Showing papers in "Canadian Medical Association Journal in 1981"

Labour is still painful after prepared childbirth training.

Abstract: Labour pain was measured with the McGill Pain Questionnaire in 87 primiparas and 54 multiparas The average intensity of labour pain ranked among the most intense pains recorded with the questionnaire However, the pain scores had a wide range and were influenced by several medical and social variables They were significantly higher for the primiparas than for the multiparas Moreover, high pain levels were associated with a history of menstrual difficulties and lower socioeconomic status The primiparas who had received prepared childbirth training had lower pain scores than those who had received no such training Nevertheless, the effects of prepared childbirth training were relatively small, and most patients (81%) who received it requested epidural anesthesia Because many women who received training suffered severe pain during labour, prepared childbirth training and epidural anesthesia should be regarded as compatible, complementary procedures

Early identification of alcohol abuse: 2: Clinical and laboratory indicators

Abstract: Despite awareness of the wide variety of clinical and laboratory abnormalities associated with alcohol abuse, drinking problems often remain undetected in hospital and in general medical practice. The diagnosis of alcohol abuse has been emphasized repeatedly in the literature but far less attention has been paid to indicators that would permit detection of excessive drinking at a stage when intervention might be more effective and less costly. The search for indicators of early alcohol abuse is complicated since many of the medical sequelae of alcoholism are nonspecific and may only be manifested after a number of years of excessive drinking. Part 2 of this two-part series considers various clinical and laboratory features related to alcohol abuse and highlights items that are potentially more sensitive for detecting early stages of problem drinking. Use by physicians of a composite profile of both biomedical and psychosocial indicators of excessive alcohol consumption is recommended for early identification of this problem.

Observations on the relation between alcohol absorption and the rate of gastric emptying

Abstract: Alcohol (ethanol) is absorbed slowly from the stomach and rapidly from the small intestine, and the rate of its absorption depends on the rate of gastric emptying. When gastric emptying is fast, the absorption of alcohol is fast. When gastric emptying is slow the absorption of alcohol is delayed and peak blood alcohol concentrations are reduced. Alterations of the gastric emptying rate, which may have a physiologic, pharmacologic or pathologic cause, markedly influence the rate of alcohol absorption. The gastric emptying rate makes an important contribution to inter- and intraindividual variations in the rate of alcohol absorption and therefore the timing and magnitude of the acute intoxicating effect of an oral dose of alcohol.

Early identification of alcohol abuse: 1. Critical issues and psychosocial indicators for a composite index.

Abstract: Traditional approaches to the medical management of alcohol-related disorders have met with limited success in altering the prevalence of alcohol abuse. Evidence suggests that identifying early those who drink to excess and intervening with low-cost educational and motivational programs could significantly reduce the prevalence of alcohol-related disabilities. However, physicians must take systematic steps to detect alcohol abuse. Part 1 of this two-part series discusses the need for early identification of individuals who drink to excess and the factors that may either facilitate or hinder the development of effective programs for detecting alcohol abuse. A profile is given of important psychosocial indicators of alcohol abuse, including the classic signs of alcohol abuse, the early manifestations of heavy drinking, the predisposing or high-risk factors for alcohol abuse, and the precipitating events and correlated habits of excessive drinking.

Treatment of acetaminophen poisoning

Abstract: Acetaminophen is an analgesic that is frequently used in Canada, and the occurrence of overdoses with this drug seems to be increasing. The most serious complication of acetaminophen overdose is hepatic failure. Because of pathophysiologic effects of acetaminophen poisoning and the mechanisms of its toxic effects are now better understood, a rational approach to treatment is possible. Several precursors of glutathione, acetylcysteine in particular, are effective in preventing liver damage if administered within 10 hours of acetaminophen ingestion. Plasma acetaminophen levels are a helpful guide to therapy.

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

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

Benefits and risks of circumcision

Abstract: Circumcisions are performed either prophylactically in the neonatal period or therapeutically at a later age. About 10% of males not circumcised at birth will eventually require circumcision. The present neonatal circumcision rate is about 80% in the United States and 40% in Canada. The single most important determinant of whether a newborn male will be circumcised is the attitude of the attending physician. The literature was reviewed to determine the proven benefits of circumcision and to compare these with the known risks. Circumcising the newborn facilitates penile hygiene, prevents cancer of the penis and decreases the incidence of genital herpes in later life. Whether it decreases the incidence of cancer of the cervix is still uncertain. More important, neonatal circumcision is associated with much lower morbidity and mortality and with lower costs than therapeutic circumcision. Thus, prophylactic circumcision is recommended for the male population as a whole.

Alcohol and abnormal outcomes of pregnancy

Abstract: Heavy alcohol consumption by the mother during pregnancy has long been suspected of being a risk factor for abnormalities in the fetus or infant. Only during the last decade have these assumptions been supported by scientific studies. A clustering of fetal defects observed in some cases has been labelled the fetal alcohol syndrome. The syndrome involves prenatal and postnatal growth retardation, central nervous system involvement and craniofacial abnormalities, some of which are characteristic of the syndrome. Fetal alcohol syndrome is relatively rare, affecting from 1 in 300 to 1 in 2000 infants; approximately 450 cases have been reported since the syndrome was identified. Despite this rarity, however, heavy alcohol consumption is an important risk factor during pregnancy. A review of the current literature indicates that in animals alcohol in high doses is embryotoxic and teratogenic, the heavy drinking is not uncommon before and during pregnancy and that the fetal alcohol syndrome and other effects on the fetus associated with alcohol abuse appear with significant frequency among mothers who drink heavily. Heavy alcohol consumption is a perinatal risk factor that not only can be detected by the physician, but also can be reduced in concerned, cooperative patients. Thus, awareness of this problem gives health care personnel an opportunity to help in the prevention of abnormal outcomes of pregnancy.

Effects of oral supplementation with stable strontium

Abstract: The biologic effects of stable strontium, a naturally occurring trace element in the diet and the body, have been little investigated. This paper discusses the effects of oral supplementation with stable strontium in laboratory studies and clinical investigations. The extent of intestinal absorption of various doses of orally administered strontium was estimated by determining serum and tissue levels with atomic absorption spectrophotometry. The central observation is that increased oral intake produces a direct increase in serum levels and intracellular uptake of strontium. The results of these studies, as well as those of other investigators, demonstrate that a moderate dosage of stable strontium does not adversely affect the level of calcium either in the serum or in soft tissues. In studies of patients receiving 1 to 1.5 g/d of strontium gluconate, a sustained increase in the serum level of strontium produced a 100-fold increase in the strontium:calcium ratio. In rats, studies indicate that an increase in intracellular strontium content following supplementation may exert a protective effect on mitochondrial structure, probably by means of a stabilizing effect of strontium on membranes. The strontium:calcium ratio in animals receiving a standard diet is higher in the cell than in the extracellular fluid; this may be of physiologic significance.An increase in density that corresponded to the deposition of stable strontium was observed in areas of bone lesions due to metastatic cancer in patients receiving stable strontium supplementation. This suggests the possibility of using strontium to mineralize osteophenic areas and to relieve bone pain. Also, because of reports of an inverse relation between the incidence of dental caries and a high strontium content in drinking water, the use of natural water containing relatively high levels of stable strontium should be considered. In each of these instances it is important to maintain a normal dietary intake of calcium.

Wood exposure and smoking: association with cancer of the nasal cavity and paranasal sinuses in British Columbia

Abstract: A case-control study of 121 men seen for cancer of the nasal cavity or paranasal sinuses in British Columbia between 1939 and 1977 showed increased relative risks associated with occupations involving exposure to wood (2.5) and with smoking (4.9). The occupations involved were chiefly forestry and carpentry. Both risk factors appeared to be associated with the principal sites within the nasal cavity paranasal sinuses and with most histologic subtypes of cancer.

Risk factors for benign breast disease: a 30-year cohort study

Abstract: Data on the menstrual history, family history and degree of obesity of 1374 Vancouver nursing students were collected in 1945 and from 1947 to 1956. In 1979, 768 of these women were located; 726 (94%) responded and participated in a follow-up study, providing information on their subsequent medical history and on breast-related problems. No major differences were found between the early histories of these participants and those who were not located or did not respond. Among the respondents 215 gave a history of symptoms compatible with benign breast disease; in 107 this diagnosis was confirmed by biopsy. By age 50 the cumulative risk for benign breast disease was 17% for biopsied and 31% for symptomatic disease. Biopsied benign breast disease was associated with premenstrual breast discomfort, irregular menses, a history of abortions, a family history of both benign and malignant breast disease, lack of use of oral contraceptives, a low index of obesity and small breasts, obesity and breast size being independent. Factors associated with symptomatic benign breast disease were usually associated with a greater likelihood of biopsy for symptomatic disease; hence, the relative risks for biopsied disease were generally greater than those for symptomatic disease. Although the risk factors for benign breast disease differ from those for breast cancer, the findings are consistent with the hypothesis of excessive circulating estrogen.

Cardiorespiratory fitness and muscular strength of wheelchair users

Abstract: The classification of lower-limb disabilities is commonly based on the site of the spinal cord lesion or the amount of functional muscle. Another important variable in assessing wheelchair users is their ability to carry out the activities of daily living. The cardiorespiratory fitness of those with lower-limb disabilities is usually assessed with arm-ergometry and wheelchair tests, each of which has some advantages. Muscle strength and endurance are also important aspects of the disabled person9s ability to function. Fitness is often poor in the disabled, and normal wheelchair use does not seem to prove an adequate training stimulus. Exercise with an arm ergometer and with pulleys and participation in vigorous wheelchair sports can improve physical condition. Participation in exercise programs should be based on the results of a fitness assessment and on the level of the spinal cord lesion in those with paraplegia. Progression in such programs should be gradual to ensure that the exerciser does not become discouraged and drop out of classes before fitness is increased. Data on wheelchair athletes suggest that, with persistence, many individuals in wheelchairs can adjust relatively well to their disabilities.

Causes of atypical pneumonia: results of a 1-year prospective study

Abstract: In a protocol study of cases of atypical pneumonia over a 1-year period an etiologic agent was established in 16 cases: Legionella pneumophila in 8, Coxiella burnetii in 3, Chlamydia trachomatis in 2, Mycoplasma pneumoniae in 1, para-influenza 3 virus in 1 and cytomegalovirus in 1. In the remaining 11 cases no agent was identified; the illnesses in these cases tended to be less severe. The pneumonia took much longer to resolve in the patients with Legionnaires9 disease than in all the other patients (mean interval from onset of symptoms to clearing of the chest roentgenogram: 69 days v. an average of 16 days). However, the length of stay in hospital was similar for the three groups: those with Legionnaires9 disease, those with atypical pneumonia of unknown cause and those with atypical pneumonia of various other established causes. L. pneumophila infection may explain a proportion of atypical pneumonias that previously could not be diagnosed, although in this series the cause of 41% of the pneumonias remained unexplained.

Nutritional services during pregnancy and birthweight: a retrospective matched pair analysis

Abstract: Since 1963, unselected prenatal patients at the Royal Victoria Hospital, Montreal, have been given nutritional counselling and, if it was judged necessary, dietary supplementation by the Montreal Diet Dispensary. From uniform data collected for all obstetric patients in 1963--74, 1213 recipients of the dispensary services (89.7% of those available and eligible for matching) were paired with controls matched for date of delivery (within 12 months), religious affiliation, parity, trimester of pregnancy during which prenatal care was begun and weight at the time of conception. The proportion of infants of low birthweight (less than 2500 g) was 5.7% for the recipients and 6.8% for the controls; the difference was not significant, but the recipients9 infants were heavier at birth than the controls9 infants, by an average of 40 g (P less than 0.05). The difference in birthweight was greatest for the infants of women in their first pregnancy (average 61 g) and least for the infants of women with three or more past deliveries (average 9 g). Increased birthweight (by an average of 53 g, P less than 0.02) among the recipients9 infants was limited to those born to women weighing less than 140 lb (63 kg) at the time of conception; among the heavier women the controls had infants who were heavier, but not significantly so. Differences between the groups in duration of gestation and maternal weight gain accounted for only a small part of these differences in birthweight. This study provides evidence that the Montreal Diet Dispensary program significantly increased birthweight. Further efforts must now be directed towards judging the long-term benefit of these changes.

Suggested limits to the use of the hot tub and sauna by pregnant women

Abstract: Because of reports of the potential risk of maternal hyperthermia to a developing embryo or fetus, studies were done to determine the length of time a woman must stay in a hot tub or sauna before her temperature reaches 38.9°C. The vaginal temperatures of 20 nonpregnant women of childbearing age were recorded while they sat in hot tubs set at 39.0°C or 41.1°C and in a sauna with an average temperature of 81.4°C. Five women were able to remain in the 39.0°C tub and six in the 41.1°C tub until their temperature reached 38.9°C, but in none did their temperature reach that level before 15 minutes in the 39.0°C tub or 10 minutes in the 41.1°C tub. The remainder left in discomfort while their body temperatures were lower. This indicates that the usual use of hot tubs is unlikely to raise a woman's body temperature to potentially teratogenic levels, although prolonged use may. None of the women were able to remain in the sauna long enough for their temperature to reach 39.9°C.

Effects of alcohol on the fetus: impact and prevention

Abstract: In the spectrum of adverse effects on the fetus or infant associated with maternal drinking during pregnancy the most dramatic is the fetal alcohol syndrome, a pattern of malformation that has been associated with maternal alcohol abuse. Other undesirable outcomes of pregnancy linked to alcohol exposure in utero include growth deficiency, major and minor anomalies, decrements in mental and motor performance, and fetal and perinatal wastage. Alcohol, like other teratogens, does not uniformly affect all those exposed to it. Rather, there seems to be a continuum of effects of alcohol on the fetus with increasingly severe outcomes generally associated with higher intakes of alcohol by the mother. The cost of fetal damage associated with alcohol exposure is very high. A program to decrease the incidence of fetal alcohol effects is therefore imperative. The cornerstone of such a program must be not only education of the public but also careful training of all professionals who provide health care for pregnant women.

Oxalate nephropathy due to gastrointestinal disorders

Abstract: Renal failure secondary to oxalate interstitial nephritis developed in three patients with malabsorption and steatorrhea following a jejunoileal bypass, extensive small intestine resection and a partial gastrectomy. Hyperoxaluria was documented in two of the cases. The possibility that this complication can occur in patients after a jejunoileal bypass operation is now recognized. This report shows that it can also occur in patients with other bowel disorders that cause malabsorption and steatorrhea. Since the prognosis for patients with oxalate nephropathy is poor, renal function should be closely monitored in patients who are at risk because of these disorders. Therapy should be directed at correcting malabsorption, steatorrhea and hyperoxaluria. When the renal function of patients with a jejunoileal bypass continues to decline despite intensive medical therapy, restoration of bowel continuity is strongly recommended.

Urinary tract infections due to Staphylococcus saprophyticus biotype 3

Abstract: Staphylococcus saprophyticus biotype 3 (Micrococcus subgroup 3 or M3) has usually been shown to be the second commonset cause of urinary tract infections in European women who are not in hospital. It generally causes pyuria and symptoms as severe as those caused by Escherichia coli. Unlike S. epidermidis it is seldom found as a contaminant in midstream urine specimens, and almost exclusively infects women in their reproductive years. However, S. saprophyticus is seldom differentiated from S. epidermidis in Canadian clinical laboratories. Urinary isolates of S. saprophyticus were presumptively differentiated from other coagulase-negative Micrococcaceae by their resistance to novobiocin as demonstrated by a simple disc susceptibility test that misidentified the infecting organism in only 3.4% of specimens. These novobiocin-resistant, coagulase-negative organisms caused similar proportions of the urinary tract infections in young women in York, England and Vancouver -- 6.6% and 6.9% respectively. In York these organisms were associated with significantly greater pyuria than novobiocin-sensitive organisms or bile-tolerant streptococci but not S. aureus or Enterobacteriaceae. In both communities novobiocin-sensitive, coagulase-negative Micrococcaceae were appreciably more resistant to penicillin than novobiocin-resistant organisms. Thus, differentiating S. saprophyticus from novobiocin-sensitive, coagulase-negative organisms provides information that is clinically useful, particularly for primary care practitioners working in the community or in outpatient clinics.

Survival after recurrence of breast cancer

Abstract: A series of 456 patients with cancer of the breast that was first diagnosed between 1961 and 1970 were studied to determine the effect of certain prognostic factors on survival after recurrence. The prognostic factors studied included those recorded at the time of initial diagnosis and at the time of recurrence. Life-table and log-rank methods were used to analyse the influence of individual prognostic factors, and the simultaneous effects of multiple factors were assessed with Cox's proportional hazards model. The analysis indicated that, in addition to the strong effect of the length of the free interval and the nature and number of sites of recurrence, variables assessed at the time of initial diagnosis -- stage and histologic subtypes of the tumour -- also influenced survival after recurrence. This supports the contention that the presenting characteristics of breast cancer reflect the underlying biologic aggressiveness of the tumour as much as the length of time the tumour has been present.

Advances in Psychosomatic Medicine

Abstract: In what case do you like reading so much? What about the type of the blunt chest trauma general principles of management book? The needs to read? Well, everybody has their own reason why should read some books. Mostly, it will relate to their necessity to get knowledge from the book and want to read just to get entertainment. Novels, story book, and other entertaining books become so popular this day. Besides, the scientific books will also be the best reason to choose, especially for the students, teachers, doctors, businessman, and other professions who are fond of reading.

Accuracy of clinical diagnosis in a Canadian teaching hospital.

Abstract: Two hundred autopsies were investigated to determine the correlation between the clinical and pathological diagnoses in three categories--major underlying disease, cause of death and significant incidental pulmonary findings. There was concurrence in diagnosis of the major underlying disease in 76% of cases, with 12% of disagreements being considered minor and 12% major. In only three cases might different management have affected the outcome had the correct diagnosis of the major underlying disease been made during life. There was concurrence of the diagnosis of the cause of death (which was often different from the underlying disease) in 64% of cases, and in 10% of cases the outcome might have been different had the clinical diagnosis been accurate. The clinical opinion that lung disease was the cause of death was confirmed at autopsy in 54% of cases, and 45% of the pulmonary causes of death as determined at autopsy had been recognized clinically. Major incidental pulmonary findings diagnosed clinically were confirmed in 76% of cases, and major pulmonary findings diagnosed at autopsy had been recognized clinically in 83%. The major sources of these discrepancies were pulmonary embolism and pneumonia. If autopsies are to play a role in patient management, clinicians will have to be made aware of discrepancies between clinical and autopsy diagnosis. The real test of efficacy would be modification of patient management for the good.