Alcohol-related brain damage--the concerns of the Mental Welfare Commission

Scottish mental health legislation permits 'guardianship' for certain mentally impaired individuals, which imposes a requirement on place of residence, access and attendance at specified services for treatment and rehabilitation. The use of guardianship for alcohol-related brain damage increased steeply in the years 1993-1998. Possible explanations include: (1) increased prevalence or diagnosis of these conditions; (2) reduction of hospital beds; (3) a trend towards diminishing family and social support; (4) increased social work involvement in caring for such individuals; (5) increased consideration of the use of guardianship; (6) new private residential services; (7) lack of interest in the condition by existing services. There have been legal and clinical concerns about such individuals under guardianship relating to quality of ongoing clinical assessment, need for specific treatment and for the management of associated psychiatric illness, issues over control of drinking and control of personal finances, uncertainty over the use of restraint, and need for programmes helping the individual's progress towards independent living.

Blood pressure perturbations caused by subclinical sleep-disordered breathing

We studied the acute effects of apneas and hypopneas on blood pressure in a nonclinic population of middle-aged adults. Arterial pressure was measured noninvasively (photoelectric plethysmography) during an overnight, in-laboratory polysomnographic study in 72 men and 23 women enrolled in the Wisconsin Sleep Cohort Study, a population-based study of sleep-disordered breathing. Sleep-disordered breathing events (272 apneas and 1469 hypopneas) were observed in 92% of subjects. The across-subject mean decreases in arterial O2 saturation were 9+/-8% (SD) for apneas (17+/-8 seconds duration) and 4+/-3% for hypopneas (21+/-6 seconds duration; 41+/-17% of baseline ventilation). In both apneas and hypopneas, even those with only 1% to 3% O2 desaturations, blood pressure decreased during the event, followed by an abrupt increase in the postevent recovery period. Mean values for peak changes in blood pressure (difference between the maximum during the recovery period and the minimum during the event) were 23+/-10 mm Hg for systolic and 13+/-6 mm Hg for diastolic pressure. The strongest predictors of the pressor responses to apneas and hypopneas were (in order of importance): magnitude of the ventilatory overshoot, length of the event, magnitude of changes in heart rate and arterial O2 saturation, and presence or absence of electroencephalographic arousal. We speculate that these fluctuations may play a role in the pathogenesis of hypertension in individuals with subclinical sleep-disordered breathing.

Participation in CME activities

OBJECTIVE

To compare the continuing medical education (CME) activities of family physicians in the province of Quebec with more than 25 years in practice with those with less than 25 years in practice.

DESIGN

Mailed questionnaire survey.

SETTING

Family practices in the province of Quebec.

PARTICIPANTS

All physicians (n = 722) with more than 25 years in practice (expressed as older) and a matched sample of 721 physicians with less than 25 years in practice (expressed as younger).

MAIN OUTCOME MEASURES

Types of CME activities and time spent on them, participant characteristics.

RESULTS

Older physicians spent more time in individual CME activities than younger ones (21 hours vs 18 hours monthly). Younger physicians, however, spent more time in group CME activities than older ones did (100 hours vs 80 hours yearly). Excluding physicians who devoted no time to CME activities, only two activities differentiated between the two groups: older physicians spent more time than their younger colleagues reading and listening to audiocassettes.

CONCLUSIONS

Older physicians maintained their clinical competence by participating in different CME activities from younger physicians. They participated in as many CME activities as their younger colleagues.

When to recommend compulsory versus optional CME programs? A study to establish criteria

When should remedial continuing medical education (CME) be compulsory for family physicians? When should it be optional? Should it be structured or not? In 1993-1994, the authors addressed this need for criteria by conducting a study that used reports on 14 physicians who had undergone a structured oral interview (SOI) at the College of Physicians of Quebec. (The SOI is a day-long encounter during which two specially trained physician-interviewers present a physician with standardized clinical cases that focus on ten specific aspects of a family physician's competence.) The 14 SOI reports were reviewed by 12 external physician-judges in an attempt to see how consistently they could link the ten aspects of competence, as shown in the reports, to five particular types of recommended remedial CME programs (the strictest being "compulsory program with suspended license" and the most lenient being "simple suggestions for improvement"). There was substantial agreement among the judges when choosing between compulsory and optional programs (kappa = 0.63, p < .05). The main criteria used when recommending an optional program were overall strengths and the quality of clinical reasoning. The same two criteria were also used for recommending a compulsory program, but the judges also considered three additional factors: the physician's ability to recognize his or her limits and how he or she handled referrals and prescribed medications. Many of the criteria used by the judges were based on unique information that came out of observations and interactions during the SOIs, such as quality of argumentation, sustaining a train of thought, sense for the case as a whole, or awareness of one's limits. Finally, the external judges corroborated the decisions previously made by the College of Physicians of Quebec concerning the appropriate CME programs for the 14 physicians.

The Office of the Future Project: the integration of new technology into office practice. Academic detailing through the super highway. Quebec Research Group on Medication Use in the Elderly

Effective management of drug therapy in the elderly is a challenge for primary-care physicians. There are 20,400 drugs approved for marketing in Canada. Most elderly patients will fill 33 prescriptions per year and take 5 different medications. To be a safe prescriber in the 1990s, physicians need to be aware that 33,000 drug interactions, 6,500 drug-disease contraindications, and 3,500 drug-allergy contraindications have been documented. Inappropriate prescribing is a problem in the elderly. At least one inappropriate prescription is given to 12% to 46% of seniors, and 25% of drug-related hospital admissions are due to prescribing errors. Half of all physicians will write at least one inappropriate prescription for an elderly patient each year, and one quarter of inappropriate prescriptions will be created by the presence of multiple prescribing physicians. Academic detailing is the most effective approach to improve physician prescribing. However, it is an expensive intervention that must be limited to a small number of drugs and conditions, and it must be continued to retain its effectiveness. Furthermore, it fails to address the problems created by multiple prescribers. In this project, we developed a prototype of the future office practice. Physicians are equipped with personal computers and expert prescribing-system software. This electronic academic detailer reviews all current medications for a patient, identifies therapeutic duplications, generates alerts for 50 prescribing problems that have been identified as clinically relevant by a Canadian expert panel, suggests suitable alternatives, and reviews all new prescriptions for potential problems. Information on all prescriptions received by the physicians' elderly patients is downloaded weekly from the provincial prescription claims database, so that the primary physician is able to coordinate and manage all drugs prescribed to their patients by all physicians. The effectiveness of this intervention is being evaluated in a randomized controlled trial of 110 physicians and approximately 16,000 elderly patients in Montreal. We will test whether the intervention reduces the rate of inappropriate prescribing, as well as the rate of drug-related injuries and hospitalizations among patients treated by physicians in the experimental group.

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.