(beclomethasone 11. Orrossot'i JO: Psychological theories of ECT: a review. Psychological or physiological theories of ECT. mt J Psychiatry 5: 170, 1968 12. Idem: in Psychobiology of Convulsive Therapy, FINK M, Ks'r. S. MCGAUGH 3, et al (eds), New York, Halsted Pr, 1974, p 19 13. KETY SS: Effects of repeated electroconvulsive shock on brain catecholamines. Ibid. p 231 14. BLACHLY PH (ed): Multiple monitored ECT: (MMECT). Convulsive Therapy Bulleiin with Tardive Dyskinesia Notes 1: 23, 1976

15. LANCASTER NP, STEINERT RR, FROST I: Unilateral electro-convulsive therapy. I Ment Sci 104: 221, 1958 16. D'ELIA G, RAOTMA H: Ts unilateral ECT less effective than bilateral ECT? Br I Psychiatry 126: 83, 1975 17. SQUIRE LR, CHACE PM: Memory functions six to nine months after electroconvulsive therapy. Arch Gen Psychiatry 32: 1557, 1975 18. CRow TJ, JOHNSTONE EC: Cerebral atrophy and cognitive impairment in chronic schizophrenia (C). Lancet 1: 357, 1977 19. MoIR DC, CROOKS J, SAWYER P, et al: Car-

diotoxicity of tricycic antidepressants. Br I Pharmacol 44: 371P, 1972

Medical education in Afghanistan It is difficult sometimes for a physician with a background in North American medicine to appreciate fully the priorities in health care delivery necessary in developing nations. The need for, and yet the fiscal impracticality of, such a basic necessity as a potable water supply for all the citizens of such countries, so recognized by the 1976 United Nations Habitat Conference in Vancouver, exemplifies the widespread deficiencies in health care in these countries and underlines the small offerings that most Canadian physicians are prepared, by experience, to give these nations. At the same time, because of, or coincident with, these deficiencies in basic public health measures, illnesses that can better be managed with the help of sophisticated clinical skills do occur. It is because of this that many Canadian physicians offer their clinical or teaching skills to programs established by various organizations operating throughout the world. In the Islamic Republic of Afghanistan, a land-locked country in central Asia (population, approximately 15 million) the size of Alberta, Care! Medico established in 1961 a postgraduate teaching program in medicine and surgery. The permanent team now includes five Canadians: two physicians, a surgeon and two nurses. With an expenditure of less than $200 000 per year plus donated supplies and skills, a clinical service for medicine and surgery has developed that is probably the best in the country, and it trains most physicians in these specialties. There have been 25 graduates from the postgraduate training program in surgery and 30 graduates from the program in medicine. Of these graduates 22 now are serving in provincial hospitals.1 Comparable service and teaching units in pediatrics and ophthalmology are supervised by a team from India and the international Afghan Mission (a Christian organization), re-

spectively. The Care/Medico teaching program depends to a large degree on visiting specialists from Europe, Australia and North America, more than 200 of whom have participated since 1965. The trainees are English-speaking graduates from the two medical schools in Afghanistan, chosen by the Ministry of Health and assigned to the programs on the basis of their rank in competitive examinations. Both medical schools now have exclusively Afghan faculty. The newest school, at Ningrahar University in Jalalabad, initially had the help of American faculty members. The older school, at Kabul University, was founded in 1932 with the help of a Turkish medical mission. From 1947 to 1963, French teachers were prominent in the faculty and many of the present Afghan faculty were trained in France. From 1938 to 1974, 1195 physicians graduated from Kabul University and in 1975 the 1st-year class in medicine totalled 210 students. It is estimated that there are 1600 physicians in the country, 170 of whom are women, and that 400 to 500 live in the city of Kabul. There is little or no immigration of physicians into the country and permission for them to leave the country for even brief visits is difficult to obtain, especially if their compulsory military service has not been completed. Hence, under present conditions the development of medical and surgical skills in Afghan graduates depends on the teaching teams now resident in the country and, to a large degree, upon visiting volunteer teachers. Adaptation to the limited patient-care resources and support services available in Afghanistan is difficult and extremely challenging. Infectious diseases such as tuberculosis, hepatitis, gastrointestinal infections, malaria and trachoma are very common. It has been estimated that the mortality in the first 5 years of life outside Kabul approaches 85%.

10 CMA JOURNAL/JANUARY 7, 1978/VOL. 118

Beconase Nasal Spray Prescribing information indications and clinical uses Beconase is indicated for the treatment of perennial and seasonal allergic rhinitis unresponsive to conventional treatment. Contraindications Active or quiescent tuberculosis or untreated fungal, bacterial and viral infections. Children under six years of age. Warnings In patients previously on high doses of systemic steroids, transfer to Beconase may cause withdrawal symptoms such as tiredness, aches and pains, and depression. In severe cases adrenal insufficiency may occur, necessitating the temporary resumption of systemic steroids. The safety of Beconase in pregnancy has not been established. If used, the expected benefits should be weighed against the potential hazard to the fetus, particularly during the first trimester of pregnancy. Precautions The replacement of a systemic steroid with Beconase has to be gradual and carefully supervised by the physician. The guidelines under "Administration" should be followed in all such cases. Unnecessary administration of drugs during pregnancy is undesirable. Corticosteroids may mask some signs of infection and new infections may appear. A decreased resistance to localized infection has been observed during corticosteroid therapy. During long-term therapy, pituitary-adrenal function and hematological status should be periodically assessed. Fluorocarbon propellants may be hazardous if they are deliberately abused. Inhalation of high concentrations of aerosol sprays has brought about cardiovascular toxic effects, and even death, especially under conditions of hypoxia. However, evidence attests to the relative safety of aerosols when used intranasally and with adequate ventilation. There is an enhanced effect of corticosteroids on patients with hypothyroidism and in those with cirrhosis. Acetylsalicylic acid should be used cautiously in conjunction with corticosteroids in hypoprothrombinemia. Patients should be advised to inform subsequent physicians of the prior use of corticosteroids. During Beconase therapy, the possibility of atrophic rhinitis and/or pharyngeal candidiasis should be kept in mind. Adverse reactions No major side effects attributable to Beconase have been reported. Occasional sneezing attacks have followed immediately after the use of the intranasal aerosol. A few patients have complained of burning sensation and irritation in the nose after Beconase nasal inhalation. When patients are transferred to Beconase from a systemic steroid, allergic conditions such as asthma or eczema may be unmasked.

Dosage and administration The usual dosage for

patients of all ages who received no previous systemic steroid is one application (50 mcg of beclomethasone dipropionate) into each nostril three to four times daily. Maximum daily dose should not exceed twenty applications in adults and ten applications in children. If Beclovent is used concurrently, the maximum dose of each aerosol is ten applications in adults and five applications in children. Beconase should not be used under six years of age. Since the effect of Beconase depends on its regular use, patients must be instructed to take the nasal inhalations at regular intervals and not, as with other nasal sprays, as they feel necessary. They should also be instructed in thecorrect method, which is to blow the nose, then insert the nozzle firmly into the nostril, compress the opposite nostril and acuate the aerosol while inspiring through the nose, with the mouth closed. In the presence of excessive nasal mucus secretion or edema of the nasal mucosa, the drug may fail to reach the site of action. In such cases it is advisable to use a nasal vasoconstrictor for two or three days prior to Beconase. Careful attention must be given to patients previously treated for prolonged periods with systemic corticosteroids when transferred to Beconase. Initially, Beconase and the systemic corticosteroid must be given concomitantly, while the dose of the latter is gradually decreased. The usual rate of withdrawal of the systemic steroid is the equivalent of 2.5 mg of prednisone every four days if the patient is under close supervision. If continuous supervision is not feasible, the withdrawal of the systemic steroid should be slower, approximately 2.5 mg of predriisone (or equivalent) every ten days. If withdrawal symptoms appear, the previous dose of the systemic steroid should be resumed for a week before further decrease is attempted. Dosage form Beconase is a metered-dose aerosol, delivering 50 micrograms of beclomethasone dipropionate with each depression of the valve. There are two hundred doses in a container. Official product monograph on request.

Allen & Hanburys A Glaxo Canada Ltd. Company Toronto, Canada

Diagnostic endeavours are hampered by generally inadequate radiologic equipment and personnel, the result of which is frequently inadequate basic studies such as chest roentgenography and gastrointestinal and urinary tract studies. Vascular, myelographic and central nervous system radiologic studies are not available. There are only rudimentary bacteriologic services, a limited spectrum of biochemical and hematologic services, which are erratic in quality and sometimes slow in responding, a virtual absence of postmortem studies and a complete absence of radionuclide studies. Nevertheless, therapy, both medical and surgical, is pragmatic, ingenious - and surprisingly successful as a result of the devotion of the various teaching teams and the Afghan staff and their residents. An example of the knife-edge upon which geographic, climatic and economic circumstances place the health and, indeed, the survival of the citizens of Afghanistan is the recent appearance of "Guiran disease", as reported by Mohabbat and colleagues.2 Following a severe drought in 1970-72 around the village of Gulran, affecting a population of 35 000, an epidemic of severe liver disease began to appear in mid1974. Clinicopathologic studies, many of them performed in Avicenna Hospital in Kabul, where the Care/Medico team was centred, have indicated that it is a type of occlusive disease of the central hepatic vein, probably caused by the consumption of bread made from the only available food staple, wheat, which had been contaminated with Heliotropium seeds containing a pyrrolizidine alkaloid. Signs of hepatic dysfunction or failure developed in affected persons. In a field survey of the area in 1975, 7200 persons were examined, and evidence of liver disease - ascites, emaciation, hepatomegaly and occasionally jaundice was found in 22.6%; of these, 46% were children less than 14 years of age. The disease was usually fatal, an estimated 3000 deaths having occurred by 1975. The simple preventive measure of using wheat-cleaning equipment, so common on Canadian farms, was not available. With an estimated 75. per person being spent per year in Afghanistan for all health services it is apparent that a sophisticated medical-surgical unit is not practical if it depends entirely on this support. The need to overcome this difficulty has been recognized by the Afghanistan government and has been made possible, in part, by the Care! Medico program. It is recognized by both that the ultimate objective of this program must be its independence of foreign aid and, therefore, the development of a trained Afghan staff

capable of carrying on and developing further at least a single unit of excellence. In addition to the specific patient services provided by such an independent unit a more important effect may be that these physicians and surgeons will play a leading role in advocating and developing the necessary basic public health measures now lacking. The Care! Medico training program in Afghanistan has now been operating for 12 years and there is mutual agreement between Care/Medico and the Afghanistan government that the program and its graduates are not yet selfsustaining. With the modest budget available to the program from Care! Medico and the central government and with the continued dependency of the program on brief visits by volunteer teachers it is difficult to envisage how or when, in the foreseeable future, a self-sustaining unit will be developed. In recent years discussions between the Afghanistan Ministry of Health, the Medical College and Care/Medico have been carried out in an attempt to hasten the creation of a recognized group of specialists within the country. It seems that the need for more advanced training of Afghan physicians is now recognized and desirable. This could be achieved in several ways: by arranging for advanced overseas training of selected graduates of the present training programs, by funding visits of significant duration by overseas medical school teachers or by funding similar visits to overseas schools of Afghan medical school faculty. The risk of loss to North America of such physicians is a very sensitive issue but now the risk is significantly less with our more stringent immigration regulations. Canada's foreign aid program, under the auspices of the Canadian International Development Agency, already has a nonmedical presence in Afghanistan. For a modest expenditure of funds and without necessarily a prolonged commitment, Canada could provide an exciting opportunity for Afghanistan physicians and Canadian medical school teachers to enrich their respective training programs and, especially, benefit the people of Afghanistan. At the same time one must appreciate the practical but not insurmountable fact that the initiation of such an exchange must originate in Afghanistan. DR. MACFADYEN, MD, FRcP[c] Department of clinical neurological sciences University Hospital Saskatoon, Sask.

References 1. D#.vis F: Care/Medico in Afghanistan. Medico Rec 36: 9, t976 2. MOHABBAT 0, YouNos MS, MERZAD AA, Ct al: An outbreak of hepatic venoocciusive disease in north-western Afghanistan. Lancet 2: 269, 1976

12 CMA JOURNAL/JANUARY 7, 1978/VOL. 118

222* Tablets

INDICATIONS: For relief of mild to moderate pain, fever and inflammation as in influenza, common cold, low back and neck pain, headache, trauma, following dental and surgical procedures. DOSAGE-Adults-i or 2 tablets one to three times daily; Children's dosage, when recommended by a physician: 10 to 14 years, one tablet, one to three times daily; 5 to 10 years, one-half tablet, one to three times daily. CONTRAINDICATIONS: Gastrointestinal ulceration and sensitivity to any of the components. WARNINGS: Salicylates increase the effects of anticoagulants. Caution is necessary when salicylates and anticoagulants are prescribed concurrently. Also, salicylates may depress the concentration of prothrombin in the plasma. Large doses of salicylates may affect insulin requirements of diabetics. Salicylates may potentiate sulfonylurea hypoglycemic agents. Analgesic abuse (excessive and prolonged therapy) has been associated with nephropathy. TO AVOID ACCIDENTAL POISONING ACETYLSALICYLIC ACID PREPARATIONS MUST BE KEPT WELL OUT OF REACH OF CHILDREN. PRECAUTIONS: Give with caution to patients with asthma, other allergic conditions, bleeding tendencies, or hypoprothrombinemia. Saucylates can produce changes in thyroid function tests. Observe care in use of codeine, although tolerance and addiction are rare. Give codeine with caution to patients with severe respiratory depression. Its depressant effect may be enhanced by concurrent administration of sedatives and tranquilizers.

ADVERSE REACTIONS: Acetylsalicylic acid: Gastrointestinal: dyspepsia, heartburn, nausea, vomiting, diarrhea, gastrointestinal ulceration and bleeding. Ear reactions: tinnitus, hearing loss. Hematologic: anemia, leukopenia, thrombocytopenia, purpura. Dermatologic and Hypersensitivity: urticaria, angioedema, pruritus, various skin eruptions, asthma and anaphylaxis. Miscellaneous: mental confusion, drowsiness, sweating and thirst. Codeine: Average or large doses may cause various gastrointestinal symptoms such as nausea, vomiting and constipation. Caffeine: May cause nausea, nervousness, insomnia, headache, vomiting, palpitation, vertigo, muscle tremor, sensory disturbances, excessive diuresis in sensitive patients. Large doses may cause gastric ulceration. FULL INFORMATION AVAILABLE ON REQUEST HOW SUPPLIED O 222* Tablets-White, scored, engraved 222 on one side. Each tablet contains: acetylsalicylic acid 375 mg, caffeine citrate 30 mg, codeine phosphate 8 mg. Available in tubes of 12; bottles of 40, 100 and 250, also bottles of 60 with safety cap. Weiss, H.J.: AspirIn-a dangerous drug? 1. JAMA 229(9): 1221-1222, Aug. 26,1974. Beaver, W.T.: MIld analgesIcs in the 2. treatment of pain, pp. 1094-1120. *Trademark

CHARLES E. FROSST & Co. KIRKLAND (MONTREAL) CANADA

222T-7-71 9-JA

Medical education in Afghanistan.

(beclomethasone 11. Orrossot'i JO: Psychological theories of ECT: a review. Psychological or physiological theories of ECT. mt J Psychiatry 5: 170, 19...
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