A randomized, controlled trial of child psychiatric assessments conducted using videoconferencing.

We used a PC-based videoconferencing system to conduct child psychiatry assessments. The telecommunications link was six digital lines, giving a total bandwidth of 336 kbit/s. Twenty-three patients (aged 4-16 years), accompanied by their parents, completed two psychiatric assessments, one via videoconferencing and another face to face (FTF). The order of assessments was randomized. Questionnaires were used to record the diagnosis, treatment recommendations and the psychiatrists', patients' and their parents' satisfaction with each assessment. An independent evaluator concluded that in 22 cases (96%) the diagnosis and treatment recommendations made via the videoconferencing system were the same as those made FTF. The psychiatrists stated that videoconferencing assessments were an adequate alternative to FTF assessments and did not interfere with diagnosis. However, the responses from the psychiatrist satisfaction questionnaire showed that they preferred FTF assessments. No significant difference was found in the patients' or parents' satisfaction responses after the two types of assessment. The majority of children (82%) 'liked' using the telepsychiatry system and six (26%) preferred it to a FTF assessment. Most parents (91%) indicated that they would prefer to use the videoconferencing system than to travel a long distance to see a psychiatrist in person.

Telemedicine activities at memorial University of Newfoundland: a historical review, 1975-1997.

Memorial University of Newfoundland has been continuously involved in telemedicine activities since 1975. Unlike most early telemedicine programs, which did not continue after grant funding ended, Memorial made the transition to create a self-sufficient Telemedicine Centre. Key to its success was the vision and drive of its founder, Dr. Max House, and adherence to the following principles: (1) all activities were based on a legitimate need; (2) the simplest, least expensive technology was used to meet the need; (3) the network was shared by a variety of users; and (4) users were given proper training and support. Over the years, Memorial has been involved in 30 telemedicine projects, many of which became ongoing services. Although most initial activity was health related, educational activities have played an increasingly important role. In 1997, the Telemedicine Centre delivered approximately 7000 hours of programming and administered a network of 247 dedicated audioconference sites in 161 communities (168 of the sites had telewriter workstations and 75 had multimedia workstations) and eight videoconferencing sites. Approximately 70% of all programming was distant high school and university education, 20% health education, 5% clinical activities, and 5% other uses. Current clinical activities include tele-electroencephalograms, tele-ultrasonography, tele-nuclear medicine, child telepsychiatry, general teleconsultation from a remote nursing station, and general teleconsultation from an offshore oil platform. Lessons learned from more than 20 years of telemedicine experience are presented.

A practical approach to lifestyle change counselling in primary care.

Many contemporary medical conditions have been found to be the consequence of lifestyle choices. These adverse habit patterns have their origin in the individuals family and/or natural social network. Primary care practitioners frequently interact with their patients for the purpose of helping them resolve medical problems by clarifying issues or presenting different options. In lifestyle related conditions, the initiation and maintenance of possible behaviour changes is usually the optimal resolution. How people intentionally change well-established behaviour patterns is still not well understood, and most clinicians are not confident in their ability to help patients alter adverse behaviours. Several studies provide support for a 'stage-matched framework' of behaviour change that integrates readiness for change with intervention processes from various theoretical models. This article provides a brief overview of the current thinking with respect to self-initiated and professionally facilitated behaviour change, and then describes a generic five-step approach to individualized lifestyle counselling for use in primary care clinical settings.

Putting prevention into practice.

In primary medical care settings, disease prevention services are delivered at lower rates than recommended. Furthermore, practitioners tend to overestimate the rate at which they perform them. There are essentially two steps in delivering evidence-based preventive services: (1) knowing what the evidence is for performing various detection and intervention manoeuvres, and (2) integrating the preventive services into daily practice. The first is a scientific process and is carried out in Canada by the Canadian Task Force on the Periodic Health Examination. However, after a decade of experience with evidence-based guidelines, we now know that guidelines are not enough. Integrating clinical prevention into busy practices is a political and logistical process. This truth is best captured by the quip, "An ounce of prevention requires a pound of office system change". A number of studies have demonstrated that continuing medical education (CME) courses and workshops for physicians are not enough to ensure that clinical preventive services are incorporated into practice. According to Lomas, the traditional CME educational approaches need to be complemented by strategies from such paradigms as the social influence model, the diffusion of innovation model and the adult learning model. Battista, in "From Science to Practice," points out the complexity of the communication process required for the diffusion of innovation into practice. Walsh's Systems Model of Clinical Preventive care best captures the interacting factors that mediate between practitioners' intentions and their actions when it comes to delivering clinical prevention services. This paper reports on a practical example of helping family practitioners develop a "sustaining office system in prevention" that minimizes barriers, focuses energy and integrates clinical prevention into office routines. The key components are (i) a practice coordinator for prevention, (ii) clear clinical prevention-related job descriptions for all persons who deal with patients, (iii) an information management system that reinforces prevention, and (iv) a practice feedback and problem solving strategy.

Case-control study of prenatal ultrasonography exposure in children with delayed speech.

OBJECTIVE: To determine whether there is an association between prenatal ultrasound exposure and delayed speech in children. DESIGN: Case-control study. SETTING: Network of community physicians affiliated with the Primary Care Research Unit, University of Calgary. SUBJECTS: Thirty-four practitioners identified 72 children aged 24 to 100 months who had undergone a formal speech-language evaluation and were found to have delayed speech of unknown cause by a speech-language pathologist. For each case subject the practitioners found two control subjects matched for sex, date of birth, sibling birth order and associated health problems. MAIN OUTCOME MEASURES: Rates of prenatal ultrasound exposure and delayed speech. RESULTS: The children with delayed speech had a higher rate of ultrasound exposure than the control subjects. The findings suggest that a child with delayed speech is about twice as likely as a child without delayed speech to have been exposed to prenatal ultrasound waves (odds ratio 2.8, 95% confidence limit 1.5 to 5.3; p = 0.001). CONCLUSION: An association between prenatal ultrasonography exposure and delayed speech was found. If there is no obvious clinical indication for diagnostic in-utero ultrasonography, physicians might be wise to caution their patients about the vulnerability of the fetus to noxious agents.

In vivo regulatory responses of four Escherichia coli operons which encode leucyl-tRNAs.

Four Escherichia coli operons, the leuV operon which encodes tRNA(1Leu), the leuX operon which encodes tRNA(6Leu), the metT operon which encodes tRNA(3Leu), and the argT operon which encodes tRNA(1Leu), were examined for the stringent response induced by serine hydroxamate and for growth rate-dependent regulation. In nuclease protection assays, the leuV operon displayed the stringent response in response to leucine starvation, analog inhibition, and growth of a temperature-sensitive leucyl-tRNA synthetase mutant at nonpermissive temperatures. The leuV operon also exhibited the stringent response in multicopy plasmids. The promoters of all four leucyl operons were fused to the gene for beta-galactosidase and inserted into the chromosome by using bacteriophage lambda. All except the leuX promoter displayed growth rate-dependent regulation, consistent with the recent report that the concentration of tRNA(6Leu) actually decreases as growth rate increases. The leuV promoter fused to the beta-galactosidase gene showed a decrease in efficiency in the presence of extrachromosomal copies of rRNA genes. All chromosomal tRNA genes examined showed decreased transcriptional activity following a stringent response, but the leuX gene responded to a lesser extent (3-fold versus 10-fold or more) than the others. Primer extension analysis of this promoter showed little if any response to serine hydroxamate treatment, suggesting that multiple levels of control may exist or that promoter context effects are important in regulation.

Mutagenesis and functional analysis of the Escherichia coli tRNA(1Leu) promoter.

The leuV promoter which produces tRNA(1Leu) in Escherichia coli has been extensively mutagenized in order to determine the effects of altered sequences on promoter efficiency (strength) and on growth-rate-dependent regulation (GDR). Each mutant promoter was ligated with a beta-galactosidase reporter gene into the chromosome of a host cell by phage lambda lysogenization. Reporter gene activities were measured for cells growing in selected media at various growth rates. Sequences which flank the -10 consensus region, when altered, caused remarkable up-promoter effects, increasing efficiency in some cases almost 10-fold. One up mutation which had five successive T residues in the 'discriminator' region completely abolished GDR, whereas several mutations with single base changes in the discriminator had little or no effect on GDR. Another mutation which changed one base in the -35 region to bring it to consensus increased promoter strength 18-fold and sharply reduced GDR. Chimaeric promoters in which segments of leuV were replaced by segments of the his operon showed that only when the discriminator of leuV is replaced by the his discriminator was GDR-disturbed. All upstream sequences which were replaced by his sequences had little effect on GDR. Overall, there appeared to be little correlation between promoter efficiency and GDR.

Reducing the Risk of Coronary Artery Disease: Helping patients change.

Lifestyle and prevention are increasingly emphasized as ways to promote cardiovascular health. Family physicians will play a central role in detecting risk and encouraging lifestyle changes. This article outlines an effective preventive approach to coronary artery disease. The steps and skills involved are discussed as well as aspects of practice cultures that influence family physicians' activities.

Detecting Elevated Cholesterol Levels: Part 1: How accurate is the Reflotron?

To assess accuracy of blood cholesterol measurements in the office, fingerprick blood cholesterol assays by a dry reagent chemistry analyzer were compared in 151 patients with simultaneous venipuncture cholesterol assays by standard laboratory methods. Compared with the laboratory assay, seven of eight analyzers had total absolute biases less than 5%. Variability in results was comparable to that of community laboratories.

Detecting Elevated Cholesterol Levels: Part 2: Prevalence and feasibility considerations.

The Reflotron dry chemistry reflectance photometer was studied as a case-finding method in physicians' offices. A total of 713 adult patients had their risk factor profiles determined along with fingerprick blood cholesterol measurements. Blood cholesterol levels were classified into three categories, (<5.2 mmol/L), 51%; borderline high (5.2 to 6.1 mmol/L), 28%; and high (≥6.2 mmol/L), 21%. The physicians' predictions from clinical risk factor profiles of which patients had elevated serum cholesterol levels were inaccurate.

Nucleotide sequence of the Escherichia coli tRNA(3Leu) gene.

A 300-nucleotide sequence was determined which includes the tRNA(3Leu) coding region and the flanking sequences.

Pharyngitis 1987: a survey of physicians' attitudes and practices in southern Alberta.

A questionnaire survey concerning Streptococcal pharyngitis was completed by 85 southern Alberta family physicians. The data revealed a significant trend to overtreat pharyngitis with antibiotics because of the unreliability of clinical diagnosis and the lack of diagnostic manoeuvres with suitable ability to influence management. These data and a further questionnaire survey directed to the appreciation of other bacterial pharyngitides, demonstrate the importance of laboratory reports in biasing treatment, and further suggest that significant overtreatment of non-Streptococcal pharyngitis also occurs.

One approach to demystifying research in primary care.

"Research" means different things to different people. "Organized curiosity" has been proposed as a suitable description for family-practice research. Studies involving patients in community practices are becoming recognized as a unique type of research that contributes new understanding to matters relating to primary care. Such research, however, requires an infrastructure that makes a study as unobtrusive as possible in participating practices. One approach is the development of a primary care research unit (PCRU): a central co-ordinating communications office which can provide the human and technical resources needed to assist each community office with protocol and data-collection steps. The author of this article describes the functional components of a PCRU in five groupings: namely, technical, human, communication and support systems, a network of community physicians, and facilities. Finally, several important principles about funding primary care research are suggested.

The impact of preventive cardiology on coronary artery disease.

Ischemic heart disease continues to be the leading cause of death among middle-aged people in industrialized countries. However, in North America the rates of death and disability from coronary artery disease (CAD) have declined, mostly because of a reduction of the main modifiable risk factors (high serum cholesterol levels, smoking and hypertension). Intervention trials have consistently shown that the lowering of the severity of risk factors decreases the incidence of CAD. These studies have introduced the goals of preventive cardiology to clinicians but have not provided the necessary knowledge and skills to achieve them. Unfortunately, with the exception of hypertension, the risk factors for CAD are infrequently assessed and managed in ambulatory patients. Incorporation of detection and intervention strategies derived from recent epidemiologic, behavioural and biomedical research into the existing primary health care system may be the most efficient and effective approach to further reducing the impact of CAD. The family physician's office is the ideal location to implement behavioural change strategies. However, primary care intervention to decrease the risk of ischemic heart disease among people at high risk has yet to be studied. In addition, whether the same clinicians who render primary care can assume the responsibility for surveillance and preventive care has to be demonstrated.

Do the beta-hemolytic non-group A streptococci cause pharyngitis?

Implication of the beta-hemolytic non-group A streptococci (BHNAS) as pharyngeal pathogens has been based predominantly on reports of a few outbreaks, small case clusters, and anecdotes. These organisms have long been noted to constitute a significant number of the beta-hemolytic streptococcal isolates from throats of symptomatic and asymptomatic patients in a variety of populations. Laboratory studies have demonstrated the usefulness of anaerobic atmosphere and prolonged incubation in maximizing isolation of the BHNAS. More recently, genetic studies have furthered our appreciation of the taxonomy and have defined two major groups: Streptococcus anginosus-milleri group and large-colony BHNAS; the latter can be further separated on the basis of serogrouping and biotyping. Recognition of this diversity gives justification to the reexamination of the epidemiology and disease course of BHNAS pharyngitis. Treatment studies will also be required if all or subsets of these organisms can be confirmed as pharyngeal pathogens.

Sequence determinants for promoter strength in the leuV operon of Escherichia coli.

The promoter for the leuV tRNA operon of Escherichia coli has been studied. Derivatives of this promoter were examined in vivo, fused to the cat gene or to the lacZ gene. When compared to other promoters, the leuV promoter was found to be at least three times stronger than the tyrT promoter (for the tyrT tRNA operon), or the lac promoter (trp::lac promoter fusion) and as strong as the P1,P2 promoter of the rrnB operon (a ribosomal RNA operon). Deletion analysis revealed that, while removal of sequences downstream from +11 (relative to the transcription start point) did not affect activity, removal of sequences upstream from -39 resulted in a ten-fold reduction in expression. Unlike rRNA operons which also display upstream activation, sequences responsible for this effect in the leuV promoter are separated into two regions, one between -76 and -47, and the other between -45 and -39. DNA fragments carrying the leuV promoter migrate aberrantly on polyacrylamide gels, a phenomenon usually associated with DNA bending. One sequence thought to be involved in bending is a TTTTT run centered around -71. Point mutations engineered at this T5 region resulted in a loss of activation but had no apparent effect on migration rate. Transcription efficiency of promoter derivatives was examined in vitro using supercoiled, relaxed, or linearized plasmids as templates. Upstream activation was observed only when using relaxed templates, although maximum activity was obtained using supercoiled forms. Insertion of the very efficient 16S transcription terminator between the leuV promoter and the cat gene resulted in barely detectable activities, indicating that no antitermination mechanism was present.

Fusion of the Escherichia coli tRNALeu1 promoter to the galK gene: analysis of sequences necessary for growth-rate-dependent regulation.

We have fused DNA fragments derived from an Escherichia coli tRNALeu1 operon to the galK gene of E. coli to identify sequences necessary for the in vivo initiation of transcription and growth-rate-dependent regulation. Promoter sequences consisting of residues from -50 to +56 or -50 to +5 with respect to the in vivo site for initiation of transcription were introduced into chimeric plasmids upstream from the galK gene. Cells bearing these chimeric plasmids exhibited much higher levels of galactokinase than did cells bearing plasmids wherein the galactose promoter was fused to galK. This indicates that the tRNALeu1 promoter is substantially more efficient than the gal promoter. The tRNALeu1 promoter-galK chimeras exhibited marked growth-dependent regulation in a manner consistent with that reported for tRNA regulation. Since tRNALeu1 DNA spanning residues -50 to +5 was sufficient to provide growth rate regulation of galK, an inverted repeat centered at position +17 is not, under the conditions we used, required for this type of regulation.