Simulation modeling of change to breast cancer detection age eligibility recommendations in Ontario, 2002-2021.

PURPOSE: The purpose of this project was to demonstrate the development and use of a decision support tool based on simulation modeling of breast cancer screening to evaluate the implications for the provision of health services and the economic impact of extending routine radiographic screening for breast cancer to women in the 40-49 age group between 2002 and 2021. METHODS: The main method was computer simulation with a Markov model that used published estimates of population size by age group, breast cancer prevalence and incidence, screening program participation rate, sensitivity and specificity of the screening test and diagnostic test, stage transition probabilities, directed diagnosis rates and costs. FINDINGS: The model predicted that changes to age eligibility requirements would result in the detection of an additional 6610 women with breast cancer in Ontario requiring treatment, at an additional cost of 795 Canadian per case. These costs include those related to screening, diagnosis and initial treatment and apply to the 20-year period. CONCLUSIONS: The model provided a useful decision support tool for those planning and implementing breast cancer screening programs.

Regional variation in dental procedures among people with an intellectual disability, Ontario, 1995-2001.

BACKGROUND: The literature indicates that people with an intellectual disability have a prevalence of dental caries that is either lower than or similar to that of the general population. However, many of their caries go untreated, and extractions are more often used as a means of treatment than in the general population. A substantial percentage (40%) of day admissions to hospital of people with intellectual disabilities in Ontario is related to dental diseases. In this paper, we examine whether rates of in-hospital dental procedures are evenly distributed across Ontario and discuss possible explanations for the findings. MATERIALS AND METHOD: A retrospective analysis was made of routinely collected hospital admission data for people with an intellectual disability. Age- and gender-adjusted rates for dental procedures were calculated using the direct method of adjustment and 1996 census population estimates of Ontario. Three different summary measures for the assessment of regional variation were used. RESULTS: Two areas had dental procedure rates among those with an intellectual disability that were significantly lower than the overall Ontario rate: Hamilton-Wentworth and Quinte-Kingston and Rideau. The 3 district health council areas with the highest rates for dental procedures were Niagara, Essex-Kent and Lambton, and Durham-Haliburton-Kawartha and Pine Ridge; all 3 rates were higher than the overall Ontario rate. CONCLUSIONS: The use of day surgery and in-hospital visits to treat dental diseases in people with an intellectual disability varies considerably by region in Ontario. Observed differences may indicate inequities.

Family physician views about primary care reform in Ontario: a postal questionnaire.

BACKGROUND: Primary care reform initiatives in Ontario are proceeding with little information about the views of practicing family physicians. METHODS: A postal questionnaire was sent to 1200 randomly selected family physicians in Ontario five months after the initial invitation to join the Ontario Family Health Network. It sought information about their practice characteristics, their intention to participate in the Network and their views about the organization and financing of primary care. RESULTS: The response rate was 50.3%. While many family physicians recognize the need for change in the delivery of primary care, the majority (72%) did not expect to join the Ontario Family Health Network by 2004, or by some later date (60%). Nor did they favour capitation or rostering, 2 key elements of the proposed reforms. Physicians who favour capitation were 5.5 times more likely to report that they expected to join the Network by 2004, although these practices comprise 5% of the sample. CONCLUSIONS: The results of this survey, conducted five months after the initial offering of primary care reform agreements to all Ontario physicians, suggest that an 80% enrollment target is unrealistic.

An epidemiologically-based needs assessment for stroke services.

Stroke is amenable to the entire spectrum of health services, ranging from prevention of its risk factors, to the treatment of acute stroke and rehabilitation and palliation of stroke. The aim of this study was to determine the number of persons with the capacity to benefit from evidence-based effective stroke services. Population-based survey and registry data along with published, evidence-based recommendations for services were used to determine the number of persons in Eastern Ontario with stroke (including risk factors, acute stroke and chronic stroke) and their related need for services (including prevention programs, diagnostic services, treatment of acute stroke and rehabilitation). These estimates were then compared to the actual provision of these services. Estimates of the need for effective services exceeded the provision of all services with the exception of pharmacologic treatment for diabetes mellitus and carotid endarterectomy for acute stroke. The approach was able to identify both the under-provision and over-provision of evidence-based effective services for stroke. This study has shown that an epidemiologically-based needs assessment could be a useful basis for the planning of health services.

Do medical students have the knowledge needed to maximize organ donation rates?

INTRODUCTION: The chronic shortage of organs for donation could be improved by increasing the numbers of potential and actual donors. Physicians can play a key role in solving this problem but may miss opportunities because they lack knowledge about organ donation to answer questions or concerns. Education of physicians early in their careers may lead to better procurement rates for donor organs. We carried out a study at Queen's University in Kingston, Ont., to determine whether medical students have sufficient knowledge of topics shown to affect organ donation rates. METHODS: Medical students from years 1-4 completed a self-administered questionnaire. Section 1 tested general knowledge about organ donation; section 2 tested the students' ability to identify potential donors; and section 3 dealt with the approach to the potential donor's family. Univariate predictors of mean test scores were assessed using the t-test. RESULTS: Of 322 medical students who received the questionnaire, 260 (81%) responded. The mean age of the students was 25 years and 54% were men. The mean knowledge score was 6.7 out of a possible score of 14. Third-year students had the best knowledge scores (7.6), followed by fourth- (7.4), second- (6.6) and first-year students (5.7). Teaching about organ donation and a student's comfort with approaching a family for organ donation were also predictive of higher knowledge scores. There was no correlation between knowledge score and age, gender or whether the student was carrying a signed donor card. Knowledge scores were low in all 3 sections. Thirty-six percent of students did not know that brain death means that the patient is dead rather than in a coma. Half the medical students believed that people of certain religious groups should not be approached about organ donation. CONCLUSIONS: Medical students possess limited knowledge about organ donation topics important for maximizing procurement rates. A teaching intervention designed to target these shortcomings may be beneficial.

Organ donation: a pilot study of knowledge among medical and other university students.

BACKGROUND: Physicians' knowledge of and attitudes towards organ donation may be a factor in organ procurement rates. There is a lack of information about how Canadian medical students perceive organ donation, and what they know about it. OBJECTIVE: This pilot study assesses the knowledge and attitudes of university students toward organ donation. METHODS: Medical students completed a self-administered questionnaire after a lecture. Non-medical students completed the same questionnaire at the university student center. The questionnaire included a test that was used to assess knowledge about organ donation. Attitudes were assessed by determining whether the student carried a signed organ donor card, and their reasons if they did not. RESULTS: Of the 76 students in the first-year medical class, 39 responded. A sample of the first 40 non-medical students to visit a booth at the student centre was selected for comparative analysis. The mean age of medical students was 23.5 years; 23 for non-medical students. Of those surveyed, 56.6 per cent were women. Of medical students, 30.8 per cent reported carrying a signed card compared with 50 per cent of non-medical students. The most common reason for not carrying a card in both groups was apathy. Median test scores were 2.4/6 for both groups. Students carrying a signed card had a median test score of 2.7/6, with the median score for those not carrying signed cards being 2.2/6. CONCLUSION: More investigation of the knowledge and attitudes of medical students regarding organ donation is warranted.

MSHAKE. A tool for measuring staff knowledge related to geriatric mental health.

This article describes the development of a knowledge-screening instrument used with staff caring for elderly patients with neuropsychiatric disability. A 25-item tool, referred to as the Mary Starke Harper Aging Knowledge Exam (MSHAKE), was developed to verify knowledge competencies of 171 employees at a geropsychiatric center in the Southeastern United States. The MSHAKE assesses basic geriatric mental health knowledge in an educationally diverse health care work force. A variety of descriptive and inferential statistics provide preliminary evidence supporting the use of the MSHAKE as an effective measure of staff members' essential knowledge of aging and neuropsychiatric disorders. This tool has practical application in the clinical setting as part of a competency verification system or in-service evaluation.

Long thoracic nerve injury due to an electric burn.

A 19-year-old white man was burned over 7.5% of his body when he sustained an electric injury from a transformer. There was no associated fall or loss of consciousness. Debridement and grafting were required. The patient had some transient weakness of the muscles of his right arm associated with lower cervical nerve-root injury. This subsequently improved. He also was found to have paralysis of the serratus anterior muscle, with winging of the scapula due to long thoracic nerve injury. This has not improved. A surgical procedure suggested to improve function of the shoulder was rejected by the patient. This is only the second case reported of long thoracic nerve injury due to an electric burn of which we are aware.

Modified Hoke-Miller flatfoot procedure.

Within a relatively limited follow-up study of ten patients, the modified Hoke-Miller flatfoot operation proved effective both in removing symptoms and changing the architecture of the foot.

The role of scoliosis and pelvic obliquity on functional disability in myelomeningocele.

A retrospective analysis of 39 patients with myelomeningocele over age 16 was done to determine the effects of scoliosis and pelvic obliquity on their ambulatory ability and function. Although primarily dependent on neurologic level, prevention of an unbalanced spine and maintenance of ambulatory status also appeared to correlate closely with a curvature less than 40 degrees and a pelvic obliquity less than 25 degrees. All ambulators, regardless of neurologic level, had a pelvic obliquity of 25 degrees or less. Of the 19 ambulators, all but two had curvatures of 40 degrees or less. Ten of the 11 unbalanced sitters had a curvature of 35 degrees or more and a pelvic obliquity greater than 25 degrees. The quality of life style also appeared to correlate well with the severity of scoliosis and pelvic obliquity. Sixteen untreated patients with progressive curvatures prior to age 16 appeared to have insignificant curve progression past age 16. Twelve patients underwent posterior fusion in situ. This procedure alone is not recommended for the treatment of scoliosis associated with myelomeningocele because of the high morbidity.

The role of the nurse in the care of sexual assault victims.

In this article, a unique and comprehensive role has been described for the nurse who functions within the context of a rape counseling team. Nurses can assume a variety of nontraditional roles in facilitating the recovery of sexual assault victims. They can function as crisis intervention counselors, victim advocates with regard to law enforcement and medical personnel, as well as educators in relation to both the victim's significant other and to legal, medical, mental health personnel with whom the victim may interact. The nurse who responds to the victim in a holistic manner, fulfilling a number of nontraditional roles, can promote the victim's smooth navigation of systems involved with her care. In so doing, the nurse provides continuity of care and facilitates the victim's recovery from the trauma of sexual assault by simplifying the process of treatment.

Mixed Streptococcus pneumoniae and gram-negative bacillary pneumonia in the elderly.

Of 24 elderly patients with Streptococcus pneumoniae pneumonia confirmed by transtracheal aspiration, six had concomitant infection with gram-negative aerobic bacilli. All six patients were elderly men with underlying cardiopulmonary disease. Three had had recent prior episodes of gram-negative pneumonia and four had previously received antibiotics. The clinical, laboratory, and epidemiologic characteristics of these six patients with mixed bacterial pneumonia are reported.

Idiopathic chondrolysis of the hip.

Eight patients were seen with idiopathic chondrolysis in nine hips, with from one to eight years' follow-up. The adolescent patients showed characteristic diagnostic patterns--patients in the hip and a limp. The disease occurs most frequently in black girls and in them it tends to be more severe. Threre is progressive loss of articular cartilage, frequently progressing to flexion-adduction contracture and fibrous ankylosis. The pathological process in our patients mainly consisted of chronic synovitis and loss of articular cartilate in the weight-bearing surface of the femoral head. The patients with mild cases were satisfactorily treated with physical therapy, non-weight-bearing, and analgesics. The other hips, however, did best when allowed to undergo fibrous ankylosis with the hip in a functional position.

Hoke triple arthrodesis.

One hundred and nine cases of the Hoke triple arthrodesis which were done between 1945 and 1974 are reviewed. The results of the procedure are similar to other series insofar as correction of the deformity and the non-union rate are concerned. There was, however, an over-all incidence of aseptic necrosis of the talus of 6.5 per cent. A change in technique, in which the origin of the artery to the tarsal canal was left intact, has eliminated this complication. Excessive stress on the ankle joint as a result of the triple arthrodesis, although theoretically a problem, was not significant during follow-up of these patients. In the fourteen patients with myelomeningocele, there was acceleration of degeneration of the ankle joint, but Charcot joints did not develop.