The patient-centred case presentation.

The presentation of case histories is an important part of medical education, socialization and research. The traditional format of presentation, developed at the beginning of the century and based on disease-centred nosologies, has been criticized as minimizing the patient's story and subjective experience. It results in a separation of biological processes from the person. With the development of a patient-centred clinical method, it is desirable to have a patient-centred case presentation format that places the patient's subjective experience in the forefront, without sacrificing traditional biomedical aspects. This paper describes such a method and presents an example. This method is especially useful in the education of senior residents in family medicine, as it can serve to reinforce an attitude of 'patient-centredness'. The method can also serve as a useful bridge between the passive learning inherent in much of the education in medical schools and the active, adult learning necessary for graduate practitioners. By placing an emphasis on the person's subjective experience of illness, rather than solely on the disease, this way of presenting a case history readily suggests new questions and directions in research. The presentation of case histories is an underrecognized tool in family medicine. Changing the format of such presentations to be more consistent with the family medicine world view has implications for education and research.

Illness after measles-mumps-rubella vaccination.

OBJECTIVES: To provide accurate information on the common sequelae of measles-mumps-rubella (MMR) vaccination and to compare post-vaccine symptoms in children vaccinated at 13 and 15 months. DESIGN: Prospective cluster randomized controlled trial. SETTING: Twenty-two family practices in southwestern Ontario. PATIENTS: All 376 infants who were due to receive MMR vaccine in the next year, 253 (67.3%) successfully completed the study. INTERVENTION: MMR vaccine administered at 13 months by half of the family physicians and at 15 months by the remaining half. OUTCOME MEASURES: Family physician's physical findings in children 7 days and 30 days after vaccine; reported illnesses by mothers in a daily diary in the month before and after vaccination and medical records of visits to family physicians and hospital admissions in the month before and after vaccination. RESULTS: Compared with the incidence rates in the corresponding weeks before vaccination, the rates of lymphadenopathy (23.8%) and fever (16.8%) were higher 1 week afterward and the rate of rash (26.9%) was higher 7 to 14 days afterward. Fewer health problems were reported in the third and fourth weeks after vaccination than in the corresponding weeks beforehand. Hospital admissions after vaccination were no more frequent than those before once cause and time of admission were taken into account. The two age groups did not differ in any of the outcomes. CONCLUSIONS: Mothers should be informed about the possibility of increased physical findings in the weeks after MMR vaccination, especially lymphadenopathy, nasal discharge and rash. Since the occurrence of sequelae does not seem to differ significantly between 13-month-old recipients and 15-month-old recipients, it should not influence the decision of when to administer the vaccine.

Intercondylar notch size and anterior cruciate ligament injuries in athletes. A prospective study.

Published reports agree that there is a strong association between intercondylar notch stenosis and anterior cruciate ligament injuries. In a previously published retrospective study on bilateral anterior cruciate ligament injuries and associated intercondylar notch stenosis, we formulated the notch width index to measure and compare intercondylar notch width. The purpose of this prospective study was to establish a normal range for the notch width index and to correlate intercondylar notch size and anterior cruciate ligament injuries. We gathered data on 902 high school athletes, including range of motion, thigh girth, ligament stability and intercondylar notch width using the notch width index. The population was then followed prospectively and anterior cruciate ligament injuries were recorded and correlated with notch width index in a blind manner. Two-year results showed that the overall anterior cruciate ligament injury rate was 3%. The normal intercondylar notch ratio was 0.231 +/- 0.044. Intercondylar notch width index for men was larger than that for women. Athletes sustaining noncontact anterior cruciate ligament tears have statistically significant intercondylar notch stenosis (notch width index, 0.189). Ten of 14 athletes with noncontact anterior cruciate ligament injuries had a notch width index that was at least 1 SD below the mean. Athletes with contact anterior cruciate ligament injuries had a mean of 0.233. We conclude that athletes with a stenotic intercondylar notch are at significantly greater risk for sustaining noncontact anterior cruciate ligament injury.

Risk language preferred by mothers in considering a hypothetical new vaccine for their children.

OBJECTIVES: To determine the type of risk language preferred by mothers considering the use of hypothetical new vaccine for their children and to compare their choice with what their physicians perceived they would prefer. DESIGN: Mail survey. SETTING: Thirteen family practices in southwestern Ontario. PARTICIPANTS: Women with at least one child between the ages of 6 months and 5 years and their physicians. MAIN OUTCOME MEASURES: Preferred risk language and physicians' predictions about patient preference. RESULTS: Of the 226 women sent the questionnaire 208 (92%) responded. Of the 192 who indicated their risk language preference 118 (61%) chose a numeric statement. Of the 11 physicians who answered the question 8 (73%) predicted that their parents would prefer non-numeric statements. Although the women in the study were more likely to be married, were better educated and had higher family incomes than women of the same age in the Ontario population, risk language preference was not found to be related to any of those demographic characteristics. CONCLUSION: Physicians must be prepared to outline the risks associated with vaccination in both quantitative and qualitative terms.

Determinants of maternal tolerance of vaccine-related risks.

In a time when informed consent requires knowledge of the risks and benefits of medical care and technology to be communicated to the public, perceptions of benefits and risks of these techniques and procedures take on special importance. The purpose of the present study was to examine the determinants of maternal tolerance of vaccine-related side-effects in their children. A questionnaire was sent to 226 mothers of young children in southwestern Ontario seeking their opinion of the benefits and risks of selected medical procedures. It asked them to identify the risk of serious reactions they would tolerate for a new vaccine with benefits similar to that of pertussis vaccine. The response rate to the questionnaire was 92%. This group of young, well-educated mothers had high regard for some of the most common procedures and treatments used in family practice. The less common and more invasive procedures (heart surgery, brain surgery) were viewed as carrying almost as much risk as benefit. Abortion was perceived as involving more risk than benefit. Levels of acceptable risk with respect to a hypothetical new childhood vaccine were determined. A risk level of 1 in 1 million was the most popular level of acceptable risk, chosen by 25% of the respondents. The next most frequently chosen risk level was 1 in 100,000, chosen by 22%. Tolerance of possible vaccine side-effects did not differ with maternal age, education or prior experience with adverse vaccine or drug reactions. A summary net benefit score was derived for four technologies commonly used in family practice (antibiotics, vaccinations, birth control pills and X-rays).(ABSTRACT TRUNCATED AT 250 WORDS)

Rapid isolation and presumptive diagnosis of uropathogens by using membrane filtration and differential media.

Random urine samples from hospitalized patients (n = 550) and seeded sterile filtered urine samples (n = 730) were used to test a membrane filtration technique, Qualture (Future Medical Technologies International, Inc., West Palm Beach, Fla.), for the detection and identification of uropathogens. Results for each sample were compared with those obtained by the calibrated loop (0.01 ml) method to demonstrate the sensitivity of the method as a screening tool and the specificity of the presumptive diagnosis obtained from the pattern of growth on differential media. The medium was supplied as dehydrated nutrient pads (Sartorius AG, Goettingen, Germany) and was activated by rehydration by the addition of the liquid specimen. With a threshold of 10(4) CFU/ml defining a positive culture, the sensitivity of the Qualture was 100%. At lower levels of bacteriuria, the Qualture was more sensitive than the calibrated loop method. Significant infections were presumptively diagnosed at 4 h by filtration rather than at 24 h on agar medium. The specificity of uropathogen identification ranged from 99% for Enterococcus spp. to 83% for Pseudomonas spp. Citrobacter spp. could not be differentiated from Escherichia coli and Providencia spp. could not be differentiated from Proteus spp., which does not create a therapeutic dilemma. Filtration, isolation, quantitation, and presumptive diagnosis are performed in one step, without subculture. Membrane filtration is a sensitive and rapid technique, with the advantage that it can be used as a collection and transport device without the use of growth inhibitors.

Effect of exchange transfusion on cell-mediated immune function following thermal injury.

We assessed the effect of syngeneic and allogeneic exchange transfusion (XTF) on cell-mediated immunity in a murine burn model. Mice were given a 30% TBSA scald injury and lymphocyte function was monitored with the popliteal lymph node assay for host-versus-graft (HVG) or graft-versus-host (GVH) response. Nonexchanged burned animals exhibited suppression of GVH response on postburn days (PBD) 3 and 8 and suppression of HVG response on PBD 3, 8, 11, and 14. Syngeneic XTF stimulated GVH response on PBD 3, and significantly improved both GVH and HVG response to alloantigens on postburn days 3 and 8 compared to the response of burned controls. Allogeneic XTF significantly improved GVH response on PBD 3 and 8, but did not improve HVG response. Restoration of lymphocyte function in all experimental groups occurred between PBD 14 and 18 and coincided with wound healing.

Effect of anti-PGE antibody on cell-mediated immune response in thermally injured mice.

Prostaglandin E (PGE) production is elevated in burn-injured individuals and has been implicated as a mechanism in thermal injury-induced immunosuppression. Profound depression of cell-mediated immune response (CMIR) is a characteristic effect of burn injury, and was evaluated using the popliteal lymph node assay for graft-versus-host and host-versus-graft responsiveness in mice. Preservation of CMIR after burn injury was observed in animals treated with 40 mg/kg ibuprofen and in mice given anti-PGE antibody. It appears that PGE is a central immunoregulatory mediator of suppressed CMIR following thermal injury and that treatment resulting in inhibition of PGE production or neutralization of PGE with anti-PGE antibody prevented burn-induced immunosuppression.

A study of telephone prescriptions in family practice.

Telephone prescriptions are a unique aspect of North American medicine which has received relatively little attention. This paper examines certain behaviors of the physician and the patient with respect to prescriptions in the office and over the telephone. The results indicate that patients receiving prescriptions over the telephone are demographically distinct, tend to receive large amounts of psychotropic drugs, and are more likely to be seen by their physicians as "problem patients." Suggestions are made to help identify the habitual telephone prescription patient to allow the physician to review the need for the medication and the status of the physician-patient relationship.

Metastatic carcinoma of the iris.

Of three women and one man with metastatic carcinoma of the iris, the average age of the four was 50.2 years. Two of the tumors originated in the breast and two in the lungs. The average survival from time of diagnosis of the iris lesion was less than six months. Each patient presented with characteristic grayish-white translucent nodules on the iris or in the anterior chamber angle. The patients displayed other features of iris metastases such as secondary glaucoma, rubeosis iridis, iris atrophy, anterior uveitis, hypopyon, and hyphema. As an aid in the clinical evaluation, anterior segment fluorescein angiography was performed, revealing vascular details not seen clinically. Leakage of dye was a constant feature of the angiogram.