Family physicians' involvement in two hospitals. Two different models of inpatient care

OBJECTIVE

To describe the roles of family physicians in two hospitals with different models of inpatient care.

DESIGN

Cross-sectional descriptive study of a random sample of 11528 patients admitted to two hospitals between 1985 and 1988.

SETTING

Two acute-care community hospitals in suburban Montreal, Que.

SUBJECTS

Family physicians providing inpatient care at the two hospitals.

MAIN OUTCOME MEASURE

How often family physicians were attending physicians (attending responsibility); what percentage of patients were visited by at least one family physician (case load); and what percentage of bedside visits were made by family physicians (workload).

RESULTS

In one hospital, where family physicians were actively promoted as primary care providers, they were frequently attending physicians, had heavier case loads, and made more patient visits. Also, they collaborated more often with specialists. In the other hospital, family physicians tended to care for specific populations of patients.

CONCLUSION

When hospitals promote different organizational models of medical care, family physicians' roles are affected.

Physician-assessment and physician-enhancement programs in Canada

Since the mid-1980s, the licensing authorities in Quebec, Ontario and Manitoba have introduced programs to conduct in-depth assessments of the clinical skills and abilities of physicians with suspected deficiencies. These assessments are intended to supplement the provincial licensing authorities' existing peer review or patient-complaint mechanisms by confirming the physicians' overall level of competence and identifying specific clinical strengths and weaknesses. An "educational prescription," based on the results of the assessment, focuses on aspects of clinical practice in which the physicians need or wish to enhance their skills. In some situations, licensure decisions are based on the assessment information. This article describes the programs in Quebec, Ontario and Manitoba. Each program comprises a different process of personal assessment and individualized continuing medical education to help physicians improve their clinical competence, and each is built on sound principles of clinical-competence assessment and educational planning.

A comparison study of day hospital and day centre attenders

There has been much recent debate on the appropriateness and relative roles of the two main forms of day care available for dementia sufferers (day hospitals and day centres). The characteristics of day care attenders are an important aspect of this debate and have been examined in this study. The area surveyed (North Edinburgh) is unusual not only in respect of the relatively high number of day centre places but also in respect of the close working relationship between day centre and day hospital staff. Current data indicates that many of the attenders at day hospitals and day centres have similar characteristics suggesting that much of the work currently done in day hospitals could be done in day centres, and that even in North Edinburgh there is room for a further expansion in day centre places. Such expansion should not be wholly at the expense of day hospital services as not only are they providing, almost exclusively, a service for the most severely affected, but there is evidence that a small number of day centre attenders would benefit from a multi-disciplinary assessment such as the day hospital provides. For the two services to work effectively close liasion between workers, such as already exists in North Edinburgh, is a prerequisite.

Structured oral interview. One way to identify family physicians' educational needs

OBJECTIVE

To design and test a structured oral interview that would elicit information on the educational needs of physicians in order to help them plan individualized continuing education.

DESIGN

Seven different sets of problems were prepared, each including 40 cases, of which 26 are common. Each pilot test candidate was interviewed by two physician-interviewers during a 1-day session. After each answer, candidates were told the predetermined correct answer.

PARTICIPANTS

Six candidates were selected at random from among Montreal physicians aged 50 and older with no hospital privileges. All had to have no history of professional complaints or prosecution and to be unknown to the interviewers.

MAIN OUTCOME MEASURES

Inter-rater reliability and perceived difficulty of the cases.

RESULTS

Candidates rated the interview process and cases used pertinent, credible, and not too difficult. Candidates' performance level was about 50%. Agreement between interviewers averaged 91.2%.

CONCLUSIONS

A structured oral interview appears to be a credible instrument for helping determine practising physicians' deficiencies in clinical knowledge and reasoning.

Epidural analgesia

Epidural analgesia is becoming more widely used. Epidural analgesia can be administered either by topup or bolus injection or by continuous infusion. Many drugs and drug combinations can be used to obtain the best control of pain. Monitoring of vital signs is important in order to provide early detection of any complications. Awareness of the complications and side effects which can occur is necessary in order to care safely for the individual with an epidural cannula in situ.

Physiology of pain

In order to fully understand pain control, professionals need not only to be aware of the effect that pain can have on the individual and the therapies that are available to help them but also to have some insight into pain mechanisms. This article describes pain impulse transmission and the inhibitory process which are present.

The use of insulin in diabetes mellitus

1. The DNA structure of human insulin is very similar to animal insulin. 2. Many insulin preparations are available in order to achieve the best possible control. 3. Care needs to be taken with regard to insulin administration in order to avoid complications.

[A pulsed Doppler study of left atrial and ventricular inflow in 2 populations of normotensive and hypertensive subjects]

OBJECTIVE

Comparative analysis of left atrial and left ventricle Doppler inflow patterns in patients with essential systemic mild to moderate hypertension and normal global left ventricular systolic function.

PATIENTS

A group of out patients with the diagnosis of hypertension referred to the Echocardiographic Laboratory of Egas Moniz Hospital in Lisbon.

SETTING

Echocardiographic Doppler prospective study.

MATERIAL AND METHODS

We studied a group of 50 patients with the diagnosis of mild to moderate arterial hypertension (Group H), which was compared with a population of 50 normal subjects (Group N). In each case we analysed the pulsed Doppler flow of the right upper pulmonary vein and the diastolic inflow of the left ventricular cavity. We calculated the peak velocities and time velocity integrals of the systolic, diastolic and atrial contraction waves of the pulmonary venous flow and also the systo-diastolic velocity and time velocity integral ratios. In the transmitral Doppler flow analysis we evaluated the peak velocities and time velocity integrals of the early (E wave) and late (A wave) waves, and their time velocity and velocity ratio. We assessed also the isovolumic relaxation time and left ventricular mass index.

RESULTS

In groups N and H the peak velocity of the pulmonary venous flow systolic wave was 0.53 +/- 0.15 cm/sec and 0.75 +/- 0.10 cm/sec (p = 0.01), diastolic wave was 0.50 +/- 0.10 cm/sec and 0.41 +/- 0.09 cm/sec (p = 0.03) and atrial contraction wave was 0.18 +/- 0.03 cm/sec and 0.35 +/- 0.08 (p = 0.001), with a systo-diastolic ratio of 1.06 +/- 0.10 and 1.83 +/- 0.10 (p < 0.001), respectively. In these two groups the time velocity integral of the pulmonary venous flow systolic wave was 14.4 +/- 2.6 cm and 17.8 +/- 1.8 cm (p = 0.001), the diastolic wave was 12.5 +/- 3.2 cm and 9.3 +/- 1.3 cm (p = 0.05) and the atrial contraction wave was 4.4 +/- 0.07 cm (p = 0.001), with a systo-diastolic ratio of 1.1 +/- 0.16 and 1.9 +/- 0.12 (p < 0.001), respectively. For the group H and considering the three subgroups, hypertensive patients without anatomical or functional alterations, with isolated diastolic dysfunction and with left ventricular hypertrophy associated to diastolic dysfunction, the velocity systo-diastolic ratio was 1.08 +/- 0.12, 1.57 +/- 0.08 (p < 0.01) and 2.4 +/- 0.08 (p < 0.01) and 2.4 +/- 0.08 (p < 0.001), the systo-diastolic time velocity integral ratio was 1.22 +/- 0.17, 1.72 +/- 0.13 (p < 0.01) and 2.4 +/- 0.15 (p < 0.001), the peak velocity of the atrial contraction wave was 0.28 +/- 0.07, 0.3 +/- 0.08 (p < 0.01) and 0.43 +/- 0.07 (p < 0.001) and its time velocity integral was 4.6 +/- 0.06 cm, 5.6 +/- 0.07 cm (p < 0.01) and 7.0 +/- 0.08 cm (p < 0.001).

CONCLUSIONS

Pulsed Doppler study of pulmonary venous flow is significantly abnormal in patients with arterial hypertension. This abnormal pulmonary venous flow pattern has a close relationship with structural and functional alterations of the left ventricle. Combined analysis of the pulsed Doppler inflow at these two cardiac anatomical levels is fundamental to understand the pathophysiology of hypertensive heart disease.

[A double ambulatory product (blood pressure and heart rate), mild arterial hypertension and left ventricular hypertrophy]

OBJECTIVE

Analysis of the different ambulatory blood pressure monitoring derived parameters in terms of cardiac structural repercussion, in patients with isolated systolic and mild systolic-diastolic hypertension.

SETTING

Prospective study involving simultaneously the two-dimensional echocardiographic technique and the ambulatory blood pressure monitoring method.

PATIENTS

Out patients regularly observed in the Cardiology Department of Egas Moniz Hospital in Lisbon, were included in our study.

MATERIAL AND METHODS

We studied 50 hypertensive patients who fulfilled the inclusion criteria of our study (Group H) and 20 subjects who were the normal aged matched population (Group N). through ambulatory blood pressure monitoring, in each individual of these two groups, we considered the mean values of daily systolic blood and diastolic blood pressure, heart rate and ambulatory heart rate blood pressure product. Through two-dimensional echocardiography we calculated the left ventricular mass and the correspondent index corrected for the body surface.

RESULTS

In the H group an comparing to the N group, the mean value of the daily systolic blood pressure was 112 +/- 6 mmHg and 159 +/- 8 mmHg (p < 0.001) respectively, diastolic blood pressure was 60 +/- 5 mmHg and 75 +/- 7 mmHg respectively (p < 0.001), heart rate blood pressure product was 6720 +/- 580 and 12561 +/- 678 (p < 0.0001) and of the left ventricular mass index was 109 +/- 10 gm2 and 145 +/- 7 g/m2 (p < 0.001). The correlation coefficient between the left ventricular mass index and mean systolic, diastolic blood pressures and ambulatory heart rate blood pressure product was 0.60 (p < 0.01), 0.45 (p = NS) and 0.73 (p < 0.001) respectively.

CONCLUSIONS

In the evaluation of the increase in left ventricular mass, ambulatory heart rate blood pressure product is a more accurate parameter compared to the mean daily blood pressure values. Ambulatory blood pressure monitoring is a method with a great potential and clinical application, when studying patients with hypertension diagnosis.

[The indices of pressure variability by noninvasive ambulatory monitoring of the arterial pressure. A study in 2 normotensive and hypertensive populations]

OBJECTIVE

Analysis of different indices of blood pressure (BP) variability using the ambulatory blood pressure monitoring (ABPM) method in two populations of hypertensive patients (HTA Group) and normotensive volunteers (NOR Group).

SETTING

Noninvasive prospective ambulatory study to assess the alterations of the circadian blood pressure profile through ABPM indices of blood pressure variability.

PATIENTS

Patients with the diagnosis of essential arterial hypertension referred for clinical investigation to the Cardiology Department of Egas Moniz Hospital in Lisbon.

MATERIAL AND METHODS

40 hypertensive patients (HTA Group) and 30 normal subjects (NOR Group) were included in this study. We calculated the short and long term variability indices. The short term variability indices were the casual and mean immediate BP deviation, percentage of BP peaks and BP peak relative deviation and maximal range variation. Some clinical and general factors considered were namely age, gender, height, weight, body area and index, mean and casual systolic-diastolic blood pressure.

RESULTS

Concerning systolic blood pressure in hypertension Vs normal groups respectively, the casual BP deviation was 15 +/- 4 mmHg and 7 +/- 4 mmHg (p 0.003), the mean immediate BP deviation was 18.5 +/- 4 mmHg and 7.5 +/- 3 mmHg (p 0.002), the percentage of BP peaks was 27 +/- 6% (p < 0.001), the percentage of BP peak area was 29 +/- 7% and 6 +/- 3% (p 0.001) and the percentage of relative deviation was 14 +/- 4% and 8 +/- 3% (p 0.03). For diastolic blood pressure all differences were not statistically significant between the two groups and the same happened for systolic blood pressure in relation to standard deviation and maximal range variation. Among these parameters and general and clinical characteristics, the systolic mean and casual blood pressure level showed an acceptable correlation with mean immediate deviation (R = 0.54/0.49), percentage of BP peaks (R = 0.56/0.49) and percentage of BP peak area (R = 0.60/0.53).

CONCLUSIONS

Blood pressure variability can be adequately evaluated through the method of ambulatory blood pressure monitoring. Some variability indices can be extracted from the 24 hour curves of ambulatory blood pressure monitoring. Long-term variability indices are not related to the level of blood pressure. In the hypertension group we found a greater variability concerning short term indices, namely immediate deviation, percentage and are of peak curve.

Effects of residency training in family medicine v. internship training on professional attitudes and practice patterns

OBJECTIVES

To determine whether the professional attitudes and practice patterns of physicians with residency training in family medicine differ from those of generalists with internship training.

DESIGN

Mail survey conducted in 1985-86.

SETTING

Province of Quebec.

PARTICIPANTS

A stratified random sample of French-speaking family and general practitioners who graduated after 1972 (325 physicians with residency training and 304 with internship training) (response rate 82%).

MAIN RESULTS

Physicians with residency training were 3 years younger on average than those with internship training, were more likely to be female (38% v. 18%, p less than 0.001) and were more likely to work on a salaried basis in CLSCs (public community health centres) (36% v. 14%, p less than 0.001). Even after these confounding factors were controlled for, physicians with residency training seemed to be more sensitive to the psychosocial aspects of patient care and tended to attach more importance to informing patients about useful materials and resources concerning their health problems. They were not, however, more likely to value health counselling or integrate it in medical practice.

CONCLUSION

Our findings provide some evidence that the new requirement that physicians complete a residency in family medicine to obtain medical licensure in general practice in Quebec may foster a more patient-centred approach to health care.

Do you believe I'm in pain? Nurses' assessment of patients' pain

Expression of pain is influenced by physical, psychological and cultural background. It is important, therefore, that assessment is based on individual needs and not value judgements.

Mémoire du CMFC, Section du Québec à la Commission Rochon

The mandate of the Rochon Commission, a board of inquiry into Quebec's health and social services, is to analyse and rationalize the use made of those services in the Province of Quebec. The Quebec Chapter of CFPC presented a brief to the Commission, describing the place of the College in promoting high standards of quality in family practice. The brief submitted by the Chapter emphasizes, also, on the necessity of a specific two-year residency training program that all family physicians would be obliged to complete before they become eligible to obtain a licence to practice. The brief also states the necessity of a CME program for all family physicians and details the financial and human resources required for the development of a Family Medicine Program for all family physicians in the Province of Quebec.

Inhibition of T cell-mediated cytotoxicity by anti-inflammatory steroids

We have tested the capacity of glucocorticoids to modulate the effector function of splenic cytotoxic T lymphocytes (CTL) obtained after i.p. immunization with allogeneic cells. Although acute exposure to glucocorticoids did not inhibit the activity of freshly obtained splenic CTL, preincubation of these CTL for several hours with subnanomolar concentrations of several different glucocorticoids caused marked inhibition. The relative inhibitory potency of the steroids tested correlated with their reported activity both in glucocorticoid receptor binding assays and in assays of anti-inflammatory potency in man. The inhibitory effects of low concentrations (10(-10) M to 10(-9) M) of dexamethasone were reversed by human or mouse interleukin 2 (IL 2)-containing supernatants, but were not reversed by IL 1-containing supernatants. The inhibitory effects of higher concentrations (10(-8) M to 10(-7) M) of dexamethasone could not be reversed even by very high doses of mouse IL 2. In contrast to previous reports of minimal direct glucocorticoid effects on CTL activity, the present results suggest that after preincubation, splenic CTL from in vivo-immune mice are sensitive to inhibition by glucocorticoids, and that the glucocorticoids may act both indirectly (on IL 2 production) and directly on the CTL.

Inhibition of T cell-mediated cytotoxicity by anti-inflammatory steroids

We have tested the capacity of glucocorticoids to modulate the effector function of splenic cytotoxic T lymphocytes (CTL) obtained after i.p. immunization with allogeneic cells. Although acute exposure to glucocorticoids did not inhibit the activity of freshly obtained splenic CTL, preincubation of these CTL for several hours with subnanomolar concentrations of several different glucocorticoids caused marked inhibition. The relative inhibitory potency of the steroids tested correlated with their reported activity both in glucocorticoid receptor binding assays and in assays of anti-inflammatory potency in man. The inhibitory effects of low concentrations (10(-10) M to 10(-9) M) of dexamethasone were reversed by human or mouse interleukin 2 (IL 2)-containing supernatants, but were not reversed by IL 1-containing supernatants. The inhibitory effects of higher concentrations (10(-8) M to 10(-7) M) of dexamethasone could not be reversed even by very high doses of mouse IL 2. In contrast to previous reports of minimal direct glucocorticoid effects on CTL activity, the present results suggest that after preincubation, splenic CTL from in vivo-immune mice are sensitive to inhibition by glucocorticoids, and that the glucocorticoids may act both indirectly (on IL 2 production) and directly on the CTL.

[The campaign "Viva la vie": trial of a modern technic of communication applied to the promotion of blood transfusion]

Since it was opened 18 months ago, the blood donor sampling Center at Orsay has used traditional means of advertising. However, although the results were satisfactory for the first year, they soon levelled off; and it was decided to adopt another approach, in the form a promotion campaign, including posters, brochures, cartoons... The campaign "Vive la Vie" has been limited to the immediate vicinity of Orsay. It was set up in such a way to enable the staff to implement it easily and progressively and thus precisely follow and record the results. The data are reported in this article. The advantages of the system are a two-step appeal which allows more persuasive information to be given; a graduated approach welcoming both the convinced and the more reluctant donors to the Centre; and the compiling of an index by means of the forms returned by the population.

Differential endotoxin sensitivity of lymphocytes and macrophages from mice with an X-linked defect in B cell maturation

The in vitro sensitivity of B lymphocytes and macrophages derived from (CBA/N X DBA/2N) F1 male mice, which carry an X-linked recessive gene that produces defective B cell maturation, was compared to phenotypically normal F1 female mice. B lymphocytes of F1 males exhibit an abnormal mitogenic response to LPS in serum-free culture conditions, which is partially reversed in the presence of serum. In contrast, both resident and thioglycollate-induced peritoneal macrophages of F1 male mice respond normally to LPS. In response to LPS in vitro, F1 male macrophages produce the monokine, lymphocyte-activating factor (LAF) and release prostaglandins. Furthermore, F1 male macrophages are sensitive to the lethal effects of LPS. Therefore, the defective CBA/N gene appears to be expressed only in B lymphocytes and not in macrophages. Since F1 male mice are normally sensitive to the lethal and adjuvant effects of LPS in vivo, these findings suggest that a mature B lymphocyte population is not required for these effects and support the role of the macrophage in the mediation of LPS-induced lethality and adjuvanticity.

Resistance of Macrophages from C3H/HeJ Mice to the in Vitro Cytotoxic Effects of Endotoxin

Endotoxin (LPS) is toxic for normal mouse macrophages in vitro at concentrations (50 µg/ml) that are fully mitogenic and nontoxic to lymphocytes. Macrophages from LPS-resistant C3H/HeJ mice are not killed by LPS in vitro whereas those from a closely related LPS-responsive strain (C3H/HeN) are killed. Killing is the result of a direct interaction between LPS and the macrophage since this phenomenon is observed in lymphocyte-depleted cultures and since the presence of additional LPS-sensitive spleen cells will not enhance the killing of either C3H/HeN or C3H/HeJ macrophages. Furthermore, C3H/HeJ macrophages remain resistant to LPS-induced killing despite prior immunization with LPS in vivo or incubation with anti-LPS serum in vitro. LPS preparations vary in their cytotoxic effect on macrophages, and Escherichia coli K-235 LPS (phenol-water extracted), which discriminates well between LPS responsive and nonresponsive B cells, also discriminates well between LPS-sensitive and resistant macrophages. However, there is no apparent correlation between the mitogenic potential of LPS preparations and their cytotoxic effect on macrophages. These findings suggest that the C3H/HeJ mouse strain possesses a defect in LPS responsiveness which is intrinsic to its macrophages as well as its B lymphocytes.