Postpancreatectomy hemorrhage (PPH): predictors and management from a prospective database.

BACKGROUND: Postpancreatectomy hemorrhage (PPH) is a dreaded complication in pancreatic surgery. Today, there is a definition and grading of PPH without therapeutic consensus. We reviewed our prospective database to identify predictors and assess therapeutic strategy. METHOD: We included all patients who underwent pancreatectomy between 2005 and 2010. Data were collected prospectively. We used the International Study Group Of Pancreatic Surgery (ISGPS) definition for PPH to include patients in the PPH group. RESULTS: Forty-six of 285 patients showed a PPH (16.1 %). The ISGPS classification was graded A = 3, B = 26, and C = 17. The average time to the onset of PPH was 7 days. CT-scan identified the origin of PPH in 43.5 % of the cases. PPH was responsible for a longer duration of hospital stay (p = 0.004), a higher hospital mortality (21.7 vs 2.5 %, p < 0.0001) and a lower survival (40 vs 70 % (p = 0.05) at 36 months). The first-intention treatment of PPH was conservative in 32 % and interventional in 68 %: endoscopy (6.4 %), transcatheter arterial embolization (TAE, 30.4 %), and surgical (30.4 %). In multivariate analysis, predictors of PPH were: pancreatic fistula (24 vs 8 % p = 0.028), pancreatoduodenectomy (70 vs 43 % p = 0.029), age (61.6 vs 58.8 %, p = 0.03), and nutritional risk index (NRI) (p = 0.048). CONCLUSION: In our series, risk factors for PPH were age, pancreatic fistula, pancreatoduodenectomy, and NRI. Its occurrence is associated with significantly higher hospital mortality and a lower survival rate. Our first-line treatment was radiological TAE. Surgical treatment is offered in case of failure of interventional radiology or in case of uncontrolled hemodynamic.

Facilitating grant proposal writing in health behaviors for university faculty: a descriptive study.

Grant proposal writing in the behavioral sciences is important for fiscal reasons and scientific reasons at many universities. This report describes a grant proposal-writing seminar series provided to University faculty (N = 20) and explores factors facilitating and impeding writing. Summary statistics are provided for quantitative data. Free responses were sorted by independent raters into meaningful categories. As a consequence of the training, 45% planned to submit within 18 months; 80% of grant proposals targeted NIH. At 1-year follow-up, 40% actually submitted grants. Factors impeding grant proposal writing included competing professional demands; factors facilitating writing included regularly scheduled feedback on written proposal sections and access to expert collaborators. Obtaining grants generates financial resources, facilitates training experiences, and vastly contributes to the growth and dissemination of the knowledge base in an area.

Morbidity and mortality of Hartmann's procedure for sigmoid volvulus at the University Hospital of Cocody, Abidjan.

BACKGROUND: The restoration of intestinal continuity following Hartmann's procedure is associated with high morbidity and mortality rates and low restoration rate. OBJECTIVE: To determine the causes of complications and deaths associated with Hartmann's procedure and the secondary restoration of digestive continuity for sigmoid volvulus. METHODS: This was a retrospective study involving 25 patients treated for sigmoid volvulus according to Hartmann's procedure, from January 1998 to January 2008; at the Cocody university hospital, Abidjan (Cote d'Ivoire). The mortality and morbidity rates were assessed on the basis of the age, the duration of illness, the ASA (American Society of Anesthesiologists) score, the state of the sigmoid colon and peritoneal cavity. RESULTS: The mean age of the patients was 42.52 years (range: 22-77 years). The mean duration of illness was 02.80± 0.71 days (range: 06 hours to 07 days). Sixteen (64%) of the patients had an ASA score lower than III. The mean length of intervention was 209.75 min.±102.530 min. (range: 120 min. to 327 min). The mortality rate was 12% (n=3) in the Hartmann's procedure. The necrosis state of the sigmoid colon was not significantly associated with a higher death risk (p=0.071) but the contamination of the peritoneal cavity by stools (p=0.001) or an ASA score ≥3 (p=0.036) was significantly associated with a higher death risk. Infections of the operative site (42.86%) were the most common complications. The mean length of hospital stay was 12.05 ± 25.45 days. Eleven patients (50%) out of 22 had the intestinal continuity restored. The median time of restoration was 3.43 months (range: 3-12 months).The mortality rate among the restoration group was nil and the morbidity rate was 27.27% represented by parietal suppurations only. The mean length of hospital stay was 14 ± 2.83 days. CONCLUSION: Hartmann's procedure remains associated with an significant mortality. Morbidity, essentially arises from infections of the operative site. However the restoration of the intestinal continuity remains a sure intervention with an acceptable morbidity.

[Colonoscopic perforation: 6 cases in Abidjan, Cote d'Ivoire]. / Plaies coliques per coloscopiques: 6 observations à Abidjan (Côte d'lvoire).

OBJECTIVES: The purpose of this report is to describe diagnostic and therapeutic management of colonoscopic perforation and identify risk factors. MATERIAL AND METHODS: The charts of 6 patients who underwent surgery for colonoscopic perforation between January 2003 and December 2008 were reviewed. Study data included patient age, indication for colonoscopy, operative findings, repair technique, and outcome. RESULTS: All 6 perforations occurred during diagnostic colonoscopy. There were 5 females and 1 male. Endoscopy was performed by an experienced operator in 5 cases and by a training fellow in 1. Preparation of the colon was considered as good in 5 cases. The operator reported procedural problems in only 1 case. Diagnosis of perforation was immediate in 5 cases and delayed for 30 hours in 1. The lesion was located in the sigmoid colon in 5 cases and transverse colon in 1. All patients underwent laparotomy. The repair technique consisted of simple closure in 2 cases, closure with colostomy in one, and bowel resection with anastomosis (n=2). Two deaths occurred intraoperatively in I case and postoperatively in 1. The patient who died intraoperatively had not yet undergone repair when death occurred. In both patients who died, laparotomy was performed late in the presence of co-morbidity. CONCLUSION: Colonic perforation is a rare but severe iatrogenic complication following colonoscopic examination. Early recognition and treatment are essential to optimize outcome. Prevention depends on training to obtain skillful advancement technique.

[Nontraumatic digestive surgical emergencies in elderly patients at the Cocody University Hospital Center in Abidjan, Côte d'Ivoire: etiology and outcome]. / Urgences abdominates digestives non traumatiques chez les sujets âgés au CHU de Cocody à abidjan, Côte d'Ivoire: étiologies et résultats thérapeutiques.

OBJECTIVES: The purpose of this retrospective report is to describe etiologies and therapeutic outcomes of nontraumatic abdominal surgical emergencies in elderly patients. MATERIAL AND METHODS: The charts of patients aged 60 years or more who underwent emergency surgery for nontraumatic abdominal disorders at a Teaching Hospital in Abidjan, Cote d'Ivoire from August 1998 to July 2008 were reviewed. Demographic data, clinical findings, operative protocols, and postoperative outcomes were noted. RESULTS: A total of 137 patients with a mean age of 68.3 years (range, 60-93 years) underwent emergency surgery for nontraumatic abdominal disorders during the study period. The underlying etiologies were strangulated hernia (n = 40), abdominal parietal abscess (n = 6), bowel obstruction (n = 32), acute diffuse peritonitis (n = 29), acute appendicitis (n = 23), acute cholecystitis (n = 6) and massive rectorragy from colonic diverticulitis (n = 1). Coexisting medical problems (n = 84) were noted in 69 patients. Surgical procedures were tailored to operative findings. Twenty-seven patients were admitted to the intensive care unit in the immediate postoperative period. Mean hospital stay was 7.7 days (range, 2-23 days). Surgical complications included wound infection (n = 14), stoma-related complications (n = 7), digestive fistula (n = 4), scrotal hematoma (n = 5) and postoperative evisceration (n = 2). The mortality rate was 10.21% (n = 14) mainly due to postoperative peritonitis. CONCLUSION: The findings of this study indicated that most nontraumatic abdominal surgical emergencies in elderly patients were related to complications of neglected or undiagnosed preexisting disease. Prognosis was related to the stage of the disorder, initial surgical management, and deterioration of the coexisting medical problems.

[Strangulated groin hernia still frequent in tropical milieu]. / Les hernies étranglées de l'aine : une urgence chirurgicale toujours d'actualité en milieu tropical.

This study aimed to describe the epidemiological, clinical, therapeutic and postoperative data of strangulated groin hernia. Details of consecutive adults patients admitted to our emergency wards for strangulated groins hernia and operated on from august 1998 to december 2007 were recorded. In addition the mode of presentation, hernia type, treatment and outcome were also recorded for each case. The statistical analysis used the Chi2 test and the Fischer test. 149 strangulated groin hernias were recorded in 135 men and 14 women. Inguinal hernias were seen in 143 patients and femoral hernia in 6. Median age was 40 years. The mean delay for consultation was 2 days. Richter hernia, Maydl hernia and hernia abscess were seen in eight, two and three cases each. Bowel resection was required in 30 patients. Inguinal hernia underwent Bassini's procedure, Shouldice procedure and Mac Vay's procedure. While femoral hernia underwent only Mac Vay's procedure. No hernia repair was undergone in hernia abscess. Mortality was 10%. Bowel necrosis, long duration of symptoms, ASA class, bowel resection and strangulated groin hernia with hernia abscess, peritonitis and occlusion were found to be significant factors linked with unfavorable outcome. Morbidity was 16.7% and required reoperation in 9 patients; sepsis and hematoma were the most frequent complication. In conclusion, strangulated groin hernia still remain a frequent matter of consultation in visceral ward in tropical milieu. The high morbidity and mortality rate are unacceptable because of the possibility of avoiding them by early consultation and elective repair of groin hernia.

[Early oral feeding versus classic oral feeding after appendicectomy for acute appendicitis]. / Réalimentation orale précoce versus réalimentation orale classique après appendicectomie pour appendicite aiguë.

The appendectomies for acute appendicitis are the most frequent surgical interventions (43.6%) in our service. The recent studies demonstrated the feasibility and the economical gain of the early oral feeding vs. classic oral feeding, after elective digestive surgery. We wanted to spread these results therefore to the appendectomy for acute appendicitis. It is about a prospective survey carrying on 110 patients also left in two groups, and comparing the classic postoperative oral feeding vs. the early postoperative oral feeding on one year. The two groups were comparable and the studied parameters were : the length of the postoperative ileus, the hospitable morbidity, the length of the hospitalization and the cost of the hold in charge. The length of the postoperative ileus was not different in the two groups as well as the morbidity. The difference of the median length of hospitalization in the two groups was not meaningful. The cost of the hold in charge was meaningfully more elevated in the group with classic postoperative feeding. In conclusion, the early postoperative oral feeding in our survey doesn't reduce the length of the postoperative ileus and don't drag a morbidity anymore that the classic oral feeding. However if it doesn't shorten the length of the hospitalization, it drags a reduction of the cost of the hold in charge. There is a gain therefore precociously to nourish the patients after appendectomy for acute appendicitis.

Validation of the Marijuana Effect Expectancy Questionnaire-Brief.

The purpose of this study was to evaluate a brief version of the Marijuana Effect Expectancy Questionnaire (MEEQ; Schafer & Brown, 1991). The original MEEQ was reduced to 6 items (MEEQ-B). Principal component analysis (PCA) was performed and two factors were identified (positive effects and negative effects) accounting for 52.3% of the variance. Internal consistencies (0.42 to 0.60) were slightly lower than those of the original MEEQ. The negative effect expectancy scale correlated with criterion variables that assess marijuana use (p ≤ .05). This measure is a helpful tool for clinicians to use when assessing youth expectancies. Replication across different samples of adjudicated youth is recommended.

A Case of Rare Complication of Inguinal Parietoplasty according to Lichtenstein: Entero Cutaneous Fistula.

Lichtenstein intervention is currently the classic model of the regulated treatment of inguinal hernias by direct local approach. This "tension-free" technique satisfies both patients and practitioners. However, it does not often evade severe complications of parietal surgery. The authors report their treatment experience in rural Africa of a late enterocutaneous fistula which aggravated an inguinal hernia repair according to the Lichtenstein procedure. Physiopathology, diagnosis, and treatment of that disease are analyzed in the light of literature.

[Psoas abscess in Cote d'Ivoire: a report of eighteen cases]. / Les abces du psoas en Cote d'Ivoire: a propos de 18 cas.

BACKGROUND: Psoas abscess is a rarely encountered entity with a non specific clinical presentation resulting in delayed diagnosis and treatment. No published data exist on this disease in our country. OBJECTIVE: To describe the diagnostic and therapeutic features of psoas abscesses in Côte d'Ivoire. Methodes: A retrospective study of 18 psoas abscesses seen over seven years in two teaching hospitals. RESULTS: There were 10 women and eight men with a mean age of 35.7 years (range:16-62 years). The abscess was primary in 15 cases, secondary in three, right sided in 15 and left sided in three cases. Fever, abdominal pain, difficulties in walk, abdominal mass and psoitis were the main clinical signs. Ultrasonography allowed the diagnosis of psoas abscess in 14 cases and in the remaining 4 cases the diagnosis was done peroperatively. The germs were identified in 12 patients and were: Escherichia coli in 3 cases, Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcus pneumoniae, Klebsiella pneumoniae in two cases each and Mycobacterium tuberculosis in one case. Patients were given antibiotics together with surgical drainage of the abscess (n=16) or percutaneous needle aspiration (n=2). Postoperative complications included parietal suppurations (n=5) and intraperitoneal abscesses (n=2). No death occurred. CONCLUSION: For psoas abscess in our practice, ultrasonography is a useful diagnostic tool and surgical drainage remains an effective therapeutic method.

[Acute peritoneal tuberculosis in HIV-infected patients. Study of 4 cases in Abidjan, Côte-d'Ivoire]. / Péritonite aiguë tuberculeuse au cours de l'infection par le VIh. Etude de 4 cas à Abidjan, Côte-d'Ivoire.

This paper presents 4 cases of histologically verified peritoneal tuberculosis in HIV-infected patients followed in a 18 month-period. The patients were admitted in emergency and were suspected of present acute appendiceal peritonitis. There were 3 females of 18, 22 and 27 years old, and a 41-year-old male. The main symptoms were acute abdominal pain (4 cases), fever superior to 38 degrees C (4 cases) and abdominal defence (4 cases). Laboratory findings were hyperleucocytosis with lymphocytic predominance, anemia and CD4+ rate variable from 250 to 460/mm3. They underwent emergency laparotomy which led to diagnosis of peritoneal tuberculosis by histopathological analysis of peritoneal biopsies. Two patients died from surgery at days 3rd and 10th. The 2 remaining patients were successfully treated by tuberculostatic tritherapy with rifampicin, isoniazid, and pirazinamid. Acute peritoneal tuberculosis in HIV-infected patients is not to be missed in our practice. It must be considered in differential diagnosis of acute abdomens.

[Acute intestinal intussusceptions in adults: analysis of 20 cases]. / Invaginations intestinales aiguës de l'adulte: analyse d'une série de 20 cas.

AIM OF THE STUDY: To report our experience in the management of acute intestinal intussusceptions in adults. PATIENTS AND METHODS: Retrospective study of data of patients older than 15 years who were operated on for acute intestinal intussusceptions from January 1997 to December 2001. RESULTS: Twelve of the patients were males and eight females with an average age of 41 years (range: 16-71). The clinical and radiological findings were suggestive of bowel obstruction (N = 14), peritonitis (N = 5) and appendicular abscess (N = 1). Correct preoperative diagnosis of acute intestinal intussusceptions was established in 6 cases. Type of intussusception was jejunojejunal (N = 1), ileo-ileal (N = 8), ileocolic (N = 1), ileocecocolic (N = 7) and colocolic (N = 3). Necrosis was found in the intussusceptum in 10 cases and a tumor on the lead point in 14 cases (5 benign lesions and 9 malignant ones). For intussusception involving the colon, all patients underwent en bloc resection with immediate anastomosis, while intussusception located on the small bowel were treated by surgical reduction (N = 1), en bloc resection (N = 8) with immediate (N = 7) or delayed (N = 1) anastomosis. The mortality rate was 15%. CONCLUSION: In our experience, intussusceptions in adults is not an uncommon clinical entity but correct diagnosis is often established peroperatively. En bloc resection is recommended because of the frequency of neoplasms and bowel ischemia.

[Rectal and colonic injuries induced by enemas: a 10-case series at the university hospital center in Bouake, Ivory Coast]. / Les rectocolites par les lavements à propos de 10 cas au CHU de Bouake (RCI).

The purpose of this study is to report our experience in the management of rectal and colonic injuries induced by enemas. A retrospective analysis was carried out in a series of 10 patients treated at the Bouake, Ivory Coast University Hospital Centre for rectal and colonic injuries induced by enemas between January 1, 1997 and December 31, 2001. There were 6 men and 4 women with a mean age of 26.2 +/- 5.6 years. Based on history taking five enemas involved criminal intent. The other five were carried out for abortion (n=3), therapy (n=1) or autolysis (n=1). The injurious product was known in 7 cases, i.e., sulphuric acid (n=4) and hot pepper (n=3). The mean quantity administered was 158 +/- 64 ml. The presenting picture involved diffuse acute peritonitis in 7 cases and abdominal pain with bloody mucoid rectal discharge in 3. One patient died at the time of admission. The remaining patients underwent either operative (n=6) or medical (n=3) treatment. Prognosis was unfavourable. Four patients died and one patient required colostomy that could not be removed due to sclerosis of the anal sphincter. Management of rectal and colonic injuries induced by enemas requires differential diagnosis to distinguish patients that require emergency laparotomy from patients that can be treated medically. For patients treated medically, close surveillance based on imaging and repeated clinical examination is of paramount importance to allow diagnosis of complications requiring surgical treatment.

Physicians' attitudes to the pharmacological treatment of patients with stable angina pectoris.

BACKGROUND: Little is known about how physicians' knowledge of and attitudes to practice guidelines for stable angina may influence their implementation. AIM: To explore the association between physicians' demographics, their knowledge, and opinions about stable angina and their self-reported adherence to guideline recommendations. DESIGN: Questionnaire-based survey. METHODS: We surveyed 1228 Quebec physicians using a questionnaire based on the 'awareness-to-adherence' conceptual framework to measure their adherence with recommendations for the pharmacological treatment of stable angina. Independent predictors of adherence with the targeted recommendations were determined by stepwise linear regression analysis. RESULTS: We received 877 (71.4%) responses from the 1228 eligible physicians. More than 90% of respondents were aware of and agreed with the targeted recommendations. However, the adoption rate varied, even among physicians who generally agreed with the guidelines. Factor analysis indicated that most physicians agreed with recommendations concerning ASA. More negative attitudes were expressed toward beta-blockers and hypolipaemic drugs. Respondents trusted the recommendations of a variety of scientific and professional organizations. Awareness, agreement, and adoption were the strongest predictors of adherence for the three recommendations. Physician demographics and practice characteristics did not predict adherence. DISCUSSION: Physicians were aware of and agreed with the recommendations, so additional large-scale dissemination of the guidelines would be unlikely to improve prescription patterns. However, negative attitudes about beta-blockers and hypolipaemic therapy affected adherence to recommendations for these drugs. Continuing medical education interventions involving local opinion leaders might address some of the obstacles identified.

[Appendicitis and pregnancy: 21 cases]. / Appendicite aiguë et grossesse. A propos de 21 cas.

OBJECTIVE: Describe the epidemiological, diagnostic and therapeutic features of acute appendicitis in pregnant women. MATERIAL AND METHODS: Retrospective analysis of a series of 21 cases of appendicitis in pregnant women who underwent surgery between January 1997 and June 2001. RESULTS: The association of acute appendicitis with pregnancy was noted in 0.2% of the pregnant women. Ten patients were in the first trimester of pregnancy, ten in the second and one in the third. Abdominal pain was noted in all patients. The localization varied with gestational age. Abdominal ultrasound contributed to the diagnosis in twenty patients who underwent the examination. Diagnoses retained were: acute uncomplicated appendicitis (n=18), acute appendicitis with focal induration (n=1) and acute diffuse peritonitis (n=2). Appendectomy was performed in all cases. Intensive care, peritoneal cleaning and drainage were associated in cases with appendicitis. In cases with focal induration, medical treatment was followed by appendectomy performed after delivery. Tocolysis was instituted in all cases. Twelve pregnancies continued to delivery: one fetal death, one premature delivery and ten term deliveries of live infants. CONCLUSION: Pregnancy makes it difficult to confirm the diagnosis of appendicitis. Appendectomy should be performed in patients presenting a highly suggestive clinical and ultrasonographic picture, preferably by laparoscopy in order to avoid more severe complications which could be life-threatening for the mother or infant.

Abnormal cardiovascular reactivity in borderline and mild essential hypertension.

Cardiovascular and hemodynamic reactivity was evaluated with M-mode echocardiography, phonocardiography, and carotidography in correlation with circulating catecholamine levels in 25 normotensive subjects, 15 borderline hypertensive patients, and 42 mildly hypertensive patients during isometric exercise at 30% of the maximum force for 3 minutes. At rest, norepinephrine and epinephrine levels were significantly higher, and the cardiac index was similarly increased in both groups of hypertensive patients, but the cardiac mass index was significantly increased only in the mildly hypertensive group. During isometric exercise, the sympathoadrenal reactivity as well as the pressor and chronotropic responses were similar in normotensive subjects and both groups of hypertensive patients. However, the variations in blood pressure were achieved through totally different hemodynamic mechanisms in normotensive subjects and hypertensive patients. In normotensive subjects, the increase in blood pressure could be linked mainly to an increase in cardiac contractility and performance, whereas in either group of hypertensive patients, the increase in blood pressure was mainly associated with an increase in peripheral resistance. These observations are consistent with the hypothesis of a blunted beta-adrenergic reactivity and a predominance of alpha-adrenergic vascular reactivity in borderline and mildly hypertensive patients. This phenomenon, which appears to be unrelated to age or severity of hypertension, could be an important mechanism underlying the development of hypertension in humans.

Effects of trandolapril on the sympathetic tone and reactivity in systemic hypertension.

Hemodynamic and autonomic evaluations were carried out after 2-3 weeks of treatment with placebo and at the end of 4 weeks of treatment with an angiotensin converting enzyme (ACE) inhibitor, trandolapril, 2 mg/day in 18 hypertensive patients (average age, 48 +/- 2 years) of either sex. This treatment lowered the mean arterial pressure in the whole group from 112 to 105 mm Hg (p < 0.05) without significant changes in basal heart rate or norepinephrine (NE) and epinephrine plasma levels. Based on daytime ambulatory blood pressure monitoring, the patients were separated into 2 equal groups of 9 patients: the better responders (R), with an average decrease in mean arterial pressure of 12 mm Hg, and the lesser responders (NR), with an average fall of mean arterial pressure of 2 mm Hg. Before treatment, the R group had a higher resting heart rate, a lower cardiac output (-16%), and a higher peripheral resistance (+22%) than the NR group (difference not significant). Moreover, the R group was also observed to have a 33% higher plasma NE level (p < 0.05) in the supine position, associated with a 52% higher NE response to standing (p < 0.05), and a 40% lower number of beta-adrenergic receptors on lymphocytes, suggesting a higher sympathetic tone and reactivity in that group. Following treatment with the ACE inhibitor, heart rate and plasma NE levels were not altered significantly in either group, suggesting a blunting of the baroreflex response concomitant with the lowered blood pressure, especially in the R group.(ABSTRACT TRUNCATED AT 250 WORDS)

Drug treatment of stable angina pectoris and mass dissemination of therapeutic guidelines: a randomized controlled trial.

BACKGROUND: Public agencies responsible for implementing health care policies often adapt and disseminate clinical practice guidelines, but the effectiveness of mass dissemination of guidelines is unknown. AIM: To study the effects of guideline dissemination on physicians' prescribing practices for the treatment of stable angina pectoris. DESIGN: Randomized controlled trial. METHODS: A sample of 3293 Quebec physicians were randomly assigned to receive a one-page summary of clinical practice guidelines on the treatment of stable angina (in February 1999), to receive the summary and a reminder (in February and March 1999, respectively), or to receive no intervention (controls). The prescribing profiles of participants, as well as sociodemographic characteristics of the physicians and their patients, were examined for June-December 1999. RESULTS: The intervention had no effect on prescription rates of beta-blockers, antiplatelet agents, or hypolipaemic drugs. Compared to 1997 data for the same physicians, there was an overall 10% increase in appropriate prescription rates, irrespective of the intervention. DISCUSSION: In-house production and dissemination of clinical practice guidelines may not improve physicians' practice patterns if there is pre-existing substantial scientific consensus on the issue.

Are patients suffering from stable angina receiving optimal medical treatment?

There is good evidence for the use of antiplatelet, beta-blocker and lipid-lowering drugs in the treatment of ischaemic heart disease, but few data on how these medications are used in treating stable angina pectoris. We examined prescription profiles for a sample of patients aged > or =65 years with stable angina, to compare the profiles to local guidelines and to explore the determinants of these profiles, in a cross-sectional study. We identified 11 141 individuals from the Quebec provincial out-patient pharmaceutical database for the period 1 June 1996 to 31 May 1997, and examined the percentage of these patients with and without associated co-morbidities receiving antiplatelet, beta-blocker and lipid-lowering medications. We used hierarchical modelling to examine the role of patient and physician characteristics in explaining the variation in the use of these medications. Calcium-channel blockers were the class of anti-ischaemic drugs most prescribed (63%). Beta-blockers were prescribed in 52.1% of patients. Antiplatelet and lipid-lowering drugs were prescribed to 56.8% and 32.6%, respectively. Increasing age and female gender made patients less likely to be prescribed these treatments. General practitioners were less likely than cardiologists to prescribe beta-blockers and lipid-lowering drugs (OR 0.79, CI 95% 0.68-0.91 and OR 0.77, CI 95% 0.66-0.91, respectively). There is a general under-use of antiplatelet, beta-blocker and lipid-lowering medications in the treatment of stable angina pectoris patients, possibly leading to adverse patient outcomes.

Unstructured cases in case-based learning benefit students with primary care career preferences.

BACKGROUND: The impact of instructional method on students with opposing surgical career orientations was investigated in a prospective study. METHODS: Students were randomly assigned to structured or unstructured case-based discussions. Clinical reasoning (OSCE and a diagnosis exercise), subject knowledge (multiple choice test [MCT]), method preference, and pre-third year career preference were compared. RESULTS: Twenty-two students listed a surgical career high (Surgical) and 20 low (Primary). Surgical MCT scores were higher than Primary regardless of instructional method. Surgical diagnosis exercise scores were higher than Primary with the structured method (22.0+/-2.3 versus 15.1+/-3.0, P <0.08). Unstructured scores on this exercise were similar (19.7+/-1.8 Surgical versus 20.3+/-3.5 Primary). Analysis of variance suggested an interaction on the diagnosis exercise between method and career (P = 0.16). Students preferred the unstructured method. CONCLUSIONS: The improved diagnosis exercise performance implies that unstructured cases positively influence surgical domain specific reasoning for nonsurgical career students. These method effects increase our understanding of case-based methods in surgical education.