Anti blood group-M autoantibodies with livedo reticularis, Raynaud's phenomenon, and anaemia.

A 63-year-old woman presented with Raynaud's phenomenon and extensive cold-induced livedo reticularis. A skin biopsy showed no abnormality of the blood vessels but the blood contained high titres of a very unusual autoantibody against the M blood group, most active at low temperatures. An IgM cryoglobulin was detected, and anti-M activity was found in this fraction. The cells of the patient were grouped as MM. The direct antiglobulin test was positive due to C3 component of complement bound to the red cells. The haematological and biochemical results indicate a mild haemolytic process, which is at present well compensated.

Influenza vaccination: a comparison of two outreach strategies.

Despite longstanding recommendations for annual influenza vaccination of all people age 65 and older, only 20% or less are regularly immunized. This paper compares two methods of immunization outreach to the elderly population. In 1985 and 1986 vaccine was offered to patients who attended one family practice for any reason during the months of October and November. In 1985 if patients had not received vaccine by October 31 an informational letter recommending immunization was also mailed. In 1986 nonimmunized patients were telephoned by the family practice nurse and informed of the rationale, availability, and advisability of receiving the vaccine. The immunization rate improved in patients attending the practice over the two study years. Additional outreach efforts showed a high degree of failure or refusal to receive immunization.

Are antihistamine-decongestants of value in the treatment of acute otitis media in children?

Acute otitis media is the most common bacterial infection of childhood. The effectiveness of oral antihistamine-decongestant mixtures in the treatment of this illness remains controversial in clinical practice. In a double-blind randomized study, 82 children (aged under 15 years) with acute otitis media were treated with amoxicillin and either a decongestant-antihistamine mixture (Dimetapp) or placebo. All diagnoses required agreement between a family practice resident and the supervising family physician. Clinical course was assessed by symptom diaries completed by parents and by follow-up examination at approximately two weeks, which included pneumatic otoscopy. No statistically significant benefit of the antihistamine-decongestant mixture was shown in terms of resolution of the symptoms or prevention of the complications of acute otitis media. It is recommended that antihistamine-decongestants not be routinely added to an antibiotic in the treatment of acute otitis media in children.

The sportsman with hypertension.

The widespread use of antihypertensive therapy in a large number of active Australians has prompted a review of the effects of sporting activity on hypertension and its treatment.

Masking and unmasking the sexual abuse of children: perceptions of violence against children in "the Badlands" of Ontario, 1916-1930.

This article explores the legal and social understandings of incest in early-twentieth-century Canada, examining the way in which sexual abuse was identified in sensational court cases but ideologically masked in social consciousness. First, the legal treatment of incest is examined through court cases, with special focus on one case that animated a grand jury report on a rural area where incest and violence supposedly flourished. Second, the grand jury's legal, medical, and social assumptions about incest, reflecting eugenic priorities as well as class and gender prejudices, are surveyed. Third, the actual use of the grand jury report in subsequent cases is probed. The report became a generalized explanation for all kinds of familial violence placing blame for violence on poor, degenerate, and immoral parents but ignoring the structural problems of power and patriachy.

Cardiac biomarkers in hyperthyroid cats.

BACKGROUND: Hyperthyroidism has substantial effects on the circulatory system. The cardiac biomarkers NT-proBNP and troponin I (cTNI) have proven useful in identifying cats with myocardial disease but have not been extensively investigated in hyperthyroidism. HYPOTHESIS: Plasma NT-proBNP and cTNI concentrations are higher in cats with primary myocardial disease than in cats with hyperthyroidism and higher in cats with hyperthyroidism than in healthy control cats. ANIMALS: Twenty-three hyperthyroid cats, 17 cats with subclinical hypertrophic cardiomyopathy (HCM), and 19 euthyroid, normotensive healthy cats ≥8 years of age. Fourteen of the hyperthyroid cats were re-evaluated 3 months after administration of radioiodine ((131)I). METHODS: Complete history, physical examination, complete blood count, serum biochemistries, urinalysis, blood pressure measurement, serum T4 concentration, plasma concentrations of NT-proBNP and cTNI, and echocardiogram were obtained prospectively from each cat. RESULTS: Hyperthyroid cats and cats with HCM had plasma NT-proBNP and cTNI concentrations that were significantly higher than those of healthy cats, but there was no significant difference between hyperthyroid cats and cats with HCM with respect to the concentration of either biomarker. In hyperthyroid cats that were re-evaluated 3 months after (131) I treatment, plasma NT-proBNP and cTNI concentrations as well as ventricular wall thickness had decreased significantly. CONCLUSIONS AND CLINICAL IMPORTANCE: Although there may be a role for NT-proBNP in monitoring the cardiac response to treatment of hyperthyroidism, neither NT-proBNP nor cTNI distinguish hypertrophy associated with hyperthyroidism from primary HCM. Therefore, the thyroid status of older cats should be ascertained before interpreting NT-proBNP and cTNI concentrations.

Evaluating A Graduate Studies Program: A survey of former participants.

To evaluate the outcome of the program for graduate studies in family medicine at the University of Western Ontario, all 45 participants in the program were surveyed. Thirty-six percent of respondents held full-time academic appointments and 42% part-time academic positions. Eighty-four percent indicated a moderate to major effect on their career as a teacher; 67% indicated a moderate to major change in research skills; 42% indicated such a change in administrative skills. Ninety-one percent said they had achieved all or most of their objective in taking the program.

The impact of an organized approach to prevention.

A study was conducted to compare preventive strategies in an urban, southwest Ontario family practice before and after the adoption of a periodic health assessment flow sheet. The flow sheet is similar to one developed by Frame and Carlson; the patient's history, screening procedures, health practices, and individual risk factors can be recorded on it. Approximately one hundred charts of patients between age 20 and 55 were randomly selected for the study. A comparison was made between the first general health assessment made from 1970-1977, before the flow sheet was used, and the first assessment from 1978-1982, when the sheet was used. There were significant differences between the assessments. Before 1978, a cholesterol test was requested for only 15.1% of patients in the study, immunization status was discussed with only 11.3%, and no record was made of their health practices. After 1978, cholesterol tests were requested for 82.2%, immunization status was discussed with 93.3%, and health practices were recorded for 82.2%. It is relatively easy to incorporate the flow sheet into practice, and it can be used to provide consistent preventive care.

Managing patient discharge to home: the challenges of achieving quality of care.

Discharging older patients from hospital to care at home presents considerable challenges for those concerned about the current mandate of quality management. A great many professionals with different priorities and organizational commitments are involved. The policies and procedures of at least two agencies, a hospital and a home care agency, play a role in shaping the whole process. The purpose of this study was to explore and describe factors other than medical condition and treatment which shaped the quality of the discharge experiences of older patients. Qualitative research methodology was used to document the discharge process from the perspective of 12 rural and nine urban patients, and a purposeful sample of 22 family caregivers and 117 professionals involved in their care. As well, 24 agency administrators with an overview of related policies and procedures provided data. Findings provide an in-depth description of the different implementation approaches and related quality issues in rural and urban settings. Quality management was undermined by role confusion, compromised and overly zealous pursuit of efficiency, fragmented work, variable physician practice style, and communication and coordination problems. Several readily implemented solutions to these problems are recommended. The implications of the more difficult leadership challenges related to achieving reasonable efficiency and maintaining a humane orientation in the complex care system are addressed.

Pap smear practice patterns of family physicians.

London, Ontario family physicians were surveyed, to compare the frequency of their Pap smear screening and their management of the abnormal smear with the recommendations of the 1982 Task Force report on cervical cancer screening. Considerable variation was observed between the Task Force recommendations and frequency of screening 36-60-year-old women, and the management of mild, recurrent mild, and moderate dysplasia. Many family physicians appeared to rely heavily on the cytopathologist's recommendations. More uniformity is required, both in cytopathologists' recommendations and in the practice of family physicians, if cervical cancer screening programs are to achieve their maximum effectiveness.

Management of cervical dysplasia.

Since the 1982 Revised Task Force Report on Cervical Cancer Screening, controversy has developed over the management of mild dysplasia. Recent developments have led some investigators to recommend colposcopy for any degree of cervical dysplasia because of significant false-negative factors in Pap smear reporting and the observation that some patients have lesions more severe than suggested by the cytology. Over a four-year period, all patients with dysplastic smears in the practice were evaluated by colposcopic examination and biopsy. In 20 cases of mild dysplasia, five cases of cancer in situ were found. Considerable variation from the Task Force's report was noted in cytopathologists' recommendations for cytological smears. Judging from the results of this audit, colposcopic evaluation of all dysplastic smears should be considered.

A perspective on preceptor training.

The authors outline their experience of preceptorship teaching in a private group practice with third year medical students; their conclusions are based largely on feedback from the students involved. The article emphasizes the availability and usefulness of the community as a classroom for undergraduate teaching.

Mental illness, loneliness and helplessness: a challenge for research and therapy.

The purpose of this article is: (1) To discuss the complex relationship between mental illness and the related factors of loneliness and helplessness, in a specific attempt to show why people with mental and/or emotional difficulties have a greater propensity for problems in these areas: (2) To challenge therapists, counselors, pastors, and community health professionals to become more holistic in their orientation towards their patients by giving special emphasis to interpersonal needs and personal responsibility over outcomes.

Screening for carcinoma of the colon: a family practice perspective.

Carcinoma of the colon is the second commonest malignancy in both sexes in North America. With little hope for a suitable method of primary prevention, physicians are forced to look for an effective secondary preventive technique. Through a collaborative effort between the physician and family practice nurse, an effective protocol for screening was developed and implemented on 355 patients aged over 40. Of these, 17 were positive. Ten of those were true positive and seven false positive. One false negative was found, but no carcinoma has been found to date-the positive patients have polyps, diverticular disease or hemorrhoids. In view of increasing evidence for the polyp-cancer sequence, this finding may be significant. Widespread use of Hemoccult II in this fashion will clarify the usefulness of this test.