[Desmoid tumour around the DIEP anastomosis - a rare complication after breast reconstruction]. / Desmoidtumor an DIEP-Lappen Anastomose Eine seltene Komplikation nach Mammarekonstruktion.

Abdominal desmoid tumors are so called non-metastatic tumors. They occur by proliferation of fibroblasts of muscle, fascia or aponeuroses. After breast reconstruction with a DIEP flap (Deep Inferior epigastric Artery Perforator Flap), a progressive growth of a desmoid tumor was seen around the DIEP-anastomosis. A total excision was not possible without compromising the vascular pedicle. With taking into account a recurrence rate up to 65% another operation is probably necessary. In this case the main vessels of the graft have to be cut out and a necrosis of the flap can or may appear.

A technique to detect and to quantify fasciocutaneous blood vessels in small laboratory animals ex vivo.

PURPOSE: A microangiographical technique is described, which allows visualization of small and capillary blood vessels and quantification of fasciocutaneous blood vessels by means of digital computer analysis in very small laboratory animals. MATERIALS AND METHODS: The left carotid artery of 20 nu/nu mice was cannulated (26 gauge) and a mixture of gelatin, bariumsulfate, and green ink was injected according to standardized protocol. Fasciocutaneous blood vessels were visualized by digital mammography and analyzed for vessel length and vessel surface area as standardized units [SU] by computer program. RESULTS: With the described microangiography method, fasciocutaneous blood vessels down to capillary size level can be clearly visualized. Regions of interest (ROIs) can be defined and the containing vascular network quantified. Comparable results may be obtained by calculating the microvascular area index (MAI) and the microvascular length index (MLI), related to the ROIs size. Identical ROIs showed a high reproducibility for measured [SU] < 0.01 +/- 0.0012%. CONCLUSION: Combining microsurgical techniques, pharmacological knowledge, and modern digital image technology, we were able to visualize small and capillary blood vessels even in small laboratory animals. By using our own computer analytical program, quantification of vessels was reliable, highly reproducible, and fast.

[A microangiography technique to quantify fasciocutaneous blood vessels in small laboratory animals]. / Eine mikroangiographische Technik zur Quantifizierung fasziokutaner Blutgefässe am kleinen Versuchstier.

PURPOSE: A microangiographic technique is described, which allows visualization of small blood vessels with a diameter of approximately 20 microm and quantification of fasciocutaneous blood vessels by means of digital computer analysis in very small laboratory animals. METHOD: The left carotid artery of 45 nu/nu mice was cannulated (26 gauge) and a mixture of gelatine, barium sulfate and green ink was injected according to standardized protocol. Fasciocutaneous blood vessels were visualized by digital mammography and analyzed for vessel length and vessel surface area as standardized units (pixel) by computer program. RESULTS: With the described microangiography method fasciocutaneous blood vessels can be clearly visualized. Regions of interest (ROIs) can be defined and the containing vascular network quantified. Identical ROIs showed a high reproducibility for measured unit (pixel) < 6.5 +/- 2.4 %. By the use of digital image, processing the quantification of vessels was reliable, reproducible and fast. CONCLUSION: Combining microsurgical techniques, pharmacological knowledge and modern computer imaging analysis systems, we were able to visualize and quantify blood vessels with a diameter of approximately 20 microm even in small laboratory animals.

Mental health, job satisfaction, and intention to relocate. Opinions of physicians in rural British Columbia.

OBJECTIVE: To determine the prevalence of depression and burnout among family physicians working in British Columbia's Northern and Isolation Allowance communities. Current level of satisfaction with work and intention to move were also investigated. DESIGN: Cross-sectional, mailed survey. SETTING: Family practices in rural communities eligible for British Columbia's Northern and Isolation Allowance. PARTICIPANTS: A random sample of family physicians practising in rural BC communities. Initial response rate was 66% (131/198 surveys returned); excluding physicians on leave and in temporary situations and those who received duplicate mailings gave a corrected response rate of 92% (131/142 surveys returned). MAIN OUTCOME MEASURES: Demographics; self-reported depression and burnout; Beck Depression Inventory and Maslach Burnout Inventory scores; job satisfaction; and intention to leave. RESULTS: Self-reported depression rate was 29%; the Beck Depression Inventory indicated 31% of physicians suffered from mild to severe depression. About 13% of physicians reported taking antidepressants in the past 5 years. Self-reported burnout rate was 55%; the Maslach Burnout Inventory showed that 80% of physicians suffered from moderate-to-severe emotional exhaustion, 61% suffered from moderate-to-severe depersonalization, and 44% had moderate-to-low feelings of personal accomplishment. Depression scores correlated with emotional exhaustion scores. More than half the respondents were considering relocation. CONCLUSION: Physicians working in these communities suffer from high levels of depression and very high levels of burnout and are dissatisfied with their current jobs. More than half are considering relocating. Intention to move is strongly associated with poor mental health.

Epidural analgesia use as a marker for physician approach to birth: implications for maternal and newborn outcomes.

BACKGROUND: Understanding the association between caregiver belief systems and practice patterns is an emerging area of research. We hypothesized an association between a maternity caregiver's belief system and his or her behavior. The study objective was to determine if a family physician's overall approach to maternity care, as measured by average use of epidural analgesia, was associated with maternal and fetal outcomes. METHODS: Retrospective analysis was conducted of the births of three cohorts of 1992 nulliparous, low-risk women attended by 96 family physicians within an 18-month period in the department of family practice at the largest maternity hospital in Canada. Cohorts were based on the physicians' mean use of epidural analgesia for the women. Family physicians attending fewer than 5 births were excluded. The main outcome measures, by physician epidural utilization cohort, were maternal/newborn morbidity, procedure rates, consultation rates, and length of stay. RESULTS: Family physicians were separated into cohorts based on their mean use of epidural analgesia at rates of: low, 0-30 percent (15 physicians, 263 births); medium, 31-50 percent (55 physicians, 1323 births); and high, 51-100 percent (26 physicians, 406 births). After adjustment for maternal age and race, patients of low versus high epidural users were admitted at a later state of cervical dilation (mean 4.0 vs 3.1 cm), received less electronic fetal monitoring (76.4 vs 87.2%) and oxytocin augmentation (12.2 vs 29.8%), sustained fewer malpositions (occiput posterior or transverse) (23.2 vs 34.2%), had fewer cesarean sections (14.0 vs 24.4%), less obstetric consultation (47.9 vs 63.8%), and fewer newborn special care admissions (7.2 vs 12.8%). CONCLUSIONS: In our setting, high use of epidural analgesia is a marker for a style of practice characterized by malpositions leading to dysfunctional labors and higher intervention rates leading, in turn, to excess maternal/newborn morbidity.

Induction of labour: a continuous quality improvement and peer review program to improve the quality of care.

This article describes a program developed to improve the process of planned induction of labour and to reduce the rates of inappropriate induction. The setting is a tertiary-care maternity hospital in urban Vancouver, BC, in which 7000 deliveries take place annually. Approximately 65% of these can be considered primary care; the remainder are secondary- or tertiary-level cases. Continuous quality improvement (CQI) methods were used by a multidisciplinary team, which included nursing staff, physicians, health records personnel and a CQI facilitator. Interventions included the development of a new induction-booking process, clear criteria for induction, feedback to caregivers about changes and a peer review system to oversee and maintain improvement. The overall induction rate for the institution decreased, and this change has been maintained.

Identifying educational influentials for formal and informal continuing medical education in the province of British Columbia.

BACKGROUND: The objective of this study was to identify physicians in the province of British Columbia (BC) who are perceived by their colleagues to be the most educationally influential. METHODS: A cross-sectional study using a previously validated survey tool was mailed to a randomly selected sample of 2300 BC registered primary care physicians. Follow-up mailings were sent to nonresponders. RESULTS: The survey response rate was 53%. A list of 375 educationally influential physicians (EIs) was proportionately determined and tabulated by region. IMPLICATIONS: The top 5% of provincial EIs were identified to serve as a resource for formal and informal continuing medical education (CME). Their names will be brought forward in response to selected requests for CME speakers.

Review of University of British Columbia Family Practice Resident Research Projects 1990-1997.

BACKGROUND: Resident research projects can be an important component of building a strong and diversified research presence in family medicine. One of the requirements for graduation from the University of British Columbia (UBC) Family Practice Residency Program is that family practice residents complete a scholarly piece of work. METHODS: UBC family practice resident projects from 1990-1997 were reviewed and classified by methodology. A survey was sent to 251 former residents to determine 1) if their project was published, 2) if not, was there any interest in publication, and 3) what were the main reasons for not pursuing publication. Fifteen projects were selected as suitable for publication and were, with permission of the resident, submitted to medical journals. RESULTS: Sixty-nine percent of the resident projects involved data collection and hypothesis testing, and 40% were cross-sectional, of which patient surveys were the most common method. A total of 190 former residents (71%) have responded to our survey. Seven percent of respondents stated that their project had been published, and 55% would have liked to have tried to publish their project. Of the 15 resident projects we submitted for publication, seven were accepted. CONCLUSIONS: Family practice residents are capable of producing a wide variety of research projects. Only a minority of projects are being published despite the fact that the majority of residents are interested in pursuing publication. Greater assistance by faculty can increase publication of research projects.

Maternity care calendar wheel. Improved obstetric wheel developed in British Columbia.

PROBLEM BEING ADDRESSED: Gestational calendar "wheels" are not well designed for routine prenatal care or for presenting the uncertainties of predicting date of delivery. OBJECTIVE OF PROGRAM: To design and pilot-test a new gestational calendar wheel that predicts the range of normal due dates in a way that reflects the biological realities of pregnancy. The calendar has prompts that could facilitate provision of antenatal care, support prenatal education, and guide the timing of induction for pregnancies past their due dates. MAIN COMPONENTS OF PROGRAM: The calendar sets out the key issues to be addressed with patients during pregnancy. It is designed to be photocopied while set to patients' dates: patients keep one copy; another is placed in their charts. The probability of delivering on a given date is presented graphically and as a percentage likelihood of giving birth during specified intervals. Twelve practising physicians, 12 residents, and 10 pregnant women pilot-tested and evaluated the wheel. Their responses were favourable. CONCLUSIONS: The Maternity Care Calendar wheel is a substantial advance on existing obstetric calendar wheels. It incorporates evidence-based information that should facilitate prenatal care, promote prenatal education, and foster realistic expectations about the likely timing of delivery. Early in the pregnancy, it can help establish the timing of induction for pregnancies past their due dates. Further testing of the calendar's effectiveness in improving patient outcomes is needed.

Maternity Care Guidelines checklist. To assist physicians in implementing CPGs.

PROBLEM BEING ADDRESSED: Implementing the recommended clinical practice guidelines for prenatal care can be difficult for busy practitioners because the guidelines are numerous and continually being revised. OBJECTIVE OF PROGRAM: To develop a checklist outlining the current recommended activities for prenatal care to assist practitioners in providing evidence-based interventions to pregnant women. MAIN COMPONENTS OF PROGRAM: We reviewed guidelines for prenatal care from the Canadian Task Force on the Periodic Health Examination (CTFPHE) and from the report of the US Preventive Services Task Force (USPSTF). We searched MEDLINE for interventions commonly performed in pregnancy, but not reviewed by either task force. Interventions graded A or B are listed in bold type on the checklist. Interventions graded C by either task force or recommended by organizations not necessarily using the same rigorous criteria are listed in plain type. Recommended interventions are displayed along a time line under three headings: clinical maneuvers, investigations, and issues for discussion. Pilot testing by 12 practising physicians and 12 family practice residents showed that most respondents thought the checklist very useful. CONCLUSIONS: Providing a one-page checklist summarizing recommended clinical maneuvers, investigations, and topics for discussion should help physicians with implementing the many clinical practice guidelines for prenatal care.

The race of the millennium: CD-ROM versus the textbook.

OBJECTIVE: To determine whether CD-ROMs are as fast as everyone thinks they are. METHODS: A grand contest between 2 textbooks and their electronic versions, held with the help of 10 victims. RESULTS AND INTERPRETATION: We can't be expected to tell you that now. You'll have to read the paper.

Procedural skills training. Canadian family practice residency programs.

OBJECTIVE: To survey Canadian family practice residency programs to discover which procedural skills residents are expected to learn. DESIGN: Cross-sectional eight-item questionnaire. SETTING AND PARTICIPANTS: The survey was sent to all 92 program directors and site or unit directors of family practice residency programs across Canada. MAIN OUTCOME MEASURES: Information on procedural skills lists was solicited. We sought date of creation, date of most recent revision, and who was involved in creating the list. A copy of the most recent list available was requested. RESULTS: We received 65 responses, for a 71% return rate. Surveys were received from all provinces and from all Canadian universities offering family practice residency programs. We received 24 unique lists of procedural skills: the shortest listed only 10 procedural skills; the longest, 75 skills; and the average, 36 skills. Only five procedural skills were found on more than 80% of the lists; 30 skills were listed on half or more of the lists. CONCLUSIONS: Canadian family practice residency programs have widely varying expectations of procedural skills for their residents. This survey is a first step in examining the whole issue of procedural skills training in Canadian family medicine programs.

The street value of prescription drugs.

BACKGROUND: Although most physicians are aware of the potential for abuse and resale of prescribed medications, little has been done to document it. The purpose of this study was to determine which prescription drugs have street value, what that value is and why these drugs are used. METHODS: A descriptive cross-sectional survey using a semistructured interview technique was carried out on 2 weekdays (Mar. 10 and Apr. 1, 1997) in Vancouver's Downtown Eastside. A total of 58 users and dealers of prescription sedative/hypnotic and narcotic drugs were approached. Information collected included the demographic characteristics of those interviewed, the common street names of the drugs of interest, and their value and method of use. RESULTS: Thirty-two people agreed to participate in the study (participation rate 55%), 7 of whom were dealers. The range in price of sedative/hypnotic drugs was $0.10 to $2. For narcotic drugs the range was much greater, at $0.25 to $75. Descriptive analysis identified the minimum and maximum price and the mode of each preparation. Among the weak narcotic drugs the index drug (highest in demand on the street) was Tylenol No. 3 and among the more potent narcotics, MS Contin 30 mg. INTERPRETATION: A wide variety of prescription sedative/hypnotic and narcotic drugs are available on the street. The mark-up from pharmacy cost can be considerable. Factors influencing pricing include the relative inexperience of the buyer, the availability of illicit narcotics, the current street supply of prescription medications and the time of the month (before or after issue of social assistance cheques).

Haida perspectives on living with non-insulin-dependent diabetes.

OBJECTIVE: To understand the experience of Haida people living with non-insulin-dependent diabetes mellitus (NIDDM), in order to provide a basis for a culturally sensitive community-based approach to managing NIDDM. DESIGN: Qualitative study using grounded theory. SETTING: The villages of Skidegate and Old Massett in Haida Gwaii (Queen Charlotte Islands), British Columbia. PARTICIPANTS: Nine focus groups met at the beginning and six at the end of the project. The focus groups had 8 to 12 members each and roughly the same number of men and women overall. The groups included people with diabetes, family members of people with diabetes, community leaders and elders. FINDINGS: Conceptual findings related to the participants' views on the impact of NIDDM on their lives, their views on what life was like before the effects of NIDDM were felt and their beliefs about the prevention and treatment of NIDDM. Six themes recurred in the discussions: fear; grief and loss; the loss of and desire to regain control; food and eating; physical and personal strength; and traditional ways. CONCLUSIONS: Insights into the illness experience of different cultural groups can inform program development and the creation of culturally sensitive health care interventions.