Natural disasters in developing countries: an environmental health perspective.

Inadequate water supply and sanitation services underscore the lives of billions of people in the developing world. This situation is compounded when natural disasters strike because the existing infrastructure is destroyed, and scarce resources are diverted to cope with the crisis and then the reconstruction. In comparison, many industrialised countries have prevention measures in place to reduce the risk of damage, and policies and actions in place to reduce the impact of the next disaster. Environmental health professionals from both government and non-government organisations can play an important role in disaster prevention, mitigation and response in these situations. However, the success of environmental health programmes does depend on the existing social inequities. This is because in many developing countries, the poorest and least powerful people already live in a situation with poor water supply and sanitation, which is compounded by natural disasters.

Gluconeogenesis from glutamine and lactate in the isolated human renal proximal tubule: longitudinal heterogeneity and lack of response to adrenaline.

Recent studies in vivo have suggested that, in humans in the postabsorptive state, the kidneys contribute a significant fraction of systemic gluconeogenesis, and that the stimulation of renal gluconeogenesis may fully explain the increase in systemic gluconeogenesis during adrenaline infusion. Given the potential importance of human renal gluconeogenesis in various physiological and pathophysiological situations, we have conducted a study in vitro to further characterize this metabolic process and its regulation. For this, successive segments (S1, S2 and S3) of human proximal tubules were dissected and incubated with physiological concentrations of glutamine or lactate, two potential gluconeogenic substrates that are taken up by the human kidney in vivo, and glucose production was measured. The effects of adrenaline, noradrenaline and cAMP, a well established stimulator of gluconeogenesis in animal kidney tubules, were also studied in suspensions of human renal proximal tubules. The results indicate that the three successive segments have about the same capacity to synthesize glucose from glutamine; by contrast, the S2 and S3 segments synthesize more glucose from lactate than the S1 segment. In the S2 and S3 segments, lactate appears to be a better gluconeogenic precursor than glutamine. The addition of cAMP, but not of adrenaline or noradrenaline, led to the stimulation of gluconeogenesis from lactate and glutamine by human proximal tubules. These results indicate that, in the human kidney in vivo, lactate might be the main gluconeogenic precursor, and that the stimulation of renal gluconeogenesis observed in vivo upon adrenaline infusion may result from an indirect action on the renal proximal tubule.

Health care system reform. Ontario family physicians' reactions.

OBJECTIVE: To determine the effect on a cohort of family physicians of health care system reforms in Ontario and the relationship of reforms to their career satisfaction. DESIGN: Follow-up survey in 1999 of a cohort initially studied in 1993, posing many of the original questions along with some new ones. Four focus groups of other Ontario family physicians. SETTING: Family practices in Ontario. PARTICIPANTS: All family physicians who had received certification after completing a family medicine residency between 1989 and 1991 and were practising in Ontario in 1993. This report addresses only those members of the cohort who continued to practise family medicine in Ontario (N = 236). Four focus groups with a total of 27 family physicians. MAIN OUTCOME MEASURES: Reaction to health care system reforms. Perceived effect of reforms on practice. Current perception of quality of health care system and level of career satisfaction and changes in these variables since 1993. RESULTS: Response rate was 53% of original cohort. Only three of 13 selected health reforms were believed to have had a favourable effect. Physicians reported lower levels of satisfaction with their careers. Overall quality of the health care system was perceived by both respondents and focus group members to have declined. Several difficulties affected practice and personal life. CONCLUSION: Family physicians viewed the effect of health care reforms negatively and were significantly less satisfied with their careers than they were in 1993. Better consultation with stakeholders before implementation of reforms is needed to ensure that these stakeholders understand the likely effects of these reforms.

Physicians certified in family medicine. What are they doing 8 to 10 years later?

OBJECTIVE: To determine field of medicine and location of a cohort of physicians certified in family medicine between 1989 and 1991 and residing in Ontario in 1993 and to gather information on the scope of practice of family physicians in the cohort in 1999. DESIGN: Responses to a mailed questionnaire sent in 1999 were compared with responses to a 1993 survey of this group. SETTING AND PARTICIPANTS: All family physicians in Ontario in 1993 who received certification in 1989, 1990, or 1991 after completing a family medicine residency. Seven of 557 respondents to the 1993 survey were ineligible; 293 physicians (53%) responded to the 1999 survey. MAIN OUTCOME MEASURES: Field, location, and scope of practice. RESULTS: About 91% of the cohort were still practising family medicine, although 11% of these had restricted their practices to certain areas within family medicine. Physicians migrated from Ontario (6%) in nearly equal numbers to other provinces and other countries, predominantly the United States. More family physicians offered counseling, shared antenatal care, and newborn care in 1999 than in 1993. Those with restricted family practices provided fewer types of services and were less likely to provide antenatal or intrapartum care or to provide in-hospital services. CONCLUSION: Receiving certification in family medicine does not guarantee that physicians will remain in family practice 8 to 10 years later. Loss from general family medicine to restricted practices within family medicine and specialization was greater than loss from migration.

Professional activity. How is family physicians' work time changing?

OBJECTIVE: To examine hours worked professionally, work preferences, and changes in both of these and their correlates. DESIGN: Repeated surveys done in 1993 and 1999. SETTING: Ontario family practices. PARTICIPANTS: Cohort of physicians certified in family medicine between 1989 and 1991 after family medicine residency who were surveyed in 1993 when they resided in Ontario. MAIN OUTCOME MEASURES: Self-reported hours spent weekly on professional activities, desired hours of professional work, and balance between work and other activities. RESULTS: Fifty-three percent (293) of 553 physicians responded to the 1999 survey; 91% had remained family physicians; 85% of these had participated in the 1993 survey. The difference between the hours that family physicians preferred to work professionally and their actual hours of work had increased since 1993. Childless physicians, women physicians with preschool children, and women physicians married to other physicians worked fewer hours professionally than other physicians in 1999. Female physicians and physicians without children worked closer to their preferred hours than other physicians. Reporting a preference to work fewer hours professionally in 1993 was linked with a reduction in professional activities by 1999. CONCLUSION: Greater attention should be paid in physician resource planning to the family life cycle of female physicians. Lifestyle changes could lead to a reduction in professional activity among these physicians.

Glutamine synthesis is heterogeneous and differentially regulated along the rabbit renal proximal tubule.

Glutamine synthesis, a major process for ammonia detoxification and the control of acid-base balance, occurs from various precursors in suspensions of rabbit proximal tubules. However, no data are currently available on the distribution of glutamine synthesis along the rabbit proximal tubule, and its modulation by changes of substrate concentration. Therefore we have microdissected and incubated the three parts (S1, S2 and S3) of rabbit proximal tubules and measured glutamine synthesis from alanine and aspartate. With a physiological concentration of alanine (0.25 mM) or aspartate (0.05 mM), glutamine synthesis in the S1 segment was about half of that in the S2 and S3 segments, and was greater from alanine than from aspartate along the entire proximal tubule. Elevation of alanine and aspartate concentrations to 5 mM increased glutamine synthesis in both a substrate- and segment-dependent manner. It is concluded that glutamine synthesis occurs from alanine and aspartate along the entire rabbit proximal tubule; however, contrary to what might have been expected on the basis of measurement of glutamine synthetase activity, the basal rate of glutamine synthesis and its adaptation to increased substrate availability are heterogeneous along this nephron segment.

Preoperative assessment for difficult intubation in general and ENT surgery: predictive value of a clinical multivariate risk index.

Several clinical multifactorial indexes have been described for predicting difficult laryngoscopy or intubation, or both, mostly in general surgery, and less frequently in ENT surgery. The objective of this study was to develop and validate a single clinical index for prediction of difficulty in tracheal intubation in both ENT and general surgery. We studied a population of 1200 consecutive ENT and general surgical patients. Clinical criteria were tested using univariate and multivariate analysis. Difficult intubation was defined as requiring unusual techniques. Logistic regression identified seven criteria as independent predictors of difficult tracheal intubation; previous history of difficult intubation; pathologies associated with difficult intubation; clinical symptoms of pathological airway; inter-incisor gap and mandible luxation; thyromental distance; head and neck movement; and Mallampati's modified test. Point values were assigned to each of these factors in proportion to regression coefficients representing the relative weight of each predictive intubation difficulty factor, the sum comprising the score. The best predictive threshold was chosen using a receiver operating characteristic curve. We then prospectively studied and validated the score in a population of 1090 consecutive ENT and general surgery patients. The sensitivity and specificity of the predictions were 94% and 96% in general surgery, 90% and 93% in non-cancer ENT surgery, and 92% and 66% in ENT cancer surgery, respectively.

Closed and restricted practices.

OBJECTIVE: To determine the proportion of recently certificated Ontario family physicians who have closed their practices to new patients or restricted their services. DESIGN: Cross-sectional survey mailed between September 1993 and January 1994. SETTING: Ontario family practices. PARTICIPANTS: All family medicine residency-trained certificants of the College of Family Physicians of Canada from 1989 to 1991 currently practising in Ontario. Response rate was 70% (395 of 564 eligible physicians). Otherwise eligible physicians practising as locums, emergency room physicians, or military physicians were excluded. MAIN OUTCOME MEASURES: Self-report of practices being closed to new patients and of various restrictions placed on practices. RESULTS: Nearly one third of respondents had closed their practices to new patients. Although the decision to close a practice correlated with length of time in practice, physicians in metropolitan Toronto were significantly less likely to report closed practices than physicians practising in other regions of Ontario. Restrictions reported related to patients and problems, geographic area, and type of setting(s) serviced. About 45% of respondents did not provide one or more of a defined set of five services. CONCLUSIONS: Results of this study suggest that family physicians restrict their practices in various ways within the first 5 years after certification.

Increase in oxidative key enzymes in a case of muscle ubiquinol-cytochrome c reductase deficiency.

In a 29-year-old patient suffering from exertional muscle intolerance with a ubiquinol-cytochrome c reductase deficiency related to a cytochrome b gene point mutation of the mitochondrial DNA, we conducted a study of the aims of which were: (1) to test whether changes in the maximum activities of muscle key enzymes of the main energy-producing pathways occur, (2) to address the issue of whether fibers of different types are equally affected in their enzymatic machinery involved in energy production, and (3) to correlate the results obtained with histochemical and 31P NMR spectroscopy data. When compared to results obtained in six normal subjects, our study clearly shows that the type I fibers of the patient virtually all contained subsarcolemmal mitochondrial aggregates and increased activities of succinate dehydrogenase and cytochrome c oxidase; microdissected type I fibers also displayed a significant increase in both citrate synthase and beta-hydroxyacyl-CoA dehydrogenase, two key enzymes of mitochondrial oxidative metabolism. Despite these changes in the patient's muscle, its whole energy-producing machinery remained impaired as revealed by a slowed post-exercise recovery of phosphocreatine.

Cohort, gender and practice organization: examining the bounds of collaborative medicine among newly established female and male family physicians in Ontario.

This paper analyzes data from a 1993 survey of 395 newly established female and male family physicians in Ontario, Canada, to examine the relationship between practice organization and gender. Previous research suggests that younger physicians, particularly women, tend to enter group practice. Compared to solo practice, groups may offer more predictable incomes, more manageable workloads, peer collaboration and review, and economies of scale. Further, female physicians in groups may develop distinctive styles of collaborative medicine. The results show that a majority of physicians in our cohort are in private community-based group practice. However, while many groups share premises, staff and expenses, and many have common charts and practice guidelines, only a minority incorporate regular meetings to discuss business or patient care, have shared care of hospitalized patients, or audits of physicians' practices. Few gender differences are observed in private group practice: although women physicians attract larger proportions of female patients than do their male colleagues, women and men organize their groups in similar ways and have similarity strong patient-centered attitudes.

Advantages and limitations of the use of isolated kidney tubules in pharmacotoxicology.

Among the cellular models used in in vitro renal pharmacotoxicology, isolated kidney tubules, used as suspensions mainly of proximal tubules, offer important advantages. They can be prepared in large amounts under nonsterile conditions within 1-2 h; thus, it is possible to employ a great number of experimental conditions simultaneously and to obtain rapidly many experimental results. Kidney tubules can be prepared from the kidney of many animal species and also from the human kidney; given the very limited availability of healthy human renal tissue, it is therefore possible to choose the most appropriate species for the study of a particular problem encountered in man. Kidney tubules can be used for screening and prevention of nephrotoxic effects and to identify their mechanisms as well as to study the renal metabolism of xenobiotics. When compared with cultured renal cell, a major advantage of kidney tubules is that they remain differentiated. The main limitations of the use of kidney tubules in pharmacotoxicology are (1) the necessity to prepare them as soon as the renal tissue sample is obtained; (2) their limited viability, which is restricted to 2-3 h; (3) the inability to expose them chronically to a potential nephrotoxic drug; (4) the inability to study transepithelial transport; and (5) the uncertainty in the extrapolation to man of the results obtained using animal kidney tubules. These advantages and limitations of the use of human and animal kidney tubules in pharmacotoxicology are illustrated mainly by the results of experiments performed with valproate, an antiepileptic and moderately hyperammonemic agent. The fact that kidney tubules, unlike cultured renal cells, retain key metabolic properties is also shown to be of the utmost importance in detecting certain nephrotoxic effects.

Interest in different types of patients. What factors influence new-to-practice family physicians?

OBJECTIVE: To identify factors that influence new-to-practice family physicians to be particularly interested in certain types of patients. DESIGN: Qualitative study and cross-sectional survey. SETTING: Ontario family practices. PARTICIPANTS: Seven focus groups involved a volunteer sample of 34 physicians who completed family medicine residency training between 1984 and 1989. A convenience sample of 43 physicians who had completed their residencies between 1990 and 1992 were interviewed. All certificates of the College of Family Physicians of Canada currently practising in Ontario who received certification between 1989 and 1991 were surveyed. MAIN OUTCOME MEASURES: Physician interest as determined by scores on two scales: one labeled "Chronic/Older Patient," designed to assess special interest in geriatric patients, chronic pain patients, palliative care patients, and chronically ill patients, and one labeled "Young Patient," designed to assess special interest in young families and adolescents. RESULTS: In general, new-to-practice physicians had little interest in caring for older or chronic patients; older physicians and male physicians had greater interest in caring for chronic or older patients. Women physicians, physicians rating higher on the "empathy" and "interest in counseling" scale, and physicians receiving primarily fee-for-service remuneration showed greater interest in caring for young families and adolescents than other physicians. CONCLUSIONS: Physicians' age, sex, attitudes to patient care, method of remuneration, undergraduate and postgraduate schools of medical training, and the age and sex composition of their practices all influenced their interest in caring for different types of patients.

Time spent on professional activities and unwaged domestic work. Is it different for male and female primary care physicians who have children at home?

OBJECTIVE: To examine how having children affects the hours spent by male and female family physicians on professional activities and on unwaged domestic work. DESIGN: Survey fielded between September 1993 and February 1994. SETTING: Ontario. PARTICIPANTS: All Ontario-based physicians certificated by the College of Family Physicians of Canada between 1989 and 1991 after completing a family medicine residency. MAIN OUTCOME MEASURES: Self-reported hours spent per week on professional activities and unwaged domestic work. RESULTS: Response rate was 70%; men and women were equally likely to respond. About half (47.7%) had children at home. Women with children at home spent fewer hours on professional activities (P < 0.001) than men with children, whose hours of professional activity were similar to hours of men without children. Both women and men with children reported spending more time on household maintenance than did those without children. Among physicians with children, although men spent time on child care (mean time 11.4 hours; SD 11), women spent much more time on it (mean time 39.7 hours; SD 21; P < 0.001). The women worked an average of 90.5 hours per week in professional and unwaged activities; men averaged 68.6 hours. Childless physicians worked fewer hours: men 54.1, women 52.6. CONCLUSIONS: Female physicians with children at home spend more time on child care and household maintenance than their male partners. These responsibilities reduce professional work time (at least until all children are at school full time) and might deter women from active involvement in professional organizations.

Clinical practice guidelines. New-to-practice family physicians' attitudes.

OBJECTIVE: To examine the attitudes toward clinical practice guidelines of a group of family physicians who had recently entered practice in Ontario, and to compare them with the attitudes of a group of internists from the United States. DESIGN: Mailed questionnaire survey of all members of a defined cohort. SETTING: Ontario family practices. PARTICIPANTS: Certificants of the College of Family Physicians of Canada who received certification in 1989, 1990, and 1991 and who were practising in Ontario. Of 564-cohort members, 395 (70%) responded. Men (184) and women (211) responded at the same rate. MAIN OUTCOME MEASURES: Levels of agreement with 10 descriptive statements about practice guidelines and analyses of variance of these responses for several physician characteristics. RESULTS: Of respondents in independent practice, 80% were in group practice. Women were more likely to have chosen group practice, in which they were more likely to use practice guidelines than men. Generally favourable attitudes toward guidelines were observed. Physician characteristics occasionally influenced agreement with the descriptors. The pattern of agreement was similar to that noted in the study of American internists, but, in general, Ontario physicians were more supportive. CONCLUSIONS: This group of relatively new-to-practice Ontario family physicians shows little resistance to guidelines and appears to read less threat of external control in them than does the US group.

Current health policy initiatives and options. New-to-practice family physicians' attitudes.

OBJECTIVE: To obtain information about new-to-practice family physicians' attitudes toward current health policy options and initiatives. DESIGN: Cross-sectional, mailed survey. SETTING: Ontario family practices. PARTICIPANTS: Residency-trained Ontario family physicians (395 of 564 eligible physicians replied) who were certified between 1989 and 1991. MAIN OUTCOME MEASURES: Extent of approval or disapproval for 14 health policy options and initiatives. RESULTS: A 70% response rate was achieved. More than half of surveyed physicians expressed approval for shifting resources from acute care into preventive care and health promotion (71.6% approved), stricter immigration requirements to limit licensing of foreign physicians in Canada (60.4%), offering physicians salaries as an alternative to fee-for-service (54.0%), and incentives to physicians who wish to practise in community health centres or other forms of salaried group practice (51.1%). Some diversity of opinion was associated with sex, type of practice, primary source of remuneration, and practice location. CONCLUSIONS: These new-to-practice family physicians display diverse views and should not be seen as sharing a single opinion of health care policy options and initiatives. Many approve of changes to the health care system or are willing to consider policy alternatives.

Medicine and the Canadian state: from the politics of conflict to the politics of accommodation?

This paper analyzes data from three large-scale surveys of Canadian physicians conducted over the past decade to examine the politics of a cohort of recently established family physicians in Ontario, and to assess the extent to which these politics represent a "softening" of professional resistance to government health insurance. Politically, this is an important cohort because the physicians in it have grown up without any firsthand knowledge of the pre-Medicare period, and because they are among the first to establish practices in the wake of the month-long 1986 Ontario physicians' strike, a high point of profession-government conflict. Factors which may have contributed to a moderation of medical politics include the progressive entry of women into medicine. Our data suggest that professional opposition to Medicare is declining and that fewer physicians support a return to voluntary and commercial control of the health system, a shift which could assist in breaking the historical cycle of profession-government conflict and moving to the politics of accommodation. In the conclusions we discuss implications for medical politics in Canada and other countries such as the United States.

Effects of chronic renal failure on enzymes of energy metabolism in individual human muscle fibers.

In order to improve knowledge about the mechanisms underlying the alterations of energy metabolism recently observed in the skeletal muscle of patients suffering from chronic renal failure, this study was designed to test (1) whether changes in the activity of key enzymes of energy metabolism occur in the muscle of these patients, and if so (2) whether the different muscle fiber types are equally altered in their metabolic machinery. For this, the maximum activities of 14 enzymes were measured in individual muscle fibers microdissected from biopsies of rectus abdominis muscle obtained from seven normal subjects and seven patients with end-stage renal failure before renal replacement therapy. A large decrease in the activities of beta-hydroxyacyl-coenzyme A dehydrogenase, a key enzyme of the beta-oxidation pathway, of citrate synthase, which initiates the tricarboxylic acid cycle, and of fructose-1,6-bisphosphatase, which contributes to the synthesis of glycogen from lactate, was observed in the three fiber types (slow-twitch oxidative, fast-twitch oxidative-glycolytic, and fast-twitch glycolytic). A smaller reduction of the activities of phosphofructokinase and/or pyruvate kinase, two key enzymes of glycolysis, was also observed in slow-twitch oxidative and/or fast-twitch oxidative-glycolytic fibers. These results demonstrate that the abnormalities of muscle energy metabolism observed in patients with chronic renal failure are due, at least in part, to intrinsic changes in the key enzymes of major energy-providing pathways; they also offer a satisfactory explanation for the defect of oxidative metabolism recently demonstrated in the muscle of these patients.

Sanctions against sexual abuse of patients by doctors: sex differences in attitudes among young family physicians.

OBJECTIVE: To explore attitudes of new-to-practice certified family physicians in Ontario concerning sanctions against sexual abuse of patients by physicians and to assess the importance of concern about accusations of sexual abuse in influencing clinical decisions. DESIGN: Qualitative study and cross-sectional survey. SETTING: Ontario. PARTICIPANTS: Focus groups: 34 physicians who completed family medicine residency training between 1984 and 1989 participated in seven focus groups between June and October 1992. SURVEY: all certificants of the College of Family Physicians of Canada who received certification between 1989 and 1991 and were currently practising in Ontario. Of the 564 eligible physicians 395 (184 men and 211 women) responded, for an overall response rate of 70.0%. The response rates among the male and female physicians were 70.5% and 69.6% respectively. OUTCOME MEASURES: Physicians' attitudes toward restricting physical examinations done by physicians to same-sex patients, mandatory reporting of sexual impropriety and loss of licence in cases of sexual violation and the perceived importance of concern about accusations of sexual abuse as an influence on clinical decisions. RESULTS: During the focus groups male physicians in particular expressed concerns about the effect on their practice patterns of the current climate regarding sexual abuse of patients. Female physicians were less concerned about possible accusations of sexual abuse but expressed concerns regarding possible sexualization of the clinical encounter by male patients. In the survey equal proportions of men (163 [93.7%]) and women (191 [92.3%]) disagreed with restricting examinations to same-sex patients. The women were more likely than the men to agree that all suspected cases of sexual impropriety committed by other physicians should be reported (121 [58.7%] v. 86 [50.0%]), whereas the men were more likely to disagree (48 [27.9%] v. 32 [15.5%]) (p = 0.008). The women were also more likely than the men to agree that physicians should lose their licence permanently if they were found guilty of sexual violation (125 [62.2%] v. 73 [43.5%]), whereas the men were more likely to disagree (61 [36.3%] v. 37 [18.4%]) (p < 0.001). Almost half of the men (80 [46.5%]) but only 28 women (14.1%) reported that concerns about accusations of sexual abuse were of importance in their clinical decisions (p < 0.001). CONCLUSIONS: Young female family physicians practising in Ontario are much more likely than their male counterparts to endorse permanent loss of licence for physicians who sexually abuse patients and are significantly less concerned about accusations against themselves. Neither sex endorses only same-sex examinations by physicians. Educational approaches to protect patients while ensuring that appropriate care continues to be delivered are essential.

[Cocaine contact anesthesia for endonasal surgery. Kinetics and clinical tolerance of a concentrated solution]. / Anesthésie de contact à la cocaïne pour chirurgie endonasale. Cinétique et tolérance clinique d'une solution concentrée.

OBJECTIVE: To assess the pharmacokinetics and clinical tolerance of a 33% cocaine solution administered topically for intranasal surgery. STUDY DESIGN: Clinical prospective open trial. PATIENTS AND METHODS: Twelve ASA I patients scheduled for intranasal surgery were sedated with midazolam 2 mg and fentanyl 50 micrograms. Topical anaesthesia was obtained with aqueous 33% cocaine HCl 360 mg, lidocaine HCl 140 mg, adrenaline 0.04 mg and naphazoline 0.4 mg. Venous blood samples were taken before cocaine application and 15, 30, 45, 60, 90, 120, 150, 180, 240 min later. The plasma was immediately separated and the samples were frozen. The concentration of cocaine was measured by HPLC. Potential cardiotoxic and neurotoxic effects were clinically monitored. RESULTS: The mean dose of cocaine applied was 5.85 +/- 1.3 mg.kg-1 and the dose actually delivered was 4 +/- 1.5 mg.kg-1. The Cmax was 859 +/- 503 ng.mL-1 after a Tmax to 47 +/- 17 min. The mean elimination half-life was 87 +/- 19 min (mean +/- SD). The total clearance and the volume of distribution were respectively 4,521 +/- 1,858 mL.min-1 and 568 +/- 273 L. No clinical evidence of toxicity was found. CONCLUSIONS: This study shows that it is possible to perform major intranasal surgery under topical anaesthesia with a concentrated solution (33%) of cocaine at a high dose (6 mg.kg-1). These results differ completely with data obtained in addicts.