Diabetes Screening in Canada (DIASCAN) Study: prevalence of undiagnosed diabetes and glucose intolerance in family physician offices.

OBJECTIVE: To assess the prevalence of undiagnosed diabetes and glucose intolerance in individuals > or =40 years of age who contacted their family physician for routine care. RESEARCH DESIGN AND METHODS: The study used a stratified randomized selection of family physicians across Canada that was proportional to provincial and urban/rural populations based on Statistics Canada Census data (1996). Consecutive patients > or =40 years of age were screened for diabetes. If a casual fingerprick blood glucose was >5.5 mmol/l, the patient returned for a fasting venous blood glucose test. If the fasting blood glucose was 6.1-6.9 mmol/l, a 2-h 75-g post-glucose load venous blood glucose was obtained. Results of these tests were used to classify patients in diagnostic categories. RESULTS: Data were available for 9,042 patients. Previously undiagnosed diabetes was discovered in 2.2% of the patients, and new glucose intolerance was found in an additional 3.5% of patients. Overall, 16.4% of patients had previously known diabetes. The decrease in fasting plasma glucose criterion from 7.8 to 7.0 mmol/l resulted in a 2.2% versus a 1.6% prevalence of new diabetes. Several risk factors were reported in a significantly greater proportion of patients with new glucose intolerance and either new and known diabetes compared with the normal glucose tolerance group of patients. CONCLUSIONS: Routine screening for diabetes by family physicians is justified in patients > or =40 years of age, given the finding of previously undiagnosed diabetes in 2.2% of these patients and newly diagnosed glucose intolerance in an additional 3.5% of these patients. Another 16.4% of primary care patients > or =40 years of age have known diabetes. This has important implications regarding health resources and physician education.

Modafinil: a double-blind multicentric study.

Modafinil is a central putative alpha-1 postsynaptic agonist with vigilance-promoting properties. Fifty narcoleptics (33 male and 17 female) participated in a multicentric study aimed at assessing the effects of the compound on night sleep, feeling on awakening, excessive daytime sleepiness and cataplexy. Modafinil was administered in a double-blind cross-over design at a daily dosage of 300 mg versus placebo. The duration of the study was 12 weeks, including a 2-week "run in" period with placebo, a first 4-week treatment period with either modafinil or placebo, a 2-week wash-out period with placebo and a second 4-week treatment period with either placebo or modafinil. Daily evaluation was based on a sleep log, visual analog scales, a sleep questionnaire and a clinical global index. Sleep laboratory evaluation took place on nights 1, 28, 42 and 70. It included 1 night of polysomnography preceded by a questionnaire on therapeutic and side effects, and a maintenance of wakefulness test (MWT). Sleep logs did not show any modification of night sleep, but a reduction of daytime sleepiness and sleep. Feeling on awakening was not modified. An overall benefit was noted by physicians as well as by patients. MWT disclosed a positive effect of modafinil on excessive daytime sleepiness. Cataplexy was not modified.

Effects of modafinil on symptomatology of human narcolepsy.

We studied the effects of modafinil, a putative central alpha-1 agonist, on the excessive daytime sleepiness (EDS) of 10 narcoleptic patients while using a double-blind design and objective measurements of vigilance. There were two treatment periods, in which either modafinil or placebo was used; each lasted four weeks and was preceded by a 2-week "run-in" period and separated by a 2-week "wash-out" period. The effects of treatment on EDS were evaluated by daily home questionnaires and a psychomotor performance test, the Four Choice Reaction Time Test (FCRTT). Modafinil reduced the daily number of sleep attacks significantly, and markedly improved performances during the FCRTT. Results of this study suggest that modafinil is effective in treating EDS in narcolepsy, and that noradrenergic mechanisms could be involved in the physiopathology of EDS in that disorder.

Palliative care--could your patient have been managed at home?

Palliative care, supportive care of the dying, is rapidly changing to better meet the needs of the patients and families. If palliative care is provided in the home rather than in hospital, there is a potential for improvement in the quality of life for patients and their families and a potential for cost reduction in the health care system. Our study was undertaken to determine whether or not palliative care patients admitted to University Hospital could have been cared for at home rather than in the hospital. The hospital charts of 96 palliative care patients were reviewed retrospectively. The results indicated that 61% of these palliative care patients did not receive any palliative care at home and that 94% died in an acute care hospital setting. Only 18% lived in a setting other than their own home, and 68% had a spouse or other family member living with them at the time of their final admission. Based on the level of support in the place of residence prior to final admission and the reasons for admission, we determined that many of the patients could have been managed at home for at least some of the palliative care period if appropriate support from a home care team had been available.

[Sudden death during continous electrocardiographic recording by Holter's method]. / Mort subite au cours d'un enregistrement électrocardiographique continu par la méthode de Holter.

The case of a 79 year old patient who died during continuous electrocardiographic recording by Holter monitoring is reported. There was a previous history of respiratory insufficiency, postero diaphragmatic myocardial infarction and left hemiplegia. Death occurred suddenly at home after defecation. Analysis of the recording showed multiple polymorphic ventricular extra-systoles, often occuring in doublets at the beginning of the record. Death was caused by a salvo of three ventricular extrasystoles triggering ventricular tachycardia which rapidly degraded to irreversible ventricular fibrillation. This major arrhythmia may have been due either to adrenergic stimulation from the effort of defecation or to acute myocardial infarction. This case underlies the value of Holter monitoring in the assessment of the gravity of an arrhythmia. It is also of interest because of the absence of an R on T phenomenon before the terminal event.

[Noradrenaline and cerebral aging]. / Noradrénaline et vieillissement cérébral.

The central functions of norepinephrine (NE) are a recent discovery: regulation of alertness and of the wakefulness-sleep cycle, maintenance of attention, memory and learning, cerebral plasticity and neuro-protection. The anatomical, histological, biochemical and physiological properties of the central noradrenergic system: extreme capacity for ramification and arborization; slow conduction, non-myelinized axons with extrasynaptic varicosities producing and releasing NE; frequency of co-transmission phenomena, and; neuromodulation with fiber effect responsible for improvement in the signal over background noise ratio and selection of significant stimuli form a true interface between the outside world and the central nervous system, notably for the neocortex in the context of the cognitive treatment of information. This central noradrenergic system is involved in the neurophysiology and the clinical features of cerebral aging (ideation-motor and cognitive function slowing down, loss of behavioral adjustment), neuro-degenerative disorders (SDAT, Parkinson's disease), certain aspects of depression and less obvious conditions (head injuries, sequelae of cerebrovascular accidents, sub-cortical dementia). The recent development of medications improving alertness (adrafinil, modafinil) with a pure central action and specifically noradrenergic, may contribute to an improvement in these multifactorial disorders.

[Effect of phloroglucinol on rectosigmoid motility stimulated by a test meal. Study in patients with irritable bowel syndrome]. / Effet du phloroglucinol sur la réponse motrice du rectosigmoïde à l'alimentation. Etude chez des sujets atteints du syndrome de l'intestin irritable.

Twenty patients (15 women, 5 men, mean age: 46.3 +/- 11.82 years, mean weight: 70.9 +/- 8.83 kg) presenting with a 8.5 +/- 4.7 years' history of irritable bowel syndrome associated predominantly with postprandial abdominal pain were recruited into the study. They underwent, after an enema, a rectosigmoid manometry (4 channels, low compliant infusion pump and catheters) before and after a 1000 kcal standardized meal. At the end of the meal they were administered intravenously phloroglucinol (two 40 mg ampoules) or placebo (two ampoules). Both treatments were strictly similar and the order of administration was randomly assigned Motor activity at the rectum, rectosigmoid, lower sigmoid and sigmoid level was determined using a motor index calculated for each 15 min period. Three preprandial and four postprandial indices were calculated. Both groups were statistically similar for sex ratio, age and history of disease. A slight difference was noted for mean weight: the caloric instake per kg of weight was a little higher in the phloroglucinol group. Mean preprandial indices were comparable in both groups. Variance analysis showed that the increase in postprandial motor indices was statistically less pronounced in the phloroglucinol group than in the placebo group. In the placebo group a clear cut increase in motor activity was assessed, which was not observed in the phloroglucinol group. This variation of motricity, which was observed at every level, was more pronounced for the first two postprandial indices than for the last two ones. These results suggest that phloroglucinol is able to reduce rectosigmoid motor response after a test meal. This could explain its activity in abdominal pain associated with irritable bowel syndrome.

Glucose Control and Diabetic Complications: Is tight control of IDDM justified?

Tight glucose control is clearly beneficial in the pregnant insulin-dependent diabetic. In other areas (retinopathy, established nephropathy, and hypoglycemia) the question whether tight control of diabetes is justified remains unanswered. Preliminary evidence suggests that tight control, if begun early, can prevent clinical nephropathy and neuropathy.

Family-practice anesthesia in british columbia.

This study of family practitioners as anesthetists is based on data extracted from records of the Medical Services Plan of British Columbia. During the period from 1976 to 1986, the proportion of anesthetics that were administered by non-certified anesthetists declined from 28.3% to 22.1% of the total number. Small and medium-sized hospitals continue to depend on family-physician anesthetists. Family practitioners make up 96.9% of all anesthetists practising in hospitals with fewer than 50 beds and 88.2% of anesthetists in hospitals with 50-99 beds. Rural areas are served almost exclusively by family-practice anesthetists, since 16 of 29 B.C. regional districts have one or no certified anesthetists. The author discusses the implications of this situation for the future of family-practice anesthesia.

The appropriate use of oxygen.

The scientific evidence for the efficacy of oxygen therapy in acute hypoxemia is limited. In chronic hypoxemia continuous oxygen therapy appears to decrease mortality. Current indications for oxygen treatment are PaO(2) less than 60 in acute hypoxemia and less than 55 in chronic hypoxemia. Physical and physiological hazards of oxygen are reviewed. Three syndromes of pulmonary oxygen toxicity are described: tracheobronchitis, adult respiratory distress syndrome, and bronchopulmonary dysplasia.

Are automobile head restraints used effectively?

Observation of 992 motor vehicles and their drivers revealed that most drivers do not have their head restraints effectively positioned. Improper positioning was more common with adjustable restraints, in commercial vehicles, and among male drivers. Some head restraints could not be adjusted properly. Improvements in headrest adjustment might help decrease morbidity in motor vehicle accidents.

Factors associated with low cognitive performance in general practice.

In the preparatory phase of a randomised controlled trial data were collected to assess the magnitude of changes on cognitive functions in 1628 volunteers (age range 45-75 years) that were recruited from general practitioners' patient population. Subjects were administered a short neuropsychological battery of tests including three paper-and-pencil tests, which assessed immediate recall, delayed memory, and attention. Being on antihypertensive medication was associated with low results for all three tests in every age group, and in all strata according to blood pressure levels. Psychotropic drug use was correlated with low results for all three tests. Differences between psychotropic drug users and nonusers increased with age. Antihypertensive treatment and psychotropic drug use seem to be important to consider in longitudinal studies of cognitive decline in aging.