Preparedness for hospital practice among graduates of a problem-based,graduate-entry medical program

OBJECTIVE: To compare preparedness for hospital practice between graduates from a problem-based, graduate-entry medical program and those from other programs (undergraduate problem-based and traditional). DESIGN: Survey of graduates (by mailed questionnaire) and organisers of clinical training (by semistructured interview); results were compared with published results of surveys of graduates from other programs. SETTING AND PARTICIPANTS: All graduates of the first intake of the University of Sydney graduate-entry medical program were surveyed at the end of their first intern year (2001), along with the director of clinical training or intern manager at each of the New South Wales hospitals that employed the graduates. MAIN OUTCOME MEASURES: Graduates' self-reported level of preparedness in the eight domains of the Preparation for Hospital Practice Questionnaire; and organisers' opinions of their strengths and weaknesses. RESULTS: 76 of 108 graduates from the graduate-entry program (70%) and organisers of clinical training at all 17 hospitals participated. Graduates from the program felt more prepared than did those from other programs in five of the eight domains assessed (interpersonal skills, confidence, collaboration, holistic care, and self-directed learning) and no less prepared in any domain. Organisers rated the graduates highly, especially in clinical competence, confidence, communication and professional skills. Opinions of interns' knowledge of basic sciences conflicted, with strengths and weaknesses mentioned with equal frequency. CONCLUSION: Graduates from the graduate-entry, problem-based program are at least as well prepared for their intern year as graduates from traditional and undergraduate problem-based programs.     

High STOP-BANG questionnaire scores predict intraoperative and early postoperative adverse events

INTRODUCTION

Obstructive sleep apnoea (OSA) is the most common sleep-related breathing disorder associated with multisystemic organ involvement. The STOP-BANG questionnaire is a concise, validated questionnaire that is used to screen for OSA. This study aimed to establish the use of the STOP-BANG questionnaire for perioperative patient risk stratification.

METHODS

In this retrospective cohort study, we extracted the demographic, medical and perioperative outcome data of all patients who underwent elective surgery, excluding ophthalmic surgeries, from January to December 2011. Multivariate regression analysis was used to predict independent risk factors for intraoperative and early postoperative adverse events.

RESULTS

Of the 5,432 patients analysed, 7.4% had unexpected intraoperative and early postoperative adverse events. We found that the risk of unexpected intraoperative and early postoperative adverse events was greater in patients with STOP-BANG scores ≥ 3 compared to those with a STOP-BANG score of 0 (score 3: odds ratio [OR] 3.6, 95% confidence interval [CI] 2.1–6.3, p < 0.001; score 4: OR 3.4, 95% CI 1.8–6.5, p < 0.001; score 5: OR 6.4, 95% CI 2.7–15.0, p < 0.001; score ≥ 6: OR 5.6, 95% CI 2.1–15.4, p < 0.001). Patients with STOP-BANG scores ≥ 5 had a fivefold increased risk of unexpected intraoperative and early postoperative adverse events, while patients with STOP-BANG scores ≥ 3 had a ‘one in four’ chance of having an adverse event. Other independent predictors included older age (p < 0.001), American Society of Anesthesiologists class ≥ 2 (p < 0.003) and uncontrolled hypertension (p = 0.028).

CONCLUSION

STOP-BANG score may be used as a preoperative risk stratification tool to predict the risk of intraoperative and early postoperative adverse events.     

[Fréquence des maladies transmises sexuellement chez des étudiants universitaires.]

OBJECTIVE: To estimate the incidence rate of sexually transmitted diseases (STDs) among university students and evaluate the associated sociodemographic factors. DESIGN: Mail survey in April 1990. Included in the questionnaire were questions about the subjects' STD experience since their admission to the university and the type and date of the infection. SUBJECTS: Of the 19,682 undergraduate students 2920 subjects, in 10 groups of 292, were randomly selected. A total of 1731 (59.4%) completed the questionnaire. MAIN OUTCOME MEASURES: Estimated annualized incidence rates of genital human papillomavirus infection and Chlamydia infection. RESULTS: The estimated annualized incidence rates of genital human papillomavirus and Chlamydia infections were 2.2% and 1.5% respectively. Among the students who indicated being infected with genital human papillomavirus 59% were 18 to 21 years old (p < 0.05), 76% were women (p < 0.01) and 69% had more than one sexual partner (p < 0.01). No statistically significant associations were observed between age, sex and Chlamydia infection. On the other hand, 95% of the cases of Chlamydia infection were found among those who had more than one sexual partner (p < 0.01). CONCLUSION: University students continue to have sexual activities at risk for STDs and should be specifically targetted by general practitioners and health services in an effort to slow the spread of STDs.     

Factors associated with the decision of family physicians to provide intrapartum care.

OBJECTIVE: To investigate which characteristics and beliefs of family physicians determine their decision to provide intrapartum care. DESIGN: Confidential survey questionnaire mailed in spring 1993. SETTING: Alberta and Ontario. SUBJECTS: Random selection of 207 physicians who had graduated from medical school between 1953 and 1990 and were thought to be in family or general practice. Of 178 eligible physicians, usable replies were received from 104 (58.4%). OUTCOME MEASURES: Beliefs (measured on a 7-point Likert scale) about the relevance of 16 primary factors to the type of obstetric care provided; demographic, training and practice characteristics. RESULTS: The respondents who provided intrapartum care differed from those who did not in their beliefs about the availability of a local hospital suitable for intrapartum care (p < 0.001), their practice partners' views on the role of family physicians in providing obstetric care (p < 0.002), their own concept of the role of family physicians in providing obstetric care (p < 0.001) and women's views on the type of obstetric care they want (p < 0.002). They also differed, although less significantly, in their beliefs about the adequacy of their obstetric training before entering family practice (p < 0.04), the expected effects of providing obstetric care on their free time (p < 0.006), their fear of malpractice litigation (p < 0.028) and their perceived competence in performing practical obstetric procedures (p < 0.05). Logistic regression analysis revealed that certain secondary factors were particularly relevant to the respondents' provision of intrapartum care at present. These included the physician's perceived competence at managing postpartum maternal hemorrhage (odds ratio [OR] 48.90, 90% confidence interval [CI] 4.70 to 509), the belief that medical insurance premiums should not be affected by the type of obstetric care provided (OR 3.55, 90% CI 1.67 to 7.57]) and the number of practice partners who provided intrapartum care (OR 10.08, 90% CI 2.31 to 44.10). CONCLUSION: Several factors appear to influence family physicians in their decision to provide intrapartum care. This information will help to focus efforts to provide appropriate obstetric training for family practice residents and to retain involvement of family physicians in intrapartum care.     

Comparison of activity level and service intensity of male and female physicians in five fields of medicine in Ontario.

OBJECTIVE: To examine the extent to which physician's sex explains variation in the activity level and service intensity of a cohort of physicians in each of five medical fields after other sources of variation are taken into account. DESIGN: Data from the Ontario Ministry of Health (MOH) and the CMA were analysed by means of multivariate regression techniques for panel data. SETTING: Ontario. PARTICIPANTS: A total of 137 dermatologists, 974 general internists, 330 pediatricians and 941 psychiatrists and a random sample of 2771 family physicians and general practitioners who met the eligibility criteria. Physicians were eligible if they billed the MOH for at least three quarters in 1983, did not bill as a medical laboratory director, provided direct patient care, did not have an alternative funding arrangement with the MOH, remained in the same specialty throughout the study period (1983-90) and billed from an Ontario address. OUTCOME MEASURES: Three measures of total activity level (annual number of services provided, annual fee-for-service billings and annual mean number of patients seen per quarter) and one measure of service intensity (annual mean number of services per patient per quarter). RESULTS: Although several variables (e.g., full-time work status, age, type of practice and recent practice move) influenced the four measures examined, physician's sex contributed significantly to explaining variation in activity in 70% of the regression equations. The women provided 33.0% fewere services per year than the men in family and general practice (p < 0.001), 25.0% fewer services in general internal medicine (p < 0.01), 22.1% fewer services in pediatrics (p < 0.05) and 22.3% fewer services in psychiatry (p < 0.001). Total billings by the women in these fields were also significantly less than those of their male colleagues, the difference being greatest among the family physicians and general practitioners (28.0%) and the general internists (27.0%) (p < 0.001). The women in these four fields saw significantly fewer patients per quarter than their male colleagues, the difference being greatest in psychiatry (33.0%) (p < 0.001). Sex affected service intensity in three fields. The female psychiatrists (14.8%) (p < 0.001) and general intenists (5.5%) (p < 0.10) provided more services per quarter than their male colleagues, whereas the female family physicians and general practitioners delivered 2.2% fewer services per patient per quarter than their male colleagues (p < 0.01). In two specialties differences between women aged 40 years or less and those over 40 years were observed. In general internal medicine the younger women had higher activity levels than the older women (p < 0.01). Conversely, in dermatology the younger women had lower activity levels (p < 0.05) and provided fewer services per patient per quarter (p < 0.001) than the older women. CONCLUSIONS: Although physician's sex explained much of the variation in activity level and service intensity, even after other important correlates were controlled for, the type and extent of differences observed between female and male physicians depended on the particular medical field examined. To understand the effect of the large increase in the number of women on the physician workforce, more detailed analyses by medical field are needed of the volume, mix and intensity of services provided by men and women, with adjustment for any possible differences in the patients seen in their practices.     

Fee code creep among general practitioners and family physicians in Ontario: Why does the ratio of intermediate to minor assessments keep climbing?

BACKGROUND: "Fee code creep" is the increasing tendency of primary care physicians in Ontario to bill for more intermediate than minor assessments over time. The authors examine the extent and nature of fee code creep and describe physician characteristics associated with the changes. METHODS: A cross-sectional and longitudinal analysis of Ontario Health Insurance Plan billing and physician characteristic data was conducted for fee-for-service general practitioners and family physicians (GP/FPs) in Ontario. The ratio of intermediate to minor assessments (I-M ratio) was determined for the period 1978-79 to 1994-95, and the relation of various physician characteristics to high ratios was tested with bivariate and multivariate analysis. RESULTS: The I-M ratio rose 10-fold, from 0.3 in 1978-79 to 2.9 in 1994-95. Although the I-M ratio was higher for older patients and young children, changes in population age profile over time did not account for any of the increase. The median ratio varied widely among groups of physicians: urban physicians had higher ratios than rural ones (3.9 v. 3.0, p < 0.05), and recent graduates had higher ratios than physicians 60 years of age or older (5.1 v. 2.9, p < 0.05). The I-M ratio was inversely related to number of visits; physicians billing for fewer than 5000 visits had a median ratio of 4.2, whereas those billing for 20,000 visits or more had a median ratio of 1.6. INTERPRETATION: Fee code creep has contributed to expenditure growth in Ontario. This phenomenon was related to both an increase in I-M ratio over time among physicians practising throughout the study period and an influx of new physicians billing at a higher ratio. Creep was not the result of aging of the population.     

Negative affect moderates the link between body image dissatisfaction and disordered eating among psychiatric outpatients in a multi-ethnic Asian setting

INTRODUCTIONFew studies have investigated the factors that affect the relationship between body image dissatisfaction and disordered eating locally. Our study aimed to investigate the moderating effects of depression and anxiety levels on the body dissatisfaction-disordered eating link in Singapore.METHODSA total of 329 participants completed a set of questionnaires that included various scales pertaining to eating behaviours, body image, psychological distress and quality of life.RESULTSParticipants were diagnosed with schizophrenia (47.4%), depression (46.8%) and substance use disorders (5.8%). Moderation analyses revealed that depression (F [9, 251] = 18.50, p < 0.001, R² change = 0.021) and anxiety levels (F [9, 268] = 19.54, p < 0.001, R² change = 0.014) were significant moderators of the relationship between body dissatisfaction and disordered eating scores. Subsequent multivariate linear logistic regression analyses showed that high disordered eating scores were significantly associated with lower physical (F [8, 273] = 9.59, R² = 0.22, p < 0.001, β = −0.27, p < 0.001), psychological (F [8, 273] = 10.51, R² = 0.49, p < 0.001, β = −0.27, p < 0.001), social (F [8, 256] = 6.78, R² = 0.18, p < 0.001, β = −0.18, p = 0.004) and environment (F [8, 273] = 5.29, R² = 0.13, p < 0.001, β = −0.19, p = 0.001) quality of life scores after controlling for sociodemographic covariates.CONCLUSIONGreater effort should be dedicated to the screening of disordered eating behaviours in psychiatric outpatients presenting with greater psychological distress.     

The medical undergraduate programme at McMaster University: learning epidemiology and biostatistics in an integrated curriculum.

The medical undergraduate programme at McMaster University is a three-year integrated course in which major emphasis is placed upon self-directed, problem-based learning. Group tutorials are the major meeting place for students, and there are very few formal lectures. In this paper we describe the curriculum in broad outline and the way in which epidemiology and biostatistics have been incorporated into it in the past seven years.     

Regionalized delivery and variable utilization of coronary artery bypass grafting in Ontario from 1981 to 1991.

OBJECTIVE: To analyse the geographic variation in the rates of coronary artery bypass grafting (CABG) between 1981 and 1991. DESIGN: Retrospective study of discharge abstracts (from the provincial hospital discharge database) for odd fiscal years. SETTING: Ontario. PARTICIPANTS: All Ontario residents undergoing CABG between 1981 and 1991. OUTCOME MEASURES: Age- and sex-standardized median, maximum and minimum (plus 25th and 75th percentile) rates of CABG per 100,000 population aged 20 years and over, as well as interregional variation. RESULTS: The median rate of CABG rose from 46.2 to 72.7 per 100,000 adults between 1981 and 1991. The minimum rate varied from 1.9 to 12.4 per 100,000 and the maximum rate from 110.4 to 172.1 per 100,000 during the study period. Variations in the area-specific rates were significant in all years (p < 0.0001, based on the likelihood ratio chi 2 test after adjustment for age and sex). None of the four summary statistical measures showed any obvious diminution between 1981 and 1989, nor was there a change in the utilization pattern during the waiting-list crisis years of 1987 and 1989. However, the summary measures did reach their lowest level in 1991. The relative consistency of local practice patterns was tested by means of ranking area-specific rates and comparing the rankings for different years. Correlation coefficients varied from 0.50 to 0.82 (p < 0.0001); the correlation coefficient for 1991 on 1981 was 0.61 (p < 0.0001). CONCLUSIONS: Consistent and marked variations in the use of CABG existed across the counties of Ontario from 1981 to 1991. Despite a major expansion in provincial caseload capacity and planned regionalization of CABG as a surgical service, incremental resources were apparently not allocated in a manner that reduced interregional discrepancies.     

Physical activity and sedentary behaviour of ambulatory older adults in a developed Asian community: a cross-sectional study

INTRODUCTION:Physical activity (PA) and sedentary behaviour (SB) independently influence the health outcomes of older adults. Both provide interventional opportunities for successful ageing. We aimed to determine levels of PA and SB in ambulatory older adults and their associated factors in a developed Asian population known for its longevity.METHODS:We conducted a cross-sectional observational study in a Singapore public primary healthcare centre. Multi-ethnic Asian adults aged ≥ 60 years took an interviewer-administered questionnaire survey. PA and SB were assessed using the Physical Activity Scale for the Elderly (PASE; score range 0 to > 400) and the Sedentary Behaviour Questionnaire for the Elderly, respectively.RESULTS:Among 397 participants (50.9% female; 73.2% Chinese; 47.9% aged ≥ 70 years; 33.5% employed, including voluntary work), 58.7% had ≥ 3 chronic illnesses and 11.1% required walking aids. The median PASE score was 110.8 (interquartile range 73.8–171.6) and decreased significantly with increasing age. Higher PASE score was associated with higher educational level, employment, independent ambulation without aid, and fewer chronic illnesses (p < 0.01). Employment status significantly influenced PASE score (β = 84.9, 95% confidence interval [CI] 66.5–103.4; p < 0.01). 37.0% spent ≥ 8 hours daily on sedentary activity and were twice as likely to do so if they were employed (odds ratio 2.19, 95% CI 1.34–3.59; p < 0.01).CONCLUSION:The PA of the older adults decreased with increasing age and increased with employment. One-third of them were sedentary for ≥ 8 hours daily. Those who were employed were twice as likely to have SB.     

The delay to thrombolysis: an analysis of patient and hospital characteristics

OBJECTIVE: To describe the various components of the delay to thrombolytic treatment for patients with acute myocardial infarction (MI) and to identify the hospital and patient characteristics related to these delays. DESIGN: Cohort analysis from a hospital registry of patients receiving thrombolytic treatment. SETTING: Forty acute care hospitals in Quebec. SUBJECTS: All 1357 patients who received thrombolysis between January 1995 and May 1996. MAIN OUTCOME MEASURES: Time from onset of symptoms to arrival at hospital and the various components of the in-hospital delay. RESULTS: The median delay before presentation to hospital was 98 (interquartile range [IR] 56 to 180) minutes and was longer for women (p < 0.001), patients over 65 years of age (p < 0.001) and patients with diabetes mellitus (p < 0.01). The median time from arrival at hospital to thrombolysis was 59 (IR 41 to 89) minutes, the medical decision-making component taking a median of 12 (IR 4 to 27) minutes. Women (p < 0.005), older patients (p < 0.001) and patients with a past history of MI (p < 0.001) had increased in-hospital delays to thrombolysis. Delays were longer in community hospitals (p < 0.05) and low-volume centres (p < 0.01) and when a cardiologist made the decision to administer thrombolysis (p < 0.001). Multivariate analysis showed that increased age (odds ratio 1.5, 95% confidence interval 1.3 to 1.7, p < 0.001) and having the medical decision made by a cardiologist (odds ratio 1.8, 95% confidence interval 1.6 to 2.0, p < 0.001) were independently associated with an increased risk of being in the upper median of in-hospital delays. CONCLUSIONS: Despite certain improvements, there remain substantial delays between symptom onset and the administration of thrombolysis for patients with acute MI. A large part of the delay is due to the hesitation of patients (particularly women, older patients and patients with diabetes) to seek medical attention. Although the median time for medical decision-making appears reasonable, care must be taken to ensure that all patient groups receive timely evaluation and therapy. The delay associated with having the treatment decision made by a cardiologist probably represents a marker for more difficult, complex cases. Methods should be developed to permit specialty consultation, if needed, while minimizing treatment delays. Community and low-volume hospitals may require special attention.     

Improving medical undergraduate trauma education through the Trauma Evaluation and Management programme at Mona

This study examines the potential role of the Trauma Evaluation and Management (TEAM) programme in the undergraduate curriculum for medical students in Jamaica. Thirty-two final year medical students were randomly assigned to two groups of 16. One group (No TEAM) completed two 20-item multiple choice question (MCQ) examinations on trauma resuscitation topics. The second group (TEAM group) completed the first 20-item MCQ. The TEAM manual was then distributed to both groups. After the TEAM programme for both groups, the TEAM group had the second MCQ examination. Unpaired "t" tests were used for in-between group and paired "t" tests for between group comparisons with p < 0.05 being considered statistically significant. Both groups completed a post-course questionnaire rating five items on a scale of one to five. The No TEAM group showed no difference in mean scores between the 1st and 2nd tests (55.3% in the 1st test to 52.2% in the 2nd test, p = 0.32). The TEAM Group improved their MCQ scores from 53.1% pre-module to 69.4% post-module (p < 0.001). A score of four of five was assigned by 28 students for the statement that the objectives were met, that trauma knowledge was improved and that there was overall satisfaction; by 17 students that clinical trauma skills were improved and 29 students that TEAM should be mandatory in the undergraduate curriculum. The TEAM programme improved trauma knowledge skills among senior medical students in Jamaica. The questionnaire results suggested enthusiasm for the programme and that it be made mandatory in the senior undergraduate medical curriculum.     

Skipping Breakfast is Correlated with Obesity

Objective: Despite the fact that the total energy intake of Japanese people has decreased, the percentage of obese people has increased. This suggests that the timing of meals is related to obesity. The purpose of the study was to investigate the relationship between the timing of meals and obesity, based on analyses of physical measurements, serum biochemical markers, nutrient intake, and lifestyle factors in the context of Chrononutrition.Participants and Methods: We analyzed data derived from 766 residents of Toon City (286 males and 480 females) aged 30 to 79 years who underwent detailed medical examinations between 2011 and 2013. These medical examinations included. (1) physical measurements (waist circumference, blood pressure, etc.); (2) serum biochemical markers (total cholesterol, etc.); (3) a detailed questionnaire concerning lifestyle factors such as family structure and daily habits (22 issues), exercise and eating habits (28 issues), alcohol intake and smoking habits; (4) a food frequency questionnaire based on food groups (FFQg); and (5) a questionnaire concerning the times at which meals and snacks are consumed.Results: The values for body mass index (BMI) and waist circumference were higher for participants who ate dinner less than three hours before bedtime (<3-h group) than those who ate more than three hours before bedtime (>3-h group). The Chi-square test showed that there was a significant difference in eating habits, e.g., eating snacks, eating snacks at night, having dinner after 8 p.m., and having dinner after 9 p.m., between the <3-h group and the >3-h group. Multiple linear regression analysis showed that skipping breakfast significantly influenced both waist circumference (β = 5.271) and BMI (β = 1.440) and that eating dinner <3-h before going to bed only influenced BMI (β = 0.581).Conclusion: Skipping breakfast had a greater influence on both waist circumference and BMI than eating dinner <3-h before going to bed.     

Management of the early and late presentations of rheumatoid arthritis: a survey of Ontario primary care physicians.

OBJECTIVE: To examine primary care physicians' management of rheumatoid arthritis, ascertain the determinants of management and compare management with that recommended by a current practice panel. DESIGN: Mail survey (self-administered questionnaire). SETTING: Ontario. PARTICIPANTS: A stratified computer-generated random sample of 798 members of the College of Family Physicians of Canada. OUTCOME MEASURES: Proportions of respondents who chose various items in the management of two hypothetical patients, one with early rheumatoid arthritis and one with late rheumatoid arthritis. Scores for investigations, interventions and referrals for each scenario were generated by summing the recommended items chosen by respondents and then dividing by the total number of items recommended in that category. The scores were examined for their association with physician and practice characteristics and physician attitudes. RESULTS: The response rate was 68.3% (529/775 eligible physicians). Recommended investigations were chosen by more than two thirds of the respondents for both scenarios. Referrals to physiotherapy, occupational therapy and rheumatology, all recommended by the panel, were chosen by 206 (38.9%), 72 (13.6%) and 309 (58.4%) physicians respectively for early rheumatoid arthritis. These proportions were significantly higher for late rheumatoid arthritis (p < 0.01). In multiple regression analysis, for early rheumatoid arthritis, internship or residency training in rheumatology was associated with higher investigation and intervention scores, for late rheumatoid arthritis, older physicians had higher intervention scores and female physicians had higher referral scores. CONCLUSIONS: Primary care physicians' investigation of rheumatoid arthritis was in accord with panel recommendations. However, rates of referral to rheumatologists and other health care professionals were very low, especially for the early presentation of rheumatoid arthritis. More exposure to rheumatology and to the role of physiotherapy, occupational therapy and social work during primary care training is strongly recommended.     

Serum S100β as a predictor of severity and outcomes for mixed subtype acute ischaemic stroke

INTRODUCTIONSerum S100β levels are mostly used for predicting outcomes of large-vessel stroke. Its application to mixed subtypes of acute ischaemic stroke (AIS) has been limited.METHODSPatients with mixed subtypes of AIS who were aged over 18 years and presented within 24 hours of stroke onset were consecutively enrolled. Serum S100β levels at presentation (S100β_b) and 72 hours (S100β_72hrs), and corresponding National Institutes of Health Stroke Scale (NIHSS_b and NIHSS_72hrs, respectively) scores were assessed. Stroke outcomes were evaluated using the modified Rankin Scale (mRs) at 30 days (mRs₃₀) and 90 days (mRs₉₀). Correlations between S100β_b and S100β_72hrs, as well as differences between the two (∆S100β) and the corresponding NIHSS, mRs₃₀ and mRs₉₀ scores, were evaluated (p < 0.05).RESULTS35 patients were eligible for analysis. On univariate analysis, stroke outcomes had a significant association with S100β_b, S100β_72hrs, NIHSS_b, NIHSS_72hrs and ∆S100β. Both S100β_b and S100β_72hrs correlated with corresponding NIHSS values (ρ_b = 0.51, p < 0.001; ρ_72hrs = 0.74, p < 0.001), mRs₃₀ (ρ_b = 0.58, p < 0.001; ρ_72hrs = 0.72, p < 0.001) and mRs₉₀ (ρ_b = 0.51, p = 0.002; ρ_72hrs = 0.68, p < 0.001). Correlations existed between ∆S100β and mRs₃₀ (ρ = 0.74, p < 0.001) and mRs₉₀ (ρ = 0.71, p < 0.001). Practical cut-off points for unfavourable outcomes (mRs 3–6) were S100β_72hrs > 0.288 µg/L (sensitivity 92.3%, specificity 86.4%) and ∆S100β > 0.125 µg/L (sensitivity 100%, specificity 81.8%).CONCLUSIONHigh serum S100β is associated with unfavourable outcomes for mixed subtype AIS. Cut-off values of S100β_72hrs and ∆S100β were optimal for predicting unfavourable stroke outcomes.     

以问题为基础的学习方法在全科医学规范化培训内科教学中的应用

将52名参加全科医学规范化培训的住院医师学员随机分为以问题为基础的学习（PBL）教学组和传统教学组,各26名,分别采用PBL教学方法和传统的课堂授课教学方法,进行全科医学内科学授课。采用调查问卷和理论考核相结合的形式,评价PBL教学组和传统教学组学员的教学效果。结果显示：PBL教学组学员对PBL的整体评价较高,认为此教学方式能提高解决问题的能力、改善学习积极性等;PBL教学组学员在病例分析题考试中成绩平均为（73．7±4．1）分,显著优于传统教学组的（71．1±4．8）（P〈0．05）。提示,PBL教学在全科医学规范化培训的内科教学中较传统教学有更好的教学效果。     

Efficacy and safety of finasteride therapy for benign prostatic hyperplasia: results of a 2-year randomized controlled trial (the PROSPECT study). PROscar Safety Plus Efficacy Canadian Two year Study.

OBJECTIVE: To evaluate the efficacy and safety of 2 years' treatment of moderate benign prostatic hyperplasia (BPH) with finasteride. DESIGN: Double-blind, parallel-group, placebo-controlled, multicentre, prospective randomized study. SETTING: Outpatient care in 28 centres across Canada. PARTICIPANTS: Men aged 45 to 80, in good health, with moderate BPH and no evidence of prostate cancer. A total of 613 men were entered into the study; 472 completed the 2 years of treatment. INTERVENTION: After 1 month of receiving a placebo (run-in period), patients were given either finasteride (5 mg/d) or a placebo for 2 years. OUTCOME MEASURES: Efficacy: changes from baseline in BPH symptom scores, maximum urinary flow rates and prostate volume. Safety: onset, course and resolution of all adverse events during the treatment period. RESULTS: In the efficacy analyses the mean BPH symptom scores decreased 2.1 points (from 15.8 to 13.7) in the finasteride group, as compared with a decrease of 0.7 points (from 16.6 to 15.9) in the placebo group (P < or = 0.01). The maximum urinary flow rate increased by a mean of 1.4 mL/s (from 11.1 to 12.5 mL/s) in the finasteride group, as compared with an increase of 0.3 mL/s (from 10.9 to 11.2 mL/s) in the placebo group (p < or = 0.01). The mean prostate volume decreased by 21% (from a mean volume of 44.1 cm3 at baseline) in the treatment group; it increased by 8.4% (from a mean volume of 45.8 cm3 at baseline) in the placebo group (p < or = 0.01). In the safety analysis, the proportion of patients who experienced any adverse event was similar in the two groups (81.0% in the treatment group and 81.2% in the placebo group). However, the incidence of adverse events related to sexual dysfunction were significantly higher in the finasteride group than in the placebo group (ejaculation disorder 7.7% v. 1.7% and impotence 15.8% v. 6.3%; p < or = 0.01 for both parameters). CONCLUSION: Finasteride is a well-tolerated and effective alternative to watchful waiting in the treatment of moderate BPH.     

Effect of Pilates exercises on postpartum maternal fatigue

INTRODUCTION

Postpartum fatigue is a pervasive phenomenon and often affects mothers immediately after delivery. The present study aimed to assess the effect Pilates home exercises had on postpartum maternal fatigue.

METHODS

A total of 80 women participated in our clinical trial study. The women were randomly divided into two groups – the intervention group (n = 40) and the control group (n = 40). In the intervention group, the women performed Pilates exercises five times a week (30 min per session) for eight consecutive weeks. The first session was conducted 72 hours after delivery. The control group did not receive any intervention. Each woman’s level of fatigue was evaluated at hospital discharge (as a baseline), and at four and eight weeks after delivery, using the standard Multidimensional Fatigue Inventory (MFI-20) questionnaire and repeated measures analysis.

RESULTS

During the eight weeks of follow-up, we found that the intervention group had lower mean MFI-20 scores than the control group with regard to general fatigue (7.80 ± 2.07 vs. 12.72 ± 1.79; p < 0.001), physical fatigue (7.12 ± 1.41 vs. 10.42 ± 2.02; p < 0.001), reduced activity (6.95 ± 1.35 vs. 11.27 ± 1.70; p < 0.001), reduced motivation (6.20 ± 1.01 vs. 9.80 ± 2.04; p < 0.001) and mental fatigue (6.85 ± 1.45 vs. 10.72 ± 1.98; p < 0.001).

CONCLUSION

The present study’s findings show that physical exercise can significantly reduce postpartum maternal fatigue in all subscales.     

Recent trends in infant mortality rates and proportions of low-birth-weight live births in Canada

OBJECTIVE: To identify spatial patterns of changes in infant mortality rates and proportions of low-birth-weight live births observed in 1994. SETTING: Canada. SUBJECTS: Live births and infant deaths in Canada between 1987 and 1994. Data for Newfoundland were unavailable for 1987 through 1990. OUTCOME MEASURES: Annual infant mortality rates (crude and after excluding live newborns weighing less than 500 g); proportion of live births by low-birth-weight category (500-2499 g). RESULTS: Nova Scotia, New Brunswick, Quebec and Manitoba had lower crude and adjusted infant mortality rates in 1994 than in 1993. Newfoundland, Saskatchewan, Alberta and British Columbia had higher rates in 1994 than in 1993. The crude rate in Ontario was lower, and the adjusted rate higher, in 1994 than in 1993. A downward trend in the proportion of low-birth-weight live births was observed in Quebec (chi(2) for trend = 29.2, p < 0.01). Conversely, an upward trend was observed in Ontario (chi(2) for trend = 241.3, p < 0.01). However, the increase may have been due to data errors, especially in 1993 and 1994, involving truncation of ounces in 2 digits to 1 digit (e.g., 5 pounds 10 ounces became 5 pounds 1 ounce). CONCLUSIONS: Although the marginal increases in infant mortality observed in several provinces could be the result of random variation, future trends should be closely monitored. The proportion of low-birth-weight live births in Canada (excluding Ontario) appears to be stable, with Quebec showing significant reductions. The errors in data for Ontario need to be corrected before trends can be estimated for that province and for Canada as a whole.     

Sudden unexpected death in the emergency department: caring for the survivors.

OBJECTIVE: To determine whether emergency department staff met the needs of the next of kin and close friends ("survivors") of patients dying in an emergency department and to assess the effectiveness of a program to improve care of survivors. DESIGN: Mail survey before and after program implementation. SETTING: Emergency department of a tertiary care, adult teaching hospital. PARTICIPANTS: Two groups of survivors, identified through a review of emergency department records of deaths during two 6-month periods. In the first group, surveyed in 1987, before program implementation, 26 (53%) of 49 responded; in the second group, surveyed in 1990, after program implementation, 40 (70%) of 57 responded. INTERVENTIONS: A structured, multidisciplinary protocol for notifying next of kin of death and supporting the survivors was implemented. An educational program was provided to all emergency department staff. An information pamphlet was created and provided to survivors. MAIN OUTCOME MEASURES: Questionnaire responses regarding the adequacy and timeliness of information provided, the support and actions by emergency department staff and the survivors' desire to be present during resuscitation efforts. RESULTS: Comparison of responses before and after program implementation showed that adequate information was provided before notification of death in 32% and 83% of cases respectively (p < 0.001), lengthy delays in receiving medical information occurred in 60% and 15% of cases (p < 0.01), adequate medical information concerning the events of death was provided in 53% and 88% (p < 0.05), the presence of emergency department staff was sufficient in 40% and 79% (p < 0.01), survivors spent less than 2 hours in the emergency department in 50% and 81% (p < 0.05), and survivors expressed a desire to be present during resuscitation efforts in 95% and 11% of cases (p < 0.001). CONCLUSION: The grievous experience of learning that a loved one has suddenly and unexpectedly died in the emergency department can be alleviated somewhat by a structured, multidisciplinary approach combined with staff sensitization and education.