New tuberculosis epidemic. Controversies in screening and preventive therapy.

The incidence of tuberculosis is increasing in many regions of Canada and the world. Accurate and current knowledge of screening and prevention is of utmost importance for family physicians caring for patients who might be at risk. This article presents guidelines on screening, skin testing, interpretation of results, and preventive therapy.

Prompting for cost-effective test ordering: a randomized controlled trial.

This randomized, controlled trial tests the efficacy of a computerized prompting system for test ordering. The system, makes use of the sensitivity, specificity, positive and negative predictive values of tests. It was tested using clinical vignettes in an academic family medicine center with first and second year residents. We found that there was a 38% decrease in the numbers of tests ordered (p < .01) and a 12% decrease in the costs of tests ordered by using the prompting system. We suggest that when used at the point of the patient encounter, this system has the potential for promoting more appropriate test ordering and for saving considerable health care dollars.

Prompting physicians for cost-effective test ordering in the low prevalence conditions of family medicine.

We have developed a computerized prompting system for test ordering which we feel will decrease the cost of investigations and at the same time promote an evidence based learning approach to test ordering. Prompting systems have been shown to be cost-effective but suffer from many disadvantages in the family practice setting. They tend to be difficult to modify by the user and contingent on an inflexible rule based structure. Many suggestions are ignored implying that they are not relevant. In family practice most conditions are of low prevalence. Prompting for test ordering where the pre-test likelihood of disease is small will result in a large number of false positives and many unnecessary repeat or confirmatory investigations and attendant anxiety unless the prompting system is specifically designed to be used in a low prevalence environment. PROMPTOR-FM (PRObabilistic Method of Prompting for Test ORdering in Family Medicine) was developed to overcome these perceived difficulties. It allows the physician to rapidly calculate the positive and negative predictive values of a test being considered based on the clinical index of suspicion. The physician is able to repeat the calculations and compare the results with previous calculations. By using PROMPTOR-FM repetitively, the clinician can learn to balance the risk of "missing" a rare but serious condition against the risk of falsely identifying disease with its downstream hazards and costs of further investigation. Prompting for test ordering is therefore uniquely tailored to each patient's situation.

Family practice informatics: research issues in computerized medical records.

There are unique features of family and general practice which lead to unique issues in medical informatics for family physicians. The nature of practice in office based community settings and the discipline of dealing with all ages, sexes, and health conditions over the lifetime of a patient and his/her family lead to models of the thinking that are different from those used in most other specialties. Research is urgently needed to verify the models of thinking that physicians use during patient care encounters and the associated nomenclatures and classifications which support them. User interfaces need to be optimized for accuracy and speed. Standards for medical records computing in family practice need testing and validation.

CFPC's Certification Examination: An overview.

The certification examination of the College of Family Physicians of Canada is designed to assess the extent to which the College's educational objectives have been achieved. Since the first examination in 1969, more than 7000 physicians have received their certification. The authors describe the basic elements of this test and the process through which the Committee on Examinations designs and sets the examination. The authors comment on the role of the certification process in the education of family physicians in Canada.

Spinal manipulation for low-back pain: an office procedure.

In properly selected patients, spinal manipulation is an alternative to the standard conservative approach to low-back pain. In this paper, an approach to the patient with low-back pain emphasizes the importance of a thorough history, physical examination, and diagnosis prior to manipulation. In addition to listing indications and contraindications, the authors discuss the process of selecting patients for manipulation according to pain and range of motion. Two manipulative techniques which can be easily learned and performed in the office by the family physician are described.

Comparison of injection techniques for shoulder pain: results of a double blind, randomised study.

Seventy seven patients with soft tissue shoulder lesions including adhesive capsulitis and disorders of the rotator cuff and acromioclavicular joint were admitted to a trial comparing two different methods of corticosteroid injection with local anaesthetic in a randomly allocated double blind study. The method of anatomical injection after diagnosis by the technique of selective tissue tension gave 60% success compared with the method using tender or trigger point localisation, giving 20% success (p less than 0.001).

Toxic shock syndrome: diagnosing recurrence.

Toxic shock syndrome (TSS) is not easily recognized, despite explicit criteria for diagnosis. These include fever, rash, desquamation of palms and soles, and hypotension, plus involvement of up to seven other organ systems. The disease is associated with tampon use; Staphylococcus aureus is the most likely causative organism. Recurrence with menstruation is unique to this disease, although recurrences have been reported without the use of tampons and efforts to isolate Staphylococcus aureus from cultures may prove fruitless. In this case, a 27-year-old woman experienced recurrences which could be diagnosed only by hindsight. All suspected cases should be reported to the Laboratory Centre for Disease Control in Ottawa so that a true picture of this disease may be obtained.