Collagenous gastritis in children: A national cohort

BACKGROUND

Collagen gastritis is a rare disease that manifests in children mainly as isolated gastric involvement associated with martial deficiency anemia. There are no recommendations for the management and follow-up of these patients. We aimed to describe the clinical data, endoscopic findings, and treatments deployed in France's children with collagenous gastritis.

METHODS

All French pediatric gastroenterology centers and pediatric centers for rare digestive diseases (Centres de Maladies Rares Digestives) were contacted to collect cases of collagenous gastritis, defined on gastric biopsies and diagnosed before 18 years of age.

RESULTS

A total of 12 cases diagnosed (4 males and 8 females) between 1995 and 2022 could be analyzed. The median age at diagnosis was 12.5 years (7-15.2). The most frequent clinical presentation was abdominal pain (6/11) and/or nonspecific symptomatology attributed to anemia (8/10). Anemia was present in all children (11/11; Hb 2.8-9.1 g/dL). Nodular gastritis was present in 10 patients (antrum: 2; fundus: 4; in antrum and fundus: 4). All patients had a basement membrane thickening (from 19 to 100 μm). The treatments received were PPI (11), oral or intravenous martial supplementation (12), budesonide (1), and prednisone (1). Martial supplementation improved anemia in all cases. At discontinuation, nine of 10 patients had a recurrence of anemia.

CONCLUSION

Collagenous gastritis is an exceptional condition, clinically manifested in children as abdominal pain and iron deficiency anemia probably of hemorrhagic origin. Patients require long-term follow-up and monitoring of their disease to describe the risk of progression better.

Association of nursing overtime, nurse staffing and unit occupancy with medical incidents and outcomes of very preterm infants

OBJECTIVE

To examine the association of nursing overtime, nursing provision and unit occupancy rate with medical incident rates in the neonatal intensive care unit (NICU) and the risk of mortality or major morbidity among very preterm infants.

STUDY DESIGN

Single center retrospective cohort study of infants born within 23 to 29 weeks of gestational age or birth weight <1000 g admitted at a 56 bed, level III NICU. Nursing overtime ratios (nursing overtime hours/total nursing hours), nursing provision ratios (nursing hours/recommended nursing hours based on patient dependency categories) and unit occupancy rates were pooled for all shifts during NICU hospitalization of each infant. Log-binomial models assessed their association with the composite outcome (mortality or major morbidity).

RESULTS

Of the 257 infants that met the inclusion criteria, 131 (51%) developed the composite outcome. In the adjusted multivariable analyses, high (>3.4%) relative to low nursing overtime ratios (⩽3.4%) were not associated with the composite outcome (relative risk (RR): 0.93; 95% confidence interval (CI): 0.86 to 1.02). High nursing provision ratios (>1) were associated with a lower risk of the composite outcome relative to low ones (⩽1) (RR: 0.81; 95% CI: 0.74 to 0.90). NICU occupancy rates were not associated with the composite outcome (RR: 0.98; 95% CI: 0.89 to 1.07, high (>100%) vs low (⩽100%)). Days with high nursing provision ratios (>1) were also associated with lower risk of having medical incidents (RR: 0.91; 95% CI: 0.82 to 0.99).

CONCLUSION

High nursing provision ratio during NICU hospitalization is associated with a lower risk of a composite adverse outcome in very preterm infants.

Treatment for calcium channel blocker poisoning: a systematic review

CONTEXT

Calcium channel blocker poisoning is a common and sometimes life-threatening ingestion.

OBJECTIVE

To evaluate the reported effects of treatments for calcium channel blocker poisoning. The primary outcomes of interest were mortality and hemodynamic parameters. The secondary outcomes included length of stay in hospital, length of stay in intensive care unit, duration of vasopressor use, functional outcomes, and serum calcium channel blocker concentrations.

METHODS

Medline/Ovid, PubMed, EMBASE, Cochrane Library, TOXLINE, International pharmaceutical abstracts, Google Scholar, and the gray literature up to December 31, 2013 were searched without time restriction to identify all types of studies that examined effects of various treatments for calcium channel blocker poisoning for the outcomes of interest. The search strategy included the following Keywords: [calcium channel blockers OR calcium channel antagonist OR calcium channel blocking agent OR (amlodipine or bencyclane or bepridil or cinnarizine or felodipine or fendiline or flunarizine or gallopamil or isradipine or lidoflazine or mibefradil or nicardipine or nifedipine or nimodipine or nisoldipine or nitrendipine or prenylamine or verapamil or diltiazem)] AND [overdose OR medication errors OR poisoning OR intoxication OR toxicity OR adverse effect]. Two reviewers independently selected studies and a group of reviewers abstracted all relevant data using a pilot-tested form. A second group analyzed the risk of bias and overall quality using the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) checklist and the Thomas tool for observational studies, the Institute of Health Economics tool for Quality of Case Series, the ARRIVE (Animal Research: Reporting In Vivo Experiments) guidelines, and the modified NRCNA (National Research Council for the National Academies) list for animal studies. Qualitative synthesis was used to summarize the evidence. Of 15,577 citations identified in the initial search, 216 were selected for analysis, including 117 case reports. The kappa on the quality analysis tools was greater than 0.80 for all study types.

RESULTS

The only observational study in humans examined high-dose insulin and extracorporeal life support. The risk of bias across studies was high for all interventions and moderate to high for extracorporeal life support. High-dose insulin. High-dose insulin (bolus of 1 unit/kg followed by an infusion of 0.5-2.0 units/kg/h) was associated with improved hemodynamic parameters and lower mortality, at the risks of hypoglycemia and hypokalemia (low quality of evidence). Extracorporeal life support. Extracorporeal life support was associated with improved survival in patients with severe shock or cardiac arrest at the cost of limb ischemia, thrombosis, and bleeding (low quality of evidence). Calcium, dopamine, and norepinephrine. These agents improved hemodynamic parameters and survival without documented severe side effects (very low quality of evidence). 4-Aminopyridine. Use of 4-aminopyridine was associated with improved hemodynamic parameters and survival in animal studies, at the risk of seizures. Lipid emulsion therapy. Lipid emulsion was associated with improved hemodynamic parameters and survival in animal models of intravenous verapamil poisoning, but not in models of oral verapamil poisoning. Other studies. Studies on decontamination, atropine, glucagon, pacemakers, levosimendan, and plasma exchange reported variable results, and the methodologies used limit their interpretation. No trial was documented in humans poisoned with calcium channel blockers for Bay K8644, CGP 28932, digoxin, cyclodextrin, liposomes, bicarbonate, carnitine, fructose 1,6-diphosphate, PK 11195, or triiodothyronine. Case reports were only found for charcoal hemoperfusion, dialysis, intra-aortic balloon pump, Impella device and methylene blue.

CONCLUSIONS

The treatment for calcium channel blocker poisoning is supported by low-quality evidence drawn from a heterogeneous and heavily biased literature. High-dose insulin and extracorporeal life support were the interventions supported by the strongest evidence, although the evidence is of low quality.

Hip fracture in the elderly: does counting time from fracture to surgery or from hospital admission to surgery matter when studying in-hospital mortality?

This study aims to analyze whether the interval from hospital admission to surgery may be used as a surrogate of the actual gap from fracture to surgery when investigating in-hospital hip fracture mortality. After analyzing 3,754 hip fracture admissions, we concluded that those intervals might be used interchangeably without misinterpretation bias.

INTRODUCTION

The debate regarding the influence of time to surgery in hip fracture (HF) mortality is one of the most controversial issues in the HF medical literature. Most previous investigations actually analyzed the time from hospital admission to surgery as a surrogate of the less easily available gap from fracture to surgery. Notwithstanding, the assumption of equivalency between those intervals remains untested.

METHODS

We analyzed 3,754 hospital admissions of elderly patients due to HF in Quebec, Canada. We compared the performance as predictors of in-hospital mortality of the delay from admission to surgery and the actual gap from fracture to surgery using univariate and multiple logistic regression analysis.

RESULTS

The mean times from fracture to surgery and from admission to surgery were 1.84 and 1.02 days (P < 0.001), respectively. On univariate logistic regression, both times were slightly significant as mortality predictors, yielding similar odds ratios of 1.08 (P < 0.001) for time from fracture to surgery and 1.11 (P < 0.001) for time from admission to surgery. After accounting for other covariates, neither times remained significant mortality predictors.

CONCLUSION

The gap from admission to surgery may be used as a surrogate of the actual delay from fracture to surgery when studying in-hospital HF mortality.

Physicians' attitudes to the pharmacological treatment of patients with stable angina pectoris

BACKGROUND

Little is known about how physicians' knowledge of and attitudes to practice guidelines for stable angina may influence their implementation.

AIM

To explore the association between physicians' demographics, their knowledge, and opinions about stable angina and their self-reported adherence to guideline recommendations.

DESIGN

Questionnaire-based survey.

METHODS

We surveyed 1228 Quebec physicians using a questionnaire based on the 'awareness-to-adherence' conceptual framework to measure their adherence with recommendations for the pharmacological treatment of stable angina. Independent predictors of adherence with the targeted recommendations were determined by stepwise linear regression analysis.

RESULTS

We received 877 (71.4%) responses from the 1228 eligible physicians. More than 90% of respondents were aware of and agreed with the targeted recommendations. However, the adoption rate varied, even among physicians who generally agreed with the guidelines. Factor analysis indicated that most physicians agreed with recommendations concerning ASA. More negative attitudes were expressed toward beta-blockers and hypolipaemic drugs. Respondents trusted the recommendations of a variety of scientific and professional organizations. Awareness, agreement, and adoption were the strongest predictors of adherence for the three recommendations. Physician demographics and practice characteristics did not predict adherence.

DISCUSSION

Physicians were aware of and agreed with the recommendations, so additional large-scale dissemination of the guidelines would be unlikely to improve prescription patterns. However, negative attitudes about beta-blockers and hypolipaemic therapy affected adherence to recommendations for these drugs. Continuing medical education interventions involving local opinion leaders might address some of the obstacles identified.

[Could we trust clinical statistics from data banks of the National Health Service (NHS)?]

Can we accept the statistics provided by the Ministry of Health, which uses large computerized databases? Through MEDECHO, the Ministry provides to hospital managers, reports cards on different interventions. These reports compare different hospitals performances. Surgeons involved in the process hesitate to accept this information. Using the results of the performance of cholecystectomy provided by this system (Gr: A), we compared the same cohort (1 April-31 December 1996 = 346 cholecystectomies) but using specific criteria determined as relevant to our surgeons (Gr: B). The rate of complication gives a crude aftermath and no attempt was used to adjust for severity. The MEDECHO data are adjusted for severity. The global rate of complications is similar Gr: A 11%, Gr: B 12%. Major complication rate for pulmonary embolism, hemorrhage and biliary duct trauma are identical. The rate of surgical site infection is higher in Gr: B (5% vs. 2%). The patients are seen in the outpatient clinic and these observations are not included by the analytical system unless the patient has been readmitted. For our hospital, the MEDECHO data are valid and reliable even though they underestimated the wound infection rate. These results could be explained by an appropriate interpretation of the code system by the archivist and by the surgeons' precision to complete the summary sheet of hospitalization. We can conclude that these data can be used as a means to evaluate the quality of outcome of a surgical service.

Drug treatment of stable angina pectoris and mass dissemination of therapeutic guidelines: a randomized controlled trial

BACKGROUND

Public agencies responsible for implementing health care policies often adapt and disseminate clinical practice guidelines, but the effectiveness of mass dissemination of guidelines is unknown.

AIM

To study the effects of guideline dissemination on physicians' prescribing practices for the treatment of stable angina pectoris.

DESIGN

Randomized controlled trial.

METHODS

A sample of 3293 Quebec physicians were randomly assigned to receive a one-page summary of clinical practice guidelines on the treatment of stable angina (in February 1999), to receive the summary and a reminder (in February and March 1999, respectively), or to receive no intervention (controls). The prescribing profiles of participants, as well as sociodemographic characteristics of the physicians and their patients, were examined for June-December 1999.

RESULTS

The intervention had no effect on prescription rates of beta-blockers, antiplatelet agents, or hypolipaemic drugs. Compared to 1997 data for the same physicians, there was an overall 10% increase in appropriate prescription rates, irrespective of the intervention.

DISCUSSION

In-house production and dissemination of clinical practice guidelines may not improve physicians' practice patterns if there is pre-existing substantial scientific consensus on the issue.

Comparing women's assessment of midwifery and medical care in Québec, Canada

In 1990, the province of Québec, Canada, adopted a law that authorized the evaluation of the practice of midwifery through pilot projects before its legalization. A key objective of this evaluation, as defined by the law, was the documentation of women's assessment of maternity care, especially with regard to humanization and continuity of care. Two to 3 months after birth, 933 midwifery clients and 1,000 physicians' clients, matched on several characteristics, responded to a mailed questionnaire (response rates were 93% and 76%, respectively). Results showed that women from both groups were generally satisfied with the care they received, although women who received midwifery care were assessed as more positive on every issue surveyed. Objective measures supported impressions that were also confirmed through qualitative data analysis: midwifery clients had a greater number of and longer prenatal visits, their care was perceived to be more personalized, and a greater number of midwives' clients breastfed their infants. However, the interpretation of these results must take into account that the two groups had different personal expectations and values with regard to health and health care. These findings are enlightening in evaluating women's needs, expectations, and satisfaction with health care services and should be included in future development of maternity care, including idwifery services, in Québec and other locations.

Ambulatory use of inhaled beta(2)-agonists for the treatment of asthma in Quebec : a population-based utilization review

STUDY OBJECTIVES

To assess whether the utilization of inhaled short-acting beta(2)-agonists (ISAB) and inhaled long-acting beta(2)-agonists (ILAB) for the treatment of asthma was appropriate according to the 1996 Canadian Asthma Consensus Conference recommendations.

DESIGN

Population-based retrospective drug utilization review using pharmacists' billing data of the Prescription Drug Insurance Plan administered by the Quebec health insurance board. However, the database used did not contain complete patient clinical information to accurately assess severity of asthma.

SETTING

Province of Quebec, Canada.

PATIENTS

Persons who received at least one outpatient prescription of ISAB (age range, 5 to 45 years) or ILAB (age range, 12 to 45 years) for the treatment of asthma between August 1997 and April 1998.

MEASUREMENTS

Percentages of patients whose use was appropriate according to three criteria regarding the average daily dose of ISAB (criterion 1), the renewal interval of ILAB (criterion 2), and the concomitant daily use of corticosteroids for the expected length of utilization of ILAB (criterion 3).

RESULTS

Overall proportions of appropriate use according to criterion 1 were as follows: 75% (without inhaled corticosteroids [ICS]) and 84% and 43% (with one or more than one prescription of ICS, respectively). Appropriateness was slightly higher for female patients, younger patients (5 to 18 years old), and those treated by pediatricians. However, appropriateness was only 9% among patients who received at least two prescriptions of ISAB during the study period. The proportion of appropriate use was 19% according to criterion 2 and 15% according to criterion 3; there were few differences by gender or by age, but the appropriateness according to criterion 2 was somewhat higher for patients of respirologists.

CONCLUSION

Compared to the 1996 Canadian asthma consensus conference recommendations, ISAB are overused, ICS are underused, and ILAB are often used improperly. Close collaboration between health professionals and patients is essential to improve the pharmacotherapy of asthma.

Are patients suffering from stable angina receiving optimal medical treatment?

There is good evidence for the use of antiplatelet, beta-blocker and lipid-lowering drugs in the treatment of ischaemic heart disease, but few data on how these medications are used in treating stable angina pectoris. We examined prescription profiles for a sample of patients aged > or =65 years with stable angina, to compare the profiles to local guidelines and to explore the determinants of these profiles, in a cross-sectional study. We identified 11 141 individuals from the Quebec provincial out-patient pharmaceutical database for the period 1 June 1996 to 31 May 1997, and examined the percentage of these patients with and without associated co-morbidities receiving antiplatelet, beta-blocker and lipid-lowering medications. We used hierarchical modelling to examine the role of patient and physician characteristics in explaining the variation in the use of these medications. Calcium-channel blockers were the class of anti-ischaemic drugs most prescribed (63%). Beta-blockers were prescribed in 52.1% of patients. Antiplatelet and lipid-lowering drugs were prescribed to 56.8% and 32.6%, respectively. Increasing age and female gender made patients less likely to be prescribed these treatments. General practitioners were less likely than cardiologists to prescribe beta-blockers and lipid-lowering drugs (OR 0.79, CI 95% 0.68-0.91 and OR 0.77, CI 95% 0.66-0.91, respectively). There is a general under-use of antiplatelet, beta-blocker and lipid-lowering medications in the treatment of stable angina pectoris patients, possibly leading to adverse patient outcomes.

Evaluation of the midwifery pilot projects in Quebec: an overview. L'Equipe d'Evaluation des Projets-Pilotes Sages-Femmes

In 1990, the province of Quebec adopted a law authorizing the evaluation of the practice of midwifery through eight pilot projects. The projects, which took the form of birth centres outside hospitals, started operating in 1994. The objectives of the evaluation were 1) to compare midwives' services to current physician services with regard to maternal and neonatal mortality and morbidity, the use of obstetrical intervention, individualization and continuity of care as perceived by clients, and cost; and 2) to identify the professional and organizational factors associated with the integration of midwives into the health care system. A mixed evaluative design was used: a multiple case study with each pilot project representing a case and a cohort study where 1,000 women followed by midwives in the birth centres were matched with 1,000 women followed by physicians in the usual hospital-based services. Various quantitative and qualitative data collection instruments were used. Overall, many results were favourable to midwifery practice, while some were favourable to medical care. Following the evaluation, the Government of Quebec decided to legalize the practice of midwifery.

A variable speed translating couch technique for total body irradiation

We have developed a variable speed translating patient couch system for the delivery of total body irradiation (TBI). For a whole body Rando-type phantom, dose variation at mid-plane relative to the prescription point (navel) can be as high as 15% (neck or legs) with a constant velocity. By taking into account variations in body thickness, the intensity modulation radiation therapy, resulting from variable velocities, effectively delivers a uniform dose distribution at mid plane. The couch control user interface, technical aspects and dose planning optimization procedure for determining velocity distribution are described.

Integration of midwives into the Quebec health care system. L'Equipe d'Evaluation des Projets-Pilotes Sages-Femmes

This paper reports on one aspect of the evaluation of the midwifery pilot projects in Quebec: the identification of the professional and organizational factors, as well as the mode of integrating midwives into the maternity care system, that would promote the best outcomes and the autonomy of midwives. The research strategy involved a multiple-case study, in which each midwifery pilot project represented a case. Based on a qualitative approach, the study employed various sources of data: individual interviews and focus groups with key informants, site observations and analyses of written documents. Results show that midwives were poorly integrated into the health care system during the evaluation. Four main reasons were identified: lack of knowledge about the practice of midwifery on the part of other health care providers; deficiencies in the legal and organizational structure of the pilot projects; competition over professional territories; and gaps between the midwives' and other providers' professional cultures. Recommendations are provided to facilitate the integration of midwives into the health care system.

Cost-effectiveness of midwifery services vs. medical services in Quebec. LEquipe dEvaluation des Projets-Pilotes Sages-Femmes

This study compared the cost-effectiveness of midwife services provided in birth centres operating as pilot projects with current hospital-based medical services in the province of Quebec. One thousand midwives' clients were matched with 1,000 physicians' clients on the basis of socio-demographic characteristics and obstetrical risk. Direct costs for the prenatal, intrapartum and postpartum periods were estimated. Effectiveness was assessed on the basis of three clinical indicators and four indices related to the individualization of care as assessed by women. Results show that the costs of midwife services were barely lower than or equal to those of physician services, but cost-effectiveness ratios were to the advantage of the midwife group, except for one clinical indicator (neonatal ventilation). Overall, this study provides rational support for the process of legalizing midwifery in the province.

Comparison of midwifery care to medical care in hospitals in the Quebec pilot projects study: clinical indicators. L'Equipe dEvaluation des Projets-Pilotes Sages-Femmes

The purpose of this study was to compare indicators of process and outcome of midwifery services provided in the Quebec pilot projects to those associated with standard hospital-based medical services. Women receiving each type of care (961 per group) were matched on the basis of socio-demographic characteristics and level of obstetrical risk. We found midwifery care to be associated with less obstetrical intervention and a reduction in selected indicators of maternal morbidity (caesarean section and severe perineal injury). For neonatal outcome indicators, midwifery care was associated with a mixture of benefits and risks: fewer babies with preterm birth and low birthweight, but a trend toward a higher stillbirth ratio and more frequent requirement for neonatal resuscitation. The study design does not permit to conclude that the associations were causal in nature. However, the high stillbirth rate observed in the group of women who were selected for midwife care raises concerns both regarding the appropriateness of the screening procedures for admission to such care and regarding the quality of care itself.

What accounts for physician opinions about midwifery in Canada?

The objective of this study was to identify the characteristics of physicians practicing obstetrics in the province of Quebec, Canada and relate these to their opinions about midwifery practice. A self-administered questionnaire was sent to a systematic random sample of 844 physicians; 597 physicians answered (response rate = 71%). Results show that physicians who were more open to midwives had a more client-centered approach to maternity care. They had attended premed school outside Canada but received their specialty training in Canada. They also had often collaborated with midwives since they had begun practicing. Physicians who were more open to midwives were less demanding in terms of level of midwife training. They agreed that midwives should be self-regulating. It is concluded that greater knowledge of midwives' practice, gained through collaboration in the workplace and interdisciplinary education, could help physicians to better understand the significant contributions that midwives can make to the health care system.

Do ethnic groups use health services like the majority of the population? A study from Quebec, Canada

The purpose of this study was to compare the use of medical services over a period of one year by members of ethnic groups and native Quebecers in Canada, while controlling for a number of confounding factors. The objective was to determine whether the two groups made the same number of medical visits to the same sites (private offices, outpatient clinic and emergency room and hospital inpatient care) and the same types of physicians (general practitioners, specialists). Two sources of data were used. The first was the Quebec Health Survey conducted in 1987 on a representative sample of 31,995 noninstitutionalized persons. Through personal interviews and self-administered questionnaires, data were collected on the demographic characteristics and health status of the respondents. The second source of data was the Quebec physician claims database, which contains a complete registry of services paid to physicians on a fee for service basis in the 12 months prior to the survey. The two databases were linked at the individual level (success rate is 88%). Members of ethnic groups aged 15 years and older were then individually matched to native Quebecers having the same six characteristics (age, gender, household income, access to health care facilities, perceived health and overall health). Final sample size was 1182 (divided equally into the two study groups). Results showed that neither the average number of medical services used over a year by the two groups nor the number of users differed. However, ethnic groups made more visits to specialists in private offices. Although not definite, possible explanations of these results are discussed. It is concluded that health care professionals should be sensitive to the particular needs of ethnic groups in order to provide them with accessible and appropriate services.

How different are users and non-users of alternative medicine?

PURPOSE

To determine whether users and non-users of alternative medicine in the province of Quebec differ in terms of demographic characteristics, health profile or utilization of medical services.

METHODS

The Quebec Health Insurance Board (QHIB) medical service records of the Quebec Health Survey (1987) respondents for the 12 months before the survey were linked with respondents' survey answers. Those who saw an alternative medicine practitioner at their last professional consultation (the "users", n = 169) were matched by diagnosis and area of residence with those who saw a physician instead (the "non-users", n = 169).

RESULTS

Users and non-users of alternative medicine differed in age, activity, education and income. After adjustment for age, education and income, the two groups had a similar health profile, but users of alternative medicine had made fewer medical visits in the previous year.

CONCLUSION

Alternative medicine attracts a particular clientele. More research is needed to understand the reasons people look to alternative therapies instead of conventional medicine.

A survey of midwives in Quebec: what are their similarities and differences?

BACKGROUND

Until recently, Canada was the only industrialized country that had not legalized midwifery. In the province of Quebec the government adopted a law to evaluate midwifery in eight pilot projects before generalizing the practice. This study examined the similarities and differences among midwives in Quebec.

METHODS

Using data from a 1991 mail survey, we compared 31 nurse-midwives, 12 professional midwives, and 27 lay midwives to assess professional background and opinions about selected maternity care issues and aspects of future midwifery practice, such as midwife training options, responsibilities, setting for midwifery care, relationship to other maternity caregivers, autonomy, and control over their profession.

RESULTS

Midwives largely shared the same philosophy of care but had different viewpoints on two main professional aspects: compared with professional midwives and nurse-midwives, lay midwives preferred to deliver antepartum, intrapartum, and postpartum care at a client's home or an independent birthing center; like professional midwives, they rejected nursing as a prerequisite to midwifery training. Other interrelated personal, social, political, and legal factors were also associated with different beliefs.

CONCLUSIONS

Despite the differences among the three groups, the process under way in Canada is to recognize a single profession of midwife. Creating a unified profession is a challenge that Canadian midwives with different backgrounds face in the 1990s.

Acute pulmonary toxicity linked to use of a leather protector

Leather protectors are used extensively for waterproofing leather garments. Inhalation exposure to this type of product is usually considered a benign incident. We report two cases of acute pulmonary toxicity associated with the use of a new leather protector recently introduced to the Canadian market. Emergency physicians must be aware of the potential acute toxicity of new leather protectors.

Controversies in maternity care: where do physicians, nurses, and midwives stand?

Through a mail survey in 1991, we compared the opinions of 597 physicians practicing obstetrics, 723 maternity care nurses, and 70 midwives from the province of Quebec, Canada, about selected maternity care issues, including the practice of midwifery. Results showed that divergent points of view existed between and within the three groups on many maternity care issues. Physicians were more divided over the routine use of obstetric intervention than the approach to care or their opinion about midwives. Midwives held more client-centered and less interventionist attitudes than nurses or physicians. Nurses were much more open to midwives than physicians, but 20 to 30 percent of physicians saw some advantages in legalizing the practice of midwifery. Physicians and nurses generally considered midwives as a greater professional threat to the other group than to themselves. The fact that many physicians were critical of current maternity care is difficult to reconcile with their general opposition to midwives. How and to what extent physicians will respond to women's desire for more humanized and less interventionist care remains an open question. Given the problems facing maternity care in North America, expanding midwifery services is an alternative to examine seriously.

Midwifery defined by physicians, nurses and midwives: the birth of a consensus?

OBJECTIVE

To describe the form of midwifery practice preferred by physicians practising obstetrics, nurses providing maternity care and midwives.

DESIGN

Mail survey conducted in 1991.

SETTING

Province of Quebec.

PARTICIPANTS

A systematic random sample of 844 physicians, 808 nurses and 92 midwives; 597, 723 and 92 respectively completed the questionnaire, for an overall response rate of 80%.

MAIN OUTCOME MEASURES

Midwife training options, range of responsibilities, location of midwifery care, relationship to other maternity care providers and degree of autonomy.

RESULTS

Most of the physicians, nurses and midwives surveyed agreed that if midwifery was legalized, midwives should have a university degree, provide basic care to women with normal pregnancy and delivery, provide prenatal and postnatal care in hospitals and community health centres, perform delivery in hospitals and work in close collaboration with the other maternity care professionals. Disagreement existed concerning the level of university training required, the need for training in nursing first, the scope of medical intervention performed by midwives, out-of-hospital delivery, the autonomy of midwives and control over their practice.

CONCLUSION

Some consensus on midwifery practice exists between physicians, nurses and midwives. In jurisdictions where opposition to midwives is strong, such consensus could serve as the starting point for the introduction of midwifery.

Factors influencing the practice of vaginal birth after cesarean section

OBJECTIVES

Vaginal birth after cesarean has been recommended for most women with previous cesarean sections for the past 10 years. This practice, however, has not yet been generalized because high variations can still be observed among countries, hospitals, and physicians.

METHODS

A case-control study involving 635 case patients and 2593 control patients was carried out to determine which characteristics of the physician, the patient, or the hospital were important in the adoption of this practice.

RESULTS

The results of the multiple stepwise logistic regression analysis indicate a higher likelihood that women will experience vaginal birth after cesarean if their physicians had cesarean rates under 20%, had less than 5% of their patients considered at risk, and were younger than 54 years old. Vaginal birth after cesarean was also favored by hospitals characterized by a high degree of neonatal and obstetrical specialization, and a patient population with a low level of education.

CONCLUSIONS

This policy is still in the developmental stage, as evidenced by the great variability between hospitals and physicians in rates of vaginal birth after cesarean. Further efforts are required for this policy to become the norm.

Variations in surgical rates in Quebec: does access to teaching hospitals make a difference?

OBJECTIVE

To document the geographic variations in the rates of 10 common surgical procedures in Quebec and to examine the relation between surgical rates and level of access to teaching hospitals.

DESIGN

Population-based rates standardized for age and sex were calculated from 1985-88 data from MED-ECHO (the provincial hospital discharge database) for each of the 32 community health districts (départements de santé communautaire [DSCs]) in Quebec. Variation across DSCs was analysed with the use of the ratio of the highest to the lowest rate, the coefficient of variation and the systematic component of variation. On the basis of an urbanization index designed by Statistics Canada, DSCs were classified as having a low, medium, high or very high level of access to teaching hospitals.

PATIENTS

All Quebec residents except those whose DSC of residence could not be traced (accounting for no more than 1.7% of patients for any study procedure) and aboriginal people from northern Quebec. SURGICAL PROCEDURES STUDIED: Appendectomy, cesarean section, cholecystectomy, coronary artery bypass grafting (CABG), hysterectomy, inguinal hernia repair, prostatectomy, tonsillectomy with or without adenoidectomy, total hip replacement and varicose vein stripping.

RESULTS

There was considerable systematic variation in the surgical rates for all 10 procedures. Cesarean section, the rates of which varied the least, still exhibited almost a twofold variation between the highest and lowest rates. The rates of tonsillectomy varied the most, by a factor of more than five. With a few exceptions there was relatively little relation between the rates of the procedures within the DSCs. The rates of appendectomy, cholecystectomy, hysterectomy and tonsillectomy tended to be lower in the DSCs containing teaching hospitals, whereas the reverse was true for CABG. For the other procedures the relation between the rates and the level of access to teaching hospitals was nonsignificant.

CONCLUSIONS

The overall consistency of the observed variations with those of previous studies invites a closer look at the practice patterns and the scientific basis of the clinical decisions associated with procedures showing high variations in rates. The lack of a systematic relation between the surgical rates and the level of access to teaching hospitals challenges the belief that remote regions are underserved with respect to the procedures studied.

Vapors from collodion and acetone in an EEG laboratory

In the many EEG laboratories, the collodion-acetone technique has lost favor because of offensive vapors. We measured vapor concentrations of diethyl ether and acetone, the two principal vapors from this technique, to determine whether they reached toxic levels. We found that diethyl ether vapors usually reached the olfactory threshold, but acetone concentration did not. Neither reached concentrations that were systemically toxic. We then developed an inexpensive, effective method of reducing concentrated vapors during electrode application and removal and documented a significant reduction in vapor concentrations. With this information and with an inexpensive, "in house" vapor extraction system, technologist and patient satisfaction with the collodion method should greatly improve.

Prostatectomy in Denmark. Regional variation and the diffusion of medical technology 1977-1985

In many countries prostatectomy is one of the most common surgical operations in elderly men. We used administrative data for the entire male population of Denmark to study temporal and regional variations in the use of prostatectomy from 1977 to 1985. The total annual number of prostatectomies increased by 43% during the period, when the transurethral procedure (TURP) gradually replaced traditional open surgery. TURP accounted for 56% of all operations in 1977 but increased its share to 92% in 1985. Substantial regional variations occurred with index values for prostatectomy in 72 recruitment areas ranging from 0.56 to 1.62 (SCV x 100 = 5.3). The amount of variation decreased during the process of technology diffusion, but remained at a relatively high level (as in other countries) even after the process had been completed (SCV x 100 = 5.1).

Using administrative data bases for technology assessment in health care. Results of an international survey

This study assesses the nature, use, and quality of large administrative data bases available in different countries for technology assessment in health care. Using postal questionnaires, data were collected describing 91 data bases from 15 countries. Current uses are promising, but more efforts are needed if the full potential of administrative data files is to be tapped.

Effects of patient, physician and hospital characteristics on the likelihood of vaginal birth after previous cesarean section in Quebec

Repeat cesarean section is a major factor contributing to the rising cesarean section rate. Although vaginal birth after a previous cesarean section (VBAC) is advocated in most cases, it has not yet been adopted as widespread policy. In a case-control study we compared 400 women in Quebec who underwent VBAC with 1600 women who had a repeat cesarean section from 1985 to 1987 in an attempt to identify factors that favour vaginal delivery. Using both simple and multiple logistic regression analyses we examined the effect of independent variables linked to the patients (two variables), the attending physicians (seven) and the hospitals (two) on the dependent variable (type of birth) with the use of odds ratios. We found that the physician characteristics related to type of practice and the degree of hospital specialization were significant factors in predicting the type of delivery. Women who gave birth vaginally were more likely than those who had a repeat cesarean section to be attended by a physician with a specialized practice and to give birth in a hospital providing an intermediate or high level of care. This suggests that VBAC is still perceived as a high-risk option and is managed by only a minority of specialized obstetricians.

[Geographic variations: focal point for the re-evaluation of health services. Strategies of action]

This second article, in a series of two, proposes a number of strategies to deal with geographic variations in health care services and its main cause, professional uncertainty. These strategies, which call for a reassessment of health services, should be implemented in a non-punitive but educative context, where feedback should be constructive and where physicians should participate at every step. In order to be more effective, this process of health care reassessment should use international collaboration as much as possible.

[Study of geographic variations: starting point in the reassessment of health services. The phenomenon, its causes and its implications]

This first article, in a series of two, reviews the evidence on geographic variations in the use of health care services. Large variations exist both between countries and between regions within countries. These variations cannot be explained satisfactorily by errors of data, population characteristics or health care system features. Rather, they seem to stem from the professional uncertainty surrounding the current use of health care procedures. In the absence of solid scientific knowledge regarding the relevance and the efficacy of various alternatives, different practice styles are acceptable. Geographic variations raise important questions concerning the cost of care, the health of the population and health policies. In order to deal with geographic variations and professional uncertainty, a major reassessment of health care services is warranted. Specific action strategies will be described in a second article.

Morphologic prognostic factors of malignant mixed müllerian tumor of the uterus: a clinicopathologic study of 58 cases

Sixty-one patients with malignant mixed müllerian tumor (MMMT) of the uterus were seen at L'Hôtel-Dieu de Québec between 1950 and 1986, and the histopathologic material was available for review in 58 cases. Of the morphologic parameters studied, the histologic grade of both epithelial and mesenchymal components correlated with the initial stage. Patients with stages I and II disease had a significantly better survival rate than those with stages III and IV (P less than 0.006). Twenty-five patients with a minimum follow-up of two years were initially stage I or II. All six patients of this subgroup with an epithelial component of serous carcinoma type were dead of their disease at 2 yr. Although not statistically significant, tumor necrosis, the mode of tumor invasive (pushing and infiltrative), and the ratio of epithelial to mesenchymal components tended to influence the outcome. The mitotic rate, the type of mesenchymal components, and vascular and myometrial invasion were of no prognostic significance. We conclude that the outcome of patients with uterine MMMT is mainly influenced by the initial stage and the type of epithelial component. The influence of tumor necrosis, the ratio of epithelial to mesenchymal component, and the mode of tumor invasion deserve further studies.

Increased hematocrit with normal red blood cell mass in early borderline essential hypertension

Hematocrit, red blood cell mass, plasma volume and plasma renin activity were evaluated in 33 (15 women) young patients with borderline hypertension and in 30 (15 women) age- and sex-matched normotensive control subjects. Mean hematocrit values were slightly but significantly higher (P less than 0.05) at this early stage of hypertension and it correlated with the elevation of arterial hypertension (r = 0.39, P less than 0.05). Red blood cell mass was normal indicating normal bone marrow production. Plasma volume was significantly contracted (p less than 0.05) and it can account in part for the increased hematocrit and plasma renin activity. These results indicate that the alterations in circulating fluid components and in hematocrit described in moderate to severe forms of hypertension are also present in early borderline hypertension.

Coping with regional variations: the case of surgery in Denmark

This article examines some of the key research and policy issues that are emerging as a result of recent analyses of regional variations in health care. The article presents a historical background to this important new field of health services' research, and indicates, using some Danish examples of research on hysterectomy, cholecystectomy, and prostatectomy, the relevance of this research to management and policy planning. Regional variations are not yet fully explained in terms of what causes them. What is clear and what is the primary focus of this article is that their very existence, whatever their explanation, creates a major challenge for the management and planning of future health services.

Abnormal relation of extracellular fluid volume and exchangeable sodium with systemic arterial pressure in early borderline essential hypertension

Interrelations between systemic arterial pressure, extracellular fluid (ECF) volume, exchangeable sodium (Na) and the renin-angiotensin-aldosterone system were studied in 38 young patients with borderline hypertension and in 37 age- and sex-matched control subjects. ECF volume and exchangeable Na were subnormal (not significant) in borderline hypertension. In normal subjects, volume data did not relate to arterial pressure; in contrast, negative correlations were observed between arterial pressure and ECF volume or exchangeable Na in patients with borderline hypertension (in hypertensive women, r greater than or equal to 0.7, p less than 0.01). Plasma renin activity was consistently elevated in borderline hypertension, mainly in the upright posture, and these values were inversely correlated with ECF volume and exchangeable Na. No correlation was observed between arterial pressure and plasma renin activity. These results show that slight elevation of arterial pressure in the early stage of hypertension induces a proportional decrease in ECF volume, suggesting that the phenomenon of pressure-natriuresis is operative in young borderline hypertensive persons. The renin-angiotensin system is activated in these patients, in part to preserve sodium homeostasis.

Internal mammary lymphoscintigraphy in breast carcinoma--a surgeon's perspective

Internal mammary lymphoscintigraphy (IML) should now be considered a standard staging procedure in the present state of the art of the management of the patient with breast carcinoma. It provides clues for assessing the extent of disease and helps one to select individualized therapy. The interpretation is reliable enough in expert hands, to rule out the necessity of internal mammary node histopathologic diagnosis. In view of the significance of nodal invasion in relation to distant spread of the disease, one would be entitled to use this test as an indication for complementary systemic therapy when positive. On the other hand, if systemic therapy is to be employed without selection according to the multitude of relevant criteria, there may be no need to carry out this staging procedure prior to a management decision. The authors have reviewed their experience with more than 1000 examinations and have shown some of the practical implications of IML as a staging procedure as well as a guide to therapy.

[Breast neoplasms: a 1980 dilemma]

For many reasons, breast cancer is still the most controversial topic in oncology. Questions raised many years ago in relation to diagnosis and treatment have not yet been answered. Clinical classification, such as the TNM system, is open to many pitfalls and the degree of error in axillary staging is still high, even in expert hands. The situation with regard to management is similar. The types of treatment are numerous and controversial, so that interpretations of results is unreliable. The fundamental questions will be answered only by clinical trials.

Alteration of the volume-renin component in borderline essential hypertension

Interrelations between blood pressure, circulatory volumes and the renin-angiotensin system were studied in 15 normal subjects and in 25 young patients with borderline hypertension after equilibration on controlled sodium intake. Total blood and plasma volumes were consistently lower and plasma renin activity higher in borderline hypertensive as compared to normotensive controls. The decreased volumes were inversely correlated with blood pressure and plasma renin activity, but no correlation was found between blood pressure and plasma renin activity or the product of circulating renin and volumes. The fact that blood pressure and plasma renin activity were independently correlated to circulating volumes but did not correlate between themselves would suggest a common causal factor for the three observed phenomena: elevated renin, decreased volume and borderline hypertension; these anomalies of the volume-renin axis might be mediated through the well documented hyperresponsiveness of the sympathetic nervous system in these patients.