Insomnia and its relationship to health-care utilization, work absenteeism, productivity and accidents.

BACKGROUND AND PURPOSE: To document and provide a micro analysis of the relationship between insomnia and health problems, health-care use, absenteeism, productivity and accidents. PARTICIPANTS AND METHODS: A population-based sample of 953 French-speaking adults from Québec, Canada. Participants were categorized as having insomnia syndrome (SYND) or insomnia symptoms (SYMPT) or as good sleepers (GS). They completed questionnaires on sleep, health, use of health-care services and products, accidents, work absences and reduced work productivity. Data were also obtained from the Québec-government-administered health insurance board on selected variables (e.g., consultations with health-care professionals, diagnoses). RESULTS: There were significantly more individuals in the SYND group relative to the GS group reporting at least one chronic health problem (83% vs. 53%; OR: 2.78) and who had consulted a health-care professional in the past year (81% vs. 60%; OR: 2.8). There were also higher proportions of individuals in the SYND group than in the GS group who had used prescription medications (57% vs. 30.7%; OR: 2.8), most notably to treat insomnia, mood and anxiety disorders, or who had used over-the-counter products (75.6% vs. 62.0%; OR: 1.8) and alcohol as a sleep aid (17.8% vs. 3.9%; OR: 4.6). In terms of daytime function, 25.0% of the SYND had been absent from work relative to 17.1% of GS (OR: 1.7), 40.6% reported having experienced reduced productivity compared to 12.3% of GS (OR: 4.8) and non-motor-vehicle accidents occurred at higher rates in the SYND group (12.5% vs. 6.4% for GS; OR: 2.4). No differences were found for hospitalisations or motor-vehicle accidents. Most of the associations remained significant even after controlling for psychiatric comorbidity. Rates for the SYMPT group were situated between SYND and GS on all major dependent variables. Furthermore, insomnia and fatigue were perceived as contributing significantly to accidents, absences and decreased work productivity, regardless of insomnia status. CONCLUSIONS: This study indicates that insomnia is associated with significant morbidity in terms of health problems and health-care utilization, work absenteeism and reduced productivity, and risk of non-motor-vehicle accidents. Future studies should evaluate whether treating insomnia can reverse this morbidity.

Older adults' acceptance of psychological and pharmacological treatments for depression.

Two hundred participants aged 65 and older recruited from 4 different family medicine clinics rated the acceptability of 3 different treatments for geriatric depression: (a) cognitive therapy (CT), (b) cognitive bibliotherapy (CB), and (c) antidepressant medication (AM). Results showed that the acceptability of the treatments is a function of the severity of the symptoms of the depressed patient to whom they would be applied. CT and CB were rated as more acceptable than AM when patient symptoms were mild to moderate. However, CT was more acceptable than both CB and AM when patient symptoms were described as severe. Acceptability ratings were not related to the raters' own depressive symptoms. The practical implications of these results are discussed.

[Behavior and cognitive treatments for insomnia. An alternative to pharmacotherapy]. / Traitements cognitifs et comportementaux de l'insomnie. Une alternative à la pharmacothérapie.

OBJECTIVE: To familiarize family physicians with cognitive and behavioural treatments for insomnia. DATA SOURCES: MEDLINE was searched from 1983 to 1995 and Psychlit from 1974 to 1995 using the key words "behaviour therapy," "cognitive therapy," "phototherapy," and "insomnia." STUDY SELECTION: We chose randomized trials and meta-analyses on the treatment of insomnia. Information was extracted on time-lag before sleep, frequency and duration of wakeful periods during the night, consumption of hynotics, and subjects' own assessment of their sleep before and after treatment. SYNTHESIS: The most effective interventions were relaxation training, sleep restriction, and stimulus control. Practising good sleeping habits was only somewhat effective and should always be used in conjunction with other interventions. CONCLUSION: Stimulus control for insomnia has been demonstrated to be effective when used by primary care physicians. Other nonpharmacologic treatments should be evaluated in a similar manner.

[Not Available]. / Suivi des cytologies cervicales anormales dans une unité de médecine familiale.

This study assesses the follow-up provided to patients of a family medicine clinic in Quebec who had abnormal cervical smears that were possibly precancerous or cancerous. Less follow-up was provided in the case of benign atypical smears, probably because the role of benign atypia in the pathogenesis of cervical cancer is as yet unclear.

Stimulus-control: nonpharmacologic treatment for insomnia.

OBJECTIVES: To evaluate the efficacy and applicability of a behavioural treatment for insomnia that can be administered by family physicians in various clinical settings. DESIGN: Efficacy of the treatment was evaluated by single-case experimental designs (multiple baseline across subjects). Applicability was assessed through semistructured interviews with physicians. SETTING: Two private offices, two offices in community health centres, and one office in a family medicine unit. PARTICIPANTS: Six general practitioners and 24 chronic insomniac patients recruited through media advertisements and from physicians' practices. Of an initial 38 subjects screened, six were excluded for sleep-onset latency less than 30 minutes, five for psychological conditions, one for physical handicaps, and two for other reasons. INTERVENTIONS: Physicians used stimulus-control treatment during individual therapeutic sessions. Patients using hypnotics were encouraged to taper off their medications after treatment was initiated. MAIN OUTCOME MEASURES: Time it took patients to get to sleep (sleep-onset latency), amount of hypnotic use, and practitioners' evaluation of the treatment. RESULTS: Fifteen patients completed the treatment; 80% of them reduced their sleep-onset latency. Six of the seven patients using hypnotics at the beginning of the study reduced or stopped their medications. All therapeutic gains were maintained at 3 and 6 months. Physicians thought stimulus-control treatment could be used in medical practice, but specified that it was most useful for highly motivated patients. CONCLUSION: Family physicians can use stimulus-control treatment effectively for patients with chronic insomnia. This nonpharmacologic approach could help motivated patients reduce their use of hypnotics.

Calmodulin-binding proteins in bovine semen.

An 125I-labelled calmodulin gel overlay procedure was used to direct calmodulin-binding proteins in bovine spermatozoa and seminal plasma. Several calmodulin-binding proteins with molecular masses ranging from 12 to > 200 kDa were detected in epididymal and ejaculated spermatozoa. Certain of these proteins exhibited preferential calmodulin-binding in the presence of Ca2+, while others exhibited binding only in its absence. In seminal plasma, only two major proteins with molecular masses of 15 and 16 kDa showed a higher calmodulin-binding activity in the presence of Ca2+, whereas several polypeptides in the range of 6-17 kDa bound higher amounts of radiolabelled calmodulin in the absence of Ca2+. Our previous study has shown that a group of closely related major proteins, designated as BSP-A1, BSP-A2, BSP-A3 and BSP-30 kDa, isolated from bovine seminal plasma (BSP) have molecular masses in the range of 15-30 kDa. This prompted us to investigate whether these polypeptides from bovine seminal fluid interact with calmodulin. The results indicated that calmodulin binds to purified BSP-A1, -A2, -A3 and BSP-30 kDa proteins in the presence and absence of Ca2+. Furthermore, many polypeptides of low molecular mass (6-14 kDa) in bovine seminal plasma that crossreact with these BSP proteins also show high calmodulin-binding activity, particularly in the absence of calcium. This was further demonstrated following the limited proteolysis of the BSP proteins. Several tryptic-peptides of BSP-A1/-A2 and BSP-30 kDa exhibited higher calmodulin-binding activity than the intact BSP proteins. In view of the key role of Ca2+ in triggering the acrosome reaction and the role of calmodulin in intracellular transport of calcium, it is suggested that BSP proteins are involved in sperm capacitation and the acrosome reaction.

[Recording of drug prescriptions in medical records. How to improve the quality?]. / Inscription des ordonnances de médicaments au dossier. Comment en améliorer la qualité?

OBJECTIVE: To describe the evaluation of a program to improve the recording of drug prescribing in medical records. DESIGN: Experimental study with before and after measurements, without a control group, of the medical files of all patients who consulted during 2 different weeks, 9 months apart. SETTING: Family Medicine Unit of Centre hospitalier de l'Université Laval. PARTICIPANTS: Teachers and residents in the Family Medicine Unit. MAIN OUTCOME MEASURE: Proportion of prescriptions for drugs having a systemic effect (n = 206 for week before, n = 257 for week after) for which the following information was recorded: concentration, dosage, quantity prescribed or length of treatment, number of renewals. RESULTS: After the program, recording frequency increased from 86% to 97% for concentration, 80% to 95% for dosage, 52% to 79% for the quantity prescribed, and 20% to 71% for number of renewals. Both groups of doctors showed a notable improvement, except for the recording of quantity prescribed by residents, which remained stable. CONCLUSION: We observed an improvement in the recording of drug prescriptions in medical files. The program had a greater effect on teachers who had been exposed to activities that are known to be effective in improving recording.

Regulation of cartilage oligomeric matrix protein synthesis in human synovial cells and articular chondrocytes.

OBJECTIVE: Cartilage oligomeric matrix protein (COMP) is a component of the extracellular matrix of articular cartilage. Its increased presence in synovial fluid and serum has been associated with accelerated joint damage in patients with rheumatoid arthritis (RA) and osteoarthritis. To fully understand the reasons for fluctuations of COMP levels, we studied the biosynthesis of this molecule in cells derived from joint tissues. METHODS: Synovial cells were derived from synovial tissues of patients with RA, and human articular chondrocytes were prepared from normal articular cartilage. Analysis by Northern blotting was used to evaluate steady-state levels of COMP messenger RNA (mRNA), while secretion of the protein into culture media was analyzed by Western blotting. Expression of COMP in synovial tissues was studied by reverse transcriptase-polymerase chain reaction analysis and by in situ hybridization. RESULTS: COMP was synthesized and secreted by synovial cells as well as by articular chondrocytes in culture. The basal rate of synthesis was very low; however, COMP biosynthesis in both cell populations was induced very strongly by transforming growth factor beta1 (TGFbeta1). Interleukin-1beta counteracted COMP induction by TGF-beta1. COMP was not detected in culture media of skin or fetal lung fibroblasts, either in the absence or the presence of TGFbeta1. COMP mRNA was also present in fresh synovial tissue specimens obtained from patients with RA. CONCLUSION: COMP is synthesized and secreted not only by articular chondrocytes, but also by synovial fibroblasts. The demonstration of COMP expression in surgical specimens of synovial tissues suggests that the inflamed synovium may provide an additional source for the elevated levels of COMP observed in arthritis. Thus, increased COMP levels in body fluids may be indicative of active synovitis as well as of accelerated joint erosion.

[Study on insomnia treatment by family physicians]. / Enquête sur le traitement de l'insomnie par les omnipraticiens.

OBJECTIVES: To describe treatment of insomnia in general practice and to identify family physicians' training needs in this area. DESIGN: Mail survey using Dillman's total design method. PARTICIPANTS: A sampling of 484 general practitioners in the Quebec City area was done to provide roughly equal representation of six practice settings. The response rate was 65%; 295 of the 315 questionnaires returned were selected for analysis. RESULTS: Most physicians reported treating insomnia with general advice and lifestyle changes; 25% reported prescribing hypnotics frequently; 56% reported they prescribed them occasionally. Although 58% often recommend relaxation techniques, only 8% taught these techniques to their patients. Other cognitive and behavioral approaches are rarely used. Most felt that training in treating insomnia should be offered. CONCLUSION: Cognitive and behavioral approaches are very effective approaches are very effective nonpharmacological treatments for insomnia. General practitioners make little use of these treatments that could be easily integrated into clinical practice. Strategies for increasing their use discussed.

Distribution of indomethacin in human milk and estimation of its milk to plasma ratio in vitro.

1. The distribution of indomethacin in fat and protein fractions of colostrum and mature milk as well as its milk to plasma drug concentration ratio (M/P ratio) were determined in vitro. 2. The extent of plasma protein binding of indomethacin (5-20 microg ml(-1)) was > or = 99.6%. The protein binding of indomethacin in colostrum was 46.0% at pH 7.4. The lower protein content of mature milk compared with colostrum was associated with a significant decrease in the extent of drug protein binding (46 +/- 1.93 to 35 +/- 1.0 s.e. mean). Protein binding was also decreased significantly in 8% fat mature milk (20.3 +/- 2.4 s.e mean) but was constant over the pH range 7.4 to 6.8. 3. About 40% of indomethacin added to milk was associated with the fatty layer. The indomethacin M/P ratio determined by equilibrium dialysis was less than 0.01. Hence the maximum infant daily dose was estimated to be 0.006 mg kg(-1). 4. Our results indicate that indomethacin transfers to milk by simple diffusion according to its physicochemical properties, and that treatment with indomethacin is not a contraindication to breast feeding.

Caffeine-cigarette interaction on fetal growth.

The influence of caffeine and cigarette consumption on fetal growth during pregnancy was studied retrospectively in 913 newborn infants. Analysis of variance was adjusted for length of gestation and sex. A significant caffeine-cigarette interaction was found on birth weight (F = 85.4, p less than 0.01). Among women smoking 15 cigarettes or more per day, birth weight was 206 gm (+/- 57.7 gm) lighter for babies whose mothers consumed 300 mg or more of caffeine per day. Head circumference and length of the newborns were affected only by cigarette smoking. Another caffeine-cigarette interaction was observed on placental weight (F = 15.0, p less than 0.01). Among women who consumed less than 300 mg of caffeine daily, placental weight increased with cigarette consumption. However, it diminished (p less than 0.05) among women smoking 15 cigarettes or more per day if they consumed 300 mg or more of caffeine daily. This is the first time that such interactions were found to influence birth and placental weights, indicating that the concomitant consumption of caffeine and cigarette constitutes a higher risk for the developing fetus.

Paracetamol pharmacokinetics during the first trimester of human pregnancy.

Paracetamol pharmacokinetics was evaluated in groups of pregnant (8-12 weeks) and non pregnant women given the standard oral dose of 650 mg. The mean half-life was significantly lower and oral clearance was significantly higher in the first trimester group compared to the control group. The AUC was lower in the first trimester but the difference was not significant. The maximum serum concentration (Cmax) was reached 48 min after administration in both groups, and the mean maximal serum concentration was similar in the pregnant and non-pregnant women (11.16 and 11.58 micrograms.ml-1). A correlation of r = 0.85 was found between Cmax and the weight of the pregnant women (P < 0.01) but not with the weight of the control women, this suggests that weight gain might be used to determine the women in whom dosage adjustment is needed.

[The effects of Arnica Montana on blood coagulation. Randomized controlled trial]. / Les effets de l'Arnica Montana sur la coagulation sanguine. Essai clinique randomisé.

The purpose of this study, which took the form of a two-period cross-over clinical trial, was to determine whether a homeopathic substance, Arnica Montana, significantly decreased bleeding time (Simplate II) and to describe its impact on various blood coagulation tests. It was not shown that this substance had a significant impact on various parameters of blood coagulation in healthy volunteers in the period immediately following administration [corrected].

Screening for diabetic retinopathy. Do family physicians know the Canadian guidelines?

OBJECTIVE: To assess whether family physicians and family medicine residents know what the Canadian guidelines for screening for diabetic retinopathy are, and to assess whether they believe they can perform this screening. DESIGN: Mailed survey with two mailed reminders. PARTICIPANTS: All general practitioners (N = 1038) listed in two health catchment areas, Québec and Chaudière-Appalaches administrative regions in the province of Québec, and all family medicine residents (N = 125) at Laval University Medical School. Response rate was 62% among general practitioners and 77% among residents. MAIN OUTCOME MEASURES: Knowledge of screening guidelines for diabetic retinopathy in type I and type II diabetes, including timing of the initial screening examination, risk factors, natural history, and treatment of ocular complications; and perception of ability to screen for diabetic retinopathy. RESULTS: Among GPs, 80% of respondents correctly chose the statement with the current guideline for first screening for diabetic retinopathy to be performed shortly after diagnosis of type II diabetes. Only 13% of respondents were familiar with the guideline for first screening 5 years after diagnosis of type I diabetes. Agreement with other correct guideline statements was also low. Overall, residents had higher scores than GPs. Most respondents were not confident in the accuracy of their eye examinations. CONCLUSIONS: General practitioners and family medicine residents have varying levels of knowledge about the Canadian guidelines for screening for diabetic retinopathy. These results will be useful in designing and improving educational programs for GPs in diabetic retinopathy screening.

Association between median episiotomy and severe perineal lacerations in primiparous women.

OBJECTIVE: To evaluate the association between median episiotomy and severe (third- and fourth-degree) perineal lacerations in primiparous women. DESIGN: Retrospective cohort study. SETTING: University-affiliated hospital providing secondary obstetric care in Quebec City. PATIENTS: A total of 6522 primiparous women who gave birth vaginally to a single live baby in cephalic position between 1985 and 1993. OUTCOME MEASURE: Incidence of third- and fourth-degree perineal lacerations. RESULTS: Median episiotomy was performed in 4390 women (67.3%). A total of 1002 women (15.4%) had a third- or fourth-degree laceration. The frequency of severe perineal lacerations was 20.6% with episiotomy and 4.5% without episiotomy (relative risk [RR] 4.58, 95% confidence interval [CI] 3.74-5.62). This association persisted after adjustment by stratified analysis for type of delivery and birth weight (RR 3.03, 95% CI 2.52-3.63) and by logistic regression for type of delivery, birth weight, epidural analgesia, shoulder dystocia, baby's head circumference, experience of the physician and year of delivery (odds ratio 3.58, 95% CI 2.84-4.50). CONCLUSION: Median episiotomy is strongly associated with third- and fourth-degree perineal lacerations in primiparous women. Reducing the use of this procedure could decrease the occurrence of severe perineal tears.

[Evaluation of medical web sites. Interobserver and intraobserver reliability of an evaluation tool]. / Evaluation des sites web médicaux. Fidélité interobservateur et intraobservateur d'un outil d'évaluation.

OBJECTIVE: To develop and test the reliability of a tool for rating websites that provide information on evidence-based medicine. DESIGN: For each site, 60% of the score was given for content (eight criteria) and 40% was given for organization and presentation (nine criteria). Five of 10 randomly selected sites met the inclusion criteria and were used by three observers to test the accuracy of the tool. Each site was rated twice by each observer, with a 3-week interval between ratings. SETTING: Laval University, Quebec city. PARTICIPANTS: Three observers. MAIN OUTCOME MEASURES: The intraclass correlation coefficient (ICC) was used to rate the reliability of the tool. RESULTS: Average overall scores for the five sites were 40%, 79%, 83%, 88%, and 89%. All three observers rated the same two sites in fourth and fifth place and gave the top three ratings to the other three sites. The overall rating of the five sites by the three observers yielded an ICC of 0.93 to 0.97. An ICC of 0.87 was obtained for the two overall ratings conducted 3 weeks apart. CONCLUSION: This new tool offers excellent intraobserver and interobserver measurement reliability and is an excellent means of distinguishing between medical websites of varying quality. For best results, we recommend that the tool be used simultaneously by two observers and that differences be resolved by consensus.

Relation of caffeine intake during pregnancy to intrauterine growth retardation and preterm birth.

Whether caffeine intake during pregnancy is related to intrauterine growth retardation, low birth weight, and preterm birth remains unclear. The purpose of this population-based study is to assess these associations and to evaluate the interaction between caffeine intake and smoking. The study participants (n = 7,025) were women who lived in Quebec City, Canada, and the surrounding area who gave birth between January 1989 and October 1989 to a singleton liveborn neonate. Information on gestational age at delivery, caffeine intake (coffee, tea, chocolate, and colas) during pregnancy, and several potential confounders was obtained by telephone a few weeks after delivery. Birth weight was abstracted from the birth certificate. Caffeine consumption was associated with an increased risk of intrauterine growth retardation (birth weight less than the 10th percentile for sex and gestational age). For women whose average daily caffeine consumption was 0-10, 11-150, 151-300, or > 300 mg, the adjusted odds ratios for delivering a newborn with growth retardation were 1.00, 1.28 (95% confidence interval (CI) 1.04-1.59), 1.42 (95% CI 1.07-1.87), and 1.57 (95% CI 1.05-2.33), respectively. Caffeine intake, however, was not related to preterm delivery or low birth weight. We conclude that caffeine intake during pregnancy is a risk factor for intrauterine growth retardation.