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Showing papers in "Canadian Family Physician in 2001"


Journal Article
TL;DR: The SMMSE requires little time to complete and is a key component of a comprehensive dementia workup and a valuable tool for family doctors who are often the first medical professionals to identify changes in patients' cognitive function.
Abstract: OBJECTIVE: To review administration of the Standardized Mini-Mental State Examination (SMMSE) for dementia and depression and to evaluate how well it interprets older people's cognitive function. QUALITY OF EVIDENCE: Literature from January 1990 to December 1999 was searched via MEDLINE using the MeSH headings Alzheimer Disease, Vascular Dementia, Lewy Bodies, and Depression. Several studies have described the reliability and validity of the SMMSE. MAIN MESSAGE: The SMMSE, a standardized approach to scoring and interpreting older people's cognitive function, provides a global score of cognitive ability that correlates with daily function. Careful interpretation of results of the SMMSE, together with history and physical assessment, can assist in differential diagnosis of cognitive impairment resulting from Alzheimer's disease, vascular dementia, dementia with Lewy bodies, or depression. Repeated measurements can be used to assess change over time and response to treatment. CONCLUSION: The SMMSE is a valuable tool for family doctors who are often the first medical professionals to identify changes in patients' cognitive function. The SMMSE requires little time to complete and is a key component of a comprehensive dementia workup. Determining whether a patient has dementia is important because there are now effective medications that are most beneficial if started early.

183 citations


Journal Article
C K Bowering1
TL;DR: Underlying causes of diabetic foot ulceration are reviewed, a practical assessment of patients at risk, and an evidence-based approach to therapy for diabetic patients with foot ulcers are outlined, which indicates family physicians are often primary medical contacts for patients with diabetes.
Abstract: OBJECTIVE To review underlying causes of diabetic foot ulceration, provide a practical assessment of patients at risk, and outline an evidence-based approach to therapy for diabetic patients with foot ulcers. QUALITY OF EVIDENCE A MEDLINE search was conducted for the period from 1979 to 1999 for articles relating to diabetic foot ulcers. Most studies found were case series or small controlled trials. MAIN MESSAGE Foot ulcers in diabetic patients are common and frequently lead to lower limb amputation unless a prompt, rational, multidisciplinary approach to therapy is taken. Factors that affect development and healing of diabetic patients' foot ulcers include the degree of metabolic control, the presence of ischemia or infection, and continuing trauma to feet from excessive plantar pressure or poorly fitting shoes. Appropriate wound care for diabetic patients addresses these issues and provides optimal local ulcer therapy with debridement of necrotic tissue and provision of a moist wound-healing environment. Therapies that have no known therapeutic value, such as foot soaking and topical antiseptics, can actually be harmful and should be avoided. CONCLUSION Family physicians are often primary medical contacts for patients with diabetes. Patients should be screened regularly for diabetic foot complications, and preventive measures should be initiated for those at risk of ulceration.

149 citations


Journal Article
TL;DR: Physicians working in British Columbia's Northern and Isolation Allowance communities suffer from high levels of depression and veryhigh levels of burnout and are dissatisfied with their current jobs.
Abstract: OBJECTIVE To determine the prevalence of depression and burnout among family physicians working in British Columbia9s Northern and Isolation Allowance communities. Current level of satisfaction with work and intention to move were also investigated. DESIGN Cross-sectional, mailed survey. SETTING Family practices in rural communities eligible for British Columbia9s Northern and Isolation Allowance. PARTICIPANTS A random sample of family physicians practising in rural BC communities. Initial response rate was 66% (131/198 surveys returned); excluding physicians on leave and in temporary situations and those who received duplicate mailings gave a corrected response rate of 92% (131/142 surveys returned). MAIN OUTCOME MEASURES Demographics; self-reported depression and burnout; Beck Depression Inventory and Maslach Burnout Inventory scores; job satisfaction; and intention to leave. RESULTS Self-reported depression rate was 29%; the Beck Depression Inventory indicated 31% of physicians suffered from mild to severe depression. About 13% of physicians reported taking antidepressants in the past 5 years. Self-reported burnout rate was 55%; the Maslach Burnout Inventory showed that 80% of physicians suffered from moderate-to-severe emotional exhaustion, 61% suffered from moderate-to-severe depersonalization, and 44% had moderate-to-low feelings of personal accomplishment. Depression scores correlated with emotional exhaustion scores. More than half the respondents were considering relocation. CONCLUSION Physicians working in these communities suffer from high levels of depression and very high levels of burnout and are dissatisfied with their current jobs. More than half are considering relocating. Intention to move is strongly associated with poor mental health.

135 citations


Journal Article
TL;DR: Adults who receive regular care from a family physician are more likely to receive recommended preventive services, and those without regular doctors and those reporting only some care are less likely to have ever had their blood pressure checked.
Abstract: OBJECTIVE: To assess whether regular care from a family physician is associated with receiving preventive services. DESIGN: Secondary analysis of the 1994 National Population Health Survey. SETTING: Cross-sectional sample of the Canadian population. PARTICIPANTS: A total of 15,731 non-institutionalized adults. MAIN OUTCOME MEASURES: Reported visits to general practitioners and specialists in the previous year and reports of having had blood pressure measurements, mammography, and Pap smears. RESULTS: A graded relationship was observed between level of regular care by a family physician in the previous year (none, some, regular) and receiving preventive services. Those without regular doctors and those reporting only some care by a family physician were less likely to have ever had their blood pressure checked than adults receiving ongoing care from a regular family physician. Women reporting some or no care were less likely to have had mammography within 2 years or to have ever had Pap smears. CONCLUSION: Adults who receive regular care from a family physician are more likely to receive recommended preventive services.

95 citations


Journal Article
TL;DR: Whether overprescribing is common in treatment of pediatric upper respiratory infections and whether antibiotic use was an important factor in promoting resistance in their communities is investigated and education in current treatment of Pediatrics and antimicrobial drug resistance is required.
Abstract: OBJECTIVE: To investigate whether overprescribing is common in treatment of pediatric upper respiratory infections and to examine factors that influence prescribing antibiotics for children. DESIGN: A random, stratified sample of practising family physicians was surveyed with a mailed questionnaire. Initial nonresponders were mailed a second questionnaire. SETTING: British Columbia. PARTICIPANTS: A total of 608 general and family physicians. Response rate was 64%; 392/612 surveys were completed. MAIN OUTCOME MEASURES: Physicians' self-reported prescribing practices and knowledge of and attitudes toward using antibiotics for children's upper respiratory tract infections. RESULTS: Relative to treatment guidelines developed for the study, most physicians responded appropriately to the cough (94%) and lobar pneumonia (99.1%) vignettes. More than half the physicians (56.5%) reported they would immediately prescribe antibiotics for tympanic membrane dysfunction, and 79.4% indicated they would prescribe antibiotics for pharyngitis without obtaining a laboratory culture. Approximately 25% of physicians in the study did not believe that prior antibiotic use increased personal risk for acquiring drug-resistant infection, and 23.1% did not believe that antibiotic use was an important factor in promoting resistance in their communities. CONCLUSION: Education in current treatment of pediatric upper respiratory tract illnesses and antimicrobial drug resistance is required. The high response to the questionnaire (64%) and the many requests from physicians to receive the project's educational materials (45%) indicate a high level of interest in this subject.

94 citations


Journal Article
TL;DR: Investigating factors that affect the integrity of palliative cancer patients' relationships with family physicians and to ascertain their perceptions of their FPs' roles in their care finds that family physicians can enhance care of cancer patients.
Abstract: OBJECTIVE: To explore factors that affect the integrity of palliative cancer patients' relationships with family physicians and to ascertain their perceptions of their FPs' roles in their care. DESIGN: Qualitative study using grounded-theory methods, taped semistructured interviews, and chart reviews. SETTING: Two palliative care hospital wards in Winnipeg, Man. PARTICIPANTS: A purposeful sample of 11 men and 14 women. METHOD: Qualitative content analysis of interview transcripts. MAIN FINDINGS: Cancer care is organized in a sequential, parallel, or shared manner between FPs and cancer specialists, with sequential care a common outcome if patients' relationships with their FPs wane. Cancer patients can lose contact with FPs because of patient or physician relocation, distrust over delays in diagnosis, failure to perceive a need for FPs, poor communication between FPs and specialists, and a lack of FP involvement in the hospital. People with cancer value FPs for being accessible through prompt appointments and telephone contact; for providing emotional and family support; and for referral, triage, and general medical care. CONCLUSION: Family physicians can enhance care of cancer patients. Contact with FPs can be maintained by ensuring good communication between specialists and FPs, defining a clear role for FPs, addressing concerns about delays in diagnosis, and referring patients back to FPs, particularly after hospitalization.

71 citations


Journal Article
TL;DR: The difference in rates of prescription between high prescribers and low prescriber is largely explained by assignment of diagnoses of RTIs, and family doctors frequently prescribe antibiotics.
Abstract: OBJECTIVE: To evaluate the association between diagnostic labeling of respiratory tract infections (RTIs) and antibiotic prescription rates in family practice. DESIGN: Descriptive analysis of outpatient chart review supplemented by interviews with physicians. Charts of patients attending 73 general practitioners were reviewed between October 1997 and February 1998. Two days of practice were evaluated per physician. SETTING: Urban family practices in greater St John's, Nfld. PARTICIPANTS: Of 96 family physicians contacted, 73 (76%) agreed to participate. MAIN OUTCOME MEASURES: Rates of diagnoses and antibiotic prescriptions for acute infections. Physicians were divided into "low prescribers" and "high prescribers" based on overall rates of prescription to patients with infections. Low prescribers were compared with high prescribers with respect to physician characteristics, patient characteristics, and diagnoses assigned. RESULTS: Of all patients seen, 22% were seen for acute infections; RTIs accounted for 76% of diagnoses. Low prescribers and high prescribers were of similar ages and saw similar numbers of patients of similar ages with very similar presenting complaints. Both groups diagnosed urinary tract and skin and soft-tissue infections at similar rates, but differed markedly in their rates of diagnoses of RTIs. High prescribers diagnosed bacterial RTIs in 65.4% (147/225) of their patients; low prescribers diagnosed bacterial RTIs in 31.0% (66/213 (P < .001). CONCLUSION: Family doctors frequently prescribe antibiotics. The difference in rates of prescription between high prescribers and low prescribers is largely explained by assignment of diagnoses of RTIs.

54 citations


Journal Article
TL;DR: Future primary care programs could be targeted to improve coverage of relatively underserviced people, particularly men, people on low incomes, those without confidants, and recent immigrants.
Abstract: OBJECTIVE: Because having a regular medical doctor is associated with positive outcomes, this study attempted to determine the characteristics of Canadians without regular doctors so that alternative methods of delivering care to people with those characteristics can be studied. DESIGN: Secondary data analysis of the National Population Health Survey using bivariate analyses and logistic regression. PARTICIPANTS: A total of 15,777 respondents older than 20 years. MAIN OUTCOME MEASURES: Responses to the question "Do you have a regular medical doctor?" and analysis of 11 variables covering demographics, health status, and lifestyle factors. RESULTS: One in seven respondents did not have a regular doctor. Younger respondents, men, single people, poorer respondents, respondents who perceived themselves in better health, recent immigrants, those without confidants, and smokers were more likely not to have regular doctors. Comparing provinces, participants from Quebec were least likely to have regular doctors. CONCLUSION: Primary care reform might need to consider alternative ways of providing care to certain people. Future primary care programs could be targeted to improve coverage of relatively underserviced people, particularly men, people on low incomes, those without confidants, and recent immigrants.

54 citations


Journal Article
TL;DR: In this paper, a third-party payer perspective was used to estimate savings if all elderly patients currently receiving vitamin B12 (cobalamin) injections were switched to high-dose oral therapy.
Abstract: OBJECTIVE: To estimate savings, using a third-party payer perspective, if all elderly patients currently receiving vitamin B12 (cobalamin) injections were switched to high-dose oral therapy. DESIGN: We modeled high-dose oral B12 supplement costs to include drugs, pharmacists' fees, and one-time conversion costs consisting of two physician visits and laboratory monitoring. The number of vitamin-injection visits avoided by switching to oral therapy was predicted using a multivariate model that considered covariates for overall patient illness. SETTING: Ontario family physicians' and internists' practices. PARTICIPANTS: Population-based administrative databases for Ontario were used to identify all people between 65 and 100 years who received parenteral vitamin B12 during 1995 and 1996. MAIN OUTCOME MEASURES: The cost of parenteral vitamin B12 for each patient, including drugs, injections, pharmacists' fees, and injection-associated physician visits, was measured directly from the databases. RESULTS: The annual cost of parenteral vitamin B12 therapy averaged $145.88 per person and totaled a maximum $25 million over 5 years. Converting all patients to high-dose oral B12 and treating them for 5 years would cost $7.4 million. Depending on how many vitamin-injection visits are avoided by switching to oral therapy, between $2.9 million and $17.6 million would be saved. Switching to oral B12 administration saved costs as long as 16.3% of injection-associated visits were avoided. CONCLUSION: Switching all patients from B12 injections to oral cobalamin therapy could result in substantial savings.

49 citations


Journal Article
TL;DR: Differences between rural and metropolitan residents and between sexes affect family medicine graduates' choices of practice location should be taken into account in recruitment strategies.
Abstract: OBJECTIVE: To examine factors that influence family medicine graduates' choice of practice location. DESIGN: Cross-sectional, retrospective survey employing a self-administered, mailed questionnaire. SETTING: Family medicine residency programs at the University of Alberta (U of A) and the University of Calgary (U of C) in Alberta. PARTICIPANTS: Graduates (n = 702) who completed the family medicine residency program at U of A or U of C between 1985 and 1995. MAIN OUTCOME MEASURES: Current practice location; 23 factors influencing current practice location; physicians' sex; community lived in until 18 years of age. RESULTS: Response rate was 63% (442 graduates completed the questionnaire). Overall, the most influential factors in attracting graduates to their current practice locations were spousal influence, type of practice, and proximity to extended family. Type of practice, income, community effort to recruit, medical need in the area, and loan repayments had a substantial influence on family physicians' decisions to practise in rural areas. Male physicians ranked type of practice, whereas female physicians ranked spousal influence, as having the most influence on choice of practice location. Significantly more female than male physicians identified working hours, familiarity with the medical community or resources, and availability of support facilities and personnel as having a moderate or major influence on their decisions. CONCLUSION: Differences between rural and metropolitan residents and between sexes affect family medicine graduates' choices of practice location. These differences should be taken into account in recruitment strategies.

48 citations


Journal Article
TL;DR: To review common repetitive strain injuries that occur in the workplace, emphasizing diagnosis, treatment, and etiology of these conditions, a search from January 1966 to June 1999 focused on articles published since 1990.
Abstract: OBJECTIVE: To review common repetitive strain injuries (RSIs) that occur in the workplace, emphasizing diagnosis, treatment, and etiology of these conditions. QUALITY OF EVIDENCE: A MEDLINE search from January 1966 to June 1999 focused on articles published since 1990 because RSIs are relatively new diagnoses. MeSH headings that were explored using the thesaurus included "cumulative trauma disorder," "overuse injury," and "repetitive strain injury." The search was limited to English articles only, and preference was given to randomized controlled trials. MAIN MESSAGE: Repetitive strain injuries result from repeated stress to the body's soft tissue structures including muscles, tendons, and nerves. They often occur in patients who perform repetitive movements either in their jobs or in extracurricular activities. Common RSIs include tendon-related disorders, such as rotator cuff tendonitis, and peripheral nerve entrapment disorders, such as carpal tunnel syndrome. A careful history and physical examination often lead to the diagnosis, but newer imaging techniques, such as magnetic resonance imaging and ultrasound, can help in refractory cases. Conservative management with medication, physiotherapy, or bracing is the mainstay of treatment. Surgery is reserved for cases that do not respond to treatment. CONCLUSION: Repetitive strain injury is common; primary care physicians must establish a diagnosis and, more importantly, its relationship to occupation. Treatment can be offered by family physicians who refer to specialists for cases refractory to conservative management.

Journal Article
TL;DR: Family physicians, counselors, and psychiatrists expressed great satisfaction with a shared mental health care program based in primary care based on the Hamilton-Wentworth Health Service Organization's Mental Health Program.
Abstract: OBJECTIVE To determine whether health care providers are satisfied with an integrated program of mental health care. DESIGN Surveys using a mailed questionnaire. Surveys were developed for each of the three disciplines; each survey had 30 questions. SETTING Thirty-six primary care practices in Hamilton, Ont, participating in the Hamilton-Wentworth Health Service Organization9s Mental Health Program. PARTICIPANTS Family physicians, psychiatrists, and mental health counselors providing mental health care in primary care settings. MAIN OUTCOME MEASURE Satisfaction as shown on 5-point Likert scales. RESULTS High levels of satisfaction with the model were recorded. Family physicians increased their skills, felt more comfortable with handling mental health problems, and were satisfied with the benefit to their patients. Psychiatrists and counselors were gratified that they were accepted by other members of the primary care team. Areas for improvement included finding space in primary care settings and better scheduling to allow for optimal communication. CONCLUSION Family physicians, counselors, and psychiatrists expressed great satisfaction with a shared mental health care program based in primary care.

Journal Article
TL;DR: Delirium is frequently underdiagnosed in clinical practice and careful investigation of the underlying cause permits appropriate management, and findings support the current belief that neuroleptics are superior to benzodiazepines in most cases of delirium.
Abstract: OBJECTIVE To outline current approaches to diagnosing and managing delirium in the elderly. QUALITY OF EVIDENCE A literature review was based on a MEDLINE search (1966 to 1998). Selected articles were reviewed and used as the basis for discussion of diagnosis and etiology. We planned to include all published randomized controlled trials regarding management but found only two. Consequently, we also used review articles and recent practice guidelines for delirium published by the American Psychiatric Association. MAIN FINDINGS Clinical diagnosis of delirium can be aided by using DSM-IV criteria, the Delirium Symptom Interview, or the confusion assessment method. Management must include investigation and treatment of underlying causes and general supportive measures. Providing optimal levels of stimulation, reorienting patients, education, and supporting families are important. Pharmacologic management of delirium should be considered only for specific symptoms or behaviours, e.g., aggression, severe agitation, or psychosis. Only one randomized controlled trial of tranquilizer use for delirium in medically ill people has been published. Findings support the current belief that neuroleptics are superior to benzodiazepines in most cases of delirium. Most authorities still consider haloperidol the neuroleptic of choice. Controlled trials of the new atypical neuroleptics for treating delirium are not yet available. Benzodiazepines with relatively short half-lives, such as lorazepam, are the drugs of choice for withdrawal symptoms. CONCLUSION Delirium is frequently underdiagnosed in clinical practice. It should be suspected with acute changes in behaviour. Careful investigation of the underlying cause permits appropriate management.

Journal Article
TL;DR: In this paper, a case series was conducted to determine whether there were discrepancies between what medications frail elderly outpatients took and what physicians thought they took and whether discrepancies put patients at risk of taking inappropriate drugs and of increasing the potential for drug interactions.
Abstract: OBJECTIVE: To determine whether there were discrepancies between what medications frail elderly outpatients took and what physicians thought they took and whether discrepancies put patients at risk of taking inappropriate drugs and of increasing the potential for drug interactions. DESIGN: Case series. SETTING: Day Hospital Program at St Mary's of the Lake Hospital in Kingston, Ont. PARTICIPANTS: One hundred twenty community-living elderly patients attending the Day Hospital Program in 1998. Three patients and two family physicians declined to participate. MAIN OUTCOME MEASURES: Lists of medications being taken by patients compared with lists of medications in physicians' charts. Category according to explicit criteria that each drug fell into and risk of drug interactions as determined by the Clinidata Drug Interaction Program. RESULTS: Of the 120 patients, 115 had at least one discrepancy between their lists of medications and their physicians' lists. Of the 1390 medications on the lists, 521 (37%) were being taken by patients without their doctors' knowledge, 82 (6%) were not being taken by patients when doctors thought they were, and 133 (10%) were on both patients' and their doctors' lists but with dosages or frequency of administration that were different. More potential drug interactions were identified on patients' lists than on physicians' lists. No increase in risk of inappropriate drug use was identified. CONCLUSION: Family physicians are often unaware of all the medications their patients are actually taking. Medications used by patients without physicians' knowledge increase the likelihood of drug interactions. Family physicians should look at and inquire about all medications, including over-the-counter drugs, their patients are actually taking.

Journal Article
TL;DR: Findings of this study reveal some ways in which consumers' use of Internet health information can affect physicians' and other health professionals' work.
Abstract: OBJECTIVE To explore how best to make high-quality preventive health information available to consumers on the Internet. DESIGN Focus groups. SETTING Three urban workplaces and one local hospital with patients from a rural family medical practice. PARTICIPANTS Twenty-two men and 17 women patients. METHOD Qualitative survey of four focus groups, analysis of transcripts and researchers9 notes. MAIN FINDINGS Five themes characterized participants9 perceptions of a consumer website of evidence-based preventive guidelines: content expectations, website design, trustworthiness of content, marketing, and the implications of consumer health information on the Internet. CONCLUSION Consumers want preventive health information both for taking care of themselves and for participating in a more informed way in their health care when they see a physician. Findings of this study reveal some ways in which consumers9 use of Internet health information can affect physicians9 and other health professionals9 work.

Journal Article
TL;DR: On-line case-based discussion is a promising strategy for encouraging family physicians to access current research and more research is needed to determine whether it can be effectively used to change physicians' practice.
Abstract: PROBLEM BEING ADDRESSED: Traditional continuing medical education (CME) approaches do not work well in changing physicians' behaviour, but some promising strategies and technologies might help. Our program sought to meld small-group learning with an Internet e-mail approach. OBJECTIVE OF PROGRAM: In 1994, the Family medicine Education and Research Network (FERN) was developed to support on-line discussion among London, Ont, and area family physicians. To support educational, moderated case discussions using e-mail, FERN Dissemination (FERN-D) was introduced to a subgroup of participants. We hoped to increase awareness and use of evidence-based research in clinical practice and to increase use of Internet-based resources for CME. The target group was family physicians in the London area. MAIN COMPONENTS OF PROGRAM: Forty volunteers were recruited and were e-mailed one case every 2 weeks; 34 completed the study. Each case was followed by further postings and, at the end of 2 weeks, by a summary of the group's discussion. Background material for each case was researched and was evidence-based. Evaluation was conducted using preintervention and postintervention mailed surveys combined with an e-mail feedback questionnaire and a modified focus group. CONCLUSION: On-line case-based discussion is a promising strategy for encouraging family physicians to access current research. More research is needed to determine whether it can be effectively used to change physicians' practice.

Journal Article
TL;DR: Lithium intoxication can be avoided by conservative dosing, care in combining drug therapies, regular clinical observation, monitoring drug plasma concentrations, and educating patients and caregivers to recognize early signs of intoxication.
Abstract: OBJECTIVE: To raise awareness of risk factors for, and symptoms of, lithium intoxication. QUALITY OF EVIDENCE: The literature was searched via MEDLINE from January 1970 to December 1999 using the MeSH headings Lithium, Lithium Carbonate, Drug Toxicity, and Aging. Articles were selected based on clinical relevance and design. Most were case reports, case series, or reviews. MAIN MESSAGE: A case study illustrates both risk factors predisposing patients to lithium intoxication and the symptoms of lithium intoxication. Lithium intoxication can be avoided by conservative dosing, care in combining drug therapies, regular clinical observation, monitoring drug plasma concentrations, and educating patients and caregivers to recognize early signs of intoxication. CONCLUSION: Knowing about lithium intoxication and how to avoid it is most important for family physicians who regularly treat patients receiving lithium.

Journal Article
TL;DR: The six-step approach to decision making was more helpful than the SOGC's information document in increasing subjects' knowledge of the risks and benefits of H RT, in creating more realistic expectations of HRT, and in increasing the congruence between subjects' personal values and their decisions on HRT.
Abstract: OBJECTIVE: To compare the efficacy of a decision-making aid with an information document from the Society of Obstetricians and Gynaecologists of Canada (SOGC) with regard to decisions about hormone replacement therapy (HRT). DESIGN: Randomized clinical trial. SETTING: Quebec city region. PARTICIPANTS: Menopausal Francophone women 45 to 69 years old. INTERVENTIONS: Subjects were given a manual and an audiocassette describing a six-step approach to making a decision about HRT. MAIN OUTCOME MEASURES: Amount of anxiety over the decision (main outcome), general knowledge of the risks and benefits of HRT, personal expectations and values concerning these risks and benefits, and women's views on HRT. RESULTS: Anxiety levels were significantly reduced in both groups, but the difference between the effectiveness of the two interventions was not significant (P = .77). Percentages of women whose general knowledge increased and of women with realistic expectations were significantly higher in the experimental group (P < .003 and P < .0001, respectively). Congruence between personal values and decisions about HRT increased significantly more in the experimental group (P < or = .003). CONCLUSION: The six-step approach to decision making was more helpful than the SOGC's information document in increasing subjects' knowledge of the risks and benefits of HRT, in creating more realistic expectations of HRT, and in increasing the congruence between subjects' personal values and their decisions on HRT.

Journal Article
F C Blais1, Charles M. Morin, A Boisclair, V Grenier, B Guay 
TL;DR: Patients attending general practice clinics have a high prevalence of insomnia, and respondents suffering from insomnia made heavier use of health care services and reported more worry and symptoms of anxiety and depression than those who slept well.
Abstract: OBJECTIVE: To evaluate the prevalence of insomnia and the treatments used by patients attending general practice clinics. DESIGN: Survey of outpatients. SETTING: Quebec city, Que. metropolitan area. PARTICIPANTS: Two hundred eighteen patients recruited in waiting rooms of general practice clinics. MAIN OUTCOME MEASURES: Participants completed a survey on sleep and use of substances for insomnia, a questionnaire documenting their medical history and use of health care services, and three indices measuring presence of worry and symptoms of anxiety and depression. RESULT: Close to 38% of respondents suffered from insomnia: 26.2% had chronic insomnia and 11.4% had short-term insomnia. Prevalence was higher among women and people 35 to 54 years old. Among respondents who used substances to help them sleep, those 55 years and older consumed more prescription and medications (benzodiazepines); those 35 to 54 years old used mainly natural products; and those 16 to 34 years old consumed mainly over-the-counter medications. Respondents suffering from insomnia made heavier use of health care services and reported more worry and symptoms of anxiety and depression than those who slept well. CONCLUSION: Patients attending general practice clinics have a high prevalence of insomnia. Physicians must be on the lookout for these sleep disturbances so they can offer appropriate treatment.

Journal Article
TL;DR: Promotion programs focusing on peer influence could increase vaccination of family physicians, which could in turn improve vaccination coverage of elderly patients.
Abstract: OBJECTIVE To assess influenza vaccination status and influenza vaccination practices of family physicians in Quebec. DESIGN Mail survey of a random sample of 1000 family physicians. SETTING Family practices in the province of Quebec. PARTICIPANTS Of 1000 Quebec family physicians sent questionnaires, 550 responded. After excluding physicians who worked only in institutions, had no patients older than 65 years, or did clinical work less than 20% of the time, 379 respondents were eligible for the study. MAIN OUTCOME MEASURES Vaccination status of family physicians in 1996 and professional practices based on six clinical and administrative activities pertaining to influenza vaccination. RESULTS Prevalence of vaccination was 35.5% (95% confidence interval 30.8% to 40.4%) among responding physicians and was higher among those 60 years and older, those with a chronic condition, and those perceiving high peer pressure to get vaccinated. Most respondents frequently assessed the current influenza vaccination status of their patients, risk factors for influenza-related complications, and contraindications to the vaccine. They also frequently provided education about influenza and its vaccine, recommended vaccination, and administered the vaccine. Only a few reported assessing prior influenza vaccinations or recording vaccination status regularly. Finally, vaccinated physicians recommended the vaccine more frequently to their patients than unvaccinated physicians did. CONCLUSION Promotion programs focusing on peer influence could increase vaccination of family physicians. This could in turn improve vaccination coverage of elderly patients.

Journal Article
TL;DR: To provide family doctors in busy office practices with a model for counseling compatible with patient-centred medicine, including the techniques, strategies, and questions necessary for implementation, MECSTAT provides a framework that facilitates development of skills.
Abstract: OBJECTIVE To provide family doctors in busy office practices with a model for counseling compatible with patient-centred medicine, including the techniques, strategies, and questions necessary for implementation. QUALITY OF EVIDENCE The MEDLINE database was searched from 1984 to 1999 using the terms psychotherapy in family practice, brief therapy in family practice, solution-focused therapy, and brief psychotherapy. A total of 170 relevant articles were identified; 75 abstracts were retrieved and a similar number of articles read. Additional resources included seminal books on solution-focused therapy (SFT), bibliographies of salient articles, participation in workshops on SFT, and observation of SFT counseling sessions taped by leaders in the field. MAIN MESSAGE Solution-focused therapy9s concentration on collaborative identification and amplification of patient strengths is the foundation upon which solutions to an array of problems are built. Solution-focused therapy offers simplicity, practicality, and relative ease of application. From the perspective of a new learner, MECSTAT provides a framework that facilitates development of skills. CONCLUSION Solution-focused therapy recognizes that, even in the bleakest of circumstances, an emphasis on individual strength is empowering. In recognizing patients as experts in self-care, family physicians support and accentuate patient-driven change, and in so doing, are freed from the hopelessness and burnout that can accompany misplaced feelings of responsibility.

Journal Article
TL;DR: A recent Motherisk study showed that use of echinacea during the first trimester of pregnancy was not associated with increased risk of major malformations, and there is little evidence showing they are safe.
Abstract: QUESTION: Many of my patients are now using herbal medicines; some even use them during pregnancy. As we enter the "cold and flu" season, many are inquiring about use of the herb echinacea to prevent these ailments. Is there any evidence to suggest that use of echinacea during pregnancy is safe? ANSWER: Although herbal products have been used in the past during pregnancy and delivery, there is little evidence showing they are safe. Many authoritative reviews of echinacea report that its safety for use during pregnancy has not been established. A recent Motherisk study showed that use of echinacea during the first trimester of pregnancy was not associated with increased risk of major malformations.

Journal Article
J Bain1
TL;DR: A review of the rationale for treating symptomatic aging men whose testosterone levels are mildly reduced or low-normal with testosterone replacement therapy can be found in this article, where the main cause of reduced testosterone production is primary gonadal insufficiency, but secondary causes such as hypothalamic-pituitary disease, should be considered.
Abstract: OBJECTIVE To review the rationale for treating symptomatic aging men whose testosterone levels are mildly reduced or low-normal with testosterone replacement therapy. QUALITY OF EVIDENCE Large-scale multicentre prospective studies on the value of treating andropausal men with hormone therapy do not exist because the whole area of hormone therapy is barely 10 years old. Evidence presented is based on physiologic studies, particularly studies in which treatment has been assessed. These were largely uncontrolled open studies. Studies to date report positive responses to testosterone treatment with very few serious side effects. MAIN MESSAGE Physicians should consider hypoandrogenism if male patients complain of loss of libido, erectile dysfunction, weakness, fatigue, lethargy, loss of motivation, or mood swings. Less obvious associations with reduced levels of testosterone are anemia and osteoporosis. The main cause of reduced testosterone production is primary gonadal insufficiency, but secondary causes, such as hypothalamic-pituitary disease, should be considered. Evidence shows that most men treated with testosterone will feel better about themselves and their lives. CONCLUSION Andropause is a term of convenience describing a complex of symptoms in aging men who have low testosterone levels. Physicians should be aware of its existence, should consider ordering tests for men who have symptoms, and should treat carefully selected patients whose serum testosterone levels are low.

Journal Article
TL;DR: A charting system, such as the Rourke Baby Record, functions as an aide-mémoire, allows for efficient use of time, encourages a team approach, and is an ideal teaching tool for comprehensive well-baby and well-child care.
Abstract: Since the 1985 publication of the Rourke Baby Record in Canadian Family Physician, the document has been revised several times to incorporate the most current evidencebased recommendations for well-baby and well-child care. These evidence-based recommendations are discussed in detail in the March 1998 issue of Canadian Family Physician. Despite changes over the past 15 years, the basic philosophy of the Rourke Baby Record has not changed; a charting system, such as the Rourke Baby Record, functions as an aide-mémoire, allows for efficient use of time, encourages a team approach, and is an ideal teaching tool for comprehensive well-baby and well-child care.

Journal Article
R Jackson1
TL;DR: Knowing the difference between changes caused by sun and by aging can help physicians predict which patients are most likely to get skin cancers and will help physicians diagnose and manage the skin abnormalities of elderly people and of people with dermatoheliosis.
Abstract: OBJECTIVE: To review and distinguish between skin changes produced by aging and changes produced by habitual exposure to sun. QUALITY OF EVIDENCE: The literature was searched from 1969 to 1999 for articles on dermatoheliosis and sun-damaged skin. Surprisingly few were found comparing the difference between elderly skin and sun-damaged skin. A few articles focused on certain small aspects of sun-damaged skin. Many excellent articles described particular changes (e.g., actinic keratosis), but few covered all the changes due to aging and to sun. MAIN MESSAGE: Skin changes due to aging can be distinguished from those due to sun damage. All changes due to sun exposure can be grouped under the term dermatoheliosis; five parts of the skin are involved: epidermis (actinic keratosis), dermis (solar elastosis), blood vessels (telangiectasia), sebaceous glands (solar comedones), and melanocytes (diffuse or mottled brown patches). Habitual exposure to sun and a white skin are prerequisites for developing these changes. Knowing the difference between changes caused by sun and by aging can help physicians predict which patients are most likely to get skin cancers. CONCLUSION: Knowledge of these common skin changes will help physicians diagnose and manage the skin abnormalities of elderly people and of people with dermatoheliosis.

Journal Article
TL;DR: Careful attention to parents' concerns and specific inquiry into and observation of how children interact, communicate, and play will help ensure that early signs of autistic spectrum disorders are detected during regular health maintenance visits.
Abstract: OBJECTIVE To review existing data on early signs of autistic spectrum disorders (ASD) and on how these disorders can be distinguished from other atypical patterns of development, and to describe a developmental surveillance approach that family physicians can use to ensure that children with these diagnoses are detected as early as possible. QUALITY OF EVIDENCE MEDLINE was searched from January 1966 to July 2000 using the MeSH terms autistic disorder/diagnosis AND diagnosis, differential AND (infant OR child, preschool). Articles were selected based on relevance to developmental surveillance in primary care and on experimental design, with emphasis on prospective studies with systematic measurement procedures using up-to-date diagnostic criteria. MAIN MESSAGE Autistic spectrum disorders are characterized by impairments in social interaction and verbal and nonverbal communication, and by preferences for repetitive interests and behaviours. Early signs that distinguish ASD from other atypical patterns of development include poor use of eye gaze, lack of gestures to direct other people9s attention (particularly to show things of interest), diminished social responsiveness, and lack of age-appropriate play with toys (especially imaginative use of toys). Careful attention to parents9 concerns and specific inquiry into and observation of how children interact, communicate, and play will help ensure that early signs are detected during regular health maintenance visits. CONCLUSION Family physicians have an important role in early identification of children with ASD. Early diagnosis of these disorders is essential to ensure timely access to interventions known to improve outcomes for these children.

Journal Article
TL;DR: To allow GPs to use the Up and Go test in patients’ homes, it was investigated whether using the types of chairs commonly present in the homes of elderly people influenced outcomes of the test.
Abstract: mpaired mobility is an important cause of disability and discomfort for elderly people. Prevalence of disability in mobility increases from 26% among people 70 years old to 51% among those 80 and older. General practitioners (GPs) often underestimate or fail to recognize functional disabilities. A useful way of assessing mobility is the timed “Up and Go” test developed by Podsiadlo and Richardson, which has proven interrater reliability and consistent results over time. The Up and Go test has content validity, in that it evaluates a well recognized series of maneuvers used in daily life, and concurrent validity, in that it correlates well with more comprehensive measures of balance, gait speed, and functional ability: on the Berg Balance Scale, r = –.81; for gait speed, r = –.61, and on the Barthel Index of Activities of Daily Living, r = –.78. Most elderly people who need more than 30 seconds for the test have difficulties with basic tasks, such as getting on or off a toilet, climbing stairs, and going outside alone, and cannot live on their own without assistance. Most people who can do the test in less than 20 seconds seem to be independently mobile. Patients who take between 20 and 29 seconds for the test should be monitored carefully to discover whether they can manage on their own or need support. Frail elderly people living in the community who cannot get to their physicians’ offices can be assessed at home. They might not have the “standard armchair” (Figure 1) recommended for the Up and Go test, and it was not clear to what extent the different geometry of a chair would influence results of the test. A literature search on use of the timed Up and Go test in general practice found one article, but the authors did not investigate the influence of different chairs on the time needed for the test. To allow GPs to use the test in patients’ homes, we investigated whether using the types of chairs commonly present in the homes of elderly people influenced outcomes of the test.


Journal Article
TL;DR: This editorial defines clinical descriptive research, discusses the four cornerstones on which it is built, suggest some reasons for its neglect, and tries to convey the rich opportunities that exist in the authors' day-to-day clinical experiences.
Abstract: Family medicine is a clinical discipline. So why are so few family physicians doing clinical research? Certainly there are notable exceptions to that generalization. But if you look at our publication record as a whole, clinical descriptive research is only a small part. Yet it is an important issue, with consequences for our place in medical schools. In this editorial, I want to address this issue and hope to stimulate discussion about how we can raise the profile of this field of research. I will define clinical descriptive research, discuss the four cornerstones on which it is built, suggest some reasons for our neglect, and try to convey the rich opportunities that exist in our day-to-day clinical experiences. Our neglect of clinical research is puzzling. Of all types of research, this area is for clinicians the most fitting, the most practical, and the most enjoyable. We are also heirs to a rich tradition of clinical research in general practice. It is fitting because it can be part and parcel of our clinical practice and need not require blocks of segregated time. Once we have decided which patients to study, it will add only a few minutes to the consulting time for these patients and will add some record keeping. Because our interventions are no different from our usual care, clinical research does not pose ethical problems. Although it does need thought and preparation, it does not call for complicated research designs. Because we do not need research assistants, large grants are not necessar y. Clinical research is enjoyable because we are looking at our own work and our own patients. If you look very closely at a group of your patients over time, I can almost promise that you will find things that are not in the books or that are in the books but are wrong. As a result you will experience the joy of discovery.

Journal Article
TL;DR: In this paper, the decision to discontinue these drugs during pregnancy should be based on scientific evidence rather than "hearsay" that women should not take psychotropic medications during pregnancy, and after receiving appropriate evidence-based information, a woman decides to stop taking the drugs, they should be gradually tapered off to avoid abrupt discontinuation syndrome.
Abstract: QUESTION: Two of my patients are planning to become pregnant. One is taking paroxetine and the other lorazepam. We have discussed what to do when they become pregnant and have decided they should stop taking these drugs as soon as pregnancy is confirmed. Is this the right decision? ANSWER: The decision to discontinue these drugs during pregnancy should be based on scientific evidence rather than "hearsay" that women should not take psychotropic medications during pregnancy. Recent epidemiologic studies have documented the relative safety of these drugs, so women should not feel compelled to stop taking them when they become pregnant. If, after receiving appropriate evidence-based information, a woman decides to stop taking the drugs, they should be gradually tapered off to avoid abrupt discontinuation syndrome.