Patients with eating disorders. How well are family physicians managing them?

OBJECTIVE: To assess the attitudes and behaviour of family physicians toward patients with eating disorders (EDs) and to assess these physicians' ongoing learning needs. DESIGN: Confidential survey by mail. SETTING: Family practices in London, Ont. PARTICIPANTS: Two hundred thirty-six general FPs. MAIN OUTCOME MEASURES: Proportion of FPs seeing patients with EDs, screening and management practices, learning needs. RESULTS: Survey response rate was 87.7%; 64% of respondents were male, 36% were female, and 54% had completed a family medicine residency program. Overall, FPs were more comfortable with diagnosis, and less comfortable with management, of EDs. Most respondents shared care with other professionals, usually psychiatrists and nutritionists. Female physicians had identified a larger number of ED patients in their practices and were more likely to screen routinely for EDs. Three quarters of FPs rated their undergraduate training in EDs as poor, and 59% thought their postgraduate training was poor. Outpatient services, diagnostic issues, screening needs, and management planning were identified as important learning needs. Family physicians thought these needs could be best addressed in interactive workshops or peer-led case-discussion groups. CONCLUSION: Family physicians are important in first-line treatment of EDs, but many barriers prevent effective diagnosis and management. Validated screening tools and management strategies could assist FPs in caring for patients with EDs.

Cognitive impairment after head injury.

Cognitive impairment is common after head injury, even when the injury has been minor and does not require inpatient assessment or management. The intellectual deficit is maximal in the first week after injury and tends to resolve spontaneously within three or four weeks. It may, however, still be present six months or longer after the injury. Neuropsychologic testing is required to detect subtle cognitive deficits that may nevertheless have far-reaching effects. Cognitive impairment after head injury has specific implications for family physicians, team physicians, educators and athletic coaches.

Abnormal eating attitudes: prevalance at a canadian university.

The authors conducted a survey of the prevalence of abnormal eating attitudes and behaviours among all women undergraduates living in on-campus residences at Queen's University and systematic samples of men and women undergraduates living in off-campus residences, using the Eating Attitudes Test-26 (EAT-26) as the study instrument. The results, although comparable to those of similar studies at other universities and colleges, are unusual in that they identify a group of high scoring respondents who did not return to Queen's University the year following the study.Of 1,982 students surveyed, 1,082 were women living in on-campus residences, 450 were women living in off-campus accommodation and 450 were men also living off-campus. The off-campus groups were matched with the on-campus groups for program and year.The response rate was 50.6%. Of these respondents, 14.7% had scores of 20 or more on the EAT-26; scores typical of those reached by persons sufferering from eating disorders. Both groups of women had the same prevalence of high scorers (16.8%), while the prevalence of high scores in male students was 2.7%. Of 16 high scorers clinically interviewed, 13 (81.3%) fulfilled diagnostic criteria for eating disorders.

Pseudoseizures: a real problem!

Introduction of new anticonvulsants, widespread use of serum anticonvulsant-level measurement, and availability of equipment for simultaneous video-electroencephalogram (EEG) monitoring have shown that not everyone who has seizures has epilepsy, even when other medical conditions have been excluded. Non-epileptic seizures, or pseudoseizures, occur in 20% of patients with conversion syndromes and can be difficult to diagnose and treat. Patients with pseudoseizures do not respond to anticonvulsants, may display paradoxical reactions to prescribed treatment regimens, and may develop abnormal neurological signs as a result of anticonvulsant toxicity. Both epileptic and non-epileptic patients may suffer pseudoseizures, which should be suspected when seizures, which should be suspected when seizure control is unpredictable or difficult, or when ictal or post-ictal EEGs are normal and psychopathology is present. Video-EEG monitoring is the "gold standard" of pseudoseizure diagnosis. A case history illustrates how difficult the clinical diagnosis can be, and how useful a normal post-ictal EEG can be when the etiology of a seizure disorder is obscure.

Treating teens tactfully.

Providing medical care for young adults is both demanding and rewarding. Young adults are past the age when congenital defects are lethal or crippling and not yet at the stage where degenerative diseases are clinically significant. Tact, discretion, empathy and humour are necessary to deal with the issues of autonomy, sexuality, urgency and immediacy, privacy and confidentiality, and the inappropriate use of health-care resources which accompany young adults' health-care needs. The rewards are the opportunities to practise preventive medicine and exert a beneficial influence on the lifestyles of young people who are going to be society's leaders of the future.

Was Mary, Queen of Scots, anorexic?

Medical historians have traditionally believed that Mary, Queen of Scots, suffered from gastric ulceration which began when she was aged thirteen years. More recent evidence indicates that she may have suffered from porphyria with her first severe attack occurring when she was aged twenty four years. The medical history of Queen Mary's teenage years is reviewed and thought to be compatible with a diagnosis of anorexia nervosa. A brief outline of the historical awareness, diagnostic criteria and epidemiological aspects of anorexia nervosa supports this view.

Diagnosing infectious mononucleosis.

Infectious mononucleosis can be diagnosed with certainty only when suggestive clinical findings are corroborated by relative and absolute lymphocytosis, lymphocyte atypia of more than 20 percent and a positive serologic test. A serologic test is not absolutely necessary when atypical lymphocytes exceed 40 percent since this is specific to infectious mononucleosis. The diagnosis is difficult when clinical findings are scanty and the blood picture is unhelpful.

Abrupt cessation of nadolol therapy: a cause of the discontinuation syndrome.

Abrupt cessation of antihypertensive drug therapy is potentially hazardous, especially when beta blocker drugs are suddenly withdrawn from patients with ischemic heart disease, when unstable angina, myocardial infarction and sudden death may result. A milder 'discontinuation syndrome' may follow abrupt cessation of many drugs commonly used to treat hypertension. The syndrome consists of symptoms and signs suggesting sympathetic nervous system overactivity, with or without an accompanying rise in blood pressure. If this rise occurs, pre-treatment levels may be reached or even exceeded. Treatment of this condition is simple once it is recognized. Reintroduction of the drug or drugs in question, perhaps in reduced dosage, is effective management and guidelines are suggested for the safe withdrawal of antihypertensive drug therapy where it is medically indicated. Nadolol (Corgard) has not previously been reported as a cause of the discontinuation syndrome. A case is described where abrupt cessation of nadolol provoked unusually prolonged and severe signs of sympathetic overactivity on two occasions in the same patient.

Chlamydia trachomatis and the fitz-hugh-curtis syndrome.

Right upper abdominal pain in the presence of pelvic inflammatory disease is called Fitz-Hugh-Curtis syndrome. It is due to perihepatitis secondary to transperitoneal spread of Neisseria gonorrhoeae or Chlamydia trachomatis. Twenty-five percent of all patients present with right upper abdominal pain as their sole complaint. In order to recognize and manage Fitz-Hugh-Curtis syndrome, the clinician must carefully consider that young, sexually active women may have occult pelvic inflammatory disease. A case history demonstrates how clinical recognition allows effective management before the results of laboratory investigations are available. The Fitz-Hugh-Curtis syndrome is readily treated with conventional antibiotic regimens.

Diagnosing infectious mononucleosis: avoiding the pitfalls.

Infectious mononucleosis may be diagnosed with confidence only when Hoagland's diagnostic criteria have been met. The illness must be compatible with the known clinical features of infectious mononucleosis; there should be absolute and relative lymphocytosis on differential white cell count; there should be more than 20% atypical lymphocytes and serological tests should be positive-either a Paul-Bunnell Davidsohn or a rapid slide test for heterophil antibody. Failure to diagnose this common viral infection accurately may lead to inappropriate and perhaps harmful management, and may delay recognition of potentially life-threatening complications.

Herpes genitalis in a student population.

Increased reporting of genital herpes has led to claims in the lay press of an epidemic of herpes genitalis. In a study at Queen's University Student Health Service during a nine-month period, a first diagnosis of genital herpes was made in 5.9/1,000 students attending the clinic. Excluding those patients with recurrent illness by history, the incidence of genital herpes was 4.5/1,000. Recovery of the virus was successful in 91 percent of attempted cultures. Complications were low. Genital herpes is an important sexually transmitted disease in the student population, but claims of an epidemic are exaggerated.

The diagnostic challenge of anorexia nervosa.

Anorexia nervosa is apparently increasing in incidence and prevalence. Accurate diagnosis may be delayed because of the wide range of presenting complaints and the grossly misleading history. Expenditure of valuable time and resources on fruitless investigations may be avoided if physicians acquire some knowledge of common anorexic behavior patterns. It should be possible to make a confident diagnosis on clinical grounds alone.

Anorexia nervosa and bulimia: problems of "the pleasing child".

Widespread media publicity has resulted in increased case findings of eating disorders such as anorexia nervosa and bulimia. The etiology of these conditions is complex and multifactorial, and they may have devastating effects on physical and psychological health. Family physicians have an important role to play in recognizing, evaluating and managing eating disorders. Severe anorexics-those who have lost 25% or more of the average weight for their age and height-require specialist management, but milder forms respond to treatment which can be undertaken by an interested family physician. Most cases of uncomplicated bulimia can be treated successfully in a family practice setting.