIENT, with Louis M. Heliman, M.D., Deputy Assistant Secre- tary for Population Affairs, U. S. Department of Health, Education and Welfare, Washington, D. C., Professor and Chairman Emeritus, De- partment of Obstetrics and Gynecology, State University of NeW York Downstate Medical Cen- ter, In New York City. An update on oral contra- ceptives and how to counsel patients for In- formed consent. Dr. Heilman interviews a healthy young patient, beginning contraception, and an older patient with complications related to oral contraceptive drugs. This program is presented as part of the American Society for Clinical Pharmacology and Therapeutics Drug Spotlight Program. (29 minutes) (in color) 1623450 PILLS, PRISONERS AND PROGRESS. In the U-S., much of the controlled study drug research done among "normal" human beings is conducted among prisoner volunteers. Four disparate views of drug research using such human subjects are presented to medical student moderator, John Trowbridge, by: Gilbert McMahon, M.D., head of Therapeutics Section, Department of Medicine, Tulane University Medical School; Mr. WillyI{ol- der, an ex-convict and President of the California Prisoner's Union; Mr. Michael Mills a research associate for the Center for Criminal Justice at the University of Chicago Law School; and Alan Varley, MD., Medical Director of the Upjohn Company. (19 mInutes) (In color) SAMA 2811064 PULMONARY EMBOLISM: A RATIONAL AP- PROACH TO MANAGEMENT, with William Hall, M.D., Director of the Pulmonary Functiort Unit at Strong Memorial Hospital, and Assistafr~t Pro- fessor of Medicine, University of Rochester School of Medicine, Rochester, New York. The mortality rate for untreated pulmonary embolism patients is between 25 and 50 percent. Doctor Hall demonstrates that such gloomy results can be avoided through prompt and effective management, which Includes anticoagulant ther- spy and fhe treatment of hypoxia. (This program is part of the "Drug Spotlight ProgranY' of the American Society for Clinical Pharmacology and Therapeutics.) (17 minutes) (in color) 1619744 1~: L-DOPA, with Melvin D. Yahr, M.D,, Professor of Neurology, Columbia University College of Physicians & Surgeons, Columbia Presbyterian Medical Center, New York City, and Executive Di- rector, Parkinson's Disease Fol4ndation; and `i'letcher MclDowell, MD., Professor of Neurology and Associate Dean, Cornell University Medical College, New York City. For the first time since Parkinson's dise.isc wos described more than 15Oyears ago, a substantial number of Parkinsonism patients can be effec- tively treated by a drug. The drug gives functional improvement and prac- tical relief in a majority of Parkinson cases. L-DOPA is described in terms of its effective- ness, side effects and indicated dosages. ((9 minutes). 1811624 SINGLE PATIENT-ORIENTED NEURO-PSYCHO- PHARMACOLOGY, with Walter Knopp, M.D.; Associate Professor of Psychiatry, Ohio State University College of Medicine. Dr. Knopp presents an objective method of eval- uating the effects of drug therapy in neuropsy- chiatric disease. us minutes). 1~06511 SKIN ERUPTlON5~ DUE TO DRUGS?, with ôavid L. Cram, M.D., Chief of the Deirnatology Clir~ic, Uni- versity of California at San Francisco. Is your pa- tient's skin reaction due to drugs? Is it dangerous enough to warrant removing a i~ecessary unedlca- tion? Which of several drugs is the culpriO (16 minutes) (In color) 1922140 A TALK WITH LINUS PAULING, Ph.D., Director, Linus Pauling Institute of Science and Medicine, Stanford University. Dr. Pauling is interviewed by family practitioner Rafael Sanchez, MD., As- sociate Dean, Louisiana State University School of Medicine, and member of the NCME Medical Advisory Committee. The controversial two-time Nobel laureate responds to some practical ques- tions about his work in the medical uses of ascorbic acId. (14 minutes) (In color) 2021536 101 PAGENO="0456" 14362 COMPETITIVE PROBLEMS IN TITE DRUG INDUSTRY TIME BORROWERS IN SHOCK, with Leon I. Gold- berg, M.D., Ph.D., Professor of Medicine and Pharmacology, and Director of Clinical Pharma- cology, Emory UniversIty School of Medicine In Atlanta, Georgia. When th~ physician needs to "borrow time" while treating the underlying causes of shock, a cautious use of sympathomi- metic amlnes is often a worthwhIle temporary solution. (14 minutes) (in color) 2020737 PHYSIOLOGY CELLULAR DISTURBANCES: A NEW CONCEPT OF OBESITY Some extremely obese patients may be incapa- ble of losing weight and maintaining the loss because they may have acquired an excessive number of fat cells early in life. This is one of the findings of Jules Hirsch, MD., Professor and Senior Physician to The Hospital, Rockefeller University, New York. (59 minutes) 0308704 WHAT ARE WE LEARNING IN SPACE MEDICINE? (HUMAN ADAPTATION TO SPACE), with Charles A. Berry, M.D., Director of Medical Research and Operations, NASA, Houston, Texas. Dr. Berry reveals how he and his team of physicians have answered the question: "What is the worst thing that can happen to the astronauts during a flight?" Such considerations as prophylactic surgery and medication aboard the flight are dIsclosed. (14 minutes) (In color) 2313705 WHAT ARE WE LEARNING IN SPACE MEDICINE? (IN-FLIGHT CONCERNS), with Charles A. Berry, M.D., DirectQr of Medical Research and Opera- tions, NASA, Houston, Texas. Dr. Berry takes us through the countdown of medical activity during a rocket launch. He offers anecdotes, supplemented with official NASA film - such as the implications of losing Alan Shepard, Jr.'s EKG sensor prior to Apollo 14 liftoff. (28 minutes) (in color) 2313704 WHAT ARE WE LEARNING IN SPACE MEDICINE? (THE PHYSIOLOGICAL ENVIRONMENT), with Charles A. Berry, MD., Director of Medical Re- search and Operations, NASA, Houston, Texas. Among the many medical problems Dr. Berry highlights in this telecast are loss of red cell mass on long flights and new monitoring leads for various bodily functions with a suggestion of how they might .be used in conventional" pa. tient practice. (13 mInutes) (in color) 2313703 PRACTICE MANAGEMENT & MEDICAL ECONOMICS BARGAINING FOR POWER: PHYSICANS' UNIONS, with Sanford A. Marcus, M.D., Presi- dent of the Union of American Physicians, San Francisco, California; Stephen Baker, M.D., President of the Committee of Interns and Resi- dents, New York City; Anthony Bottone, M.D., Executive Secretary of the Committee of Interns and Residents; and Murray Gordon, labor rela- tions attorney. Spurred by their own needs and those of their patients, many physicians are or- ganizing unions. Their aims and how they hope to achieve them are the subject of this telecast. (18 minutes) (in color) 0216817 CLINICAL LABORATORIES: PHYSICIAN EVALU- ATION AND UTILIZATON, with Randolph M. Chase, Jr., M.D., Director, Microbiology Depart- ment, New York University Hospital; Joseph H. Boutwell, M.D., Chief of ~Licensure and Develop- ment Branch, Laboratory Diyision of the National Corrimunicable Disease Center in Atlanta, Geor- gia; and Edward Cavanaugh, M.D., Chief of Labo- ratoly Training Section of the NCDC. An over- view of clinical laboratories in the U.S. today, including costs, range of tests, quality of work and selecting a lab, is presented in this program produced at the National Communicable Dis~ ease Center. (17 mInutes) (in color) 0310317 THE HEALTH CARE TEAM. The team approach to primary health care is a multi-disciplinary ap- proach to the treatment of the whole patient and his environment. George Blatti, fourth year student at the University of Minnesota an4 past President of SAMA, discusses the advantages of this approach to health care delivery with three members of a health care team from the Martin LUther King Medical Center, Bronx, New York, Applications of the team concept in rural set- tings and opportunities for health care students to participate in health teams are also presented. (17 minu(es) (in color) SAMA 2811373 MANAGING YOUR PRACTICE: BILLING AND COLLECTION Gene BalIiett, President of Medical Practice Management Consultants and an Editorial Con. sultant to Medical Economics~ describes tech- niques and procedures to use in billing patients regardless of the type of practice. (17 minUtes). 1309309 102 PAGENO="0457" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14363 MANAGING YOUR PRACTICE: IS INCORPORATION FOR YOU? A decision by the US. Internal Revenue Service, `along with state legislation, enables individuals and groups to form professional corporations for tax purposes and other benefits. Discussing these benefits with two physicians is Gene Bal- liett, President of Medical Practice Management Consultants in Teaneck, N.J. (17 minutes). 1310010 MANAGING YOUR PRACTICE: SPACE, EQUIPMENT, PERSONNEL The money a physician Invests in his practice may provide him with the best return of invest' ment he will ever make. This is demonstrated by Gene Balliett, President ŕf Medical Practice Man- agement Consultants and EditOrial Consultant to Medical Economics. (19 minutes). 1309111 MEDICAL ADVANCES INSTITUTE: AN NOliIE RE- PORT. MAI, an organization of physicians in Ohio advocating a system of health care `review, is providing guidance to physicians in that state who are attempting to establish Professional Standards Review Organizations. Neither the MAI system nor any other has yet been totally accepted by HEW as a model system for PSRO. (17 minutes) (in color) 1321454 THE PEDIATRIC NURSE PRACTITIONER: AN EVOLVING ROLE IN PATIENT CARE, with Henry K. Silver, M.D., Professor of Pediatrics, University of Colorado Medical Center, Denver; and Loretta C. Ford, R~N., Ed.D., Professor and Chairman of Community Health Nursing, University of Colo- rado School of Nursing, Denver, If your pediatric practice is about one-half well-child supervision and one-fifth minor respiratory infections man- agement, then your office could be a candidate for a pediatric nurse practitioner (PNP). A group with six years' experience in the PNP program helps you understand this new role and the PNP-doctor relationship with vignettes of a PNP on.the-job. Although this telecast concerns pedi- atric practice, other physicians, too, can benefit from this look at the PNP experience. (20 minutes) (in color) 1614535 THE PEDIATRIC NURSE `PRACTITIONER IN YOUR OFFICE, with Henry K. Silver, M:D,, Uni- versity of Colorado Medical Center, Denver; Don- ald Cook, M.D., Lewis R. Day, M.D., and Robert Schiff, M.D., all pediatricians practicing with PNP's;' and Loretta C. Ford, R.N., EdD., Profes- sor and Chairman of Community Health Nursing, University of Colorado School ofNursing, Denver. In six years of experience with over 80 PNP's, there have been no legal problems. Three physi- cians and their PNP associates describe their own enthusiastic reactions and those of their col- leagues to this innovative, patient-accepted pro- gram that provides security and a lighter work load for physicians as well as professional grati- fication for PNP's. (18 minutes) (in color) 1614636 PsRO: THE ISSUE OF 1974, with Senator Wal- lace F. Bennett (R-Utah); James L Henry M.Ř., President Ohio State Medical Association; Robert B. Hunter, M.D., member, AMA Board of Trustees; and 3. Lewis Schl-icker,' Jr., `M.D., Pres- ident, Utah State Medical AssOciation. Edmund 0. Pellegrino, M.D~, Chancellor for ` Health Sciences, University of Tennessee, is moderator. Senator Bennett's controversial PSRO amend- ment to Public Law 92.603, the Social Security Act, is outlined and examined. Dr. Pellegrino challenges panelists with major questions sur- rounding the legislation. Topics include PSROs cost, effect on malpractice liability, and possible interference in the practice of medlcine.~ (22 minutes) (in color) 1620947 SIMPLIFYING THE MEbICOLEGAL REPORT, with Robert M, Fox, an attorney ahd authdr Of the book, The Medicolegal Report: Theory and Prac- tice. This telecast will be helpful to physicians who have problems composing a medical-legal report for attorneys or insurance carriers - particu- larly when injuries are Involved. (17 minutes) (in color) 1912010 THE DOCTOR AND HIS TAXES, with Ernest R. Field, C.P.A., and tax attorney, The professional corporation, trusts, estate plan- ning, an ij,vestment program, deductions and the ,business of record keeping are subject~ covered In this telecast. (18 mInutes) (in color) 0412220 THE DOCtOR AS INVESTOR, with Gene BaIIiett, Medical Management Consultant. Some of the basics of investment are explored from the physician's point of view by Mr. Bal- liett, two physicians and their wives. The tele- cast addresses itself particularly to the investment situation as it exists. (16 minutes) (in color) 0412521 THE PROBLEM-ORIENTED MEDICAL RECORD, with Paul Y. Ertel, M.D., Associate Protessor of Pediatrics, Ohio ,State University College of Medicine, Columbus,. Ohio. This Special Work- shop offers a comprehensive picture of what, physicians and other health professionals need to know to initiate and maintain Problem- Oriented Medical Records. This unique inter- active Workshop~ combines television instruc- tion and workbooks, which include' POMR forms for the `participants to use as they work along with the videotape. Please inquire for special rental information. (50 mInutes) (In color) 2800048 103 PAGENO="0458" 14364 co~i~rrivi~ PROBII13~MS IN TE~ DRUG I~(DtJSTRY PSYCHIATRY AFTER THE SPONTANEOUS ABORTION: COUN SELING BY THE FAMILY PHYSICIAN, with Wil- tam C. Rigsy, M.D., Assistant Professor, De- partment of Obstetrics and Gynecology and Adolph Hass, M.D., Clinical Associate Professor, Department of Psychiatry, Ohio State University School of Medicine. Using an actual case of spontaneous abortion in a much wanted preg- nancy, Drs. Rigsby and Hess - and the patient in question - delineate areas in which the physi. cian can support and reassure his patient in the time of crisis. (19 minutes) (in color) 0116129 BABY . . . ARE YOU MINE? ARE YOU REALLY ALIVE? Medical treatment was successful, but the mother couldn't care for her premature baby. Why? Did hospital care interfere with the mother's attachment to her baby? Marshall H. Klaus, M.D., Professor of Pediatrics and Director of the Neonatal Nurseries at Case Western Reserve University of Medicine in Cleve- land, Ohio, presents the highlights of studies on maternal attachment. In addition, there are poe. itive clinical hints on how to strengthen and support parental attachment. (26 minutes) (in color) SAMA 2811774 BODY LANGUAGE IN DIAGNOSIS, with Gordon H. Deckert, M.D., Professor and Chairman, De- partment of Psychiatry and Behavioral Sciences, University of Oklahoma Health Sciences Center, Oklahoma City. A psychiatrist shows how to ob- tain a wealth of information during the first five minutes of an office visit by observing how a patient walks, talks, and acts. (17 minutes) (in color) 0220919 CAN YOU TREAT OBESITY IN CHILDREN? with Platon J. Coiiipp, M.D., Chief Pediatrician, Nas. sau County Medical Center, and Professor of Pediatrics, State University of New York, Stony Brook, Long lsiand, N. V. Long-standing obesity, a health hazard in iater life, can be stemmed in thildhodd and adolescence. Dr. Coliipp shows how diet, group treatment, challenge and support have successfully removed "SO tons of Long island baby fat." (18 minutes) (in color) 0318076 CLARIFYING ENQOUNTER THERAPY, with F. Theodore Reid, MD., Associate Professor, De- partment of Neuroiogy and Psychiatry, Michael Reese Hospital, Chicago, Illinois. The non-psychiatric physician will learn about the dynamics of an encounter group by viewing an actual session in progress. Dr. Reid explains characteristics of the session as they develop. The purpose is to offer the general physician enough information to respond to patients who ask questions about encounter therapy. (19 mInutes) (In color) 0312112 CLARIFYING GROUP THERAPY, with F. Theodore Reid, M.D., Associate Professor, Department of Neurology and Psychiatry, Michael Reese Hos- pital, Chicago, lii. Dr. Reid expiains the dynamics of group therapy ir~ comments running between the videotaping of an actual session in progress. This program aids the non-psychiatric physician in answering his patient's questions about a currently popular subject. (16 minutes) (in color) 0312213 COMPUTER TECHNIQUES AS AN ADJUNt~T TO CLINICAL IMPRESSIONS IN THE EVALUATION OF DRUG RESPONSE - PART I - "The First Five Weeks." Burton J, Goldstein, M.D., Chief, Division of Research, Department of Psychiatry, University of Miami School of Medicine, Presents the design of a research project and a demon- stration of computerized patient tests. (14 minutes). 0302136 COMPUTER TECI4NIQUES AS AN ADJUNCT TO CLINICAL IMPRESSIONS IN THE EVALUATION OF DRUG RESPONSE - PART II- "Clinical Evolu- tion." John Caldwell, MD., Professor of Psy- chiatry and Head, Department of Psychiatry, Burton J. Goldstein, MD., Chief, Division of Re- search, Department of Psychiatry, and the Psy- chiatric staff, University of Miami School of Medicine, evaluate a patient's progress under specific drug therapy. (26 minutes). 0302237 COMPUTER TECHNIQUES AS AN ADJUNCT TO CLINICAL IMPRESSIONS IN THE EVALUATION OF DRUG RESPONSE - PART Ill - "Conclusions," Burton J, Goldstein, M.D., Chief, Division of Research, Department of Psychiatry, University of Miami School of Meditine, and Dean J. Clyde, Ph.D,, Director, Computer Center, University of Miami, demonstrate the usefulness of a computer in evaluating patient data. (15 minutes). 0302338 COUNSELING THE POST-ABORTION PATIENT, with Ronald J, PiQn, M.D., Associate Professor, Department of Obstetrics and Gynecology, and Director of the Division of Family Planning; and Nathaniel N, Wagner, Ph.D., Associate Professor of Psychiatry and Obstetrics and Gynecology, both from the University of Washington School of Medicine, Seattle, Post-abortion patients are interviewed in an at- tempt to show physicians the opportunities that exist for helping patients beyond a period of crisis. its minStes) (in color) 0312555 104 PAGENO="0459" COMPETIPXVE PROBLEMS IN PIlE DRUG INDUSTRY i4~65 COUNSELING THE VD PATIENT. The sexual overtones of venereal disease expose VD pa- tients to a special complication . . . a value judgment of their behavior. Such judgment, how- ever unintentional, can detract from the treat- ment of the disease. Dr. Mary Howell of the Somerville Women's Health Project in Somer- ville, Massachusetts, Rev. Thomas Mauer of the University of Minnesota Human Sexuality Program, and three medical students use role playing to illustrate these difficulties and dis- cuss their solution. (20 minutes) (In color) SAMA 2810860 DEALING WITH THE TERMINALLY ILL PATIENT Elizabeth Kubler-Ross, M.D., Assistant Professor of Psychiatry, University of Chicago, demon- strates the stages a patient goes through once he becomes aware he is dying. Dr. Ross also dis- cusses the reaction of people around the patient. (16 minutes) 0409401 DEATH OF A SIBLING, with Thomas S. Morse, M.D., Associate Professor, Surgery, Ohio State University College of Medicine, and Thomas E. Schaffer, M.D., Professor of Pediatrics, Ohio State University College of Medicine. In a time of crisis for parents and surviving children, the family physician can assume an essential role in sup- port of both. Drs. Morse and Schaffer focus on specific problems that result from the death of a sibling: questions to expect, points to em- phasize; emotions to look for; how to use your medical authority to smooth the way. (19 minutes) (is color) 0416035 DIAGNOSING THE MALTREATMENT SYNDROME IN CHILDREN, with Vincent J. Fontana, M.D., Di- rector of the Department of Pediatrics, St. Vin. cent's Hospital; and Medical Director, New York Foundling Hospital, both in New York City. In full agreement with a JAMA editorial stating that the "maltreated or battered child could be the leading cause of death in infants and children," Dr. Fon- tana describes the presentIng signs that should make any physician suspect battered child or maltreated syndrome - a diagnosis that may prevent future trauma to the child and may even save its life. (14 minutes) (in color) 0414329 DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS OF MIGRAINE AND MUSCLE CONTRACTON HEAD- ACHES - PART I - "The Migraine Headache" -with Arnold P. Friedman, M.D. Associate Clin ical Professor of Neurology and Director, Head- ache Unit, Montefiore Hospital. (11 minutes) 0402706 DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS OF MIGRAINE AND MUSCLE CONTRACTION HEAD- ACHES - PART II - "Muscle Contraction ahd Other Headaches that Mimic Migraine" - with Arnold P. Friedman, M.D., Associate Clinical Professor of Neurology and Director, Headache Unit, Montefiore Hospital. (14 mInutes). 04029Q7 THE DIAGNOSIS AND TREATMENT OF tIE- PRESSION. These programs were produced with the cooperation of the Council on ScientIfic As- sembly of the American Medical Association. MASKED DEPRESSION: THE INTERVIEW AND THE RECOGNITION AND DELINEATION OF DEPRESSION, with Thomas P. Hackett, M.D., Acting Chief, Department of Psychiatry, Massa- chusetts General Hospital and Associate ProS fessor of Psychiatry, Harvard Medical School, Boston. A comprehensive look at depression for the non-psychiatrist. Interview techniques are demonstrated and explained for one of the most common, yet hidden, forms this illness can take. (30 minutes) (in color). 1322759 BIOGENIC AMINE TF+EORIES OF DEPRESSIOr~I, with Ross J. Baldessarini, M.D Chief, Neuro~ pharmacology Laboratory, Massachusetts Gen- eral Hospital, and Associate Professor of Psy- chiatry, Harvard Medical School, Boston. This program concerns management, which may be based on theories of metabolic etiolggy~ a~ well as on traditional psychiatric tenets. Dr. Baldessarini presents the biological theory. (14 minutes) (in color) 0222822 MANAGING THE DEPRESSED PATIENT, with Gerald L. Klerman, M.D., Superintendent. Erich Lindemann Mental Health Center, and Profes- sor of Psychiatry, Harvard Medical School, Bos- ton. Dr. Klerman presents the treatment of six common types of depressed patients. (34 mInutes) (in color) -- 1322857 DIFFERENTIAL DIAGNOSIS OF DEPRESSION. with F. Theodore Reid, M.D., Associate Professor, Department of Neurology and Psychiatry, Michael Reese Hospital, Chicago, Illinois. Dr. Reid will use three patients in this telecast to classify three types of depression. Two of the three types, according to Dr. Reid, can be managed in the physician's office - providing the correct diag- nosis is made. (23 minutes) (In color) 0414127 105 PAGENO="0460" 14366 COMPETITIVE PROBLEMS IN THE DRUG IN~DUSTRY TYPE A PERSONALITY AFFECT YOUR HEART? with Ray H. Rosenman, M.D., Associate Director of the Harold Brtinn Institute and Asso- ciate Chief of the Department of Medicine, Mpunt Zion Hospital and Medical Center, San Francisco; William B. Kanriel, M.D., Medical Director of the Framingham Heart Study in Massachusetts; and Campbell Moses, M.D., Vice-President of Medicus Communications in New York City. Is stressful behavior a coronary risk factor? ~octor Moses moderates a lively discussion. (18 minutes) (in color) 0421858 "DOCTOR, I CAN'T SLEEP NIGHTS," with Julius Segal, Ph.D., of the National Institute for Men- tal Health, and Professor of Psychology, George Washington University Washington, 0. C. A cleat look at the many facets of insomnia through graphic representations of the com- ponents of sleep, based on findings at the na tion's sleep research centers. (15 mInutes) (In color) 0417439 DRINKERS IN CRISIS, with Henry D. Abraham, M.D., Harvard Medical School, and Chief, Marl- borough-Westborough Unit, Westborough State Hospital, Westborough, Massachusetts; and John A. Renner, M.D., Director of the Alcoholism Clinic, Massachusetts General Hospital, Boston. The Scene: The psychiatric emergency depart- ment at Mass. General. The Players: Walk-in alcoholics seeking help. The Plot: How to use an alcoholic's time of crisis to set the stage for short-and long-terni care. (16 minutes) (in color) 0421255 EARLY DIAGNOSIS OF ALCOHOLISM, with Mar' yin A. Block, M.D., Vice President of the AMA Society on Alcoholism, and Associate Professor, State University of New York at Buffalo. "There are all kinds of alcoholisms and all kinds of alcoholics." Dr. Block provides specific criteria by which you may judge the kind of alcoholism and the stage of the disease. (24 minutes) (in color) 0516820 FEMALE HOMOSEXUALITY - PART I - PER- SONAL ASPECTS. John F. Oliven, M.D., Associate Attending Psychiatrist, College of Physicians and Surgeons, Columbia University, analyzes the psy- chological problems of Lesbianism through his commentary on an interview between a Lesbian- transvestite and John W, Huffman, M.D., Profes- sŕr of Obstetrics and Gynecology, Northwestern University Medical School. (15 minutes). 0605702 FEMALE HOMOSEXUALITY - PART II - INTER- PERSONAL ASPECTS. An interview between a Lesbian-transvestite and John W. Huffman, M.D., Professor of Obstetrics and Gynecology, North- western University Medical School, is inter- spersed with commentary by John F. Oliven, M.D., Associate Attending Psychiatrist, College of Physicians and Surgeons, Columbia University. (21 mioutes). 0605803 HEADACHE: MIGRAINE AND HISTAMINIC CE- PHALGIA, with William G. Speed, Ill, M.D., De- partment of Medicine; and L.eonardJ. Gallant, M.~,, Department of Psychiatry; both. of the Johns Hopkins University School of Medicine, This program deals predominantly With the management of the more c;hronic forms of migraine, emphasizing pharmacotherapeutic techniques and touching on those aspects of psychotherapy that might be useful to in ternists, Histaminic Cephalgia (also known as variant) and methods of managing it are dis- cluster headache, cycle headache, or migraine cussed. Adapted from a Television Hospital Clinic of the American College of Physicians, 1972. Please inquire for special rental infor- mation. (60 mInutes) (in color) ACP 286724-4 HYPNOTIC DREAMING: SOME PHYSIOLOGICAl.. CORRELATES AND PSYCHOLOGICAL MECHA- NISMS: PART I - With Milton V. Kline, Ed.D., President, The institute for Research n Hypno- sis, and Executive Director of the Morton Prince Clinic for Hypnotherapy. The induction of hyp- notic dreams and evaluation of the subjects' responses to the dream process and dream content. (26 minutes). 0802612 HYPNOTIC. DREAMING: SOME PHYSIOLOGICAL CORRELATES AND PSYCHOLOGICAL MECHA- NISMS: PART II The induction of hypnotic dreams and an evalu- ation of the subject's responses to the dream process and dream content are presented by Mil- ton V. Kline, Ed.D., President, The Institute for Research in Hypnosis and Executive Director, the Morton Prince Clinic for Hypnotherapy. (22 minutes). 0804313 HYPNOTIC INDUCTION TECHNIQUES-PART I. Milton Jabush, M.D., Director of Research, The Institute for Research in Hypnosis, demon- strates an induction method utilized with the fearful patient. (13 mInutes). 0802914 HYPNOTIC INDUCTION TECHNIQUES-PART II "Positive Hallucinations" - with Milton Jabush, M.D., Director of Research, The Institute for Re- search in Hypnosis. (21 mInutes). 0803015 HYPNOTIC INDUCTION TECHNIQUES: PART Ill An experiment in age regression, demonstrating the subject's handwriting, drawing, and per- sonality changes underhypnosis - with Milton Jabush, M.D., Director of Research, The Institute for Research in Hypnosis. (16 minutes). 0803216 106 PAGENO="0461" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14367 WANT TO DIE, with Henry D. Abraham, M.D., of Harvard Medical School, and Chief, Marl- borough-Westborough Unit, Westborough State Hospital, Westborough, Massachusetts; and Ger- ald L. Kierman, M.D., Superintendent, Erich Lindemann Mental Health Center, Department of Mental Health, Commonwealth of Massachu- setts. Physicians at a psychiatric clinic provide practical guidelines for evaluating and managing depressed and suicidal patients in your office. Diagnostic signs and symptoms to look for are highlighted. (19 minutes) (in color) 0921129 IMPOTENCE, with Philip A. Sarrel, MO., Asso- ciate Professor of Obstetrics and Gynecology at Yale University Medical School; and Lorna Sarrel, Co-Director of the Human Sexuality Program at the Yale University Student Mental Hygiene De- partment in New Haven, Connecticut. Secondary - impotence-one of the most common sexual complaints-will usually yield to deft detective work and counselling. This program illustrates how two leading sex therapists approach the problem. (18 minutes) (in color) 0921330 INFLUENCE OF THE EMOTIONS ON THE OUT- COME OF CARDIAC SURGERY: DIAGNOSIS AND DECISION, with Janet A. Kennedy, M.D., Assist- ant Professor of Psychiatry; and Hyman Bakst, M.D., Assistant Clinical Professor of Medicine; both of the Albert Einstein College of Medicine In New York City. Eight distinct emotional stages have been observed in 148 cardiac surgery pa- tients in a nine-year study. The anxieties and reactions of patients are shown for each of these stages. (20 mInutes), 0910506 INFLUENCE OF THE EMOTIONS ON THE OUT- COME OF CARDIAC SURGERY: PSYCHOLOGICAL CATEGORIES, with Dr. Kennedy and Dr. Bakst in a separate program. They classify cardiac sur gery patients into six groups with their distin- guishing defense characteristics. Understanding these groupings during a~ interview with a patient can aid in predicting how the patient will be affected by surgery, whether he will ac- cept surgery, survive it, and avail himself of the benefits of restored cardiac function. (24 minuteo). 0910507 LEARNING TO LIVE WITH DYING. Dying is per- haps the most difficult and least understood phase of life. Terminally ill patients and their families turn to their physician for support and guldante that goes beyond clinical care. Medical students Sam Cullison and Mike O'Neil join the Reverend Barry Wood, M.D., and William Fischer, M.D., both of Roosevelt Hospital, New York City, and Robert Neale, Th.D., of Union Theological Seminary, New York City, to discuss the management of terminally ill patients and their families. (39 minutes) (In color) SAMA 2800056 MANAGEMENT OF THE BATTERED CHILD S'~N- DROME, with C. Henry Kempe, M.D., Professor and Chairman of Pediatrics; Brandt F. Steele, M.D., Professor of Psychiatry; and Helen Alex- ander, Medical Social Worker, Supervisor of Lay Therapists, Battered Child Program. All three are with the University of Colorado Medical Center. The reasons for abuse become apparent in an unrehearsed conversation with the mother of a patient. Three'experts offer some practical advice on coping with parents once child abuse has been diagnosed and the underlying problems identifie~l, (18 minutes) (in color) 1314441 MANAGEMENT OF THE TERMINALLY ILL: THE FAMILY Elizabeth Kubler-Ross, M.D., Assistant Professor of Psychiatry at the University of Chicago, offert practical help to physicians in dealing with the dying patient and his family. (16 minutes). 130970~ MANAGING THE HYPERACTIVE CHILD, with Gerald Erenberg, M.D., Pediatric Neurologist, Montefiore Medical Center and Morrisania Hos- pital, Bronx, N. Y. Amphetamines are no pana cea, nor peed they be your first plan of attack A structured approach to treatment is outlined and illustrated. (12 minutes) (in color) 1318651 MECHANISM OF MIGRAINE AND MUSCLE CON' TRACTION HEADACHES: PART I "The Migraine Headache." While its underlying causes are unkliown, the mechanism of migr4ine attack is better understood - and it can be di- vided into different stages on the basis of the pathophysiologic features. With Arnold P. Fried- man, M.D., Associate Clinical Professor of Neu- rology, College of I°hysicians and Surgeons, Co- lumbia University and Dire~tor, Headache Unit, Montefiore Hospital. (14 mInutes). 1303517 MECHP~NISM OF MIGRAINE ANDMUSCLE CON- TRACTION HEADACHES: PART II "The Muscle Contractign Headache," Probably the most common type of chronic headache, the muscle cOntraction headache can be precipitated by a number of diseases or disturbances, bi~t most dften it is In response to~ten~ion and stress. With Arnold P. Friedman, M.D., Associate Clinical Professor of Neurology, College of ~hysicians and Surgeons, Columbia University and ~irector, Headache Unit, Monfefiore Hospital. (11 minutes). 1303618 MECHANISMS OF DEFENSE, with L. C. Hanes, M.D,, Associate Professor of Psychiatry, Univer- tity of Mississippi School of Medicine. (17 minutes). 1302719 107 PAGENO="0462" 14368 COMPETITIVE PROBLEMS IN THE DRUG I~ThUSTRY MOOD-ALTERING DRUGS: STOP, THINK, PRE- SCRIBE, with W. J. Russell Taylor, MD., Ph.D., Director of Clinical Pharmacology, Philadelphia General Hospital, Philadelphia. Anxiety, depres- sion and over a hundred available drugs are the subject of this "Drug Spotlight Program" feature. Two patients who need drug therapy present their complaints, and Dr. Taylor identifies by brand the drugs hewould and would not prescribe. (18 mInutes) (in color) 1318350 MULTIPLE TICS. Presentation of three patients and discussion of multiple tics (Tourette's Dis- ease) in childhood, with Richard Finn, M.D., As- sociate in the Department of Psychiatry and George Challas, William Bell and James Chapel, MD's, from the College of Medicine, UnIver- sity of Iowa. (14 minutes). 1300336 OBESITY - THE DIFFICULT PATIENT. A tolerant attitude towards levels of expectation of weIght loss can increase the effectiveness of the practic- ing physician in dealing with the obese patient, This is the opinion of Albert J, Stunkard, M.D., Professor and Chairman, Department of Psy- chiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. The use of drugs and effectiveness of lay groups are also discussed by Dr. ~tunkard. (20 minuteS). 1507401 PROBLEMS AND PITFALLS IN PSYCHOSOMATIC MEDICINE: HYPERTENSION, with Roy R. Grinker, M.D., Associate Professor of Psychiatry and Neu- rology, and F. Theodore Reid, M.D., Associate Professor of Psychiatry and Neurology, both from the Michael Reese Hospital in Chicago, Illinois. Doctors Grinker and Reid take up the problem of a young woman suffering from hypertension. Dr. Grinker analyzes the cause of the hyperten- sioh In a series of televised interviews with the woman. (15 mInutes) (In coIOl3 ,, 1612621 PROBLEMS AND PITrALLS IN PSYCHOSOMATiC MEbICINE: PEPTIC ULCER, i~iJth Roy R. Grinker, M.D., Associate Professor of Psychiatry and Neu- rology; and F. Theodore Reid, M.D.,'As~ociate Professor of Psychi~try and Neurology; both from the Michael Reese Hospital in Chicago, Illinois. Most physicians are confronted with patients suffering from psychosomatic illnesses. Many of these patients are treated as "second class citi- zens," largely becaUse of the frustrations in treat- ing them. This program will show the non.psychi- atric physician the way to handle psychosomatic conditions by citing a peptic uiŕer patIent as an example. (16 mInutes) (in colOr) 1612522 PSYCHIATRIC ILLNESS ON SKID ROW: PART I First results of the psychiatric testing of resI- dents of skid row hotels - presented by Robert G. Priest, M.D., Professor of Psychiatry, Univer. sity of Edinburgh, and Visiting Professor, Univer- versity of Chicago, Department of Psychiatry. (14 minutes). 1604129 PSYCHIATRIC ILLNESS ON SKID ROW: PART II `The Disease." The incidence of schizophfenia, alcoholism, and other psychiatric disabilities among inhabitants of sitid 1-ow hotels. With Rob- ert G. Priest, M.D., Professor of Psychiatry, Uni. versity of Edinburgh, and Visiting Professor, Uni- versity of Chicago, Department of Psychiatry. (16 minutes). 1604230 PSYCHODRAMA - THE PROLOGUE - PART I. This workshop in psychodrama, with patients and staff oi the Hennepin County General Hos. pital, Minneapolis, demonstrates the methods used to initiate and stage psychodrama. Pre- sented by James Enneis, Director of Psycho. drama, St. Elizabeth's Hospital. and U.S. Depart- ment of Health, Education and Welfare. (26 minutes) 2700829 PSYCHODRAMA - THE PLAY - PART II. In this section of a special three-part series, psy~ chiatric patients at Hennepin County General Hospital participate in an actual psychodrama, conducted by James Enneis, Psychodramatist from St. Elizabeth's Hospital, Washington, D.C. The. patients act out inner conflicts, impossible to express in their daily lives, and the reactions of the other patients in the audience are shown. (29 minutes). 2701130 PSYCHODRAMA - THE CRITIQUE - PART Ill. Members of the medical and nursing staffs dis- cuss their impressions after having observed. and participated In a psychOdrama. CondUctin~ the critique is James Erinela, SupervIsory ~Sy~ chodramatlst, St. Elizabeth'~ Hospital, Wash- ingtovi, D.C. (14 minutes). 2701231 SELYE ON STRESS, with Hans Selye, M.D., Ph.D.; D.Sc., Director of the Institute of Experi- mental Medicine and Surgery, University of Montreal, Montreal, Canada. The originator of the General Adaptation Syndrome updates his life work, emphasizing the clinical application of treatment based on this biological phenomenon (17 minutes) (In color) 1920333 108 PAGENO="0463" COMPETIPrVE PROBLEMS IN PIPE DRUG INDUSTRY 148~9 SEX iN AGING AND DISEASE, with Philip A. Sarrel, M.D., Associate Professor of Obstetrics and Gynecology at Yale University Medical School; and Lorna Sarrel, Co-Director of the Human Sexuality Program at the Yale University Student Mental Hygiene Department in New Haven, Connecticut. Sexual development of healthy aging persons, as well as patients With the more common geriatric disorders, is dis- cussed. (19 minutes) (in color) 1921438 SEXUALITY: GETTING IT TOGETHER. How can you successfully treat your patient's sexual problems without a full understanding of your own? Dr. Harold Lear of the Department of Community Medicine at Mount Sinai School of Medicine and Dr. Helen Kaplan of the Depart ment of Psychiatry at Cornell University Medi- cal College demonstrate, with a number of med) ical students, techniques that they or you might use to expand personal sexual awareness. (20 mInutes) (in color) SAMA 2810150 SINGLE PATIENT-ORIENTED NEURO.PSYCHO PHARMACOLOGY, with Walter Knopp, M.D., Associate Professor of Psychiatry, Ohio State University College of Medicine. Dr. Knopp presents an objective method of eval uating the effects of drug therapy in neuropsy- chiatric disease. (15 minutes). 1906511 SOME PATHOLOGIES OF SLEEP, with Julius Se gal, Ph.D., of the National Institute for Mental Health, and Professor of Psychology, George Washington University, Washington, D.C. Dr. Se. gal describes the various stages of normal sleep and then relates disorders in REM and deep sleep to enuresis, somnambulism, night terrors and other patient problems. Special emphasis Is given to the diagnosis and treatment of narcolep- sy, which affects half a million people In the U.S. (19 minutes) (In color) 1917729 SUICIDE PREVENTION: THE PHYSICIAN'S ROLE. In tive authentic case histories-including that of a practicing physician-this film demon- strates ways in which the physician can recog- nize suicidal tendencies in the patient, The film begins with a woman's suicidal death, and asks, "Was there anything the physician might have done to avert this tragedy?" A summary of the growing problem of suicide, as it relates to the practicing physician, is made by Dr. Karl Men- singer. (20 minsles) 2800041 THE HYPERACTIVE CHILD: FINDING THE CAUSE, with Gerald Erenberg, MD., Pediatric Neurologist, MontefiorS and Morrisania Hos- pitals, Bronx, N. Y. The child is out of control at school or at home. You are asked to diag- nose or rule out minimal brain damage. This program shows you how - simply and quickly. (18 mInutes) (In color) 0818532 THE MULTIPHASIC TREATMENT OF ALCOHOL- ISM, with Albert N. Brown.Mayers, M.D., Direc- tor of the Alcoholic Service; Edward E. Seelye, M.D.; Unit Administrator of the Alcoholic Service; and Leonard R, Siliman, M.D., Attending Psy- chiatrist; all of the Westchester Division of the New York Hospital.Corneil Medical Center, White Plains, N.Y. A new, formalized approach to the treatment of al~ohoiism is suggested. Presenters show how residential alcoholic treatment works and outline a coOWlete program, many elementh of which you'll find practical and effective in your own practice. 129 mInutes) (In color) 131694~ THE THREAT OF SUICIDE. Those who commit suicide frequently attempt to communicate their desperation to their physicians. How can we be sensitive to these warnings, either open or covert, and how can we help a patient once his suicidal intentions are known? Two medical students discuss this issue with Harvey Resnik, M.D., Chief of the Mental Health Emergencies Section, National Institute of Mental Health, and Clinical Professřr of Psydhiatry, George Wash. ington University School of Medicine. (27 minutes) (in colol) SAMA 2810757 Rental and purchase prices cover the actual hosts of duplication; therefore, no provision is made for the previewing of catalog programs. If, in the opinion of the person for whom it was ordered, a pro- gram contains any significant flaw or in- adequacy, no charge will be made. The reviewer is, however, requested to state the reason on the program review card that accompanies each Master Library videocassette. 109 PAGENO="0464" 14870 COMPETITIVE PROBLEMS IN THE DRTJG IN~DTJSPRY THERMAL INJURIES: MEDICAL, SURGICAL, AND PSYCHIATRIC CARE, with an introduction by T. 0. Blocker, Jr., MD., Professor of Surgery and Pres- ident Emeritus, The University of Texas Medical Branch at Galveston. The following three programs were produced under the supervision of Stephen A. Lewis, M.D., Chief of Plastic Surgery and Di- rector of Continuing Education, UTMB-Gaiveston. KEEPING THE BURN PATIENT ALIVE, with Duane L. Larson, M.D., Professor of Plastic Sur- gery, UTMB-Galveston, and Director, Shriners Burns Institute, Galveston. A 1-2-3 approach to emergency care for critically-burned patients plus the steps to take in assuring the patient's survival during transportation to a hospital. (16 minutes) (in color) .1122205 HOSPITAL, BURN CARE: MINIMIZING DE- FORMITIES AND OTHER COMPLICATIONS, with Hugo Carv~jal, M.D., Pediatric Nephrol- ogist, Shriners Burns InstItute, and Assistant Professor of Pediatrics, UTMB-Galveston; and Duane L. Larson, M.D., Director, Stiriners Burns Institute, and Professor of Plastic Surgery, UTMB-Gplveston. The definitive care of burn patients. Emphasis is placed on daily wound care, fluid replacement and nutrition, and pro- cedures to minimize contracture and hyper- trophic scarring before and after grafting. (22 minutes) (In color) 0822239 THERMAL INJURY: EMOTIONAL AND PHYSI- CAL STRESS, with Mary S. Knudson, Ph.D., Chief, Division of-Behavioral Sciences, Shriners Burns Institute; Duane L. Larson, M.D., Pro- fessor of Plastic Surgery, UTMB-Galveston, and Director, `Shrinert Burns Institute; and Robert B. White, M.D., Professor of Psychiatry, UTMB-Galveston. Practical methods to combat the physical pain, toxic delirium, helplessness, and regression seen in patients with major burns. (12 mInutes) (in color) 2022240 TRANSACTIONAL ANALYSIS: A CLUE TO WHAT'S HAPPENING. Transactional Analysis, as popu- larized by `I'm OK - . . You're OK", and other books, is useful in opening doctor-patient com- munications and influencing patient response to medical instructions. William Holloway, M.D., Ass't Clinical Professor of Psychiatry at - Case Western Reserve University School of Medicine and head of the Midwest Institute of Human Understanding, Medina, Ohio, gives an Introduc- tion to this informal system of analyzing and im- proving communication patterns. (20 minutes) (in color) SAMA 2811372 TREATING THE DEPRESSED PATIENT, with F. Theodore Reid, Jr., M.D., Associate Professor, Department of Neurology and Psychiatry, Michael Reese Hospital, Chicago, Illinois. Dr Reid will demonstrate, with three patients, how norr~al and ~ome neurotic depressions can be treated by the family physician. He will also describe the ap- proach to-take with the patient and his family, when the patient requires hospitalization, (19 minutes) (In color) 2014223 WHAT GOES ON AT SEX THERAPY CLINICS, with Harold Lear, M.D., Director of the Human Sexu- ality Program, Mount Sinai Hospital, New York City. What really happens in those Masters and Johnson-type sessions? Dr. Lear and co-ther- apist Ann Welbourne, R.N., shoW you - in a counseling session with a couple whose problem is the husband's premature ejaculation. (22 minuteS) (In color) 2317006 Frontiers -of Psychiatry on Camera~ 10 film pro- grams from a~speciaI series produced by Roche Laboratories. Helical Scan Videotape copies are now available for two~week periods at no cost. BUILDING A DRUG ABUSE PROGRAM. - Dr. Jer- ome H. Jaffe, formerly of the University of Chicago, Department of Psychiatry, and later Director, Special Action Office for Drug Abuse Prevention, Executive Office of the President, describes the drug abuse program in Illinois, which uses three geographically separated treat- ment modalities: therapeutic communities, out- patient methadone maintenance and standard hospital abstinance therapy. (50 minutes). FP 2800033 CHANGING THE BOUNDARIES OF THE MENTAL HOSPITAL. An interview with Dr. Israel Zwer- ling, .Director of the Bronx -State Hospital, and Professor of Psychiatry at the Albert Ein- stein College of Medicine, New York City, ex- plores the interrelationships between the State Mental Hospital and the community mental health centers. These centers, staffed by spe- cially trained personnel, are shown actively ful- filling important roles in the mental health serv- ices of the community. (29 minutes) FP 2800031 COMMUNICATIONS PROBLEMS AND PROGRESS. Henry W. Brosin, M.D., past president of the American Psychiatric AssociatJon, examines the basis of scientific interest, in the communlca tion of emotional expression in this interview. He discusses Darwin's photographic recording of facial expressions of psychotic- patients made 100 years ago, and points to the present day use of inexpensive sound film for permanently re- cording a patient's history and treatment. And finally, the use of the computer. a tool that will enable "psychiatry to meet the canons of sci- ence," is examined by Dr. Brosin. (20 mInutes) FP 2800029 1IQ PAGENO="0465" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14371 CREATING A NEW IMAGE FOR MENTAL HOS- PITALS. George Zubowicz, M. b., Superintendent, Osawatomie State Hospital, Kansas, discusses how his hospital eradicated the "snake pit" image of the state hospital. He explains that by creating a better atmosphere for the patients and staff, they become good-will ambassadbrs. Scenes of Mental . Health Week activities at the hospital show a patient fashion show and a dance number. Dr. Zubowicz describes Opera- tion Friendship, a program providing people in the community with an opportunity to invite patients into their homes as guests for a day. The. program covers other subjects such as high school volunteers who do projects with the patients, and a speaker plan providing panels of patients who talk to high school and service groups. (27 minutes) PP 2800026 EXPLORING THE TREATMENT OF ALCOHOLISM. "Letting the patient shop arocmd for a therapy that helps him" is how Ernest W. Klatte, M.D., Superintendent of the Mendocirlo State Hos. pital in California, explains the growing success of the hospital's program for treating alcoholism. Many different therapies are utilized to motivate the patient in finding his own treatment and in following it. (27 minutes) FP 2800030 INSTEAD OF PRISON; REHABILITATING OFFENDERS. This interview with Dr. Frank A. Tyce, Superintendent, Rochester State Hos. pital, Rochester, Mlnn., describes the PORT pro. gram (Probation Offenders Rehabilitation and Training) which has been instituted at his hos~ pital. It is felt that criminal behavior is brought about by feelings of hopelessness and helpless- ness, and the PORT program tries to overcome these attitudes. The PORT program facility is almost totally governed by the inmates them selves. They select who should be accelerated into the program and are responsible for en forcing their own rules. The "clients" of the PORT program keep their jobs, pay for room and board, support their families and pay taxes while they are in this program. (27 minutes) FP 2800034 Each program is accompanied by a rezdew card. NCME asks that the person for whom the program was ordered fill out and return this card, Because reevaluation of MasterLibrary videocassettesis a cbntin- ual process, return of the program review card is essential in helping NCME deter- mine which programs remain useful as re- sources for continuing medical education. MAINTAINING MENTAL HEALTH THROUGi'J THE COMMUNITY HEALTH CENTER. James R. Harris, M.D., Director of Community Medicine, Pennsyl. vania Hospi~aI, PhiIadeIp~ia, describes a total health care program being run in Southeast Philadelphia, putting psychiatry and mecicine into the mainstream of health care. By offering the services of a neighborhood health center to treat patients with physical disease, they are also providing training programs for lab technicians and other allied health positions. Those with emotional problems are referred to the day hos~ pital at the community mental health center for treatment. The program illustrates how the neighborhood health center operates its outreach service, nursery, and referral system. A group session at the community mental health center is included. ifs minutes) FP 2800027 PSYCHIATRIC CONSULTATION AT THE NURSINI,~ HOME OF THE AGED. An Interview With Rich' ard J. Levy, M.D., Chief, Psychiatric Services, San Mateo County General Hospital, San Mateo, California, explores how psychiatrists can help in a consulting role at nursing homes for the aged. Some of the topics discussed: deaIifl~ with difficult patients; coping with staff frustra~ tion, anger and depression; establishing greater rapport between staff, physician and psychi atrist; and helping the patient's family. (12 minutes) FP 2800028 PSYCHIATRIC DAY HOSPITAL IN A GENERAL HOSPITAL. An interview with Ors. Ronald C. Young and William Jepson at Heninepin Coun~ ty General Hospital in Minneapolis, Minnesota, describes the activities of the day hospital, Pa~ tients receive psychiatric care while they main~ tam their family relationships. The techniques used to accomplish this and the manner in which the hospital provides the care with mini' mum funds and staff are revealed. (15 minUtes) FP 2800032 TROUBLED KIDS - THE MENTAL HOSPITAL SCHOOL AND THE COMMUNITY. An interview with Dr. George McK. Phillips, Superintendent, and Allan F. Brewington, Principal of the Wim terode School of Crownsville State Hospital in Crownsville Maryland, explores the purpose and workings of the school. Wirflgróde School was es tabli~hed to teach hospitalized, as well as non hospitalized, adolescent students with behavioral problems. Each child is evaluated Individually and a special teaching program Is established to meet his needs. Scenes in the classroom illus, trate teaching techniques and crisis Intervention by an educational psychologist, The program covers a family session, student dance and staff meeting. Dr. Phillips deScribeg how the school reaches out into the community to prevent hos pitalizatlon by sending representatives to evalu- ate and deal with troublesome students in the public schools. (30 minutesi FP 2800025 111 78-617 0 - 76 - 30 PAGENO="0466" 14372 COMPETITIVE PROBI~EMS IN THE DRUG IN~[)USTRY PUI3LIC HEALTH A SPECIAL REPORT: RUBELLA IMMUNIZATION A timely program containing the latest informa- tion about the Rubella Vaccine, its development and Its recommended administration is presented by H. Bruce Dull, M.D., Assistan1 Director of the National Communicable Disease Center In At- lanta, Ga 122 minutes). 1908815 BRINGING HEALTH CARE TO THE PEOPLE: RURAL COMMUNITY MEDICINE, wIth H. Jack Geiger, M.D., Professor and Chairtnan of the De- partment of Community Medicine, School of Medicine, State University of New York at Stony Brook. The 16,000 people of North Bolivar County, Mississippi, suffered from decades of untreated - and undiagnosed - conditions. They faced the consequences of stark poverty, malnutrition, substandard sanitation, impure drinking water and inferior housing. Dr. Geiger shows the efforts he and his colleagues have made over sIx years to establish comprehensive health care in the 500-square mile area. Dr. Geiger believes that much of what he describes is the medicine of the future. (20 mInutes). 0214014 CHOLERA, 1971: RISK, DIAGNOSIS AND MAN- AGEMENT, with David J. Sencer, MD., DIrector of the Center for Disease Control, Department of Health, Education and Welfare In Atlanta, Geor- gia; Philip S. Brachman, M.D., Chief of the CDC Epidemiology Program; and Eugene J Gangarosa, M.D., Deputy Chief, Bacterial Diseases Branch, CDC Epidemiology Program. Cholera, feared since biblical times, is spreading throughout the world. As more tourists travel abroad, concern grows over contacting the disease and infecting the American continent. Three experts from CDC discuss the very small risk to America, and describe the simple steps that can be taken to dM~nose and treat cholera among returning travelers. `1~y mInutes) (In color) 0312909 COUNSELING THE VD PATIENT. The sexual overtones of venereal disease expose VD patients to a special cotrrplication - - a value judgment of their behavior. Such judgment, however un- intentional, can detract from the treatment of the disease. Dr. Mary Howell of the Somerville Women's Health Project in Somerville, Massa- chusetts, Rev. Thomas Metier of the University of Minhesota Human Sexuality Prdgram, and three medical students use role playing to illus trate theSe dlfflcultlCs and discuss their solution. (19 mInutes) (In color) SAMA 2810860 COUNTRY DOCTORS: A VISIT WITH THE NA- TIONAL HEALTH SERVICE CORPS Can a kid from Brooklyn really live in Appalachia? Is it fulfilling or nerve-wracking to `practice medI- cine with a doctor/patient ratio of one to ten thousand? Don Deye, student project director for the AMSA Video Journal, takes our cameras to the hills of Pennsylvania to listen as three doctors, all participants in the National Health Service Corps, talk about problems and opportunities they've found practidng in and around Orbisonia, Pennsylvania, popUlation 600. (25 minutes) (in colol) AMSA 2812283 CURRENT STATUS OF THE PROBLEM OF VE- NEREAL DISEASE, with Frank M. Calia, M.D., Department of Medicine; and R. C. Vail Robin- son, M.D., Division of Dermatology; both of University of Maryland School of Medicine, and Richard Hahn~ M.D., Department of Medicine, the Johns Hopkins University School of Medi- cine. The panelists discuss the epidemiology, diagnosis and treatment of syphilis and gon- orrhea. Special emphasis is given to methods of diagnosis in asymptomatic infections, extra- genital manifestations of gonorrhea, Increas- ing penicillin resistance of the gonococcus, use of single dose therapy in gonorrhea, derma- tologic manifestations of syphilis, and problems related to the serologic diagnosis of syphilis. A TeleviSion Hospital Clinic of the America Col- lege of PhysIcians, 1972. Please inquire for special rental information. (57 minutes) (in color) ACP 2857242 DID YOUR PATIENT GET HIS DISEASE ABROAD? with Kevin M. Cahill, M.D., D.T.M. & I-I. (Lond.), Director of the Tropical Disease Center at Lenox Hill Hospital, New York, and Professor of TropI- cal Medicine, Royal College of Surgeons In Ire- land. Your patients may present you with ame- blasis or malaria if they travel, have been In Vietnam, have had contact with those who have been abroad or if they experImentwith drugs- Dr. Cahill shows you how to diagnose and treat these diseases, and offers advice on prevention. (19 minutes) (in color) 0417540 EARLY DIAGNOSIS OF ALCOHOLISM, with Mar- vin A. Block, M.D., Vice President of the AMA Society on Alcoholism, and Associate Professor,. State University of New York at Buffalo. "There are all kinds of alcoholisms and all kinds of alco- holics." Dr. Block provides specific crl~eria by which you may judge the kind of alcoholism and the stage of the disease. (24 minutes) (In colOr) 0516820 112 PAGENO="0467" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14373 FEMALE HOMOSEXUALITY -~ PART I - PER. SONAL ASPECTS. John F. Oliven, M.D., Associ- ate Attending Psychiatrist, i.~ollege of Physicians and Surgeons, Columbia University, analyzes the psychologic problems of Lesbianism through his commentary on an interview between a Lesbian transvestite and John W. Huffman, M.D., Profes sor of Obstetrics and Gynecology, Northwestern University Medical School. (15 minutes). 0605702 FEMALE HOMOSEXUALITY - PART II - INTER PERSONAL ASPECTS. An interview between a Lesbiantransvestite and John W. Huffman, M.D., Professor of Obstetrics and Gynecology, North- western University Medical School, is inter spersed with commentary by John F. Oliven, M.D., Associate Attending Psychiatrist, College of Physicians and Surgeons, Columbia University. (21 minutes). 0605803 FRAMINGHAM'S CORONARY CANDIDATE: IDENTIFICATION AND PROPHYLAXIS William B. Kannel, M.D., Thomas R. Dawber, M.D., and William P. Castelli, M.D., from the Heart Disease Epidemiology Study of the Na- tional Heart Institute, National Institutes of Health, Framingham, Massachusetts, demon strate, with patients, the objectives and the ap- parent successes of the Study. (21 mInutes) (In color) 0609711 GETTING A FIX ON HEROIN. Treatment of heroin-addicted patients is clouded by popular misconceptions and mythologies about heroin use and treatment. SAMA cameras take you to drug abuse treatment facilities in New York and San Francisco to explore the problems of the drug addict and the problems of treating him. Speaking for SAMA is Dahlia Kirkpatrick, a third year student at Yale, who discusses the issues with Dr. Herbert Kleber, Director of the Drug Abuse Unit of the Connecticut Mental Health Center. (34 minutes) (in color) SAMA 2810453 GONORItHEA: A PLAGUE OUT OF CONTROL The Incidence of gonorrhea is increasing at a rate of 10 to 15 per cent a year. Although many people jump to the conclusion that this is due to relaxed morals and increased liberality in sex, the National Communicable Disease Center In Atlanta, Ga., feels differently. Discussing the problem, new diagnostic techniques and ways to eradicate the disease are William J. Brown M.D., and Leslie C. Norms, M.D., Chief of the Center's Venereal Disease Research Laboratory, (12 minutes) (in color) 0709909 GONORRHEA: ELUSIVE EPIDEMIC, with Frank M. Calia, M.D., Chief of Infectious Diseases, Loch Raven Veterans Administration Hospi~aI, and Associate Professor of Medicine, University of Maryland School of Medicine, Baltimore, Maryland. An aggressive approach to this seem- ingly unbeatable venereal disease. Shows screening procedure for catching the silent car- rier, and how to handle new oriental strains of GC. (20 mInutes) (in color) 0717417 IMMUNIZATION FOR FOREIGN TRAVEL. Al- though Federal law requires certain immuni*a- tion shots for Americans going abroad, physi- cians can recommend additional protectiOn for their traveling *patients by knowing what major diseases are endemic to particular areas of the world and prescribing the appropriate shots. Discussing this proposal is E. L. Buescher, M.D., Chief, Department of Virus Diseases, Walter Reed Army Institute of Research, Washington, D.C. (15 mInutes). 0905702 INSIDE THE DOOR: A FREE CLINIC. What's free about a free clihic besides the medical care? The spirit is. And the cooperation between pro- fessionals and students of all disciplines. SAMA cameras take you to The Door, a free clinic. In New York City, that offers adolescents full medi- cal care as well as legal, social and educationel counseling. Medical students and physicians at The Door talk about how they believe free clinics can help humanize medical treatment. (20 mInutes) (In color) SAMA 2810149 INVESTIGATING MULTIPHASIC SCREENING The Director of Community Health at the Brook- dale Hospital Center in Brooklyn, N.Y., Leo Git- man, M.D., describes the concept and practical aspects of multiphasic health screening. (17 mInutes). 090991i KEEPING UP ON IMMUNIZATIONS, with Samuel L. Katz, M.D., Professor and Chairman of th~ Department of Pediatrics, Duke University Medi- cal School, and Chairman of the Committee on Infectious Disease of the American Academy of Pediatrics, Durham, North Carolina. Here's a qul~ on preventive practice. Six cases point up some problems in routii~e" office immunization (18 minutes) (in color) 1121804 All programs in this catalog are copyright by the Network for Continuing Medical Education. Duplication, reproduction, or distribution in any form of all or any part of the programs is prohibited without the express written consent of NCME. 113 PAGENO="0468" 14374 COMPETITIVE PROBLEMS IN THE DRUG IN~DUSTRY LARGE SCALE PREGNANCY TESTING FOR THE `70s with Elizabeth Connell, M.D., Associate Professor of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University in New York, and Director, Family Life Services, International Institute for Study of Human Re- production; Ralph W. Gause, M.D., Obstetrical Consultant, National Foundation-March of Dimes; and Donald P. Swartz, M.D., Clinical Professor of Obstetrics and Gynecology, College of Physicians and Surgeons, and Director of Obstetrics and Gynecology, Harlem Hospital in New York. Three physicians demonstrate the ease of administra- tion and reliability of new inexpensive pregnancy tests. The doctors also identify situations in which wider pregnancy testing may now be indi- cated, and consider issues raised by the simpli- city and accessibility of pregnancy testing kits. (19 minutes) (in color) 1213914 LOOK OUT FOR LEAD, with Jay M. Arena, M.D., Director, Duke University Poison Control Center, Durham, NC., and former President, American Academy of Pediatrics. There are potentially more lethal sources of lead poisoning than old paint in city slums, says Dr. Arena. He presents tips for diagnosi~ and treatment in your suburban and rural patients. (10 mInutes) (In color) 1217216 M.D.s ON TV: FICTION OR FACT? with Morton H. Maxwell, M.D., James N. Waggoner, M.D., Dudley M. Cobb, Jr., M.D., Chris Hutson, R.N., Phyllis Wright, M.D., and Vincent J. Maguire, M.D. A panel of consultants to the medical dramas on commercial television discusses the following questions: Are the medical programs on television of any value to the general public as patients? And, do these programs complicate the doctor-patient relationship? (20 minutes) (in color) 1310615 MANAGEMENT OF ASPIRIN POISONING, with Jay M. Arena, M.D., Director, Poison Control Center, Duke University Medical Center, Dur- ham, N. C., and former President, American Academy of Pediatrics. Dr. Arena draws on 35 years' experience to give a practical approach to handling the most common cause of poison- ing in children. (13 minutes) (IC color) 1317347 MEDICAL ASPECTS OF CIVIL DEFENSE. The im- pact on the medical community of a nuclear bomb explosion, with Victol- W. Sidel, M.D., Di. rector of Preventive Medicine Unit, Massachu- setts General Hospital Boston, Massachusetts and Dr. Barry Commoner, Henry Shaw School of Botany, Washington University. (24 mInutes). 1303923 NAME YOUR POISON: ALCOHOL Many physi- clans and medical students still treat alcoholics as second-class patients. Because of ingrown cultural attitudes, early alcoholism often goes undetected and untreated. Medical students meet with a recovered alcoholic, with Dr. Marvin Block of the State University of New YOrk at Buffalo, and Dr. Frank Seixas, Medical Director of the National Council on Alcoholism, to dis- cuss ways to detect and help incipient alcohol- ics using science to replace serendipity. (40 minutes) (in color) SAMA 2810251 PRE-HOSPITAL CORONARY CARE - A MODEL FOR YOUR COMMUNITY, with Eugene Nagel, M.D., Associate Professor, Department of An. esthesiology, University of Miami School of Medicine, and Clinical Director, Department of Anesthesiology, Jackson Memorial Hospital, Mi. ami, Florida. How quickly can your community get optimum coronary care facilities to a patient in cardiac arrest or ventricular fibrillation? Dr. Nagel shows how the Miami Emergency Rescue Service is set up, demonstrates how quickly it works in a simulated rescue, and shows what is needed to implement a complete mobile emer- gency health care system. (21 mInutes) (in color) 1615438 Many NCM.E programs have self-assess- ment quizzes, one copy of which will ac- company each videocassette, You may duplicate the quiz as your needs require. Upon completion, return the quizzes to NCME, and we will maintain a record of participation (not the score) for each phy- sician. These records are keyed to the phy- sician's Social Security numbers: please take care that the numbers are clearly written. Physicians may request their NCME activity records at any time, 114 PAGENO="0469" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14375 RX: BACON GREASE-FOLK MEDICINE. An amulet * . - "hot' vitamins - . and the heart of a frog * . - what do they have in common? They all be- long to contemporary medical systems that some patients turn to before bringing their prob- lems to a doctor. Rena Gropper, Ph.D. of Hunter College and Courtney Wood, M.D. of the Depart- ment of Community Medicine of Mt. Sinai School of Medicine discuss and demonstrate how an un- derstanding of folk medicine beliefs can improve the medical care received by patients who trust cultural beliefs as much as their doctor's advice. (19 minutes) (in color) SAMA 2811171 SICKLE-CELL ANEMIA: MANAGEMENT; with Ro- land B. Scott, M.D., Professor and Head of the Department of Pediatrics, Howard University, and Chief Pediatrician at Freedmen's Hospital in Washington, D.C. There is no curative treatment for sickle-cell anemia, according to Dr. Scott. However, early diagnosis of the disease, which afflicts more than 50,000 black Americans, can ameliorate the most disturbing symptoms. Dr. Scott describes the therapeutic program he follows to enhance survival until the patient reaches puberty - when the natural course of the disease process appears to become attenuated. (14 minutes) (in color) 1911506 SICKLE-CELL ANEMIA: SUSPICION AND DIAG NOSIS IN INFANTS AND CHILDREN, with Roland B. Scott, M.D., Professor and Head Of the De- partment of Pediatrics, Howard University, and Chief Pediatrician at Freedmens Hospital in Washington, D.C. Also V. Bushan Bhardwaj, M.D., Assistant Professor of Pediatrics, Howard Uni- versity, and Pediatric Hematologist, Freedmen's Hospital. Sickle-cell anemia afflicts more than 50,000 Americans of African descent. Perhaps another two million black Americans carry the trait, Until recently, it was believed that little could be done for the disease, Now relief from the symptoms and a prolonging Of life are possible. This telecast features the characteristics of the disease, and the laboratory procedure followed to establish a conclusive diagnosis. (20 mInutes) (in color) 1911407 SKIN TESTING FOR TB, with John A. Crocco, M.D., Director of Pulmonary Disease Section, St. Vincent's Hospital and Medical Center, New York; and Downstate Medical Center, Brooklyn, New York. A demonstration of the correct way to administer two types of TB skin tests, with guide- lines for their interpretation. (12 minutes) (in color) 1920637 SUICIDE - PRACTICAL DIAGNOSTIC CLUES. Matthew Ross, M.D., of the Department of Psy- chiatry, Harvard Medical School, and Massachu- setts General Hospital, McLean Division, Boston, describes some signs that will help the practic- ing physician to spot the potential suicide. (13 minutes). 1905120 SYPHILIS: AN ERADICABLE PUBLIC HEALTH PROBLEM William J. Brown, M.D., Chief of the Venereal Disease Program at the National Communicable Disease Center in Atlanta, Ga., warns physicians of a false sense of security in dealIng with syphilis because of recent development of drugs. The need for recognizing the various stages řf syphilis is stressed with clear exampies, (8 minutes) (in color) 1909525 SYPHILIS: BE SUSPICIOUS, with Frank M, Calls, M.D., Chief, infectious Diseases, Loch Raven Veterans Hospital, and Associate Professor of Medicine, University of Maryland School of Medicine, both in Baltimore. A new look at an old enemy, with emphasis on the pros and cons of a variety of serologic tests. (15 minutes) (in color) 1917628 TECHNIQUES IN EMERGENCY CARE, with Stephen E. Goldfinger, M.D., Director of Com- munity Programs, Department of Continuing Ed. ucation, and James Dineen, M.D., Fellow in Con- tinuing Education, Harvard Medical School and Massachusetts General Hospital, Boston, Massa- chusetts. The procedures and armamentarium of the com- munity hospital emergency room are constantly improving. Physicians who have not served as house officers recently will benefit from this pro- gram. Current emergency care is demonstrated with a patient in coma, another with unexplained fever, a third with trauma and, finally, several malingerers and depressives. 116 minutes) (in color) 2010904 THE EMERGENCY ROOM: A GROWING PUBLIC UTILITY, with Stephen E. Goidfinger, M.D., Di- rector of Community Programs, Department of Continuing Education; and James Dineen, M.D., Fellow in Continuing Education, Harvard Medical School and Massachusetts General Hospital, Bos- ton, Massachusetts. Physicians have trained their patients to seek medical attention from emergency rooms after office hours. This common practice has placed staggering demands on hospital emergency fa- cilities. How can the hospital meet these de- mands? Who will staff the emergency facilities? What technical advances have been intioduced to assist ER personnei? Doctors Goldfinger and Dineen present answers to these dilemmas. (19 mInutes) (in color) 0511009 115 PAGENO="0470" 14376 COMPEPITIVE PROBLEMS IN THE DRUG INDUSTRY THE LABORATORY IN DIAGNOSIS OF PNEU- MONIA. Pneumonia continues to account for 45,000 deaths eath year. Treating a patient with drugs which may suppress but fail to eradicate the infecting o~ganism may place him In jeop- ardy, and provides less than optional care. Dis- covery of the etiologl~ agent is determined in the laboratory by such efforts as microscopic, cultural, serological and antimicrobial sensitivity tests, according to Robert Austrian, M.D., John Herr Musser Professor and Chairman, Depart- mentof Research Medicine, University of Penn- sylvania School of Medicine. (le mlnutes). 1207201 THE MULTIPHASIC TREATMENT OF ALCOHOL- ISM, with Albert N. Brown-Mayers, M.D., Director of the Alcoholic Service; Edward E. Seelye, M.D., Unit Administrator of the Alcoholic Service; and Leonard R, Slilman, M.D. Attending Psychiatrist; all of the Westchester Division of the New York Hospital-Cornell Medical Center, White Plains, N.Y. A new, formalized approach to the treat~ merit of alcoholism is suggested. Presenters show how residential alcoholic treatment works and outline a Complete program, many elements of which you'll find practical and effective In your own practice. 129 mInutes) lie color) 1316946 THE RUBELLA IMMUNIZATION PROGRAM: A PROGRESS REPORT, with Saul Krugman, M.D., Professor and Chairman of the Department of Pediatrics; and Louis Z. Cooper M.D., Associate Professor of Pediatrics and Director of the Ru- bella Birth Defect Evaluating Project * both physicians from the New York University Medical Center, Bellevue Hospital, New York City; and John J. Witte, M.D., Chief of the Immunization Branch of the Center for Disease Control, Depart- ment of Health, Education and Welfare, Atlanta, Georgia. The Rubella Immunization Program has been in widespread use since the Summer of 1969. Three authorities on rubella report the findings of the Immunization Program and offer advice to practicing physicians based on the findings. (23 mInutes) (In color) 1812823 TOBACCO USE DISEASES AMONG GENERAL HOS- PITAL PATIENTS - PART I - NON-MALIGNANT ASPECTS. The majority of deaths and morbidity among cigarette smokers is due to non-malignant causes. These include accidents caused by care- less use of cigarettes, bronchitis, emphysema, cardiovascular disease, gastrointestinal disease, problems during pregnancy, and toxic amblyopla. Reviewing the statistics and case histories, sup plemented by radiographic and radioactive iso- topic Illustrations, is John W. Turner, M.D., Chief Radiologist, Wesson Memorial Hospital, Spring- field, Massachusetts. (15 minutes). 2005307 TOBACCO USE DISEASES AMONG GENERAL HOS- PITAL PATIENTS - PART ii - MALIGNANT AS- PECTS. Several different malignant diseases caused by cigarette smoking are presented by John W. Turner, M.D., Chief Radiologist, Wesson Memorial Hospital, Springfield, Massachusetts. (13 mInutes). 2005408 TUBERCULOSIS: A NEW MEDICAL CHALLENGE FOR THE SEVENTIES, *ith Vernon N. Houk, M.D., and Phyllis Edwards, M.D., of the Tuber- culosis Section of the National Communicable Disease Center; and William W. Stead, M.D., Professor of Medicine at Marquette School of Medicine in Milwaukee. TB is frequently diag- nosed as pulmonary fibrosis. The epidemiology of the disease In the U.S. today is shown, along with the current approach to its eradication. (17 minutes) (in color) 2010419 WHAT'S CAUSING THE INCREASED INCIDENCE OF PHOTOSENSITIVE REACTIONS?, with John H. Epstein, M.D., Associate Clinical Professor of Dermatology, University of California at San Francisco, and Chief of Dermatology at Mount Zion `Hospital and Medical Center in San Fran- cisco. Increased public obsession with sunbath~ ing and an ever increasing number of photo- sensitizers in our environment are reaching the stage where almost every physician can expect to see patients exhibiting phototoxic or photo- allergic reactions. Diagnosis and treatment of the following are explored in this telecast: photo- toxicity, photoallergy, exogenous photosensitiz- era, therapeutic and antibacterial agent reactions and plant-induced photosensitivity. (15 mInutes) (In color) 2313502 PULMONARY DISEASE ACUTE RESPIRATORY INSUFFICIENCY: MECH- ANISMS AND DIAGNOSIS, with Alfred P. Fish man, M.D., Associate Dean of the University of Pennsylvania School of Medicine and Director of the Cardiovascular Pulmonary Division; and Robert M. Rogers, M.D., Assistant Professor of Medicine and Director of the Respiratory inten- sive Care Unit. The general principles of diag- nosing respiratory failure are presented for phy- sicians unfamiliar with the recent advances in pulmonary physiology and respiratory Intensive care. (18 mInutes) (In color) 0110104 ALTITUDE STRESS-PART i-~E. R. Buskirk, M.D., Director of Laboratory for Human Performance Research, Pennsylvania State University. Olym- pics `68-research on athletic performance at high altitudes In Peru and Colorado. (13 minutes). 0102509 116 PAGENO="0471" COMPEPIPtVE PROBLEMS IN THE DRUG INDUSTRY 14377 ALTITUDE STRESS-PART Il-Hypoxia-with E. R. Buskirk, MD., Director of Laboratory for Hu- man Performance Research, Pennsylvania State University. Olympics `68-reseatch on athletic performance at high altitudes in Peru and Colo- rado. iie minutes). 0102610 BRONCHIAL BRUSHING, from the University of Chicago School of Medicine With John J. Fen- nessy, M.D., Assistant Professor of Radiology. A new method of selective catheterization of small peripheral bronchial segments for the diagnosis of indetermInate peripheral lung lesions. (28 mInutes). 0200110 BRONCHOGRAPHY IN THE MANAGEMENT OF BRONCHIAL DISEASES Robert J. Atwell, M.D., Professor of Medicine, and A. J. Christoferidis, M.D., Professor of Radiology at the Ohio State College of Medicine, demon- strate the techniques of infusing contrast media into the bronchi. (17 mInutes). 0209711 CYSTIC FIBROSIS: DIAGNOSIS AND MANAGE- MENT, with Paul R. Patterson, M.D., Director, Cystic Fibrosis Unit, Albany Medical Center, Al- barry Medical College, Union University, New York. Attention is drawn l~ó cystic fibrosis as a model genetic disease. Dr. Patterson describes, with many examples, C/Ps mode of inheritance, inci- dence, symptoms, differential diagnosis, detec. tion of carrier state, current status of manage- ability and prospects for palliative or corrective therapy. (19 minutes) (in color) 0310961 DIAGNOSING INTERSTITIAL LUNG DISEASE, with Marvin Schwarz, M.D., Assistant Professor of Medicine at the University of Colorado Medical Center and Chief of Pulmonary Service, General Rose Memorial Hospital, Denver. Complaint: Dyspnea; Chest X-Ray: Normal; Diag~o5,W: Diffi- cult. When should you suspect interstitial lung disease? What tests will confirm it? Dr. Schwarz provides clear answers with clear pictures of the diagnostic signs of both early and late Interstitial lung disease. (17 minutes) (in color) 0418143 Each program is accompanied by a review card. NCME asks that the person for whom the program was ordered fill out and return this card. Because reevaluation of MasterLibrary videocassettesija contin- ual process, return of the program review card is essential in helping NCME deter- mine which programs remain useful as re- sources for continuing medical education. THE DIAGNOSTIC CHALLENGE OF CHEST PAIN, with moderator Alfred Soffer, M.D., Professor of Cardiology at the University of Health Sciences--- Chicago Medical School, Chicago, and Editor-lIt- Chief of Chest, the Journal of the American Col- lege of Chest Physicians. Participants are: P. 0. Henderson, MB., F.R.C.S. (C)., Staff Surgeon, Toronto General Hospital and Assistant Professor of the Department of Surgery at the University of Toronto, Canada; Barry William Levine, M.D., Assistant Professor of Medicine, Harvard Medi- cal School, and Chief, Outpatient Pulmonary Services, Massachusetts General Hospital, Bo~- ton; Linda D. Lewis, M.D., Assistant Professor of Neurology, College of Physicians and Surgeons of Columbia University, and Chief of the Neu- rology Clinic, Neurological Institute bf Columbia Presbyterian Medical Center, New York City, Morton E. Tavel, M.D., Associate Professor of Medicine at the Indiana University School of Medicine, Indianapolis. Pinpointing the cause of your patient's chest pain poses an urgent diagnostic challenge. Join Dr. Soffer and four specialists on these clinical grand rounds as they reach a diagnosis on five patients. (32 minutes) (In color) 042336k DIAGNOSTIC THORACENTESIS, with James W. Kilman, M.D., Associate Professor of Surgery. and Thomas E. Williams, Jr., M.D., Assistant Professor of Surgery, Ohio State University Col- lege of Medicine, Columbus. Thoracentesis for both diagnosis and emergency therapy is per- formed following a discussion of the causes, signs, and symptoms of pleural effusion. (19 minutes) (In color) 041924-8 EMERGENCY CLOSED TUBE THORACOSTOMY, with James W. )(ilman, M,D., Associate, Professor of Surgery, and Thomas E. Williams, M.D., As- sistant Professor of Surgery, Ohio State Uni- versity College of Medicine, Columbus. The causes, consequences, symptoms, and signs of pneumothclrax are reviewed and an emergency closed tubethoracostomy is performed. (20 minutes) (in color) 0519123 HOW TO OVERDIAGNOSE PULMONARY EMBO- LISM, with Edward H. Morgan, M.D., Head of the Section of Respiratory Disease at The Mason Clinic, Seattle. To save patients from fatal pul' monary embolism, you must overdiagnose and overtreat the condition in some pati~nts, m-ain~ tains Dr. Morgan. He shows you, with, a patient, how to make a decision for or against treatment in one hour Or less. (15 minutes) (In color) 0818733 117 PAGENO="0472" 14378 COMPETITIVE PROBLEMS IN THE DRUG IN~DUSTRY MANAGEMENT OF THE AMBULATORY PATIENT WITH CHRONIC BRONCHITIS AND EMPHYSEMA, with WilmOt C, Bali, Jr., M.D.; Warde B. Allan, M.D.; and Warren Summer, M.D.; all of the Department of Medicine, The Johns Hopkins University School of Medicine, A review of the evaluation and treatment of ambulatory patients with chronic obstructive pulmonary disease. Controversial aspects of management are em- phasized, e.g., usefulness of detailed physio- logical workup, selection and use of brochodila- tors, ambulatory IPPB therapy, and the role of respjratory stimulants. Selection of severely handicapped patients for exercise training or ambulatory oxygen administration is also dis'. cussed. A Televisiqn Hospital Clinic of the American College of PhysicIans, 1972. Please inquire for special rental information. (58 minutes) (in color) ACP 2827245 MEDIASTINO~COPY IN STAGING CARCiNOMA OF THE LUNG with Edward M. Goldberg, aD, Department of 9urgery and Oncology Council, Michael Reese Hospital and Medical Center, Chicago, illinois. Lung cancer can be the most frustrating prob- lem for a physician. Techniques are available for a definite diagnosis, but uncertainty exists on how to proceed with the patient. Thoracotomies have high operative mortality and extensive morfl bldity. In addition, the procedure proves to be unnecessary in about 50 per cent of the cases. Through the use of the medlastinoscope, It is possible to view and photograph the mediastl. num. This has resulted in a new method of stag. lag lung cancer, and an improved approach to treatment. A mediastinoscopy is demonstrated, and the staging method Is shown in detail. (14 minuteS) (in color) 1312021 NEAR DROWNING: WATCH THE BLOOD GASES, with Norman L. Fine, M.D., Chief, Respiratory Services, The Griffin Hospital, Derby, Conn., and Assistant Clinical Professor of Medicine, Yale Un~versity Medical School, New Haven, The model of the fatally-drowned person is no longer relevant in treating the survivor of near drown- ing. This program brings you up to date. (15 minutes) (in color) 1422940 NEW DIRECTIONS IN PULMONARY EMBOLISM - DIAGNOSIS. A new niethodof lung scan is demonstrated, which, used in conjunction with other tests, is a valuable diagnostic aid In pul- monary embolism, the most serious lung disor- der in the U.S. The advanced technique employs a radioactive scintillation counter; The demon- stration is conducted by Henry N. Wagner, Jr., M.D., Professor of Radiology and Chief Division of Nuclear Medicine, The Johns Hopkins Med- ical Institutions, and Arthur Sasahara, M.D., As- sociate in Medicine, Harvard Medical School. (16 minutes). 1407204 NEW DIRECTIONS IN PULMONARY EMBOLISM - MANAGEMENT. Myocardial Infarction or pul- monary embolism? The differential diagnosis of the two conditions is more Important to the prac- ticing physician than ever before, because of differing modalities of treatment which recently have been developed. Henry N, Wagner, Jr., M.D., Professor of Radiology and Chief, Division of Nuclear Medicine, The Johns Hopkins Medical institutions, and Arthur Sasahara, M.D., Associ- ate in Medicine, Harvard Medical School, exam- ine the specific therapies, anticoagulant, sur- gical, arid thrompolysis, for pulmonary embolism. (16 mInutes). 1407305 OFFICE SCREENING FOR CHRONIC LUNG DIS- EASE, with Spencer K. Koerner, M.D., Chief of the Division of Pulmonary Medicine, Montéflore Hospital, New York City. Here are some oftiäC pulmonary evaluation tests which can help you detect patients with aS'ymptomatic chronic lung disease. (13 mInutes) (in color) 1519309 PULMONARY EMBOLISM: A RATIONAL AP- PROACH TO MANAGEMENT, with William Hail, MD., Director of the Pulmonary Function Unit at Strong Memorial Hospital, and Assistant Pro. fessor of Medicine, University of Rochester School of Medicine, Rochester, New York. The mortality rate for untreated pulmonary embolism patients is between 25 and 50 percent. Doctor Hall demonstrates that such gloomy results can be avoided through prompt and effective management, which includes anticoagulant thor. apy and the treatment of hypoxia. (This program is part of the `Drug Spotlight Program" of the American Society for Clinical Pharmacology and Therapeutics.) (17 minutes) (in color) 1619744 RESPIRATORY DISTRESS IN THE NEWBORN; INDICATIONS FOR SURGERY, with Alexander J. Schaffer, M.D., Associate Professor Emeritus of Pediatrics, Johns Hopkins University School of Medicine,ahd Assistant Commissioner of Health of the City of Baltimo~e, Maryland. The clinical sign6 of respiratory distress are shown, along with examples of anomalies SŘecial attention is given to, the approach of arriving at a specific diagnosis. (25 minutes) (In color) 1810314 RESPIRATORY DISTRESS IN THE NEWBORN: MEDICAL CONDITKINS, with Alexander J. Schaf- far, M.D., Associate Professor Emeritus of Pedi- atrics, John Hopkins University School of Med- icine, apd Assistant Commissioner of Health of the City of Baltimore, Md. Indications of respira- tory distress in the newborn can be detected prior to labor, in labor and In delivery. The alerting signs are clearly illustrated. Dr. Schaffer also summarizes the general principles of treat- ment. (22 minutes) (in color) 1810415 118~ PAGENO="0473" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14~79 RESPIRATORY DISTRESS SYNDROME OF THE ADULT: TREATMENT WITH PEEP, with Rpbert M. Rogers, M.D.,. Professor of Medicine, Associate Professor of Physiology, and Chief of the Pul. monary Disease Section, UnIversity of Oklahoma Health Sciences Center Oklahoma City How a reasonable therapeutic program can significantly reduce high mortality from RDSA, the major pulmonary complication from trauma, hemor. rhage, surgery, septicemia, and shock. (16 minutes) (in color) 1821131 SKIN TESTING FOR TB, with John A. Crocco, M.D., Director of Pulmonary Disease Section, St. Vincent's Hospital and Medical Center, New York; and Downstate Medical Center, Brooklyn, New York. A demonstration of the correct way to administer two types of TB skin tests, with guide. Iines~for their interpretation. (12 minutes) (In color) 1920637 THE DISTRESSED NEWBORN: THE FIRST 30 MINUTES, with Peter A. M. Auld, M.D., Director, Neonatal Intensive Care Unit, and Professor of Pediatrics, New York Hospital.Cornell Medical Center, New York. Your newborn's Apgar score is low. Here's how to manage the immediate emergencies-and how to decide whether the in- fant needs intensive care. (16 minutes) (In color) 0419650 THE TREATMENT OF BRONCHIAL ASTHMA, with Frank Penman, M.D., Clinical Professor of Medicine, University of Oregon School of MedI~ cine, Portland. How to treat the asththatic pa. tient early to avoid a potehtial respiratory crisis. (16 minutes) (in color) 2020032 TREATMENT OF RESPIRATORY FAILURE, with Robert M. Rogers, M.D., Assistant Professor of Medicine, and Director of the Respiratory Inten~ sive Care Unit, Hospit~l of the University of Penn~ sylvania. The selection and application of appropriate emergency procedures in treatipg respiratory failure are fully explored. (19 minutes) (in color) 2010217 TUBERCULOSIS: A NEW MEDICAL CHALLENGE FOR THE SEVENTIE$, with Vernon N. Houk, M.D., and °hyilis Edwards, M.D., of the Tuber- culosis Section of the National Communicable DiCease Center; and William W. Stead, M.D., Professor of Medicine at Marquette School of Medicine in Milwaukee. TB is frequently dlag. nosed as pulmonary fibrosis. The epidemiology of the disease in the U.S. today is shown, along ~lth the current approach to its eradication. (17 minutes) (in cOlor) 2010419 VENOUS THROMBOSIS AND PULMONARY EM. BOLISM PREVENTION, RECOGNITION, AND TREATMENT, with Harold A. Baltaxe, M.D., De- partment of Radiology; William Gay, M.D., De- partment of Surgery; James. W. Hii~ley, MD., and SusadA. Kline, M.D., Depa~-trnent ~f Médi~ cine; all of Cornell University Medical College, New York City. Among topics considered: key signs and symptoms of venous thrombosis; pre. ventive measures, including mini.heparinization; screening tests for the presence of emboli; and therapy, both surgical and medical, with special attention given to fibrinolytic agents. (60 minutes) (in color) ACP 2857481 RADIOLOGY ABDOMINALARTERIOGRAPHY, with Robin Cafrd Watson, M.D., Chairman of the Department of D(agnostic Radiology, Memorial Sloan.Kettering Cancer Center, and Associate Professorof RadiO ology, Cornell University Medical Center, New York City. When to order an arteriogram and what it can tell you. Dr. Watson demonstrates the tech~ nique he uses to investigate a patient with a mass in the area of the pancreas, vague upper 01 symp. toms and equivocal X-rays. (20 minutes) (In color) 01184~5 APPROACH TO UPPER GI BLEEDING with Robert M. Lowman, M.D., Profes~or and Acting Chairman, Department of Radiology; and Howard M. Spiro, M.D., Chief of Gastroenterology Dlvi. sion, Department of MedIcine, Yale University School of Medicine, New Haven, Conn. Endos. copy . . . selective arteriography . . . Cofl. tract media studies . . . gastric aspiration. Which of these aids should you employ and in what order for a~patient with upper 01 bleeding? Ors. Spiro and Lowmafl review the relevant his- tory of two patients and then show the results of several examinations including arterlography and endoscopy used for the diagnoses. (19 minutes) (in color) 0118234 BRONCHIAL BRUSHING, from the UnIversity of Chicago School of Medicine with John J. Pen' nessy, M.D., Assistant Pr~fessor of RadIology. A new method of selective catheterizatlonof small peripheral bronchial segments for the diagnosis of Indeterminate peripheral lung lesions. (28 minutes). 0200110 BRONCHOGRAPHY IN THE MANAGEMENT OF BRONCHIAL DISEASES Robert J. Atweil, M.D., Professor of Medicine, and A, J. Christoferidis M.D., Professor of Radiology at the Ohio State College of MedIcine, demon- strate the techniques of infusing contrast media into the bronchi. (17 minutes). 0209711 119 PAGENO="0474" 14380 COMi~P~2I~E PROBLEMS IN THE DRUG IN~1YtJ~1~Y DIAGNOSING DYSPHAGIA, with Robert M. LowS man, M.D., Department of Radiology, and Howard M. Spiro, M.D., Chief of the Gastroenterology Divi. sion, Department of Medicine, Yale University School ~f Medicine, New Haven, Conn. Drs. Low- man and Spiro outline the order in which to use barium swallow X-rays, esophagoscopy, bougi. nage and motility studies to differentiate psycho. genic, obstructional and physiological dysphagia. They illustrate their discussion with barium swal- low X-rays and films of esophagoscopy. (20 minutes) (in color) 0417741 DIAGNOSING PEPTIC ESOPHAGITIS, with Robert M. Lowman, M.D., Professor and Acting Chair- man, Department of Radiology, and Howard M. Spiro, M.D., Chief of the Gastroenterology Divi- sion, Department of Medicine, Yale University School of Medicine, New Haven, Conn. Drs. Low- man and Spiro demonstrate how to determine the cause of heartburn and to reveal related serious diseases using barium swallow X-rays, endoscopy and the Bernstein acid perfusion test. (16 minutes) (In color) 0417842 DIAGNOSTIC RADIATION: A SAI~ETY REPORT Methods of using radiation so that the least amount is used and the greatest benefit is de- ~ived are shown by Richard 14. Chamberlain, M.D., Pfofessor and Chairman, Department of Radiol- ogy, University of Pennsylvania School of Mcd- icMe. (15 minutes). 0407109 ECHOCARDIOGRAPHY: SOUNDING THE HEART, with Fred Winsberg, M.D., Director of the Division of Diagnostic Ultrasound, Montreal General Hos- pital, and Associate Professor of Radiology, Mc- Gill University, Monfreal, Quebec, When and how to use a non-invasive diagnostic proced~ire for your cardiac patients. (14 mInutes) (in color) 0521629 ESOPHAGEAL DISORDERS AND CHEST PAIN - (EVALUATION AND MANAGEMENT OF ESOPHA- GEAL REFLUX), with Thomas R. Hendrix, M.D., Department of Medicine; Theodore M. Bayless, M.D., Department of Medicine; Martin W. Don- ncr, M.D., Department of Radiology; Francis D. Milligan, M.D., Department of Medicine; and David B. Skinner, M.D., Department of Surgery; all of the Johns Hopkins University School of Medi- cine. Clinical, radiologic, and special procedures used In evaluation of gastroesophageal reflux are presented, including acid perfusion, esopha- goscopy, cine radiology, esophageal motility, and pH probe measurement. The relation of reflux to esophagitis and to reflux symptoms are defined. Among topics discussed: medical therapy for reflux; surgical op~tions; relation of hiatal hernia to reflux; and management of complications of reflux, stricture, and esopha- geal ulcer. A Television Hospital Clinic of the American College of Physi~iahs, 1972. Please inquire for special rental information. (59 minutes) (In color) " ACP 2817243 HOW I EVALUATE THE THYROID, wittY W. Lester Henry, Jr., M.D., Professor and Chairman of the Department of Medicine, Howard Univer- sity School of Medicine, Washington, D.C. How to examine the thyroid from the anterfbr posi- tion (Instead of `the more usual posterior) with tips on the diagnosis of thyroid enlargement. Henry emphasizes the physical exam as well as the use of radioactive scans. (14 minuteS) (In color) 0816827 LARYNGOGRAPHY: PART I "Procedures and Normal Findings." A demonstra- tion of the technique for performing the lá'ryngo- gram, and a discussion of the nOrmal structures of the larynx-with George Stassa, M.D., As- sistant Professor of Radiology, New York Hos- pital-Cornell Medical Center. (18 mInutes). 1203704 LARYNGOGRAPHY: PART II "Some Abnormal Findings." Contrast laryngogra- phy enables the radiologist to evaluate the vari- ous disease processes occurring in the larynx. George Stassa, M.D., Assistant Professor of Ra- diology, New York Hospital-Cornell Medical Cen- ter, reviews the abnormal findings that might be detected with this technique. (14 mInutes). 1203905 LYMPHANGIOGRAPHY IN DIAGNOSISAND THER~ APY, with Robin Caird Watson, M.D., Chairman of the Department of Diagnostic Radiology, Memorial Sloan-Kettering Cancer Center, and Associate Professor of Radiology, Cornell Unl~ versity Medical Center, New York City. When is lymphangiography useful? What happens `to your patient when you order it? The technique and the interpretatiop of several lymphangiograms Illus. trate the procedure's place in your practice, (17 mInutes) (in color) 1219218 THE MEDICAL MANAGEMENT OF METASTATIC BREAST CANCER, with. `Justin J. Stein, M.D., Professor of Radiology, UCLA School Of Medicine, and a past President of the American Cancer Society. Advanced breast cancer: a bleak future for the patient and a difficult management prob- lem for the physician. This program provides a step-by-step approach to improve the quality of survival for your patient. (19 minutes) (in color) 1319953 NEW LIGHT FROM HEAT: THERMOGRAPHY The current status of thermography - methods as well as clinical applicatIons-is described by Jacob Gershon-Cohen, M.D., D.Sc. Med., Emeritus Director, Division of i~adiology, Albert Einstein Medical Center, and Professor Of Research Radi- ology, Temple University Medical School. (19 mInutes). 1406409 120 PAGENO="0475" COMPEPITtVE PROBLEMS IN PEE DRUG INDUSTRY 14~81 NUCLEAR MEDICINE AND THE COMMUNITY HOSPITAL, with Alexander D. Crosett, MD., Di- rector of Nuclear Medicine and Radiotherapy, Overlook Hospital, Summit, N. J. Can the com- munity hospital justify use of the expensive and sophisticated machinery of nuclear medicine? Yes, says Dr. Crosett, and he shows how his de. partmerit does. (17 minutes) (in color) 1419033 PROSTATE CANCER: CHOOSE YOUR WEAPONS, with Harry Grabstald, M.D., Urologic Surgeon; Basil S. Hilaris, M.D., Radiologist; and Charles W. Young, M.D., Medical Oncologist; all from Memorial Hospital for Cancer and Allied Dis- eases, New York City. What happens after the primary care physician and the hospital patholo- gist diagnose prostate cancer? Drs. Grabstald, Hilaris. and Young discuss the effective treat- ment alternatives and the grading and staging involved in therapeutic decisions. A look at the therapeutic alternatives and the controversies surrounding this common and often curable form of cancer. (20 minutes) (In color) 1617241 RADIOdURABLE CANCERS IN ADULTS - PART I. The principal group of tumors known to be curable by radiotherapy is demonstrated by Si~ Brian Wlndeyer, F.R.C.P., F.R.C.S., Professor of Therapeutic Radiology, The Middlesex Hospital, University of London, England. (12 minuteS). 1806201 RADIOCURABLE CANCERS IN ADULTS - PART II. Selecting the most effective treatment for a cancer patient Is a constant problem. In this presčntatioh, Sir Brian Windeyer, F.R.C.P., F.R.C.S., Professor of Therapeutic Radiology, The Middlesex Hospital, University of London, England, evaluates the alternatives of surgery or radiation therapy - or a çombinafion of both - iq squamous cell carcinoma of the tongue, cancer of the larynx, arid breast cancer. (14 mInutes). 1806~01 RADIOISOTOPE ARTERIOGRAPHY Richatd Janeway M.D., and C Douglas Maynard, M.D., of the Departments of Neurology and Radi- ofogy at the Bowman Gray School of MedIcine p~esent a new aid to cerebróvascular disease. (10 minUtes). 1809503 RADIOLOGIC DIAGNOSIS OF THE ACUTE ABDOMEN Several radiological techniques are available iff diagnosing patients presenting with acute ab~ cioflhin~l pain. Robert 0. Moseley, Jr., MD., Pro- fe~5orand ~halrman of the Departme~lt of Radi- oIo~y. University of Chicago Pritzker School of Medicine, summarizes these techniques and considers their importance in clinical findings. (15 minutes) (In color) 1808804 RADIOLOGIC MANAGEMENT OF EARLY CAI'~CER OF THE LARYNX, with Alexander D. Crosett, M.D., Director, Radiation Therapy and Nuclear Medicine, and Charles E. Langgaard, M.D., oto- laryngologist, both at Overlook Hospital, Sum- mit, N. J. How the radiation department of a community hospital approaches early laryngeal cancer and provides the patient with an excel- lent prognosis. (12 mInutes) (In color) 1818928 RECTAL BLEEDING: FINDING.THE CAUSE, With Robert M. Lowman M.D., Professor and Acting Chairman, Department of Radiology, and How- ard M. Spiro, M.D., Chief of Gastroenterology Division, Department of Medicine, Yale Univer- sity School of Medicine, New Haven Conn. brs. Lowman and Spiro review the procedures in- volved in diagnosing minimal, moderate and massive rectal bleeding and outline the order in which sigmoidoscopy, colonoscopy, barium ene- ma and selective arteriography should be em- ployed. (18 minutes) (in color) 1817927 SCANNING THE BRAIN IN CROSS SECTION, with Paul F. J. New, M.D., Chief of Neuroradiology at Massachusetts General Hospital and Associate Professor of Radiology at Harvard Medical School. Demonstration of the new radiological technique of computerized tomography, a non~ invasive method of investigating and analyzing the brain in detail that may ba the most Im- portant single advance in radiological diagnosis in 50 years. (16 minuteS) (in color) 1920435 SELECTIVE RENAL ARTERIOGRAPHY: PART I The technique for visualizing the intrarenal vas- cular system, utilizing the opaque catheter and serial roentgenography-demonstrated b~' Klaus Ranniger, M.D., Associate Professor of Radiology, University of Chicago School of Medicine. (17 mInutes). 1903802 SELECTIVE RENAL ARTERIOGRAPHY: PART II Klaus Rannger, MO., Associate Ptofessor of Ra- diology, University of Chicago SchoOl of Medi- cine, demonstrates a technique for exarplnlflg the intrarerial vascular system using the opaqUe catheter and serial roentgenogtaphy. (11 mInutes). 1904703 All programs in this catalog are copytight by the Network for Continuing Medical Ediscation. Duplication, re/roduction, or distribution in any form~ci/ all or any part of the programs is prohibited without the express written consent of NCME. 121 PAGENO="0476" 14382 COMPETITIVE PROBLEMS IN THE DRUG IN4DtrSTRY THE PROBLEM OF POLYARTHRITIS, with Mary Betty Stevens, M.D., Department of Medicine; Martin W. Donner, M.D., Department of Radi- ology; Lawrence E. Shulman, M.D., Department of Medicine; Alexander S. Townes, M.D., De- partment of Medicine; and Thomas M. Zizic, M.D., Department of Medicine; all of the Johns Hopkins University School of Medicine. A pres. entation - with illustrative patients - of clinical and laboratory features of signif- icance to the differential diagnosis of acute polyarthritis. The value and limitations of serologic findings, synovial fluid analysis, and radiographic findings, are emphasized, and the role of arthrography in diagnosis and manage. ment is evaluated. Also discussed are manage- ment programs and problems relating to rheu- matoid arthritis and its variants~ ankylosing spondylitis, microcrystalline synovitis, and Sr. ticular sepsis. A Television Hospital Clinic of The American College of Physicians, 1972. Please inquire for Special rental informatiqn. (60 mInutes) (In color) ACP 2847246 ULTRASONIC IMAGING: ECHOES WITH AN. SWERS, with Barry B. Goldberg, M.D., Associate Professor of Radiology, Temple University Health Sciences Center, and Head of Diagnostic Ultra- sound, Episcopal Hospital, Philadelphia. Will ultrasonic imaging help a diagnosis? This pro- gram illustrates some of the most frequent uses of ultrasonic imaging for the study of normal and abnormal structures in the body. (13 minutes) (In color) 2120509 WHAT CAROTID ARTERIOGRAPHY CAN TELL YOU, with Michael D. F. Declc, M.D., Associate Attending Radiologist, Memorial Sloan-Kettering Cancer Center, and Associate Professor of Radi. ology, Cornell University Medical Center, New York City. Skull films and brain scans show bone metastases in a patient with inoperable lung cancer. Following irradiation, she has progres- sively severe headaches and slight dementia. Does she have additional riletastases in the brain? Should she have more irradiation? With this patient, Dr. Deck demonstrates carotid ar- teriography and the value of the procedure. (17 mInutes) (In color) 2318909 WHAT MAMMOGRAPHY CAN TELL YOU, with Ruth Snyder, M.D., Associate Radiologist, Mem- orial Sloan-Kettering Cancer Center, and Clinical Assistant Professor of Radiology, Cornell Univer- sity Medical Center, New York City. Mammography detects early cancerous changes in the br~ast: should It be done as routinely as a Pap sffear? Dr. Snyder explains the ifldication~ and demon- strates what the technique reveals. (17 minutes) (In color) 2318007 WHAT YOU AND YOUR PATIENT SHOULD KNOW ABOUT CORONARY ARTERIOGRAPHY, with F. Mason Sones, Jr., Director of the Department of Cardiovascular Disease and Cardiac Laboratory; and bonald B. Effler, M.D., Director of the De- partment of Cardiovascular and Thoracic Sur- gery, The Cleveland Clinic. What is coronary ar- teriography? Which patients are candidates? Which patients are not? What information does the consultant need? What happens during the procedure? These questions are answered during this program which includes a demonstration of coronary arteriography. (24 minutes) (In color) 2318708 REHABILITATION AND PHYSICAL MEDICINE "DOCTOR, I PUT MY BACK OUTI": MANIPULA- TIVE THERAPY, with Philip t. Greenman, DO., Chairman and Professor, Department of Blo- mechanics, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan. Low back pain - . - a common problem seen through the eyes of an osteopathic physician. Evaluation and treatment are demonstrated. (23 minutes) (in color) 0421757 FRACTURES OF THE LOWER EXTREMITIES. Se- lected cases and principles of management of lower extremity fractures are presented by Ed- ward J. Eyring, M.D., Assistant Professor of Or- thopedics and Physiological Chemistry, and John B. Roberts, M.D., Assistant Professor of Ortho- pedics, Ohio State University College of Med- icine. (14 mInutes) 0607510 HOME MANAGEMENT OF ARTHRITIS, with John J. Calabro, M.D., Chief of Medicine and Director of Rheumatology, Worcester City Hospital, Wor- cester, Mass. A rheumatologist demonstrates how patients with arthritis can actively partici- pate in a lifelong program of comprehensive home care. The ValUe of exercises and paraffin treatments are also considered. (16 mInutes) (in color) 0820236 MANAGEMENT OF AMPUTEES: PROSTHESIS, with Ernest W. Johnson, M.D., Professor and Chairman of Physical Medicine; and William G. Pace, M.D., ProfeSCor of Surgery and Assistant Dean of Ohit~ State University College of Medi- cine. There is a great variety of prosthetic devices available today. The range of devices -` for in- fants through geriatric patients - is illustrated with emphasis on their habilitative and re- habilitative effects. (15 minutes). 1311305 122 PAGENO="0477" COMPETITB~E PROBLEMS IN THE DRUG INDUSThY 14383 MANAGEMENT OF STROKE - PART I. Rudolph Kaelbling, M.D., Associate Professor of Psy- chiatry, Ohio State University College of Medi- cine, examines the common types of stroke and their effects on consciousness, mental acuity, speech, and physical coordination, as well as the impact of stroke on the patient's family. Rehabilitation is discussed also, and a speech therapist is shown working with patients. (14 minutes) 1305506 MANAGEMENT OF STROKE - PART. II. The physical rehabilitation of the stroke patient including rehabilitative appliances, exercise, and physiotherapy - is discussed and demonstrated by Ernest W. Johnson, M.D., Chairman, Depart- ment of Physical Medicine, Ohio State University College of Medicine. (17 minutes). 1305607 MANAGEMENT OF THE AMBULATORY PATIENT WITH CHRONIC BRONCHITIS AND EMPHYSEMA, with Wilmot C. Ball, Jr., M.D.; Warde B. Allan, M.D.; and Warren Summer, M.D.; all of the De- partment of Medicine, The Johns Hopkins Uni- versity School of Medicine. A review of the evaluation and treatment of ambulatory pa tients with chronic obstrpctive pulmonary disease, Controversial aspects of manage ment are emphasized, e.g., usefulness of de- tailed physiological workup, selection and use of brochodilators, ambulatory IPPB therapy, and the role of respiratory stimulants, Selection of severely handicapped patients for exercise training or ambulatory oxygen administration is also discussed. A Television Hospital Clinic of the American College of Physicians, 1972. Please inquire for special rental Information. (58 minutes) (In colřr) ACP 2827245 PHYSICAL MEASURES FOR ARTHRITIS, STROKE AND CARDIOVASCULAR REHABILITATION, wIth John A. Faulkner, Ph.D., Department of Physi- ology and Robert L Joyn(, M.D., George H. Koepke, M.D., Barry Miller, M.D., and Edwin M. Smith, M.D., all of the Department of Physical Medicine and Rehabilitation, University of Michi- gari Medical Scho9l, Ann Arbor, Mich. The panel discusses and demonstrates physical measures for treating arthritis, techniques to prevent con- tractures following stroke and methods to use in preserving maximal function of unaffected e- tremities, and also presents the basics for pre scribing exercise for the patient with coronary heart disease. A Television Clinic of the Ameri- can CQllege of Physicians, 1973. Please inquire for special rental Information. (60 minutes) (in colon ACP 2867370 PROBLEMS IN THE MANAGEMENT OF AMPU. TEES, with Ernest W. Johnson, M.D., Professor and Chairman of the Department of Physical Medicine; and William G. Pace, M.D., Profesqor of Surgery and Assistant Dean of the College of Medicine, Ohio State University, Columbus, Ohio. Current surgical techniques both for above-knee and below-knee amputations are shown and dis- cussed, Also, part of this telecast is devoted to a technique for immediate post-operative fitting of a prosthetic leg after above-knee amputation. (16 minutes), 1611224 ROTARY INSTABILITY OF THE KNEE: PART II REHABILITATION AND MANAGEMENI In this telecast, Donald B. Slocum, M.D., and Robert L. Larson, M.D., Department of Ortho. pedics, Sacred Heart General Hospital, Eugene, Ore., continue their discussion by showing cor- rective surgery and demonstrating the there. peutic programs that follow. (18 mInutes) (in color) 18085~2 SKELETAL TRACTION - THE TEAM APPROACH - PART II - IN TRACTION. How the patient in traction benefits from the attention of a well- organized team of specialists is demonstrated by William McCloud, M.D., Resident in Otho- pedic Surgery, Ohio State University Center for Continuing Medical Education, and a depart- meptal team caring for a patient with a frac- tured femur. The occupational therapist helps the patient tO adjust to the discomfort and anxiety of pro- longed hospitalization and to prepare for limi' tations of activity during home convalescence. The physiotherapist shows the kinds of exer- cises best suited to the patient in leg traction The orthopedic nurse evaluates the patient's con- dition, particularly skin color, circuFatiQn in the fractured leg, and any signs of infection. The im- portance of hygiene is stressed as she demon- strates the proper method for bathing the patient in skeletal tractIon. (24 minutes). 2701433 STROKE - FOCUS ON INDEPENDENCE. Help- ing the stroke patient to become self-sufficient poses a challenge to the nurse in the general hospital. Elizabeth Pliskoff, RN., works with stroke patients at Good Samaritan Hospital in Phoenix, Arizona, and demonstrates how patients can be taught self-exercise, feeding themselves, and the nature of their illness. (30 minutes). 2701028 13 PAGENO="0478" 14384 COMPETITIVE PROBLEMS IN THE DRUG IN'DUSTR~ THE EXERCISE PRESCRIPTION, with Nanette K. Wenger, M.D., Professor of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta; and William L. Haskell, Ph.D., Co. Director of the Stanford University Cardiac Re- habilitation Program, Palo Alto, Cal, You can prescribe exercise as precisely as you do drugs. Here's how the results of an exercise stress test can guide you. (22 minutes) (in color) 0519324 THE TEAM APPROACH TO CHRONIC PAIN, from the Pain Control Center of Temple University Hospital, Philadelphia. With Mary E. Moore, M.D., Ph.D., Assistant Professor of Medicine, Section of Rheumatology, and psychologist; Edward .1. Resnick, M.D., Associate Professor of Orthopedic Surgery, and coordinator, Pain Control Center; Richard Eller, M.D., Associate Professor of Anes- thesiology; Shavarsh Chrissian, M.D., Assistant Professor of Rehabilitation Medicine; and Marc Flitter, M.D., Assistant Professor of Neurosurgery. Current theories of pain are leading to new methods for treatment. The techniques demon- strated here can work for you and your patients. This program was produced with the cooperation of the Department of Continuing Medical Educa- tion, Temple University. (16 minutes) (in color) 2023841 THE TEAM APPROACH TO THE CLEFT PALATE: HABILITATION Members of the staff at the Lancaster Cleft Palate Clinic in Lancaster, Pa., along with H. K Cooper, Sr., D.D.S. fouhder and Director Emeritus of the clinic, demonstrate their approach to the birth defect found in every 700 births. (18 minutes) (in color) 2010001 THE TEAM APPROACH TO THE CLEFT PALATE: REHABILITATION, with Robert T. Millard, Chief Speech Pathologist, and Mohammad Mazaheri, D.D.S.; Chief Prosthodontist, both of the Lancas- ter (Pa.) Cleft Palate Clinic. A variety of cases is explored with the team approaches to each prob- lem described in detail. (15 minutes) (in color) 2010102 For more information about NCME's Master Videocassette Library or bi-weekly videocassette service, write: NCME/15 Columbus Circle/New York, N.Y. 10023; or phone: (212) 541-8088. THERMAL INJURIES: MEDICAL, SURGICAL, AND PSYCHIATRIC CARE, with an introduction by T. G. Blocker, Jr., M.D., Prof essor of Surgery and Pres- ident Emeritus, The University of Texas Medical Branch at Galveston. The following three programs were produced under the supervision of Stephen R. Lewis, M.D., Chief of Plastic Surgery and Di- rector of Continuing Education, UTMB-Galveston. KEEPING THE BURN PATIENT ALIVE, with Duane L. Larson, M.D., Professor of Plastic Sur- gery, UTMB-Galveston, and Director, Shriners Burns Institute, Galveston. A 12-3 approach to emergency care for critically-burned patients plus the steps to take in assuring the patient's survival during transportation to a hospital. (16 minutes) (in color) 1122205 HOSPITAL BURN CARE: MINIMIZING DE- FORMITIES AND OTHER COMPLICATIONS, with Hugo Carvajal, M.D., Pediatric Nephrol- ogist, Shriners Burns Institute, and Assistant Professor of Pediatrics, UTMB-Galveston; and Duane L. Larson, M.D., Director, Shriners Burns Institute, and Professor of Plastic Surgery, UTMB-Galveston. The definitive care of burn patients. Emphasis is placed on daily wound care, fluid replacement and nutrition, and pro- cedures to minimize contracture and hyper. trophic scarring before and after grafting, (22 mInutes) (in color) 0822239 THERMAL INJURY: EMOTIONAL AND PHYSI- CAL STRESS, with Mary S. Knudson, Ph.D., Chief, DiviCion of Behavioral Sciences, Shriners Burns Institute; Duane L. Larson, M.D., Pro- fessor of Plastic Surgery, UTMB-Galveston, and Director, Shriners Burns Institute; and Robert B. White, M.D., Professor of Psychiatry, UTMB-Galveston. Practical methods to combat the physical pain, toxic delirium, helplessness, and regression seen in patients with major burns. (12 minutes) (in color) 2022240 TREATING EDUCATIONALLY/NEUROLOGICALLY HANDICAPPED CHILDREN, with Henry S. Richan. bach, M.D., Assistant Clinical Professor of Pedi- atrics, Stanford University School of Medicine; and Lester Tarnapol, SoD., Past President of the California Association for Neurologically Handicapped - both from Stanford, California. The general physician will learn about the drugs that are being administered cautiously to educa- tionally handicapped children, and the special educational programs that have been developed to assist them in daily living. (17 minutes) (in color) 2012811 124 PAGENO="0479" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14385 UNCOVERING WHAT'S RIGHT WITH THE STROKE PATIENT, with Paul J. Corcoran, M.D. Associate Professor of Rehabilitation Medicine, Boston University Medical Center, Boston. Dr. Corcoran shows the non'rehabilitation specialist how to examine and evaluate the stroke patient during his first post-CVA days. Unlike most exams, at~ tention is given to ability rather than disability. (22 minutes) (in color) 2117007 REPRODUCTION; FERTILITY AND SEXUALITY CLINICAL MANAGEMENT OF HUMAN REPRO- DUCTIVE PROBLEMS: PART I. Alvin F. Gold. farb, M.D., Assistant Professor of Obstetrics and Gynecology, Jefferson Medical College and Hos~ pital, presents "Evaluating the Infertile couple." (19 minutes). 0303118 CLiNICAL MANAGEMENT OF HUMAN REPRODUCTIVE PROBLEMS: PART II "The Physio-Anafomic Basis of Fallopian Tube Function." The second program in this continu~ ing series - with Luigi Mastrolanni, Jr., M.D., Professor of Obstetrics and Gynecology, Univer- sity of Pennsylvania School of Medicine. (17 mInutes). 0303319 CLINICAL MANAGEMENT OF HUMAN REPRObUCTIVE PROBLEMS: PART III "Tubal Factor Treatment," Correcting dIstortion of the tubal ovarian relationships. With Celso- Ramon Garcia, M.D., Associate Professor of Ob' stetrics and Gynecology, University of Pennsyl. vania School of Medicine. (16 minutes). 0303620 CLINICAL MANAGEMENT OF HUMAN REPRODUCTIVE PROBLEMS: PART IV "The Cervix in Infertility." Evaluation of the cervi- cal factor in cases of female infertility - with Kaim'an S. Moghissi, M.D. Associate Professor of Obstetrics and Gynecology, Wayne State Uni- versity School of Medicine. (17 minutes). 0304421 CLINICAL MANAGEMENT OF HUMAN REPRODUCTIVE PROBLEMS: PART V "New Research," a discussion and demonstration of the use of frozen sperm for artificial insemina~ tion; immunologic aspects of infertility; and new laparoscopic techniques. (18 minutes). 0304622 CLINICAL MAI'~A~EMENT OF HUMAN REPRODUCTIVE PROBLEMS; PART VI- INDICES OF OVULATION The tests which are available to determine the absence or occurrence of ovulation are described by Howard Balm, M.D., Chief, Gynecic. Researih Unit, Pennsylvania Hospital, Philadelphia. (26 mInutes). 0304923 CLINICAL EVALUATION OF HUMAN REPRO. DUCTIVE PROBLEMS: PART VII - INDUCTION OF OVULATION. The several methods available for treating the anovulatory, infertile female a~e evaluated by Alvin F. Goldfarb, M.D., Assistant Professor of Obstetrics and Gynecology, arid Abraham E. Rakoff, M.D., Professor of Obstetrks and Gynecology, Jefferson Medical College and Hospital; and Howard Balm, M.D., Chief, Gynec~c Research Unit, Pennsylvania Hospital. (15 minUtes). 0305024 CLINICAL MANAGEMENT OF HUMAN REPRO' DUCTIVE PROBLEMS: FINAL PROGRAM THE SUMMATION. Alvin F. Goldfarb, M.D., As- sistant Professor of Obstetrics and Gynecology, Jefferson Medical College and Hospital, presents a review and a summation of the seven programs in the series on human reproductive problem~. (20 mInutes). 0305325 COUNSELING FOR VOLUNTARY STERILIZATION: TUBAL LIGATION, with Ronald J. Pion, MD. Associate Professor of Obstetrics and Gynecol- ogy, University of Washington, Seattle. Sterilization as a fOrm of birth control was rarely performed in this óountry. Now it is incressin~ with growing concern toward "the pill," iflcreas ing interest In overpopulation and changing sexual attitudes. Dr. Pion is seen with several couples who have decided on sterilization for the wife, and their reasons and attitudes arC explored. (17 minutes) (in color) 031235~ COUNSELING FOR VOLUNTARY STERILIZATIONI VASECTOMY, with Ronald J. Pion, M.D., Assocl~ ate Professor, Department of Obstetrics anc~ Gynecology, and Director, Division of Family Planning; Nathaniel N Wagner, PhD, Assofiate Professor of Psychiatry and Obstetrics and Gyn' ecology; and J. Williams McRoberts, M.D., As' sistant Professor of Urology-all three from the University of Washington, Seattle. The psycho- logical overtones of a vasectomy, the fear of the operation and the implications of irrevocability are considered in candid detail. Patients contem- plating the operation .and those who have had the operation are interviewed. The three teach- er-practitioners raise the questions and focus on the uncertainties that most patients will exhibit when seeking advice on a vasectomy. The th~ee presenters also discuss the attitude of the physician in the interview with the patient. (20 minutes) (in color) 0312253 125 PAGENO="0480" 14386 coMi~rrnvE PROBLE~tS TN THF~ DRVG INThISTEY COUNSELING THE CANDIDATE FOR ABORTION, with Ronald J. Pion, M.D., Associate Professor of Obstetrics and Gynecology, and Director of Divi- sion of Family Planning, University Qf Washing- ton School of Medicine, Seattle. Dr. Pion interviews three patients. In each con- versation, he concentrates on providing the patient seeking a termination to her pregnancy with options and alternatives to reach a rational decision to her crisis. (17 minutes) (in color) 0311-2454 COUNSELiNG THE POST-ABORTION PATIENT, with Ronald J. Pion, M.D., Associate Professor, Department of Obstetrics and G~,necology, and Director of the Division of Family Planning; and Nathaniei N. Wagner, Ph.D., Associate Professor of Psychiatry and Obstetrics and Gynecology, both from the University of Washington School of Medicine, Seattle, Washington. Post-abortion patients are interviewed in an attempt to show physicians the opportunities that exist for helping patients beyond a period of crisis. (18 mlnutes)(in color) 0312555 EGG TRANSPORT IN MAMMALS, with Richard J. Blandau, M.D., Professor of Biologicai Structures, University of Washington School of Medicine. Discussion and cinemicrographic visualization of egg transport in rabbits, rats, and humans. (15 minUtes). 0501404 FEEDBACK: SEX EDUCATION. The provocative subject of `Sex Education" is introduced by Alvin F. Goldfarb, M.D., Assistant Professor of Obstetrics and Gynecology, Jefferson Medical College and Hospital, Philadelphia Participants in the panel are: Moderator: Hubert L-. Allen, M.D., Instructor in Clinical Obstetrics and Gyne. cology, Washington University School of Medi. cine, St. Louis, Missouri. Clay Burchell, M.D., Associate Professor of Obstetrics and Gynecol- ogy, University of Illinois College of Medicine, Chicago. John W. Huffman, M.D., PrOfessor of Obstetrics and Gynecology,- Northwestern Uni- versity Medical School, Chicago. Capt. James P. Semmens, MC, USN, Chief of Obstetrics and Gynecology, U.S. Naval Hospital, Oakland, Call. fornia. Don W. Oakes, A.B,, M.A., Director of Secondary Education, Hayward Unified School District, Hayward, California. (50 minutes). 0604001 FEMALE HOMOSEXUALITY - PART I - PER- SONAL ASPECTS. John F, Oliven, M.D., Associ- ate Attending Psychiatrist, College of Physicians ançi Surgeons, Columbia University, analyzes the psychological problems of Lesbianism through his commentary on an interview between a Les- bian-transvestite and John W. Huffman, M.D., Professor of Obstetrics add Gynecology, North- - western University Medical School. (15 mInutes). 0605702 FEMALE HOMOSEXUALITY - PART II- INTER- PERSONAL ASPECTS. An interview between a Lesbian-transvestite and John W. Huffmart, M.D., Professor of Obstetrics and Gynecology, North- western University Medical School, is inter- spersed with commentary by John F. Oliven, M.D., Associate Attending Psychiatrist, College of Physicians and Surgeons, Columbia University. (21 minutes). 0605803 HUMAN SEXUALITY; A BARRIER TO TREAT- MENT; -with Ronald is Pion, M.D., Associate Pro- fessor of Obstetrics add Gynecology add ~lrector of the Division of Family Planning; and Nathaniel N Wagner, Ph.D., Associate Professor of Psy- chiatry and Obstetrics and Gynecology, both frotn the University of Washington School of Medicine in Seattle, Washington. Few physicians are comfortable discussing sex problems with their patients. Yet patients and physicians alike agree that a candi.d discussion can benefit the patient. Doctors Pion and Wag- ner discuss the problem and offer examples of "breaking the barrier" with three patient Inter- views. (18 minutes) (in color> 0811108 IMPOTENCE, with philip A. Sorrel, M.D., Asso- ciate Professor of Obstetrics and Gynecology at Yale University Medical School~ apI Lorna Sarfel, Co-Director of the Human Sexuality Program at the Yale University Student Mental Hygiene De- partment in New Haven, Connecticut. Secondary impotence-one of the most common sexual complaints-will usually yield to deft detective work and coudselling. This program illustrates how two leading sex therapists approach the problem. (18 mInutes) (in color) 0921330 LAPAROSCOPIC STERILIZATION, with Thorhas & Dillon, M.D., Director of Obstetrics and Gynecol- ogy, Roosevelt Hospital, and Professor of Ob- stetrics and Gynecology, Columbia UniversIty College of Physicians and Surgeons, New York City. Endoscopic film sequences taken during laparoscopic tubal sterilization accompany a demonstration of the-procedure. (20 minutes) (in color) 121881~ All programs in this catalog are copyright by the Network for Continuing Medical Education. Duplication5 reproduction, or distribution in any form of all or any part of the progrartis is prohibited without the express written consent of NCME. 126 PAGENO="0481" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14387 LARGE SCALE PREGNANCY TESTING FOR THE `70s, with Elizabeth Connell, MD., Associate Professor of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University in New York, and Director, Family Life Services, International Institute for Study of Human Re production; Ralph W. Gause, M.D., Obstetrical Consultant, National Foundation-March of Dimes; and Donald P. Swartz, M.D., Clinical Professor of Obstetrics and Gynecology, College of Physicians and Surgeops and Director of Obstetrics and Gynecology, Harlem Hospital in New York. Three physicians demonstrate the ease of administra- tion and reliability of new inexpensive pregnancy tests. The doctors also identify situations in which wider/pregnancy testing may now be indi- cated, and donsider issues raised by the simpli- city and accessibility of pregnancy testing kits. (19 minutes) (In color) 1213914 MALE FERTILITY: DIAGNOSIS, TREATMENT, CONTROL, with Robert S. Hotchkiss, M.D., with the Department of Urology, New York University School of Medicine; and John MacLeod, Ph.D., with the Department of Anatomy, Cornell Univer- sity Medical College. First, the biology of male fertility is discussed. Then the history taking, physical examination and sperm specimen collection are described. Re- nnp,rks are made on the regulation of fertility with drugs. And finally, surgical treatment for infertil- ity is explored. (18 minutes) (in color) 1311003 MANAGEMENT OF ADOLESCENT SYMPTOMS. Methods of dealing with the problems of ado- lescents - particularly experimentation with sex and drugs - are demonstrated with groups of teenagers, by Steven R. H~mel, M.D., Depart- ment of Pediatrics, Jefferson Medical College and Hospital of Philadelphia, Pa. (18 minutes). 1308004 MANAGEMENT OF THE PATIENT WITH AN IN- TRAUTERINE DEVICE, with Don Sloan, M.D., Assistant Clinical Professor and Director, Division of Psychosomatic Medicine, Dept. of Obstetrics and Gynepology, New York Medical College. The intrauterine device is now established as a stand- ard contraceptive option. By means of "typical patient" interviews, Dr. Sloan reviews indications for prescribing the IUD and outlines points to be made in counseling the patient at time of insertIon. (57 minutes) (In color) 1315645 NATURAL CH1LDBIRTH: THE PHYSICIAN'S ROLE, with Alfred Tanz, M.D., obstetrician and gynecol- ogist, Lenox Hill Hospital, and Assistant Clinical Professor of Obstetrics and Gynecology, New York Medical College, New York City. Far from relieving the physician of his responsibility in childbirth, this increasingly popular approach to labor and delivery emphasizes his role at the times he Is really needed. (15 mInutes) (in color) 1418932 THE PILL AND THE INFORMED PATIENT, with Louis M. Heliman, M.D., Deputy Assistant Secre- tary for Population Affairs, U. S. Department cif Health, Education and Welfare, Washington, D. C., Professor and Chairman Emeritus, De- partment of Obstetrics and Gynecology, State University of New York Downstate Medical Cen- ter, in New York City. An update on oral conti~a- ceptives and how to counsel patients for in- formed consent. ~r. Heilman interviews a healthy young patient, beginning contraception, and cn older patient with complications related'to oral contraceptive drugs. This program is presented as part of the American Society for Clinical Pharmacology and Therapeutics Drug Spotlight Program. (29 minutes) (In color) 1623450 SEX IN AGING AND DISEASE, with Philip A, Sarrel, M.D., Associate Professor Qf Obstetrics and Gynecology at Yale University Medical School; and Lorna Sarrel, Co-Director of the Human Sexuality Program at the Yale University Student Mental Hygiene Department in New Haven, Connecticut. Sexual development of healthy aging persons, as well ac patieptS with the more common geriatric disorders, is dis- cussed. (19 minutes) (in color) 1921438 SYPHILIS: BE SUSPICIOUS, with Frank M. Calia, M.D., Chief, Infectious Diseases,' Loch Raven Veterans Hospital, and Associate Professor of Medicine, University of Maryland School of Medicine, both in Baltimore. A new look at an old enemy, with emphasis `on the pros and cons of a variety of serologic tests. (15 minutes) (In color) 1917628 THE PILL: CLINICAL ASPECTS. Perhaps no other group of drugs has elicited such con- tinuing concern on the part of physicians and patients~ as have the oral contraceptives. In this presentation, all available data on the or- ganic effects ~f the pill are brought together by Celso Ramon Garcia, M.D., Professor of Ob- stetrics and Gynecology, Edward E. Wallach, M.D., Assistant Professor of Obstetrics and Gyne- cology, and Harold I. Lief, M.D., Professor of Psychiatry, University of Pennsylvania School of Medicine. In spite of possible risks associated with the pill, they point out that physicians must consider it in the light of fear of pregnancy, of unwanted pregnancy or of illegal abortion. (21 minutes). 0607517 127 73-617 0 - `16 31 PAGENO="0482" 14388 COMPETITIVE PROBLEMS IN THE DRUG ThThTJSTRY THE PILL: COUNSELING FOR AND AGAINST ITS USE with Don Sloan, M.D., Assistant Clinical Professor and Director Division of Psychosomatic Medicine, Department of Obstetrics and Gyflecol~ ogy, New York Medical College, New York, N.Y. One patient wants the pill and shouldn't have it. another wants an IUD but should use the pill. Dr. Sloan, in Interviews with teaching-assistant "patients' demonstrates how to obtain relevant information about medical history and sexual activity, and how to steer the patient toward the appropriate contraceptive. (15 minutes) (In color) 1615739 TREATING THE INFERTILE COUPLE: DIFFICULT DIAGNOSES AND MANAGEMEwT, with Melvin R. Cohen, M.D., of the Michael Reese Hospital and Medical Center and the Chicago Fertility InstI- tute, Chicago, III. When medIcal and marital histories, Interviews and fertility tests fall to reveal the reasons for infertility, a series of sophisticated tests can be performed. Such techniques as the Rubin Gas Test or hysterosal- pingography, culdoscopy and laparoscopy are among those that Dr. Cohen describes during this program. (17 minutes) (in color). 2013321 TREATING THE INFERTILE COUPLE: INITIAL WORKUP AND DETERMINATION OF OVULATION, with Melvin R. Cohen, M.D., of the Michael Reese Hospital and Medical Center and the Chicago Fer. tility Institute, Chicago, II). Dr. Cohen conducts an interview with an infertile couple to demon. strate the gathering of a marital and medical history, to ascertain abnormalities in the wife and to determine the fertility of the husband. (16 mInutes) (In color) 2013220 THE VAGINA AND FEMALE SEXUAL DYSFUNC. lION, with Philip A. Sarrel, M.D., Associate Pro. fessor of Obstetrics and Gynecology at Yale University Medical School; and Lorna Sarrel, Co- Director of the Human Sexuality Program at the Yale University Student Mental Hygiene Depart. ment, in New Haven, Connecticut. Vaginitis and the resulting vaginismus are diagnosed and treated. Medical and sex-counseling protocols are set forth. (18 minutes) (in color) 2220802 VASECTOMY PERFORMED IN THE OFFICE, with Philip Roen, M.D., Associate Professor of Urol- ogy, New York Medical College, and Director of Urology, St. Barnabas Hospital, New York City. In 1960, 100,000 men underwent vasectomy in the United States. The trend now indicates more than a million a year will be conducted during the seventies. Dr. Roen shows us an actual vasectomy - from incision to fascial closure - to demonstrate the efficacy of performing the procedure in the office. (17 minutes) (In color). 2214501 WHAT GOES ON AT SEX THERAPY CLINICS, with Harold Lear, M.D., Direftor of the Human Sexu- ality Program, Mount Sinai Hospital,. New York City. What really happens in those Masters and Johnson.type sessions? Dr. Lear and co-ther. apist Ann Welbourne, R.N., show you - in a counseling session with a cOuple whose problem is the husband's premature ejaculation. (22 mInutes) (In color) 2317006 WHEN THE SUBJECT TURNS TO SEX. . Sexual history taking can be the cause of embassass ment and anxiety for both the physician and the patient. Dr. Harold Lear, of the Mount Sinai Medical Center in New York City, and four medical students demonstrate and discuss when and how to take the history of a patient's seXual behavior. (29 mInutes) (in color) SAMA 2810854 SPACE MEtICINE ALTITUDE STRESS-PART I-'-E. R. Buskirk, M.D., Director of Laboratory for Human Performance Research, Pennsylvania State University. Olym- pics `68-research on athletic performance at high altitudes in Peru and Colorado. (13 minutes). 0102509 ALTITUDE STRESS- PART II - "HypoxIa" - with E. R. Buskirk, M.D., DirectOr of Laboratory for Human Performance Research, Penniylvania State University. Olympics `68-research on ath- letic performance at high altitudes in Peru and Colorado. (16 minutes). 0102610 SKYLAB: CLINIC IN ORBIT, with Capt. Joseph P. Kerwin, M.D., U.S.N., NASA Headquarters, Houston; and Charles M. Plotz, M.D., Med. Sc.D., NCME Advisor, Professor of Medicine and Chairman of the Department of Family Practice at Downstate Medical Center, Brooklyn, N.Y. Us- ing videotapes recorded in orbit, Capt. Kerwin de- scribes the implications of Skylab experiments for terrestrial medicine. (16 minutes) (in color) 1919331 WHAT ARE WE LEARNING IN SPACE MEDICINE? (HUMAN ADAPTATION TO SPACE), with Charles A. Berry, M.D., Director of Medical Research and Operations, NASA, Houston, Texas. Dr. Berry reveals how he and his team of physicians have answered the question: "What is the worst thing that can happen to the astronauts during a flight?" Such considerations as prophylactic surgery and medication aboard the flight are disclosed. (14 minutes) (in color). 2313705 128 PAGENO="0483" COMPETIT]NE PROBLEMS IN THE DRUG INDUSTRY 14389 WHAT ARE WE LEARNING IN SPACE MEDICINE? (IN'FLIGHT CONCERNS), with Charles A. Berry, M.D., Director of Medical Research and Opera tions, NASA, Houston, Texas. Dr. Berry takes us through the countdown of medical activity during a rocket launch. He offers anecdotes, supplemented with official NASA film - such as the implications of losing Alan Shepard, Jr.'s EKG sensor prior to Apollo 14 liftoff. (28 mInutes) (in color) 2313704 WHAT ARE WE LEARNING IN SPACE MEDICINE? (THE PHYSIOLOGICAL ENVIRONMENT), with Charles A. Berry, M.D., Director of Medical Re. search and Operations, NASA, Houston, Texas. Among the many medical problems Dr. Berry highlights in this telecast are loss of red cell mass on long flights and new monitoring leads for various bodily functIons with a suggestion of how they might be used in conventional" pa. tient practice. (13 mInutes) (in color) 2313703 SURGERY BEDSIDE PULMONARY ARTERY CATHETERIZA TION, with T. Crawford McAslan, M.D., Associate Clinical Director, Maryland Institute for Emer. gency Medicine, and Professor of Anesthesiology, University of Maryland School of Medicine, Balti' more. An introduction to the Swan~Ganz fIow~directed, baIIoon~tipped catheter. Indications, method of insertion at bedside, and techniques for avoiding complications. (15 minuteS) (in color) 0223621 Rental and purchase prices cover the actual costs of duplication; therefore, no provision is made for the previewing of catalog programs. If, in the opinion of the person for whom it was ordered, a pro- gram contains any significant flaw or in- adequacy, no charge will b~ made. The reviewer is, however~ requested to state the reason on the program review card that accompanies each Master Library videocassette. CARDIAC TRANSPLANTATION. With Denton A. Cooley, M.D., Professor of Surgery; Robert D. Bloodwell, M.D., Assistant Professor of Surgery; Grady L. Haliman, M.D., Associate Professor of Surgery; and Robert D. Leachman, M.D., Pro' fessor of Cardiology, Baylor University College of Medicine. Cardiac transplantation deserves now to be ac cepted in the vast armamentarium of treatment of the coronary patient, according to Dr. Cooley. Noting this, he points out that the 2roblems sur~ rounding rejection of the donor heart are being met with increasingly good results. Thus, he adds, the major drawback to increased use of cardiac transplantation is the availability of donor hearts. The implications of this - the need for a new definition of death as well as possible procedures for storing donor hearts - are discussed by Dr. Cooley and his colleagues. The film for this presentation was taken during the first transplantation. While the procedure has not changed radically in transplantations that followed this one, the attitudes of the phy' sicians have. No longer Is the transplant patient treated like a "cardiac cripple," they contend. Rather, where possible, every attempt is made to handle him as any other postoperative case with ambulation after 48 hours the goal. (30 minutes) (In color) 2007014 CESAREAN BIRTH Delivery by Cesarean Section - with Stanley H. Tischler, M.D., Associate Obstetrician.Gynecolo' gist of The Jewish Hospital of Brooklyn. (8 mInutes). 0303201 CLINICAL MANAGEMENT OF HUMAN REPRODUCTIVE PROBLEMS: PART III "Tubal Factor Treatment." Correcting distortion of the tubal ovarian relationships. With Celso- Ramon Garcia, M.D., Associate Professor of Ob. stetrics and Gynecology, University of Pennsyl- vania School of Medicine. (16 mInutes). 0303620 CRYOSURGERY A demonstration of the treatment of chronic en' docervicitis with cryosurgery, and a discussion of its advantages in other gynecologic pro' cedures with Sidney Lefkovics, M.D Chief, Sec- tion of Obstetrics and Gynecology, St Barnabas Hospital, Livingston, New Jersey. (16 mInutes). 0303556 CRYOSURGERY, A CATARACT PROCEDURE The special indications and technique for utiliz- ing the cryostylet in cataract surgery are demon- strated and discussed by Gerald Fonda, MD, Director, Ophthalmology Division, Department of Medicine, St. Barnabas Medical Center, Living- ston, New Jersey. (13 mInutes). 0303957 129 PAGENO="0484" 14390 COMPETITIVE PROBLEMS IN THE DRuG IN~DUSTRY DIAGNOSIS OF OCCULT INTRA-ABDOMINAL NEOPLASMS, with Herbert B. Greenlee, MD., Department of Surgery, Loyola University of Chi- cago, Stritch School of Medicine, Maywood, Ill., and Veterans Administration Hospital, Hines, Ill.; Erwin M. Kammerling, M.D., Department of Medi- cine, University of Health Sciences, The Chicago Medical School, and Louis Weiss Memorial Hos- pital, Chicago; Sumner C. Kraft, M.D., Depart- ment of Medicine, University of Chicago; and Armand Littman, M.D., Department of Medicine, University of Illinois, College of Medicine, Chi- cago, and Veterans Administration Hospital, Hines, Ill. The panel presents cases illustrating some of the difficulties and solutions involved in tracking down a diagnosis of intra-abdominal neoplasms. Emphasis is given to the tests (some old, some new, some under-utilized) which are helpful in deciding to perform exploratory Iapa- rotomy. A Television Clinic of the American Col- lege of Physicians, 1973. Please inquire for special rental information. (60 mInutes) (In color) ACP 2847368 THE DIAGNOSTIC CHALLENGE OF CHEST PAIN, with moderator Alfred Soffer, M.D., Professor of Cardiology at the University of Health Sciences- Chicago Medical School, Chicago, and Editor-in- Chief of Chest, the Journal of the American Col- lege of Chest Physicians. Participants are: R. D. Henderson, MB., F.R.C.S. (C)., Staff Surgeon, Toronto General Hospital and Assistant Professor of the Department of Surgery at the University of Toronto, Canada; Barry William Levine, M.D., Assistant Professor of Medicine, Harvard Medi- cal School, and Chief, Outpatient Pulmonary Services, Massachusetts General Hospital, Bos- ton; Linda D. Lewis, M.D., Assistant Professor of Neurology, College of Physicians and Surgeons of Columbia University, and Chief of the Neu- rology Clinic, Neurological Institute of Columbia Presbyterian Medical Center, New York City, Morton E. Tavel, M.D., Associate Professor of Medicine at the Indiana University School of Medicine, Indianapolis. Pinpointing the cause of your patient's chest pain poses an urgent diagnostic challenge. Join Dr. Soffer and four specialists on these clinical grand rounds as they reach a diagnosis on five patients. (32 minutes) (in color) 0423362 DIAGNOSTIC THORACENTESIS, with James W. Kilman, M.D., Associate Professor of Surgery, and Thomas E. Williams, Jr., M.D., Assistant Professor of Surgery, Ohio State University Col- lege of Medicine, Columbus. Thoracentesis for both diagnosis and emergency therapy is per- formed following a discussion of the causes, signs, and symptoms of pleural effusion. (19 mInutes) (In color) 0419248 DICEPHALUS DIPUS TETRABRACHIUS. Row- ena Spencer, M.D., Associate Professor of Sur. gery and Pediatrics, Louisiana State University School of Medicine, presents the surgical separa' tion of partial Siamese twins. (13 minutes). 0402114 EARLY SURGERY FOR THE ARTHRITIC HAND, with Alan H. Wilde, M.D., Head of the Rheuma- toid Surgery Section, Department of Orthopaedic Surgery, The Cleveland Clinic Foundation. When six months of intensive medical management fail to help the patient with rheumatoid arthritis of the hand, synovectomy may preserve useful function and relieve pain. In this program: * the rationale for synovectomy; * the history and physical exam used to disclose indications for surgery; and * the operative procedure and the postoperative results. (20 minutes) (in color) 0518522 EMERGENCY CLOSED TUBE THORACOSTOMY, with James W. Kilman, M.D., Associate Professor of Surgery, and Thomas E. Williams, M.D., As- sistant ProfessOr of Surgery, Ohio State Uni- versity College of Medicine, Columbus. The causes, consequences, symptoms, and signs of pneumothorax are reviewed and an emergency closed tube thoracostomy is performed. (20 mInutes) (In color) 0519123 HERNIA. One in a series of Anatomical Relation- ships from Duke University Medical Center, A graphic review and patient presentation of in- gulnal and diaphragmatic hernias, with F. D. McFalls, M.D., and John L. Dobson, M.D., De- partment of Anatomy. (31 minutes). 0800704 HOW I DO SUBCLAVIAN VENIPUNCTURE, with Josef E. Fischer, M.D., Assistant ProfessOr of Surgery, Halyard Medical School, and Instructor in Surgery at Massachusetts General Hospital, Boston. Dr. Fischer demonstrates catheter place- ment in the subclavlan vein and outlines Indica- tions and contraindications for the procedure. (17 mInutes) (In color) 0817830 HOW I TREAT VARICOSE VEINS, with Robert A. Nabatoff, M.D., Chief of the Vascular Clinic, Mount Sinai Hospital and Medical Center, New York City. Injection or surgery? Dr. Nabatoff's outpatient stripping procedure, which he dem- onstrates, answers a number of the practical objections to surgical therapy. (20 mInutes) (In color) 0818231 130 PAGENO="0485" COMPETITtVE PROBLEMS IN THE DRUG INDUSTRY 14391 INGUINAL HERNIA REPAIR: THE SHOULDICE TECHNIQUE, from the Lankenau Hospital in Philadelphia, with Edwin W. Shearburn, M.D., Director of Surgery; and Richard N. Myers, M.D., Associate Surgeon. Dr. Shearburn is also Pro- fessor of Surgery and Dr. Myers, Associate Pro- fessor of Surgery at Thomas Jefferson Medical College In Philadelphia. Anesthesia? Local. Re- covery? Patient ambulatory within a few hours. Should you recommend this operation to your next inguinal hernia patient? Two surgeons who have performed over 1,000 Shouldice procedures say `yes" and demonstrate the technique. (17 minutes) (in color) 0923433 INTERNAL JUGULAR VEIN CATHETERIZATION, with T. Crawford McAslan, M.D., Associate Clini- cal Director, Maryland Institute for Emergency Medicine, and Professor of Anesthesiology, Uni- vertity of Maryland School of Medicine, Balti- more. the internal jugular vein - - - an attractive alternative to the basilic with its high failure rate and the subclavian with its high incidence of pneumothorax. (11 minutes) un cřlor) 0923735 KIDNEY TRANSPLANTATION The following physicians from Cedars-Sinai Med ical Center in Los Angeles, Calif., discuss renal transplantation with the general physician in mind: Stanley S. rranklin, M.D., Medical Director of the Transplantation Program; Charles R. Klee- man, M.D., Director of Medicine; Morton H. Max- well, M.D., Chief of Nephrology and Hypertension Service; Paul Teraski, M.D., Professor of Surgery at the UCLA School of MedicIne; Richard L. Treiman, M.D., and Harold 0. Kudish, M.D., both vascular surgeons. (19 minuses) (In color) 1109003 LAPAROSCOPIC STERILIZATION, With Thomas F. Dillon, M.D., Direttqr of Obstetrics and Gynetol' ogy, Roosevelt Hosp'ttal, and Professor of Ob- stetrics and Gynecology; ColumbIa University College of Physicians and surgeons, New York City. Endoscopitt film sequences taken during laparoscopic tubal sterilization accompany a demonstration of the procedure. (20 minutes) (In color) 1218817 PRIMARY TREATMENT OF SOFT TISSUE IN- JURIES, with Ronald B. Berggren, M.D., Pro- feSso~ and Director, Division of Plastic Surgery, Ohio State University College of Medicine, Co- lumbus. The three Ds of sound management, Diagnosis, Debridement and Definitive Care, are demonstrated. Special emphasis is given to ways to avoid particulaf deformities. (19 minutes) (in color) 1619443 MANAGEMENT TIPS FOR SOFT TISSUE INJU~ RIES IN CHILDREN, with Thomas S. Morse, M.D., Associate Professor of Surgery, Ohio State Uni~ versity College of Medicine, Columbus, Ohio. The surgical technique for repairing a laceration in a child is about the same as that used for adults, but there are ways to make it easier. In this program, special attention is given to dress- ings, restraints and slings, as Dr. Morse shares his "little tricks" that help make it easier to deal with children. (18 mInutes) (in color) 1319552 RECONSTRUCTIVE HAND SURGERY, with Leo A. Keoshian, M.D., Clinical Instructor of Surgery, Stanford University School of Medicine, Stanford, California. Highlights of surgical procedures carried out in Vietnam are detailed. The reconstructive hand surgery necessitated by war injuries is related to similar civilian injuries (le., a firecracker injury). (21 minutes) (in color) 1811707 REDUCTION MAMMOPLASTY, with José Castillo, M.D., Assistant Professor of Surgery, Jefferson Medical College, Philadelphia, Pa. (Excerpts from surgical procedure presented at American College of Surgeons' 57th Annual Clinical Con- gress.) Although introduced In the U.S. as re- cently as the mid-19~Os, the StrOmbeck proce- dure for relief of mammary hypertrophy was performed on more than 5,000 women in 1971. This program details indications for the opera. tion, shows the major points of surgery, and assures the referring physician of Its safety and positive results. (12 minutes) (In color) 1815426 REPAIR OF A RUPTURED VENTRICULAR SEPTUM A ruptur~ of the ventricular septum is a com- paratively uncommon phenomenon. most often occurring in patients who have suffered an occlu- sion, particularly of the left coronary artery in- volving the septal branch. The technique fof repairing the rupture is demonstrated by Adrian Kantrowitz, M.D., Director of Surgery, Maimoni- des Medical Center, Brooklyn, and Professor of Surgery, State University of New York, College of Medicine. (Se mInutes). 1803810 RES~CTING AN ANEURYSM OF THE ASCEND- ING AORTA The demonstration illustrates the standard tech niques for resection of an ascendIng aorta using pump oxygenator by-pass. continuous coronary perfusion, and replacement with dacron pros- thesis--with Adrian Kantrow,tz, M.D., Director of Surgery, Maimonides Medical Center and Pro- fessor of Surgery, State University of New York, College of Medicine. use minutes). 1803313 131 PAGENO="0486" 14392 COMPETITIVE PROBLEMS IN THE DRUG INDUSPRY RESPIRATORY DISTRESS IN THE NEWBORN: INDICATIONS FOR SURGERY, with Alexander J. Schaffer, M.D., Associate Professor Emeritus of Pediatrics, Johns Hopkins University School of Medicine, and Assistant Commissioner of Health of the City of Baltimore, Maryland. The clinical signs of respiratory distress are shown, along with examples of anomalies. Special attention i6'given to the approach of arriving at a specific dIagnosis. (25 minutes) (In color) 1810314 RETAINED COMMON DUCT STONES. George M. Saypol, M.D., Associate Clinical Professor of Sur. gery, New York University Medical Center, and Director of Surgery, The Long Island Jewish! Queens Hospital Center, discusses the manage- ment of stones left in the bile ducts following cholecystectomy. (19 mInutes). 1801117 SCOLIOSIS: WHEN TO OPERATE, with Hugo A. Keim, M.D., Director of the Scoliosis Clinic, New York Orthopaedic Hospital of the Columbia Uni- versity Medical Center; and David B. Levine, M.D., Associate Attending Orthopedic Surgeon, Hospital for Special Surgery, and Clinical Asso- ciate Professor, Cornell University Medical Col~ lege, New York City. The choice between brac- ing and surgery for scoliosis may pose a dilem. ma. Doctors Levine and Keim demonstrate when surgery is indicated, and offer the referrIng physician insight into the whys and the hows of current surgical and bracing techniques. (15 minutes) (in color) 1914827 SELECTING PATIENTS FOR TOTAL KNEE RE. PLACEMENT, wIth John A. Lynch, M.D., Ortho., pedic Surgeon Topeka, Kansas, and Associate Professor of Clinical Orthopedics,. University of Kansas School of Medicine, Ka'nsds City, Kansas. Which, of your patients with arthritic knees is a candidate for a knee prosthesis? Here are the guidelines plus new information on this con- stantly changing solution to severe knee pain. (17 minutes) (In color) 1921639 SPECIAL PROBLEMS OF FACIAL TRAUMA SURGERY - PART I. Examination and repair of lacerations of the soft tissue of the face are discussed and demonstrated by Ross H. Mus- grave, M.D., Clinical ASsociate Professor of Sur. gory (Plastic), University of Pittsburgh School of Medicine. (26 mInutes) (in color) 1905412 SURGICAL TREATMENT `OF HEART BLQCK - PART I. Robert Schramel M.D., Associate Pro- fessor of Surgery, Tulane University School of Medicine, discusses and demonstrates surgical use of electronic pacemakers. (15 minutes). 1902823 T & A: PANACEA OR PLACEBO?, with Melvin' E. Sigel, M.D., Clinical , Associate Professor, De. partment of Othiaryngology, University of Miji~ nesota Medical School, Minneapolis. The oldest surgical thera~y still In use . . . when Is it in order today? iie minutes) (in cOlor) 2022038 THE PRESENT STATUS OF CORONARY A~TERY BYPASS SURGERY, with RoIf M. Gunnar, M.D., Department of Medicine, Loyola University of Chicago, Stritch School'of Medicine, Maywood, liI. and Veterans Administration Hospital, Hines, Ill.; John M. Moran, M.D., Department of Sur- gery, Rlmgaudas Nemickas, M.D., Deparment of Medicine, Roque Pifarré, M.D., Department of Surgery, and Patrick Scanlon, M.D., Department of Medicine, all of Loyola University of Chicago, Stritch School of Medicine, Maywood, Ill The indications, contrai,ndications, and ways to assess the prognosis of coronary aftery surgery, including vein grafts, endartérectomy, and In- ternal mammary artery grafts, are illustrated and discussed. in addition, postoperative comrn plications are put in perspective and ways to evaluate postoperative results are discussed, A Television ~Iinic, of the American College of Physicians, 1973. Please inquire for special rental informatiOn. (60 mInutes) (in col6r), ` ACP 2837367 THE VALUE OF RENAL BIOPSIES IN THE MAN- AGEMENT OE, PATIENTS, with Kent Armbruster, MD., Department of Medicine, Rush Medical `College, Chicago; David P. Earle, M.D.,, Depart- ment of Medicine, Northwe,skern University, Medi- cal School, Chlcčgo; Robert Jennings, M.D., De- partment of Pathology, Nort~wSstern Univer~ity Medical Scho~I, ~hicagô; Robert M. Kark, MD., Department of Medicine, Rush Medical College RUsh-Presbyterian~St. LUkg's Medical Center, Chicago; Robert C., Muehrcke, M.D., Department of Medicine, Rush Medical College, Rush. PreSbyterian-St. Luke's Me~ical Center, Řhicago; Conrad Pira~i, M.D., Departrn~nt of Pathology, Columbia University Co~Iege of PhysicIans and Surgeons, New York. .City; an~. Hock H Yeoh,' M.1~., Depar~ftlčr~t of Medicihe,' NorthweStern University Medictl SchooJ, chicago. To,illt~strate the usefulness `~f reiTa~ biopsy lr~ tl~e,Qi~hSgS- meitt of certait~ pSfients with. r~flalŘlseaSe, both pathoIogist~ and cflnicianik diScuss particular patient problems along ~iitIi the corrCspondlqg history, clini~a~ and laboratory flndIng~s, and renal bIops~'reCtilts for each `patient. A TCl9ViSlOn Clinic of the. Atheric~p college of Physitians, 103. Pte~se inq'UirS for special reiit~ ~ mation. (60 minutes) (~n color) , ,ACP 28~7369', 132 PAGENO="0487" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14393 THE UNIFORM DONOR CARD, with Alfred M. Sadler, Jr., M.D., and Blair Sadler, LL.B., of the National Institutes of Health, Bethesda, Mary- land. Another NCME program explained how the Uniform Anatomical Gift Act affected the practicing physician. Since that program a re lated development has occurred in the form of a newly-approved Uniform Donor Card. This is a special report on the card. (9 minutes). 2110502 THERAPEUTIC LAMELLAR KERATOPLASTY, with A. Benedict Riizuti, M.D., Director of Corneal Service, Brooklyn Eye and Ear Hospital. A dem- onstration of specialized corneal surgery. (15 minutes). 2003005 THERMAL INJURIES: MEDICAL, SURGICAL, AND PSYCHIATRIC CARE, with an Introduction by T. 0. Blocker, Jr., MD., Professor of Surgery and Pres- ident Emeritus, The University of Texas Medical Branch it Galveston. The following three programs were produced qnder the supervision of Stephen A. Lewis, M.D., Chief of Plastic Surgery and Di- rector of Continuing Education, UTM~-Galveston. KEEPING THE BURN PATIENT ALIVE, with Duane L. Larson, M.D., Professor of Plastic Sur- gery, UTMB-Galv~ston, and Director, Shriners Burns Institute, Galveston. A 1-2-3 approach to emergency care for critically-burned patients plus the steps to talçe in assuring the patient's siirvival during trahsportation to a hospital. (16 minutes) (in color) 11.22205 HOSPITAL BUF~N CARE: MINIMIZING DE- FORMITIES AND OTHER COMPLICATIONS, with Hugo Carvajal, M.D., Pediatric Nephrol- ogist, Shriners Burns Institute, and Assistant Professor of Pediatrics, UTMB-Galveston; and Duane L. Larsot, M.D., Director, Shriners Burns Institute, and Professor of Plastic Surgery, JTMBGalveston. The definitive care of burn patients. Emphasis is placed on daily wound care, fluid replacement and nutrition, and pro- cedures to minimize contracture and hyper- trophic scarring before and after grafting. (22 minutes) (In color) 0822239 THERMAL INJURY: EMOTIONAL AND PHYSI- CAL STRESS, with Mary S. Knudson, Ph.D., Chief, DiviSion of Behavioral Sciences Shriners Burns Institute; Duane L, Larson, M.D., Pro- fessor of Plastic `Surgery, UTMB-Galveston, and Director, Shriners Burns Institute; and Robert B. White, M.D., Professor of Psychiatry, UTMB-Galveston. Practical methods to combat the physical pain, toxic delirium, helplessness, and regression seen in patients with major burns. (12 minUtes) (in colOr) 2022240 TOTAL HIP REPLACEMENT, with John J. Gartlartd, M.D., James Edwards Professor of Orthopaedic Surgery, Jefferson Medical College of ThomaC Jefferson University, Philadelphia, Penn~yivania. $ince the mid-sixties thousands of American men and women have obtained celief from crippling hip disease through the implantation of total hip arthroplasties. Dr. Gartland employs the tech nique advanced by Charnley and Muller to replace the right hip of a middle-aged man who had his left hip similarly replace~d five months previously. (19 minutes) (In color) 2015126 TRANSFUSION THERAPY: THE GROWING IMPA~T OF FROZEN BLOOD, wih Charles Huggins, M.D., Director of the Blood Bank and Transfusion Serv~ ice, Massachusetts General Hospital, Boston. Blood transfusion therapy as it is practiced in a major medical center, with guidelines to the use of fresh and freshly frozen components. (14 minutes) (in color) 2022139 TRANSLUMINAL RECANALIZATION. A diagram- matic and clinical demonstration of a technique which may eliminate the need for surgery, in the case of a patient with uncomplicated segmental atheromatous obstructions causing lower extrem~ ity ischemia. The simple procedure is illustrated by Charles T. Dotter, M.D., Professor and Chair~ man~ Department of Radiology, University of Oregon Medical School. Dr. Dotter advocates consideration of the technique when there are symptoms of lower extremity ischemia in the presence of an adequate femoral pulse, (20 minutes). 2007309 TRANSPLANTATION OF THE HUMAN LIVER: A CLINICAL EVALUATION The first three consecutive liver transplant pa- tients at Memorial Hospital in New York have been long term survivors. Discussing the cases and the special problems implicit in liver trans- plantation is Joseph 0. Fortner, M.D., Chief, Division of Surgical Research, Sloan Kettering Research Institute, and Director of Surgical Re- search, Memorial Center for Cancer and Allied Diseases, New York. (~0 minutes) (in color) 2009210 TRAUMA TO THE LIVER: PRIMARY CARE AND DIAGNOSIS, with Gordon F. Madding, M.D., Asso- ciated Clinical Professor of Surgery, University of California School of Medicine and Associate In Surgery, Stanford University School of Medicine; and Paul A. Kennedy, M.9., Assistant Clinical Professor of Surgery, Stanford University School of Medicine. In the opinion of Drs. Madding and Kennedy, there are ten specific steps that should be taken when a patient presents with traumatic injury to the abdomen. These measures lead most rapidly to effective therapet~tic actions. (18 mInutes) (in color) 2014924 133 PAGENO="0488" 14394 COMP~PITIVE PROBLEMS IN THE DRtJG INDUSTRY TRAUMA TO THE LIVER: OPERATIVE APPROACH AND SURGICAL PROCEDURE, with Gordon F. Madding, M.D., Associate Clinical Professor of Surgery, University of California School of Medi- cine and Associate in Surgery, Stanford University School of Medicine; and Paul A. Kennedy, M.D., Assistant Clinical Professor of Surgery, Stanford University School of Medicine. Anatomically and surgically this large, vital organ is not widely un- derstood. Drs. Madding and Kennedy demon- strate a few basic principles which can make emergency treatment of damaged liver safer and surer. (17 mInutes) (in color) 2015025 TRAUMATIC HAND INJURIES: ASSESSMENT AND EMERGENCY MANAGEMENT, with Martin A. Posner~ M.D., hand surgeon and Chairman of the Hand Service, Hospital fçr Joint Diseases, New York City. An organized approach to the evaluation and care of patients with lacerations, crushing wounds, and other traumatic hand injuries. (16 minutes) (in color) 2021535 TREATMENT OF CORONARY HEART DISEASE - POSTINFARCTION COMPLICATIONS. Aortlc an eurysm, ventricular septal defect, heart block these complications to recovery of coronary patients are treatable, bUt require prompt evalua. ation and advanced surgical techniques. Denton A. Cooley, M.D., ProfesCor of Surgery; Grady 1. Hallman, M.D., Assotiate Professor of Surgery; Robert D. Blocidwell, M.D., Assistant Professor of Surgery; and Robert D. Leachman, M.D., Pro fessor of Cardiology, Baylor University College of Medicine, delineate the management of these conditions. (21 mInutes) (in color) 2007116 U.S. ACUPUNCTURE: STATUS REPORT 1973, with physicians and scientists from Boston; Cm. cinnati; Los Angeles and Canoga Park, California; New York City; St. Louis; and Washington, D.C. moderated by John J. Bonica, M.D., Director of the Anesthesia Research Center, University of Washington, Seattle, and Chairman of the NIH ad hoc Committee on Acupuncture. NCME explores the state of acupuncture research and practice in the US. with visits to acupunc- ture clinics, classrooms, and research labs and interviews with acupuncture researchers. (30 minutes) (in Color) 2118608 VASECTOMY PERFORMED IN THE OFFICE, with Philip Roen, M.D., Associate Professor of Urol. ogy, New York Medical College, and Director of Urology, St. Barnabas Hospital, New York City. In 1960, 100,000 men underwent vasectomy In the United States. The trend now indicates more than a million a year will be conducted during the seventies. Dr. Roen shows us an actual vasec tomy--from incision to fascial closure-to dem onstrate the efficacy of performing the procedure in the office. (17 minutes) (in color) 2214501 VENOUS THROMBOSIS AND PULMONARY EM- BOLISM PREVENTION, RECOGNITION, AND TREATMENT, with Harold A. Baltaxe, M.D., De. partmčnt of Radiology; William Gay, M.D., De- partment of Surgery; James W, 1-lurley, M.D., and Susan A. Kline, M.D., Department of Medi- cine; all of Cornell University Medical College, New York City. Among topics cřnsldered; key signs and symptoms of venous thrombosis; pre- ventive measures, including mini-heparinization; screening tests for the presence of emboli; and therapy, both surgical and medical, with special attention given to fibrinolytic agents. (60 minutes) (in co(or) A~P 2857481 TOPICAL AND HISTORICAL ACUPUNCTURE ANAESTHESIA AS PERFORMED IN THE PEOPLE'S REPUBLIC OF CHINA, with Samuel Rosen, M.D., Clinical Professor of Otology Emeritus, Mt. Sinai School of Medicine, and Consulting Otologist, New York Eye and Ear Infirmary, and Ben Park, Director of Pro- gramming, NCME. Films of major surgery under acupuncture anaesthesia, received from mainland China, provide the basis of Dr Rosen't obServa- tions about acupunptufe anaesthesia and how it works. His comments carr~1 the added weight of his personal experience In witnessing ~5 such operations in China late in 1971. (21 minutes) (in color). 0115528 A FORENSIC AUTOPSY WITH DR. MILTON HEL- PERN, Chief Medical Examiner for the City of New York, and Professor and Chairman of the Department of Forensic Medicine, New York University School of Medicine; and John F. Dcv- lin, M.D., Deputy Chief Medical Examiner, City of New York, and Associate Professor of FQren- sic Medicine, New York University School of Medicine. A 32'year-old stockbroker, known to be a heavy drinker, depressed and with a recent prescription for sleeping pills, is found dead in bed. Although he was treated for diabetes in childhood, he has not seen a physician recently. What would you write on the death certificate? Suicide? Accident? Natural causes? Dr. Helpern, the noted forensic pathologist, takes you through the autopsy to determine the cause of death. (21 m(nutes') (in color) 0617518 A REPORT ON SOVIET MEDICINE - PART I - "The Institute of Cardiovascular Surgery." Henry Mayer, M.D. Clinical Instructor in Medicine, Stanford University Medical School, presents a glimpse of The Institute of Cardiovascular Sur- gery. Moscow. (31 minutes). 1802211 134 PAGENO="0489" COMPETITIVE PROBLEMS IN TIlE DRUG INDUSTRY 14~395 A REPORT ON SOVIET MEDICINE - :PART II * The Institute of Oncology" Henry Mayer, M.D., Clinical Instructor in Medicine, Stanford Uni versity Medical School, presents a brief tour of The Institute of Oncology, Moscow. (15 minutes). 1802412 BAC SI MY - AMERICAN DOCTORS IN VIET- NAM. Ministering to the medical needs of the Vietnamese civilian population offers a contIn- uous succession of new challenges. Two partici- pants in Project Vietnam report on their mis- sions: William Lyons, M.D., Chief Anesthesia Department, Veterans Administration ~-IospltaI, West Haven, Connecticut; and Lynn A. Hughes, student at University of Oklahoma School of Medicine. (9 minutes). 0206001 BARGAINING FOR POWER: PHYSlCIA~'JS' UN- IONS, with Sanford A. Marcus, M.D., President of the Union of American Physicians, San Fran cisco, California; Stephen Baker, M.D., President of the Committee of Interns and Residents, New York City; Anthony Bottone, M.D., Execu- tive Secretary of the Committee of Interns and Residents; and Murray Gordon, labor relations attorney. Spurred by their own needs and those of their patients, many physicians are organiz- ing into unions. Their aims and how they hope to achieve them are the subject of this telecast. (16 mlnuteC) (In color) 0216817 CARDIAC TRANSPLANTATION. With Denton A. Cooley, M.D., Professor of Surgery; Robert D. Bloodwell, M.D., Assistant Professor of Surgery; Grady L. Hallman, M.D., Associate Professor of Surgery; arid Robert D. Leachman, M.D., Pro- fessor of Cardiology, Baylor University College of Medicine. Cardiac transplantation deserves now to be ac- cepted in the vast armamentarium of treatment of the coronary atient, according to Dr. Cooley. Noting this, he points out that the problems stir rounding rejection bf the donor heart are being met with Increasingly good results. Thus, he adds, the major drawback to increased use of cardiac transportation is the availability `of donor hearts. The implications of this - the need for a new definition of death as well as possible pro- cedures for storing donor hearts - are dis- cussed by Dr. Cooley and his colleagues. The film for this presentation was taken during the first transplantation. While the procedure has not changed radically in transplantations that followed this one, the attitudes of the phy- sicians have. No longer is the transplant patient treated like a "cardiac cripple," they contend, Rather, where possible, every attempt is made to handle him as any other postoperative case with ambulation after 48 hours the goal. (30 minutes) (In color) 2007014 GONORRHEA: A PLAGUE OUT OF CONTROL The incidence of gonorrhea Is increasing at a rate of 10 to 15 per cent a year. Although many people jump to the conclusion that this is due to relaxed morals and increased liberality In sex, the National Commupicable Disease Center in Atlanta, Ga., feels differently. Discussing the problem, new diagnostic techniques and ways to eradicate the disease are William ,J. Brown, M.D., and Leslie C. Norms, M.D., Chief of the Center's Venereal Disease Research Laboratory. liZ minutes) (In color) 0709909 THE HEALTH CARE TEAM. The team~approach ~o primary health care is a multl.dls~ipllnary ap. proach to the treatment of the whole patient and his environment. George Blatti, fourth year student at the University of Minnesota and past President of SAMA, discusses the advantages o~ this approach to health care delivery with three members of a health care team from the Martin Luther King Medical Center, Bronx, New York, Applications of the team concept in rural set' tings and opportunities for health care students to participate in health teams are also presented. (17 minutes) (in color) SAMA 2811373 HEXACHLOROPHENE~ OPEN TO DEBATE, with Harold C. Neu, MD., Associate Professor of Medicine and Chief, Division of Infectious Dis- eases; Stanley James, M.D., Professor of Pedi- atrics and Chairman of the American Academy of Pediatrics Committee on the Fetus and New- born; Carl Nelson, M.D., Professor of Derma- tology and President of the American Derma- tological Association. All of the participants are on the faculty, of the Columbia University Col. lege of Physicians and Surgeons, New York City. Since December 15, 1971, batjilng newborns with hexachlorophefle, routine in most nurs- eries, has been banned by the F.D.A. and the American Academy of Pediatrics-or has It? Our panel looks at this problem from several angles and comes up with some interesting conclusions. (16 minutes) (In color) 0815520 IMMUNOLOGY: FRONTIERS OF THERAPY, with Robert A, Good, M.D., Ph.D., Professor and Head, Department of Pathology, University of Minnesota School of Medicine, Minneapolis. Research meets clinical medicine as Dr. Good explains a "new kind of cellular engineering." The application of this new therapy is demon~ strated in patients, and, in a look at the future, Good speaks of giving cancer patients `an im- proved immunity system" to help the "host look at cancer as the foreigner it really Is." (22 mInutes) (In color) 0916519 135 PAGENO="0490" 14396 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY IMMUNOLOGY: THE FUTURE, with Robert A. Good, M.D., PhJD., Professor and Head, Dc partment of Pathology, University of Minnesota' School of Medicine, Minneapolis. `The next few years are really bright for immunobiology," says Dr. Good. He and his colleagues review the in. formation already In hand which will eventually open the doors to the transplantation era and facilitate treatment and preilentlon of cancer. The program's emphasis is on coming im- munologic toOls for the clinician. (19 minutes) (In color) 0916621 IMMUNOLQGY: THE NEW PATHOLOGY, with Robert Good, M.D., Professor and Head, Depart~ ment of Pathology, University of Minnesota Sthool of Medicine. In a wide~ranging discus- sion of recent discoveries In immunology, Dr. Good describes the function of T-cell and beta cell systems and their meaning for clinicians. (19 minutes) (in color) 0916418 INSIDE THE DOOR: A FREE CLINIC. What's free about a free clinic besides the medical care? The spirit Is. And the cooperation between pro- fessionals and students of all disciplines. SAMA cameras take you to The Door, a free clinic in New York City, that offers adolescents full mcdi cal care as well as legal, social and educational counseling. Medical students and physicians at The Door talk about how they believe free clinics can help humanize medical treatment. (23 minUtes) (In color) SAMA 2810149 M.D.s on TV: FICTION OR FACT? with Morton H. Maxwell, `M.D., .lames N. Wag~onCr M.D., Dudley M. Cobb, Jr., M.D. Chris Hut~on, RN., Phyllis Wright M.D., and Vincent .1. Maguire, M.D. A panel of consultants to the medical thames on commercial television discusses the following questions: ,Are the medical programs on tele- vision of any value tO the general public as pa- tients? And, do these programs complicate the doctor-patient relationship? (20 mInutes) (In color) 1310615 MEDICAL ADVANCES INSTITUTE: AN NCME RE- PORT. MAl, an organization of physicians in Ohio advocating a system of health care review, Is providing guidance. to physicians in that state who are attempting to establish Professional Standards Review Organizations. Neither the MAI system nor any other has yet been totally accepted by HEW as a model system for PSRO. (17 mInutes) (in cOlor) 1321454 Master Library services are made possible through the support by Roche Labora- tories of the production and regular distri- bution of all NCMR telecasts. MEDICAL STUDENTS ON EDUCATION, with Fred Connell, New York University School of Medi- cine; Dennis Dove, University of Cincinnati School of Medicine; Jim Hassell, University of Oklahoma School of Medicine; Mason Smith, University of Oregon School of Medicine; and Mike Smith, University of South Carolina School of Medicine. John Knowles, M.D., General Director of Massa- chusetts General Hospital, will introduc~e five medical students with strong views of major social issues that confront American medicine today. All five, members of the -Student Medi- cal Association, will air their views on the chasm between medical services promised and medical services delivered; the quality of med- icine today and the equality of access to it. More specifically, the students will comment on how they feel about their medical education, and how they believe it is or is not preparing them to meet the social problems of medicine. (21 minutes) (In color) 1312627 MEDICAL STUDENTS ON PRACTICE. John Knowles, M.D., Ileneral Director of Massachu- setts General Hospital, introduces a con- tinuation of a discussion among five medical students, all members of the Student American Medical Association. During this telecast, the students turn their attention to the prob- lems they expect to face in practice. (21 minutes) (in color) , 1312728 MEDICINE AND HEALTH IN CHINA TODAY, with Victor W. Sjdel, M.D., Chief, Department of So- cial Medicine, Monteflore Hospital and Medical Center, and Professor of Community Health, Albert Einstein College of Medicine, New York City. Dr. Sidel was one Of four U.S. physicians invited to visit the People's Republic of China in September and October 1971. From the hun- dreds of color photos that he took and his per- sonal observations, Dr. Sidel reconstructs his impressions and evaluates those aspects of Chinese medicine which he feels deserve study by Western practitioners. (18 minutes) (In color) 1315444 PAUL D. WHITE: CARDIOLOGY IN MY TIME N~ physician is better equipped to describe the development of cardiology as a specialty than one of its pioneers. The telecast is filled with anecdotes frpm Dr. White's many associations through his many years of medical practice. (Courtesy, Eli Lilly and Company) (28 mInutes) (In color) 1608602 136 PAGENO="0491" COMPETITtVE PROBLEMS IN THE DRUG INDUSTRY 14397 PSRO: THE ISSUE OF .1974, with Senator Wal- lace F. Bennett (R-Utah); James L Henry, M.D., President, Ohio State Medical Association; Robert B. Hunter, M.D., member, AMA Board of Trustees; and J. Lewis Schricker, Jr., M.D., Pres- ident, Utah State Medical Association. Edmund D. Pellegrino, M.D., Chancellor for Health Sciences, University of Tennessee, is moderator. Senator Bennett's controversial PSRO amend- ment to Public Law 92-603, the Social Security Act, is outlined and examined. Dr. Pellegrino challenges panelists with major questions sur- rounding the legislation. Topics include PSRO's cost, effect on malpractice liability, and possIble interference in the practice of medicine. (22 minutes) (in color) 1620947 RESOLVED: MEDICINE NEEDS MORE WOMEN, with Elizabeth Connell, M.D., Associate Profensor of Obstetrics and Gynecology and Director of Family Life Service, International Institute for the Study of Human Reproduction, College of Physi- cians and Surgeons, Columbia University; Harold Kaplan, M.D., Professor of Psychiatry and Direc- tor of Psychiatric Training at New York Medical College; Virginia Sadock, M.D., Resident of Psy- chiatry, New York Medical College-Metropolitan Hospital Center; and Marina Bizzorri, a high school student and member of the American Medical Woman's Association Future PhysIcians Club, who intends to go to medical schOol. Why Is medicine For Men Only?" - . - and what is being done to lower the barriers? These are only two aspects of the subject explored in a lively conver- sation among three deeply involved participants, produced in cooperation with the AMWA. (18 mInutes) (In color) 1814425 RX: BACON GREASE-FOLK MEDICINE. An amulet - . . "hot" vitamins . . - and the heart of a frog - - what do they have in common? They all be- long to contemporary medical systems that some patients turn to before bringing their prob. (ems to a doctor. Rena Gropper, Ph.D. of Hunter College and Courtney Wood, M.D. of the Depart ment of Community Medicine of Mt. Sinai School of Medicine discuss and demonstrate how an un derstanding of folk medicine beliefs can improve the medical care received by patients who trust cultural beliels as much as their doctor's advice. (19 minutes) (in color) SAMA 2811171 SELVE ON STRESS, with Hans Selye, M.D., Ph.D., D.Sc., Director of the Institute of Experl. mental Medicine and Surgery, University of Montreal, Montreal, Canada. The originator of the General Adaptation Syndrome updates his life work, emphasizing the clinical application of treatment based on this biological phenomenon. (17 minutes) (in color) 1920333 SENSORY FEEDBACK THERAPY, with Joseph Brudny, M.D., Project Director, Sensory Feed- back Unit, Institute for Crippled and Disabled (lCD.), Beilevue Hospital Center; Julius Korein, M.D., Professor of Neurology, New York UnIver~ sity Medical Center; Bruce Grynbaum, M.D., Professor of Rehabilitation Medicine, NYU Medi- cal Center; Lawrence W. Friedman, M.D., Medica~ Director lCD., Believue Hospital Center; and Ms. Lucie Levidow, Research Assistant, I.C.D.~ all in New York City. "Biofeedback" techniques have been applied to diverse medical, psycho. logical, and functional conditions. One thera- peutic application, shown on this program, offers no-risk help for certain neuromuscular disorders (18 minutes) (in color) 1920232 SKYLAB: CLINIC IN ORBIT, with Capt, Joseph P. Kerwin, M.D., U.S.N., NASA Headquarters, Houston; and Charles M. Plotz, M.D., Med. Sc.D., NCME Advisor, Professor Of Medicine and Chairman of the Department of Family Practice at Downstate Medical Center, Brooklyn, N.Y. Us- ing videotapes recorded in Orbit, Capt. Kerwin de- scribes the implications of Skylab experiments for terrestrial medicine, (16 minutes) (in color) 1919331 A TALK WITH LINUS PAULING, PhD., Director, Linus Pauling Institute of Science and Medicine, Stanford University. Dr. Pauling is Interviewed by family practitioner Rafael Sanchez, M.D., As- sociate Dean, Louisiana State University School of Medicine, and member of the NCME Medical Advisory Committee. The cOntroversial two-time Nobel laureate responds to some practical ques. tions about his work in the medical uses of ascorbic acid. (14 minutesl (in color) 2021536 THE PROBLEM-ORIENTED MEDICAL RECORD, with Paul V. Ertel, M.D., Associate Professor of Pediatrics, Ohio State University College of Medicine, Columbus, Ohio. This Special Work- shop offers a comprehensive picture of what physicians and other health professionals need to know to initiate and maintain Problem- Oriented Medical Records. This unique Interac- tive Workshop combines television instruction and workbooks which include P0MR forms for the participants to. use as they work along with the videotape. Please inquire for special rental information. (50 mlnutesi (In color) . 2800048 TIBETAN MEDICINE: 1000-YEAR-OLD PRACTICE, with members of the Intercuiture Medical and Social Study Group-1973, from the~ Medical College of VIrginia, Virginia Commonwealth Uni- versity, Richmond. An expedition of American physicians and theologians to India examines the ancient heritage of Tibetan medicine. Living in exile, Tibetan physicians preserve practices believed similar to those in use at the time of Aristotle. (19 minutes) (in color) Z019031 137 PAGENO="0492" 14398 COMPETITIVE PROBLEMS IN THE DRUG ThTDUSTRY U.S ACUPUNCTURE: STATUS REPORT 1973, with physicians and scientists from Boston; Cm. cinnati; Los Angeles and Canoga Park, California; New York City; St. Louis; and Washington, D.C. moderated by John J. Bonica, M.D., Director of the Anesthesia Research Center, University of Washington, Seattle, and Chairman of the NIH ad hoc Committee on Acupuncture. NCME explores the state of acupuncture research and practice in the U.S. with visits to acupunc- ture clinics, classrooms, and research labs and interviews with acupuncture researchers. (30 minutes) (in coior) 2118600 UROLOGY COUNSELING FOR VOLUNTARY STERILIZATION: VASECTOMY, with Ronald J. Pion, M.D., Associ- ate Professor, Department of Obstetrics and Gynecology, and Director, Division of Family Planning; Nathaniel N, Wagner, Ph.D., Associate Professor of Psychiatry and Obstetrics and Gyne- cology; and J. Williams McRoberts, M.D., Assist. ant Professor of Urology - all three from the University of Washington, Seattle, Washington. The psychologital overtones of a vasectomy, the fear of the operation and the implications of irrevocability are considered in candid detail. Patients contemplating the operation and those who have had the operation are interviewed. The three teachers-practitioners raise the questions and focus on the uncertainties that most pa. tients will exhibit when seeking advice on a vasec- tomy. The three presenters also discuss the at- titude of the physician in the interview with the patient. (20 mInutes) (In color) 0312253 FEMALE STRESS INCONTINENCE: DIAGNOSIS AND DECISION, with Vincent J. O'Conor, Jr., M.D., Chairman of the Department of Urology at Northwestern Memorial Hospital, and Professor of Urology at Northwestern University Medical School, Chicago. A urOlogist demonstrates how to do the stress at~d urethral elevation tests for stress incontinence and tells how the results determine the decision for treatment. (14 minutes) (in color) 0621422 HEMATI,IRIA: DON'T STOP THE WORKUP TOO SOON, with Vincent J. O'Conor, Jr., M.D., Chair. man of the Department of Urology at North. western Memorial Hospital, and Professor of Urol- ogy at Northwestern University Medical School, Chicago. A urologist shows his method of evaluat- ing patients with hematuria which is always a danger signal of undertying urologic or renal disease. (16 minutes) (in color) 0821938 IMPOTENCE, with Philip A. Sarrel, M.D., Asso- ciate Professor of Obstetrics and Gynecology at Yale University Medical School; and Lorna Sarrel, Co-Director of the Human Sexuality Program at the Yale University Student Mental Hygiene De- partment in New Haven, Connecticut. Secondary impotence-one of the most common sexual complaints-will usually yield to deft detective work and counselling. This program Illustrates how two leading sex therapists approach the problem. (18 minutes) (in color) 0921330 INGUINAL HERNIA REPAIR: THE SHOULDICE TECHNIQUE, from the Lankenau Hospital In Philadelphia, with Edwin W. Shearburn, M.D., Director of Surgery; and Richard N. Myers, M.D., Associate Surgeon. Dr. Shearburn Is also Pro- fessor of Surgery and Dr. Myers, Associate Pro- fessor of Surgery at Thomas Jefferson Medical College in Philadelphia. Anesthesia? Local. Re- covery? Patient ambulatory within a few hours. Should you recommend this operation to your next inguinal hernia p~tient? Two su~gčons who have performed over 1,000 ShoUldice procedures say "yes" and demonstrate the technique. (17 minutes) (in color) 0923433 MALE FERTILITY: DIAGNOSIS, TREATMENT, CONTROL, with Robert S. Hotchkiss, M.D., with the Department of Urology, New York University School of Medicine; and John MacLeod, Ph.D., with the Department of Anatomy, Cornell Ujiiver- sity Medical College. First, the biology of male fertility is discussed. Then the history taking, physical examination and sperm specimen collection are described. Remarks are made on the regulation of fertility with drugs. And finally, surgical treatment for infertility is explored. (18 minutes) (in color) 1311003 PROSTATE CANCER: CHOOSE YOUR WEAPONS, with Harry Grabstald, M.D., Urologlc Surgeon; Basil S. Hilaris, M.D., Radiologist; and Charles W. Young, M.D., Medical Oncologist; all from Memorial Hospital for Cancer and Allied Dis- eases, New York City. What happens after the primary care physician and the hospital pathol- ogist diagnose prostate cancer? Drs. Grabstald, Hilaris and Young discuss the effective treat- ment alternatives and the grading and staging involved in therapeutic decisions. A look at the therapeutic alternatives and the controversies surrounding this common and often curable form of cancer. (20 mInutes) (in color) 1617241 RECURRENT URINARY TRACT INFECTIONS IN CHILDREN, with A. Barry Belman, M.D., Attend- ing Pediatric Urologist, Children's Memorial Hos- pital, and Assistant Professor of Urology, North- western University Medical School, Chicago. How should you evaluate a child with recurrent U.T.I.? Compare your routine with that of a pediatric urologIst. (14 minutes) (in color) 1821632 138 PAGENO="0493" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 143~9 SEX IN AGING AND DISEASE, with Philip A. Sarrel, M.D., Associate Professor of Obstetrics and Gynecology at Yale University Medical School; and Lorna Sarrel, Co-Director of the Human Sexuality Program at the Yale University Student Mental Hygiene Department in New Haven, Connecticut. Sexual development of healthy aging persons, as well as patients with the more common geriatric disorders, is dis- cussed. (19 minutes) (in color) 1921438 THE TWIN-COIL ARTIFICIAL KIDNEY. In recent years, hemodialysis has proved its usefulness In maintaining chronic uremic patients. At New York University-Bellevue Medical Center, four units are used to maintain as many as eight patients who are candidates fçr kidney trans- plantation. The special problems faced by physicians and nurses responsible for the care of these patients are discussed by Avron I. DanIller, M.D., Trans plantation Fellow, and Lee Zatowski, R.N., Charge Nurse at New York University's Dialysis Units. Salah Al-Askari, M.D., Associate Professor of Urology, demonstrates the twin-coil artificial kidney. (27 minutes). 2701727 TREATING THE INFERTILE COUPLE: DIFFICULT DIAGNOSES AND MANAGEMENT, with Melvin R. Cohen, M.D., of the Michael Reese Hospital and Medical Center and the Chicago Fertility Insti- tute, Chicago, III. When medical and marital histories, interviews and fertility tests fail to reveal the reasons for infertility, a series of sophisticated tests can be performed. Such techniques as the Rubin Gas Test or hysterosal- pingography, culdoscopy and laparoscopy are among those that Dr. Cohen describes during this program. (17 mInutes) (in color). 2013321 TREATING THE INFERTILE COUPLE: INITIAL WORKUP AND DETERMINATION OF OVULATION, with Melvin R. Cohen, M.D., of the Michael Reese Hospital and Medical Center and the Chicago Fer- tility Institute, Chicago, III. Dr. Cohen conducts an interview with an infertile couple to demon- strate the gathering of a marital and medical history, to ascertain abnormalities in the wife and to determine the fertility of the husband. (16 minutes) (In color) 2013220 TREATMENT OF CHRONIC UREMIA: CONSERVATIVE THERAPY This is the second program on kidney disease produced at the Cedars-Sinai Medical Center in Los Angeles, Calif., with Morton H. Maxwell, M.D., Director of the Kidney and Hypertension Service; Charles R. Kleeman, M.D., Director of Medicine; Arthur Gordon, M.D., Assistant Chief of the Kid- ney and Hypertension Service; and Stanley S. Franklin, M.D., Medical Director of the Trans- plantation Program. (20 minutes). 2010012 TREATMENT OF CHRONIC UREMIA: HEMODIALYSIS This program was produced at the Cedars-Sinai Medical Center In Los Angeles, Calif. with Mor- ton H. Maxwell, M.D., Director of the Kidney and Hypertension Service; Arthur Gordon, M.D., As- sistant Chief of the Kidney and Hypertension Service; John R. DePalma, M.D., Director of Hemodialysis; and Thomas R. Gral, M.D., Asso- ciate Director of Hemodialysis. They describe the relatively new modality of therapy for patients with the types of uremia that were formerly terminal. (18 minutes). 2009913 URINARY CALCULI - A UNIVERSAL, `THERAPEUTIC CHALLENGE William H. Boyce, M.D., Chief of the Section on Urology at the Bowman Gray School of Medicine in Winston-Salem, N. C., presents the range of the dlsease including the etiology. (13 minuten), 2109603 URINARY TRACT INFECTION - PART I. Distin- guishing between upper and lower urinary tract infection is crucial to proper freatment. How this can be most easily accomplished is demon- strated by Bernard Resnick, M.D., and Roger P. Kennedy, M.D., Assistant Chiefs of Medicine, The Perhianente Medical Group and Kaiser Foun- dation Hospitals, Santa Clara and Oakland, Cali- fornia. (19 minutes). 2107604 URINARY TRACT INFECTION - PART II. Treat- ment of this condition, which depends on classification and identification of the offending organisffis, Is demonstrated by Roger P. Kennedy, M.D., Assistant Chief of Medicine, and Bernard Resnick, M.D., Assistant Chief of Medicine, The Permanente Medical Group and Kaiser Founda- tion Hospitals, Santa Clara and Oakland, Cali- fornia. (18 minutes). 2107705 VASECTOMY PERFORMED IN THE OFFICE, with Philip Roen, M.D., Associate Professor of Urol- ogy, New York Medical College, and Director of Urology, St. Barnabas Hospital, New York City. In 1960, 100,000 men underwent vasectomy in the United States. The trend now indicates more than a million a year will be conducted during the seventies. Dr. Roen shows us an actual vasectomy - from incision to fascial closure- to demonstrate the effio~cy of performing the procedure in the Office. (17 mInutes) (In color) 2214501 VESICOURETERAL REFLUX IN CHILDREN, with A. Barry Belman, M.D. Attending Pediatric Urologist, Children's Memorial Hospital, and As- sistant Professor of Urology, Northwestern Uni- versity Medical School, Chicago. How to find the congenital anomaly that can cause renal damage in t~hildren with recurrent U.T.I.s. (9 minutes) (in color) 2221703 139 PAGENO="0494" 14400 coi~rrn~rriv~ PROBIJEMS IN THE DRUG IN'DUSTRY VIROLOGY A SPECIAL REPORT: RUBELLA IMMUNIZATION. A program containing information about the Rubella Vaccine, its development and its recom- mended administration Is presented by H. Bruce Dull, M.D., Assistant Director of the National Communkable, Disease Center in Atlanta, Ga. (22 mInutes). 1908815 DIAGNOSTIC VIRUS LABORATORY, with Thomas C. Merigan, M.D., AsSociate Professor of Medi- cine and Director of the Diagnostic Virus Labo- ratory, Stanford University Medical Center, Stan- ford, Calitornia. Dr. Merigan conducts a tOur of Stanford's Virus Laboratory to point out the techniques of rapidly dagnosing a specific virus, This is ex- tremely impoitant as we move into an era of anti-viral chemotherapy. (13 minutes). 0412812 HERPES SIMpLEX: VIRAL DILEMMA, with Richard C. Gibbs, M.D., AssQciate Professor of Clinical Dermatolog~j, New York University Medical Cen- ter, New York City. A clinical, présentčtion, streSsing Some precautions in the differential diagnOsis arid treatment of the herpes simplex virus, Types I and II. (13 mInutes) (In color) 0820135 INTERFERON, with ThOmas C. MerIg~n, M.D., Associate Professor of Medicine and Dlré~ctor of Diagnostic VIrUS Laboratory at Stanford Univer- sity Medical Center, Stanford, California. There Is ~tonsiderable interest in the role of interferOn as an anti-viral agent in the bodys cells. Dr .Merigan explains interferon, discuSses what triggers it and consjders the long range possibilities of Stimulating interferon to head off a virus. (1~7 minuteS). 0911808 RUBELLA.. Albert tyldkee, M.D., Departriient of MicrobiOlogy, University Of Iowa School of Medi- cine, disciiss~s the lsoiation of the rubella viruS and tbe problems that the disease CauSes in p~egnanc~ (26rnInu~s). 2800002 ZOSTER:rPS qOURS~ AND TREAtMENT, wIt~ Riřhard ~ Gibbs, M.D., Assodate Professor of CliniOal Defriiŕtoióg~ arid Philip A. Brunell, M.D., Director Laboratory of infectious Disease, Pedi- atrics Department; both of New York University Medical Center in. New York City, Recommends treatment for the eevere pain of this generally onetime, but unforgettable, illnCss. (9 minStes) (In Oolor) 2620201 Many NCME programs have self -assess- ment quizzes, one copy of which will ac- company each videocassette. You may duplicate the quiz as your needs require. Upon completion, return the quizzes to NCME, and we will maintain a record of participation (not the score) for each phy- sician. These records are keyed to the phy- sician's Social $ecurity numbers: please take care that the numbers are clearly written. Physicians may request their .NCME activity records at any time. 140 PAGENO="0495" NASBEOPPROGRAM (1 dstnnd at pmgram p~nar~on~ dssnelpttno) o Root O P'onh.so 0 PynmototS Is onctosod' 0 Ptnnse Bilt Us PLAYINGDATEOFVIDEOTAPE BEIOOG000EREO_________________________________ ShipTic NAMEO~iNolVtOUAL INSTITUTION TYPEOFV1OEOTAPEREc005ER(Mfr,'ss.o,.& ORott 0 P.euhtsc 0 Paytnootnf $ Is d,tot,obor) snclosed' . 0 PI~.ssBfil Us PLAYINODATEOFYIDEOTaPEBEINGORDERra_~ osnOedo:N~ ShipTor AMEOEBODIhIDUAL INSIITUOON A.C~ STATE Zip coy °Reatal charges are for each program (La., program), Tapes may be keptforthe rent- one "pair' of a series Is considered one al period- not Including shipping time. NMIEOFPROGRAM Prsgronfiln. tfn,tndattndotprngrantdnsn,fpun,t) TYPEOFVIDEOCA5SEJTE PLAYER(Mfr.'sn.,nn&modaln.ob,r) 0 Root 0 P,,~cI,ns. 0 P.ynr.ntof$ tnnnnlosnd' 0 P%t.t. BItt Ut Psreh.snOrdmN~ Ship To BEINGOROERED______________________________ Master Tape Library-Order Form Videocassette Library--Order Form (Annogcntnnloomkat.pmccsn calm) cReof~l charges are foreach program (i.e., program)~ Tapes may he kept forthe rent- one "part" of a series is considered one al period - not including shipping time. Master Tape Library-Order Form iAltooRootnstnrecakstopmcasnord.r) 0 LTj LTJ 0 w (12 °Rental charges are for each program (Le., one "part" of a series is considered one program). Programs may he kept for the rental period - not including shipping time. frot.sd.tn.datpmgra,n~lptltn) RATE SCHEDULE (FRrS.bnmtbttnOnly) The rate schedule for each program title, one pervideocassette-not including ship- ping time-is as follows: Rentw Arninimirm period of two weeks $2000 TwOweelcstoonemonth Purchase $50.00 NI_An .ttn,t Is aiadn~ annonty, to eState trans th* Ubmty than. prngumnehlnjt nnttt.ls tnatmtstn that am to longer contRa, Nnenno~ Ifs fragrant rnmln.d hy ~o htstlta5aa Isoatteldesdant Is bsspth.nn,tsanfth.thn. today, the.ppaa.bla reatni isa elIl to mndltnd tcmad~ t.t.reardeu Ito.sbaf&sha, sn.dn.000l.qaltylasam,snta PAGENO="0496" 14402 COMPETITIVE PROBLEMS IN THE DRUG IN~DUSPRY VISUAL INFORMATION SYSTEMS 15 COLUMBUS CIRCLE NEW YORK CITY 10023 (212) 541-8080 A DIVISION OF REPUBLIC CORPORATION July 9, 1976 The Honorable Gaylord Nelson United States Senate Select Committee On Small Business Subcommittee on Monopoly Russell Senate Office Building Washington, D.C. 20510 My dear Senator Nelson: The transcript of my recent testimony (May 10) before the Subcommittee on Monopoly includes reference (p. 35) to information about the tapes distributed by us to be inserted in the record at a later date. I have since had our tape output carefully examined and would like to enter in the record, if it is not too late, the following analysis which, I believe, goes to the heart of the Subcommittee's concerns. I believe these findings should be a part of the record and a part of the Subcommittee's awareness as it considers issues raised by drug company support of medical informat~on~ NCME distributes 69 programs each year. In the in?erest of easy quantification, I asked our staff to examine the last 100 programs distributed by us. Here is their analysis: Of the 100 program~, 64 do not deal with drugs at all except in a few instanCes, peripherally. In 5 additiond programs, the amount of time devoted to drugs was very sniall but slightly more than 5peripheral ." Thirty-one programs did devote ~ significant portion of their time to drugs. Of these 31, 17 are judged to have dealt with the drugs in a balanced way, presenting both their desirable and undesirable characteristics. Another 12 of the 31, while presenting both desirable and undesirable drug characteristics stressed the limitations of the drugs. The two programs remaining deaFt in depth with the limitations oc drugs. N~t a single program emphasized the favorable qualities of a drug. PAGENO="0497" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14403 We believe that this exami~nation of all programs distributed by us since January, 1975 shows first, that NCME programs generally do not deal with drugs and that, when they do, they are as likely to present unfavorable as favorable information about them. This bears out statements made in my May 10 testimony. Of course, this is our own analysis and It seems to me you would very much want to make your own in order to confirm these findings. I should be pleased to make these and any other tapes available to you and I respectfully submit that It is only in an examination of these that one can find the answer to the question of whether drug company support biases the Information contained in NCME programs. I shall appreciate learning whether this information can be added to my statement and would like to know what we might do to assist the Subcommittee in Its examinatioh of our materials. Sincerely, (J President JER:bp CC: Mr. Benjamin Gordon 73-617 0 - 76 - 32 PAGENO="0498" 14404 CO~PETIT~VE PROBLEMS ~ THE `DRUG INDUBrQRY: STATEMENT OF EARL J. SOHERAGO, PRESIDENT, SOHERAGO AssoowrES, INC. Mr. Chairman, I want to thank you for inviting me here today, to alert you to a problem which is jeopardizing the scientific and technical capabilities of our nation. It is a threat which if not aborted, could well produce a serious delay in the solving of many medical and scientific problems. Dr. George Crout of the Food and Drug Administration, in his recent testimopy before this com- mittee, touched on the problems Controlled Circulation (Throw Away) publica- tions have generated in the medical field. Dr. Crout talked mainly about the in- tellectual problems presented by pharmaceutical industry dominated post grad- uate education for me~l1cal doctors I would like to discuss with you today, the financial impact of Throw Away Journals, not only upon the medical profession but the entire scientific research community as welL Before I begin, however, I would like to tell you what our ~rm does so that you will have a better understanding of how we fit into the picture. Scherago Associates has for the past 20 years served as a publisher's representative for scientific and medical societies. In essence, this involves the solicitation of advertising for placement in the journals published by non-profit societies. As a scientist, I have long recognized that Scientific Societies need revenue other than membership dues in order to publish their journals. Most scientific socie- tIes do not have their own sales staff because they prefer not to be involved in the commercial aspects of publishing. Because of this, they leave such details to us. In the market place, we compete with the sales staffs of the Throw Away Magazines, published by- profit making organizations, who have unlimited staffs and resources at their command. Because of our involvement with the sale or loss of sales In Society Journals, we are in the best position to evaluate the impact of Throw Aways on Society publishing programs. Before proceeding further with my discussion, I think it necessary to define here, the meaning of peer review, as It applies to publishing and recap briefly the history of Scientific Societies and Publishing in the U.S. From the beginning of Scientific Research Reporting, the accepted method of recording, has been through Peer Review Scientific Journals. Each area of scientific specialty has its own Journal and serves as a means of communication with other scientists in the same field. These scientists of like interest often band together into groups which ultimately grow into scientific societies. These societies range in size from a few members to the 140,000 constituency of the American Association for the Advancement of Science. Early in the history of organized science, it became apparent that a system of assuring the authenticity of the scientific work appearing in Society Journals was essential, for the scientific community was not without its share of charla- tans. Since each piece of research in a given area served as a basis for further work in the same field, an erroneous piece of information could cause untold damage to the whole field. To protect themselves, scientists established the Peer Review Doctrine. In its simplest form, the doctrine says that no piece of scien- tific research can be considered valid unless it has been reviewed by at least two recognized authorities in the field of science involved. Furthermore, these re- viewers can have no financial or academic involvement in the wo:rk reviewed and in most cases are to remain unknown to the performer of the work. Through the years, scientists have tenaciously stuck to the Peer Review System of Jour- nal Editing. The tremendous strides in science and medicine of the last hundred years, would not have been possible without strict adherence to Peer Review and the existence of Society Journals as a means of communicating Peer Reviewed in formation to other scientists. I would like to emphasize here that once a piece of scientific work is published in a Peer Review Journal, it becomes forever a part of the archives of Science. Consequently, Peer RevIew or Society Journals are often referred to as archival or scholarly journals. Virtually all archival journals are published by non-profit societies. That is because commercial pub- lishing firms have found that it is very difficult to make a profit with Peer Re- view Journals. They have turned to other ways of profiteering from the scien- tific communities, which I shall discuss later. It is my sad duty to inform this committee that Peer Review Journals as a group, are in serious financial difficulty. So much so, in fact that more and more meetings are being held by Society Journal editors to discuss the problem. One PAGENO="0499" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14405 such symposium took place at the annual meeting of the American Association for the Ad~rancement of Science In ~`ebrnary of this 3rear. In a paper delivered to this meeting, Robert Day, Managing Editor o~ the publications of the Amen- can Society for Microbiology made this statement. I quote, "But will the our- rent trend of rising costs continue? If they do, the scientific journal as we know it today, that is a package of research papers which is distributed each month directly into the hands of many of the individuals who are peers of the authors and Into virtually all of the departments and laboratories involved with similar research will no longer be endangered, it will be extinct." Mr. Day is not alone in his concern. Virtually every Peer Review Journal has seen its number of scientific pages dwindling to half their former number. Most societies have increased membership fees to the point where fewer' and fewer scientists can afford them. Mr. Day says that the subscription price for the Journal of Bacteriology has tripled since 1968 and by 1985 will triple again, if present trends continue. Most society omcials agree that they have `reacbed the point where no further reduction in scientific pages, and increases in mem- bership dues and subscriptions can be made. Let me dwell a moment here on the current state of scientific research. l~iacb year this country spends almost 18 billion dollars on scientific research. A substantial portion of those research funds are supplied by' the federal govern- ment. The National Institutes of Health alone spends almost 2 billion dollars in grants and intramural research. This colossal investment in research activity has in recent years produced an avalanche of new important scientific and medical information, Dr. Donald S. Fredrickson, Diredtor of the National Insti- `tutes of Health, said in a speech at the recent meeting of the American Asso~ ciation for the Advancement of Science (see appendix 2). Biomedical knowledge like all scientific knowledge, has been accumulating at an exponential rate, as reflected in `the output of scientific literature. One sampling of biomedical pub- lications suggests an average annual increase in scientific papers of between 4 and 5% each year from 1965 to 1973. Not all papers which are delivered before a society are published in Peer Review Journals. Some authorities esti- mate that less than 60% of significant scientific papers ever appear in estab- lished sci~ntifie or medical jthirnals. It is tragic to think that much of the pro- ductive research generated by this enormous expenditure in research dollars is never seen by the scientists and doctors who could best utilize it. What then has led to this sorry state of affairs in scientific publishing? Four factors have been at' work during recent history, which have created this dilemma. The first of these is the tremendous increase in the number of scientific papers competing for the available pages in scientific journals The second Is the rap idly spiraling costs of )ournal production The cost for printing a page of scien tific material in the average journal has increased 80%' in the last two years. Postage too has increased substantially. Increases in labor and salarieS due to inflation are well known facts. Most societies have sought to fight these spiraling costs by Increasing membership dues. This in turn has led to a downturn in association members which keeps the net increase in society revenue small. Re- duction in pages published is also an unsatisfactory solution All things con sidered, however, attempts at cost reduction and increases in subscriptions arid dues will not solve the problem. The third factor and by far the most volatile, is the decreased or lack' of in- crease in advertising revenue. Societies have traditionally subsidized a good portion of their publication costs with paid advertising from firms selling the products used in the conduct of scientific research. In the case of Medical Jour- nals this advertising support has come largely from drug manufacturers In Peer Review Journals, `advertisers are never allowed to influence the editorial content. This is because `the control of editorial content is in the hands of rS- view~rs who do not partidpate in the revenue from advertising. Peer Review journals have steadfastly `refused to let advertisers influence either their edt- tonal content, graphic presentation or advertising positioning. ~This policy has led advertisers to seek other means of communicating with their customers which would cater to their demands of editorial and format involvement~ The business press community was waiting and willing to provide such a services Thus was born the Controlled Circulation or Throw Away Magazine Con trolled Circulation magazines ask' group, constitute a serious i'nancial tht~eat to PAGENO="0500" 14406 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Peer Review Publishing. In addition, because their scientific and editorial content does not undergo a stringent review process as do scholarly journals, they provide no service to the scientific or medical community. Yet each year, such publications syphon off sizeable amounts of advertising revenue from Peer Review Journals. Last year, as a group 10 publications distributed to the research and laboratory field collectively billed over 10 million dollars in advertising revenue, money that would have been used to publish Peer Review material, had those ads ap- peared in scholarly journals. At this point, it might be helpful to look at the various types of controlled circulation journals Essentially there are three types: 1. Product tabloids which publish as their sole editorial content, non-adver- tising product ~lescriptions from advertisers which are essentially free ads. In general these publications are newspaper size and it is commonly accepted in the trade that one must advertise in order to get an article published about their product. 2. Clinical or Research Type Journals, which have the appearance of schol- arly .Journals, but do not utilize any accepted review process for editorial. It is not unknown for these journals to allow an advertiser to write an article or to accept an article from an individual designated by the advertiser. 3. News Publications which contain News Releases that are handed out by industry, reviews or abstracts of articles appearing in Peer Review lournals or interviews with scientists who give papers at scientific meetings It is often P05 sible for a scientist or~ doctor to obtain publicity, in such a magazine about scientific theories or drugs which are held in disrepute by most scientists. In this manner an unscrupulous scientist or doctor may circumvent the traditional Peer Review Process. I have brought with me today, some excerpts of ads from some of these publicatIons, which appear in a trade journal circulated to buyers of advertising space. * It is interesting to note that in many cases, these magazines infer that doc- tors cannot effectively practice without these non-scholarly journals. By this time, some of you may be asking why Scholarly publications cannot compete effectively in the advertising market place with Throw Away Journals. The answer to that is simple They just aren t willing to make the compromises with established scientific practice which advertisers demand. To do so, would mean there would no longer be any Peer Review Journals. Better to preserve the few that survive under the old system, than to have no communication sys- tem for authentic scientific materiaL What do Throw Aways do for advertisers that learned journals cannot? First of aR they send all copies of their magazines to the place where scien- tists and doctors work. Advertisers feel that professionals read on their jobs more than they do at home. For the most part, Scholarly scientific and medical journals are sent to home address at the request of the subscribers. This would seem to indicate that advertisers are wrong about where scientists and doctors read professional journals. On the other hand, advertising executives often ask their salesmen what publications they see on their prospect's desk. Obvi- ously, a salesman sees fewer scholarly journals on customer's desks because the doctor receives them at home. Since Throw Away Publishers insist on sending their products to laboratOries and doctors', offices, most professionals receive at least six and as many as twelve of these journals. One wonders when they find time to work! Another reason that learned journals cannot compete with Throw Aways is that no Peer Review Journal will allow an advertiser or pros- pect to influence its editorial and scientific content. Furthermore, learned jour- nals often print adverse references to advertisers' products or pres~nt views which are unpopular with groups of advertisers, In no instance, will a scholarly Journal ever agree to run articles or product descriptions in exchange for ad- vertising. Advertisers and advertising agencies both abhor the grouping together of ads In the front and back of Scholarly Journals. They want to see their ads next to scientific content because they believe the ads will receive more attention there. Learned journals group ads in order to keep from having them sand- wiched in the scientific articles thus causing articles to be continued on other pages Editors of Peer Review Journals also resist this practice because they feel it implies advertisers influence if advertisements appear mixed in with the articles. In general, advertisers group publications into stacked and interspersed, PAGENO="0501" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 144~7 depending on whether ads are grouped. Most society journals are stacked and all Throw Aways are Interspersed. Another prime reason for the popularity of Throw Aways with advertisers, Is that they can understand the articles in them. In general non-scientists cannot believe that anyone would read articles written in Scholarly style which is per- celved by advertisers as dull and uninteresting, One other selling advantage is the fact that society journals usually have drab and uncolorful formats wb~le Throw Aways make ample use of graphics, color and artwork to make their journals more attractive. So it is easy to see that in the classic sense of provid- ing the customer with what he wants, Throw Aways have done a much better job of giving the advertiser what he wants. Scholarly journals have concén- trated on the other hand, on giving the scientific and medical community what it needs. It Is interesting to note that in virtually every case, where Throw Aways are competing with society journals for advertising, the society journal was in existence long before the Throw Away. Usually, it was the Scholarly Journals' volume of advertising which accumulated because there were i~o other journals in the field, that attracted the Throw Away In the first place. History has shown that every time a controlled circulation enters a field served by a Learned Journal, it syphous off advertising. In some cases this produces disastrous results. One respected chemical journal has lost over 50% of Its advertising revenue to two Throw Aways. It Is common practice In the Journal field to make scientists pay to have their papers pub- lished in a scientific journal. This is especially true in the case of journals having little or no advertising revenue. It is an interesting paradox that some scientists are paying to have their papers published while buying supplies and equipment from firms who support that journal's Throw Away competition. For the last 10 years, the business publishers have used their Association to put pressure on the Internal Revenue Service to force societies to pay tax on their advertising. In 1969, the IRS established new guide lines which have resulted in many societies having to pay taxes on advertising revenue. Thus, the society uses money to pay taxes that otherwise would go to publIs~i more scientific information. The paradox here is almost ludicrous. On the one hand, the government creates a non-profit status for scientific societies so that continued scientific excellence will be assured, and then turns around and takes away a substantial portion of its money in taxes. The business publishers hava insisted that the tax free status of societies constitutes unfair competition. They say this even though the society was here first and, as we have seen, there is no way the Scholai~ly Journal can compete effectively against the Throw Away, In Dr. Crout's testimony, he listed for you twenty eight publications which have circulations of se'srenty thousand or more. Of these publications only two em- ployed the Peer Review system. I have included in the appendix a list of the same publications, indicating also, the total advertising billings of these publi- cations for the year 1975. These 28 Throw Away publications billed over $60,. 000,000 in advertising revenue. One wonders how much important scientific ln~ formation could have been published In Pee1'~Beview Journals with that amount of money. It is time now for the Congress to addres'~ Itself to this problem for without legislative assistance, I believe that our system of Scholarly Publications may become extinct. Obviously, any legislative relief must be gorerned by our tradi- tion of Freedom of the Press However I do not believe that such freedom was meant to be used where it so obviously adversely affects the best Interests of our society. We must preserve the Peer Review system, If science is to survive. Here then are some remedies which this committee might consider: 1. Encourage the Congress to repeal the tax code provision which requires associations to pay tax on their advertising. 2, Require vendors of products used by scientists or medical doctors, who are buying such products with Federal Funds to confine the advertising of such products to publications employing Peer Review techniques. Such a regulation would not exclude commercial publications for the market place, for they also can use the Peer Review System. 3. Make it illegal for any publisher who distributes his publication to scien- tists or medical doctors working with Federal Funds to engage In the direct exchange of editorial coverage for advertising. Thank you again for allowing me to present my views. I sincerely hope they wPl be helpful. PAGENO="0502" 14408 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY E)CC.ERPTS FROM A STATE~VtENT MADE BY ROBERT ORMES, MANAGING EDITOR OF SCIENCE MAGAZINE, PUBLISHED BY THE AMERICAN ASSOC- IATION FOR THE ADVANCEMENT OF SCIENCE Purposes of Society Publications The j*,urnals published by scientific and other professional sOcieties differ from tyçical commercial and business or trade publications in a number of ways. The basic objective of the society publications is to provide readers with information releyant to their scholarly discipline, while that of commercial publi~atio~~s is to make L profit and that of business or trade publications is to help t~eir readers make a profit. In view of these disparate objective 3 the contents of the three types of magazines usually are qu. te different both with respect to quality a~d quantity of eiitorial material and also with respect to advertisements. In general, the edit.~rial content of the society journals meets the very high intelLectual standards of the scholars in the disciplines which they cover. Articles are donated by their authors. These articles are judged by outside reviewers of high professional reputation. Selection [s made on the basis of the article's contribution to the discipline and Is not affected by business considera~ons. Business considerations may force the society to delay publication of an article, but they do not affect the decision to publish. Publication delays of 1, ~2, or more years are not at all uncommon among scholarly journal~, particularly if the soáietv is primarily deoendent on dues for sut'oort er ~F ``~ journal car, attract only sr.all ~~ounts of advertising or other revenue. Other things being equal, the society spends incremental revenue from dues, advertising, or other sources to reduce the backlog of unpublished but accepted manuscripts. In contrast, the editorial content of commercial and business or trade publications is determined by the editorial staff without recourse to outside experts. The editorial staff, however large, can never be large enough to bring uniformly execellent intellectual resources to bear on the choice of what to accept or reject. Furthermore, the staff must necessarily give thought to business considerations if profit is to be made -- payments to authors, effects on advertisers, effects on copy sales and subscriptions. Trivial, intellectually mediocre, and even bizarre stories often get into print. Other things being equal, Incremental revenue is expected to flow through to profit. Some business and trade publications include considerable editorial content consisting of advertisers' new product releases, which may or may not be rewritten to ~onform to edit~o.rial style. A few publications have no editorial content !~cept product releases. In general, the advertising content of scholarly jo.urnal~ varies from zero up to about 30 percent and occasionally to 40 percent, PAGENO="0503" COI~tPETITIVE PROBLEktS IN THE DRUG INDUSTRY 14409 Scientific Journals: An Endangered Species 1 ROBERT A. DAY Managing Editor, if merican Society br i%1:crob:ology, JVasIth;gton, D.C. 20006 ent trends Co Arc scientific journals an endangered spe- it is $90. If pres 1n~JtJ~9~iite des? I will express my opinion in Thó current possi to t tt ~n idiom: you'd better believe it. ~ re Li In my position with the American Society ~ ption ~r~e for Microbiology, 1 am responsible tor the man- price, the last of the individual subscribers ~vill agement of nine sci~ have lont~ since been priced out of the market, cntifi~ journals. In .as will tIl but the larger institutions. 1975, we published But will these trends continu~? If they do, about 18,000 text the scientific journal as we know it today, that * pages in these nine is, as a package of research papers which is journals and another distributed each month directly into the hands ~, -~) ~ 3,000 pages of of many of the indiviauals who are peers of / books For the past the authors and into virtt~ally all of the de- ~ 15 years, I have partments and laborato~ics rnvolved with sitni- i I spent most of my lar research, will no longer be endangered; it 44 ~ waking hours think-)! svill be extinct. log, worrying, and ~T~t'~is~eaniiue any alternatives that might $ c h c mi n g about be available whereby we might reverse tJ~e cur- ways to pay the rent trends. costs of producing First, however, we should ask the question: the ASM publica- should the scientific journal as we know it Robert A. Day tions, be l)reserved, or should we assume that a new Let us look at this and better (and more economic) syst~m of cost problem, because it is the cost that is. en- scientific communication will become available dangering the specics to us? In 1965, it cost our Society $452,384 to One rather interesting answer to this ques- produce its publications. In 1975, the cost Was tion has bccn offered by Profcsspr ~l~bert about $2.6 million. True, there has been a Lechevalier, of Rutgers University, in a Letter substantial increase in the number of pages to the Editor of ASM News in a recent issue published, from 7,000 hi 1965 to 21,000 in (February 1976). Dr. Lechevalier says: 1975; however, with more pages in more publi- Obviously the only solution to our publication cations, we can and do attract more subscribers problem is to stop publishing. This, of course, (income). ~sit what is endangering us is the is about as easy to do as it is for the USA and tremendous increase in the cost per page. In the USSR to stop meddling in other countries' our basic journals, thc per-page manufactur- affairs. ing cost has gone up by 30% in just the past The proposal that I have the honor to draw two years. As most of you know, the primary to the attention of the members of our Society culprit in recent years has been the skyrocket- may not be perfect but still may have some ing cost of paper, greatly exacerbating the de- merit. In the USA we should disseminate in- bilitating effects of our Nation's woeful inila- formation only through 7/ic New ~`ork Titus's. If this newspaper would devote only one page tionary problems a day to microbiology, our problems would be These increased ~5er-pnge costs certainly do solved. Of course, I don't mean a full page~ not attract increased numbers of subscribers, but only what would be left after advertisements On the contrary, these costs, which represent of microbiological products would have been as- the largest expense component in journal pub- * sured. lishing, must in large measure be matched by With the limited space available, The New income from subscriptions, which is the l~irgest Yo,k Times reporters would be forced to prac- income component in journal publishing. And, * tice brevity, a virtue which so far has escaped as subscription prices go up, the number of them, thtis leading as a by'product to an ins- subscribers tends to go down. provement in the quality of lIds outstanding The nonmember subscription price for the newspaper. Journal of Bacteriology in 1965 was $28; now At the risk of offending several of my col. ~ leagues on this panel, and obviously the good `Presented at the Annual Meetine of the American Professor l.ecltevulicr, I will give my opinion Association for the Advaucement of Science, Boston, Massadrusetis, 22 February 1976. without qualiliers: the scientific journal, and 288 AS/I! News PAGENO="0504" 14410 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY The Impact of Biomedical Research on Health Care DONALD S. FREDRICKSON Director, National Institutes of health, Bethesda, ?faryland 20014 Health care today is one of the most corn- ~ an average antwgijn plex of human endeavors. It involves all kinds cr ase in scientific -~`cr. betwccn 4 and of practitioners, diverse in their organization ~ ye~~oi~ 1965 1 and modes of delivery, facilities of special de- It will take years to assess the impact of this sign, and a constantly proliferating array of avalanche Qf new knowledge, if indeed we can instruments, techniques, devices, and therapies. ever accurately measure it. In fact, one of our At the base of it all is biomedical research, important tasks is to sharpen the tools for such Medicine is still empirical enough; without measurement. Once gained, knowledge is research it would be medieval. We might still added to a pool from which it can be drawn be relying on leeches and the purge, be re- forever, and future applications cannot be fore- signed to periodic outbreaks of devastating told. plagues, and have to endure calamity with un- The results of biomedical research seem controlled anxiety and pain, usually designed for the professional who de- The purpose of biomedical research is to im- livers health care, They sharpen his skills prove the well-being of man through greater and increase his armamentarium. Often re- Understanding of the nature of life. At the search results become, translated into social basic level, knowledge is generated about action, such as mass fluoridation, mandatory the functioning of biological systems and sanitation practices, and pollution control. about the processes of growth, development, Sometimes the individual can directly par- and decay, Resynthesis and development of ticipate in research application, by changes this information leads to ways of understand- in life style, for example, in improving nutri- ing. preventing, treating, and curing disease. tion~ and stopping smoking. When biomedical Biomedical knowledge, like scientific kno~vl- knowledge becomes a part of daily living, we edge generally, has been accumulating at stn tend to forget its origins in the processes of exponential rate, as retlected in the output of discovery and development. scientific literature. One sampling of bioniedi- Some ~claim can be made~ of course, that the disappearance of smallpox should also I resented at the AAAS Meeting, Boston, Maso., 18 Febrttary 1976. mean an end to amortizing our debt to William 266 ASM Ness's PAGENO="0505" COMPETITIVE PROBLEMS IN ~HE DRUG INDUSThY 14411 Circulation of U. S. Medical Journals With Total Circulation Over Seventy Thousand According to March 24~, 1976 Issue of Standard Rate & Data Service JOURNAL DISTRIBUTION 1975 BILLING American Family Physician 108, 714 American Medical News 261, 118 Consultant 142, 120 Current Prescribing 118,168 Drug Therapy 113,793 Emergency Medicine 109, 974 Hospital Medicine 178, 687 Hospital Practice 187,134 Hospital Tribune 100,000 Infectious Diseases 139,840 * Journal of the American Medical Association 239,435 Journal of Legal Medicine 125, 626 MD Medical Newsmagazine 181,481 Medical Aspects of Human Sexuality 161,522 Medical Challenge 77, 749 __________ Medical Economics 169,624 Medical Opinion 152, 191 Medical Tribune 150,000 Medical World News 164, 652 Modern Medicine 170, 311 * New England Journal of Medicine 159, 113 Patient Care 101,145 Physicians Management 179,386 Physician And Sportsmedicine 90, 533 Postgraduate Medicine 108, 068 Practical Psychology 104, 092 Private Practice 171,659 Resident and Staff Physician 96, 267 __________________ Total Billing ( excluding Medical Challenge ) $ 63, 818, 331. * Denotes Peer Review Journals according to Dr. Crout's testimony $ 3,429,391. 667, 643. 3,449, 776. 528, 952. 2,715,616. 4,176,358. 1,932,165. 2,843,413. 698,156. 516, 275. 3,912,878. 211, 961. 3,566,184. 3,128,745. not available 10, 221, 480. 1,102,447. 2, 157, 365. 4,793,021. 1,873,372. 2,395,607. 1,274,123. 1,101,501. 1,424, 066. 2, 054, 874. 807, 756. 1,274,123. 1,561,083. 1975 Billing figures obtained from Perq Corp, Ridgefield, Conn. PAGENO="0506" 14412 COMPETITtVE `PROBLEMS IN THE DRUG INDUSTRY TOTAL 1975 BILLINGS FOR THROW AWAYS SERVING THE LABORATORY AND SCIENTIFIC FIELDS JOURNAL Clinical Laboratory Products Laboratory Management Lab World Medical Laboratory Medical Laboratory Observer American Laboratory Industrial Research Laboratory Equipment Research & Development 1975 BILLING 702, 564. 435, 904. 332, 146. 177, 780. 920, 883. 891 ,050. 1,764,800. 850, 000. 1,244,130. $ 7,319,257. Total PAGENO="0507" COMPEPIPIVE PROBLEMS IN TRE DRUG INrnxs'rrt~ 14413 Testimony of Henry E. Sirnmuus, M.D., M.P.H. Senior Vice President J. Walter Thompson Company, New York Mr. Chairman, I appreciate your invitation to testify today on the transfer of medical information (Technology Transfer), how to bring about appropriate behavioral changes in the use of drugs by the public and health professionals and how the tool of `Social Marketing' can help bring about necessary improve- ments in these areas. We are all aware of the serious problems which today face the health care system. These include rapidly rising costs, poor quality of care, the lac)t of standards for care, problems in compliance with therapeutic regimens and problems in informa~ tion and technology transfer. For the purposes of this discussion, I will consider any useful new medical information as synonymous with technology which must be transferred from its point of origin to those who need it (health professionals and consumers) to enable them to make rational decisions and ultimately to maximally enhance or preserve the health of the public. Many of our problems in the health care system are due to deficiencies in informa- tion transfer or efficient and effective technolDgy transfer. There is a wide and probably widening gap between what we know should be done and what is done or practiced in this nation's medical care system. Problems exist in the premature introduction of inadequately tested technology, the failure to eliminate outmoded technology promptly and the failure to rapidly adopt new technology which has been established as beneficial. Examples of the latter include inadeq~tate use of the drugs available for treatment of hypertension and immunization against the common childhood diseases. PAGENO="0508" 14414 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY We have all witnessed with dismay the spectacle of important new scientific information falling on deaf ears -- or, worse, remaining unspoken at all, Time and time again, the objective of research - - benefit to the consumer public - - has been frustrated as the communications abort, The disparity between our operant knowledge of communications and its application is crippling and, finally, intolerable. You are well aware of the frustrations of the congress as it surveyed H. E. W. `s efforts in technology transfer. That is why I ventured into the world of communications to see if there were elements we have been overlooking in our efforts to implement the health informa- tion we possess. The answer to my inquiry is resoundingly positive. A brief overview of the technology transfer process of biomedical research communica- tions points them up. There seem to be two factors which necessitate taking a fresh look at how effect- ively biomedical communications (technology transfer) are conducted. One is the fact of the sheer volume of information now being generated - - many thousands of discrete items per year. The other is the fact that many of these findings now require the active cooperation, often times necessitating a reversal of long-term practice, attitudes and behavior, not only of health professionals but of the public at large in order to become beneficial. A pair of communications tasks are then manifest: seasitive priorities and persuasive messages. The two tasks are inextricably intertwined, at each of three stages of communication between 1) scientist and scientist; 2) scientist and practitioner; 3) and scientist/practitioner and the public. -2- PAGENO="0509" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14415 Communications between scientist and scientist are the most effectively managed at present. A communications expert would probably attribi~te this to the follow- ing factors: a) biomedical scientists are a relatively homogeneous population - conditioned by a well-understood set of procedures and underlying principles of investigation; b) scientists communicate with considerable precision through the use of an assiduously defined and carefully used set of language and symbols; c) the scientific community is largely pre-motivated to understand and implement accurately what new information is communicated to them, as the price of neglect to do so is eventual if not immed- iate failure at one's life work, given the high degree of peer review and testing operative in science; to discover error is to further one's success, in pure terms; d) the channels of communication - - primarily scientific journals, semi- nars, and working papers - - are relatively few in number and are attended by virtt~ally all scientists active in a given field; additionally, they have ready access to supplementary data through efficient stor- age and retrieval systems now in place; -3- PAGENO="0510" 14416 COMPETITIVE PROBLEMS IN TEE DRUG INDUSTRY e) the context of communications' reception is businesslike and absent of significant diversionary messages or efforts to peruade opposite conclusions for non~scientific reasons. Although some of the assumptions above may be subject to thoughtful evaluation in the field, requiring some modification, they are probably reasonable, for our purposes. Taking the same categories, however, and applying them to subsequent stages of communication en route to the goal of consumer-benefit, it quickly becomes clear why the process breaks down, Between scientist and practitioner, the factors are diffeient: a) practitioners' diversity is encouraged by such forces as the development of medical specialties, the emergence of para- and sub-professionals, and the flourishing of competing attitudes and philosophies of treatment, oftentimes influenced by such idiosyncratic elements as practitioners' personality: b) Motives of practitioners are highly diversified, ranging from the totally altruistic to the totally materialičtic, and the responsiveness of practitioners to new information is not as subject to the rigorous process of peer review and interdependence which characterizes the scientist -to-scientist communication; nor is the controverting of previously held data taken as sheer advance of knowledge: the authori- tative contradiction of current practices may be thought - - by both -4- PAGENO="0511" COMPETITIVE PROBLEMS IN `1~HE DRUG INDTJSTE( 14417 the practitioner and his client - - to refledt unfavorably on the practitioner; c) Channels of communication drawn upon by the practitioner include not only professional literature from sanctioned scientific sources but also professional polemics, pharmaceutical and other medical industry information or rebuttals, federaland other regulatory documents, continuing education materials of unc ertain consistency, and popular media; d) The context of reception of communication is awash with diverting and/or competing messages. As complex as the factors in the scientist-to-practitiOner stage appeai~, they all but pale when compared with efforts to communicate with the public, whose informed cooperation is increasingly the sine qua non of translating scientific advance into personal health benefit. Here we have to contend with awesome obstacles: a) The diversity of the public is patent, manifested in literally dozens of sub-groups segmentable by demographics, and medically rele~ vant predisppsitiOnal factors; b) Far from sharing a finely honed operational language constantly redefined in function, the various publics rely on figurative and -5- PAGENO="0512" 14418 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY connatative - - and even non-verbal -- communications, for the most part; and these, of course1 are subject to a nearly infinite range of local and regional expressions and interpretations; c) Whereas the motives of the scientist to heed new knowledge are relatively clear-cut and positive, and those of the practitioner also strong if somewhat conflicting, the motives of the individuals in the public are thoroughly contaminated with inhibiting forces, ranging from fear of discovering disease or risk, to unconscious perpetuation of self-defeating behaviors, to life-style habits; and the example of their peers tends, by and large, to support a willful resistance; d) The channels of communication used by the public ate legion, including every imaginable medium of mass communication, local health professionals, family and friends; e) The context into which health communications come, is cluttered with stimuli to an unimaginable extent; it is estimated that in a given day, the average person is subject to more than 5, 000 separate communications seeking to promote some response; no small number of these seek to reinforce the behaviors which may be inimical to health, and others reinforce misinformation and confusion, -6- PAGENO="0513" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14419 In addition to recognition of the awesome obstacles to communication mentioned above a communicator must be aware of certain principles of effective communi- cation. 1. The first of these principles is to assume non-compliance from your audience. In the case of physicians, we know that they are bombarded with literally thousands of messages in the course of a month that deal with technical drug information, new drug introductions, new research findings on existing drugs, new Fod and Drug administration regulations, etc. We should assume that these physicians will not necessarily do what the messages ask them to do or even listen to the messages. 2. A mistake commonly made in communications is tö~as some that inforrna- tion is enough to produce behavioral change. If information were enough, very few people in this country would still be smoking. On the side of every pack of cigarettes sold in this country there is a warning from the surgeon General stating that cigarette smoking is harmful to health, We can assume that every smoker has been informed. Many, however, have not yet been persuaded. 3. It is unwise to assume that a need is recognized by the intended consumer of a product or program. Personal hygiene is a self-evident need from the point of view of health departments everywhere, yet in country after country that need has had to be explained, or, if you will, sold. And very few -7- 73-617 0 - 78 - 33 PAGENO="0514" 14420 COMPETITWE PROBLEMS IN THE DRUG INDUSTR1~ farmers recognized that they needed a tractor the first time they saw one. 4. Do not take relevance for granted. It is possible to perceive a need without understanding its applicability to you. It is possible to listen to a message and yet not hear it because the language is that of another age group, another social class, another ethnic group. 5. The mass market is a fiction. Our population is made up of an accumu- lation of special markets with special attitudes and interests. Communi- cations must be designed with a prec lee knowledge of the group or groups to which they are addressed. 6. Repetition is necessary both for widespread awareness and for the main- tenance of that awareness. 7. Conflict of information exists in most significant communications areas. It must be allowed for and dealt with. 8. In all areas there are barriers to persuasion. In the health care area these are frequently profoundly emotional and must be clearly understood before communications are undertaken. 9. The relationship between stimulus and response must be clearly understood. A message is a stimulus, the receiver!s reaction to that message is the -8- PAGENO="0515" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14421 response. Professional communications start by identifying the response that is desired from the target audience before developing the message. The desired response should dictate the message, not vice versa. It is very dangerous to assume that your audience will receive your idea exactly as written. They will color it; they will change it; they will interpret it. In short, by making it their own, they can also make it different from what you intended. In the marketing of goods and services, which for 106 years has been the daily business of the 3, Walter Thompęon Company, they have developed a plan for the production of communications which help solve a client's marketing problem. This is called the "T" plan and consists of five steps. The "T' plan process contains no magic. It is simply organized common sense. A method designed to help arrive at an accurate fact base and to help avoid operating under false assumptions. It involves the posing and answering of five very basic questions. Questions designed to focus and concentrate thinking where it will be most productive. Though these questions are listed in a certain order during the development process, as the environment changes or new information becomes available, we will backtrack, reasking and reanswering certain questions. It is in short a fluid process that we can never assume is finished. Even when success is achieved, continual pressure must be used to maintain that degree of success. -9- PAGENO="0516" 14422 COMPETITIVE PROBLEMS IN THE DRUG INDuSTRY' In attempting to motivate people, in making a deliberate attempt to influence change and not juat passively react to events, we need the best planning possible. In answering the following questions, we make important strides toward that end. Where are we and why are we there? Where do ~ve want to be? How do we get there? Are we getting there? Should we change, direction? The application ~o social problems of the principles we have described , coupled with the asking'and'am;wering of the questions posed above, is what we describe as "Social Marketing". Social Marketing is defined as the design, implementation. and control of programs, calculated to influence the acceptability of social ideas. It involves considerations of program or product planning, pricing, communication or education, distribution, and marketing research These marketing technique'; serve as the bridging mechanisms between the simple possession of medical or health knowledge and the socially useful implementation of what such knowledge allowS. In the hands of its best practitioners, "Social Marketing" is applied behavioral science. I would now like to desribe how the technique of Social Marketing would be applied to solve a major current medical problem involving a type of drug use. The case in point is the necessity to immunize almost 200 million Americans against swine influenza before a new flu season begins this fall. A re'ated and also urgent `.10- PAGENO="0517" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14423 problem is the need to raise the present dangerously low immunization levels of many American children to the recommended levels for the common childhood diseases. Without use of these Social Marketing techniques it is unlikely that success in either area will be achieved since both problems aremuch more complex than they would appear to be at first glance and both will require wide public understanding, acceptance and support if we are to succeed. Applying this development process to the area of Swine virus, we find that posing the question seems simple, but the intelligent answering of the question will probably require the employment of a number of different research techniques. We must know what consumers' attitudes are toward immunization in general and toward the Swine vaccine in particular. Does the name "Swine Influenza" create confusion (Since I haven't been near a pig in the last year, am I safe?)? What do doctors think of this immunization effort? Do they agree with the position taken by authorities ? Certainly not all agre~, and the press in recent weeks has given a great deal of attention to doctors of opposing views who maintain that immunization itself poses a greater risk than the imagined epidemic it wants to alleviate. Will newspapers and journalists considerably hamper this effort or are they doing so now? These are but a few of the points that must be clarified. The second question we must ask is one that sets the goal we are attempting to achieve, "Where do we want to be?". Again, we should attempt to answer this .11 - PAGENO="0518" 14424 COMPETITTVE PROBLEMS IN THE DRUG. INDUSPflT in the most detailed manner possible. Not only do we wish to have immunization of all Americana by later this year, but we would like to have immunization of high-risk individuals first. In short, a complete timetable must be developed for different audience segments, identifying high-risk groups and areas as well asa host of other factors. The third question takes us from the area of planning and into the harsh reality of execution. Question No. 3 is "How do we get there?". I won't go through a detailed listing of all the strategies that are involved in the process, but I would like to mention a few. First, in the area of audiences and audience segmentation, we would begin by specifically identifying our target audience, their geographic and demographic characteristics. In short, their profiles and what groups they would logically fall into. Having identified our audience, we would define through market research those specific appeals most effective at eliciting the desired response from each segment. For instance, it may be found that the suburban housewife should be the primary target for our communications in Midwest areas where the median income is $20, 000 and above; and it might be determined that the appeal most effective with her would be love of family or the desire to be a "good mother". It may, however, be found that in the lower income areas of the city that the father should be the target, and perhaps the most effective appeal with him would be pride in being a good protector. In short, we must develop the most appropriate fact base and make the most effective appeals to the proper audiences, and we must rigorously resist operating under false assumptions. -12- PAGENO="0519" COMPETITIVE PROBLEMS IN PEIE DRUG INDUSTRY 14425 We would also identify the actual materials and messages and the actual public relations strategies and approaches that would be needed. An example of the creative materials which might be required for the effort would be 6 television commercials for prime and fringe time television; 3 television commercials for c\hildren's television programs; 12 radio commercials or radio fact sheets for radio personalities to develop their own commercials; 6 posters or poster designs, probably leaving blank space so that locations, times organizations, etc., can be identified; 6 newspaper advertisements; 6 magazine advertisements; button designs; bumper stickers; comic books; leaflets explaining immunization timetables; maps showing directions to nearest immunization centers; direct mail inserts for mailing with welfare checks; an immunization stamp developed by the Post Office, etc. These materials should also be developed in various language versions. Having segmented the audience, identifying the appeal, developed the creative materials and the public relations approaches, the next step is media placement; and in this step, as in all other steps, you must have planning which includes stated objectives, strategy to meet those objedtives, an agreed-upon timetable and also a method of evaluation to find out if in fact you have met your objectives, and if not, bow you can make adjustments in the overall plan. In the area of media it is imperative that reach (the percentage of each audience segment you wish to appear before) and frequency (the number of appearances) targets be developed for all audiences, developed on a week-by-week plan, and that the campaign builds towards a peak before October 1976. -13- PAGENO="0520" 14426 COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY Another crucial factor is manpower. We might broadly sub-divide this into 3 different areas and these of course can be sub-divided again and again. For purposes of this discussion, let's just concentrate broadly on volunteer organi- zations, professional organizations and business organizations. Certaioly the core of this effort will be the professional organizations and we must secure the active assistance of such groups as the medical profession, League of Nursing, Agriëultural Assistance Service and the Center for Disease Control and others as vital. In the area of implementation, cert~ nly a detailed plan must be made for each group dovetailing their actions with the other ma:~power groups. A second group would be volunteer organizations, and this is a vast resevoir of organizational and creative talent; a resevoir whose efforts are vital to the success of this effort. We must enlist, train and supply with localized market plans, community actiop kits, timetables and quotas, organizations such as the National PTA, Girl Scouts, Boy Scouts, Little League and many others. Finally, business organizations. Too often, this audience is overlooked as a source of volunteer manpower and professional expertise. Yet there is no group on the American scene better equipped or more experienced in charting a clear course and getting things done. We would enlist their assistance whenever possible. We would talk to package goods companies and request that they insert messages either inside packages of cereal, or on the exteriors of packages, we would also ask them to use their considerable influence to get displays, banners, and signs placed in grocery stores, drug stores; in short, anyplace where a member of our target audience may see it. -14- PAGENO="0521" COMPETITIVE PROBLEMS IN THE DRUG INDUSTRY 14427 Finally, another crucial area to be considered is the delivery s~stem or immuni.~ zation locations. We must determine h~w we plug into the existing system and, if we admit it's not sufficient for our needs, we must determine how we build on to that system, how we amplify it for thi s specific effort. Unlike a package. goods marketer, who can always rely on the grocery stores or drug stores as the outlet for his product, a national immunization prograhi requires the creation of a new delivery system. Strategically, we want to plan for the optimum use for thi $ system and the manpower we have available. We want a controlled traffic flow, Certainly, this program will be a failure if all children appear on Monday, October 25 for immunization. We must control the flow of traffic. We must plan for and attempt as far as possible to guarantee the orderly use of clinics, school locations, mobile vans, doctors' offices, hospitals and any other location that may be needed or be effective. Having established this system, we must also, through communications, create an awareness of the locations, times of operations, the fact of its convenience, etc., etc. These are just the highlights of some of the actions reqitired for a successful program but having put a plan in motion, question No. 4 arises. `Are we getting there?" In far too many cases, programs are enacted at great expebse and never evaluated. Only by answering this question do we have a sufficient fact base for !ature decision~ -15- PAGENO="0522" 14428 COMPETITIVE PROBLEMS t~ THE DRUG INDUSTRY making. As it pertains to immunization, we must ascertain what our success ratios are with each of our target publics. Are we reaching the inner cities but not the suburbs? Why? Are we 20% more successful in the midwest than on the east coast? Why? Are our late night television commercials on television shows that have a sufficiently high rating? Are our Nebraka immunization centers conveniently located? Do they remain open late enough at night? Are younger west cx)ast physicians distributing.our- literature in their waiting rooms and clinics? Only when we have this information can we make the decision called for in our final question. "Should we change direction?' We must believe that no part of a strategy is sacrosanct, and if we have been thoroughly objective in our answering of question No. 4~ we will have set the stage -for effectiv~ decision- making at this point. We might simply engage in fine-tuning such as seeking increased commercial exposureS to the 20 to 30 age groups or by eliminating mobile van immunizations as inefficient delivery tools. We might, however, have to rework our entire appeal or possibly scale down our objective. In short, the application of this- Social Marketing process to the area of social needs is a step too vital to be ove~Looked if we want to insure success. -16- PAGENO="0523" COMPETITIVE PIWBLEMS IN TE~ DRUG INDUSPRY 14429 The approach just described for a successful immunization effort might be equally necessary for the successful transfer of any new information on drugs, achievement of appropriate behavior change in the use of the drugs in question, or improvement in compliance with therapeutic regimens which is today such a serious problem. A case in point would be tb~ implementation of the drug use changes warranted by the results\f the Coronary X~rug Project or indeed the implementation of any new beneficial or adverse drug Information. Some of these same Social Marketing tecbni4ues should be applied before major fundamental procedural changes are promulgated in the drug area, such as the requirement for patient package insertB for all prescription drugs. Unless this is required, neither society or policy makers will have any way of knowing whether a desirable end Is achieved by a new policy. In summary, I have attempted to describe for you the difficulties inherent in the communication process and the techniques necessary to bring about success- ful technology transfer and appropriate behavior change on the part of health professionals and the public. It is clear we are not doing this job well today. It is equally clear that informa- tion alohe, or a seminar report, or a scientific article, ot a study report, or a drug bulletin, or a press release, or a regulation, or a warning alone are not' enough. The technique of Social Marketing, does not share government's apparent confidence that the public or health professional care to listen, and to act on what they hear. Rather, the practitioners of Social Marketing assume -17- PAGENO="0524" 14430 COMPETITIVE PROBLEMS IN PIlE L)RUG INDUSThY just the opposite - - that both are bombarded with a surfeit of messages day and night, a~d they will resolutely ignore all but the most carefully crafted and per suasively conveyed communications which attract their attention. It is high time for all of us concerned about the health care system to acknowledge the clear truth of that assump±jQn, There are many illustrations of the bank- ruptcy of a passive communications policy. The health establishmen\has a `tproduct't, and a worthy one at that. The product is information - - vital, life.~giving information. But the life-giving capacity of those data is often aborted in the absence of a determined and effec$ve effort to make them heard and heeded. The application of the techniques of Social Marketing will be necessary for the technology transfer NIH and I'DA and others are required to accomplish and to impact on the prevention, early diagnosis of and appropriate and timely therapy of disease, This will involve communicating with the ptiblic and the health professions in such a way as to bring about appropriate attitude and behavior changes. At this point, it might be useful to recount some real life examples of Social Marketing in several other countries. -18- PAGENO="0525" COMPETITIV1~ PROBLEMS IN THE DRUG INDUSTRY 14431 In Great Britain, we undertook a two year educational effort to prepare the entire population for the changeover from pound-shilling to decimal currency. We believe this represents the most intense and successful Social Marketing campaign ever undertaken. This necessarily involved not only the comprehensive - promulgation of somewhat technical data tO a wide variety of publics (consumers, merchants, bankers, teachers, etc.) but also the cultivation of attitudes favorable to cooperating in the effort. After all, they were phasing out a custom and habit of four hundred years' standing for the nation, and of perhaps sixty or seventy years' standing for many individuals. But the campaign was professionally wrought, governmentally financed, and publicly respected. It was effective beyond the most optimistic expectations. The same was true for an anti-drug program in West Germany, directed primarily to potential teenage abusers. Once again, the professional marketing communi- cators employed their unparalleled understanding of t~ieir audience ai~d of bow communications must be used to effect real change. They avoided mistakes made by other well-intended but less astute anti-df~ug ~ampaig~ts, and the project appears to have rendered a demonstrable public serv~e. I believe there are areas where we mnst now bend to our own ends the cotnpetence of professional communicators, in a deliberate stroke Df public policy, to accomplish widely desired health benefits. Such a policy is prefigured in other areas of public priority -- the military, for instance. All of the U.S. armed services routinely engage in the use of marketing communications and paid media - - broadcast and otherwise -- to ensure fulfillment of their recruiting objectives. -19 PAGENO="0526" 14432 COMPETIP]NE PROBLEMS IN THE DRtJG INDUSTRY Surely the objectives of th~ NIH, FDA and innumerable other health agencies are no less worthy. Every public agency which is party or privy to the develcpment of technology has an obligation, it seems to me, to actively foster the fruitful application of that technology. It is clear that information dissen~lnatlon alone does not necessarily bring about appropriate change. The Cç~igr~~~s can make that Qbli- gation explicit and irrefutable by.calling for each agency to demonstrate the provisions it has r~iade to market its knowledge. Only then can we achieve a conscionable balance among medical technology, medical practice, the rights of the private sector to promote its viewpoint, agency accountability, and - - ultimately - - the health of our citizens. Thank you. -20-