A randomized, controlled trial of high-dose dextromethorphan in facial neuralgias.

BACKGROUND: NMDA glutamate receptor antagonists such as ketamine and dextromethorphan reduce pain in certain neuropathic pain conditions. However, there have been no controlled trials of NMDA antagonists in facial neuralgias. METHODS: A randomized, double-blind, crossover trial compared 6 weeks of oral dextromethorphan with active placebo (low-dose lorazepam) in 19 patients, stratified into three groups: 11 with facial pain and possible trigeminal neuropathy, five with anesthesia dolorosa, and three with idiopathic trigeminal neuralgia. Dosage was titrated in each patient to the highest level reached without disrupting normal activities. RESULTS: Patients completing the trial included 10 with possible trigeminal neuropathy, four with anesthesia dolorosa, and two with trigeminal neuralgia. In patients with possible trigeminal neuropathy and anesthesia dolorosa, dextromethorphan decreased pain by a mean of only 2 to 4%, and these estimates were not significant. Both patients with trigeminal neuralgia had more pain during dextromethorphan treatment than during placebo treatment. Of three patients who demonstrated an analgesic response to dextromethorphan during the main trial, only one repeatedly responded in four subsequent confirmatory drug-placebo crossovers. CONCLUSIONS: Dextromethorphan shows little or no analgesic efficacy in pain due to possible trigeminal neuropathy and anesthesia dolorosa. Additional trials are necessary to conclusively evaluate the efficacy of NMDA-receptor antagonists in trigeminal neuralgia.

Identifying office resource needs of Canadian physicians to help prevent, assess and treat patients with substance use and pathological gambling disorders.

A study was conducted to determine whether there is a need for office-based resources to assist physicians in the prevention, assessment and/or management of patients, self and peers with substance use (excluding alcohol and tobacco) or pathological gambling disorders. The needs assessment was undertaken in three parts. Survey information was collected from 54 respondents including Executive Directors of the Canadian Medical Association's national affiliates and provincial/territorial Divisions, Deputy Ministers of Health, Registrars of provincial/territorial licensing bodies and Deans or Associate Deans of Continuing Medical Education programs in universities. Key informant interviews were conducted with 22 "experts" in the field of substance use and/or pathological gambling disorders. Focus groups were held in Vancouver, Toronto, Ottawa, Montreal and Halifax with 34 physicians who are interested in and whose caseload included patients with substance use and/or gambling disorders. Results suggest that current resources for both substance use and pathological gambling disorders are inadequate for physicians because there are gaps in the types activities and resources available, existing resources have not been effectively diffused or disseminated to physicians and training is needed to complement these resources to encourage proper implementation.

Evaluation of the red blood cell and plasma transfusion guidelines.

OBJECTIVES: To determine physicians' preferred content and format for the Guidelines for Red Blood Cell and Plasma Transfusion for Adults and Children before development in order to guide the development process. To obtain physicians' recommendations about the Guidelines' content, format, dissemination and future directions after development to guide future work on the Guidelines. DESIGN: Pre-post Guidelines qualitative design using 20 focus groups (nine pre and 11 post). STUDY PARTICIPANTS: One hundred and seven physicians (5-11 per group) who used at least 1 unit of blood over the past 6 months; with a minimum of 1 year in practice and not retired. A total of 24 physicians attended both pre and post focus groups. In general, specialties of participants included: general practice, surgery pediatrics, obstetrics/gynecology and hematology/oncology. Years of practice ranged from 1 to 35 years (mean = 7 years). MAIN OUTCOME MEASURES: Pre Guidelines focus groups made recommendations on the content and format of the Guidelines; post Guidelines focus groups made recommendations on the same areas along with dissemination and future directions. RESULTS: Three main components of the Guidelines were evaluated: content, format and dissemination. The content, which followed as much as possible that recommended by pre Guidelines focus groups, was deemed appropriate by post Guidelines focus groups, with minor gaps noted (e.g. information on alternatives to blood products). The format addressed many of the concerns raised by pre Guidelines focus groups; however, the post Guidelines focus groups were concerned about the lack of visual aids and categorization of information. The dissemination strategy was successful at diffusing the Guidelines, with some concerns expressed about reaching specific physician target groups. CONCLUSION: The pre-post focus group method was useful in conducting an evaluation of the Guidelines and this method which examined content, format and dissemination could contribute to evaluations of other guidelines.

Mobilizing physicians for clinical tobacco intervention in Canada: evaluating a national and provincial partnership.

This paper examines the activities of the 'Mobilizing Physicians for Clinical Tobacco Intervention' project, a multi-partner project established in 1995 to provide resources to physicians to help them counsel patients about smoking. The evaluation was a multi-level case study which used a variety of national and provincial data sources, including surveys and document review. Findings from each of the partners are presented, and their implications for future tobacco control projects discussed. The study also discusses problems encountered in implementation and their solutions, and assesses the implications for those planning or conducting large scale, multi-centre evaluations.

Smoking cessation, physicians, and medical office staff. Clinical tobacco intervention in Prince Edward Island.

OBJECTIVE: To assess attitudes and self-reported behaviours of physicians and medical office staff in Prince Edward Island concerning clinical tobacco intervention (CTI). DESIGN: Mail survey of PEI primary care physicians and their medical office staff. Most surveys were not mailed back but picked up in person by research staff. SETTING: Primary care settings in PEI. PARTICIPANTS: All active primary care physicians in PEI identified in the Canadian Medical Association database and medical office staff. Respondents included 63/88 (71.6%) physicians and 59/88 (67.0%) medical office staff. Fifty-seven physicians and medical office staff surveys overlapped. MAIN OUTCOME MEASURES: Attitudes and self-reported behaviours in CTI. RESULTS: More than 70% of the time, 68.3% of physicians reported asking new patients about their smoking behaviour and 66.7% reported that they listen to and acknowledge patients' feelings and fears about stopping smoking. Close to half (43.3%) of physicians reported thinking about or planning to do more CTI. Physicians and medical office staff reported that staff had limited involvement in methods to cue smoking interventions. Only half (50.8%) of physicians reported that their offices are well set up to identify smokers and to help them quit smoking. Offices were well set up for CTI if physicians perceived that office staff had an active role in CTI and if follow-up visits were frequently arranged. CONCLUSIONS: This study identified apparent opportunities for improving CIT, particularly in the areas of physician training, involvement of medical office staff, and awareness of billing codes. This could improve the quality of preventive care for patients in PEI.

Qualitative evaluation of the Canadian Medical Association's counselling guidelines for HIV serologic testing.

OBJECTIVE: To evaluate the face and content validity of the CMA's counselling guidelines for HIV serologic testing in order to prepare a revised edition. DESIGN: Qualitative evaluation by structured focus groups in September and October 1994 to assess the relevance, clarity and practicality of the guidelines, followed by content analysis of the discussions. SETTING: Vancouver, Winnipeg, Toronto, Montreal, Quebec City and St. John's. PARTICIPANTS: Primary care physicians randomly selected from the CMA database and nonrandomly selected from the Canadian Medical Directory who had limited experience with HIV testing and counselling and who provided an appropriate mix of characteristics in terms of practice type (solo and group), setting (urban and rural), age and sex. A total of 1247 physicians were approached for the study; a convenience sample of 68 were recruited, of whom 56 participated. The average size of each focus group was eight physicians. OUTCOME MEASURES: Clinical experience and information sources with respect to HIV testing, reactions to the counselling guidelines, and suggestions for revisions and improvements to the guidelines. RESULTS: Most (96% [54/56] of the participants had ordered HIV serologic testing for patients in the 6 months preceding the focus groups, and about half of them (52% [28/54]) had at least one patient with a positive test result. Many (59% [33/56]) of the participants had a copy of the guidelines at the time of recruitment; 19 (58%) of them had used the guidelines in the months before the focus groups. The parts of the guidelines most often read were the checklists and inset boxes. Recommendations for revisions in content were for more information on legal and ethical issues, information on new issues (e.g., rapid testing) and guidelines on how best to tell a patient about a positive test result; recommendations for revisions in format included more tables, algorithms, bulleted points and white space, less text, larger type and plainer language. CONCLUSIONS: The focus groups provided detailed, credible and consistent information about the face and content validity of the HIV counselling guidelines. They are a useful qualitative method for evaluating the relevance, clarity and practicality of clinical practice guidelines at the inception or revision stage.

Core and comprehensive health care services: 1. Introduction to the Canadian Medical Association's decision-making framework.

The CMA's decision-making framework on core (i.e., publicly funded) and comprehensive health care services emphasizes flexibility and recognizes three levels at which decisions can be made: between patients and physicians (micro), in the community or by society (meso) and by governments (macro). Three major content dimensions are considered quality of care (e.g., effectiveness, appropriateness and efficiency of health care services), ethics (e.g., decisions that reflect fairness and acceptability to patients and physicians) and economics (e.g., measurement of service costs against economic benefits in a time of severe economic restraint). There are challenges in applying the framework; however, by providing decision-makers with the knowledge and tools needed to assist in the process, it is hoped that the first and foremost concern will continue to be the quality of patient care so highly valued by Canadians.

Immunization policies in Canadian medical schools.

OBJECTIVE: To determine the policies of Canadian medical schools concerning immunization of students and the methods used to promote these policies. DESIGN: Mail survey with the use of a 12-item, self-administered questionnaire; telephone follow-up to ensure response. SETTING: All 16 medical schools in Canada. PARTICIPANTS: Deans of Canada's 16 medical schools or their designates. All of them responded to the questionnaire. MAIN OUTCOME MEASURES: Policies on vaccination of students against diphtheria, hepatitis B, influenza, measles, mumps, poliomyelitis, rubella, tetanus and typhoid fever; recommended or required timing of such vaccination; methods for making students aware of immunization policies and for making vaccinations available to students; responsibility for payment for vaccination; compliance rates; methods used to monitor compliance; problems associated with noncompliance; policies for compensating students infected with hepatitis B or other vaccine-preventable diseases; and future plans for vaccination of medical students. RESULTS: Vaccination against rubella was required in 11 (69%) of the 16 medical schools, and vaccination against tetanus, diphtheria and hepatitis B was required in 10 (63%). Nine schools (56%) required vaccination against measles and poliomyelitis, and eight (50%) required mumps vaccination. Only three schools (19%) required or recommended influenza vaccination, and only one recommended vaccination against typhoid fever. The authors identified various methods used to promote student awareness of immunization policies, make vaccinations available, pay for vaccinations and monitor compliance. CONCLUSIONS: Each medical school has a unique set of requirements and recommendations for the vaccination of medical students. National guidelines on immunization for medical students and a comprehensive and nationally coordinated vaccination program would help to ensure that students receive proper protection from disease.