A Group-Based Training Programme for General Practitioners: A Norwegian Experience

Westin S, stensen A I, Lvslett K, Prytz J, Telje J, TelstadW and Lie A. A group-based training programme for general practitioners:a Norwegian experience. Family Practice 1988; 5: 244–252. There are approximately 3000 general practitioners in Norway,serving a population of slightly above four million people.A three year postgraduate education scheme for general practitionershas been in effect since 1973, to be replaced by a five yearvocational training programme from January 1985, making generalpractice a fully recognized specialty from that date. The educationalrequirements consist of one year of hospital training, fouryears of training in general practice, and a total of 400 hoursof course education, mainly in clinical subjects. The core elementof the training is attendance at a group-based structured educationalprogramme of two years' duration. This article describes theconcepts and content of this decentralized group-based education,as well as some of the conflicting considerations which eventuallyled to this new Norwegian model of general practice training.The first evaluation studies indicate that the educational programmehas met a long standing need among general practitioners.     

Prediction of lethal pulmonary hypoplasia and chorioamnionitis by assessment of fetal breathing

Summary. Twenty-three pregnancies with fetuses at risk for pulmonary hypoplasia were studied weekly until delivery. The amount of time spent in fetal breathing activity was recorded under controlled conditions during 1 h using real-time ultrasound. An amniotic fluid index was determined. The clinicians and the pathologist were unaware of the ultrasound findings. Eight of 23 fetuses did not breathe at the last ultrasound examination. Three babies died of pulmonary hypoplasia and two of these showed fetal breathing before birth. The three deaths were associated with rupture of the membranes at <20 weeks gestation and of ≥44 days duration. One infant developed bronchopulmonary dysplasia. The amniotic fluid index in these four pregnancies was low and the newborn infants had limb contractures. Chorioamnionitis/funisitis was noted in 13 placentas. Eight fetuses were assessed for fetal breathing within 2 days of birth. The lack of fetal breathing had sensitivity, specificity, positive and negative predictive values of 0.75 for chorioamnionitis/funisitis. In this pilot study the absence of fetal breathing was of no value in predicting lethal pulmonary hypoplasia, but was related to chorioamnionitis/funisitis. We recommend further studies of fetal breathing in relation to fetal/neonatal infections.     

EXCRETION OF BILE ACIDS IN ERYTHROBLASTOSIS FOETALIS

The excretion pattern of intramuscularly injected cholic acid-24–¹⁴C was studied for 4 days after the injection in 10 cases of erythro-blastosis (EB). Seven patients with EB and raised serum conjugated bilirubin excreted 3643% of the injected isotope in the urine, whereas the amounts of isotope in the faeces varied greatly. In 3 cases without raised serum conjugated bilirubin less isotope was recovered in the urine and always more than 10% of injected isotope was recovered in the faeces. Cholic acid-24–¹⁴C was excreted essentially unchanged in all cases but in conjugated form. In all cases of EB the urine was found to contain bile acids, chiefly cholic acid. The infants with EB associated with cholestasis excreted 4.8–132.3 μmol of these acids per day; the corresponding values in the absence of cholestasis being 0.4–0.9 μmol per day. In the infants with physiological jaundice the excretion ranged from less than 0.01 to 0.7 μmol per day; the correspondign values in the 2 patients with hyperbilirubinaemia were about 0.2 μmol per day. The infants with EB associataed with cholestasis were found to excrete as large amounts of bile acids in the urine as the infants with intrahepatic cholestasis. These findings strongly suggest that increased serum conjugated bilirubin, irrespective of the patho-genesis of the liver damage, is associated with an impaired bile acid excretion to the intestine. EB without increased serum conjugated bilirubin did not seem to alter the bile acid metabolism, since the urinary excretion of cholic acid and chenodeoxycholic acid in these cases was practically the same as in jaundiced newborn infants.     

EXCRETION OF BILE ACIDS IN EXTRAHEPATIC BILIARY ATRESIA AND INTRAHEPATIC CHOLESTASIS OF INFANCY

This series included 24 infants, 16 boys and 8 girls, who were admitted to hospital with the diagnosis of obstructive jaundice. Five of the infants were subsequently found to have extra-hepatic biliary atresia (BA) and the other 19 infants intrahepatic cholestasis of infancy (IHC). The infants were investigated given special attention to: the quantitative urinary excretion of cholic and chenodeoxycholic acids, the isotope excretion after intramuscular injection of cholic acid-24–¹⁴C, the nature of labelled urinary bile acids, the half-life and the pool size of cholic acid. At the first examination of the infants after admission the urinary excretion of cholic and chenodeoxycholic acids varied greatly between the patients. However, on comparing the values obtained in the two groups, it was found that there was virtually no difference between the mean daily values of cholic and chenodeoxycholic acids in urine, and the ratio cholic to chenodeoxycholic acid between the BA group and the IHC group. After the injection of isotopic cholic acid most of the isotope was recovered in the urine in all cases. In the infants with BA the faecal excretion of the isotope was low, being less than 3 per cent of the injected isotope. Out of the 19 infants with IHC the recovery of the injected isotope in faeces was also less than 3% in 11 infants. In 8 infants with IHC the faecal isotope excretion was significantly high to exclude extrahepatic biliary atresia. The first 24 hour urine specimen contained small amounts of unconjugated labelled cholic acid in all cases whereas in no case did the patients excrete unconjugated labelled cholic acid 48 hours after the injection of the isotope. No transformation of cholic acid was observed. There was no difference between the BA group and IHC group with regard to the percentage labelled glycine conjugates of total excreted urinary conjugates. Neither was there any difference between the two groups with regard to half-life and pool size of cholic acid. There was no difference with respect to the bile acid metabolism between infants with congenital CMV infection, decreased serum concentrations of alfal-antitrypsin and the other patients.     

Hemodynamic Effects at Rest and during Exercise in Long-term Treatment with Prazosin in Chronic Congestive Heart Failure

ABSTRACT. The long-term effects of prazosin in chronic congestive heart failure were studied in 10 patients (New York Heart Association class III-IV) in a double-blind cross-over study. Patients with systolic blood pressure > 120 mmHg and left ventricular filling pressure > 15 mmHg were included. Prazosin lowered the arteriovenous oxygen difference both at rest and during exercise (p < 0.05), increased cardiac index (p < 0.01) and reduced right atrial pressure and systemic vascular resistance (p < 0.05) during exercise. Left ventricular filling pressure was also reduced, but not significantly, during exercise. Our data show that prazosin has beneficial long-term effects during exercise in patients with chronic congestive heart failure.     

Hemostatic Factors and Renin in Greenland Eskimos on a High Eicosapentaenoic Acid Intake

ABSTRACT. The Fifth UmanaK expedition compared the fatty acid composition of platelets, bleeding times before and after ingestion of acetylsalicylic acid, 24-hour urinary tetranorpros-tanedioate, creatinine and Na output, as well as plasma renin, serum electrolytes and anti-thrombin III in 20 Greenland Eskimos and 20 Danes. The results indicate that the prostaglandin production was not inhibited in the Eskimos, and that the antiaggregatory prostanoids predominate in Eskimos compared to Danes. Although blood pressure and 24-hour urinary Na output were similar, the plasma renin level was significantly higher in the Eskimos on a high eicosapentaenoic acid intake. Acta Med Scand 1986; 219: 473–9.     

Unilateral, isometric bite force in 8-68-year-old women and men related to occlusal factors

Abstract – Unilateral bite force was studied in 63 women and 59 men, 8-68 yr of age. The subjects had a minimum of 24 teeth and no symptoms or signs of disorders of the craniomandibular system. Bite force was stronger in men (522 N) than in women (441 N). It increased with age until 25 yr ( P <0.0001). The level decreased significantly after this age in women, whereas it only tended to decrease in men and not until after 45 yr of age. Body height was positively associated with force. However, the strongest correlation (r: 0.43–0.49, p <0.01) with adult bite force was occlusal contact. The normal bite-force values with important determining factors provide reference data for screening of elevator muscle strength in routine examination of craniomandibular function.     

Hydroxocobalamin for Initial and Long-term Therapy for Vitamin B12 Deficiency

ABSTRACT. Skouby AP (Medical Department II, Municipal Hospital, Copenhagen, Denmark). Hydroxocobalamin for initial and long-term therapy for vitamin B₁₂ deficiency. Seventeen patients were treated for vitamin B₁₂ deficiency with i.m. injection of 1 mg hydroxocobalamin every three months as maintenance therapy for eight to 20 years after an initial depot treatment of one or two series of five i.m. injections on alternate days. In three of four patients given two depot series ≤3 months apart, and with no antibody to transcobalamin II (TC II) detected previously, abnormally high values of serum cobalamins were measured at the end of injection intervals after seven to 12 years. No increase in unsaturated B₁₂ binding capacity (UB₁₂BC) was found in contrast to findings in patients given identical therapy, in whom an early increase above the normal level occurred associated with antibody to TC II. One depot series followed by i.m. injection of 1 mg hydroxocobalamin every third month secured values within the normal range for serum cobalamin, UB₁₂BC and total B₁₂ binding capacity (TB₁₂BC).