Towards Excellence in Asthma Management: final report of an eight-year program aimed at reducing care gaps in asthma management in Quebec.

BACKGROUND AND OBJECTIVES: Asthma care in Canada and around the world persistently falls short of optimal treatment. To optimize care, a systematic approach to identifying such shortfalls or 'care gaps', in which all stakeholders of the health care system (including patients) are involved, was proposed. METHODS: Several projects of a multipartner, multidisciplinary disease management program, developed to optimize asthma care in Quebec, was conducted in a period of eight years. First, two population maps were produced to identify regional variations in asthma-related morbidity and to prioritize interventions for improving treatment. Second, current care was evaluated in a physician-patient cohort, confirming the many care gaps in asthma management. Third, two series of peer-reviewed outcome studies, targeting high-risk populations and specific asthma care gaps, were conducted. Finally, a process to integrate the best interventions into the health care system and an agenda for further research on optimal asthma management were proposed. RESULTS: Key observations from these studies included the identification of specific patterns of noncompliance in using inhaled corticosteroids, the failure of increased access to spirometry in asthma education centres to increase the number of education referrals, the transient improvement in educational abilities of nurses involved with an asthma hotline telephone service, and the beneficial effects of practice tools aimed at facilitating the assessment of asthma control and treatment needs by general practitioners. CONCLUSIONS: Disease management programs such as Towards Excellence in Asthma Management can provide valuable information on optimal strategies for improving treatment of asthma and other chronic diseases by identifying care gaps, improving guidelines implementation and optimizing care.

Paper stamp checklist tool enhances asthma guidelines knowledge and implementation by primary care physicians.

BACKGROUND: The Canadian Clinical Practice Guidelines (CPGs) for the management of asthmatic patients were last published in 1999, with updates in 2001 and June 2004. Large disparities exist in the implementation of these guidelines into clinical practice. OBJECTIVE: The present study evaluated the knowledge of Quebec-based primary care physicians regarding the CPGs, as well as patient outcomes before and after introducing physicians to a new clinical tool--a memory aid in the form of a self-inking paper stamp checklist summarizing CPG criteria and guidelines for assessing asthmatic patient control and therapy. The primary objective of the present study was to assess whether the stamp would improve physicians' knowledge of the CPGs, and as a secondary objective, to assess whether it would decrease patient emergency room visits and hospitalizations. METHODS: A prospective, randomized, controlled study of 104 primary care physicians located in four Quebec regions was conducted. Each physician initially responded to questions on their knowledge of the CPGs, and was then randomly assigned to one of four groups that received information about the CPGs while implementing an intervention (the stamp tool) aimed at supporting their decision-making process at the point of care. Six months later, the physicians were retested, and patient outcomes for approximately one year were obtained from the Régie de l'assurance maladie du Québec. RESULTS: The stamp significantly improved physicians' knowledge of the CPGs in all Quebec regions tested, and reduced emergency room visits and hospitalizations in patients who were followed for at least one year. CONCLUSION: A paper stamp summarizing CPGs for asthma can be used effectively to increase the knowledge of physicians and to positively affect patient outcomes.

[Systemic learning planification for residents during the 6-month pediatric radiology training]. / Planification systémique de l'apprentissage des internes pendant un semestre de radiopédiatrie.

Diagnostic Radiology and Medical Imaging residents of French University Hospitals benefit from a wide array of learning tools. However, the professors' clinical workload, lack of sufficient proper formal training, lack of practical applicability of existing standards, and absence of rigorous assessment during the specialized training, reduce their very good quality formation to the level of accidental learning. This study originates from the need to apply a systemic planification of learning activities to the French residents' formal training curriculum, such as the one originally designed and applied within the Quebec educational system. This presentation also benefits from the recent introduction of the CanMEDS 2000 objectives by the Royal College of Physicians and Surgeons of Canada, in order to design an adapted version for the professional and academic activities of French radiologists. Needless to say this work will respect the outlined systematic planning of any learning activity: learning requirements, definition of learning objectives, selection of learning methods, assessment of the participants' achievement of these objectives, and evaluation of the learning activity itself.

Benzodiazepine poisoning. Clinical and pharmacological considerations and treatment.

Benzodiazepines are among the most frequently prescribed drugs worldwide. This popularity is based not only on their efficacy but also on their remarkable safety. Pure benzodiazepine overdoses usually induce a mild to moderate central nervous system depression; deep coma requiring assisted ventilation is rare, and should prompt a search for other toxic substances. The severity of the CNS depression is influenced by the dose, the age of the patient and his or her clinical status prior to the ingestion, and the coingestion of other CNS depressants. In severe overdoses, benzodiazepines can occasionally induce cardiovascular and pulmonary toxicity, but deaths resulting from pure benzodiazepine overdoses are rare. Quantitative determinations of benzodiazepines are not useful in the clinical management of intoxicated patients since there is no correlation between serum concentrations and pharmacological and toxicological effects. Benzodiazepine overdoses occurring during pregnancy rarely induce serious morbidity in mothers or fetuses, although large doses administered near delivery can induce respiratory depression in neonates. The teratogenic potential of benzodiazepines remains controversial, but is probably small if it exists at all. There is clear evidence that the prolonged use of even therapeutic doses of benzodiazepines will lead to dependence. The risk of developing significant withdrawal symptoms is related to dosage and duration of treatment. Prevention of gastrointestinal absorption should be initiated in all intentional benzodiazepine overdoses. Forced diuresis and dialysis techniques are not indicated since they will not significantly accelerate the elimination of these agents. Intravenous administration of flumazenil, a pure benzodiazepine antagonist, effectively reverses benzodiazepine-induced CNS depression.

Adherence to management of high blood pressure: recommendations of the Canadian Coalition for High Blood Pressure Prevention and Control.

Adherence or compliance, in the context of medical treatment, refers to how well a patient follows and sticks to the management plan developed with her/his health care provider, which may include pharmacologic agents as well as changes in lifestyle. Adherence is of great concern in asymptomatic conditions such as hypertension, where lack of control may have serious ramifications including end organ damage and premature mortality. To address this issue, the Canadian Coalition for High Blood Pressure Prevention and Control established a national Advisory Committee on Adherence to the Management of High Blood Pressure. The Advisory Committee consisted of 11 members from different disciplines of health care providers. The Committee reviewed all evidences to date and drew up four practical recommendations with respect to patient, provider and environment. Based on Canadian Task Force on Periodic Health Examination's guidelines, all four recommendations can be classified as 'level C' with a quality of evidence of II.

[Stimulation of continuing self education for pediatricians using questions with choice of responses]. / Stimulation de l'autoapprentissage continu des pédiatres au moyen de questions à choix de réponses.

During a 15-month period a trial program of continuing self medical education for pediatricians in the province of Quebec was performed by sending out 5 questionnaires, each containing 10 multiple choice questions related to new, controversial, or changing medical subjects. Appropriate responses, relevant references and commentaries, were added to each questionnaire. At the end of the trial period another questionnaire was sent to all pediatricians in order to determine their opinion on the program. The majority gave a favorable response, encouraging its continuation.

Experience with guidelines for cardiac monitoring after electrical injury in children.

The objective of the study was to evaluate the use of guidelines to determine the need of cardiac monitoring in children who sustained an electrical injury. The prospective use of guidelines since implementation July 1994 to June 1998 in a tertiary care pediatric teaching hospital was reviewed. Guidelines were cardiac monitoring for 24 hours is done on children with past cardiac history, loss of consciousness, voltage >240 volt or abnormal electrocardiogram (ECG); an ECG was obtained only when theoretical risk factors were present (tetany, decreased skin resistance by water or burns) or an unwitnessed event. Cardiac monitoring was performed in 29/224 (13%) patients (all normal) for 421 hours since implementation of the guidelines. Reasons included abnormal ECG (n = 10), voltage >240 volts (n = 6), lost of consciousness (n = 3), past cardiac history (n = 2), and unjustified (n = 9). There was no morbidity (0/172 patients 95% CI 0 to 1.7%) or mortality (0/224 patients 95% CI 0 to 1.3%). The guidelines were helpful in determining the need of cardiac monitoring in children after an electrical injury without any apparent risk.

Cardiac monitoring of children with household electrical injuries.

STUDY OBJECTIVE: Because death has occurred with injury involving voltage as low as 50 to 60 V (probably the result of arrhythmias), we wanted to evaluate the necessity of cardiac monitoring in children sustaining electrical injuries with 120 or 240 V. DESIGN: The charts of 151 children who presented to the emergency department between April 1, 1989, and March 31, 1992, were reviewed. SETTING: A tertiary care pediatric teaching hospital. RESULTS: A total of 141 patients presented with 120-V electrical injuries. An ECG or a rhythm strip was performed in 93 patients (66%), and no arrhythmias were believed to have resulted from the electrical injury. Cardiac monitoring was done in 113 patients (80%) for a mean duration of 7.4 +/- 6.6 hours (median, 4 hours), and no arrhythmias were observed. Creatine phosphokinase levels were measured in 62 patients (44%) with a mean of 137 +/- 154 U/L (median, 96 U/L). The levels were elevated in 8 patients (12%), with no clinical significance. Follow-up was done in 112 patients (77%), and no significant adverse outcome was reported. There were only 10 patients in the 240-V group; no arrhythmias or adverse outcomes had occurred. CONCLUSION: On the basis of our findings, initial cardiac evaluation (ECG) and monitoring do not appear to be necessary in children sustaining household electrical injuries (120 and 240-V); however, the significance of loss of consciousness, tetany, wet skin, or current flow that crossed the heart region could not be determined in our investigation. Therefore, cardiac monitoring should be performed if one of these factors is present.

Single daily doses of trimethoprim/sulphadiazine for three or 10 days in urinary tract infections.

We conducted a prospective randomized study to evaluate the efficacy of a single daily dose of 4 mg/kg of trimethoprim coupled with 17.5 mg/kg of sulphadiazine for three (group 1) or 10 days (group 2) in the treatment of uncomplicated urinary tract infections in children. Forty patients (nine boys and 31 girls) aged 2.5-18 years, presenting with a urinary tract infection were allocated to one of the two groups. Patients were seen three, 10, and > or = 38 days after the initiation of treatment. Control urine cultures were negative in all patients at days 3 and 10. Two patients in group 1 and one patient in group 2 suffered a relapse within a month. Single doses of trimethoprim/sulphadiazine for three or 10 days are effective in the treatment of uncomplicated urinary tract infections in children.

[Continuing medical education in pediatrics: maintaining of professional competence with different interactive models]. / Formation médicale continue en pédiatrie: maintien de la compétence professionnelle par divers modèles interactifs.

The forming of professional competence constitutes the primary mission of the university. It follows that the maintenance of professional competence is part of that same mission. Physicians will always remain the first motor of their own competence, but the university will play a major role in organizing and providing continuing medical education activities. At the University of Montreal, many CME programs are regularly offered to practising physicians concerned by pediatric patients (400 pediatricians and 7,000 family physicians). These programs include the following collective activities: 1), biannual convention on pediatric updates; 2), one-day meeting on selected topics; 3), advanced pediatric life support courses; 4), regional conference touring programs by university staff. We have also developed the following individual CME activities: 1), CME letter; 2), self-evaluation questionnaires; 3), miniresidency programs; 4), CME TV series; 5), problem-solving slide series. All these activities are planned according to a need assessment basis and an on-going evaluation process. Priority is given to interactive methods of student-teacher relationship.

Comparative efficacy of terbutaline sulphate delivered by Turbuhaler dry powder inhaler or pressurised metered dose inhaler with Nebuhaler spacer in children during an acute asthmatic episode.

AIMS: To compare the efficacy of terbutaline sulphate delivered via Turbuhaler with a pressurised metered dose inhaler (pMDI) connected to Nebuhaler spacer in a population of asthmatic children presenting to emergency departments because of an acute episode of asthma. METHODS: Randomised double blind, double dummy, parallel study of acute asthma in the emergency department. A total of 112 children (6-16 years), who had a diagnosis of asthma, a baseline FEV1 of 25-60% of predicted normal value (PNV), and the ability to perform spirometry were studied. Patients received two doses of 0.5 mg/10 kg (maximum 2.0 mg) of terbutaline sulphate at time 0 minutes and time 30 minutes. The two groups were also stratified into subgroups based on FEV1: 25-45% and 45.1-60% PNV. FEV1 before treatment and at two 15-minute intervals after each treatment was the main outcome measure. PIF, PEF, heart rate, SpO2, and tremor were also measured at these times. RESULTS: Both the Turbuhaler and pMDI+Nebuhaler groups showed significant increases from baseline to final value in their FEV1 results, 49% and 50% change from baseline to t = 60 min, respectively (p < 0.001) using last value carried forward. No significant difference was found between the two groups for these results. Subanalysis of the stratified groups revealed similar results. In addition, no significant difference was found in the group and subgroup comparisons for heart rate, SpO2, and tremor. CONCLUSION: Results show that Turbuhaler and pMDI+Nebuhaler are similar in terms of benefit and side effects in the treatment of acute moderate to severe asthma attacks in this study population.