No psychiatry? Assessment of family medicine residents' training in mental health issues.

OBJECTIVE: To assess whether the mental health component of the family medicine residency program at Memorial University of Newfoundland, which contains no formal mental health training with psychiatrists, adequately prepares residents for practice, and to assess which aspects of their training enhanced their mental health skills most. DESIGN: Cross-sectional mailed survey. SETTING: A 2-year family practice residency program with a focus on training for rural practice offering integrated and eclectic multidisciplinary mental health training rather than formal psychiatry experience. PARTICIPANTS: Graduates of the family practice residency program, 1990 to 1995. Completed questionnaires were returned by 62 of 116 physicians. MAIN OUTCOME MEASURE: Confidence of respondents in dealing with 23 mental health problems. RESULTS: Respondents felt prepared to address most of the mental health needs of their patients. Higher levels of confidence were associated with lower referral rates. There was no significant relationship between time spent in practice and confidence in dealing with mental health problems. Graduates' confidence correlated with areas in the program identified as strong. CONCLUSIONS: The program appears to train family doctors effectively to meet the mental health needs of their patients.

Occult lifelong persistence of infectious hepadnavirus and residual liver inflammation in woodchucks convalescent from acute viral hepatitis.

Traces of hepatitis B virus (HBV) genome can persist for years following recovery from hepatitis B. To determine overall duration, molecular characteristics, and pathological implications of this serologically undetectable form of hepadnaviral carriage, we have analyzed the expression of transcriptionally active virus genomes, their infectivity, and examined liver alterations during the natural lifespan of woodchucks convalescent from acute infection with HBV- related woodchuck hepatitis virus (WHV). In this study, we document lifelong persistence of scanty amounts of replicating virus both in the liver and lymphatic system after spontaneous resolution of an episode of experimental hepadnaviral hepatitis. Antibodies to virus nucleocapsid (core) were found to be the most reliable immunovirological marker coexisting with occult infection. In the majority of convalescent woodchucks, serial liver biopsies showed protracted minimal to mild necroinflammation with periods of normal morphology; however, hepatocellular carcinoma (HCC) ultimately developed in 2 of 9 animals studied. Inocula derived from lymphoid cells of convalescent animals induced classical acute hepatitis in virus-naive woodchucks that progressed to chronic hepatitis and HCC in 1 of the animals, demonstrating infectivity and pathogenic competence of the carried virus. Our results reveal that low levels of infectious WHV and residual hepatic inflammation usually continue for life after resolution of hepatitis and that this recovery does not avert HCC development. They also demonstrate that, in addition to the liver, the lymphatic system is the site of the occult lifelong maintenance of replicating hepadnavirus.

Are rural general practitioner--obstetricians performing too many prenatal ultrasound examinations? Evidence from western Labrador.

OBJECTIVE: To determine the frequency of prenatal ultrasonography (PNU) in western Labrador in 1994, assess the appropriateness of the ultrasound examinations according to current guidelines and determine whether there was any relation between number of PNU examinations and patient management and obstetric outcomes. DESIGN: Review of all obstetric charts and PNU requisition forms for all deliveries in one hospital in 1994. SETTING: Labrador City and Wabush, Newfoundland. RESULTS: During the study period, there were 103 singleton deliveries, and these mothers underwent a total of 225 PNU studies (mean 2.16 studies per delivery). More than half (53.3%) of the examinations were classified as inappropriate. There were no significant differences in the number of studies between low- and high-risk pregnancies or between uncomplicated deliveries and those in which induction or instrumental or operative delivery occurred, nor was there any relation between number of PNU examinations and maternal or neonatal outcome. CONCLUSION: Compared with PNU use as recommended by the Canadian Task Force on the Periodic Health Examination, this type of examination was overused in Labrador City and Wabush, although the rate of use was comparable to that reported in other Canadian studies. This overuse was not associated with any identifiable effect on maternal or neonatal outcome or on the management of pregnancy and labour. More judicious use of PNU, in accordance with evidence-based guidelines, is recommended.

The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review.

OBJECTIVE: To assess the evidence for the effectiveness of clinical practice guidelines (CPGs) in improving patient outcomes in primary care. DATA SOURCES: A search of the MEDLINE, HEALTHPLAN, CINAHL and FAMLI databases was conducted to identify studies published between Jan. 1, 1980, and Dec. 31, 1995, concerning the use of guidelines in primary medical care. The keywords used in the search were "clinical guidelines," "primary care," "clinical care," "intervention," "randomized controlled trial" and "effectiveness." STUDY SELECTION: Studies of the use of CPGs were selected if they involved a randomized experimental or quasi-experimental method, concerned primary care, were related to clinical care and examined patient outcomes. Of 91 trials of CPGs identified through the search, 13 met the criteria for inclusion in the critical appraisal. DATA EXTRACTION: The following data were extracted, when possible, from the 13 trials: country and setting, number of physicians, number of patients (and the proportion followed to completion), length of follow-up, study method (including random assignment method), type of intervention, medical condition treated and effect on patient outcomes (including clinical and statistical significance, with confidence intervals). DATA SYNTHESIS: The most common conditions studied were hypertension (7 studies), asthma (2 studies) and cigarette smoking (2 studies). Four of the studies followed nationally developed guidelines, and 9 used locally developed guidelines. Six studies involved computerized or automated reminder systems, whereas the others relied on small-group workshops and education sessions. Only 5 of the 13 trials (38%) produced statistically significant results. CONCLUSION: There is very little evidence that the use of CPGs improves patient outcomes in primary medical care, but most studies published to date have used older guidelines and methods, which may have been insensitive to small changes in outcomes. Research is needed to determine whether the newer, evidence-based CPGs have an effect on patient outcomes.

Care of patients with type II diabetes: a study of family physicians' compliance with clinical practice guidelines.

BACKGROUND: Most patients with type II diabetes mellitus receive care by family physicians. The goals of this study were to determine the level of diabetes care provided by family physicians; to assess family physicians' compliance with the Canadian Diabetes Association (CDA) guidelines; and to examine relationships between various aspects of diabetes care and glycemic control. METHODS: A retrospective medical chart review was conducted of 118 patients with type II diabetes mellitus in 10 family practice clinics in Newfoundland. The study population consisted of 55 male and 63 female patients with a mean age of 64 (range 29 to 88) years. Using standardized forms based on the CDA guidelines, information about plasma glucose and lipid levels, presence of diabetes complications, and physician management practices were extracted from patient charts. The main outcome measure was glycosylated hemoglobin (HbA1c) levels. RESULTS: Only 53% patients had HbA1c measurements done in the previous year; these persons had a significantly longer duration of diabetes that those who did not have their HbA1c measured. Eighty-seven percent of patients had optimal or good plasma glucose levels. Compliance with CDA guidelines by physicians was poor; physicians were doing about half the recommended checks and procedures. CONCLUSIONS: Data from the present study seem to suggest that family physicians are doing a good job of providing care for their patients with type II diabetes. The results, however, should be interpreted with caution until further research is done to replicate our findings because of the limitations of this small retrospective study.