Do adolescent trajectories of riding with an impaired driver and driving impaired predict similar behaviors in early adulthood?

BACKGROUND

A recent study shows four trajectories of riding with an impaired driver (RWI) and driving while impaired (DWI) from adolescence to emerging adulthood. We examined prospective associations of adolescent RWI/DWI trajectory class with early adulthood RWI/DWI behavior.

METHODS

Data were from the NEXT Generation Health Study (NEXT), a nationally representative longitudinal study (N = 2783) beginning with a 10th-grade cohort completing 7 annual assessment waves (W1-W7) between 2010 and 2016 and a later follow-up mixed methods study. Four RWI and DWI trajectories derived from a recently published latent class analysis study (RWI (last 12 months); DWI (last 30 days) dichotomized as ≥ once vs. none) were used: Abstainer, Escalator, Decliner, and Persister. In the follow-up examination, a purposive subsample (N = 105, 26.3 ± 0.5 y/o, Female 50.5%) of NEXT participants were selected by trajectory (31 Abstainers, 33 Escalators, 14 Decliners, and 27 Persisters) for in-depth interviews 4 years after NEXT. In interviews, self-reported RWI events (number of times) related to alcohol (Alc-RWI) or marijuana (MJ-RWI) use in the last 12 months, and DWI events (number of times) related to alcohol (Alc-DWI) & marijuana (MJ-DWI) use in January 2020 (pre-COVID pandemic) were collected using structured surveys. General linear models were used to examine associations of adolescents' RWI/DWI trajectories with early adulthood RWI/DWI behavior, controlling for sex, health status, education attainment, and work hours.

RESULTS

The mean number (SD) of Alc-RWI and MJ-RWI events reported by Escalators (3.83(2.48), 2.43(2.77)) and Persisters (3.83(2.43), 3.57(2.54)) were higher (p≤0.05) than Abstainers (0.82(1.42), 0.77(2.04)) and Decliners (1.81 (2.69), 1.38 (2.04)). Similarly, Escalators (1.61 (2.28), 1.88(2.69)) and Persisters (1.96(2.08), 1.93(2.48)) reported more Alc-DWI and MJ-DWI events than Abstainers (0.18 (0.53), 0.42(1.38)) and Decliners (0.00 (0.00), 0.08(0.28)). Linear regression models indicated membership in Escalator and Persister classes compared to Abstainer class was associated (p≤0.01) with higher engagement in RWI/DWI in early adulthood.

CONCLUSION

Adolescents with escalating and persistent high RWI/DWI may continue these health risking behaviors into their mid-twenties. Decliners during the transition maintained low RWI/DWI into their mid-twenties. Taken together, these findings suggest that earlier reduction may have long-term effects. Our findings can be used to inform the precision tailoring of prevention efforts aimed at effectively reducing alcohol/drug impairment crash injuries and related deaths among those in early adulthood.

Seeking Healing for a Mental Illness: Understanding the Care Experiences of Service Users at a Prayer Camp in Ghana

Human rights abuses in mental health care are a global concern. Addressing the problem requires input from key stakeholders, particularly from people using mental health services. This study explored the experiences of persons with mental illness receiving care in a faith-based setting in Ghana. The study employed a qualitative design, with in-depth interviews (n = 23) and focus groups (n = 18 participants in 3 groups). The constant comparative method of analysis was used to identify themes in participants' descriptions of their experiences. The first three themes identified are consistent with human rights and coercion, and the last two themes related to service users' views on participation in spiritual practices. Themes included: decision-making around care; consent and efficacy of religious healing; experiences with chaining; views around biomedical treatment; participation in religious activities as part of healing and recognition of the need for spiritual healing. It was observed that participants with prior experience of psychiatric treatment were happy about the absence of chaining in psychiatric facilities but strongly disliked the side effects of medications. These findings underscore the need for faith-based institutions to provide care that is consistent with patient preferences, thereby helping to address the resultant human rights abuses.

A cumulative dose, safety and tolerability study of arformoterol in pediatric subjects with stable asthma

PURPOSE

Short-acting β(2) -agonists (SABAs) are recommended for treating acute pediatric asthma. The long-acting β(2) -agonist (LABA) arformoterol is approved for the maintenance treatment of chronic obstructive pulmonary disease (COPD). Arformoterol acts rapidly, is delivered via nebulization, and, as such, raises concerns from the FDA over possible off-label use in acute asthma in children. As a step to investigate this issue, this study evaluated the safety and tolerability of three consecutive doses of arformoterol administered over 1 hr in children with stable asthma.

METHODS

This study consisted of a double-blind, crossover period in which subjects (ages 2-11 years) with stable asthma were randomized to three consecutive nebulized doses of arformoterol (7.5 µg/dose) or levalbuterol (0.63 mg/dose) administered over 1-hr (0, 30, and 60 min) followed by an open-label period with three consecutive doses of arformoterol (15 µg/dose) administered over 1 hr. Endpoints were change in heart rate, blood pressure, and serum potassium and glucose levels. Other endpoints included adverse events and pulmonary function.

RESULTS

There were no clinically important mean changes from pre-dose in heart rate, blood pressure, or serum glucose levels, across treatment groups. Substantial declines in serum potassium levels were observed both 2 and 6 hr post-dosing. Two subjects had declines to 2.8 mEq/L and 2.9 mEq/L 2-hr post-dosing. Adverse events were infrequent and differences in forced expiratory volume in 1 sec and peak expiratory flow across treatment groups were not clinically meaningful.

CONCLUSION

In this study, in children with stable asthma, three consecutive doses of arformoterol (7.5 and 15 µg) and levalbuterol were overall well tolerated. Nonetheless, serum potassium levels demonstrated substantial mean declines after dosing. These findings do not address or support the safety and tolerability of arformoterol use in acute exacerbations of asthma in children.

Association studies of ALOX5 and bone mineral density in healthy adults

Animal studies suggest that arachidonate 5-lipoxygenase (encoded by ALOX5) may be a genetic determinant of bone mineral density. We tested this hypothesis in a sample of healthy men and women and did not find consistent evidence for an association between variation in this gene and either lumbar spine or femoral neck BMD.

INTRODUCTION

Phenotypic variation in bone mineral density (BMD) among healthy adults is influenced by both genetic and environmental factors. A recent mouse study implicated ALOX5, which encodes arachidonate 5-lipoxygenase, as a contributing factor to areal BMD (aBMD).

METHODS

Fifteen single nucleotide polymorphisms (SNPs) distributed throughout ALOX5 were genotyped in three healthy groups: 1,688 European American, premenopausal sisters, 512 African American premenopausal sisters and 715 European American brothers. Statistical analyses were performed in the three groups to test for association between these SNPs and femoral neck and lumbar spine aBMD.

RESULTS

Significant (p < or = 0.05) evidence of association was observed with three of the SNPs. However, despite the linkage disequilibrium between SNPs, adjacent SNPs did not provide statistical evidence of association in any of the three study groups.

CONCLUSIONS

These data do not provide consistent evidence of association between genomic variation in ALOX5 and clinical variability in aBMD in healthy subjects.

Physicians' voices on physician-assisted suicide: looking beyond the numbers

Most empirical research examining physician views on physician-assisted suicide (PAS) has used quantitative methods to characterize positions and identify predictors of individual attitudes. This approach has generated limited information about the nature and depth of sentiments among physicians most impassioned about PAS. This study reports qualitative data provided by 909 physicians as part of a larger survey (N = 2,805) regarding attitudes toward and experiences with PAS and palliative care. Emergent themes illustrate important clinical, social, and ethical considerations in this area. The data illustrate the diverse and ardent responses that PAS evokes among certain physicians. The role of physicians' personal values is central to discussions about legalization of PAS. Polarized views such as those expressed by physicians in this study are not likely to be reconciled, thereby constraining the development of public policy regarding PAS.

The effects of knowledge, attitudes, and significant others on decisions to enroll in a clinical trial on osteoporosis: implications for recruitment of older African-American women

This preliminary study explored the roles of knowledge, attitudes, and significant others on decisions of older African-American women to enroll in a clinical trial involving estrogen and osteoporosis. Sixteen older African-American women (average age 75 years) participated in three focus groups. Twelve of the women had enrolled in the clinical trial and four, although eligible, refused to enroll. Discussions revealed that knowledge of osteoporosis and estrogen and expectations of personal rewards and group benefits from medical research appear to differentiate the women who participated in the clinical trial from those who refused. The women who participated also perceived the research institution as accessible. In addition, assuring full disclosure of testing procedures and test results eased their apprehensions about participation. However, the women who refused to enroll saw no personal benefit and were unwilling to expose themselves, in part because of their age, to the risks of taking estrogen and the uncertain outcomes of the clinical trial. The study illustrates how focus groups can be used to develop multiple strategies to enable recruitment of older African-American women with different demographic characteristics, levels of knowledge, and attitudes toward a disease and medical research.

The sequence of the human genome

A 2.91-billion base pair (bp) consensus sequence of the euchromatic portion of the human genome was generated by the whole-genome shotgun sequencing method. The 14.8-billion bp DNA sequence was generated over 9 months from 27,271,853 high-quality sequence reads (5.11-fold coverage of the genome) from both ends of plasmid clones made from the DNA of five individuals. Two assembly strategies-a whole-genome assembly and a regional chromosome assembly-were used, each combining sequence data from Celera and the publicly funded genome effort. The public data were shredded into 550-bp segments to create a 2.9-fold coverage of those genome regions that had been sequenced, without including biases inherent in the cloning and assembly procedure used by the publicly funded group. This brought the effective coverage in the assemblies to eightfold, reducing the number and size of gaps in the final assembly over what would be obtained with 5.11-fold coverage. The two assembly strategies yielded very similar results that largely agree with independent mapping data. The assemblies effectively cover the euchromatic regions of the human chromosomes. More than 90% of the genome is in scaffold assemblies of 100,000 bp or more, and 25% of the genome is in scaffolds of 10 million bp or larger. Analysis of the genome sequence revealed 26,588 protein-encoding transcripts for which there was strong corroborating evidence and an additional approximately 12,000 computationally derived genes with mouse matches or other weak supporting evidence. Although gene-dense clusters are obvious, almost half the genes are dispersed in low G+C sequence separated by large tracts of apparently noncoding sequence. Only 1.1% of the genome is spanned by exons, whereas 24% is in introns, with 75% of the genome being intergenic DNA. Duplications of segmental blocks, ranging in size up to chromosomal lengths, are abundant throughout the genome and reveal a complex evolutionary history. Comparative genomic analysis indicates vertebrate expansions of genes associated with neuronal function, with tissue-specific developmental regulation, and with the hemostasis and immune systems. DNA sequence comparisons between the consensus sequence and publicly funded genome data provided locations of 2.1 million single-nucleotide polymorphisms (SNPs). A random pair of human haploid genomes differed at a rate of 1 bp per 1250 on average, but there was marked heterogeneity in the level of polymorphism across the genome. Less than 1% of all SNPs resulted in variation in proteins, but the task of determining which SNPs have functional consequences remains an open challenge.

Medicaid estate planning: perceptions of morality and necessity

PURPOSE

Although several studies have examined the magnitude and prevalence of Medicaid estate planning (MEP), little is known about factors that influence individual behaviors in this area. Normative data regarding public perceptions of and motivations for MEP are nonexistent. This study explored views about MEP among community-dwelling older adults and family caregivers.

DESIGN AND METHODS

Eighteen focus groups were completed (N = 155), with a stratified homogeneous sample to ensure representation from individuals of varying race/ethnicity, experience with nursing home and home care services, and socioeconomic status. Analyses of transcripts were completed with NUD*IST 4.0 software.

RESULTS

Disincentives for MEP included losing control of one's assets, Medicaid stigma, and perceived immorality of MEP. Incentives for MEP included preservation of one's estate and protection of a spouse. Finally, variability in accessibility to and awareness of MEP was described.

IMPLICATIONS

This exploratory study identifies motivations for individual behaviors and describes evolving social norms regarding MEP; implications for policy and research are discussed.

Preferences for CPR among the elderly: the influence of attitudes and values

OBJECTIVES

While many older individuals wish to forgo cardiopulmonary resuscitation regardless of potential positive outcomes, others desire this intervention despite low chances of survival. This study examines the extent to which health, function, attitudes, and values influence preferences for cardiopulmonary resuscitation.

DESIGN

An in-person, physician-administered survey.

SETTING

Three clinical sites affiliated with a university-based geriatrics program.

PARTICIPANTS

One hundred three individuals age 65 or older with ability to speak, read, and write English.

MEASUREMENTS

Demographic, health and functional status, social involvement, religiosity, attitudes, and values were assessed. A standard description of cardiopulmonary resuscitation was followed by open-ended questions regarding treatment preferences.

RESULTS

Mean age was 81 (+/- 7), 66% were women and 78% had an advance directive. The majority (75%) declined cardiopulmonary resuscitation. Women were more likely to decline cardiopulmonary resuscitation. Attitudes toward life were the strongest predictors for the cardiopulmonary resuscitation decision. Family issues were important, especially the prospect of becoming a burden, as well as the outcome of cardiopulmonary resuscitation.

CONCLUSION

Attitudes toward life, perceived outcome of cardiopulmonary resuscitation, and family issues play a significant role in end-of-life treatment decision-making.

Mammography utilization in a skilled nursing facility

OBJECTIVE

To examine mammography utilization and subsequent clinical decisions in a skilled nursing facility in women aged 75 years and older with no history of breast cancer.

METHODS

This study was a retrospective medical chart review of 95 women living in a skilled nursing facility aged 75 years and older who did not have a history of breast cancer.

RESULTS

One-hundred seventy-nine mammograms were performed on 95 patients with an average of 1.9 mammograms per patient. Forty-five percent of the women had some evidence of abnormal results requiring further investigation.

DISCUSSION

Determining the utility of screening mammography in long-term care populations is essential to the development of appropriate guidelines. Future research should further explore the influence of patient preferences and psychological burden.

Physician-assisted suicide in Connecticut: physicians' attitudes and experiences

OBJECTIVE

This study examined aspects of physician attitudes toward physician-assisted suicide (PAS) not fully examined to date: evaluation of risks related to PAS, particularly the presence of depression, and the influence of religious and professionally-based values.

DESIGN

Anonymous, self-administered mailed questionnaire using Dillman methodology.

PARTICIPANTS

Targeted sample of physicians licensed by the Connecticut Department of Public Health in 1997 (n = 2,805 completed surveys; 40% response rate). DATA INCLUDE: Physician and patient characteristics, attitudes toward physician assisted suicide, and confidence in treating depression.

RESULTS

Religious affiliation, religiosity, ethnicity and medical specialty were strongly associated with views on PAS. Seven percent of respondents had been asked to write a lethal prescription during the past year, 15% of whom (n = 24) had complied with at least one request.

CONCLUSIONS

Most respondents expressed concern regarding certain risks associated with PAS, including movement toward involuntary euthanasia and the influence of undetected depression. Findings raise practical issues to be addressed through statutory or professional safeguards if PAS were to be legalized.

Individualized care: perceptions of certified nurse's aides

Despite substantial attention devoted to the development of individualized care in nursing homes during recent years, empirical research assessing progress is limited. Further, few studies have explored the experiences of certified nurse's aides (CNAs) in this regard. This survey examines the perceptions and experiences of CNAs in providing individualized care. CNAs (n = 254) were asked to describe a number of current practices and obstacles to implementing individualized care in nursing homes. The majority of respondents reported experiencing: flexibility to change daily schedules; supervisor assistance with challenging residents; active participation in care planning; freedom to test new approaches to care; and supervisors who are open to CNA suggestions. Several barriers to individualized care were also described, including: inadequate staffing; poor team communication; staff attitudes; and a lack of knowledge and training in alternative approaches. These findings provide important insights into the supports and obstacles to implementing individualized care in nursing homes from the perspective of CNAs.

Cognitive and learning styles in medical education

In this paper, the author describes the three types of styles (affective, learning, and cognitive) that play roles in education and outlines the history of cognitive- and learning-style research. She then explores the range of ways learning styles can be applied in medical education, including ways to use information about students' learning styles to help them cope with the challenges of content mastery and professional socialization; to offer assistance to students coping poorly with the demands of medical education; and to shape efforts to recruit students from underrepresented racial and cultural groups.

The physician-assisted suicide policy dilemma: a pilot study of the views and experiences of Connecticut physicians

Development of fully informed public policy regarding physician-assisted suicide (PAS) requires a thorough understanding of the experiences, attitudes, and beliefs of physicians with respect to this issue. This study gathered data on physician characteristics, attitudes toward PAS, factors influencing attitudes toward PAS, and sensitivity to the role of depression in a sample of 397 psychiatrists, internists, and family practitioners in Connecticut. Central considerations included: the influence of religious values, professional discipline and practice patterns, and ability to diagnose depression in a single evaluation. Psychiatrists were significantly more likely to be supportive of PAS than were internists or family practitioners. Most respondents expressed concern regarding the influence of depression on PAS requests. A subset of physicians endorse PAS yet do not share such concern about risks, suggesting substantial challenges for policy-makers.

Growth regulation of cultured endothelial cells by inflammatory cytokines: mitogenic, anti-proliferative and cytotoxic effects

The inflammatory cytokines tumor necrosis factor-alpha (TNF alpha) and interleukin-1 alpha (IL-1 alpha) have angiogenic properties but generally inhibit cultured endothelial cell (EC) proliferation. Investigations into the growth-regulatory effects of these two agents on a variety of cultured EC types showed that they exert mitogenic, anti-proliferative or cytotoxic effects depending upon cell type and cytokine combinations. The anti-proliferative effect was distinct from cytotoxicity. Nitric oxide (NO) release from EC, examined as a potential mechanism underlying some of these effects, did not appear to mediate the anti-proliferative effects of these cytokines. However, NO also seemed to have a bimodal effect on EC proliferation depending upon whether the NO was endogenous or exogenous. These data underscore the diversity in cytokine and NO effects on cultured EC which, if reproducible in vivo, may be partly responsible for the variable and sometimes contradictory results obtained with regards to the role of inflammatory cytokines and NO on angiogenesis.

Podiatric educational enhancement project. A project overview

Commitment to steady, adaptive improvement in podiatric medical professionals has taken shape in the Podiatric Educational Enhancement Project. This project involves wide representation from all interests, aspects, and constituencies in the profession to study opportunities and develop consensus on both small and large enhancements possible in the continuum of podiatric medical education. More than 1,300 podiatric physicians have contributed information and expertise, and more will be involved as the project develops during the next 18 months.

Continuing medical education. The next steps

Continuing medical education has been following essentially the same model for the past seventy years. The past decade has brought such significant change in society's expectations of medical professionals that medical schools, continuing medical education providers, and physicians themselves are being forced to consider alternate models. These pressures for change and possible directions for change are outlined.

Preparing for accreditation: an opportunity for faculty development and curriculum renewal

An approach to ACEHSA accreditation is described which turns this exercise into an occasion for faculty self reflection, development, and renewal. The carefully facilitated process examines the curriculum, its fundamental bases, processes, and products from multiple points of view including those of the faculty, current students, graduates, and employers. The process is derived from deliberative curriculum inquiry and results in curriculum specifications that are ordered by actual practice and truly understood and supported by faculty, students, and practitioners. Feedback from participants indicates that the carefully guided process of introspection turned a negative expectation surrounding the preparation for accreditation into a positive experience of faculty development and curriculum renewal. The process was improved across the two replications documented here.

Priority issues in continuing medical education show sensitivity to change in Canadian health care

The degree and scope of significant change in health care expectations, roles and delivery patterns in Canada have been widely documented. In 1988 the Sub-Committee on Research of the Standing Committee on CME [continuing medical education], Association of Canadian Medical Colleges, conducted a survey to determine whether those responsible for the CME portion of the medical school curriculum are changing their perceptions to keep pace with the changes in health care. The results were compared with those of a similar survey done in 1983. In both surveys people directly responsible for delivery of formal CME were asked to identify and rank research needs in CME. The response rates were very high. The CME issues identified in the two surveys had changed considerably, with entirely new issues being identified in 1988 and the emphasis placed on issues having changed. The identification of factors that promote or inhibit application of new knowledge by practising physicians was of lowest importance in 1983 and of primary importance in 1988, and comparison of the cost-effectiveness of CME methods was an important issue in 1983 and among the least important in 1988. The noted changes mirror developments in Canada's health care milieu.

Joint case writing: maintaining the validity and relevance of training in health care administration

The Canadian College of Health Service Executives, the personal membership professional association for senior health care managers in Canada, has developed a unique approach to enriching the quality and increasing the productivity of the academic-field relationship. This paper describes the development of the program, the need for linkages between faculty, and the field and the limitations of the case method as traditionally practiced.

Identification of functionally necessary knowledge and skills in the practice of Canadian health care management

The Canadian College of Health Service Executives (CCHSE) conducted a project in 1985-87 to identify basic competencies required in the field practice of health care management in Canada. The project derived from the College's mission to establish and promote professional standards for all health care executives in Canada. The project also addressed more specific short-term problems: to validate an existing examination purporting to measure the basic competence required for field practice of health care management in Canada; to create a data base upon which a CCHSE criterion reference test of field-based professional competence in health care administration could be created; and to provide to the training programs in Canadian health care management a detailed compilation and testing of the knowledge and skill attributes considered necessary for adequate field practice in Canadian health care administration. The project demonstrated an improved model for professional competence identification. The first step was to identify the level of professional targeted for competence assessment. Then a representative expert committee was to return to the field to examine the range of jobs done by those target individuals. This expert committee collected lists of elements from the tasks done in these target positions and then organized the elements into mutually exclusive groupings. Finally a stratified random sample of field practitioners was asked to rate the importance of these elements for competent job performance.

Physicians' participation in establishing criteria for hypertension management in the office: will patient outcomes be improved?

We designed this study to determine whether an intensive 1-day educational workshop involving family physicians in establishing essential criteria for hypertension management would significantly affect the short-term outcomes of hypertensive patients in their practices. Forty randomly selected physicians were separated into three groups: those who would be involved in establishing the criteria (15), those who would receive the criteria by mail (15) and those who would act as controls and not be aware of the criteria (10). We found no significant difference between the three groups in the number of hypertensive patients whose condition remained uncontrolled after the intervention. We conclude that physicians' participation in the establishment of standards of care for conditions such as hypertension or their awareness of such standards does not independently result in significantly better patient outcomes. Consequently, we recommend that physicians and health care planners concerned with improving outcomes not rely on any single intervention strategy when planning change.

Expectant management of abruptio placentae before 35 weeks gestation

Forty-three patients with abruptio placentae before 35 weeks of pregnancy were managed expectantly with observation or with tocolytic therapy when contractions were present. Mean time to delivery was 12.4 days. Twenty-three patients were delivered within 1 week of admission. In the remaining 20 patients, the mean time to delivery was 26.8 days. There were no intrauterine deaths. In properly selected patients with preterm gestation and low-grade abruptio it is reasonable to defer delivery. These patients must be followed closely with antepartum fetal heart rate monitoring, serial hematologic and coagulation profiles, and serial sonograms when indicated.

Effects of training in cardiopulmonary resuscitation on competence and patient outcome

Between 1981 and 1985 we carried out a study in two medium-sized nonteaching community hospitals to determine the rate of deterioration of knowledge and skills in cardiopulmonary resuscitation (CPR) among physicians and nurses, the accuracy of their perceptions of their knowledge and skills, the effects of practice on retention and the effect of CPR training on mortality. The participants' knowledge and skills were measured before training and immediately after, 6 months after and 12 months after training. Information on all attempts at CPR involving hospital staff was collected from medical records and from interviews with the participants. A total of 31 physicians and 54 nurses were followed during the study. Six months after training there was no difference in CPR knowledge or skills between the physicians and the nurses. In both groups CPR skills had deteriorated to near pretraining levels. By 6 months the physicians' knowledge had deteriorated to a level not significantly different from that before training. The nurses maintained a significant improvement in knowledge test scores at 12 months over those before training (p = 0.037). The physicians had an accurate perception of their knowledge but not their skills 6 months and 12 months after training, whereas the nurses did not accurately perceive either their knowledge or their skills after training. Experience with CPR did not contribute to post-training knowledge or skills in either group. There was no evidence that death rates were lower when basic life support (BLS) was begun by trained staff than when it was begun by untrained staff. The probability of survival was greater when BLS was begun within 4 minutes of arrest than when it was begun after 4 minutes, regardless of whether advanced cardiac life support was begun within 10 minutes.

Is there a problem with benzodiazepine prescribing in maritime Canada?

The benzodiazepine prescribing habits of 64 maritime doctors were studied through collection and examination of carbon copies of all prescriptions over a 22 week period. Diazepam was the most frequently prescribed anxiolytic benzodiazepine, followed by chlordiazepoxide, then oxazepam. These three drugs accounted for almost 60% of all benzodiazepine prescriptions. Triazolam and flurazepam were prescribed eight times more frequently than the other hypnotics, nitrazepam and temazepam. The number of prescriptions judged to be inappropriately excessive was small (3.3% of 7,066). Efforts by drug manufacturers, pharmaceutical sales representatives and CME providers are needed to make the practicing physician aware of the phamacokinetics of the different benzodiazepines, so that an appropriate choice of drug and frequency of daily doses can be made.

Postgraduate training route and content of subsequent practice

This study compared the practices of family medicine residency graduates with those of graduates from rotating internship programs. Proportions of medical services billed to the provincial government in each of 15 service classes formed the data base. No significant differences were observed between the groups in general, across groups for any class of medical services. Although the two groups appear to provide the same services, these results do not indicate that the two groups perform in the same manner or with the same results. Practice content, however, appears to be patient dictated rather than physician dictated. The issue is not, then, which training is better, but rather, are any of the present routes adequate.

Filing reprints: can office staff help?

Filing systems for reprints must be tailored to the individual's practice profile, to maximize usefulness as a resource for clinical problem solving. However, the clerical time involved often reduces the physician's ability to maintain such a filing system. The authors tested two hypotheses that using the International Classification of Health Problems in Primary Care (ICHPPC) nurses or receptionists could code, cross reference and file reprints after the physician has selected the articles. Contents pages of five primary care journals were given to two academic family physicians, two practicing physicians, a research assistant and two receptionists, one of whom had used ICHPPC to record patient encounters. All coders except the second receptionist, who was unfamiliar with ICHPPC, reached good agreement in coding. Filing reprints may therefore be done by trained staff for groups of physicians.

Impact of patient care appraisal on physician behaviour in the office setting

The effect of patient care appraisal on physicians' management of patients' problems was assessed. Sixteen family physicians were involved. The eight in the experimental group helped in the selection of two of the five disease conditions to be audited and in the generation of optimal criteria of care for two of the conditions. Participation in the generation of optimal criteria was followed by a significant improvement in the physicians' behaviour, but involvement in the selection of the conditions to be audited caused no change. The patient care appraisal did not lead to significant improvement of physicians' management of the conditions. In a second analysis, in which only essential criteria of care were considered, the physicians who participated in the patient care appraisal significantly improved their management of patients' problems. However, participation in the selection of the conditions and in the generation of the criteria of care had no effect on their performance. Patient care appraisal is an effective tool in continuing medical education and leads to improvement in the quality of care, provided the process focuses on essential criteria of care.

Do family physicians differ from specialists? A particular care in continuing medical education patterns

This study contrasts specialists with family physicians in use, preference for and perceived effectiveness of different CME methods. Results indicate that FPs differ substantially from specialists in their CME choices. CME providers can utilize the patterns reported here in designing continuing education programs to match more specifically the learning habits of their clients. Individual physicians can also plan their CME choices in the light of these differences.

Computerization of undergraduate medical curriculum content

A method is reported for the computerized storage and retrieval of informative summaries of the didactic portion of the first 3 years of the medical undergraduate curriculum utilizing the MICOM word processor and SORT 200 program with disc storage. Each lecture, small group session, laboratory or clinical experience summary is assigned a page of computer memory and is coded in the header line for various indices describing the session format, location, audiovisual usage, teacher and other demographics. The second line contains the lecture title and its situation within the teaching block. A summary of the teaching session follows. This was compiled and distilled from summaries prepared by the individual teachers, lecture handouts and the personal notes of the two medical students who divided the lectures equally between themselves and prepared individual summaries which were then exchanged. The resulting composite summary was returned to the teacher for comment and/or modification before entry onto the MICOM word processor. The SORT 2000 program permits search, selection and retrieval of the content of each teaching session from the data contained in the header line or any word, word segment or phase occurring in the summary. Reproduction of the data discs facilitates multiple access and allows each department or teaching block to review the complete curriculum quickly, identify redundancies and more fully integrate new or existing material.

Physicians' and nurses' retention of knowledge and skill after training in cardiopulmonary resuscitation

Physicians and nurses in a community hospital who successfully completed the standard 1-day training program in basic life support cardiopulmonary resuscitation (CPR) were retested 6 and 12 months after training. Their perceptions of their knowledge of and skill in CPR were recorded along with an account of the roles they had taken in CPR incidents. The physicians and nurses initially had the same level of knowledge of CPR, but the physicians learned significantly more and retained it longer. After training, the nurses participated much more in CPR incidents, limiting themselves to basic life support functions. The physicians' participation, however, remained at about the same level and was limited to advanced life support functions. By 12 months after training the scores in both groups were similar to the pretraining scores, which suggests that practice with feedback is necessary during the 1-year period before retraining and recertification. It may be that the two groups require different training programs.

Physician practice profiles for CME: four investigations into sampling methods

Sampling physicians' patient contacts to produce a practice profile forms the basis of three present individualized CME programs. The practical and statistical adequacy of these sampling procedures was examined and found to be seriously lacking. Samples were compared to a 6-month continuously coded data base on 16 family physicians. Following analysis of the 6-month data base for significant sources of variance, two new sampling procedures were proposed and tested against a 12-month continuously coded data base. Results indicate both practical acceptability and adequate representation by these two sampling procedures.

Patterns of intellectual deficit in Huntington's disease

The study investigated patterns of intellectual deficit in 13 patients with recently diagnosed Huntington's disease (mean duration of 2.3 years) and 46 offspring "at risk" for the illness using the Wechsler Adult Intelligence Scale (WAIS). The results support the idea that certain cognitive skills remain relatively intact at early stages of the disease while other skills are impaired. A consistent pattern of impairment was observed in the patient group which included the Arithmetic, Digit Span, Digit Symbol, and Picture Arrangement subtests. The most striking result was a demonstration of significantly increased variability among the "at risk" population of the Digit Span and Picture Arrangement subtests. These findings suggest that the WAIS may be a useful adjunct to neurological diagnosis for longitudinal monitoring of intellectual changes even at very early stages of the illness.

The content of family practice: do we need more studies?

Having an accurate job description of family physicians is important to a number of audiences. There is a tendency to produce another content profile of family practice in response to every specific request for an accurate job description, rather than examining the existing profiles. We analyzed the amount of similarity and therefore redundancy in currently available profiles of family practice. Our findings indicate remarkable consistency across profile studies. We conclude that there is no need to continue producing profiles of family practice unless something significant occurs in the medical environment to suggest there might be a change in the profile.

Continuing medical education in Maritime Canada: the methods physicians use, would prefer and find most effective

A study of the continuing medical education of practising physicians in Nova Scotia, New Brunswick and Prince Edward Island was conducted in 1979-80 by means of a mailed questionnaire. Most of the responding physicians ranked reading as the method most used to update knowledge (73.3%) and skills (55.7%); courses and informal instruction were in second place for updating knowledge and skills respectively, ranked most used by 9.3% and 17.1%. With unlimited time and funds 38.0% and 20.5% of the physicians would still most prefer to read to update knowledge and skills respectively. However, 35.2% would most prefer to attend courses to update knowledge and 26.9% and 24.8% would most prefer to do clinical traineeships or attend courses to update skills. When asked what method of learning had provided the most impetus to change their ways of managing patients, 42.5% chose reading, 18.8% courses, 14.6% informal discussions and 12.4% formal consultations. Appropriate developments would therefore include improving methods of providing physicians with the best information available when it is needed, removing roadblocks to participation in continuing education programs, matching individual learning styles to programs of learning, training physicians as peer tutors and helping consultants become better instructors through written consultations.