Volume 70 number 2 Fall 2000 by Joanne Paterson

The UNIVERSITY ofWESTERN ONTARIO ~

~ -An interdisciplinary medical science publication; established 1930 Volume 70

Fall 2000

umber 2

FAMILY M

TAY periodical Wl."E3440

"edical journal. Received on: 00-12-20 70 :2

EDITORIAL

STAFF

Editor-in-Chief Dan Hackam ........... Meds 2000

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Senior Associate Editor Mason Ross ............. Meds 2001 Junior Associate Editor Eric Wong ................ Meds 2002

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Departmental Editors Ethics .............................................. David Satin ...........................Med 2001 yan arine ......................... Meds 2002 Michael Lee-Poy ..................Med 2003 Kim GilmoUI ........................Med 2003 Humour ......................................... Ben Barankin ....... ................. Meds 2001 Keir Peterson ........................ Med 2003 Medical Myths ...................... ........Matt Crystal ..........................Meds 2001 Heather Cox ... ............. ......... Meds 2003 Medicine On The Internet ........... Munsi£ Bhirnani ...................Med 2002 Mark Baumgartner ..............Med 2003 Profile ........................................... Helen Lewandowski ........ ... Meds 2001 aji Touma ...........................Med 2003 Promotion and Prevention .......... Daniel Mendonca ................Med 2001 Albina Veltman ....................Med 2003 Thinking on YoUI Feet ................. Allan Vescan .........................Med 2001 John Lee ............................. ...Med 2003 History of Medicine .......... ........... Vadirn Sherman ................... Med 2000 Alli on Suk .... .................... ...Meds 2003 Medicine and the Law ................. Mahmoud Sharaf ................. Meds 2001 ajib Safieddine .................. Med 2001 Azadeh Moaveni .................Meds 2003 Cover Art .......................... .. ....... ....Scott Kish, Human Interactive co .

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GUIDELINES

FOR

AUTHORS

The UWO Medical Journal is an interdisciplinary medical publication, es ta~lished in 1930. The Journal is published twice each acad~ic yea~: Fall and Spnng. . . ÂŠ All material published by the UWO Medical Journalts copynght_protected -:- "!o sectwn of ~he UWO M edtcal journal may be reproduced withou t the expressed wntten permtsswn of the Edt tor. SUBMISSIONS WHICH DO NOT FOLLOW THESE GUIDELINES WlLL NOT BE ACCEPTED FOR PUBLICATION.

All inquiries should be directed to the Editorial Board. Please do not contact the editorial staff at home. Office: e-mail: Phone & Fax: WebSite:

MS-175, Health Sciences Building journal@julian.uwo.ca (519) 661-4238 www.med.uwo.ca / medjml /

Nature of The Journal The purpose of the UWO Medical Journa l is to provide a single forum for original articles ba e d on research or clinical medicine of topical or historical interest. Since readership of the Journal is interdisciplinary, articles published will attempt to reflect a w ide range of medical intere ts . In this r gard, submissions should be directed towards the ge neral medical reader. Articles which do not pertain to the feature topic will be given lower priority as will those with excessive technical jargon. Please restrict submissions to under 2,000 words. Informal peer review is required, i.e., non-sp cialist authors are encouraged to collaborate with, or at minimum, have their work reviewed for conten t by a specialist in the field . This individual, if not a co-author, is to be acknowledged at the end of the paper. In addition, it is recommended that ali submissions be proof read for significant stylistic or grammatical errors. The editor will not assume responsibility for corrections of thi na ture and articles requiring such revisions will be returned to the author. Submissions and disks become the property of the Journal. The Journal reserves the right to correct errors of punctuation or spelling. Affiliation with UWO i not a prerequisite for author hip. References are indicated numerically in the te t 1 and listed as endnotes in order of appearance.2 Do not use the 'endnote' feature of your word processing program; list references as part of the text on a separate page immediately following the bod y of the document. Punctuation comes before reference number and sentences are separated by one space only. Examples of Journal reference format follow below: 1. Douglas NJ, Thomas S, Jan MA. Clinical va lue of

polysomnography. Lancet 1992; 339(2):347-50. 2. Dement WC, Carskadon MA, Richardson G. Excessive daytime sleepiness in the sleep apnea syndrome. In: Guilleminault C, Dement WC, eds . Sleep A pnea Syndromes. New York: Alan R Liss, 1978:23-46.

SUBMISSIONS Please direct submissions, including return addre s, phone and fax numbers, to: UWO Medical Journal, Health Science Building, Room MS-175, University of Western Ontario, London, Ontario, 6A 5Cl. Submissions are to include a cover letter, two doublespaced paper copies, and the full text on a 3.5" IBM compatible floppy diskette in Microsoft Word or WordPerfect format. The cover letter should be signed by all authors and indicate that the manuscript has not been published previously. Sho rt biographical notes on the authors are to be included at the beginning of each paper, on a separate page. Figures should be professi onall y dra w n; photocopying of illustrations from texts, without the permission of the publisher, is copyright infringement. Each figure, table, or illustration should be submitted on a separate page. Any illustration with a grey-scale should be in the form of a photograph. Two copies of each figure, table, or illustration should be included; each should have it number written on the back, as well as the name of the first author. Legends, which are to be included at the end of the text, should start on a separate page with Arabic numerals corresponding to the figures and tables. Electronic Submission Articles and letters to the Editor may be submitted via our e-mail link on our site on the world wide web at our URL: www. med .uwo .ca/ medjrnl /. An y documents intended for publication should be sent as attached file , and not as e-mail messages . Acceptable formats for attached files are document files of any ve rsion of Microsoft Word, or WordPerfect; other file formats will not be accepted. All elements of the submission, including biographical notes on the author , body of the article, captions for tables and figures, and references should be included as de cribed above. A statement indicating that the manuscript is original and has not been published previously should be included as a separate page at the beginning of the document file . Illustrations a nd photographs cannot be submitted electronically at present, and must be delivered or mailed to the Journal office.

Submit To Us!! U. W. 0 . Medical Journal 70 (2) 2000

CONTENTS EDITORIAL THE IMPORTA CE OF FAMILY MEDICINE AND A FO D FAREWELL TO WESTER By Dan Hackam ........................................................................................................... 6

D E PAR T MENTS PROFILES 1. AN TERVIEW WITH DR. CAROL HERBERT, DEAN OF MEDICINE AND DENTISTRY AT UWO By Helen Lewandowsk.i .............................................................................................. 7

Profi les

THINKING ON YOUR FEET 1. A CASE OF THE FLU By John Lee and Ken Luk ......................................................................................... 10 MEDICINE AND THE LAW 1. HMO-HEALTH CARE OF THE FUTURE? By Mahmoud Sharaf ................................................................................................. 12 ZEBRA FILES 1. A REVIEW OF THE CHILD WITHIN - FETUS IN FETU By John Stein and ja on Ashley ............................................................................... 14 HISTORY OF MEDICINE 1. ANCIE T GREEK IDEAS OF MEDICINE AND DISEASE LEAD G UP TO HIPPOCRATES By Allison Suk ............................................................................................................ 1 PROMOTION AND PREVENTIO 1. ACCESSlliiLITY OF PRIMARY HEALTH CARE SERVICES AMO G PEOPLE WITH PHYSICAL DISABILITIES By Albina Veltman ...................................................... .............................................. 20 ETHICS 1. ETHICAL CASE ANALYSIS: TREATMENT OF A CHILD WITH TRISOMY 1 SYNDROME By yan arine .........................................................................................................23 HUMOUR 1. HAPPY 70TH BIRTHDAY By Keir Pe terson ......................................................................................................... 28 MEDICINE AND THE INTERNET 1. BEYOND THE TERNET: RECOG IZING AND DEVELOPING THE POTENTIAL OF INFORMA TIO TECHNOLOGY FROM A MEDICAL PERSPECTIVE By Mark Baumgartner ............................................................................................... 29

The Zebra Files

MEDICAL VOCABULARY By Joe Chan and Heather Cockwell... ..................................................................... 32

U. W .O. Medical Journal 70 (2) 2000 - - - - - - - - - - - - - - - - - - - - - - - -

Content FEATURE ARTICLES

1. A DIFFERENT KIND OF MEDICI NE By Dr. Jim McSherry .................................................................................................35 2. ASSESSING AND MANAGING COMMON SKIN PROBLEMS IN THE PRIMARY CARE SETTING By Benjamin Barankin ............................................................................................... 38 3. GENERAL PRACTITIONERS OR FAMILY PHYSICIANS? By Eric Wong, Junior Associate Editor ................................................................... 44 4. DIFFUSE GASTROINTESTINAL MOTILITY DISORDER IN YOUNG WOMEN By Helen Lewandow ki ............................................................................................46 5. RED EYE: A BRIEF OVERVIEW FOR THE PRIMARY CARE PHYSICIAN By Gurvinder Dhatt ................................................................................................... 49 6. THE ROLE OF THE FAMILY PHYSICIAN IN SCREENING FOR LONG-TERM COMPLICATIONS OF DIABETES By il h Chande ......................................................................................................Sl

Til e Zebra Files

7. INTEGRATING HERBAL THERAPY INTO FAMILY PRACTICE By Zahra Alidina and Elaine Guzik ....................................................................... .53 8. ANTE ATAL PSYCHOSOCIAL HEALTH ASSESSMENT: A BROADER EXPLORATION OF WOMEN' S ANTENATAL HEALTH By icole Sikorsky and Kerri Engli h ................. ................. ,.................................57 9. THE IMPORTANCE OF THE GP PSYCHOTHERAPIST IN COMMUNITY MEDICINE By Paul Winston ........................................................................................................60 lO. MAN CEMENT OF BREAST CYSTS By Sandy Widder .......................................................................................................63 11. DEALING WITH WOMAN ABUSE IN FAMILY PRACTICE By Daruelle Martin and Sameena Uddin ............................................................... 64 12. LEARN1NG ABOUT LEARNING: HOW PRIMARY HEALTH CARE CAN BENEFIT By irit Bernhard and Raffaela Profiti .................... ............................................... 68 13. UNDERSTANDING INFANT COLIC By Tammy j. Clifford, M. Karen Campbell, Kathy ixon Speechley and Fabian Gorodzinsky ...............................................................................................................72

{<~,~>u

~L 5

RU 7

MISCELLANEOUS ARTICLES

14. CARDIAC MYXOMAS By Shafie Fazel ........................................................................................................... 76

U. W .0. Medical Journal 70 (2) 2000

ABOUT THE EDITORIAL BOARD

OUTGOING EDITOR-IN-CHIEF Dan Hackam is a fourth-year medical student at UWO. He will be tarting his re idency training in internal medicine in Hamilton on July 1. Dan has a strong interest in cardiova cular medicine and the determinants of athero clerosis. He plans to pursue training a a clinician dentist.

INCOMING EDITOR-IN-CHIEF Mason Ross is a third-year medical student at UWO . He completed an HBSc in Physiology at UWO, and is currently intere ted in pur uing a career in a surgical discipline. Mason will be Editor-in-Chief of the UWO Medical Journal this year.

SENIOR ASSOCIATE EDITO R Eric Wong is a second-year medical student at UWO. He will be Senior Associate Editor of the UWO Medical Journal this year.

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EDITORIAL THE IMPORTANCE OF MEDICINE AND A FOND TO WESTERN

FAMILY FAREWELL By Dan Hackam, BSc., Editor-in-Chief

y sheer chance, I find myself writing this editorial on the last day of medical school. It has been a long road, these past four years. They began on a warm sunny day in September 1996, in Auditorium A of University Hospital, where a congegration of 96 nervous, eager, energetic young initiates assembled-in the pre ence of family and friends-to solemnly receive their first white coat and utter the Hippocratic Oath ("The White Coat Ceremony" ). The end of medical school will s e us assemble again, if only for a morning, to receiv our degrees. We will then scatter across this country to begin our lives anew.

These last four years have infinitely enriched my understanding of myself and the world around me. It is as though four years of lectures attended, exams written, patients seen, and camraderie enjoyed, have emblazoned a subconscious set of ethics and values on the de pest recesses of my mind . What seemed important prior to medical school seems trivial now. What was unimportant then is vastly more important now. Before came the boy, now comes the man. Perhaps this is the highest purpose of an undergraduate medical training: not merely to indoctrinate the student with a set of knowledge and skills, but to provide the nourishment and encouragement that enables the student to "grow up". And grown I have.

I have also been musing lately on the perceptions of the public towards physicians, both family doctors and specialists. We live in a country blessed with a free and accessible health care system. Much has been made lately of the decline in patients' attitudes towards health care providers-previously touted as being respectful and deferential, now bemoaned as disrespectful, aggressive, even ungrateful. In the same breath, editorialists usually remark that this has come to pass in an era of internet medicine, declining physician power, and an increasing influence of allied health professionals and so forth . When I reflect back on my clinical clerkship and the electives that followed, I recall many positive interactions with patient and their families. Indeed, with very few exceptions, I encountered respect and interest in my views and opinions. A teacher once told our class that when one is positive and open-minded, one will receive such emotions in return. In closing, I would like to thank the many individuals who taught us over the last four years, who informed us, challenged the way we think and act, and served as role models in their warmth, integrity, compassion, and diligence. I hope they continue to impart their wisdom to the next generation of physicians. Teaching may be viewed as a thankless task by some; in my opinion, it is its own reward. Thank you for a wonderful four years. Q

This is the seventieth year of The University of Western Ontario Medical Journal, an organization of which I am particularly proud, and which I will particularly mi s. It seems fitting that this issue be so broad and encompa s so much of what medicine has to offer, since for me it represents the culmination of four years of growth and development as a human being. I must admit that during my clinical clerkship, family medicine was not alway cast in the best light. And yet, my appreciation of the importance of the family physician has only increased in recent months. The diversity of knowledge and clinical skills required, the ability to recognize the importance of family and community in the lives of one's patient , the many roles that need to be undertaken-all of these impress me when I consider how difficult and underappreciated the lot of the family doctor can be. This issue of the medical journal is therefore dedicat d to family medicine and family physicians.

U. W. 0. Medical Journ al 70 (2) 2000

PROFILES EDITORS: NAJI TOUMA AND HELEN LEWANDOWSKI

AN INTERVIEW WITH DR. CAROL HERBERT, DEAN OF MEDICINE AND DENTISTRY AT UWO By Helen Lewandowski

Carol Herbert is the newly appointed Dean of the Faculty of Medicine and Dentistry at the Univer ity of We tern Ontario. Previou to her recruitment for this po ition, she was a Professor of Family Medicine and Head of the UBC Department of Family Practice from 1988-98. She was also the Founding Head of the Divi ion of Behavioural Medicine in the Department of Family Practice at U BC. In addition, he wa a pioneer in providing service for sexually abu ed children and was founder and co-director of the Sexual Assault Service for Vancouver from 1982-88. Her appointment at Western reflects a trend toward greater integration of the community in medical education and practice, which was initiated with the establishment of a new, patient-centred curriculum two year ago. However, it also repre ents the appointment of an energetic, visionary leader and distinguished re earcher to the Faculty of Medicine and Dentistry at Western. Her current re earch interests are in clinical health promotion; patient-doctor communication in primary care; and how to influence family physician behaviour and decision-making. Dr. Herbert is Principal Inve tigator of a Health Transition Fund randomised controlled trial of educational interventions to improve prescribing. She has been a leader nationally and internationally in the development of primary care re earch, and i a past Chair of the National Research Committee of the College of Family Physicians of Canada and a past President of the orth American Primary Care Re earch Group. She is the winner of the 1997 W. Victor Johnson Medal for lifetime contribution to the College of Family Physicians of Canada, and was named Vancouver YWCA Woman of Distinction in Health and Education in 19 5.

Can you describe some of the events that led up to your becoming Dean at Western? I began my career in practice in a multiethnic Community Health Centre in Vancouver, where I remained for almost 12 years. Throughou t that time, I was

teaching medical student in my practice, and I had a real interest in medical education since the beginning. I al o became more and more involved in community-ba ed re earch. In fact, tho e were the early days and there were not many other people doing re earch in primary care altogether, but certainly there wasn't much going on in terms of looking at community and community partnership research. Over the years, I became convinced of two things. One was that in fact we could teach people things that they were going to need to know when they we nt into practice that we had not been taught. For example, most of us were flying by the seat of our pant when it came to things like counselling and behavioural medicine. Secondly, I became convinced that a re earch ba e was essential for this particular discipline. I had a biochemistry background, I was certainly scientifically trained but for family medicine it was essential to develop a broader research basis. Consequently, I went to the University full-time as a teacher and researcher in 1982. I moved, and some of my practice moved with me, and I started practicing at the Community Health Centre at the University of British Columbia. The rea on I mention thi is that I have remained active in practice throughout my career and eventually I became head of the department of Family Practice at UBC. This allowed me to achieve orne of the goals for which I was at the niversity, that is to say, to affect the curriculum in a major way with a lot of help from colleagues and to develop a research pre ence for Family Medicine. I was successful as the department head. It was a time of fiscal constraint, but we were able to generate income from a variety of places and build the department. Over that period, in the latter part of my term, I became convinced that there were issues relating to medical schools and universities in society that we were not addressing, and that universities were in jeopardy. There had been a loss of re pect for the profession, and generally po t-secondary education across provinces . It wa essential that we re-group and re-create ourselves as universities and medical schools, as ocial re ources. My wish was to have a platform from which to assist in that proce s. At the same time, I was participating in health care reform and I was very concerned at the relative ab ence of academic medicine from the table, at a critical time in the development of health care services in Canada. It was interesting that if there was a school that was more

U. W .O. Medical Journal 70 (2) 2000 - - - - - - -- -- - - - - - - - - - - - - - -

P rofil es p re e nt at the t a ble a t the time, it w a We s tern . In December 199 , when I began my abbatical after 10 year a department head, I thought I would decide w hat I w anted to do nex t, when I came back . When I was recruited to We s tern a few month s later, I wa very intere ted in what I aw, partl y becau e I kne w the strength and reputation of the chool and partly b cause of what I di covered when I visited and met with people atWe tern. Could you elaborate on some of the goals which you would like to accomplish in your position as Dean? In the Ia t few year , We tern a a medical chool has oriented it elf quite squarely towards the communi ty. We have begun the process of developing partner hip . Through rural and regional outreach program in the community of Southwe tern Ontario, we have begun to figure out w hat the health problem are in this community. We now want to look at how we could orient medical education in a broader way, moving learner into the community. Our tudent , both in Medicine and Denti try, need to ha ve both the competence and the confidence to meet community need in the region. I've already begun meeting with people from the region and there i a lot of intere t in thi ty pe of recip r ocal relationship. This is not London at the centre teaching e very thing el e out there, but it i a relation hip of reciprocity where we recognize that tudent and faculty alike can learn from our co-faculty in communitie and patient in communitie . Equally, when we do re earch in the community, we can go out and study an area in the "living laboratory", but we must do that with humility and the under tanding that we do not know everything, we can learn from our community partner . I think that We tern i particularly well positioned to do this, because of the nature of the community, the w a y in w hich Southwe tern Ontario i configured and the way in w hich the referral pattern work. I also want to mention the importance of the continuum of re earch from basic through to community implementation. We ha ve an unbelievable et of re ource in London, including the ho pital , the re earch in titute , and our faculty which include many world-class re earcher . We' re working in a broad range of area but we need to develop orne foci and build on our trengths. We need to pu h the edge on the ba ic science side and al o on the implementation ide. At the end of the day, I' m interested in u being ocially re ponsible and providing improved patient care.

Could you elaborate on some of the research that you have done? The basi from which I started was that a lot of the que tions that I had in practice could not be answered by the data sets which we had available. It i n' t possible to answer que tion about the nature of illne e or the care of ob tetrical patient by looking only at a tertiar care ho pital. It i nece ary to look at the primary care setting as well. My early work was de criptive and wa looking at program development and adole cent health services. I became increasingly involved in studying family violence

and exual abu e i ue . There wa very little known at the time, and one of my earlie t publications wa a letter to the editor de cribing a child with gonococcal infection, w hich at the time was thought to be spread by bed heet . We were pointing out the connection with exual abuse. Along with others, I a! o developed ervice to conduct sexual abuse assessments for children, and to address exual assault in adults. Then, I became engaged with the broader field of clinical health promotion. I wa one of the group that began the In titute of Health Promotion Re earch at UBC, which wa a multidisciplinary venue from w hich we could look at i ues of prevention and health promotion. I worked a an executive member of that ins titute while I wa heading my department and developed research in a range of topics, such a the role of the family phy ician in alcohol, diabetes, and cancer care. More recently, I have been involved in an MRC trial on how doctor make deci ion in situations of uncertainty. Currently, I'm running a randomi ed controlled trial to look at adult learning model for changing pre cribing behaviour. All of the e are in the ervice of under tanding how we can make a difference, and how we can improve what we do as phy ician in a way that' more quality improvement than looking for the bad apple . Thi fit with m y management tyle , becau e I believe fundamentally in a notion ba ed in cognitive psychology that people do their be t work when they are trusted, re pected and assisted rather than governed, directed and puni hed. Wha t do you think of the changing nature of the medical school curriculum at Western, and how do you see it evolving over the next few years? I am a pragmatist about mo t things, and I think that if you take really bright people like we do in medicine, it' po ible to educate people in a variety of way and they will till come out good doctor . So there i no uch thing a the perfect curriculum or the only curriculum. It' really important to remember that, b cau e when imrner ed in curriculum change, the true believers begin to think that there i only one way. I'm really interested in the fact that at We tern we' ve created a hybrid curriculum rather than going in one direction or another. We' ve tried to take the be t of a number of different approaches. However, I am concerned about the fact that the curriculum i very full. ot urpri ingly, when you pull a lot of thing out of the curriculum and you let people fill it in their own little block , it gets filled up again. The difficulty i that you can' t necessarily a k tudent what they want, because they will say that they want more lectures. That's becau e medical school is such a time of anxiety, and students just want to make sure that they' ve "got it all". However, what we know is that if you teach people in a passive way, the decrement in learning i rapid. Within a very short period of time, 50% of learning i lo t, and by the end of four year it' probably more like 90% unle the material is reinforced or taught in an active way. So, I think that the problem-based component of the curriculum i one that we really need to work on. This also applie to the course at Western which looks at health and the community. In my experience, these

U. W . 0. Medical Journal 70 (2) 2000

P r of il e s courses are seen as somewhat interesting at the beginning of the term, but as final exams approach and terror strikes, they are seen as an annoyance. However, when people look back on medical school, thi is amongst the most important learning that people have. We're hoping that with the development of the ecosystem health program, we will grab the imagination of students and allow people to think more broadly. People need to understand that the role of physician requires someone to be a clinical expert, but also to be part of a larger social order. Do y ou f ores ee an y ch anges i n the adm issi o n process to medical school at Western? There's actually an evolution going on in that commi ttee at the moment. I think that everyone in the pool that we are looking at is academically capable of doing medicine. We want to admit people who are star , in terms of all the points of the five-star doctor. The fivestar doctor is a concept of the World Health Organization, and includes the roles that a doctor plays in society, such a ed ucator, scholar, practitioner, manager and social advocate. So if we're looking at developing this kind of doctor, then we need to have criteria in an admission proce s that looks for these feature . Academically, people have to be strong, and we have that one covered. I al o think that all doctors need to have good communication skills. We want to ensure th at our own students are

interpersonally competent. We are also interested in recruiting students who are prepared to work in areas of need such as rural practice. I think that what medical schools are obliged to ensure as socially responsible institutions that we have the broadest possible access in terms of people who represent the social reality. One problem that has existed historically is that we've had admissions committees that all look the same and they tend to look for students who are clones of themselves. Here at Western, we have a broader ba ed admissions committee, and we've broadened it purpo ely to include students and members of the community. I think that's an advance, and a good thing. Will we choo e different students than we would have chosen if we didn' t have community members there? Quite possibly. Will they be less able students? No, I'm sure not. They may do different things than the tudents we would have cho en without community members, and that remains to be seen. We need to follow them and see what happens. I believe so fundamentally in this business of the university and the medical school being in a relationship with its community that I am establishing a community advisory board for the Faculty that will engage people from the Southwestern Ontario community. I am hopeful that they will advise u s and carry our story into the larger community and government. Q

Southwestern Ontario's Leading Centre for Patient Care, Teaching and Innovation

LONDON Health Sciences Centre Congratulates the UWO Faculty of Medicine Graduates.

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THINKING

YOUR FEET

EDITORS: ALLAN VESCAN AND ]OHN LEE

C A 5 E OF

THE

FLU By John Lee and Ken Luk, MEDS 2003

You are a family phy ician in Chatham, Ontario. A 66 yea r-old male, Rohen, comes into your pra ctice complaining of cold symptoms. He claims that he has been suffering from a high fever, cough, runny nose, chills, and muscle aches for the last 3 days. PLEASE STOP AND ANSWER THE FOLLOWING QUESTIONS: 1. What are the symptoms of the flu? How can you distinguish the flu from the common cold? After dutifully performing your history and a physical examination, you explain to Rohen that he appears to have a case of the flu . As an active individual, Roh e n is somewhat discouraged over the prospect of being bedridden for the next few days. However, he anxiously tells you that while watching the news recently, he has heard of some new drugs available to combat influenza. Not wanting to miss too many of his daily tennis matches, Rohen inquires about getting a prescription for these antiviral medications. PLEASE STOP AND ANSWER THE FOLLOWING QUESTIONS: 2. What steps should be taken to manage influenza? 3. Describe any available anti-viral pharmacological agents for influenza. You reassure Rohen that he is a very he a lthy individual and that bed rest and plenty of fluids will put him on his way to recovery. However, Rohen live in a retirement home and fears that others may contract the illness from him. PLEASE STOP AND ANSWER THE FOLLOWING QUESTIONS: 3. What precautions sho uld be taken in nursing / retirement homes to prevent the development of an epidemic? Rohen comes back to your practice 2 days later and claims to be feeling much better except for a nagging cough. He asks you if he can participate in an outdoor field

ABOUf THE AUTHORS John Lee is a first year medical student at the University of Western Ontario. Prior to entering medical school, he completed a Bachelor of Science degree in Human Biology at the University of Toronto. Ken Luk is a first year medical student at the University of Western Ontario. He previously completed an Honours Bachelor of Science degree in Immunology at the University of Toronto.

excursion in Perth County tomorrow. Although he feels fine, some of the nurses at the retirement home don' t share his enthusiasm and worry about Rohen getting sick again. PLEAS E STOP AND ANSWER THE FOLLOWING QUESTIONS: 5. What is the duration of the flu and what secondary complications may arise from it? After much convincing, Rohen agrees to rest for a few more days before returning to his active schedule. You emphasize that if he starts to feel ill again, he should contact yo u immediately to prevent any further complications. ANSWERS TO CASE STUDY 1. The ' flu' can be caused by influenza A, influenza B or influenza C viruses. Influenza A and influenza B are responsible for most clinical cases that present to a family medicine practice. Typically, one sees the abrupt and severe onset of symptoms such as high fever (38째C - 41 째C), chills, malaise, headache, sore throat, cough, rhinorrhoea (runny nose) and myalgia (generalized muscle aching). Although most of the e findings usually subside within one week, patients often complain of persistent fatigue and cough.I The common cold is caused by an upper respiratory tract viral infection that has the following presentation: fatigue , sore throat, runny nose, purulent nasal discharge, cough, headache, and a fever.2 Because the cold and the flu share some common symptoms, patients often confuse the two illnesses. The gold standard for distinguishing between them is the abrupt onset and extreme severity of influenza symptoms. The cold produces milder systemic manifestations and more prominent nasal symptoms. I 2.

When the flu has been diagnosed, certain steps should be taken to manage the discomfort felt by the patient. Most importantly, rest is needed to allow an individual to recover from the debilitating effects of influenza. High fluid intake is also recommended to maintain hydration . Analgesics such as aspirin or acetaminophen may be used to help alleviate pain and fever.l Antiviral therapies such as amantadine or new drugs such as Relenza or Tamiflu are available to the public. However, since these pharmacological agents must be used within the first few days of the illness, patients will often present to the family ph ysician outside of the therapeutic window. As such, most physicians recommend managing the symptoms of the flu and allowing the body' s immune system to U. W . 0. Medical Journal 70 (2) 2000

----------------------- T h i n k i n g

o n

Yo u r

Fe e t

fight the viru a the primar y cour e of action . However, one must remain vigilant when treating influenza patients in orde r to avoid secondar y complications that could exacerbate the illness. It hould be noted that antibiotics hould not be prescribed unless these individuals are suffering from econdary bacterial infections.J

the flu season in the winter. Studies have hown that influenza vaccination protects up to 50-80% of the administered population for the given year. If a case is reported, then all residents should be given amantadine as a prophylactic measure; vi itors into the complex should be monitored to prevent further spread of infection.3

Amantadine (Symmetrel) - first available in 1976; effective for only influenza A; taken orally; if begun within 48 hours of onset of illness, can reduce duration of symptoms by approximately 50%3; 5-10% of adult experience mild C S side effects such a insomnia, lightheadedness, irritability, or difficulty concentrating; prophylactic use approved .4 Rimantadine - first available in 1993; do ely related analogue of amantadine; effective for only influenza A; equally efficacious but le frequent side effect .3 Ribavirin - nucleoside analogue; effective for influenza A and influenza B; administered a a n aerosoJ.3 Zanamivir (Relenza) - first available in December 1999; neuraminidase inhibitor; effective for influenza A and influenza B; taken intra-na ally within the fir t 2 days of symptoms; for patients >= 12 yrs; can reduce severity of flu symptoms throughout course of illne ; can reduce duration of symptoms by up to 1 day; also s hown to reduce complications in high ri s k populations; no side effects.5,6,7 Oseltamivir (Tamiflu) - fir t available in December 1999; neuraminida e inhibitor; effective for influenza A and influenza B; taken orally within the first 2 day of symptoms; for patients >= 18 y rs; can reduce duration of illnes by up to 1.3 day ; ide effects include nausea and vomiting in some.5,6,8

5. Typically, influenza ymptoms last anywhere between 3-5 days. However, as mentioned earlier, certain symptoms such as cough and fatigue may persist for 2-3 weeks after.J One mu t al o be wary of econdary complications that may ari e from influenza. The most common of these is pneumonia . Pneumonia can be cau ed by a primary influenza virus or secondary bacterial infection. Primary viral pneumonia is the least common but most evere form of the illness. Clinically, a mixed viral and bacterial pneumonia is usually present. Patients will experience a 2- to 3-day improvement from the flu symptoms followed by the reappearance of fever, chest discomfort, and sputum production. Other econdary complication to be aware of include bronchitis and ear infections.9

There are pecific high-ri k population in which the flu could have disastrou s e ffect (i .e . elderl y, chronicall y ill, immuno-compromi ed) .2 Quick precautions to prevent an epidemic in a retirement home hould be taken as oon as a ca e of influenza is reported . Flu vaccine should be administered to aU resident of the home a well as all per ons in contact with the home, including everyone from medical staff to janitorial staff. The vaccine should be administered in the fall eason so its peak activity will coincide with

ACKN O~E D GEMENTS

The authors would like to thank Dr. J.R. Morrissy for reviewing this ca e. Dr. Morrissy i a family physician at the St. Joseph' Health Centre, Family Medical Centre. REFERE CES 1. Murtagh f. Influenza . Inflrlenza . In : General Practice (2nd edition). Roseville: McGraw-Hill Book Company, 1998:377-379. 2. Kirkpatrick G. Viral Infections of tire Respiratory Tract. In : Taylor R. Family Medicine (4th editiorr). ew York: Springer- Verlag, 1994:268-272. 3. Dolin R. Influenza . In : I elbaclrer K. Harri on 's Principles of Internal Medicine Vol. 1 (13th edition). New York: McGraw-Hill Inc. 1994:814-819. 4. Wright P. Respiratory Viral Infections. In : Kelley W . Textbook of Internal Medicine Vol. 2 (2nd edition). Philadelphia: JB Lippincott Co. 1992:1480-1484. 5. MMWR Morb. Mortal Weekly Report Dec. 171999; 48(RR-14):1-9. 6. Couch RB. Measures for control of influenza. Pharmacoeconomics 1999; 16(1):41-45. 7. Relenza. GlaxoWelcome Inc. 1999. 8. Tamiflu. Roche Laboratories Inc. 1999. 9. Parry M , eu H, Connelly f. Infectious Diseases. In: Rake/ R. Textbook of Family Practice (5th edition). Philadelphia: W.B . Saunder Co. 1995:317392. 10. Reprinted from: Its Never Been Easier to A ttack the Flu. Hoffmamr-LaR oche f2 Ltd.1999.

Table 1: Comparison of Cold and Flu Symptoms10 Symptoms

Cold

Flu

Fever Aches and Pains Tiredness and weakness Extreme exhaustion Stuffy nose Headache Chest discomfort, cough Sneezing Sore throat

Rare Slight Quite mild Never Common Rare Mild to moderate; hacking cough Usual Common

Characteristic, high (over 38째C) and lasting 3-4 days Usual and often severe can last up to 2-3 weeks Early and prominent Sometimes Prominent Common; can become severe Sometimes Sometimes

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MEDICINE

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EDITORS: MAHMOUD SHARAF, NAJIB SAFIEDDINE, AzADEH MOAVENI

HMO-HEALTH

CARE

THE

FUTURE? By M ahmoud Sharaf

amily medicine is the frontline of health care in our society . Physicians and nurse practitioners throughout the United States and Canada addre s the majority of health care needs at the community level.l Spending by government and consumers on family health care is a major part of costs in North America. In Canada, the single payer system is in effect, and no legal challenges concerning quality of care have been made again t the federal or provincial governments.2 The story is different in the United States. The ascendancy of the HMO (Health Maintenance Organization) has been a cause for much litigation and legislative wrangling. Benefits, standards, fairness and reasonable costs have become real issue .3 Let us examine the causes of the HMO debacle and study its implications for Canada. Health Maintenance Organizations were introduced just over a decade ago in response to concerns over feefor- service health care . They signed up millions of consumers overnight promising top-quality, hassle-free care with distinct caps on exploding costs.4 That w as the theory. In point of fact, HMO's have been raising rate and prompting employers to trim, even eliminate, ce rtain benefits for workers.s A 1999 Discovery-Newsweek Poll determined that 61% of Americans were "frustrated and angry" with the current HMO s y stem, 50% believed " fundam e ntal change" was necessary and 70% concurred "some kind of action" was needed on the part of the Federal Government. Some sixteen percent of Americans to date, 44.3 million individuals, have no health insurance.6 What are the specific complaints levied ag a inst HMO ' ? There are issues of choice and limitations, benefits, quality of care, costs and accountability? Many HMO's permit no more than 3 doctor visits a y ear, excluding necessary referrals. If visits are made contrary to this condition, the incurred cost must be covered by the consumer.s Pre-authorization is needed for many ho pital visits and procedures. Unless there is HMO approval, reimbursement will not be provided . Antibiotics and medications are often prescribed to s uit insu r ance directives, not optimal medical suitability.9 There are often restrictions on choice, and many horror stories on " HMO greed" . There are lists of approved doctors, approved treatments, lengths of convale cent periods, maximum benefits in cases of transplant or serious injury and a m yriad of other technicalities.lOThere are cases of expensive cancer and heart drugs being denied. Half of eligible heart patients are not receiving the Betablockers that could prevent heart attack risk.ll This brings up questions of quality of care for the fees paid. Sixty-five percent of Americans believe health care is too expensive and 51% believe there are too many coverage restrictions. " The power is in the hands of purchasers - the large

employers and Medicare," says Dr. Paul Ellwood, the man who invented the term HM0.12 Canadians, however, should not come to premature conclusions . Many HMO' s have excellent records of consumer satisfaction, although admittedly they have higher rates. Americans largely reject the Canadian and European concept of single-payer health care because it stifles competition and ultimately quality, an argument with some v alidity . Onl y 5.3% of American famil y earnings go towards health care, less than for restaurants and entertainment. This contrasts sharply with Canadian and European tax burdens.13 Despite the low cost, the population health of the United States is only marginally inferior to Canadian and European exemplars. Average health care spending on the uninsured is 60% of the amount spent on the insured .14 Health care providers recover this substantial cost by raising premiums on the insured. Much of the problem in the U.S. stems from American unwillingness to spend more of familial income on health care, forcing some HMO' s to become cutthroat. One thing that cannot be denied is the legal nightmare HMO' s have caused. Up until recently, HMO' s have been protected from lawsuits by federal legislators.ts This meant that complaints about coverage had to be scrupulously documented by the patient and presented to the applicable state' s Department of Health which oversees HMO abuses and denials. These fights were difficult because HMO's cover their tracks with explicit agreem e nt policies that dampen the U nfair In su rance Practices Act of individual states, which protects patients.1 6 Doctors have filed lawsuits against HMO' s because of restrictions on payment in the face of claimed coding and billing errors by physicians, so-called " downcoding" practices.17 Doctors are also vowing a legal fight in the face of "gag rules" . HMO's prevent organization doctors from discussing or promoting expensive tests and treatments that could come back to haunt the management.18 Policy makers have struck back. Texas passed a strong patients' rights bill in 1997.19 Judges have permitted antimanaged care lawsuits for the first time. The House of Representatives and US Senate have crafted new bills that would make HMO' s more accountable. The American Medical Association recommends making HMO's compete for money in the consumers' hands by delivering results. 20 President Clinton vowed to deliver a Patients' Bill of Rights in 2000 in his recent State of the Union Address. Presidential candidates promise to relieve the uninsu r ed by using some of the expected budget surplus.21 In Canada, our lawmakers have been slow to respond . The tax base is not increasing in line with growing health care costs, hence the cutbacks. Demand for service will

U. W. 0. Medical Journal 70 (2) 2000

Med out trip financial resources by simple mathematics. The Americans are beginning to get their act together, but the Canadian legislative apparatus is remarkably ilent. Examination of the American experience should guide us in our reform of the ingle-payer system, if it hould survive. REFERÂŁ CES 1. Mental Health et, http://mentalhelp.netlarticleslmc60628 2. Ibid. 3. HMO Hell, ewsweek, ovember 8, 1999, p 58-73 4. Ibid. 5. Ibid. 6. Ibid. 7. Judges ationwide Are Allowing Patients to File Claims Against HMO's,http://www.voiceoftheinjured.com/a-hmo-suit allowed.hhnl 8. HMO Hell . ewsweek, IW.8, 1999. P. 58-73 9. Ibid. 10. Ibid. 11 . Judges ationwide Are Allowing Patient to File Claims Against HMO 's,http://www.voiceoftheinjured.com/a-hmo-suitsallowed.hhnl 12. HMO Hell, ewsweek, ovember 8, 1999, p 58-73 13. Ibid. 14. Ibid. 15. HMO Abuse and Denials, http://yourmessage.com/lrmo.lrtm 16. Ibid. 17. Doctors file lawsuits against UnitedHealtlrcare and HIP, http://www.ilrsllre.com/statesljl/lrealth llawsuits899.1rtml 18. Doctors prescribe fight against HMO gag rules, http://mentallrelp.net/articles/mc60628.html 19. Legislation could lrold HMO 's legally liable for patient care, Mary Alice Robbins, Lubbock AvalancheJournal, March 17, 1997. 20. HMO Hell. ewsweek IW.8, 1999, p. 58-73 21. Gore and Bradley Talk Health Care,http://cnn.com /ALLPOLITICS/analysisl trxms/1999/12/17/mitdre/1 1- Find Similar Q

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THE ZEBRA FILES EDITORS: jOHN

D. STEIN AND jASON ASHLEY

A REVIEW OF THE CHILD WITHIN-FETUS IN FETU By Jason Ashley and John Stein INTRODUCTION umours and teratomas have been plaguing mankind since the dawn of time and have been somewhat of a mystery to medicine. Intriguing examples of this are the extremely rare cases of fetus in fetu. Defined by orne as a reduced and parasitic fetus within the body of a ho t fetus, fetus in fetu is often not considered a teratoma.! Others have indicated that there is a great possibility that the " fetus within" is merely a highly differentiated teratoma.2 Meckel (ca. 1800) first proposed the term fetus in fetu. However, the definition of fetus in fetu has been a loose one, only truly being examined by Lord in 1950.3 Prior to 1900, there were an alleged thirty-one cases. From the beginning of this century, there have been approximately fifty case reported. This is not an indication that the incidence is rising in the population, rather medical techniques and reporting of such bizarre ca es have become standard. The incidence of fetus in fetu is from one in five hundred thousand to one in one million.4 Patients usually present with a mass in the right upper quadrant, which does not grow, or grows at an extremely slow rate. Once the mass is resected, differentiating fetus in fetu from a teratoma can be accomplished by demonstrating, either radiographically or by dissection, the presence of a vertebral axial skeleton.3 Once this has been established, further tissue can then be examined to determine the extent of differentiation and stage of growth in which the parasitic fetus's development was halted.

CHARACTERISTICS OF FETUS IN FETU TISSUES AND CYTOLOGY While the definition of fetus in fetu require the presence of a spinal cord, others have debated that the definition should also include masses that do not indicate the presence of a vertebral column.2 The contention is that fetus in fetu should include cases where the presenting mass has organ-like structures in the absence of a

ABOUT THE AUTHORS Jason Ashley and John Stein are first-year medical students at UWO. Jason Ashley completed an HBSc in biochemistry from Laurentian University and has an interest in medical technology and radiology. John Stein holds a BScH SSP in Life Sdences from Queen's University and a B.Kin from McMaster University. Between degrees, John volunteered for Mother Teresa's mission in Calcutta and for the Human Development Center in Bangkok's "Klong Toey" slum. 14

ve:tebral. col~. There have been several cases of giant ep1gnathi, which could be included as fetus in fetu, if not for the limiting factor of the vertebral column. Most of the samples which have been studied have indicated everal different levels of differentiation. The vertebral column is, of course, the most important structure. Other bony structures that are commonly found are ribs, and appendicular skeletal segments in various stages of development. Some of the masses present with a psuedoplacenta and amniotic fluidS, while most others have po e sed voluntary muscle and glial tissue.6,7, Most of the case have demonstrated the presence of axial limbs, but in a most rudimentary form. Thus, most tissues found in normal infant and adult bodies can potentially be found, however presenting cases vary depending on the e.xte.nt ~f the mass's in differentiation. An interesting finding IS the usual lack of myocardial tissue in the fetus in fetu. This may be an important clue as to the origin of the para itic twin. Since the mass is usually a result of fusion of monozygotic, diamniotic twins, a similarity to acardiac monsters might exist. Acardiac monsters result from a host twin supplying blood to a parasitic twin, which lacks a heart. Furthermore, acardiac monsters are usually joined to the superior mesenteric artery of the twin, a feature which is also common to the fetus in fetu.4 Studies of the eight blood group systems have shown no differences between the host and the tumour in question. Also, chromosome studies of a fetus in fetu showed normal chromosomes, identical to those of the host. Furthermore, in one particular case histological studies confirmed the presence of intra-abdominal gonads. These tests indicated the sex was identical to that of the host. Thus, dizygosity or aneuploidy can be disregarded as a possible cause of fetus in fetu. 9 Also, taking all the above into account, it might be concluded that the mass presenting is that of an engulfed twin rather than highly differentiated teratogenic tissues. TYPICAL SIGNS AND SYMPTOMS Most individuals present with a painless retroperitoneal mass in their RUQ. However the rarest cases have involved the growth being present intracranially,lO, n within the oral cavity,2 and scrotum.12 The mass is usually present from birth, and does not tend to grow to any great extent. Any growth and increase in size is associated with a subsequent decrease in size due to necrosis as a result of the poor perfusion of the fetus in fetu. There is no link between sex and fetus in fetu as both males and females are equally effected . Approximately seventy five percent of all masses are diagnosed while the patient is an infant. The other twenty five percent are

U. W.O. Medical Journal 70 (2) 2000

- - -- - - -- - - - - - - - - - - - - - - - - - - T h e Host Characteristics

Fetus in Fetu Characteristics

Age: Usually present at birth, and diagnosed Can be missed and carried into adulthood

Sex: That of host

Ze b ra

F Ie s

Sex: Non-discriminatory

Skeletal tissues: Vertebral column, often present is rudimentary appendicular skeleton Other skeletal structures found can be pelvis, teeth, mandible, skull, ribs

Signs and Symptoms: Usually a painless mass in the RUQ, retroperitoneal Can be present in other areas, but very rare (scrotum, oral cavity, intracranial)

Organ tissues: Myocardial tissue always absent Brain and intestine very common Other organs are uncommon Number present per case Usually only one, but as many as five reported in a single presentation Mass: From 13 g to 1.8 kg

Table 1 -Characteristics of hosts and tumour

diagnosed as adults, when the mass becomes bothersome.t3 The presence of the tissues in adulthood would indicate the relative benignity of the mass, with the oldest individual to present with a fetus in fetu being 47 years of age.t4 Common characteristics of host and fetus in fetu are given in table 1. IMAGING TECHNIQUES Modern radiography has made the diagnosis of fetus in fetu possible prior to surgery. With respect to identifying a vertebral axis, plain film is the best method for diagnosis given the presence of a complete and calcified spine. (Figures 1-A, 2-A) However, many cases do not show the presence of a complete spinal cord, rather a column which is underdeveloped or dysplastic.? In tho e instances, the use of a more sophisticated technique, such as Cf, is indicated. Since Cf is best at axial imaging and gives high resolution between tissue types, it is best suited to vertebral axes that are poorly developed. cr might also be indicated if the plain radiographs fail to show differentiation, and if the relationship of the mass to other tissues is not certain. (Figure 2-B). TREATMENTS Treatment is very straight forward, involving surgery and excision of the tumour. It is thought that if the tumour is of teratogenic origin, then total excision must be followed to ensure no regrowth of tissue. However, some fetus in fetu masses have been fused to major vessels14 or to other vital tissue, IS requiring certain parts of the tumour to remain within the host. In these cases, there has been no sign of reappearance of the tumour and patients return to original health in all cases. Current treatment protocols have allowed most individuals to be released 2 days postopera tion.14 This ease of trea tment is mainly a characteristic of twentieth century medicine. Prior to 1900, most cases presented themselves at autopsy, p resent in children who perished following common childhood ailments of the day, which were numerous.

Fig 1-A Plain film radiograph of a fetus demonstrating a well formed spinal column, partial femur and pelvi and other skeletal features.

Fig 1-B Gross appearance of three fetuses with ruptured amnion. The arrows indicate the attached umbilical cords.

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Figure 2 Fig 2-A. Plain film abdominal radiograph of a host showing a fetus w ith a well formed skull and vertebrae positioned vertically in the upper left quadrant. A second fetus' s femur may be discerned in the hilar region of the liver. . . Fig 2-B. A cr image demonstrating the second grou p of . mall bones near the infenor surface of the liver. The larger fetus is evident near the left kidney.

RAREST CLINICAL ENTITIES Fetus in fetu removal in a 47 year old man14 A huge abdominal mass was present at birth in 1942. The patient was investigated by barium meal and barium enema scan. This investigation demonstrated a huge abdominal mass that was not related to the stomach, duodenum, or transverse colon. Calcifications w ere evident in the radiographic scans. Upon needle aspiration of the tumour, a clear fluid was obtained. The surgeon diagnosed an inoperable malignant neoplasm, and the patient returned home. There were no related symptoms when he presented to a general practitioner in June of 1988, when a CT was performed without contrast. What became evident was a cystic mass approximately twenty centimeters in diameter within which could be found calcifications resembling vertebral bodies. Surgery was done eight months later and was found to be adhere~t !o the inferior vena cava. Portions of the cyst were left Within the patients body, to ensure the integrity of the IVC. The cyst was studied postoperatively, and it was found that most of the tissues were necrotic, suffering years of decay after only a limited blood su pply. However, given the characteristics of the tumour, it was determined to be fetus in fetu . Twenty two months postoperative, the patient was reportedly doing fine and there was no .modifi~ation of the tissue which was left within the abdommal caVIty attached to the IVC.

A Cerebral Tumou r Containing Five Human Fetuses 10 A hydrocephalic female was delivered by caesarian section and lived for 19 days. The family' s history was

unremarkable except for the grandmother w hom had given birth to a still born monster . On the fifth da y postnatal, the head of the infant was e~o~ou_s with two cranial taps being performed each gwmg fifty to one hundred cubic centimeters of serosanguinous fluid . Neurological examinations proved normal, but suckling and feeding were noted to be weak. The child slow ly weakened and died. At autopsy the torso and related organs proved unremarkable. The skull was :ruarged and, on inspection of the brain, the cerebral herruspheres ~ere eight to ten times the normal size. The temporal, p~1~tal, and occipital lobes wa s mainly tumour contammg calcifications. The ventricles were obliterated. The tumour was excised for stud y. Probing within the tumour revealed five embryos, two virtually complete but lacking head s, w hile the other three were amorphous but possessed upper and lower extremities.(Figure .3). P~esent in each w ere all three germ layers, connective hssue, cartilage, lymphoid tissue, and respiratory structures. Urinary and digestive segments were in specific embryos, but not present in all. CONCLUSION Fetus in fetu may present as a gradually expanding mass, u s ually present in the abdomen. The relati v e importance of this article is to unders.t and the be~g.n nature for which this tumour presents 1tself. Also, 1t 1s important to acknowledge the difference between fetus in fetu and teratomas. While origins may be disputed, the evidence tends to indicate that monozy gotic twin fusion and engulfment is the cause of this extremely rare clinical phenomenon.

U. W .0. Medical Journal 70 (2) 2000

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6. Al-Baghdadi R. Fetus in fetu in the liver: case report and review of the literature.]. Pediatr. Surg. 27:1491-2.1992 . 7. Luzzallo C., Talenti E., Tregnaghi A., Fabris S., Scapinello A., Guglielmi M . Double fehts in feht: diagnostic imaging. Pediatr. Radio/. 24: 602-3. 1994. 8. Lee E. Y.C. Foetus in Foetu. Arch. Dis. Child. 40: 689-693. 1965. 9. Eng H.L., Chuang ].H., Lee T. Y ., Chen W.J. Fetus in fetu: a case report and review of the literature.]. Pediatr. Surg. 24: 296-9. 1989. 10. Kimmel D .L., Moyer E.K. , Peale A. R., Winborne L. W. , Gotwals j.E. A cerebral tumor containing five lmman fetuses: a case of fetus in feht. Anal. Rec. 106: 141-158. 1950. 11 . Yang S.T., Leow S.W . Intracranial fetus-in-feltt: CT diagnosis . Am.]. Neuroradiol. 13: 1326-9. 1992. 12. Kakizoe T. , Tahara M . Fetus in feltt located in the scrotal sac of newborn infant. A case report. ]. Urol. 107: 506-508. 1972. 13. Thakral C.L., Maji D.C., Sawani M.j.. Fetus-in-fetu: a case report and review of the literature. ]. Pediatr. Surg .33:1432-4. 1998. 14. Dagradi A.D., Mangiante G.L., Serio G.E., Musajo F. G., Menestrina F. V .. Fetus in fetu removal in a 47-year-o/d man. Surgery 112: 598-602. 1992. 15. Young G.W. Case of a foetus found in the abdomen of a boy. Med. Chir. Q Trans. 1: 234. 1809.

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Because you need to know that your bank is as committed to your success as you are. Figure 3 Fig 3-A Schematic of five fetus in fetu, outlining the location of ana tomical features Fig 3-B Gross Appearance of the fi ve fe tuses Fig 3-C Plain film radiograph s of the five fetu ses. Fetu s 1 d emonstrates adear vertebral column and partial pelvis and long bones. Fetus 2 demonstrates long bones, vertebral column and sk ull. Th e re maining fe tu se s d e monstrate onl y parti a l calcification.

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REFERE CES

1. Fink A.M., Cuckow P.M. , Scott R. Ca e report: fetus-in-fetu - imaging, surgical and pathological findings. Clin. Radio/. 50: 274-5. 1995. 2. Senyuz O.F., Rizalar R., Celayir S., Oz F. Fetus in fetu or giant epignatlms protruding from the mouth. ]. Pediatr. Surg. 27: 1493-5. 1992. 3. Lord J.M. Intra-abdominal foetus in foetu . j. Patlwl. Bacteriol. 72 : 627-641. 1956. 4. Carles D., Alberti E.M. , Seroille F. Fehts in feht and acardiac monster: can the similar patterns of these two ma/fomiUiions be explained by a common morphogenic mechanism ? Arch. Anal. Cytol. Pathol. 39: 77-82. 1991. 5 . Hanquinet S., Damry ., Heimann P., Delael M.H. , Perlmutter N .. Association of a fetus in fetu and two teratomas: US and MRI. Pediatr. Radio/. 27: 336-8. 1997.

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HISTORY

MEDICINE

EDITORS: VADIM SHERMAN & ALLISO

SUK

ANCIENT GREEK IDEAS OF MEDICINE AND DISEASE LEADING UP TO HIPPOCRATES By Allison Suk, MEDS 2003

ittle is known about the medicine of the Ancient Greeks before the time of Hippocrates. The writings of Homer, namely the Odyssey and the iliad, contain the earliest written source of Greek medical knowledge and practices. Traces of Greek medicine can al o be fo und in the writings of other Greek poets and in Greek myths. The medical writings at this time were a combination of folk medicine and a scientific approach to medicine. Prior to Hippocrates, Greek doctors shared the same philo o phy as other Greek pioneers of science. It was though t that much more could be discovered by reflection and argument than by practice and experiment. No distinction had been made between philosophy and science. Hippocrates was the first to suggest that disease was not a punishment for sin. By looking into the medicine of the myths and poems created before and during Hippocrates' life, one can gain insight into the medical climat that Hippocrate was raised in.

HOMER Homer's iliad chronicle the tenth and final year of the Trojan War. Being an epic concerning a war, the iliad i full of information concerning the knowledge of and treatment for injuries. The iliad demonstrates the Ancient Greeks' knowledge of anatomy through the deta iled description of almost 150 different wounds. In one cene, Homer displays the Greeks' knowledge of anatomy by graphically describing a fatal wound. The arrow pierced the soldier in the right buttock, sliced through the body missing the pelvic and pubic bones and hit the bladder. Homer displa ys an appreciation for the severity of different wounds. All of the 31 different head wounds depicted were lethal, whereas wounds to the arms and legs were painful, but not deadly. In one scene, Diomedes, struck by a spear in the shoulder, had the strength to remove the spear and go on to inflict two fatal wound . ''There slew he Astynoos and Hyperion shepherd of the host; the one he pierced above the nipple with his bronze-shod dart, the other with his great sword upon the collarbone beside the shoulder he smote, and severed the

ABOUT THE AUIBOR Allison Suk is a first-year medical student at UWO who previously completed a BSc. Honours in Biology at McMaster University.

shoulder from neck and back." (The iliad, V, 145-149). Homer not only accurately de cribes wounds, but also records the care given to an injured warrior. The majority of the care given was directed toward the comfort of the injured man as oppo ed to the treatment of the wound. There we re warriors prese nt, howe ver, that were specialists in the art of healing . One main doctor, Machaon, was the on of the legendary healer Asclepiu who later became deified as the god of healing. Machaon treated injured warriors through herbal remedies and expert bandaging . When Machaon, himself, became injured, he received a cup of hot wine sprinkled with grated goat cheese and barley. Beyond describing wounds and their treatments, the iliad commences with the earlie t account of di ease in Greek literature. A plague was sent down upon the Greek army by the god Apollo as a form of punishment for Agamemnon's insulting of a prie t and the theft of the priest's daughter. In this sense, Homer illustrates that disease was viewed as retribution for a sin. Arrows cast upon the Greek soldier spread the plague. The plague is described as being a highly communicable disea e with a sudden onset. Though exact symptoms are not mentioned, the disease is accompanied by an acute fever and quickly became fa tal. The treatment for the disease demonstrate the synthesis of folklore wi th scientific knowledge in Ancient Greek medicine. The Greeks appease Apollo through sacrifices and the return of the prie t's daughter. Following the conciliation of the god, the Greeks cleanse their camp and throw any "defilements" into the sea. This suggests that the disease may have been a severe dysentery that was made worse b y the unh ygienic conditions of the battlefield. Apollo's epithet in the Iliad also suggests that the Greeks associated rodents with the s pread of disease. Apollo is frequently addressed a Apollo Smintheus, which translates into Apollo the Mouse Hunter. The Greeks would pray to Apollo under this name in order to keep rodents away. Homer's Ody ey al o depicts Ancient Greek concepts of medicine and disease. The practice of singing incantations over wounds is mentioned when Odysseus, the hero, is wounded during a boar hunt. Again, the treatment of this wound illustrates the amalgamation of science and tradition in Greek medicine. Od ysseus ' wound is skillfully bandaged, followed by the singing of incantations in order to top the bleeding. "They bound it up skillfully, and tayed the black blood wi th a song of

U. W. O . Medical Journal 70 (2) 2000

------------------------- H i s t o r y healing." (The Odyssey, XIX, 455-458). Odysseus is then allowed a period of rest and recovery before he returns home. The Odyssey also hints upon the use of hallucinogens w hen Odysseus and his crew meet up with the Lotus Eaters. Upon eating the fruit of the lotus, Odysseus' crew lo es their memory and their desire to return home. The crew has been drugged into wanting to stay with the Lotus Eaters. The fruit of the lotus that Homer refers to is unknown, but may possibl y be opium or a form of cannabis. OTHER GREEK MYTHS

Elements of Greek medicine are present in many poems and plays of antiquity. Homer was not the only Greek poet to deal with plagues . During the Peloponnesian War, the historian, Thucydides, describes a severe plague that ravaged Athens. Thucydides provides this vivid depiction of the plague. " As a rule there was no ostensible cause, but people in good health were all of a sudden attacked by violent heats in the head, and redness and inflammation in the eyes, the inward parts, such as the throat or tongue becoming bloody and emitting an unnatural and fetid breath. These symptoms were followed by sneezing and hoarseness, after which the pain soon reached the chest and produced a hard cough. When it fixed in the stomach, it upset it; and di scharges of bile of every kind named by physicians ensued." (The History of the Peloponnesian War, IT, 47.354.5). Thucy dides states that the physicians of the time could not do anything to help; in fact, they often came down with the plague them elves. After seven or eight days the plague was often fatal . Those that survived were often left with physical scars or suffered memory loss. Thucydides does not appear to have an understanding of how the plague spread, but he does observe that any birds or beasts that preyed upon human bodies abstained from touching them, or died after tasting them. This vivid depiction of the plague and the toll it took on its victims and the city of Athens inspired other authors to discuss plagues . A plague hits Thebes in Sophocles' Oedipus Tyrannus. In this case, a priest of Zeus states that the plague is the result of the murder of the ruler of the land, Laius. The priest suggests that the plague will end with the vengeance of his murder. The idea that disease was a penalty for sin was still very prevalent in the ti me of Sophocles, who wrote during Hippocrates' lifetime. In Sophocles' tragedy, Philoctetes, the treatment of a w ound due to a snakebite illustrates the use of herbs in antiquity. The hero, Philoctetes, was bitten by a snake w hile participating in a sacrifice to a minor deity. The w ound from the bite produced such a foul odour and caused Philoctetes to cry in such pain that he was left on th e island of Lemnos . During his stay at Lemnos, Philoctetes treats his wound with an unspecified herb as a palliative. When Philoctetes was finally rescued, he went to Troy to aid the Greeks in the Trojan War. It was at Troy that the army physician, Machaon, cured him of hi s wound. Machaon put Philoctetes into a deep sleep and

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then performed surgery on his foot. This myth possesses the first operation ever reported to be completed under some form of anaesthesia. ASCLEPIUS

Asclepius is the Greek god of healing, a position that he usurped from his father, Apollo. Asclepius started life as a mere mortal, but gained much popularity during the Fifth Century BC and was raised to the status of a god. A great temple was created for him in Epidaurus where people flocked to from all over the ancient world in hopes of being cured of their illnesses. The presence of the temple illustrates the Ancient Greeks' large dependence upon religion in the healing process. Upon arriving at the temple, the ill first drank from the sacred waters in Epidaurus. They were then put on special diets and sent to sleep in a great hall adjacent to the temple. Asclepius would then visit them in their dreams. By morning, many were reported to be miraculously cured or improved. The temple of Asclepius could be viewed as an early form of the modem day hospital. The medicine of the Ancient Greeks was a synthesis of rational medicine and faith healing. Their myths and early writings indicate an understanding of human anatomy and disease. Their attempts to obtain health combined herbal remedies, bandaging and surgeries, with making s acrifices and offerings to the gods . Hippocrates' proclamation in the Fifth Century BC that disease was not a form of justice for in was a great insight at a time when medicine and disease were so strongly linked with religion. REFERE CES 1. Butdrer, S.H. and Lang, A. The Odyssey of Homer; done into English prose. MacMillan and Co., London, 1912. 2. http://classics.mit.edumrucydideslpelopwar.2.second.html 3. http:!!lUlUW.indiana.edrJ -ancmed!Homer.htm 4. http:!!lUlUW.med.virginia.edulhs-library lhistorical/antiqualtextf.htm 5. http:l!lUlUW.med.virginia.edulhs-library /historical/antiqual texti.htm 6. Lang, A. The Iliad of Homer; done into English prose. MacMillan and Co., London, 1883. 7. Reinhold, Meyer. Past and Present: The Con tinuity of Classical Myths . Hakkert, Toronto. 1972. Q

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PROMOTION AND PREVENTION EDITOR: D AN MENDON<;A

& ALBINA VELTMAN

ACCESSIBIL I TY OF PRIMARY HEALTH CARE SERVICES AMONG PEOPLE WITH PHYSICAL DISABILITIES By Albina Veltman INTRODUCTION n 1991, 4.2 million Canadians, 15.5% of the population, reported orne level of disability.! Many of the health care needs of people with disabilities are similar to tho e of people without disabilities. One exception is that the presence of a chronic or disabling condition often places an individual at risk for ill health, econdary conditions, and secondary functional losses. However, with appropriate patient education and access to knowledgeable primary care providers, many complications of disabling conditions are potentially preventable.2 Unfortunately, people with physical disabilities often lack opportunities to engage in preventive health care activities and do not have adequate access to primary care, hospital care, and long-term care services.3 Commonly recognized reasons contributing to inadequate acce s to necessary preventive or interventional health care for the disabled are: transportation difficulties4, architectural barriers such as lack of adequate ramps into health care facilities and inaccessible examining tabless, lack of provider knowledge regarding disabilities3, being refused medical treatment by a physician because of a disability6, poor coordination of health care services7, and nega tive attitudes of health care providers towards people w ith disabilities.s General practitioners are thought to have more contact with people with disabilities than any other profession or agency.9 Nevertheless, many physician's offices are inaccessible and there is little information readily available to Canadian physicians who wish to improve the accessibility of their offices. This article will attempt to explore some of the physical and attitudinal barriers faced by patients with disabilities in their attempts to access primary health care ervices and will provide a set of recommendations for physicians who would like to make

ABOUT THE AUTHOR Albina Veltman is a first year medical student at the University of Western Ontario. Prior to entering Medicine, she completed a Bachelor of Science combined honours degree in Biology and Psychology at McMaster University. She is interested in pursuing a career in psychiatry.

their office more accessible. PHYSICAL BARRIERS The offices of many primary health care providers are physically inaccessible to wheelchair users and to other persons with mobility impairments. In addition, many physicians' offices are geographically inaccessible to people with disabilities who do not have adequate private transportation or access to public transportation.10 Physical or architectural barriers that are commonly cited by patients with physical disabilities include lack of adequate ramps into health care facilities, inaccessible washrooms, narrow doorways and hallways, and improper examination tables, especially for gynaecological examinations.s Another important physical barrier to appropriate primary health care tha t is often cited by patients with physical disabilities is that office staff members do not know how to handle the physical needs of a mobility-impaired individual. For example, they are usually not knowledgeable about how to transfer patients from wheelchairs to examination tables? In a comparison of disabled patients' and physicians' perceptions of access to primary health care by Zwick, Griff-Cabelli & McCool (1990)11, while 85% of physicians stated that their offices were accessible, 35% of patients stated that their physician's office did not even have a ramp. In those offices with a ramp, there was the common complaint that the ramp was difficult to use since it was often too steep. Also, in most offices, there was no grab bar in the washroom, no adjustable-height examining table, and inadequate handicapped parking spaces. In a recent study of patients with physical disabilities living in the Toronto region that focussed on perceived access and quality of primary health care services12, 32% of respondents claimed to have difficulty physically accessing their family doctor's office and 38 % had difficulty accessing their family doctor's equipment. Almost 39% of patients with disabilities reported having difficulties keeping medical appointments because of transportation problems. ATTITUDINAL BARRIERS People with physical disabili ties contend that physicians unfamiliar wi th disability-related care focus inappropriately on their disabilities per se, rather than on the health problems they present. lO Indeed, primary health

U. W .0 . Medical Journal 70 (2) 2000

----------------------- P r care provider are prone to focu on the condition a ociated with the di ability and thus inadvertently overlook preventive and health maintenance trategie deemed secondary to the di abling condition . 2 Consequently, disabled per on ometime feel that they mu t repeatedly educate primary care phy icians about their impairments.IO In the ational Study on Women with Physical Di abilitie 13, 31% of the women were actually refused care by a physician becau e of their disability. If they did ecure an appointment for a check-up, they were often not given complete exams. Anecdotal data indicate frequent comp laint b y women with di abilities that their phy icians do not attend to their reproductive health care need . Indeed, women with di abilities are le likely than women without disabilitie to receive pelvic exam on a regular basis, and women with more evere functional limitations are significantly le likely to do o.6 In a tudy by Beckmann et. al. (1989)14, only 18.8% of the phy ically di abled women surveyed had received counselling about exuality and 68.6% had received information about contraception. Women with paralysis, impaired motor function, or obvious physical deformity were rarely offered contraceptive information or method . Only 25.5% of the phy ically di abled women reported having ever had a exual history taken after the onset of th eir di ability. Of the tudy participant , 45.3% indicated that they would have liked information about exuality and 55.5% indicated that they would have liked to di cu s their feelings about exuality with their phy ician . However, de pite this reported desire for information, only 18.8% were offered uch information by their family physician. In addition, only one-third perceived that their health care provider was comfortable discussing exuality wi th them . The author of thi tudy peculated that health care provider in general do not ee di abled women, e p cially tho e with paraly i or di figurement, a exual per ons needing contraception. Indeed, clinician may assume that the everity of the woman' di ability precludes her from being sexually active and, therefore, he would be at little ri k for cervical cancer. Con equently, Pap smears may be neglected.l3 RECOMMENDATIONS FOR PRIMARY CARE PHYSICIANS The following i a li t of recommendations for ph ician who would like to make their office more acce sible to patients with phy ical di abilitie . A more extensive guideline can be found in Jone & Tamari (1997).15 • Building entrances hould have electric, automatic hinged or tiding door unle exi ting wide revolving doors are designed to allow the pa age of wheelchairs. • Office hould be located a clo e as pos ible to public tran portation route . They hould also be do e to acce ible laboratory facilitie . • Adequate exterior pa enger loading zones should be provided directly in front of the building entrance. • Designated parking spaces should be reserved for

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•

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•

o m o

ti o n

e v e n

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people with di abilitie and the e should be located do e to the building entrance and properly marked. Corridor hould be weU lit, unobstructed and at lea t 1500 mm wide. Elevator car hould be wide enough to accommodate cooter and all wheelchair . Wherever the path of travel involves a change of level to reach a de tination in ide or outside the building, ramp , elevator , or other facilitie hould be provided to enable a person to reach the other level without having to u e tair or e calator . If the washroom has s tall s, at least 1 hould be wheelchair acce ible and single-person wa hroom hould be acce ible. Acce ible talls hould have wide door that open outward and a turning pace of 1500 mm in diameter hould be provided in ide the tall. Examination table hould be wide and adju table in height allowing ea e of transfer and examination. The tran fer of a per on with a disability to the examination table varie with each person. The patient hould be asked how he or he is accustomed to accomplishing such transfer . The physician hould never assume that imilar di abilitie tran late into similar transfer technique . Accommodation hould be made in cheduling people with di abilitie to take into account extra time ne ded (becau e of variable arrival time of public tran portation for people with disabilitie , for example). Provide auxiliary aid and ervices, such as signlanguage interpreter , Braille materials, large-print material , video and audio tape when neces ary for effective communication with your patient with di abilities.16

CO CLUSIO S This article contains a relatively extensive li t of recommendation that, if implemented, would make a family phy ician's office more phy ically acce ible to patient with a variety of physical disabilities. In term of attitudinal barriers, it is important for all physician to remember that a di ability doe not change a person' need for do eness to other people nor does a di ability nece arily limit the cope of sexual options for a per on. Preconception of what i exually appropriate deny people with disabilitie the psychological comfort nece ary to state all of their need or to ask que tion about their health care concems.I6 A ide from the i ue of sex uality in patient with di abilities, primary care physician should bring an open attitude to the patient interview and refrain from making any unwarranted a umption about a particular patient' capabilitie . A well, given that patients with disabilities complain of phy icians inappropriately focu ing on their di ability, it is crucial that physicians treat the whole per on and not ju t the individual' di ability. In the typical Canadian medical school curriculum, very little is taught about di abilitie or about treating people who have a di ability. Gi ven the fact that a practising physicians we will undoubtedly be treating a

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P r omo t

& P r even t ion

diver e group of patients, including those with a v ariety of physical disabilities, this topic should probabl y be covered more extensively within the medical chool curriculum in order to better prepare us for dealing with the challenges of treating patients who have disabilities. Also, perhaps currently practising family doctors would benefit from Continuing Medical Education (CME) regarding trea ting patients with disabilities. Such education would likely reduce the prevalence of both physical and attitudinal barriers to primary health care for people with physica l dis a hili ties.

Add these NEW TITLES to your Medical Library Physiological Medicine Lingappa A problem-based approach to the presentaion ci human physiology.

REFER£ CES 1. Health and Activity Limitations S11rvey (HALS), Statistics Canada, 1991 . 2. S11tton JP, DeJong G. Managed care and people with disabilities: Framing the Iss11es. Archives of Physical Medicine & Rehabilitation 1998; 79: 1312-1316. 3. Lislrner DM, Richardson M, Levine P, Patrick D. Access to primary health care among persons with disabilities in rural areas: A s11mmary of tire literahm. Tire Jo11mal of R11ral Health 1996; 12: 45-53. 4. Allen SM, Mor V. Tire prevalence and conseq11ence of 11nmet need. Contra Is between older and yo11nger ad11lts with disability. Medical Care 1997; 35:1132-1148. 5. T11rk MA, Geremski CA, Rosenba11m, PF, Weber RJ. The lrealtlr statiiS of women with ce rebral palsy. Archives of Physical Medicine & Relrabilitation1997; 78 Srrpp/5: S10-S17. 6. osek MA, Howland CA. Brea I and cervical cancer screening among women with physical disabilitie . Arc/rives of Physical Medicine & Rehabilitation 1997; 78 S11ppl 5: S39-544. 7. Gans BM, Mann , NR, Becker BE. Delivery of primary ca re to the physically challenged. Arc/rives of Physical Medicine & Rehabilitation 1993; 74: S15-S19. 8. Abre clr RT, Seyden NK, Wineinger MA . Q11ality of life. Iss11es for persons with neuromiiSCIIlar diseases . Ph ysical Medicine & Rehabilitation Clinics of North America 1998; 9: 233-248. 9. Chesson RA, S11therland AN. General practice and tire provision of information and service for physically di abled people aged 16 to 65 years. British Jo11mal of General Practice 1992; 42: 473-476. 10. B11ms TJ, Batavia AI, Smith QW, DeJong G. Primary health care needs of persollS with physical disabilities: What are the research and service priorities? Archive of Physical Medicine & Rehabilitation 1990; 71: 138-143. 11 . Zwick W, Griff-Cabelli R, McCool WJ . Accessing Jr ealtlr care in Delaware for people with disabilities: A comparison of cons11 mer and physician perceptions. Delaware Medical Jollma/1990; 62: 1443-1451 . 12. Veltman A, Stewart DE, Tardif, GS, Branigan M . Perceptions of primary health care services among people with physical disabilities. Part 1: Access Iss11es. [s11bmitted for p11blicationl 2000. 13. osek MA, Howland CA, Rin tala DH, Yo11ng ME, Chanpong GF. ational St11dy on Women with Physical Disabilities. Ho11ston (TX): Center for Research on Women with Disabilities, 1997. 14. Beckmann CRB, Gittler M , Barzansky BM , Beckmann CA . Gynaecologic Jrealtlr care of women with disabilities . Obstetrics & Gynecology 1989; 74: 75-79. 15. Jones KE , Tama ri IE . Making 011r offices universally accessible: guidelines for physicians. Canadian Medical Association Jormral 1997; 156: 647-656. 16. Grabois EW, osek MA, Rossi D. Accessibility of primary care physicians? offices for people with disabilities. An analysis of compliance with tire Americans with Disabilities Act. Archives of Family Medicine 1999; 8:44-51. 17. Peters L. Women's health care. Approaches in delivery to physically disabled women. urse Practitioner 1982; 7: 34-48. Q

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U. W . 0 . Medical Journal 70 (2) 2000

ETHICS EDITORS: KIM GILMOUR, MICHAEL LEE-POY, NYAN NARINE, DAVID SATIN

ETHICAL CASE ANALYSIS: TREATMENT OF A CHILD WITH TRISOMY 18 SYNDROME By yan Narine t was a moment of incredible excitement and the pure t joy for Mary. She heard the first cry of her tiny baby girl. Anne. She knew that her daughter's name would be Anne, after her favourite aunt, before he was even pregnant. Her proud, elated husband John was by her ide, holding her hand, running an excited second-byecond commentary of every detail. She trained her neck to get the fir t glimpse of her daughter. Anne came a month early. Mary was relieved. The wor t part was over now. Little did he know that her greate t difficulties lay before her. A flash of terror ran through her entire body when her eye met the furled brow of her ob tetrician, and then hifted to the nervous gaze of the assisting nur e . Anne was in trouble. Anne wa quickly whi ked away to the neonatal ICU before Mary could hold her. Anne weighed only 4.5 pounds and wa having difficulty breathing. When exa mined by physicians, he showed numerous ymptoms of trisomy 18 yndrome, a chromosomal di ease that cau es severe mental retardation and premature death. The progno i of infant diagnosed with tri omy 18 is very poor. The majority of these children die within the fir t two weeks of life.t-7 Approximately 10% of afflicted infants urvive for one year, but suffer from phy ical finding of trisomy 18 including: brain abnormalitie , congenital heart defects, apnea, cyano is, hy pertonia, kidney and ga trointe tina! malformations, and dislocated hip .t-3,1 A karyotype, which would take approximately two weeks to complete, i required to confirm trisomy 18. Anne at o pos esse other physical defects including a ventricular septal defect and e ophageal atre ia. Due to her immature Liver, the infant is al o experiencing hyperbilirubinemia and i jaundiced. The most salient abnormalitie are the ventricular septal defect and the e ophageal atresia, both of which are only correctable by surgery. The prognosis of trisomy 18 entails that if Anne survived, she would suffer from evere mental retardation (I.Q. 20-40) -11,18 with the po ibility of profound mental retardation (I.Q. below 2025) . -11.1 Anne was receiving various life-support measures including intravenous (IV) nutrition and hydration, oxygen therapy, monitoring of blood electrolyte level and light treatment to decompo e the bilirubin in the blood. Surgery for the child's heart defect was being postponed to a later date. Blood was drawn from the baby in order to produce a karyotype. In some

rare instances, when the third copy of chromo orne 18 i only partial, the patients may Live to adulthood, with less profound (although still evere) mental retardation.9-n Mary and John clearly understood the doctor' explanation of the progno is. They loved Anne and they wanted to take all measures necessary to promote her well being. It was their duty to make treatment decisions and speak on the child' behalf, since she could not communicate her own wi hes and did not have the intellectual capacity for self-governance. Mary and John had to consider four treatment option for their child. The first was to continue giving Anne all life-sustaining treatments including the surgical reattachment of the atretic esophagus to the tomach, even if the karyotype confirmed trisomy 18. The second option wa to give all life-sustaining measures except for surgery until the karyotype was reviewed. If trisomy 18 were confirmed, then all measures would be discontinued with the exception of IV hydration and nutrition. The third option was to limit life-support measures to oxygen therapy and IV hydration and nutrition until the karyotype results were obtained and analyzed . If trisomy 18 were confirmed, then all life-support would be withdrawn. The fourth option was to withhold all lifesupport measures but to maximize her comfort, keeping the baby warm and dry. Once all of the po sible options are known, the next step in making an ethical decision in this case is to identify and consider the goods and value in each scenario. In choosing the most appropriate treatment approach, they had to resolve the conflict between the arguments pre ented for the sanctity versus the quality of the infant' life. There were everal ethical principles to which the parents could appeal in order to make an ethical decision. Among the issues to be resolved, there is the conflict between the principle of beneficence and non-maleficence in the context of the goods presented by the sanctity of life argument. However, there is harmony between the e principles when appealed to from the quality of life per pective. Another important factor in this case was the very fine difference between killing the newborn and allowing the child to die of natural causes. The principle of justice also played a ignificant role in reaching an ethical decision in this ca e. The parents and phy ician must consider the intrinsic biomedical and social goods presented by each treatment

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Ethics approach in order to make a proper ethical decision about Anne's life. Biomedical goods include both physical and mental goods.12 In this case, where the prognosis was extremely poor and the disease could not be su ccessfully treated, one can argue that the prolongation of the child' s life would bring her more harm than good . By attempting to prolong Anne' s life with medically futile treatments, neither the parents nor the physician would be acting in the best interests of the child. Instead, they would inflict additional, unnecessary harm on the child by keeping the infant in a state of pain and discomfort. The prevention of pain was the most significant good that the parents were trying to achieve. The goods presented in the sanctity of life argument differ from those goods presented by the quality of life argument. In the sanctity of life argument (which favours the pre ervation of the infant's life at all cost), Mary and John h a d to consider s e v eral good s achieve d by prolonging the baby' s life. Many believe that there is inherent value in a God-given life (of which humans h ave no right to determine the fatel4,15). The baby might also enjoy a relationship with its parents and vice versa. The surgery w ould allow Anne to be fed and hydrated by mouth like a normal child . These are arguments that would be justified b y appealing to the princip le of beneficence, since they promote individuals' good by acting for their benefit and in their best interests. In the quality of life argument (where allowing the child to die of natural causes is favoured), Mary and John would have had to consider several goods if their baby w ere allowed to die. Firs t, Anne's pain and suffer ing would be ended and the infant would be at pe a ce . Although the degree of pain could not be determined, there would surely be discomfort when Anne became repeatedly apneic, requiring resuscitation. Second, there would be particular discomfort if kidney deform ities developed, and she required dialysis. Thirdly, pain would also arise during those times when all of Anne's mu de contracted in a massive spasm of her whole body or w hen her arterial smooth muscle contracted due to hypertonia (possibly resulting in hemodynamic in tability). Surgery w ould have inflicted additional trauma and physical s tress to the fragile baby ( .B. she might not have survived the ordeal of surgery). Fourth, Anne would not have to endure and suffer through stressful treatments such as bili lights or through invasive treatments such as repeated blood withdrawal and eventually dialysis and possibly open heart surgery. There were also se eral goods that did not pertain to the infant directly in thi argument. Since Anne was almost certainly going to die very early in life (unless the karyotype disproved the diagnosis), her parents would be spared the huge financial burden of funding the life-supporting treatments. They would not be subjected to the emotional suffering caused b y watching their baby suffer a slow, painful death . Furthermore, the medical staff would then be freed to help other patients who may be able to benefit more from their help and expertise. If the diagnosis were confirmed by the karyoty pe, Mary and John would then be more certain of how their child' s future would develop. They would then be able to

see that prolonging Anne's life with all of the life sustaining measures would not be in her best interes ts since the few benefits conferred by the treatments would have been overshadowed by the harm (discomfort) they would have inflicted on Anne. If the parents ignored this, then they would have been allowing Anne to suffer. Given the ineffectiveness of the available treatments, allowing Anne to die naturally, yet comfortably, would promote Anne's comfort, dignity and well being. Egalitarian interpretations of the principle of justice agree that it is moral for one to withhold an ineffective treatment from a child di agnosed with a congenital, terminal untreatable disea e in case where providing such measures are not in the patient's best interests.12 One of the components of the principle of justice states that equals s hould be treated equally, and unequal s unequally.12,13 It follows that Anne should be treated like a normal premature infant until the karyotype is reviewed and a diagnosis of trisom y 18 is confirmed . All lifesustaining modalities should be provided until it is known with certainty that Anne is afflicted with trisom y 18. However, once the diagnosi is verified, then it is known that he will lead a life that is very different from that of a normal child . This infant will be faced with extremely difficult obstacles that will no doubt cause significant suffering and premature death. As uch, Anne ha s different needs from a normal baby, and she should thus be treated differently. However, it should be noted that regardless of the baby' s health, Mary and John had to ensure that the child w as kept comfortable, and h e r inevitable suffering was kept to the absolute minimum possible. This was the only way that they could truly promote her well being. There are several goods contained in the sanctity of life argument that centre on Anne enjoying relationships with her parents and the world around her. However, such relation hips require the child to have a sufficient intellectual capacity . The severity of the mental retardation in children suffering from trisomy 18 renders these po sible benefits of survival considerably less impressive. It cannot be ea ily determined whether or not Anne would understand or appreciate the e relationships with Mary and John and w ith her environment. Normal infants do not develop elf-awareness until later in their second year of life.16 Anne may not survive long enough to develop this awarene s. As such, these goods do not bear enough weight in this case to justify the prolongation of her life in comparison to the suffering she would be ubject to . Although the urgical correc tion of the esopha ge al atre ia would relieve the child of the discomfort of IV nutrition and hydration, the potential harm of the surgery and the stress and tra uma of the operation considerably outweigh that discomfort. Thus, in the context of the sanctity of life argument, the duties to the principle of non-maleficence outweigh the duties to the principle of beneficence in this case. When appealing to the pertinent ethical principles, it is easier to justify the goods identified in the quality of life argument compared to tho e presented in the sanctity of life argument. The parents must actively promote the best interests of their child. Had Anne been allowed to die

U. W. 0 . Medical Journal 70 (2) 2000

Ethics comfortably, he would have been pared &om enduring the terrible physical symptoms of tri omy 18 and the di comfort of invasive test and treatments required to prolong her life. By con enting to have the esophageal urgery done, Mary and John would be forcing Anne to uffer through a very stre sful, traumatic and painful experience. The harm of th ese treatments outweighs their potential benefits to the child, especially since they will not greatly alter the cour e of her di ea e. Withholding them would be in Anne' be t intere t , in accordance with the principles of beneficence and non-maleficence. The cost of treatment i a morally legitimate limit constraining the principle of beneficence.t2 If one does a cost-effectiveness analysis in this ca e, it would be determined that the high cost of the treatments (>$35,000 / month) cannot be reasonably justified when one consider that they do not prevent or cure the ymptoms of trisomy 18, but rather prolong the baby's life despite these symptoms. Withholding the treatment due to their great cost with no significant benefit and low effectivenes in treating the ymptoms and cour e of tri omy 18 is morally correct according to the principle of beneficence. Since the infant is not an equal in comparison with a normal premature baby (if the diagno i i confirmed by the karyotype, her needs are different), it is justifiable to di continue ineffective inten ive life- upport if another child will benefit more from limited re ources (e.g. hili lights). The karyotype is critical to this argument since it provides Mary and John with concrete evidence of the diagnosis. This information i ab olutely required in order to make an informed decision. It is critical to the decision to determine whether the third copy of the chromo orne is full or partial. If it is partial, then full life- upport must be given as demanded by the principle of beneficence, ince the prognosis is much different (Anne may survive to adulthood with less profound mental retardation9-11). Thi prognosis sway the balance between the benefit of the treatments and the potential harm they bring (increasing the value of the benefit , and making the sanctity of life arguments stronger). It is morally wrong to make this deci ion prior to receiving all of the pertinent information ( ince the parent ' consent would not be fully informed). Once the goods of both the anctity of life and quality of life arguments have been appealed to and are understood in the context of the overlying moral principle , they can be interpreted for each treatment option. There is a fundamental problem with the first treatment option. Although full treatment may seem like the mo t humane approach on the urface, it could al o be the cruele t. The life- u taining measures would have prolonged Anne's life, but they would also have prolonged her suffering. She would have to endure a life of pain from extreme, sustained muscle cramping, di comfort &om breathing difficultie and other eriou medical complications before he died. The oe ophageal urgery would have cau ed her more tre and pain and i of questionable value becau e it had great potential harm. The benefit would have been relatively small when one consider the progno i and the effectivenes of IV nutrition and hydration. Thi option draw it upport

from the sanctity of life argument, however it would clearly not be in Anne's best interest since it would bring her additional pain and uffering. The econd treatment option would spare her the harm and pain of surgery, yet it would keep her as comfortable as possible and would treat her as a normal premature infant until the karyotype wa reviewed. If trisomy 18 were confirme d , thi egalitarian approach would recognize that her need were different from a normal baby. I t would keep her a comfortable as po ible. However, she would be allowed to die naturally of her di ease ymptoms, ending her pain and suffering. Although the third treatment option limit the cope of treatments admini tered to the child based on her preliminary diagno i , it doe offer support mea ure which would ati fy her ba ic needs and keep her comfortable. It treats her a an unequal before the karyotype is received to confirm the diagnosis, and Anne mu t be treated as an equal until it is confirmed that her needs are different from those of a normal infant. However, once the diagnosis was established, the e comforts would be withdrawn. This treatment would harm Anne (additional suffering due to starvation and dehydration), and as such, would not promote her be t intere ts. The fourth approach is the extreme oppo ite of the fir t option. Like the third treatment, it would harm Anne and would not promote her best interest . It represents an infringement of the principle of justice since the child is not even given a fair chance to survive until her diagnosis i confirmed by the karyotype. Although Anne' suffering is ended by the last three options, there is a significant difference that set the econd option apart from the third and fourth . There i a distinct difference between actively killing the child and allowing her to die &om her disease symptoms. Killing is the direct causation of the child' death. By withholding IV nutrition and hydration, Anne would die from tarvation and dehydration, and not &om the symptom trisomy 18 itself. This would be killing the child.1 7, t Omission of life-prolonging treatment would allow the patient to die from inevitable ymptoms of the di ea e from which she wa suffering. Allowing a newborn patient to die is morally permissible in cases where treatments are ineffective and futile in combating their di ea e, as it is justified by the principles of beneficence and non-maleficence (by preventing unnece ary prolongation of their suffering).19 In this case, allowing Anne to die from the symptoms of tri omy 1 by removing all life-support mea ure except for IV nutrition and hydration is morally perrni ible. I also believe that he hould be given continuou oxygen therapy ince it i not inva ive (oxygen pumped into the incubator) and it would keep Anne more comfortable (helping to reduce her respiratory distress due to her underdeveloped lung ). The other treatments can morally be discontinued to allow nature to take it cour e, since they are not as critical to the baby' comfort, a would be providing oxygen. Immanuel Kant' deontological moral structure can be applied to the obligations and dutie of the parents to their child in making this deci ion. By choosing decided to prolong Anne's life with ineffective therapy, forcing her to bear the pain and uffering of tri omy 18, Mary and John

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Ethics would be violating Kant' s Categorical Imperative. This states that a person must not be treated as a means to an end, they must be treated as an end in themselves. t2,t3,20 They would be treating Anne as a means to an end by satisfying their own feelings of guilt that they did not do everything that they could to save their baby's life. Similarly, if Mary and John caused Anne to die by withholding nutrition and hydration, they would be treating her as a means to an end. This decision would end their commitment to the child prematurely, thus fr eing them of both the emotional and financial burdens associated with waiting for the child to die a natural death. This decision would be motivated by self-int rest, and Kant deems such a decision immoral.20 According to Kant, the parents must not bring additional or undue suffering to Anne (such as that which would be brought on by the available life-support modalities).12,13,20 They must also promote Anne' s best interests,12,20 which in this unfortunate baby's case, means allowing her to die naturally without any measures to prolong her life. Kant's moral theory centres around the duties and obligations of the decision-makers but it does not make any provision for dealing with the argument between the sanctity of life and quality of life. It is necessary to resolve this conflict in order to make a fully informed decision about this infant's life. W.O. Ross' principalist theory of prima facie dutie can be applied to justify the arguments of sanctity versu s quality of life. Ross does not believe in a single, primary principle that overrides all other principles in a given scenario. 21 ,22 Rather, principles and duties can be prioritized to reach an ethical decision in any g iven circumstance.21,22 The prima facie duties applicable to this case are the principles of beneficence and non-maleficence and the duty to ensure justice. The strongest of the duties in this case is non-maleficence. It is inexcusable to prolong Anne's life with ineffective therapy, knowing that she will unfairly have to endure pain and suffering. This is the strongest point of the quality of life argument. It is also the weakness of the sanctity of life argument. Since the points arguing for Anne developing a relationship with her parents and with the world are weakened by her s vere mental retardation, the inherent value in prolonging the child's life is diminished. Mary and John had to consider the quality of their child' s life above the sanctity of her life. The tremendous suffering she would have to bear if her life were prolonged by treatments that do not combat trisomy 18 itself undermines the sanctity of her life. In conclusion, Anne' s parents had to reconcile the arguments presented for the sanctity of Anne' s life and those presented regarding the reduced quality of her life. In doing so, they had to consider the conflict between the principles of non-maleficence and beneficence. They also had to understand the difference between killing Anne and allowing her to die. The principle of non-maleficence ethically overshadows the principle of beneficence in this case. The application of the moral reasoning structures proposed by Ross ' prima fa cie theory and Ka nt' s deontological theory enabled the parents to come to a fully informed, morally sound decision. By prolonging Anne' s life, Mary and John would be forcing her to endure pain and anguish, in the face of a prognosis that predicts death

in the first week. Kant's theory centres around the duties and obligations of Anne' s parents as they make their decision on her behalf. Ross' theory supplements Kant's, dearly demonstrating that the quality of Anne' s life was a greater moral consideration in this case than was the sanctity of her life. Thus, the morally correct choice, which satisfied the considerations of all of these theories, is the second treatment option, where Anne would be given all life-sustaining measures except for surgery until the karyotype was reviewed. If trisomy 18 were confirmed by the kary otype, then all support measures would be discontinued with the exception of IV hydration and nutrition. In addition to finding justification in the principle of justice, this treatment option recognizes the duty to non-maleficence as being greater than the duty to beneficence, which is justified in the moral hierarchy by Kant's and Ross' ethical theories. Anne was kept as comfortable as possible in the NICU. Mary and John faithfully stayed with her as much as possible. There were many sleepless nights. Anne quietly succumbed to her sealed fate during her tenth evening. There were many tears for this dearl y loved baby, and now there was peace. It was very difficult for Mary and John at first, but they knew in their hearts that they had made their decisions with only love and Anne' s best interest in mind. ACKNOWLEDGEMENTS The author would like to acknowledge Lisa Robart, Kim Gilmour, Michael Lee-Poy, and Dr. Jeff Nisker, for reviewing the manuscript and offering valuable suggestions. REFERENCES 1. Baty B]. et al., uNahtral history of trisomy 18 and trisomy 13: I. Grawth, physical assessment, medical histories, survival, and recurrence risk". A merican joumal of Medical Genetics. 49(2):175-88, 1994 jan 15. 2. Embleton N.D. et al., "Natural history of trisomy 18". Archives of Disease in Childhood Fetal & Neonatal Edition. 75(1):F38-41, 1996 Jul. 3. Hodes, E.M., et al., "Clinical Experiences with Trisomies 18 and 13 ", Joumal of Medical Genetics. 15:48-60, 1978. 4. Carter PE. et.al., Anderson NG . "Survival in trisomy 18. Life tables for use in genetic counselling and clinical paediatrics". Clinical Genetics. 27(1):5961, 1985 ]a11 . 5. Goldstein H. and K. G. Nielsen. #Rates and survival of individuals with trisomy 13 and 18 ". Data from a 10-year period in Denmark. Clinical Genetics. 34(6):366-72, 1988 Dec. 6. Root S. and ].C. Carey,. #Survival in trisomy 18". American journal of Medical Genetics. 49(2):170-4, 1994 Jan 15. 7. Yotmg ID. Cook ]P. Mehta L. "Changing demography of trisomy 18 ". Archives of Disease in Childhood. 61(10):1035-6, 1986 Oct. 8. American Psychiatric Association: Diagnostic and S tatistical Ma r11tal of Mental Disorders (DSM-IV) . 4th ed. American Psychiatric Association. Washington, DC. USA. 1994. 9. Mehta L. Sharman RS. Duckett DP. Young ID. " Trisomy 18 i11 a 13 year old girl." journal of Medical Genetics. 23(3):256-7, 1986 Jun. 10. Smith A. Field B. Learoyd BM . "Trisomy 18 at age 21 years ". American journal of Medical Genetics. 34(3):338-9, 1989 Nov. 11. Wilson WG. Shires MA. Willson KA. Wyandt H E. Harris LM. Kelly TE. #Trisomy 18/trisomy 13 mosaicism in an adult with profound mental retardation and multiple malformations " . American journal of Medical Genetics. 16(1):131-6, 1983 Sep. 12. Beauchamp, T.L. , and ].F. Childress Principles of Biomedical Ethics, 4th ed., Oxford University Press Inc. NY, NY. USA 1994.

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Et h c s 13. Beauchamp, T.L. and L. Walters., Contemporary I sues in Bioethics, 4th ed . Wadsworth Publishing Co. Belmont, Ca. USA. 1994. 14. Aquinas, T . "Whether it is Lawful to Kill Oneself". Summa Theologica. , Part ii-ii, Q.64, Art.S., Ethical Issues in Death and Dying. 2nd ed. Ed. Beauchamp T.L. and R.M . Veatch., Prentice Hall., Upper Saddle River, ]. USA. 1996. 15. Aquinas, T. "Whether it is Lawful to Kill Oneself". Summa Theologica ., Part ii-ii, Q .64 , Art.5., h II p:llccel . whea ton .ed u l al aq u i nasls u m mal S 5 1 SS064.htmi#SSQ640UTP1 16. Berk. L.E., Child Development., 4th Ed. Allyn and Bacon., Needham Heights, MA. USA. 1997. 17. Scalia, ]A ., "Concurring in United States Supreme Court, Cruzan v. Director, Missouri Dept. of Health "., Ethical Issues in Death and Dying. 2nd ed . Ed . Beauchamp T.L. and R.M. Veatch. , Prentice Hall. , Upper Saddle River, NJ. USA. 1996. 18. Schaffner, K.F., "Recognizing the Tragic Choice: Food, Water and the Right to Assisted Suicide ", Contemporary Issues in Bioethics, 4th ed. Ed. Beauchamp, T.L. and L. Walters . Wadsworth Publishing Co. Belmont, Ca. USA. 1994. 19. Weir, R.F. , "Selective Nontreatment of Handicapped ewboms", Contemporary Issues in Bioethics, 4th ed., Ed. Beauchamp T.L. and L. Walters, International Thomson Publishing., Wadsworth Inc. Belmont, CA. USA.1994 . 20. Kant, I., "Grounding for the Metaphysics of Morals " Classics of Western Philosophy., 3rd ed., Ed. Steven M. Cahn, Hackett Publishing Co., Indianapolis, IN., USA. 1990. 21. Ross, W. O., The Right and the Good . Hackett Publishing Co., Indianapolis, IN., USA. 1988. 22. Ross, W.O., Prima Facie Duties., http://www. utm.edulresearchlieplplprimafac.htm Q

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HUMOUR EDITOR: KEIR PETERSO

HAPPY

70th

BIRTHDAY By Keir Peterson

ia s President. Cia Vice-President. Cia Hi torian. VP Academk. One of m y many recent di coveries as a first year medical tudent wa the overwhelming array of elected po itions in need of filling. (I'm not entirely ure VP Academic needed filling, but without it my li t wa looking a little short. My apologie to the hard working and irreplaceable VP Academic, whomever you are.) After much oul searching a nd contemplation of the many possibilitie , I cho e to run for. .. none of them. That decision was, however, reached in 1999. It is now the year 2000, the 70th birthday of thi gloriou publication, and a bizarre election year in the U.S. (The on of the previou president, and the wife of the current pre ident, are both running for elected office. Meanwhile, the former mi tress of the current pre ident is elling handbags on the internet, and recently made an appearance at the Little Beaver Re taurant in Ottawa, which i probably not relevant to the re t of this article but inspiring nonethele s.) Moved by these events, I felt the need to take up the challenge of elected office, a nd perhaps to give something back to thi publication that had given o much to our medical chool. Combining my newfound de ire to hold elected office, my interest in the journal, and the fact that there was nothing left to run for, I decided to create my own po ition. So, in honour of the historic 70th birthday of the UWO Medical Journal, I have appointed myself Journal Hi torian. At this point, in order to firmly e tabli h my elf in my new elf-created po ition, it might eem like a good idea to present a thought-provoking historical look back at the pa t 70 years of the Journal's history. This is, however, not going to happen, as I've been here le s than a year, have een precisely two issues of the Journal, and probably couldn' t find the Journal office if I had to. ( ote the refre hing candor and hone ty in your new public ervant.) Instead, I proudly pre ent you with a fa cinating look at my admittedly brief time in London, and the events leading up to my recent appointment.

ABOUT THE AUTHOR Keir Peterson is a first year medical student at the University of Western Ontario.

Late August 1999: Fre h from a relaxing summer on one of British Columbia's Gulf I lands, the oon-to-be Journal Hi torian moves to London, Ontario. September 1999 (or maybe it was October. .. having not yet appointed my elf Journal Hi torian at this time, I wa not paying much attention to da tes): From the depth of my mailbox, I recover the Summer 1998 edition of the Journal (my fir t). It i urprisingly well pre erved considering it age. Octob er 1999 (or po ibly ovember- ee previou note regarding dates and my lack of attention to them): I am bles ed with the Spring 1999 edition. I am al o blessed with a sense of confusion regarding the fact that, where I come from (Victoria, BC), October i not typically considered part of "Spring." I a ume thi mean that Ontario i a much warmer province than I had anticipated. ovember 1999: Having temporarily mi placed my u ual en e of apathy and lazine , I email the Journal, offering my writing ervices. Having temporarily misplaced his or her u ual en e of good judgment, omeone at the Journal accepts my offer. I thu become a "junior departmental editor". December 1999 to January 2000: Ontario is, a it tum out, not o warm after all ( ee previous note re. Spring in October). The soon-to-be Journal Historian would, in fact, like to flee the -20C temperatures and go home. Sadly, Victoria is without a medical chool, and therefore has no medical journal in need of my ervices. February 2000: Although having theoretically been a junior departmental editor at the Journal for a number of months, I have yet to write a ingle word, or make any phy ica1 contact with anything remotely Journal-related . This moving experience as an editor who doe n't wri te or edit in pire my reincarnation a a historian with no knowledge of history. My ( elf-) appointment as Journal Hi torian begin . There you have it, the first official document produced by your new hi torian-a birthday present from myself to our 70 year-old journal. (I considered the po ibility of an internet-ordered handbag a an alternate gift, but I thought thi article might be a tad more tasteful. I hope I made the right choice.) Q

U. W . 0 . Medical Journal 70 (2) 2000

MEDICINE AND THE INTERNET EDITORS: MARK BAUMGARTNER

& M UNSIF B HIMANI

BEYOND THE INTERNET: RECOGNIZING AND DEVELOPING THE POTENTIAL OF INFORMATION TECHNOLOGY FROM A MEDICAL PERSPECTIVE By Mark Baumgart11er

h e rece n t and u pcoming development in communication technology are poi ed to change the fundam ental stru cture of medical y terns around the world (for an excellent review of the e development ee Joe Flower's article "The Way It is, Is not the Way It Will Be" in the July I Augu t edition of the Health Forum Journal). A informa tion become more organized and accessible, patient will take an increasingly active role in their illne , diagno i , and management.! In addition, the fundamen tal of medicine - the phy ical, the hospital, xrays, antibiotic , urgery - which have remained virtually unchange d in th e la t half cent u ry, will be clo ely exa mined and mo di fied or elimina ted .2 To many, this foreca ted upheaval rep re ents a th reat to the already trained abili ty of the doctor to effectively perform hi dutie . Al th o u g h b o th patient and health care profe sionals have long acknowledged fru tration at the inefficien cies of the cu rrent ystem, many attempts at introd u cing info rm atio n technology into the medical workplace have failed to deliver on their promi es and in

ABOUT THE AUTHOR Mark Baumgartn er's initial exposure to communication issues and technologies began in 1993 at the University of New Brunswick through the SHAD Valley Engineering program. While completing concurrent degrees in Physical and Health Education and Life Sciences at Queen 's Univ ersity from 1995 to 1999, M ark became involved in an information resource database project with the Department of Pathology. The project evolved into an ongoing thesis on the potential of the Internet in health care. From the thesis have come sev eral applications including M edpulse (presented at the Infocus international health informatics conference in Vancouver, June 2000) and the Internet Imager, a script that allows the manipulation and annotation of standard web images and is compatible with a wide variety of database technologies. Currently, Mark Baumgartner is studying first year medicine at the University of Western Ontario where he is working on an elective on health informatics with Dr. William Sibbald.

orne ca e erved only to further exa perate the ability to effectively treat patient . Central to this failure i the lack of leader hip and involvement of clinical health care profe ionals. A health care evolves over the next few decade it is crucial that this trend be reversed . What follow i an examination of the curren t ta te of the technology and guidelines that will allow even th e mo t " technologicall y challenged " to make invaluable contribution to the future of medical informatic . The Internet originated from post-World War II optimi m for the potential of continued collaboration (where previously there had been primarily competition) in the cientific field . In hi 1945 Paper entitled, As we may think, Vannevar Bu h envisioned a ystem of electronic documents linked to each other that would "make more acces ible our bewildering store of knowledge". A technologies improved, the Internet made thi vi ion a realit y . Developed from a erie of interconnected computers linked b y standardized communication protocols, the World Wide Web i currently ca talyzing dramatic change in the ocial organization of developed culture around the globe. De pite medicine' hi torical ability to remain organizationally constant in the face of aturbulently economic environment, it too i now coming under pre ure to re tructure it operational trategie to take advantage of communication technology. The driving force behind thi change i two-fold : 1) the demand by individuals to have more efficient acces to information and commodities, and 2) the de ire of entrepreneurial indu trie and busine e to ca h in on the e demand and challenge the conventional a umptions underlying health care de livery. While there lies along this continu um a productive and creative medium for commerce, extreme caution must be exerci ed to avoid the commercialization of health care. Patient are not consumers, and the clinical health care environment i dramatically different in focu , organization, and complexity from that of commerce. Along with the tremendous potential the electronic future hold for both caregivers and pa tien ts, th ere lies a dangerous risk of eroding the quality and corrupting the integrity of health care. The be t people to prevent thi are tho e who under tand the vulnerability, complexity, and

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Med i c i ne and the In t ernet self-contained beauty that is the human condition. How can an already overworked paramedic, nur e, clinician, or doctor find the time or energy to attempt and learn enough to involve themselves in the future of medical informatics when many of them have trouble carrying out more than the basic functions on their computer? The answer is simple. Fit the technology around the idea, not the idea around the technology.3 Focus on what should be done first, then work with those who understand the technology to determine how to accompli h these objectives. The less technical knowledge one has the more valuable one' s vision. Those who focus on computer technology tend to specialize, and then apply their understanding of the technology around the problem. Ergo, the failure of MIS (Management information systems) teams who specialize in gen ral management computer supporting finance and business operations to perceive the intricacies of clinical medicine. 4 With a generalized understanding of communication technology health care profes ionals, working along ide communication engineers offers the best hope at a healthy future. The potential of communication in health care lies along three primary axis: 1. 2. 3.

The secure storage and retrieval of static information The facilitated collaboration betw en professionals coupled with the dynamic generation of information New tools to visualize I interact with human biology.

Examining these areas through one' s clinical experience quickly reveals the tremendous potential for improvement that these technologies offer. The Secure Storage and Retrieval of Static Information Technology is rapidly progressing to the point where the traditional limitations - storage and bandwidth - are no longer barriers to "wired" medicine. Techniques for data storage at densities of up to one million gigabits per square centimeter have been suggested by NASA-Ames. This will allow for the digitization of 100% of all printed, video, and audio material ever produced by the human race.s Already several libraries, including those at Western Ontario, are offering full text access to journals online. The ext Generation Internet (NGI) in conjunction with the increasing success of wirele s data transmission will accelerate the transfer speeds of information between 100 to 1000 percent will make instant access to this information from anywhere possible. To clinicians, who require access to new information on average of 12 times per day, yet logistically have great difficulty accessing this information this will greatly increase the confidence of diagnosis and treatment. Combine this with instant and portable access to patient information including medical histories, images, and baselines I real-time monitoring information (EEG's, EKG's, etc.) and the potential level of care increases dramatically. As the technology overcomes the old limitations the

emphasis will shift to the manner in which these tools are employed . Here is where the health professionals' leadership will prove most valuable. In addition to diligent analysis of the assumptions carried behind the reorganization of information flow wi thin the clinical setting. For example, the issue of the security of patient information, though assumed, is infinitely complex. As discussed in the following section, the information generated from patient records and reports has the potential to dramatically advance the foundation of evidence based medicine, but also presents a possible compromi e to the patients right to privacy, as their health information becomes a commodity. There is also considerable new ground to be covered in terms of the potential of these new technologies. Clinicians with their daily exposure to limitations and possibilities imperceptible to the uninitiated are at a distinct advantage to define and lead these initiatives. T he Facilitated collaboration between professionals coupled with the dynamic generation of information Email, chat rooms and bulletin boards are becoming increasingly common tools to facilita te the collaboration between medical professionals.6 Moving beyond these formats is the concept of Dynamic Feedb ack Libraries (DFL' s) where information is collected from professionals in the form of open and closed ended surveys on a variety of subject , which become automatically catalogued, into searchable knowledgebases. An applied example of this theory can be viewed in Medpulse, a corollary of the author's ongoing thesis on the potential of the Internet in health care. The site, http:/ / 130.15.161.15/medpulse I index.htm, is described as a virtual sounding board and library for the ideas and opinions of health care professionals and patients who' s experiences, opinions, and idea constitute one of the best hopes for real improvements in health care delivery. Advances in technology often outpace advances in the thinking that makes the technology useful. It is here that clinicians and health professionals can play the greatest role. For example, new algorithms for peer and self-review via evidence grading and referenci n g, as well discriminative evidence analysis are required to lend credibility to the ease of information dissemination. Collaboration and team dynamics also stand to be redefined as a result of the continued elimination of borders separating people from their ideas. Real time video conferencing and telemedicine will likely see specialists from around the world assembling as needed to effect more comprehensive levels of care. In addition, the patient will become an increasingly active and involved member of the treatment team. This phenomenon is already being demonstrated and presents several dangers and opportunities. As patients begin having access to the same information as their doctors it is not uncommon for them to self-diagnose and teat their conditions incorrectly. With online drug stores making access to medications easier, this represents cause for real concern. On the other hand as a member of the health management team the empowered patient will generally take a more active interest in their own well-being and correspondingly

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Med icin e a n d the I n t e r ne t obtain better health. One of the most pres ing is ue in medicine is the lack of comprehensive data on the comparable effectivene s of different treatments. With information within and between health centers becoming increasingly linked and accessible the possibility for a national and eventually inte rnational database of patient information and treatment outcomes offer a comprehensive solution to thi problem. For this data to be tatistically relevant, however, will require collaboration on a national and international level to determine a set of recording guidelines that provide consi tent and comprehensive m eas ure of health . A daunting task, but again this repre ents a perfect opportunity for clinicians to share the wealth of their experience and demonstrate leadership in the information revolution. New tools to visualize/interact with human biology. One of the newest and most revolutionary areas of information technology lie in the merging of genomics and nanotechnology. Genornics, essentially the biological b asis of communication, is promi ing to provide new strategies and tools to attack di ease at their most basic level. As the human genome continues to be decoded and the mechanism s and role of genetics deciphered drug companies and entrepreneurs are scrambling to develop a new breed of drugs, several of which are alread y in clinical te ting. At the center of this revolution, however, lies a tremendously important ethical debate . Dr. Haseltine, an egotistical and a mbitious geniu s is at the center of a controversy over patenting human genes for profit and the right to owner hip and control of the basics of life information.? The true potential of human genornics, however will most likely be dependent on new delivery vectors that can eek out and target isolated di ease processes. One field making considerable strides that will soon see marketable a pplications in health care is nanotechnology, or molecular machinery. Within one to five years inexpensive h a nd h e ld sensors will bring m any of the laboratory diagnostic tests instantly available at the patients bedside and have the ability to screen for a variety of diseases b as ed on blood, sali v a, and urine. Longer term the manufacturing and control of molecular machinery have th e pote ntial to make Jules Ve rne' s " Inner Space" a startling reality. As molecular circuit design and assembly become feasible nanomachines and sensors may be easily placed wi thin the human body to seek out and target, or monitor disease processes. In this way the interaction be tween machine and human w ill continue to become increasingly more complex and raise many new ethical debate . Progressing along with the ability to interact with the body is the ability to view the different biological proces es that make up life. Imaging modalities continue develop and become more accessible, opening up a new frontier in the exploration of the human brain. This is a lread y coming underway in the form of fu nctional magnetic resonance imaging (fMRI) which can create 3D mapping of brain activity for s pecific functions . In development are applications that pair EKG with ÂŁMRI to v is uali ze though t proces e and deepen the

understanding of the human mind . Operations will continue to become less invasive, and may disappear altogether as medicine learns how to stimulate the body into repairing itself. Again the daily experience of the clinician offers to provide invalu able insight in to the directions and consequences of these developments. As Dr. Silverstein describes: "The successful implementation of clinical IT has very little to do with technology (now a commodity and the data-processing thinking and methodologies of the past. Rather, success has much to do w ith excellent information science and engineering methodologies of the pre ent along with properly engaged clinical personnel. 9 A Call To Action Realizing the full potential of information technology in medicine require s a level of interdisciplinary collaboration that is d ifficult to envision. The point, however, is not to let the potential obstacles of an idea prevent the presentation and discussion of ideal solutions. REFERENCES 1. Rockefeller R. "Informed Shared Decision Making: Is This the Future of Health Care?" Health Forum Journal, May!]rme 1999. 54-56. 2. Weber DO. "Web Sites of Tomorrow: How the Internet will transform healthcare, Health Forum Jormra/, May/June 1999. p 40-45 3. Baumgartner M . " The Potential of T ire Internet in Health Care" , Unpublished thesis, Queen 's University, 1999. 4. Medica/Informatics, MIS and leadership of ehalthcare computing. 5. Flower]. 'The Way It Is, Is Not the Way It Will Be" Health Fonmr Journal, July/August 1999 pp 16-27. 6. Rendon P-M . "New Study Aims to Put Doctors Online " Tire Gazette, Tlrursday Navember 2nd 1999. 1. 7. Weeks, Linton "Mr. Green Genes ", Washing! Post, February 17th, 1998, E01 . 8. Road maps for understanding the hu man brain through use of JMRI (junctional MRI) (http://www.ccic.gerolpubslblueOO/Itecc.lrtml#applications), 1999. 9 Silverstein S. "Medical Informatics, MIS and Leaderltsip of Healtlrcare Computing: What Ails Electronic Medical Records " http:llmembers.ao/.com/MedlnformaticsMD/1999. Q

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MEDICAL VOCABULARY EDITORS: ]OE CHAN AND HEATHER COCKWELL

Thi ection is designed to test and expand y our knowledge of medical terminology. How many item can you correctly define? Scoring:

[13-15] = Excellent [10-12] = Above average [8-9] =Good [5-7]= Fair [1-5] =Poor

A coria a) ab ence of the pupil b) a form of papulonecrotic tuberculid occurring on the face c) exce ive ingestion of food, not from hunger but due to loss of sensation of atiety d) a small compress of tuft

Preeclampsia a) abnormal location of the placenta, such th a t it covers the cervix b) emergency condition in pregnancy chaiacteri ed by h ypertension, proteinuria and non-dependent edema c) severe nausea and vomiting during pregnan cy, causing weight loss, dehydration and electrolyte imbalance d) premature separation of the placenta from the uterus wall

Nostrum a) a beak haped proce b) a quack, patent, or ecret remedy c) a ridge like tructure d) an infectious disea e of hor e due to Streptococcus equi Coprolalia a) neurological condition where language function is defective or absent b) uncontrolled, often exce ive u e of ob cen or scatological language c) confu ion and u e of the wrong word or name, when referring to a known object d) rever al of letters and words, with the inability to distinguish letter sequence within words

ABOUf THE AUTHOR foe Chan is a second-year medical student at UWO with a BSc from the University of Ottawa. He is interested in rural family medicine and emergency medicine, and is currently involved in research with rural hospital emergency departments. Heather Cockwell is a member of Meds2003.

Epulis a) a non-specific term used for tumours and tumourlike masses of the gingiva b) chronic spasm of leg muscles, producing jumping motions c) impairment of s peech, consi ting in lack of coordination and failure to arrange word in their proper order d) a condition marked by fracture and plitting of a hair into strands, giving the appearance of white nodes Ranula a) a large mucocoele in the floor of the mouth, usually caused by ob truction of the duct of the sublingual salivary glands b) a flexible tube that may be inserted into a duct or cavity to deliver medication or drain fluid c) a small solid rai ed kin le ion le s than 1 em in diameter d) an abnormal respiratory pattern, characterized by irregular episodes of rapid, uniformly dee p inspirations with period of apnea Cri-du-chat syndrome a) inflammation and pustules, with lymphadenopathy, following a cat bite b) co ngenital defect of larynx, associated with microcephaly, hypotonia and heart defect c) g e netic defect res ulting in cochlear deafne , heterochromia, facial cleft and white forelock d) congenital abnormality where upper lip fail to fuse, leaving a gap to the na al prominences Philtrum a) a restraining portion or tructure b) the vertical groove in the upper lip c) cone-shaped flap u pended from the po terior border of the soft palate d ) ulcer found on lip and mouth, due to riboflav in deficiency Jactitation a) the normal response of an infant to cry, flex the limbs, and elevate the head and pelvis wh e n supported in a prone position with a fing e r pressed along the spine from the sacrum to the neck b) t w itchings or s pa s ms of mu s cles or muscle groups, a observed in the re tles bod y movements of a patient with a sever fever c) an abnormal pattern of neuromusculai activity, characterized by rapidly alternating involuntary contraction and relaxation of skeletal muscle d) the slight, continuous contraction of a muscle, which in skeletal muscles aids in the maintenance of posture and in the return of blood to the heart

U. W . 0 . Medical Journal 70 (2) 2000

Med ic a l 10. Eructation a) the act of pa sing air through the larynx to produce ounds b) a method of opening and closing a passage with air pressure c) the act of pulling air up from the stomach d) a hole or opening made through the entire thickness of a membrane or tissue 11. Homer's Syndrome a) acquired condition characteri ed by ptosis, rnio i , and anhydrosis b) nerve compression, leading to pto is and facial muscle weakness c) inability to make voluntary eye movements, following brain injury d) auto omal rece ive trait, with by hepatosplenomegaly, hydrocephalu , and corneal clouding 12. Lanugo a) any one of the mall pits in the iris along it free margin encircled by the circulu arterio us minor b) fold of pallium from the frontal , parietal, and temporal lobes of the cerebrum overlying the insula c) a brown pigment formed by the oxidation of urobilinogen, normally found in feces and in mall amount in urine d) the soft, downy hair covering a normal fetu normally entirely shed by the ninth ge tational month 13. Noonan' s syndrome a) congenital chromosomal disorder, with genital hypoplasia, short stature, and "shield chest" b) hypergonadotrophic disorder, with webbing of neck, hort stature, cubitus valgu c) auto omal recessive trait, with exopthalmos, macroglo ia and gianti m d) metabolic anomaly leading to rounded face, mu cular atrophy, and fat pad depo ition 14. Kwashiorkor a) a form of protein-energy malnutrition predominantly due to prolonged evere caloric deficit chiefly occurring in the fir t year of life with growth retardation and wasting of ubcutaneous fat and muscle b) a loss of skeletal muscle mass that ma y accompany aging, with acceleration of los a aging progre e c) a form of protein-energy malnutrition, primarily in children, produced by severe protein deficiency; becau e calorie-rich tarches are available, the child doe not lose weight dramatically and doe not look very ick d) general ill health and malnutrition, marked by weakne and emaciation, u ually a ociated with evere di ea e, uch a tuberculo i or cancer 15. Menacme a) small erythematou macule occurring on the upper abdomen and anterior thorax and lasting 2

Vocab ul a ry

or 3 da y s, characteri tic of typhoid and paratyphoid fevers. b) any abnormality relating to menstruation c) an emotional or physical state of pain, orrow, rni ery, suffering, or di comfort d) the period of a woman' life which is marked by menstrual activity

A SWERS TO M EDICAL VOCA BULARY

3. 4.

10. 11.

12.

13.

Acoria : (c) excessive inge tion of food , not from hunger but due to loss of ensation of satiety. [(a) Acorea; (b) Acniti ; (d) Pledget] Preeclampsia: (b) emergency condition in pregnancy characteri ed by hyperten ion, proteinuria and nondependent edema. [(a) Placen t a previa; (c) Hypereme is gravidarum; (d) Abruptio placentae] ostrum: (b) a quack, patent, or secret remedy. [(a) Ro trum; (c) Carina; (d) Strangles] Coprolalia: (b) uncontrolled, often excessive use of obscene or scatological language, may accompany certain mental di orders, uch as schizophrenia or Tourette' s yndrome. [(a) Apha ia; (c) Allopha ia; (d) Dyslexia] Epulis: (a) a non-specific term used for tumours and tumour-like rna es of the gingiva. [(b) Palmus; (c) Dyspha ia; (d) Trichorrhexis] Ranula: (a) a large mucocoele in the floor of the mouth, usually cau ed by ob truction of the d ucts of the sublingual alivary glands. [(b) Cannula; (c) Papule; (d) Biot' re piration] Cri-du-chat syndrome: (b) congenital defect of larynx, as ociated with microcephaly, hypotonia and heart defects. [(a) cat-scratch fever; (c) Waardenburg syndrome; (d) median cleft of the upper lip] Philtrum: (b) the vertical groove in the upper lip, from Greek philtron, charm, dimple in the upper lip. [(a) Frenulum; (c) Uvula; (d) Cheilo i ] Jactitation: (b) twitching or pasms of muscle or muscle group , as observed in the re tie bod y movement of a patient with a ever fever. [(a) Perez reflex; (c) Clonus; (d) Tonus] Eructation: (c) the act of pulling air up from the tomach. [(a) Phonation; (b) Perflation; (d) Perforation] Horner's S y ndrome: (a) acquired condition characterised by ptosis, mio i , and anhydro i . [(b) Bell ' s palsy; (c) Balint yndrome; (d) Hurler' s syndrome] Lanugo: (d) the oft, downy hair covering a normal fetus normally entirely hed by the ninth ge tational month. [(a) Crypt of iri , Crypt of Fuchs; (b) Operculum; (c) Urobilin] oonan's sy nd r ome: (b) hypergonadotrophic disorder, with webbing of neck, hort stature, cubitus

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M e d ic a I

V o c a b u I a r y -----------------------

valgus. [(a) Turner's Syndrome; (c) EMG syndrome; (d) Cushing's syndrome] 14. Kwashiorkor: (c) a form of protein-ene rg y malnutrition, primarily in children, produced by severe protein deficiency; because calorie-rich star ches are ava ilable, the child doe s not lose w e ight dramaticall y and does not look v ery sick . ((a) Marasmus; (b) Sarcopenia; (d ) Cachexia] 15. Menacme: (d ) the period of a woman' s life which is marked by menstrual activity. [(a) Rose spots; (b) Menoxenia; (c) Distress] Q

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U. W . 0 . Medical Journal 70 (2) 2000

FEATURE A

DIFFERENT

ARTICLES

KIND

MEDICINE

By James Andrew McSherry, MB ChB, FCFP, FRCGP, FRCP Glasg., FABMP

began writing this essay on 1 February 2000, the thirty third anniversary of my becoming a family doctor. Looking back, it's been a stimulating and rewarding career. Looking forward, it ain't over yet! It has not been at all as I expected when I graduated from the University of Glasgow in 1965. Like most medical students, I had been interested in just about every specialty under the sun as I passed through medical school. My original intention had been to become a general practitioner somewhere rural and I expected to stay in one place for most of my professional life. I had greatly admired our family doctors in Clydebank, Dr. Cyril Mandelstam and Dr. Harry Hart, who had helped my parents through the double trauma of a stillborn first child and the later death of my older brother from tetanus . I was scared stiff of Dr. Mary Frances O' Sullivan when she came to the house and put my hand back together after a misadventure with the garden gate. Fortunately, she said nothing to my parents about the raids on her apple trees, the best for miles around, so her heart must have been in the right place.

D ISSECTIN G T HE BACKBONE The only general practitioner or family doctor we met officially as medical students was a brisk little gentleman wh o ran the city VD clinic. We admired the expert, pragmatic way he dealt with his patients, a fair number of whom used to come in with paper bags over their heads to ensure anonymity. The consensus among the teaching hospital consultants was that the general practitioner was the backbone of British medicine, but, after that affirmation, they usually proceeded to a dissection. There were no general practitioners on the university teaching staff in those days. I was greatly influenced by the writings of A. J. Cronin whose first book, The Citadel, I devoured in one all-night reading marathon. I have it still and frequently use vignettes from his Adventures in Two Worlds as teaching tools. Cronin was a physician, a fellow Glasgow graduate who gave up the practice of medicine when he achieved world-wide fame as an author. His recurring theme was the necessity for doctors to have a personal integrity that transcended venal opportunities, an inquiring mind that eschewed empiricism and a professional ethos that

ABOUf THE AUTHOR Dr Jim McSherry is a 1965 graduate of the University of Glasgow who is Chief of Family Medicine at the London Health Sciences Centre, Medical Director of the Victoria Family Medical Centre and a Professor in Western's Department of Family Medicine. He has been in family practice in London since 1993.

embraced lifelong learning. It made sense to me then and it still does today. AN OFFER After graduation, I spent the compulsory preregistration year doing six months of medicine and six of months surgery at Glasgow's Southern General Hospital and then did another six months in obstetrics at the Royal Maternity Hospital where both my sons were born in later years. Still undecided about my professional future when I was doing obstetrics, I was intrigued when a Dr. John O'Brien phoned me at the hospital one evening and asked me if I had considered general practice as a career. I had never met Dr. O'Brien before, but it turned out that one of his sons was in the same class at school as my youngest brother. I was trying to make up my mind whether or not to accept a training position in anaesthesia at the time, but agreed to visit his practice in Glasgow's industrial northwest, more out of curiosity than anything else. I liked Jack O'Brien from the first time I met him; he seemed like a nice man who would be a kindly and congenial colleague, although some of his medical ideas appeared just a bit antiquated to my sophisticated modem way of thinking. I visited his practice, met his partner Bill Scott, and spent several evenings (evening, rather than afternoon office hours were the norm in Britain then) in the office with both of them, observing the curious phenomenon of general practice . I was confused and intrigued simultaneously; patients certainly had problems, but relatively few of those problems were identifiable or treatable in the elegant and fastidious manner I was used to seeing in teaching hospital out-patient clinics. There was no shortage of pathology, acute and chronic, but the pathology wasn' t always or necessarily the problem and there was an indefinable something about people' s lives that embroidered a layer of complexity around everything. This was a different kind of medicine indeed. Care was provided in the home and in the doctor's office, with the daily house call list a major piece of the work load. One of the compromises reached at the inception of the British National Health Service had been a division of responsibilities and resources between general practitioners and specialists. The general practitioners got the patients, the specialists got the hospitals.

A H OME CONFINEMENT The long and the short of it was that I joined Jack O'Brien and Bill Scott in practice in Glasgow's Maryhill district on the 1st of February 1967. I can't remember my firs t day very clearly, although it must have been a Monday. I do remember the Friday of that week becau e I was dispatched to attend a woman in labour at home. My

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F ea tur e

Articles

experiences as a member of the Royal Maternity Hospital's obstetrical " flying squad" had taught me one thing, women and home confinements had an inverse relationship, the ones who wanted it most were usually those for whom it was the greates t risk . The "flying quad" consisted of a registrar, a resident, a staff nurse and a trainee midwife in a cab with two big boxes full of medical kit, including a unit of 0 negative blood. We went to obstetric emergencies anywhere in Glasgow in response to requests from local doctors or patients and their families. I did this particular domiciliary obstetric visit on my own, oddly enough, to a house on Rose Street, across the road from the Cosmo cinema and about 500 yards from my old school, St Aloysius' College. This one turned out to be the family doctor' s bigge t disgrace, a BBA, born before arrival. The mother had phoned when she went into labour, but had dispen ed with the usual antenatal care formalities as this was her seventh pregnancy and she had little time to spare for visiting doctors. Labour was swift and uneventful, and the district midwife had everything in hand. The only problem was the baby: it had some funny moist red patches on its abdominal wall; I recognized the abnormality immediately as ectopia vesicae, an ectopic bladder, a rare congenital condition. I phoned a pediatric surgeon called Sam Davidson and explained the situation . He could hardly believe what I was telling him, but, when I invited him to come and see for himself, said "I' ll be there in fifteen minutes." He was driving a Jensen Interceptor, an exotic and fiendishly expensive sports car thought superior to James Bond' s Aston Martin DB6 . He immediately agreed with the diagnosis and departed as quickly as he came, taking the baby with him wrapped in a shawl. A great man, Mr Davidson operated on the baby a few days later. She was alive and thriving when I emigrated to Canada six years later. Mr Davidson died last year. A FAMILY D O CTOR'S LOT I had a most happy association with Jack O'Brien and Bill Scott; both were friendly, highly encouraging, excellent family doctors. Jack in particular went out of his way to coach me in the ways of general practice and I owe him a great deal. We were in partnership together for six years. He died peacefully in retirement, of a heart attack, a few years ago. I married Helen on 3 February 1968 and we recently celebrated our thirty second wedding anniversary, the best partnership I've ever known. I was interested in presentations of severe anemia in primary care a nd collected a personal series of 54 cases over six years. My unpublished observation was that almost all my older patients presenting with severe anemia had occult bowel cancers (no surprise nowadays, but not well recognized then), several had pernicious anemia, one or two had isolated folic acid deficiency secondary to anticonvulsant use, and one had Peutz Jaeger syndrome. I published a paper on acute gout secondary to furosemide therapy, a well known phenomenon now, but not so well known then. I stood for election to the Local Medical Committee on a reform platform and came in last. More successfully, I combined general medical practice with an interest in military medicine. I had joined the Reserve Army when I

went to university in 1959, was commissioned as an infantry officer while still a student and then transferred to the Royal Army Medical Corps when I completed my pre-registration year. I became regimental medical officer to the 71 (Scottish) Engineer Regiment (Volunteers) and retired as a major when my wife put her foot down, wisely insisting that I should behave like a husband and father, now that I was both. Among other military memorabilia, I have high frequency nerve deafness in my right ear, a legacy of my days on the University rifle team. From the Army, I learned the need for teamwork, common goals, planning, organization and coordination in any cooperative human endeavor, that battles aren't necessarily won by frontal assault and the only battle you need to win is the last one. From Jack O'Brien, I learned to see people in the context of their lives, to see my patients as persons, to take a kindly view of them and not to go looking for battles that aren't really there. From his wife Nell, Helen and I learned to appreciate kindly hospitality and good antiques. CANAD A We emigrated to Canada in 1973 and I joined the Carruthers Clinic in Sarnia, about sixty miles from London, Ontario. I found the Canadian style of family practice to be exhilarating. The opportunity to care for m y patients in both community and hospital seemed like a dream come true and the availability of diagnostic resources was absolutely incredible in contrast to the U.K. situation. At various times, I was medical director of a nursing home with an interest in geriatrics, medical director of the home care program with an interest in palliative care, and held leadership positions on the medical staff of both Sarnia hospitals with an interest in health care organization and delivery. I did a lot of obstetrics in tho e days, had over 100 deliveries a year for several years and, on one occasion, six deliveries in a single day! We made many friends , personal and professional, and I worked with a lot of professional colleagues for whom I developed the greatest respect. My daughter was born in Sarnia and we became Canadian citizens. I became involved with the College of Family Physicians of Canada, served as a Certification examiner, at on one or two CFPC committees and published some papers, mainly case reports, but one or two research studies as well. I learned that I liked working with young people, and that led to the next stage of my life. Q UEEN'S I answered an advertisement in the Canadian Family Physician in 1980. Queen's University was looking for a Director for its Student Health Service and I was fortunate enough to be given the job plus a faculty appointment in Family Medicine. We moved to Kingston in 1981 and found it a splendid place to live. Our children grew up there, went to Queen's and still think of Kingston as home. When our son Stephen graduated from Queen's with a BA one week after our son Peter received a law degree, he was surprised when the Chancellor, Dr. Agnes Benedickson, asked him if she could expect any more McSherrys at the next graduation in another week' s time! We enjoy our occasional

U. W .0. Medical Journal 70 (2) 2000

Feature Kingston visits, a great opportunity to vi it with former neighbors, friends and colleagues. My time at Queen' wa one of great professional development for me as I discovered eating disorder and the Ep tein-Barr virus as well a everything else that make the bread and butter of young people' health care. Working with student wa challenging and great fun! Eating disorders are very common on college campuses, but knowledge about them was then in its infancy and treatment facilities were even fewer than they are now. I had to educate my elf about eating di orders very quickly if I was to be any help to my patients. I've been tr y ing to help people str uggling with eating di order ever since, and I've tried to combine that with teaching, re earch and public advocacy. I founded the Primary Care Eating Di order A ociation of Canada l~ t yea r, it's a Canada-wide virtual network of family physicians intere ted in eating di orders prevention and management, and I'm actively involved with other community groups.

THE MEDICINE OF HISTORY Reading a biography of Mary Queen of Scots led me to conclude that she suffered from an eating disorder as a teenager, and that led me into a series of publication on what I call "the medicine of history," the application of modern medical knowledge to the clinical conundrum of centuries long ago. I've publi hed paper on Bonnie Prince Charlie's health as a two-year-old, the ob cure illness that afflicted Sir John A Macdonald's first wife, whether Herod the Great had guinea worm infestation, etc., etc. With Ross Kilpatrick, a friend in the Cla ics Department at Queen's, I examined the remarkable tory of the Great Plague of Athens and have argued for year that it wa an epidemic of anthrax pneumonia that caused o many Athenians to die. I'm working on the life story of the Roman Emperor Claudius ju t now, and it seem to me he must have had a neural tube defect, possibly a meningomyelocele. Thi art of exerci e, I'm convinced, fine tunes diagnostic skill and foster an appreciation for the way history reveals itself a it unravels before us. CH RONIC FATIGUE "Mono", properly known as infectious mononucleo is, is also very common in college populations. I saw so many youngsters with mono that I could diagnose it by smell alone. My fascination with the Epstein Barr virus led me to an interest in syndromes of chronic fatigue when I aw the protracted convale cence many tudent experienced after mono . Sanjay Lambore wrote hi rna ter's thesis in epidemiology on persistent symptoms and impairments after mono with my elf and Dr. Art Kraus as cosupervi ors. I became concerned with the assessment and management of people with chronic fatigue syndrome and its cousin fibromyalgia. To the horror of my children who had all taken basic psychology courses, I was given a cro appointment in the Department of Psychology, the only professor in the place who hadn't taken Psych 100! I greatly enjoyed the interdisciplinary collaboration that appointment permitted.

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LIFE AT WESTERN I came to the Universi ty of Western Ontario on 1 February 1993 (how's that for a coincidence?). I had hit the big 50 and the re ulting existential angst made me conclude that I should get back into mainstream family practice. I had always prided myself on being a generali t with some pecial interest area , rather than omeone with expertise in specific areas, but a general medical knowledge that was fast becoming outdated and irrelevant. I had actually wondere d if I should maintain my interest in eating di order and chronic fatigue syndrome, but my colleague in the London area began referring patients to me almost a oon a I arrived and there was ultimately no choice. These conditions are very challenging, not the lea t to our way of thinking, as Carte ian duality remains a pervasive theme in medicine even today. People with conditions like chronic fatigue syndrome and fibromyalgia are disadvantaged by an apparent unwillingness on the part of third party insurance carriers and orne physicians to see impairment a anything other than black or white, organic or nonorganic. Disability asse ment is highly problematic in the e conditions. The standard approach is based on measuring a persons ability to perform a series of tasks in a te t environment. Thi is all very well, but work i more than the performance of ta ks, it is the efficient, continuous, competitive, repetitive performance of ta k elected from a range of option in respon e to a variety of feedback mechanisms in a noisy and perhaps physicall y uncomfortable environment. It i the difference between antibiotic performance in vitro and in vivo. Observed ability to perform ta k doesn't nece sarily equal being fit for work. Seeing may indeed be believing, but skeptici m can be willful blindness and an open mind hould be the hallmark of an educated person. I've enjoyed practising mainstream family medicine in an academic family medical centre, although I haven' t resurrected my previously strong interest in ob tetric . The other responsibilities that go with my hospital and university roles just make that side of things unrealistic for me. CHANCEAND CHA GE Over the year , I've learned not to fear change, that change is inevitable, not all change is progress, but there's no progress without change. I've learned the wisdom of Yogi Berra's famous aphori s m, the mispoken advice, "When you come to a fork in the road, take it!" I've missed a few things I thought I had my heart set on, but the consolation prizes, together with the love and support of my wife and family, my friends and patients, have been wonderful compensation. George Bernard Shaw aid that there's only one thing war ethan not getting your heart' desire and that' getting your heart's de ire! I think he' right! Family medicine has been a wonderful career for me and it isn' t over yet! Is family medicine for you? We need sound doctors, men and women of character and enthu ia m who are ready to make a difference in people's lives with good primary care medicine, kindly interest in their patients and an appreciation for the social context in which health and illness are experienced. Are you one of them? I certainly hope so! Q

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ASSESSING AND MANAGING COMMON SKIN PROBLEMS IN THE PRIMARY CARE SETTING By Benjamin Barankin iseases of the skin, hair and nails are a common reason for visits to family physicians and other primary care providers . Unfortunately, most physicians have limited training in dermatology during their medical school and residency years, and thus it is no surprise that primary care physicians are less proficient than dermatologists in accurately diagnosing many skin disorders. I , 2, 3 Considering that approximately 6% of outpatient visits relate to skin problems and that nondermatologists manage 60% of these patients, it is important for primary care providers to be comfortable in the management of the more common cutaneous conditions) The most common skin problems diagnosed by family physicians in one study included (in descending order): dermatitis, pyoderma, warts, tinea infections, epidermoid cysts, candida, acne and actinic keratoses; the same study found that the top 10 and top 20 most common diagnoses accounted for 65% and 82% respectively, of all skin-related diagnoses. 2 Primary care providers should be able to recognize and manage the twenty most common skin problems. As well, they need to recognize less common but serious skin conditions (e.g. melanoma, pemphigus), and manage or refer them appropriately. One technique, essential to the management of many common skin lesions, is liquid nitrogen cryotherapy (or cryosurgery) . Cryotherapy is a popular treatment modality because it is relatively inexpensive, easy to use, does not require local anesthesia , and has fe w complications.4 It is most commonly delivered as liquid nitrogen or nitrous oxide, and it can be applied using either cotton swabs or a spray canister approach. The use of cryotherapy should be preceded by an understanding of which lesions are amenable to such therapy, the duration of treatment, and the proper use of margins in therapy. It has been shown to be effective in the treatment of: actinic keratoses , seborrheic keratos e s, dermatofibroma, keloids, molluscum contagiosum, condylomata and common warts, and benign nevi.4 A good knowledge of the different vehicles used in topical medications (e.g. ointments, creams, lotions) is an important consideration in managing cutaneous problems.

ABOUI' THE AurHOR Benjamin Barankin is currently a third year medical student at UWO and an avid writer. Before medical school, he studied life sciences and psychology, completing a psychology degree at Queen's University. Dr. Gottschalk is Assistant Professor (part-time), Division of Dermatology, Department of Medicine, at the University of Western Ontario.

Topical corticosteroids comprise a large part of the arsenal for managing skin problems. Their side effects are a function of steroid potency. Primary care providers should be comfortable in prescribing most low and some medium potency steroids, but should reserve more potent steroids for dermatologists. The management of skin lesions in children differs from the approach used in adults. Physicians should avoid unnecessarily traumatizing or scarring children, and so the use of invasive diagnostic techniques like skin biopsies should be reserved for when they are essential to the management of the child.S Proper education of the parent and child, the use of distraction to allay fear, and an appreciation of the maturity of the child when deciding on treatment, are all beneficial in the management of skin problems in the pediatric population.s Like any aspect of medicine, taking an appropriate history (Table 1) is the starting point to managing any skin problem. As well, being able to describe lesions in an organized manner (Table 2) and using the proper terminology (Table 3) will improve diagnostic acumen, management and necessary referrals. An informal survey of the most common skin problems noted by family doctors was conducted in the London, Ontario region. Based on these findings, the diagnosis and current management of some of the most common skin conditions observed in the family practice setting is presented. Acne Vulgaris This is an inflammation or blockage of pilosebaceous units, most commonly on the face, but also affecting the back and trunk.6. 7 It is usually more severe in males, and has a lower incidence in Asians and blacks.6 Although it most commonly affects adolescents (age 10-17 in females, 14-19 in males; 100% of boys and 90% of girls will have some acne), it can extend into, or even begin in, adulthood. 6 It is important to be aware of the psychological impact of acne as it can lead to low selfesteem, depression, and embarrassment.S The classic features are open (black) or closed (white) comedones, Acute vs. Chronic -time of onset Behaviour- do lesions come and go, recur in the same area? Change in size or colour Discomfort - itching, burning/tingling, pain Effects of external agents - sun, detergents Family History - psoriasis, atopic dermatitis Pills & Allergies Past history- sun bums & exposure, similar rash Previous Treatments -steroids, moisturizers, ointments/creams Table 1: Focused History Taking1.11 Mnemonic: ABCDEF PPP

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Feature Order of Description

Descriptives

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Description

Definition

Annular

Arranged in a ring shape

Atrophy

Depressed surface due to thinned epidermis or dermis

Location & Distribution

Symmetrical, Asymmetrical, Sun-Exposed FlexuraVExtensor, Acral (hands/feet)

Erythema

Erythematous or Non-Erythematous

Surface Features**soft palpation

NormaVSmooth, Scaly, Warty, etc.

Bulla

Blister > 1 em

Type**deep palpation

Flat or Raised, Consistency, 1° or 20

Unear 'S' shaped papule 3-Smm, found in scabies

Color

Pink/Red/Purple, White, Brown, Yellow

Burrow (=papule)

Arrangement

Single or Multiple, Discrete, Unilateral, Generalized, Disseminated, Grouped, Annular, Unear, Serpiginous

Comedone (=papule)

Plugged (pilo) sebaceous follicle 1. Closed or whitehead 2. Open or blackhead

Border & Shape

Well or Poorly Defined, Active Edge, Round/Ovalllrregular/Pedunculated

Crust (or scab)

Dried serum, pus, or blood

Special Sites

Scalp, Mouth, Nails, Genitalia

Cyst (= papule/nodule)

Epithelium-lined cavity containing fluid, pus or keratin

Ecchymosis ("bruise")

Large confluent area of purpura

Erosion

Partial loss of epidermis. ** Heals without scarring

Erythema

Redness that blanches on pressure

Table 2: Approach to Describing Skin Lesions111 Mnemonic: LES T. CABS

inflammatory papules and pustules.7 Different manifestations include comedonal acne, papulopustular acne, nodulocystic acne, and acne conglobata .6 Pitted, depressed or hypertrophic scarring may occur with severe acne (es pecially noduloc ystic).6 Steroids, oral contraceptives, emotional stress, endocrine factors, occlusion and pressure on the skin have all been implicated in worsening the condition. Despite common folklore, neither foods (e.g. chocolate) nor poor hygiene cause acne, and sunlight does not improve acne.6, 8 Treatment: 6, 7, 9-11 1) Mild Acne: Topical • Topical Antibiotics (clindarnycin, erythromycin) • Benzoyl peroxide (2%, 5%, or 10%) qhs or bid • Topical retinoids (cream or gel)

most common side effect: mild irritation (creams are less irritating than gels)

2) Moderate Acne: Oral + Topical • Oral tetracycline, minocycline, or erythromycin. * ate: do not give tetracycline or minocycline to children or

Excoriation

Local damage due to scratching

Exudate

Serum, blood or pus accumulated on skin surface

Fissure

Unear split in epidermis or dermis.

Keratin/Hom

Rough, uneven surface. Difficult to pick off, unlike crust

Uchenified

Thickened epidermis (& increased skin markings) due to excess scratching

Macule

Flat, pigmented lesion < 1 em

Nodule

Raised lesion > 1em with rounded surface ** usually dermal pathology (:. no surface~)

Papule

Raised lesion < 1em

Patch

Flat, pigmented lesion > 1 em

Petechia

Small, nonblanching, red-brown macules

Plaque

Raised lesion > 1em (diameter>>thickness) ** usually epidermal pathology (:. surface~ e.g. scaling, crust etc.)

Purpura pressure

Red or purple skin which doesn't fade with

Pustule

Pus-filled lesion < 1em

Scaly

Dry/flaky surface

pregnant women.

• In females, one may try oral estrogen dominant combined with progesterone birth control or estrogen with anti-androgen therapy (e.g. Diane 35). 3) Severe Acne • Isotretinoin (Accutane): used for severe, resistant, nodulocystic acne with scarring (typically 1mg / kg / day). 90% of people respond to a first course, with a long-term cure of 65 %. Best managed by a dermatologist.

** Isotretinoin

is teratogenic, therefore proper con traception and pregnancy testing is indicated in all females . Fasting blood lipids (esp . triglycerides and cholesterol) and liver biochemistry should be assessed monthly. Dry nose, mouth, and lips are common side effects. Night blindness and mood changes have been reported occasionally as well. Sometimes a second or third course of Isotretinoin may be needed.

Actinic Keratosis (also called Solar Keratosis)

These are small (<1cm), single or multiple, discrete, sandpaper-rough, scaly lesions.6,10 They occur on chronic sun-exposed and damaged skin (most common in the

Scar (cicatrix) Healed dermal lesion 20 to trauma, surgery, etc. (= macule/papule/plaque) Serpiginous

Snake-like in appearance

Telangiectasia

Small dilated blood vessels

Ulcer

Full-thickness loss of epidermis & some dermis. There will be either exudates or crusting present ** heals with scarring

Umbilicated

Round depression in center of surface

Vesicle

Blister< 1cm

Warty/Papillomatous

Finger-like/round projections on a surface

Wheal (= papule/plaque)

Transient swelling due to dermal edema (synonymous with urticaria)

Table 3: Common lexicon in dermato1ogys.1.u.u

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elderly).6 They are found on the head and neck, as well as the dorsum of the hands and forearrns.lO These lesions are cons idered pre-cancerous, w ith 1 in 1, 000 lesi ons developing into s qu a mou s - cell carcinoma if left untreated .6 Treatment is mos t commonly wi th li q uid nitrogen cryotherapy (5-Fluorouracil may also be used).6 Dermatofibroma (also called Fibrous Histiocytoma) A very common, small (<1cm), firm, raised nodule, which is slow-growing and usually painless)O, 12 A kin colored / pink / red / brown nodule (with occasional brown circumference) that is usually solitary, more common in females and the middle aged, and usually found on the extremities (especially legs).6, 10, 11 They are sometimes associated with recent trauma, such as an insect bite or ruptured cyst )O, 12 Clinical diagnosis aided by the Dimple sign (lateral compression with two fingers produces a depression / dimple).6 Trea tment6 is urmecessary because of benign nature, but liquid nitrogen cryotherapy can be effective. Surgical excision is also an option. Hand, Foot, and Mouth D isease (HFMD) A self-limited (7-10 day) systemic infection usually caused by a coxsackie v iral infection.6 Most commonly seen in young children, it is highly contagious and spreads by direct contact.6, A clinical diagnosis, it appear as multiple small grey vesicles with a red halo on the fingers and toes, and ulcerative orallesions.6, 8, 11 Often there is a low-grade fever, malaise and complaints of a sore mouth, although s y mptoms ma y be more severe in so m e. 6 Treatment:6 symptomatic. Impetigo An infectious skin disease, spread by direct contact, and mo s t common in children . It can be primary or secondary, and there are three types: nonbullous impetigo, bullous impetigo, and ecthyma. Most cases (>90%) are due to Staphylococcus aureus, althou gh occasionally may be due to group A beta-hemolytic Streptococcus p yogenes (GAS ), or a combination of both .6, 7 It presents as a weeping area of 1-3 em rounded lesions which heal with honey-coloured crusts.6 Lesions ty pically las t da y to w eeks a nd resol v e promptl y with proper treatment. Treatmen t:6 preventive (benzoyl peroxide wash, che ck famil y members for impetigo), topical (Mupir o cin ointment 7-10 da ys tid), or s ys temic (depend s on organism, although erythromycin or cephalexin are good options for 10 days). Intertrigo A bacterial or yeast infection developing in body folds where skin rubs on itself, most commonly in the axillae, inframammary, groin, and intergluteal areas.6, 9 Initially appears as pustules on an ery thematous base w h ich become confluent.6 Management involves keeping the area clean, cool, dry, and separated.9 Treatmen t 6, 9 options inclu de nystatin or imidazole creams bid, as well as topical mild steroids and powders. Lice-Head (also called Pediculosis Capitis)

This is an infestation of the scalp by wingless insects spread by direct contact (shared items or head-to-head ), occurring mainly in children.6, 11 Infestation is not related to poor hygiene. Head lice are difficult to see, particularly as most patients have < 10 lice and so the diagnosis is by clinical findings confirmed by finding nits or lice.6 Usually asymptomatic, itching is in some cases intolerable and can result in secondary infection (note that occipital or cervical lymphadenopathy may be s uggestive of lice).6, 11 The eggs / nits are 1 mm, oval, grey-white, and firmly attached to the base of the hair, which is the basis of diagnosis (unlike dandruff where scales easily come ofÂŁ).6, 11 Prevention: Avoid contact with possible contaminated items (e.g. hats, combs). Bedding, clothing, and head gear should be w ashed and heat-dried, and the environment vacuumed (lice can survive up to 55 hours off the head ).6 Contacts should also be treated. Treatment:6, 13 1) Permethrin (Nix) 1% (can use 5% if it fails): reduced reinfestations due to protective residual, but may repeat treatment in 7 days. Preferred treatment; 2) Lindane: 90% success rate, but potential side effects due to high ab sorption t ; 3) Other: Py rethrin, Malathion, Petrolatum (rubbed into scalp to suffocate lice). *Treat entire body for all of the above. **Most schools will not allow students to return until nits are gone, and so nit removal with a fine comb (nit comb) may be used. *** Note that resistance to all topical agents has been reported. t serious sequelae such as seizures and aplastic anemia have been associated with the use of Lindane; it should not be used in pregnant or lactating women, very young children , and those with extensive dermatitis. Bathing prior to application should be avoided.

Molluscum Contagiosum A self-limiting (las ting between 6-9 months) vira l infection of the s kin caused b y the pox virus, mo s t commonly affecting children (but also sexually active adults).6, 10,11 These are 1-5 mm, smooth, firm, white / pink umbilicated papules found anywhere on the skin; they ma y b e single or multiple (especiall y if immunocompromised; multiple facial mollusca ma y suggest HIV infection).6, 10, 11 Although itching, tenderness or pain are uncommon, roughly 10% of patients develop an eczematous dermatitis around the lesion.IO Treatment,6 although unnecessary in immunocompetent patients, includes curettage, liquid nitrogen cryotherapy (10-15 seconds), electrodessication or laser surgery. Scabies A par asitic infection usually transmitted by direct contact. Older patients in nursing homes are more prone to infestation, as are young children and sexually acti ve young adults.6 Patients present with an itchy papular rash, most commonly in the finger webs, flexor aspect of wrists, elbows, buttocks, and genitalia, with sparing of the head and neck.6, 9 With the initial infection, sensitization (and pruritus ) take a few weeks to develop, b ut after a reinfestation, pruritus develops within 24 hours.6 Because a clinical diagnosis can be difficult to make, a scabies infection should be in the differential in the setting of a

U. W. O. M edical Journal 70 (2) 2000

F ea t u r e persistent generalized pruritus.6 Pruritus is often intense, widespread, and worse at night, such that it interferes w ith sleep .6, 14 Unfortunately for some patients, this condition has been misdiagnosed and mistreated as an eczema for long periods of time.l4 Treatment:6, 13, 15 1) Permethrin (e.g. ix, Kwellada P) 5% cream (the most reliable topical cabicide, no toxicity, residual effects); 2) Lindane 1% lotion / cream (apply on successive nights); or 3) Other: Malathion Treatment is effective in over 90% of cases. Clothes and bedding must be laundered in hot water. Close personal and household contacts should be checked and treated. Pruritus may persist for weeks after successful treatment. Skin Tag (also called acrochordon or cutaneous papilloma) Skin tags are common, soft, skin or tan-colored pedunculated polyps. The y occur commonl y in intertriginou sites, and increa e in size and number over time.6, 12 They are more common in older people, females (e pecially during pregnancy), and in obese patient .6 Usually asymptomatic, they may become bothersome and tender after trauma or torsion. Skin tags are completely benign and thus only require management if the patient is ymptomatic or for cosmetic purposes. Treatment:6, 12 Snipping with scissors, liquid nitrogen, or by electrodesiccation. Tinea Pedis (also c.a lled athlete' s foot) A dermatophytic infection of the feet . Appears as ery thema with scaling and maceration .6 Usually a ymptomatic, but may be itchy (painful if infected ). Often a chronic condition made worse by hot climate. Treatment:6, 9 1) Topical: Miconazole or clotrimazole applied bid, Ketoconazole OD; * ystatin does not work; 2) Systemic (if extensive or topical failure): ltraconazole, Terbinafine. Prevention: shower-shoes in public facilities, wash feet regularly. Tinea Versicolor (also called Pityriasis Versicolor) A chronic, asymptomatic scaly rash of different colours (white, orange-brown, or dark brown), the round macules are usually < 1cm, round, and always scaly when sc ratched. 6, 11 Caused by an infection by the yeas t Malassezia furfur, it is more common in young adults and most commonly appears on the upper trunk.6, n Clinical uspicion along with a po itive KOH preparation make the diagnosis. Treatment6,9 options include Selenium ulfide (2.5%) lotion or shampoo applied daily for 15 minutes for 1 week. Can also treat with oral Ketoconazole or Itraconazole, and Terbinafine cream that are more expensive. WartsN erruca Common Warts / Verruca Vulga ris: This is a human papilloma virus in fection of the epidermis that is transmitted directly through broken skin. Th ey are found on the fingers, palm and dor urn of the hand. They appear as firm, rough, skin or brown coloured papules with tiny black dots on the surface. n Treatment is only necessary if

A rti c l e s

the warts are bother orne or for cosmetic purposes. In fact, most warts disappear spontaneously after an average of 2 years after the body has built up its immune defenses.n If medical treatment is reques ted, the mainstay is cryotherapy that may need to be repeated on several occasions. Daily treatment wi th over-the-counter wart removal preparations (17% salicylic acid, 17% lactic acid) may be helpful, but produce a slower response.9 Plantar Warts /Ve rruca Plantaris: Appear as discrete round papules with a rou gh su rface, surrounded by a layer of hyperkerato is.n Although less a cosmetic issue, the e are more likel y to be treated beca u se the hyperkera tosis around the wart may cause pain when walking.n, 14 Initial treatment may consist of paring down the hyperkeratosis with a scalpel or pumice stone which may relieve the pain, use of a 40% salicylic acid plaster, or a 17% salicylic acid / 17% lactic acid over-the-co u nter preparation .11 If the se don ' t work, liq u id nitrogen (po sibly several courses) may be used. The last line of attack involves the use of a carbon dioxide laser that can de troy the lesion, but this req u ires referral to an appropriate dermatology clinic. *There is some evidence to suggest that the H2 blocker cimetidine might be effective in tire treatment of warts an.d molluscum contagiosum by augmenting the immune response.15 A CKN O~EDG E MENTS

The author wishes to acknowledge Dr. Ronald Gottschalk for reviewing this manuscript as well as the many family doctors in the London area who responded to an informal e-mail survey of the most common skin problems seen in family practice. REFERÂŁ CES 1. Federman DG , Conca to J, Kirsner RS . Comparison of dermatologic diagnoses by primary care practitioners and dermatologists. Archives of Family Medicine 1999; 8:170-2 . 2. Fleischer Jr AB, Feldman SR, McConnell RC. The most common dermatologic problems identified by family physicians, 1990-1994. Family Medicine 1997; 29(9):648-52. 3. Whitaker-Worth DL, Susser WS, Grant-Kels JM . Clinical dermatologic education and the diagnostic acumen of medical students and primary care residents. International Journal of Dermatology 1998; 37:855-59. 4. Wetmore Sf. Cryosurgery for common skin lesions. Canadian Family Physician 1999; 45:964-74. 5. Hanson SG, Nigro JF. Pediatric dermatology. Medical Clinics of orth America 1998; 82(6):1381-1403. 6. Fitzpatrick TB, Johnson RA, Wolff K, Polano MK, Suurmond D. Color atlas and synopsis of clinical dennatology. 3rd ed. Toronto: McGraw-Hill, 1997. 7. Kumar P, Clark M. Clinical medicine. 4th ed. London: W.B. Saunders, 1998. 8. Fitzpatrick JE, Aeling JL. Dermatology Secrets. Philadelphia: Hanley & Belfus, 1996. 9. Carey CF, Lee HH, Woeltje KF. The Washington manual of medical therapeutics. 29th ed. Philadelphia: Lippincott Williams & Wilkins, 1998. 10. McKee PH. Pathology of the skin: with clinical correlations. 2nd ed. London: Mosby-Wolfe, 1996. 11 . Ashton R, Leppard B. Differential diagnosis in dermatology. 2nd ed. Oxford: Radcliffe Medical Press, 1994. 12. Pariser RJ. Benign neoplasms of the skin. Medical Clinics of orth America 1998; 82(6):1285-1307. 13. Elgart ML. Current treatments for scabies and pediculo is. Skin Therapy Letter 1999; 5(1). 14. Rossner G, Kahn G. Atlas of Dermatology. Munich: Urban & Sd1warzenberg Inc., 1978. 15. Thiers BH. Dernwtology therapy update. Medical Clinics of North America 1998; 82<6>:1405-14. n

U. W.O. Medical Journal 70 (2) 2000 - - - - - - - - - - - - - - - - - - - - - - - - -

ZIPIIDR* A7DR0:1Sl:417N CALCIUM EFFICACY TO REACH TARGET THE FIRST TIME

lJPITIJW

Musde El!acts

~ catiln)

10rrg,20mgilld40mglatiets

Tl£flAPEI1I1C ClASSf!CATJON· ~ Metaboism RegUa1Dr IIC1KJIIS ANIJ CIJMCAL I'HARJIIACOlOGY I.J'ITOR {a1Drvastati1 cabJn) is a S)'!1lhe!i; i!Jid-k:M<eri"g agent.~ is a selec!M!, ~ irtifu ci 3-h)Oo>cy-3~A (lf.1G-Coo'l reru:tase. This enzyme catalyzes the aJ1YerSioo ci tt.IG-CoA il mevalonale, wti:h is .., ear1y ;nj rale-rmtilg Sll!p il the biosynltoesis ci cllolestera. I.J'ITOR klwers J*lSrna cl1olestera il1d ~ IIM!Is 171 irllilili1g tt.IG-CoA re<1dase il1d cl1olestera syrChesis il the iYer ;nj 171 i1creasilg the runber ci he!Ja1ic LD.v Densily LWutein OJJll teCel*rS 00 the cel-sufa:e b Ert1anced ~ il1d cataboism ci LD.v Densily LWutein OJJl). I.J'ITOR nru:es Ul.~ Ul-.q il1d the runber ci Ul. pri:les.I.J'ITOR aloo nl<1l:es 'My LD.v DalSIIy ~(I.Ul.-C) . sen.m~(TG)illd -Densily~(04. asYdasf'e

rumer c1 ~ B ~B) artaiW>;l iB1i:les. tu r-aeases H!11 0er91y ~(I«.q. ElevaEd sen.m ctrJiesllltj <toe il elevaled Ul.-C is a m:;r risk tacn fa the dewlqment ci crOOiasa.Cr' ~&ase. ElevaEd J*lSrna TG is aloo a risk facn b crOOiasa.Cr' dsease. pri;UMy I <toe il ineased D.., a associaled will decreased to. -C a ineased Ul.-C. Abvaslatil is rapktf ab!iabed after aal aooiristratirl; rnaxirun J*lSrna alf1CaltratOls ClCW wiltWl 1 il 2 l'rus. Abvaslatil <re 95'!1. 1199'!1. Doavailable IXlfll91ld 1D sciJtioos. Mearllislrbful ci ailrvastatil is ~ 381 itres. Abvaslatil is 2:98'!1. tnn1 il J*!Srna JJ01eins. Abvaslatil is extensM!Iy rnetbJized 171 C)'IDctrome P-450 3A4 il ortho- il1d para-~ted deriva1iYes il1d 1D v.ms bela-<JXidatioo IJO(U:Is. Awalinalely 70'!1. ci crWatilg iffiloy adMty fa tt.1G Co-A re<1dase is allrtlutedil~metallolites.

Abvaslatil il1d ils rnetalloites <re elili'lated 171 *Y l!liOlltion. Less 11m 2% ci a IDse ci atavastafil is recxMlllld illli'e ftDW1g aal aooiristratirl. Mearl J*lSrna elili'latm ~-ife ci atavastafil illunans is ~ 14 trus. ilJI the ~-ife ci irttiDy adMty b tt.1G-CoA re<1dase is 20 ilJO toss <toe il the cooiJ'b.jjoo ci klnger-t.ed~metallolites.

/NO/CATIONS ANIJ CUN/CAL USE

I.J'ITOR (a1Drvastatil calcUn) is rocated as <r1 at.n:t 1D del, at least ~ 1D the Ameri31 Hl9t Assoaatm (AHAj Step 1 del, b the reru:tm ci elev.!1ed iltll d1oleslera, ~. Ul.-C, TG il1d ~ B ~ B) in ~ il1d ~ cord1ioos, when response il diet il1d olher ID!Jta 1113C1ilgicai rneasues alooe has been i'1adecJJale, inidrg: • Prinay tlyj:ed ...... tEUia (T)lle Ia), • Carbined (nixed) tlyj:eiiJidemia (T)lle Ill), ~ famial tlyj:eiiJidemia reg<l1less ci ..tether cl1olestera a ~ <re the l!id abmnaMy ci arcem; • Oysbetafp:..uAI!ielia (T)lle I);

· ~(T)llell');

• Famlal trn:ed.....,celia (lml0!)91IS il1d ~- F« hilmoz)gClJS famial trn:ed.....,celia.I.J'ITOR stn*l be used as.., at.n:t il trea1rTe1ls su:ll as Ul. ~ a as ~ i su:ll trea1rTe1ls <re ra avaiaiE. in clrt:allrials, I.J'ITOR (10 1D eo ~ si!J'ib'tly ~ l!id JJofies in patients IWt! a wide v.rey ci ~ ;nj ~ ardliJns. in 2 OOse-response Sll.des in miktt-I:Hlrlderalely ~ !lllienls (FfllCti:l<son l)lleS Ia il1d IJ), I.J'ITOR reiD::ed the IIM!Is ci iltll ctaesaera (l!f-45'11.), Ul.-C (39-ro'!l.), ~ B (3250'!1.), TG (19-37'!1.), il1d ineased t'q1 density~ ctaesaera (I«-C) IIM!Is (5-9'11.). ~responses WEre acl1iewld in patients with helliroz}9lJs famial tf!I:Eid-celia. rm-famial 1orms c1 trn:ed -ce1 ia. ~ ~ famial tlyj:eiiJidemia ;nj patients IWti rm-iWin dependent clabetes iTdrus. in patients IWti ~ (T)lle II'), I.J'ITOR (1 0 meo mg datyj reiD::ed TG (25 - 56%) il1d Ul.-C IIM!Is (23 • 40'!1.). Ol)bnl:roos. wti:h dmlcleri2l! T)lleS I il1d V, haYe Ill been measiJ1!d il ch:al Sll.des il patients wilh t'q1 TG IIM!Is (> 11 rrrna.t). in.., ~loiJel stutt il patients with ~IAI!ie1ia (T)lle I). I.J'ITOR 110 1o eo mg datyj reiD::ed iltii-C (40-57'!1.), TG (40-56'!1.) il1d IX.-C + VUl.-C IIM!Is (34-58'!1.). in <r1 ~ loiJel stutt in patients IWti hilmoz)gClJS famial tlyj:erddlo-lestellllceenmiaia ffli.J'ITOR (10 r:>eo mg datyj reiD::ed mean Ul.-C IIM!Is (22'!1.). in a pilot stutt. I.J'ITOR eo ~day stooled a mean Ul.-C kM<eri"g ci 30-. fa patients ra oo pm1q:leesis il1d ci 31 '!1. fa patients wto all1tirued pm 1qlleiesis. Amean Ul.-C kM<eri"g ci 35'!1. was liJseried il racepb delecliYe patients il1d ci 19'!1. in racepb ~ patients (see P!WlMACQDGY,

Clinical Sluies). f« moe oo elfi:acy restAts 171 ~ dassifi:atm il1d poOed data 171 Frech:l<soo l')1leS. see P!WlMACQDGY, Clinical Slides. Prior il ntiating 1tlera!>f with I.J'ITOR, ~causes stn*l be e>ccWld fa eleYali:Jns il J*!Srna iiJid IIM!Is (e.g. poor1y cootra1ed clabetes meitus, trjp0t1yruiism,lll!lffl0: S)\'Oome, ltjsprlAI!ilemi OOsln.diYe iYer llsease, ;nj akxltd;m), il1d a i!lid prolie performed 1D measue iltll dOestercl. Ul.-C, to. -C, il1d TG. f« palienls with TG <4.52 ,....,..,_ (<400 mgld), Ul.-C C3l be eslinated usiY,j the ftDW1g ~ Ul.-C (rrrna.t) = iJtii-C · ((0.37 X(TG) + tfl.-C))

Ul.-C (mg/11) = iltii-C · ((02 x (TG) + to. -C))' F« pa!ients with TG IIM!Is >4.52 ,....,..,_ (>400 mgld), ltis E!(JJil1iJ1 is stn*l be measiJ1!d cfredly a 171 ~-

ess acosate il1d ux.-e aronram

CONTRAIItDICATIONS tfyperlaJsitMty il iJIIf QliT1lfX81I ci 1tis medcatm. /ldNe iYer llsease a '-"""Pained persistlrt eleYali:Jns ci sen.m lr1rls<ri1ases exceeding 3 lines the LWl' irrit ci rmml(see~.

Pre!Jm:y ;nj laclatDl (see PIEAIJT10NS).

ame

iYlti1crs. I.J'ITOR lherapf mtl be Er1'llJ3tf wlth!ld a tlscooli"t88 in i!llf pa11n wilh .., awe SIJilJs ard1ir1 Sl.gjeSIM! 11 a ~a having a risk facn~ il the dewlqment ci renal falJe seard<ry l:l ~ (9rll as severe awe n.ctin lr,!Qensioo. m:;r su-gery, tama. severe metDtc. EltiJaine .m ~ dmlers. <nl troJirtjed seia.re;j. PRECAIJTIONS

lilllllil The ellects of ~Induced changes in ~ -.including reduction of,...., 1111 cardiovascular morbidity or~ or tDial ~have not'-' established. Befae ilstituling lherapf v.ilti I.J'ITOR (alorvaslatil calcUn), <r1 atenli stn*l be 11a1e 1D W1trl1 elevated sen.m ~ IIM!Is with awqriate del. exercise, ;nj weig1t red.dbl in OYeiWElig1l patients. ;nj 1D teal olher ~ medcal pr<tjems 1see NliCAOONS t>KJ UHCAL Pa1ients stn*l be acMsed 1o inloon SlbseQle1l ~ ci the 1M use ci I.J'ITOR a i!llf olher 11*1-k:M<eri"g ageniS.

usa.

Elllct 1111 the Lens n.mrt klnQ·ierm daia fl'lln ch:allrials oo ra rocate .., - . . effect c1 atavastafil oo the tunan lens. Effect on 1lhiqninQM lCoChol..Lm§ Si!Tificalt decreases in ciaJa1ig ~ IIM!Is i'1 palienls 1reated with abVaslatil il1d olher slatins haYe been lilseried. The c1rt:a1 ~ ci a polenlial klng-ierm stalil-i'd.ald defDency ci ~ has ra been esiaiJiished. Rhas been repated 1t1at a decrease il r11)00I1Ial ~ IIM!Is wAd 1e00 il i'1llaied c<r1iac fln::liln il patents IWti baderi"e argestiYe heat faiUe (see sa£CTID BllUJGIW'HY).

Elllct 1111 IJpopnJ!Ijn !al i'1 SIJI11e patients. the benefi::ial effect ci lowered iltll ~ il1d Ul.-C IIM!Is may be 1911Y bUTted 171 a W1CI1I11i1ilnt i1crease in 4l(ajleYels.l)lli f\l1her experier<:e is - . tt is suggested, where - . 1t1at meast.rements ci sen.m 4l(al be lt*lwed ~ in patients placed 00 therapy (see SEl£CTID BllUJGIW'HY). llypelseusitivjtv

awrenl tr)1lernensiiM! S)I'Oome has been repated IWti olher IMi-CoA re<1dase i1lllliDs wti:h has 1 a moe ci the ftDW1Q fealu:es: ~ <r1gioedema. k!lJs eryihemabJs-i<e S)I'Oome, poljmyalgia rhelJna1ica, vasajtis_ Jlli1XI3. ~ leU<qleria. temlytic anenia, Jl(lSiliw fWA. EllA ilcrease, llllSirqt1ia. <Yttritis. <r1lralgia. ll1bria. aslheria. photosensitMty, fe-M, chls.IUsiWig, malaise, d\'S!J1ea. 1oxi: epiBmal flllCiltiSiS, erythema nUtifoone, ~ SleYens-.l:tnsoo S)\'Oome. Alt1ou!1l il date hypersoositMty S)I'Oome has Ill been descrtJed as su:ll, I.J'ITOR stn*l be disariliuld I hypersoositMty is suspected. Useinl'll!!!!ancy UPITOR is conbaindicalllcl during """""""'(see CONTIWIIIMCATIONS). Atherosdemsis is a ctrnnic iJOO!SS il1d OOcooli'u!tbl ci ~ liugs cUi1g Jl"9'l'IOCY stn*l haYe it1le impoct oo the r0m1e c1 klnQ-II!mllherap( c1 IJiTaY trn:ect_ce1ia. ~ <r1d olher prociJ:Is c1 cl1olestera biosynltoesis are essential ~ fa fetll ~ [n:Uilg s,nlhesis ci ster00s il1d eel rrertranes). sn:e tt.IG-CoA re<1dase i1lllliDs decrease cl1olestera s,nlhesis ;nj possllly the s,nlhesis ci olher bioklgicaly aaiYe sOOslira!s deriYed fl'lln cllolestera, they may caJSe harm il the ferus when a<iTOslered 1D pregM

rmlwtmen.

There <re ro data oo the use ci I.J'ITOR cUi1g Jl"9'l'IOCY. I.J'ITOR stn*l be aaniislered 1D W00'81 ci ctikiJe<ring age crii when su:11 patients ..e ~ 1111<e1y 1o an:e;w il1d haYe been infamed c1 the polenlial ha23ds. r the palient becanes Jl'egml wtile 1ill<ing I.J'ITOR, the cl'l.ll stn*l b e - ;nj the pa1ient awised ci the polenlial risk il the ferus. in raJS. !Tilt roncen~ra~J~n; ci atavastafil <re sirrilaf illtose i'1 plasma. Ris ra l<rl<Mn-ilis cl'l.ll is excreted in tunan mil Beca.oe ci the polenlial fa adw!rne reacliJns in rusiJ;J inflr1ts. W00811ill<ing I.J'ITOR stn*1 ra IJeasl-feed (see CONTRANJICA'OONSj. ~

Trea1ment ~ i'1 a pe<jalrl: pqUa1bl is irited il dases ci I.J'ITOR ~ 1D eo ~day fa 1 'fl!i!l in 8 patients with hi:rnoz)'gous famial trn:ed.....,celia. No c1rt:a1 a tiod1eni:al alnJmailies WEre repated in these patients. ~

Trealment ~ i'1 ~ 70 years a olcB (N=221) wi1ll dases ci I.J'ITOR ~~:~eo~ has demoostrated 1t1at the safety il1d elfectM!ness ci a1Drvastatil i'lltis IJ(Il.latm was sirrilaf r:>ltlat ci palienls <70 years ci age. l'ta II axJ<i oeti: evai.latm ci abVaslatil il Sl.qects CMlf the age ci 65 years illcales <r1 ircreased ALC. As a ~ mea5lXe, the IDv.est OOse stn*l be a<iTOslered iitialy (see PIWlMACQDGY, tuTm P!ana:U<i!elics, sa£CTID BllUJGIW'HY).

Ronal !nsul!!cioncy

Pl!ann!!c!*!net ln!I!Jctions The use ci tt.IG-CoA reru:tase i1lllliDs has been asscciated with severe ~- ~ il1atxbnyotf.;i wti:h

may be moe freQuert when they <re co-a<iTOslered IWti liugs 1t1at Wti the C)'IDctrome P-450 enzyme systsm is rnetb:llzedl71 C)'IDctrome P-450 isoklm 3A4 il1d as Sld1 may i1leracl with agentS lllal Wti 1tis enzyme. !See Wl>i'HtiJS, Muscle e!feds il1d f'RECAIJTXN), Drug inleraciD1s il1d Cylochtrne P-450-medated interadirisj.

llopatic E1llcts in ch:allrials. persistlrt r-aeases in sen.m lr1rls<ri1ases gea~er 11m 1tree lines the LWl' irrit c1 roma1 ocamd in <I% ci patients wto ll!CI!iY!Ili.J'ITOR. v.ten the dosage ci I.J'ITOR was re!i.ald, a when cl'l.lllreatrTell

was ililm.!iBd a disariliuld. sen.m lr<mrninase IIM!Is reb.med 1D JntrealmentleYels. The meases WEre

generaly rrt asscciated with j<uJXe a olher c1rt:a1 sigls a S)'01lOns. Most patieRs all1tirued b'ealmeri with a reiD::ed IDse ci I.J'ITOR wiltnJI ch:aiSEl(Jlelae. LM:r hn:tm l!!s!s siJUd be oerfiJmed belae !he Otiatiln treaVne!Jt perjg!jcaly lt!ereafter. Specia attmtioo stn*l be paid 1D patients wto ~ elevated ""'-"' lr<mrninase · ;nj in these patients measu-ements stn*l be repeated JliOOlllCiy il1d then performed moe ~If lnlnases In alanine •••llb•b11:1asc (All) or aspal1a1le ll""l'*•'"'llbinii"'ISI""a"'iSC"" (AST) sr- evidence of progression, pal1icularly H they rise ID greatlllr than 3 - t h e of normal and are penisllnt, the dosage be noduced or the drug discontinued. I.J'ITOR stn*l be used with cau1ioo in patients wto oonsune Sl.tJslantial ~ ci ~ arxVa haYe a past tisDy ci iYer llsease. /ldNe iYer llsease a '-"""Pained lr<mrninase eleYali:Jns <re w ltlai ICi:atioi IS ll the use ci I.J'ITOR; I su:ll a arOiion stn*l ~ cUi1g 1tlera!Jf, the cl'l.ll stn*l be dscooti1Jed.

._WTetai. ana.em 1972; 1¥1:489-502.

M)qlalhy, deliled as ITlJSde adi1g a ITlJSde weao-ess in wj.R;tDl with roeases in creatile ~ (CPIQ "*-"'s il !1eiller 11m lerllines the LWl' lmit ci lmllill, stn*l be oonsidered in iJIIf palient with liffuse myalgia, ITlJSde teroemess a wealoiess. arxVa ma1<ed eieYation ci CI'K. Pa1ients stn*l be acMsed il feiXJI JliOOlllCiy '-"""Pained ITlJSde pa11, teroemess a wealoiess. pri:Ua1y i accaJ'4Bied 171 malaise a fe-M. I.J'ITOR 1tlera!>f stn*l be disariliuld i nakedy elev.!1ed CPK IIM!Is cx:w a rtl)qlalhy IS lia!Jlosed a suspected. The risk ci 111)qlalhy ;nj ~ cUi1g lreatrTeli\Wti tt.IG-CoA reOdase i1lllliDs is ineased v.ilti ctmmn1 ~ ci C)Qls!oil. fbi:: D deriva1iYes. eryttrlrn)Qt. riaci1 tmnc aoo), altifuY,jals a nelal!xbie. As lhete is ro ~ il date with the use ci I.J'ITOR g;..en arornnlly with these <iugs, v.ilti the e>«:eppD1 cia Jlalla:U<i etic 5llltt IWti eryttrlrn)Qt. the berefils il1d risl<s ci Sld1 tmtinedlherapf stn*l be caell.ty oonsidered (see I'RECAIJlUl3. Drug interal::ftJIS). ~has been rep:mt i'1 VI!S'/ 131! case; IWti lJ'ITOR !see PI£CAIJTlJ6. Drug~ ltiabdorn)Oysis v.ilti renal dysfu1ctiln ~ 1D il1)()QIOOiuia has also been repated with HMG-CM reru:tase

Plasma alf1CaltratOls il1d Ul.-C kM<eri"g effi:acy ci I.J'ITOR was stoMi il be sirrilaf in patients wilh moderate renal ins1Jf1i:iency Wlllafed with patients with lml1ill renal fln::liln. . -. since ........, case; ci rtlatxbn)dysis have been repated i'1 patients v.ilti a tisDy ci renal ins1Jf1i:iency ci llllollwn sewny, as a ~ measue il1d ~ ft.rther experiem! i'1 renalllsease, the 1ov.est 1Dse (1 0 ~da)l ci I.J'ITOR stn*1 be used in these patients. Sirnlaf ll'ecaOJ1s awy i'1 patients v.ilti severe renal i1stlli:iency (<:tea1me c1eararce <30 nilmin (<0.5 iiUsecjJ; 11e ~ov.est dosage stn*l be used il1d ~ ca.ciously (see w~ Muscle Effects; f'RECAIJTXN), Drug inteOODlsj. Refer also 1D DOSAGE AND ADMNSTRATJON.

Endocrine flllction tt.1G-CoA reO.dase i'lti:Js natere v.ilti ctrJiesllltj ~ il1d as su:ll n-qt theae!i::aly tot aienal arxVa !Pladal slerOd IJO(ldin an:al Sll.des wi1ll aDvaslati1 ;nj olher tt.1G-CoA reOdase ii1tiDs haYe &JggeSled 1t1at these agert; da rrt nW:e J*!Srna W1isa w-o::enratm a ir!Jai' aienal reser.e .m da ra nW:e 1r1sa1 J*!Srna

1eStlslerooe an:erirali:n ttlwEMJ, the etr.as ci tt.1G-CoA reOdase ii1tiDs 00 rmle fer1ily haYe .... been Sll.ded i'1 ~ rurlesci palieris. The el!octs,l Cllf, 00 the~ axis i'1 ~W00'81 <re llllollwn. Patienls lreated with abVaslatil wto ~ c1rt:a1 eYiderce ci erOx:rine ~ stn*l be evaklated awqrialely. CaAicn stn*l be exercised i <r1 tt.1G-CM reO.dase irtifu a olher agent used ~~- c11o1estera IIM!Is is a<iTOslered 1D patients receiW1g olher liugs (e.g. ket!X:mllDe, SlitmlacD1e a CireMre) 1t1at may decrease the IIM!Is ci erdJgero.6 SlerOO tmnooes. Drug

ln!I!Jctions

Concomilant -rt.apy 00. Upid Metabolism Regulalors: Carbined cl'l.ll1tlera!Jt stn*l be awoacl1ed with cau1ioo as i1amatiJ1 fl'lln cootra1ed Sll.des is lmited.

Ble Acid Sequeshnts: !'a!jerlt. with mild p rnode!;Ue tMlertt!!ies!er· UX.-{; r9IU:tm was geater wten L.PITffi 10 mg and ~ 20 g were ummi i>11:u:d (-45~ 1Im wten eilher ttug was iD1n:Stered iDle (·35"' fa L.PITffi and -~ fa ~· Patim!s Will! S!Mi!e !Mod dt:seOOiia. UX.-{; red.dm was srnb' (-~ wten L.PITffi 40 mg and ~ 20 g were aairOslll1ld wten UJ11BOO o IIBl with L.PITffi 00 mg iDle. Plasma uro:r1r31illl cl alnlaSI3Ii1 was biB (awoGnately 26"4) when L.PITffi 40 mg lll6 ~ 20 g were aatmislmld UJ11BOO with L.PITffi 40 mg iDle. ~. 1toe cmDnali<r1 ttug 1hera!l¥ was less e!feciM: 11 blel1g 1toe ~ 1Im L.PITffi ~ i1 boll11)1leS cl hypelctd:sa:IOOnic patients (see f'IW'MACa_()GY, Clinl:al Sb.desj. Yr1lEn L.PITffi is used un:mer1ly wi1h ~ a fDt o111er re511, ill in1l:rval c1 at least 2 hOIIs strud be mal11alned ~ 1toe two <tugs. si1ce 1toe absorptioo cl L.PITffi may be ~ by 1toe resin. Abrtc Acid Derivatives (Gernfibrozil, - . Bezalllnle) and Niacin (Nicotinic Acid): A111iotql1here is no e><perience with 1toe use cl L.PITffi ~ un:urenlly Will! fbic acid deriYaliYes and rD:i1, 1toe and tislcs cl su:h Ullibi1ed 1hera!l¥ be .,...,..,. UllSidered. fu: risk cllll)qlQ!hy cimg 1reallnelt with OOJgs i1 1f1S class IS i1ueased with Ollll:liTlrt admilislrali:ll (see WAfNIC3, t.lJSde Elfectsj. Coumari1 ~ L.PITffi had no ch:ally Slf}'ifian effect til JllliiYOrrbi1 ire wten iD1n:Stered o palier1IS rrmWrJ draW: w<rtm 1hera!l¥ (see SR.ECTHl BILOOIW'HV). Digoxin: OaJ•iioa!alb• cl ~ 00s1:s c1 L.PITffi and dgaiCI1 i1ueased stealtf·stale plasma dgaiCI1 ura:nlrali:l1s by wOICinately ~ Pa1ienls 1aki'g dgaiCilstnil be rromed OOsely and ~Oral Coo rlraceptives: Coaani1is1rali: cl L.PITffi with ill oral Ull'ilraCepCM:, UJ1Iai1ir;j 1mg rm:!t1irOll1e and 3S!Jg eUw¥ esuadO. i1ueased plasma UJI:8T.IIi:l1s lAI-C levelsl cl rm:twmre and ell*¥ esuDll by awtJOfTidlel'f :m. and ~ respoctively. These i1ueases be UJISidered wten selecliYJ ill oral ~ Antacids: AOrrislrali:l1 cl almiun and fTia!11l!SiJ'n based artacils, su:h as MaaklX" TC SuspensiJl. with L.PITffi decreased plasma UJ1Cet11raiJtl1 cl L.PITffi by wOICinately 35'!1.. UX.-{; reW:Ii:l1 was not ~ but 1toe 1iVJaride-bleilg effect cl L.PITffi may be atfeded. ~ lid'nrislla10l cl cimelifre with L.PITffi dd not alter plasma UlllUI'IJatms a UX.-{; blei1g efficacy cl L.PITOO. · 1toe ~effect c1 L.PITffi was- from 34'!1. o 26"4. Cylochrome P~ 1nllndlans: Aknaslalin IS l1'lelaOCtz!:d by 1toe cyb:tmne P-450 isoerojrre, C'IP 3M. f1)1lmn!<il. a C'IP 3M n-. taeased alnlaSI3Ii1 plasma ieiEis by 40'!1.. O>Oih>1ia1bi c1 C'IP 3M I'IUrs, su:h as~ ;ice, rnacralde ~ li"cUi'9 er,1lmT1I<i1 and~. ~ ~. d2!lle ntlrgal agens ~e. iraurlame, 1<1:bmalDie), a lle ~ nela2IXin: may haw: 1toe idflldlll i1uease plasma cm:erValitl1s cl tM>.Q)A lliiJclase n-.. id.d"g L.PITffi (see SR.ECTHl llllJlGW'HV). CamlstrudlttiS be ell8'tis8:1 wi1h UJmT1I1irt use clltoese agens (see WAfNIC3. Pta 11iilCd<inetic r.eradlms. t.lJSde Elfa:ls; ~ Renal m.trK:ieR:y and &Oluile Fl.n::titl1; IXm ANJ

AIM'tSTRATDI; SR.ECTHlllllllGW'HV). i1 a S1iJtt with hea1hy ~ u:el1i ioalalb 1cl maxm.m 005es cl boll1 afD:v.lsla1il (!lO mg) and 1l:rll:ralne (120 mg), a C'IP 3M Sltlstrate, was slnMl o IJll(lce a modest n:rease i111:rll:ralneALC. 1te Ole i1lllMII remar19d lll:la-ged. ~. si1ce ill i11eracli:l1 ~ 1toese two OOJgs (311)( be eDJied i1 patients with IJ9isposr1g lacbs fa ~ (e.g. ~ IJ'(b1gal OT il11i!rVa. sew:re cortn1Y n:ry lisease, ~. cabJlstrud be ell8'tis8:1 wten 1toese agens a-e u:el1ii>11:ioo (see Y/AfNIC3, l'taiiiaCcldlletic I1I!Jaclitl1s; IXm AI() AIJMNSTRAOON). Antipyrine: Arqr,m! was used as a non-specitic model fa OOigs rne!diXjzed by 1toe "*>twnaa hepaic ll12j!ne sysen ~ P-450 syslemj. LPITffi had no effect tlllhe ~ cl nv,me, 1ttiS ~with o111er OOigs rne!diXjzed "" 1toe same cyllCimne isozymes a-e not e.peaed El ytho omydoc i1 heal1hy llM1Jals, plasma un:erlrali:l1s c l - i1ueased apmcinately 40'!1. wi1h u:eliMGalDi cl L.PITffiand ll)'ll1tln)a1, a lcnown- cl C'IP 3M (seeWAIH«lS, t.lJSde Elfectsj. Oilier Conc:omitanl Tlierapy: i1 cH::al Slides. L.PITffi was used urmritr1t1y with ~ agens and eslrogen replau:menl1hera!J¥ witllllJ! eWlence 0 date cl diicaly sigrificillt acM:r.;e i'teradioriS. i1teraction slides with specitic agen1s haw: not beerl cxnir:tsd. Palents with 5mrJ Hme!ct tl!te' ttug ciG!ges (!lO ll'9'daY) reopecJ fa srne pa:mts with sew:re ~ [rd.d"g faft-.al hypeld'*-tEiiliil) a-e associated i1ueased plasma ieiEis cl abVaSia111. Caution should be aen:ised il sucli patients who an: also severely ...ally impalrod, -*1y, or an: c:aiCOIIIitanlly being adriiisWed digolin or CYP 3M . - s (see w.-s, ~ lntlractions, Muscle Ellects; PRECAIJT10NS, Drug lntlnctions; DOSAGE AND ADMIIISTRATION). ll!va/I,M!orJlD Test k!t!!!lctions L.PITffi may eleva~!: sen.m ~and aealine ~ ieiEis (from -llliSdej.i11toe liffererllal llag10Sis cl chesl par1 i1 a paliert tlllhera!l¥ with L.PITOO. C3dac and rm:adiac fracions clltoese ll12jlllBS strud be lleli:mWled. AINf1ISE REACTIONS L.PITffi is generally wel·lllelated. Adw:lse rea:tions haw: i.ISI.idly beerl mi!d and 1rafiSiln. i1 Ull1lroled cH::al slides ~ and adiwHxln1rtied COII'!lQ1IIiW: slides with olllerlijid-IJwerilg a;jelllsj iMliW1g 2502 pa1ienls, <2'A. c1 patients were disarDlJed rue ll aa.er.;e expeliences allriJulable m L.PITOR. Of 1toese 2502 patien1s. 1n1 were 1realed fa at least 6 rralhs and 1253 fa 1 )edl' a more. Adw:lse expeliences CXQJll'g at ill R:idero: <!1 '!1. i1 patienCs ~ i1 plau:ixHxJl1rol cH::al slides cl L.PITOO and repa1ed m be possilif, ~a delrii:ly liug related a-e slnMl i1 Tai:Ae 1 below: TABlf 1. ~ -.e Repar!!!d In <!1% of Patlonls In Placebo Controlled C1in1c:a1 Trials Plaa:llo "' (n=27Qt L.PITffi " (n= 1122 ) GASTliOIImSTIIA

fu: reumnended OO;e cl L.PITffi is 10 mg <m: a day. fu: ~ cl patients acl1iew and mainlaill<rget ~ ieiEis wrth L.PITffi 10 "9'day. Asi!rifi::art lhEfapeUic respoose is ewlent wiUlil 2 weeks, and 1toe maxm.m respoose is i.ISI.idly a:liiNed IWhl1 2-4 weelcS. fu: respoose is nW1ained ciJi1g ctnnc 1hera!J¥. Doses till be~ a1 fDt lire c1 h: day, wi1h a wilta.C bx1. and strud ~be~ i11toe ~Doses strud be i'1cM1.ial2lld auxrti>J mbaseh UX.-{; andlcr TG ieiEis, 1toe desiOO UX.-{; andlcr TG 1<1ge1 (see 1toe DelecliJ1 and Ma1agerTat c1 Hwod'*-'*"'ia. Yb10nQ Gro-ll til Hwoc:t'*-'*"•ia and om OysiJJilemas (Cill;llal andlcr 1toe US folali:l1al ODesliro Eru:ali:l1 f'm!1am (I«B'D, 1toe gJal cllhera!l¥ and 1he paliert's respoose. ~ cl lb;age, I nea:ssry, strud be rrale a t - cl4 weelcS. a more. 1te reumnended ro;e r.rge fa mosl patients is 10 m40 "9'day. fu: maxm.m ro;e IS 00 "9'day, wticll may be re<J*OO i1 a "*'<riy c1 patients (see sedmllfbol. lipid -should be monilonld periodically and, K necessary, 0 . - of UP1T0R . , . _ - oo targollipid ..........- b y guidelines. The - . g oec1Jaions i1 kJti ~ and ux.-{; haw: beerl OOseowd i1 2 <il5e-resptl1se Slides. and may serw: as a goile m 1rea11ne1t c1 patients wi1h mi!d m moderale hypelcholesll:oTABlf2.~ii-WIIII-Io-ltypad-••ia

!MeM Pera:nt C1!ange from BaseireT L.PITffi Dose (mg/day)

Dmhea Dyspepsia

Nausea fEMlUS S'tSTBI

Headache MISCElUNEOUS Pain Myalgia Aslheria

<1 1

(N-22)

(N- 20)

(N: 21)

(N-23)

·29

·33

·37

· 39

-43

·50

Total-{;: 7.1 miTOt' l.Ol-{;: 4.9omdlt'

(1 90

fT9'd1

-60

'Resul1s .... pJOied from 2 dose-response studies.

'Mean- vakoes. Smre """"""'Ms i1 palleriS wilti """"'djsliJoderrias, n:ldng lllirozygoLIS and heti:roz)9rus ,..,...lojpert:IOeSier and ~IAeiOiia (Type lie. higier ciG!ges W D 00 ~may be re<J*Bd (seeWAfNIC3, PtaiiiaCcldlletic i1tor.lditl1s, t.lJSde Effects; PRECAI.JOONS. ()ug i111:oactiaiS). Conc:omitanl Tberapy See PRECAUTlONS, Drug lnternctions. Dosage in Renallnsulliciency See PRECAUTlONS. PHA/IMACBITICAL IIIFORMATION

0rug$'MJ'q

l'rq)er Nillle: Abvaslatin calcun Olemicaltme:(R~.R")J· 214-~~~J.Itoeo¥-4·(~ 1llil'J'Tcle-1~acid,calciJnsall (2: 1 ) 10t'r,ltale

Eiol>n:a~Fum.ia: ~·JH,O

Molec:tAM Wei!jot 1209.42 Slru:llJalf<rT!Ua:

·Jy"' -A

OHOH

0 ()- Ca-

•3H.O

l "6/ Desco1Jii:l1: AIDovasta1io calciJn is a wti1e moff·- aysta1ne Jl(Mdet 1tat is pradicaly fiSoi.de i1 ~ st*Ain; cl i1i 4 and below. calciJn is Yl!l:'f slgldy !litE i1 distiled water, i1i 7.4 ~ btiler and .......-. ~ !litE i1 e1hanot. and foeely !litE 11 onetlliml. Table! Conl!osi!ion: Each 1aiEI UlillaFiS eilher 10 mg, 20 mg a 40 mg aDvastl1i1 as 1toe actiYe l'qediert. Each 1aiEI am unains 1toe -.g non-modcilal ~ calcun (3bmale, UllSI3Till!looe SO!Itrn, ~ c:eUlse, lac10se oradoy<hte, fTia!11l!SUn Slearate, mio::nx:ryslaln c:eUlse, ~ ~. pct,eltr,1ene ri'f<;<i. talc. 1ilriJn · polysabate 00 and -*"""' emAsin S!abi!itY and SbJpe f!ecanW!aMiatious; Sbe at Ull1lroled roan 1IJil)erdlln 15 m25'C.

.,.._wax,

----

AVAJI.ABIUTY OF DOSAGE FORMS L.PITOO (amasla1i1 calci.m) is available i1 <D;age SlrenQ1hs ell 0 mg, 20 mg and 40 mg a1a'laSiatil per 1alllel 10 mg: v.tlle, elipCica, fin-roaled 1alllel uxiOO "10" til tile side and "I'll 155" tlllhe olller.AIIalali: i1 tulles cl90

20 mg: - . o:lipic3, filroH:oaled 1alllel uxiOO "20" til tile side and "I'll 156" tlllhe o1toet- i1 tulles cl90

« l mg: -

Aatutence

(273 mg/d)'

....,..,.,ia:

· elipCica, fin-roaled 1alllel uxiOO "40' til tile side and "I'll 1,. tlllhe olller. Allalali: i1 tulles cl90

References: 1 Koren MJ, Smith DG, IUDnghake 06, et al. 1te oost of reaching Na1i:l1al Q10iesterol EIU:alion Progoam goals i1 ~ patienls: A~ cl atnoYastalio, sin1Yasla1io, Dvasta1io and~ Phatmacoeconomi 1998;14:59-70. 2. L.PITffi (atoovasta . calcioo1) Proruct ~ . Palke-Qavis Oiv., Wamer·l..ambel1 canada Inc.. Dec. 1998. 3. Dart A, et al. A nutl:enter, lb.tlle·blild, one-)edl' S1lJdy CCllllll<W'I1!f safely and efficacy cl atoovastalio versus simvaslalio i1 patienls with hypen:l1olester Am J Cardiol 1997;80:39-44. 4. Ber10iii S, et al. Efficacy and safety cl aDrvastalio Ctf11la-8d 1o pravastalio i1 patienls with hypelcholestaolemoa Alller!l5a:msis 1997;1:ll:191 ·7 5 Dala til fie. 6. 000 Faool.Qy, Dec. 199!1.

fu: folkJwi1g ~ act.oer.;e eYef1ts were repa1ed i1 dinl:aiVials; not al eYef1ts lisled below haw: beer1 associated with a caJSal ~ 10 L.PITOO lt'oeraW- t.lJSde ~ 111j(lSitis.lll)qlQ!hy, pa-eSihesia, perWal neuopathy, p;n:rea1i1is, tepatitis, ctdeslatic janice, araexia, 'o0l1i1ilg, aiq)ecia. Jlllih1s. rash. iqnence, ~ and ~

Pns!:fiQ1<e!m !!!!!l!!!l!i!l: v.sy rnre "''D1S cl sew:re l11)qlOI1y Wllh a willnl ~ haw: beerlleiDled (see WAIH«JS, t.lJSde Elfa:ls; ~Renal i1sd!iclency and ()ug illera::li:n;). lsclated cases c1 ltrtrrtlocyqJer and allergic rea:tions [rd.d"g Lf1icaia. dlf,jiLneuljc edema and """'i1)1alci IIBl may haw: no caJSal ~ ., aDrvasla1il, haw: am beer1 repnn ~ 005erVa1lcl1s: see I'I£CAlJTnlS. Lalnalory Tests: i1ueases 11 sen.m 1i'lrSrTW1ase ieiEis haw: beer1 notOO i1 cti::alllials (see WARNNiS) SYAI'TlliiCS AND TREA111ENT OF IWEIIOOSAGE There IS no speclic 1rea1n1:rt fa alnlaSI3Ii1 CM:rtislge. 9nal ill lMitDse =.r, 1toe paliert stnil be ttealed ~and st.WJtM: meas.JeS iiSiiUed as llQ.iOO. Due ll ex1IJlSHe liug trdrYJ m plasma JJtEi'iS, herraiatjsis is not expld:d ll si!J'ili:andy 8"hro: cle<r.n:e.

DOSAGE AND ADMINISTRATION Pa!it111s strud be ptl:ed til a stnml ~<lelia! least ..,..wa11:1t m 1toe Ameri:or1 HeanAssodatill

(AI\&.j S1ep 1 <ieij belae rrmWrJ L.PIT(JI, and -

urDu: tll111iS <lei ciJi1g 1reallnelt with L.PIT!JI. u awtl~Jia~e, a IJOPT1 c1 wei!1' ccnra and 111Ys13 e>cerase strud be i'r(Emented.

•

Co-promoted with

@ PARKE-DAVIS A Warner-Lamben 0MSIOn

• TM Warner-Lambert Export

U m ~ed

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Feature

Articles

GENERAL PRACTITIONERS FAMILY PHYSICIANS?

By Eric Wong, Junior Associate Editor

any people, whether they are part of the healthcare profession or not, use the terms "general practitioner" and "family physician" interchangeably. Are these two terms really synonymous? A peek into the development of family medicine as a specialty may give us the answer. Medical specialists did not exist at the time when French immigrants first settled in the New World. The very first medical practitioners in Canada trained in Europe, specifically France. They were either barber surgeons who st udi ed in an apprenticeship or apothecaries who dispensed and prescribed drugs. The quality of care provided by many of these practitioners was questionable. In the late eighteenth-century, when Britain had conquered ew France, the English military surgeons began to dominate the medical profession and the Fr nch practitioners moved to tend to the needs of the poor. As immigrants from Europe continued to flood into the new British colony that would later become Canada, the shortage of medical practitioners became an immense issue. This problem continued to grow even after the openings of medical schools in Toronto, Montreal and Kingston in mid nineteenth-century . Consequently, surgeons and apothecaries, whether formally trained or not, were unable to limit medical care to their respective domains. Barriers between surgeons and apothecaries blurred; surgeons began to prescribe medicine and apothecaries also practiced a medical advisors. These transformed early medical practitioners were the forefathers of general practitioners. However, they were not termed "general practitioners" until much later in the century when medical experts formally trained in surgery, midwifery and drug dispensing began to graduate in England. It was Thomas Wakley, editor of The Lancet, who first used the title "general practitioner" in 1892 to describe these doctors who practiced multidisciplinary medicine in England and North America. General practitioners dominated the medical realm in the nineteenth and early twentieth-century. But various factors caused general practitioners to loose prominence to specialists beginning in 1930s . The explosion of knowledge in technology and science made it increasingly difficult for general practitioners to keep up with medical advances. In 1889, John Hopkins, a specialist-hospital, was founded. Abraham Flexner described the poor quality of medical care in both Canada and the United States, which

ABOUT mE AUI'HOR Eric Wong is the senior associate editor of the University of Western of Ontario Medical Journal. He holds a BSc. degree in Human Biology from the University of Toronto.

fueled reforms that left medical education entirely in the hands of specialists in teaching hospitals. The consequence of these events was a decline in the number of general practitioners in Canada and the United States from the 1930 to the 1950s. onetheless, there was a renaissance of general practitioners between the 1950s and 1960s as s ubpecialties developed . urnerous rea ons bolstered this revival of the general practitioner. The specialist and subspecialist, by nature, needed to concentrate their experience to diseases in their field. Thus, they needed someone who could select these patients for them. As well, medical advances had changed the illness pattern to one dominated by chronic illnesses that required longterm care. Long-term care at hospitals was too expensive and prompted intere t in outpatient community care, where the costs would be lower. A third factor that fueled the resurgence of general practice was the development in other areas of medical care, such as sociolog y and p ychology, which required a gatekeeper to integrate various reso urce s to maximize efficacy and patient benefits. Furthermore, there was the foundation of a number of academic colleges and chairs of famil y medicine in both Canada and the United States. The College of General Practice of Canada was founded in 1954 in hopes of reviving the status of the general practitioner, maintaining high standards of practice and ensuring continuing medical education. And Dr. Ian R. McWhinney became the first academic chair of famil y medicine in Canada, at the University of Western Ontario. Besides reviving general practice, these factors set the stage for the transition of general practice into a new specialty that would address the needs of long-term outpatient care, patient-centered practice, and integration and conservation of resource . Since this new specialty would have intricate tie with patients and their families, "family medicine" was chosen to be it new name. Thus, the College of General Practice of Canada was renamed the College of Family Physicians of Canada in 1967. And hence, general practice was referred to as family practice and general practitioners were referred to as famil y physicians. Most general practitioners supported the name of the new specialty because general practice was associated with old medical practices and a new name was needed to consolidate a new body of clinical knowledge and skills. But others argued th at some general practitioners were already performing the role of a family physician and the change was unnecessary. Indeed, any general practitioner can be an outstanding family physician and there may be little or no difference between the two at all. The distinction between family physicians and general practitioners may be even less meaningful for the patient population. However, the different terminology is a direct reflection of the historical U. W . 0 . Medical Journal 70 (2) 2000

Featur e d evelopment of one of the mo s t important forms of primary care, which de erves orne basic knowledge and understanding. Family medicine is a medical specialty th a t evolved from general practice and is one that is unique in its knowledge, views, and management o f families and their health. REFERE CES 1. Biehn john T. , Ian R. McWhinney. "Family Practice in Canada. " Family Practice: An International Perspective in Developed Countries. orwalk: Appleton-Century-Crofts, 1983. 2. MacDermot, H.E. One Hundred Years of Medicine in Canada, 1867-1967. Toronto: McClelland and Stewart, Ltd., 1967. 3. McWhinney, Ian R. A Textbook of Family Medicine. New York: Oxford University Press, 1997. 4. - -. "Medicine, General Practice." TI1e Canadian Encyclopedia. Edmonton : Hurtig Publishers, 1988. 5. Roland, Charles . "Medicine, History of." The Canadian Encyclopedia . Edmonton: Hurtig Publishers, 1988. 6. Woods, David. Strength in Study: An Informal History of the College of Family Physicians of Canada. Toronto: TI1e College of Family Physicians of Canada, 1979. Q

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U.S.A Immigration Law PARKE DAVIS 5TRrvrNG To MAKE MIRACLES HAPPEN

William Newell Siebert

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Miracles can happen. But behind every miracle is hard work and determination. The determination to make our lives a little better, the hard work necessary to get closer to a cure. It doesn't happen o emight; it often takes years of dedica ted research. But when tha t research culminates in a breakthrough or a new pharmaceutical, miracles become possible. Committed to Izard work, detennination and caring. Tile qualities tlwt cannwke miracles happen.

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U. W.O. Medical Journal 70 (2) 2000 - - - - - - - - - - - - - - - - - - - - - - - -

Fea t u r e

Ar ti c l es

DIFFUSE GASTROINTESTINAL MOTILITY DISORDER IN YOUNG WOMEN By Helen Lewandowski

INTRODU CTIO N isturbed gastrointestinal motility is a phenomenon that is not well understood, and which presents great difficulties in terms of treatment. Some patients with this condition have a motility disorder associated with delayed transit through the colon. Others may, alone or in addition, be afflicted with a failure of the pelvic floor to relax during attempted defecation. ! This includes a group of patients with no predispos ing conditions who have a longstanding history of severe constipation. 1 Specifically, there is a grou p of predominantly female patients with idiop a thic constipation associated with severe abdominal pain that is refractory to all forms of treatment and that seve rely incapacitates those afflicted .2 In women with sev ere idiopathic constipation, physical exam and barium enema may not reveal any abnormalities, although some of these patients have elongated, redundant colons.3 The severity of symptoms and the failure of medical therapy may eventually lead to colectomy in these patients.4 However, these patients may also complain of upper gut symptoms, which often persist after subtotal colectomy.s In recent studies, a variety of upper gut functional disorders h ave been shown, including esophageal, gastric, small bowel and gallbladder dysmotility.s This may indicate that the underlying mechanism in these patients is a generalized ~nteric neuropathic defect. However, these patie nts' illness has often been labelled as merely psychological by the medical community, which poses difficulties for family practitioners and specialists who are involved in treating these patients. Yet, according to recent literature, these patients have a unique set of medical, psychosocial, physiological and neural characteristics. It is important to attain a better understanding of these in order to facilitate the development of an approach to the treatment of this complex problem.

CHARACTERI STICS Certain characteristics appear to be more common in women with disordered gastrointestinal motility. In one study,6 64 women with severe constipation and a normal barium enema were described. Women with constipa tion tended to have more painful and irregular menstrual periods, as well as an increased incidence of ovar ian cystectomy and hysterectomy. The y also had more hesitancy in starting to pass urine, and more somatic symptoms, such as cold hands or blackouts. In a few, the symptoms began suddenly after an abdominal operation or accident. It has also been suggested that hysterectomy has a disturbing effect on bowel function. In a study comparing women who had h ys terectomy v e rs us

cholecystectomy, women reported more deterioration in bowel function following hysterectomy than cholecystectomy.7 No significant differences were found between abdominal, vaginal, supravaginal or radical hysterectomy. In addition, women with irritable bowel syndrome had a higher incidence of bladder dysfunction than controls in urodynarnic studies.s This implies that the disorder of smooth muscle or its innervation found in these patients may not be confined to the gastrointestinal system. As well, women with functional gastrointestinal diagnoses had a higher frequenc y of severe ty pes of physical and sexual abuse than women with structural diagnoses.9 This suggests that psychosocial factors may be involved as well. PHYSIO LOGICAL ABN O RMALITIES Abnormalities in physiological tests of gastrointestinal function have also been found in young women with severe idiopathic constipation. Several studies have examined colorectal function in these patients. Patients with severe idiopathic constipation were found to have more impairment of rectal sensation than controls.! They also had a smaller mean anorectal diameter during defecation, and increased puborectalis activity on attempted defecation. In addition, transit time was significantly delayed in constipated patients.l Severely constipated women were also found to have a greater volume and pressure of rectal distention needed for sensation and sphincter relaxation.2 They also had diminished basal and postrnorphine motility indices in the distal rectum, and an empty rectum when severely constipated. This may indicate the presence of neural abnormalities affecting afferent nerves in the rectum. In another study, patients were labelled as having normal transit constipation or slow transit constipation according to colonic transit time. to Patients with normal transit constipation had lower pressures of intemal anal sphincter compared to controls . Patients with slow transit constipation had higher minimum relaxation volume and defecatory sensory threshold compared to controls.lO It is hypothesized that these abnormalities may be due to the impairment in intrinsic innervation found in constipated patients.lOIn addition, the subset of female patients whose constipation originated following hysterectomy has been studied. These patients had significantly increased rectal volumes and compliance, along with deficits of rectal sensory function. ll Following stimulation with neostigmine, a colorectal motility gradient was paradoxically reversed in patients following hysterectomy, thus constituting a functional obstruction. This may indicate dysfunction of the autonomic innervation of the hindgut in these patients.n Although chronic idiopathic constipation is generally

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Feature regarded as a colonic disorder, abnormal esophageal, ga tric and small inte tina! motility have al o been reported in the e patients.12 Many patients with evere idiopathic constipation complain of upper gastrointestinal symptoms that often per ist following ubtotal colectomy. In one study, severely constipated women had delayed gastric emptying, gastric retention of solids and prolonged small bowel transit relative to controls.13 As well, upper ga trointestinal motor activity in severely constipated patient has been studied by manometric means. Motor abnormalities were detected in 70% of these patients, repre ented by bursts of non-propagated contractions and discrete clustered contraction . After feeding, the se patients also had a significantly shorter antral motor re ponse to the meal relative to controls. In addition, 19% of the patients studied demonstrated inte tina! bursts of non-propagated contractions.s lleal motility has al o been examined in constipated patients by studying terminal ileal motility by prolonged and ambulant manometry.12 Significant differences were found between constipated subjects and control with regard to motor activity, retrograde propagation and duration of postprandial activity.t2 These findings strengthen the belief that this condition represents a panenteric disorder. Therefore, it is po sible that these patient have a diffuse motility disorder which can spread to affect the entire gastrointestinal tract.

HORMONALANDNEURALABNORMALITffiS Abnormalities in circulating gastrointestinal hormones have also been found in patients with evere idiopathic constipation. Constipated patients had higher levels of somatostatin and lower levels of pancreatic glucagon and enteroglucagon than controls. t4 There aie al o differences in neurotransmitters and the neural structure of the gastrointestinal tract in constipated patients. Decreased concentrations of vasoactive inte tina! peptide (VIP) and peptide histidine-methionine were found in the mu cularis externa of descending colon obtained from constipated patients compared with normal concentrations .ts VIP is hypothesized to be a nonaruenergic, noncholinergic inhibitory neurotransmitter that produces descending inhibition ahead of giant migrating contractions in the colon.16 This is essential for the rapid propulsion of a laige bolus. Thus, decreased concentration of VIP may be as ociated with reduced inhibitory innervation of colonic circular smooth mu de in constipated patients. In another tudy, the density of neurons producing VIP and nitric oxide was evaluated by immunocytochemistry in colonic specimens from patients with idiopathic chronic constipation. The density of VIPpo itive neurons at the m y enteric and submucos al plexuses was lower than that of controls. However, the density of nitric-oxide synthase positive neuron was higher than that of controls at both plexu es.16 itric oxide excess may lead to inhibition of giant migrating contractions.16 Thus, it is possible that an excess of nitric oxide also contributes to a per istent inhibition of contractions in constipated patient . Another report examined the neural and muscular features of the colonic wall in patients with evere

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idiopathic constipationP There was a significantly lower ratio of the thickne of circular to longitudinal mu de in the left colon of constipated subjects. There was also a higher proportion of neural tissue in the myenteric plexus, and an increa ed number of nerve fibers in the muscularis propria of the e patientsP Severely constipated patients also have reduced numbers of aigyrophilic neurons on ilver taining of the myenteric plexus.3 Argyrophilic neurons are neurons which tain darkly on ilver staining, which is thought to be econdary to the presence of neurofilaments. In these patients, the number of axons is al o reduced and there may be mild axonal degeneration and debris in some nerve tracts. Therefore, there are change in the neural campo ition of colonic innervation in the e patient , but the physiological significance of this is presently unknown. Small intestinal biop y specimens were al o taken in a subgroup of patients who displayed epigastric pain, nausea and vomiting in addition to evere constipation. Some of these patients also had delayed gastric emptying and abnormal gastroduodenal motor function on manometry. Sirnilai abnormalities on silver staining were een in the small intestinal biopsies as were demonstrated in the colon .3 This also points to an underlying organic basis for this motility disorder, but the precise mechanism thiough which this operates remains to be elucidated.

CONCLUSION Diffu e gastrointestinal motility di orders are a presently ill-defined cluster of abnormalities that is found predominantly in young female patients. They often lead to significant functional impairment, and the symptoms may become sufficiently extreme to require surgical treatment. Although thi condition has often been attributed to psychological causes, it is clear from the e v idence that this is not the only factor involved. It appears that there are neural and hormonal abnormalities in these patient which may interplay with psycho odal factors. It i al o po sible that this condition represents a general dysfunction of smooth muscle, since physiological abnormalities have been found along the entire gastrointe tinal tract and in the urinary system. At this point, the significance of the neural and physiological abnormalities in these patients is unclear, as well as how these translate into the functional impairment seen. Additional studies aie needed to elucidate the etiology and mechanism of this condition. As well, further re earch is needed to investigate treatment options, and whether patients with different symptom clusters would respond differently to treatment. This is an area which is not well understood at the pre ent time, but the di tress caused to patients by this disorder makes it worthy of further investigation. REFERENCES 1. Slwu ler P, Keighley M R B. Changes in Colorectal Function in Severe Idiopathic Chronic Constipation. Gastroenterology 1986; 90:414-20. 2. Waldron D, Bowes KL, Kingma Y], Cote KR. Colonic and Anorectal Motility in Young Women With Severe Idiopathic Constipation . Gastroenterology 1988;95:1388-94.

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3. Krislmamurthy S, Sduiffler MD. Pathology of Ne~~romusatlar Disorders of the Small Intestine and Colon. Gastroenterology 1987;93:610-39. 4. Milner P, Crowe R, Kamm MA, Lennard-fones ]E, Burnstock G. Vasoactive Intestinal Polypeptide Levels in Sigmoid Colon in Idiopathic Constipation and Diverticular Disease. Gasrtoenterology 1990;99:666-75. 5. Bassetti G, Stanghellini V, Chiarioni G, Germani U, De Giorgio R, Vantini I, Morelli A, Corinaldesi R. Upper Gastrointestinal Motor Activity in Patients with Slow- Transit Constipation-Further Evidence for an En teric europathy. Digestive Diseases and Sciences 1996;41(10):1999-2005. 6. Preston OM, Lennard-fones ]E. Sev ere chronic constipation of y oung women:Idiopathic slow transit constipation. Gut 1986;27:41-48. 7. van Dam ]H, Gosse/ink M], Drogendijk AC, Hop WC], Schouten WR . Changes in Bowel Function After Hysterectomy. Diseases of the Colon and Rectum 1997;40:1342-47. 8. Wlwrwell P], Lupton EW, Erduran D, Wilson K. Bladder smooth muscle dysfunction in patients with irritable bowel syndrome. Gut 1986;27:1014-17. 9. Drossman DA, Zhiming L, Leserman ], Toomey TC, Hu Y]B. Health Status by Gastrointestinal Diagnosis and Abuse History. Gastroenterology 1996;110:999-1007. 10. Bassetti G, Chiarioni G, Vantini I, Betti C, Fusaro C, Pelli MA, Morelli A. Anorectal Manometric Abnomwlities and Colonic Propulsive Impairment in Patients with Severe Chronic Idiopathic Constipation. Digestive Diseases and Sciences 1994;39(7):1558-64. 11. Smith AN, Varma ]S, Binnie R, Papachrysostomou M . Disordered colorectal motility in intractable constipation following hysterectomy. British journal of Surgery 1990;77:1361-66.

12. Panagamuwa B, Kumar 0 , Ortiz], Keighley MRB. Motor abnormalities in the terminal ileum of patients with drronic idiopathic constipation. British journal of Surgery 1994;81:1685-88. 13. van der Sijp ]RM, Kamm MA, Nightingale ]MD, Akkermans LMA, Ghatei MA , Bloom SR , jansen ]BM, Lennard-fones JE. Circulating Gastrointestinal Hormone Abnormalities in Patients With Severe Idiopathic Constipation. 111e American Journal of Gastroenterology 1998;93(8):1351 55. 14. van der Sijp JRM, Kamm MA, ightingale ]MD, Britton KE, Granowska M, Mather Sf, Akkermans LMA, Lennard-fones JE. Disturbed Gastric and Small Bowel Transit in Severe Idiopathic Constipation. Digestive Diseases and Sciences 1993; 38(5):837-44. 15. Koch TR, Carney ]A, Go L, Go VLW. Idiopathic Chronic Constipation Is Associated With Decreased Colonic Vasoactive Intestinal Peptide . Gastroenterology 1988;94:300-10. 16. Cortesini C, Cianchi F, Infantino A, Lise M . itric Oxide Synthase and VlP Distribution in Enteric Neroous System in Idiopathic Chronic Constipation . Digestive Diseases and Sciences 1995;40(11):2450-55. 17. Park H], Kamm MA, Abbasi AM, Talbot IC. lmmwwhistochemical Study of the Colonic Muscle and Innervation in Idiopathic Chronic Constipation. Q Diseases of the Colon and Rechan;38(5):509-13 .

YUKON Land of Gold YUKON- Not only do we have scenic mountains, sparkl ing waterways, and twenty hours of dayl ight in summer , we also offer almost any leisure activity you have dreamed of trying. Whitehorse is a city of 22 ,000 set in t he spectacular northern wilderness, wit h a reputat ion for a re laxed lifestyle. A vibrant arts and cu ltural community and exciti ng sporting act ivit ies can f ill your calendar as much as you choose. Affordable accommodations, excellent schoo ls, including French immersion and Cathol ic, and Yukon College are all here. The shops, services and amenit ies you expect to f ind in a small city make this a family fr iendly place. In addit ion , because we are north of 60, t here are special tax deduct ions and no territorial sales tax. Whitehorse General Hospital provides acute care to Yukoners, Alaskans , and cl ients from northern Brit ish Columbia. Our accredited Hospital is new, and with our 270 staff we are committed to providing exceptional care through mu lt idisciplinary patient care teams. Our staff collaborates with f ifty general practitioners, surgeons and specialists to respond to med ical needs. We offer a First Nations Health Program and French Language Services. Our employees enjoy a f itness room on-site and a smoke free working environment. Our compensation and benefits are very attractive with wage rates among the top in Canada. Contact Sherrie Hall in Human Resources and she wil l be pleased to provide add it ional informat ion. Her e-mail is sherrie.hall@gov.yk.ca, phone 867-393-8701 , or fax your resume to 867-393-8880.

Your golden opportunity awaits you under the midnight sun.

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RED EYE: A BRIEF OVERVIEW FOR THE PRIMARY CARE PHYSICIAN By Gurvinder Dhatt

ed eyes are a common presenting symptom in general practice. Accurate diagnosis is essential in order to initiate appropriate treatment or referral while optimizing resources at the same time. There are a number of common causes of red eye that the family physician will encounter. With a thorough history and physical examination, one can differentiate between rela tivel y benign conditions that can be managed conservatively from those that threaten vision and should be promptly referred to an ophthalmologist.

HISTORY The history should elicit the basic features of duration, rapidity of onset, associated pain, whether there is any discharge, photophobia, or loss of visual acuity, and whether the eyes itch.l A past history of eye problems or any recent injury should be sought. It is also important to find out if the patient is a contact lens wearer, or if any other member of the household is affected. EXAMINATIO N The first step in a proper ocular examination is the determination of visual acuity, one eye at a time. In the office setting, the Snellen chart is often used .2 The eyes should then be examined under proper illumination and some form of magnification . There are a number of questions that need to be addressed. The distribution of redness should be classified as focal or generalized. The presence of a discharge and its characteristics (purulent, watery, or mucoid) are important to determine. The cornea should be examined for haziness, ulceration, or other opacities. The use of fluorescein dye is essential for proper evaluation of the cornea. An estimate of a shallow anterior chamber can be made by lateral illumination of the eye. The pupils should be compared for symmetry and reac tion to light. Finally, the eyes may be palpated through closed lids to roughly assess intraocular pressure.3 An eye with acute glaucoma will usually feel hard like a stone. Always palpate the normal eye first to avoid spreading any infection from the involved eye. CONDITIO NS CAUSING FOCAL REDNESS Subconjunctival Hemorrhage This is extremely common and occurs due to spontaneous rupture of a conjunctival or episcleral capillary. Occasionally the patient ma y relate it to

ABOUT THE AUTHOR Gurvinder Dhatt is currently a third year medical student at the University of Western Ontario. He previously received an Honours Bachelor of Science degree from the University of Waterloo.

prolonged coughing or vomiting. The eye is painless and vision is unaffected.4 On examination, the solid redness of hemorrhage is easily distinguishable from the more diffuse "pinkness" of conjunctival inflammation. The only treatment required is reassurance that the hemorrhage will disappear in 2-3 weeks. Episcleritis This is a common, self-limiting, recurrent autoimmune inflammation of the episcleral vessels, which lie between the sclera and the conjunctiva. Rapid onset of redness is associated with a dull ache, and the area may be tender if palpated through a closed eyelid. Vision is unaffected and there may be a watery discharge. On examination, a pink, inflamed area with normal areas on either side can be seen . Normal white sclera can be seen between the episcleral vessels. Treatment is with oral or topical nonsteroidal anti-inflammatory drugs (NSAIDs), and the condition often resolves in 2-3 weeks.s Scleritis This is a rarer, more severe condition than episcleritis, and is more common in females. The redness develops gradually over a few days, and severe ocular pain, with tearing and photophobia is typical.5 Vision may be impaired. In contrast to episcleritis, the underlying sclera is not white but deep pink. Occasionally the sclera may be thinned, revealing the blue colour of the underlying choroid. Early referral to an ophthalmologist is required, and initial treatment is usually with oral SAIDs. Pterygium This degenerative condition of the conjuncti va develops over several years but may be noticed suddenly by the patient and present as a red eye . Often it is asy mptomatic but then becomes irritable. It is more common in patients who have lived in hot, dusty climates. On examination, fleshy scar tissue is observed, usually on the nasal side of the conjunctiva. Unless it extends to the central cornea, vision is not affected.2 Lubricant drops can be prescribed, and the patient referred for surgery if vision is affected.

COND ITIO NS CAUSING GENERALIZED REDNESS Viral Conjunctivitis This is the most common cause of unilateral or bilateral red eye, affecting both adults and children. Adenovirus is the most common organism. Red eyes and watery discharge develop over 1-2 days, often affecting one eye first then the other a few days later.6 History of a recent upper respiratory tract infection should be sought, as should recent exposure to another family member or work colleague with red eyes. Vision is unaffected and photophobia is uncommon. If unilateral, the normal eye

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should be checked first to avoid transmission of pos ible infection from the affected eye. The lids are often swollen and the palpebral conjunctiva is often red and velvety. The bulbar conjunctiva appears pink. A palpable preauricular lymph node is strongly supportive of the diagnosis, but is present in only about 20% of cases .6 Treatment is supportive, as there is no specific antiviral therapy. There are a couple of conditions that may be mistaken for simple viral conjunctivitis, but are more serious and require prompt referral to an ophthalmologist. Red eye associated with a characteristic dermatomal distribution of lesions over the forehead and eyelids is likely due to herpes zoster virus.? Ocular involvement represe nts reactivation of the virus in the distribution of the ophthalmic division of the fifth cranial nerve. A red eye with foreign body sensation, burning, episodic copious tearing, mildly decreased vision, and lower eye lid palpebral conjunctival follicles may be caused by the herpes simplex virus. Slit lamp examination (if available) may show the characteristic dendritic keratitis w ith fluorescein staining.7 Both of these conditions threa ten sight and should be promptly referred. Bacterial Conjunctivitis

Ba ed on history and physical exam, it is difficult to distinguish bacterial from viral conjunctivitis. Red, watery eyes developing over 1-2 days are present in both types. With bacterial infection, the discharge is usually mucopurulant, causing the eyelids to stick toge ther overnight. As with viral causes, vision is unaffected and photophobia is rarely present. Treatment is with antibiotic drops instilled very frequently for the first day or so, reducing to four times daily for the remainder of the week.3

glaucoma requires urgent referral to an ophthalmologist. Immediate medical treatment may include miotic drops, topical beta-blockers, and systemic carbonic anhydrase inhibitors. Although transfer to hospital should not be delayed while obtaining these medications, symptomatic relief will be appreciated and the sooner the intraocular pressure is reduced, the less the threat to vision. Although this paper discusses some of the common causes of red eye presenting to the family physician, it is by no means comprehensive. The management options presented are not intended to guide treatment. It reviews some of the findings that may help to differentiate between the conditions that a GP will treat, from those that threaten sight and require prompt referral to an ophthalmologist. REFERE CES 1. Bertolini J, Pelucio M. Tire red eye. Emergency Medicine Clinics of North America 1995; 13(3):561-79. 2. Berson FG . Basic Oplrtlralmology. New York: American Academy of Ophtlralmology, 1993: 57-74. 3. Gaston H. Managing tire red eye. Practitioner 1989; 233(1479):1566-72. 4. Wrigllt KW. Textbook of Opllthalmology. Baltimore: Williams & Wilkins, 1997: 665-90. 5. Watson PG, Heyrelr SS. Scleritis and episc/eritis. British Journal of Oplltha/mology 1976; 60:163-91 . 6. Morrow GL, Abbott RL. Conjunctivitis. American Family Physician 1998; 57(4):735-46. 7. Weber CM, Eichenbaum JW. Acute red eye. Postgraduate M edicine 1997; 101(5):185-96. Q

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Allergic Conjunctivitis

Most frequently the onset is bilateral a nd simultaneous. Unilateral cases may be associated with the use of a particular OTC (over the counter) eye drop. A history of atopy (often asthma or hay fever) and /or a seasonal pattern of recurrences may be obtained. On examination, mild bilateral conjunctival injection is present with a clear, watery or mucoid discha r ge. Eversion of the upper lid may reveal cobblestone-like papillae. Treatment includes allergen avoidance, cold compresses, vasoconstrictors, antihistamine drops, topical NSAIDs, and mast cell stabilizers such as cromolyn sodium.6 In some patients, oral antihistamines may help to relieve symptoms. Acute Glaucoma

In a patient presenting with severe unilateral ocular pain, with associated headache, nausea, vomiting, and blurred vision, the diagnosis of acute glaucoma should be s uspected. I The patient may also report seeing halos around lights. The patient will usually look distres ed, and the eye will be injected with a cloudy cornea. The pupil is mid-dilated and poorly reactive. The diagnostic feature is that the eye is hard to palpation when compared to the contralateral eye, which can be slightly indented on gentle pressure through the lid. An attack of acute

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THE ROLE OF THE FAMILY PHYSICIAN IN SCREENING FOR LONG-TERM COMPLICATIONS OF DIABETES By Nilesh Chande

rs. K. is a 56 year old woman, diagnosed with non-insulin dependent diabetes mellitus one year ago. She has been through a diabetic education program, and her blood glucose is well-controlled through diet and the use of oral hypoglycemic agents. She is otherwise well and has no symptoms or signs of any longterm complications of diabetes. She is currently seeing her family physician at regular intervals for assessment of glycemic control and for screening for complications. Diabetes mellitus is metabolic disorder associated with a variety of long-term complications, affecting practically every system of the body. In some instances, the patient presents with symptoms of these complications, but often the signs are subtle, and the patient does not recognize them, or ignores their significance. In other instances, screening investigations are required to pick up early changes associated with these complications. Although an endocrinological consult is frequently sought with diabetic patients, it is the family physician's responsibility to screen for other risk factors and signs of the long-term complications of diabetes, so that intervention can be initiated with hopes of delaying or preventing them from occurring. Once adequate control of blood glucose has been achieved in a newly-diagnosed diabetic, appointments at three-month intervals are instituted. At each of these visits, the patient's glucose on home-monitor readings is inspected, and a hemoglobin AlC is ordered. Aggressive management to normalize blood sugar is essential in preventing or delaying progression of complications.! The physician must titrate oral medication and be prepared to switch to insulin preparations when necessary . Discussions about adherence to diet, cessation of smoking and alcohol consumption, achievement of ideal weight, regular exercise, and control of blood pressure and lipid profile are necessary, as these are all significant risk factors for the development of many of the long-term complications of diabetes . Specific questioning and examination may provide further evidence of increased risk for certain complications.2, 3

ABOUT THE AUfBOR Nilesh Chande received his HBSc (Biology) at Queen's University in 1996. He received his MD from UWO in 2000. He is currently a PGY1 internal medicine resident at

uwo.

Cerebrovascular disease: Signs and symptoms of impending stroke can be very subtle, so it is very important for the family physician to identify signs of TIA or amaurosis fugax. On examination, a carotid bruit usually indicates stenosis and increased risk of ischemic stroke. Effective treatment of concurrent hypertension is essential.4 Diabetic retinopathy: All diabetics should be referred for annual ophthalmological examination (for type I diabetics after three to five years following diagnosis, and immediately for type II diabetics), as most family physicians lack the knowledge, experience and equipment to identify the early changes of diabetic retinopathy.s Coronary artery disease: Symptoms of coronary artery disease in diabetics may be similar to those in nondiabetics, although angina in diabetics does not always present as the classic "squeezing retrosternal chest pain". It can be much more subtle, requiring specific questioning about any pains or unusual feelings at all during exertion. Silent ischemia is also possible. If there is evidence that coronary artery disease may be present, referral for further investigation (eg - ECG exercise stress test) is required. Hormone replacement therapy should be considered in post-menopausal women. Lipid screening and appropriate treatment of hyperlipidemia, or retesting at five year intervals if lipids are normal, are required.6 Diabetic nephropathy: An annual 24 hour urine for microalburninuria must be done for all diabetic patients. Significant microalburninuria necessitates the use of an ACE inhibitor to slow deterioration of renal function . Further progression of the disease leads to end-stage renal failure and requirement for dialysis.3 Peripheral vascular disease: Claudication is an important symptom of peripheral vascular disease, and the present or absence of peripheral pulses must be sought on exarnination.2 Peripheral/autonomic neuropathy: Asking about erectile dysfunction, postural dizziness, changes in bowel habits, or paresthesiae will provide information about presence and degree of peripheral or autonomic neuropathy. Glove and stocking sensory neuropathy is common in diabetics and can be observed on physical exam.2. 7 Diabetic foot: The presence on the feet of sores, ulcers, or cuts that get infected or take longer than usual to heal all provide evidence of impending diabetic foot. Peripheral neuropathy, peripheral vascular disease, and poor vision are all important risk factors for diabetic foot. In addition to annual podiatrist referral, every office visit

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must include an examination of both feet, as well as reinforcement of proper foot care. , 9 Psychiatric syndromes: Diabetes mellitus is a risk factor for organic mood disorder and organic anxiety states. In addition, the demoralization of chronic illness may result in adjustment disorders. The primary care physician should monitor the mental status, provid ego support, and be prepared to treat or refer specific mental illnesses.lO Emergency situations: Physician, patient and family should be vigilant of the symptoms of the life-threatening emergencies of diabetic ketoacidosis, nonke totic hyperosmolar syndrome, and hypoglycemic crisis, and an emergency plan must be in place for such eventualities. Sick day rules should also be established.ll Diabetes mellitus is a disease that involves much morbidity and often leads to early mortality. Despite these frightening realities, there are many symptoms of diabetic complications that patients can watch out for, and the family physician plays a key role in screening for signs of and reducing the risk factors for these complications. The advent of diabetic education programs has allowed patients to play a greater role in the management of their disease, but ultimately it is up to the caregiver to provide appropriate intervention when the need arises. Until a cure for diabetes is found, a therapeutic relationship between patient and physician provides the gre a tes t chance at a long, healthy life.

REFERENCES 1. The Diabetes Control and Complications Trial Research Group (DCCT). The effect of in ten ive treatment of diabetes on tl1e development and progression of long-term complications in insulin-dependent diabetes mellitus. Ne-zu England founwl of Medicine 1993; 329(14):977-986. 2. Elliott T. Diabetes: a clinical approach. The Canadian foumal ofCME 1997; 9(10):141-153. 3. Yeung M. Guidelines for treating diabetes mellitus. TI1e Canadian Journal of CME 1998; 10(3):153-164. 4. Wong JH and Findlay JM. How to prevent strokes. The Canadian Journal of CME 1997; 9(1):63-75. 5. Bains R. Managing tl1e ten most common eye problems. The Canadian Joumal ofCME 1998; 15(1):68-79. 6. MacLean f. Personal communication. Deparhnent of Medicine, Win ches ter and District Menwrial Hospita/1998. 7. Herschom S, Peers G . Current concepts in erectile dysfun ction. Th e Canadian foumal ofCME 1998; 10(2): 105-119. 8. McManus R. Where the rubber hits the road: prevention and tlze diabetic foot. TI1e Canadian Journal ofCME 1996; 8(12):99-105. 9. Pawlak JK. Diabetics: does time wound all heels? The Canadian Journal of Diagnosis 1997; 14(10):64-71. 10. Talbott fA, Hales RE, and Yudofsky SC, Eds. Textbook of Psychiatry, 1st ed. The American Psychiatric Press, Inc. 1988:283. 11 . lsselbacher KJ, Braunwald E, Wilson JD, Martin JB, Fauci AS, Kasper DL, Eds. Ha rrison's Principles of lntemal M edicine, 13th ed. McGraw-Hill, Inc 1994:1988-1994. Q

MAKE YOUR PRACTICE PERRECT AT HOTEL-DIEU GRACE HOSPITAL- WINDSOR/ESSEX COUNTY www.hdgh.org Advantages: • Tertiary level programs and services in a large community hospital • $68.3M redevelopment and expansion now halfway complete which includes brand new OR's, Emergency, Diagnostic Imaging, Renal Dialysis and I.C.U. • Southern , pre-eminent underserviced community, surrounded by world class waterfront with a rapid growing vibrant economy • Key programs include: Trauma/Neurosciences Cardiology including Cardiac Catheterization Renal Dialysis Vascular!rhoracic Surgery Mental Health Paediatrics Long Term Care at Villa Maria Contact • To find out more about our community and our team approach based on "centres of excellence" please contact: Dr. John Greenaway, Chief of Staff (519) 973-4430 Fax: (519) 973-0803 Email: jrgreenawy@aol.com

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INTEGRATING HERBAL THERAPY INTO FAMILY PRACTICE By Zahra Alidina and Elaine Guzik erbal therapy i often a nebulous matter. Though physicians have recently become more accepting of herbal upplement , they have not been highly educated on this topic and remain keptical of their benefits. Perhaps this i becau e the anecdotal evidence of herbal efficacy does not measure up to the double-blinded randomized controlled trials of marketed pharmaceuticals. There have been, however, many cientific studies of herbal efficacy. It is true that the e tudies are often not a tringentl y controlled as that of the pharmaceutical industry, but they do provide more than anecdotal evidence of some important effects. Most importantly for phy icians, however, are the major contraindications and drug interactions of certain herbal . It is the popular belief of most patients, and quite a few physicians, that herbal s upplements, being derived from natural botanical sources can do no harm. This is, unfortunately, not the ca e. In fact, 25% of modem pharmaceutical are derived directl y from botanical sources, and are indeed quite potent and potentially dangerous; digoxin, morphine, theophylline and t-tubocurare are some examples. Currently over 15% of Canadians use herbal supplement , and this number is rapidly increasing, both nationally and globally. Germany ha recognized herb a an important therapeutic option and has appointed an ex pert committee, the Commi ssion E, to write herbal monograph detailing their action and effectivene s. In fact, St. John' s Wort i the mo t commonly prescribed antidepre ant by German phy icians. In orth America, however, this increasing trend to w ard the use of herbals ha s not been matched by physican involvement. Current studies e timate that of orth Americans u ing herbal upplements, seventy-two percent did not reveal this u e to their physicians . If ph ys icians are not well informed about herbal upplements, patients can unknowingly take a herbal w hich is toxic, or which ma y have a seriou s contraindication with a preexisting illnes or pharmaceutical therapy. Thi article serve to provide tho e in the health care field with information on commonl y-used herbal remedies, as well a important ad verse effects for the more potent herbs. It i hoped that increa ed awarene will lead to a more thorough evaluation of dietary supplement intake at regular health exams.

Black Cohosh (Cimicifuga racemosa) PROMOTED USES: The German Commis ion E ha approved Black Cohosh for the treatment of premenstrual symptoms, d y menorrhea and menopausal ymptoms. EVIDE CE OF EFFICACY: Black Coho h ha been hown to alleviate men trual

symptoms in everal studie . It should not be a sub tituted for hormone replacement therapy. The efficacy of Black Cohosh in protecting again t osteoporosis and heart di ea e has not yet been confirmed. MECHANISMS: Black Coho h suppresses the secretion of luteinizing hormone and thereby reduces menopausal symptoms.I, 2 Premenstrual ymptom and dysmenorrhea may al o be alleviated by Black Cohosh through the relaxation of uterine tissue.1 RECOMME DED USE: Black Cohosh should be used for a duration of 6 months only. CO TRAINDICATIO S: The inge tion of Black Cohosh is not recommended in pregnancy. Black Cohos h works synergistically with antihypertensive medication . The e patients hould therefore be made aware of hypotension as a possible side effect.3- 4 Echlnacea (Echinacea augustifolia, E. purpurea, E. pallida and

related species) PROMOTED USES: Echinacea has been approved by the German Commi sian E for use in the treatment of colds and flu . In general, echinacea has been used to help boost the immune y tern, acting as an antiviral, an antiinflammatory and a wound healing agent. EVIDE CE OF EFFICACY: In humans an injected extract raised WBC levels for 12-24 hours.s In human a ingle ubcutaneous injection of extract enhanced T cell mediated immune function, although repeated injections actually caused suppression of the same.S RECOMMENDED USE: In general echinacea hould be taken for only two to three months at a time, or on an on-off alternating schedule each 2-3 week . This is in order to avoid the depression of the immune sy tern purported to be caused by overstimulation. EFFECTNE FORMS: All of the available form of echinacea : dried root, tea , tinctures, freeze dried plants and powder extracts can be effective. CO TRAINDICATIO S: Echinacea should OT be used in tho e individuals with autoimmune or progre sive infectious disea es such a the connective tissue di ea es (SLE, cleroderma etc.),

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multiple sclerosis, HIV I AIDS and tuberculosi . In addition, echinacea may interfere with immunosuppresive therapy. A rare complication is hypersen itivity in orne individuals with allergies to ragweed, a ters, chrysanthemums and chamomile. Evening Primrose Oil (Oenothera biennis) PROMOTED USES: Evening Primrose Oil is used for premens t rual symptoms, mastalgia and recurrent symptoms of cystic breast disease. In addition, Evening Primros Oil decreases serum cholesterol, triglycerides and pla telet aggregation thus purportedly reducing the ri k of cardiovascular disease. Those diagnosed with rheumatoid arthritis, atopic dermatitis, multiple sclerosis and dia betic neuropathy have also used Evening Primrose Oil with varying degrees of success. EVIDENCE OF EFFICACY: At present there i no conclusive evidence that evening primrose oil helps relieve symptoms of PMS. MECHANISM: ot clear. RECOMMENDED USE: Evening Primrose Oil should be taken at the recommended dose to prevent mild gastrointestinal side effects such as nausea and indigestion. EFFECfiVE FORMS: Commercial products containing oils with 72% cislinoleic acid and 9% gamma-linolenic acid are effective. CONTRAINDICATIO S: Caution should be used with phenothiazine drug . Garlic (Allium sativum) PROMOTED USES: Garlic is used to decrease cholesterol and triglycerides, inhibit platelet aggregation and lower blood pressure. EVIDENCE OF EFFICACY: In several double-blinded placebo controlled studies, garlic has been shown to reduce total cholesterol an average of 6-9 % (LDL decreased by up to 11 % and triglycerides decreased up to 17%). Many cases showed also showed an increase in HDL cholesteroJ.6, 7, Garlic has been shown to inhibit platelet aggregation and interfere with thromboxane synthesis.9 Garlic has been shown to decrease systolic blood pressure by as much as 20-30mmHg, and to decrease diastolic blood pressure by as much as 10-15mmHg.lO MECHANISM: The entire mechanism of action of garlic is not clear but it is known that garlic interferes with thromboxane synthesis and with some calcium dependent proc es (such as platelet aggregation and vascular muscle ton ).9 ADVERSE EFFECfS: There are not many adverse effects of garlic use. Mainly people complain of the offensive odor of garlic which is found in most (but not all) of the commercial

products. Other rare effects are: burning of the mouth and stomach, nausea, sweating and lightheadedness. There has been one report of spontaneous spinal epidural hematoma associated with excessive garlic ingestion. DR G INTERACfiO S: Since garlic interferes with platelet aggregation, there is a potential interaction with anticoagulant . Therefore, it is important to monitor the patient who uses anticoagulants and garlic therapy concurrently. RECOMMENDED DAILY DOSE: • 1 clove of garlic or • 4g fresh garlic or • 8mg of alliine (note: enteric coated garlic tablets are best since the precursor component alliine and the active component allicin are unstable in acidic environments) Ginkgo (G inkgo biloba) PROMOTED USES: Ginkgo has been used to improve memory and sharpen concentration. In addition, ginkgo has been useful adjunctively in treating impotence. Patients suffering from impotence use ginkgo to reduce the required dose of penile injections and vasodilators. EVIDENCE OF EFFICACY: Cognitive Benefits (1) Many European studies have supported the use of ginkgo to treat conditions related to decreased cerebral blood flow. On average, IV administration of ginkgo leaf extract raised cerebral blood flow by 70% in patients aged 50-70 years old. The cerebral blood flow of you nger patients (30-50 years old) was raised 20% above baseline.ll (2) The Journal of the American Medical Association reported results of the first con trolled study of gingko in the U.S. Results showed improvement in, or at least stabilization of cognitive function and social behavior in Alzheimer patients. This was equivalent to an estimated six mon th delay in the progression of Alzheimer disease.t2 Other Circulatory Benefits (1) Ginkgo leaf extract, when given to diabetic patients, raised peripheral blood flow by 40-45%.13 (2) Patients with claudication of the lower limbs who were given ginkgo leaf extract showed a statistically significant increase in pain-free walking distance and circulatory measurements.14 (3) In patients with hearing problems due to poor circulation in the ear, 40% are able to hear better after 2-6 months of treatment with ginkgo.ll Sexual Function Benefits: (1) A trial is in progress to test the effectiveness of ginkgo in improving sexual dysfunction caused by antidepressants. At present, 84% have shown a positive response to ginkgo treatment. IS MECHANISM OF ACTION: (1) Protection of Vessel Walls: Flavenoids (ginkgo-flavo glycosides) reduce U. W . 0 . Medical Journal 70 (2) 2000

Feature capillary fragility and act as antioxidants.n (2) Reduction of Blood Clotting:

Terpenoids (ginkgoglides) inhibit platelet activating factor.n ADVERSE EFFECTS: Ginkgo may cau e mild GI di turbances, headache, dizzine s and/ or vertigo. In addition, its anticoagulant propertie may potentiate the effects of anticoagulant and antithrombotic drugs. Thus, it is important to warn patients on aspirin, warfarin, SAIDs, etc. to watch for retinal and other types of bleeding. It is important to note that it is the leaf of the ginkgo plant which is used for standardized ginkgo preparations. Inge tion of ginkgo eed and fruit pulp, however, i toxic. DOSE: For cerebral blood flow insufficiency, the recommended dosage is 120-160 mg / day. Alzheimer treatment requires 240 mg / day in divided doses. The treatment of sexual dy function requires an initial dose of 60 mg b.i.d. titrated up to 240 mg b.i.d. Ginseng (Panax Ginseng) PROMOTED USES: Gin eng is u ed to alleviate fatigue and enhance performance. It is also used to prevent tress-related illne es. EVIDENCE OF EFFICACY: o long term well controlled studies are available. MECHANISM: at known. EFFECTIVE FORMS: The efficacy of commercial products is dependent on both the plant species and the manufacturing process used. CO TRAININDICATIO S: Patients with hypertension or e trogen dependent malignancies should avoid ginseng. Patients who are prescribed warfarin should also abstain from ginseng. It may affect platelet adhesiveness and blood coagulation. Diabetics should exercise caution when using ginseng since it has the potential to cau e hypoglycemia. Finally, patient on MAOis should avoid ginseng. St. John's Wort (Hypericum perforatum) PROMOTED USES: St. John' Wort has been approved by the German Commis ion E for treatment of depression. EVIDE CE OF EFFICACY: A meta-analysis of 23 RCTs hawed greater efficacy of St. John's Wort than placebo. St. John's Wort has similar efficacy to tricyclic antidepress ants but a decreased incidence of side effects.s A more recent study also shows St. John's Wort has an antidepre sant effect which may not be a strong as amitriptyline, bupropion and other antidepressant drugs. I6 MECHANISM:

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Animal studies show that the antidepre sant effect could occur through one of the following ways: dopaminergic pathway inhibition of erotonin, NE and GABA intake. I6 RECOMMENDED USE: The recommended use as an antidepressant is 300 mg tid. ADVERSE EFFECTS: This herb has le frequent side effects than other antidepressants. Long term effects are not known, however. St. John ' Wort can cause photosensitivity. Although there i onl y anecdotal evidence, patients should be informed of symptoms related to the serotonin yndrome. This is a a result of this herb having some MAOI and serotonin related activity. This syndrome is characterized by the udden onset of some or all of the following symptom : confusion, agitation, shivering, fever, diaphoresi , diarrhea, nausea, myoclonus, hyperreflexia and tremor. A patient should be warned to contact an MD if any of the e symptoms are present. St. John' s Wort should be avoided in pregnancy since safety has not been fully established. INTERACTIO S: St. John' s Wort may cau e serotonin syndrome when combined with other drug that affect the serotonin level (eg . Theophylline, Ritalin, Dexedrine, B-agonists, antidepressants, amphetamine, cocaine, dopamine agonists ).17 Saw Palmetto (serenoa repens) PROMOTED USES: Saw Palmetto is used for treating urinary symptoms of Benign Prostatic Hypertrophy. EVIDE CE OF EFFICACY: Symptoms of d y suria, frequency , nocturia and decreased residual volume can be significantly decreased with 320 mg of Saw Palmetto daily for 30-90 days. This is upported by numerou tudies conducted throughout Europe and the United States. The size of the prostate remains unchanged however. These lipid soluble extracts are as effective as finasteride but not as efficient as alphaadrenergic blocking drugs.I , 19 MECHANISMS: Saw Palmetto has an anti-androgenic effect . It inhibits 5-alpha-reducta e and prevents dihydroxytestosterone from binding to nuclear receptor sites.2o Saw Palmetto' anti-inflammatory effect is due to the inhibition of the cyclooxygenase and lipoxygenase pathways.2I CONTRAINIDICATIO S: This herb should not be used with finasteride because of possible additive effects. CONCLUSION: It is important that the family physician integrate herbals as a therapeutic option. Regardless of the physician' s views on the efficacy of herbal supplements, patients will continue to use them. Unfortunately these upplements are not always as safe as they seem . In addition, the regulation of herbals upplement in orth

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Medications

Possible Herbal Interactions

Anticoagulants (e.g. Coumadin) Antlplatelet Drugs (e.g. ASA, NSAIDs, ticlodipine, clopidogrel)

• • • • • • • •

Alfalfa Cinchona Bark Clove Oil Gingko Garlic Ginger Ginseng Feverfew

CNS Stimulants Decongestants Methylphenidate Dextroamphetamine Beta-2 agonists caffeine/theophylline

• • • • •

Guarana Kola MaHuang St. John's Wort Yohimbe

Antidepressants Tricyclics MAO inhibitors SSRis

• • • • •

Ginseng MaHuang Passion Flower St. John's wort Yohimbe

CNS Depressants Alcohol Benzodiazepines Opioids Antihistamines

• • • •

Hawthorne Kava Skullcap Valerian

Table 1. Interaction of herbal supplements with common pharmaceuticals.22

Medical Conditions

Possible Herbal Interactions

Diabetes

• • • • • •

Hypertension

• Devil's Claw • Ginseng • Goldenseal • Hawthorne • Licorice • MaHuang • Squill • Yohimbe

Allergies to Asteraceae Composite family (ragweed, daisy, aster, chrysanthemum)

• • • •

Allergies to other Pollens

Possibly:

Garlic Ginger Ginseng Hawthorne MaHuang Nettle

Chamomile Echinacea Feverfew Yarrow

• Goldenrod • St. John's Wort • Slippery Elm Depression

• Valerian • Kava

If the Patient Is PREGNANT or NURSING

Contraindicated: • Aloe (interna~ • Black Cohosh • Dong Quai • Feverfew • Ginseng • Kava • Saw Palmetto Safety in pregnancy not fully established: • Garlic • Ginger • St. John's Wort • Valerian

Americ a is much le tringent than th a t of pharmaceuticals (both pre cription and over the counter). Herbals and pharmaceutical are regulated by the Food and Drug Administration (FDA) in the U.S . and the Health Protection Branch (HPB) of the Ministry of Health in Ottawa. Whereas the safety and effectivene s of pharmaceuticals must be proven in order to be marketed, herbal upplements are safe unless proven unsafe by the FDA and HPB. This allow for many very potent herbals to slip through the crack and be marketed without appropriate public awarene s of their adverse effects. If the famil y physician is educated about herbals, he / she can play an essential role in informing patients about the benefit and adverse effect of herbal use. REFERE CES 1. Tyler VE. Tire bright side of black cohosh. Preuention Magazine, Apri/1997. 2. Duker EM, eta/. Effects of extracts from Cimicifuga racemosa on gonadotropin release in menopausal women and ovariectomized rats. Planta Med 57:420-4, 1991 . 3. Einer-]ensen N, et a/. Cimicifuga and Melbrosia lack oestrogenic effects in mice and rat . Maturitas 25:149-53, 1996. 4. BotarJical Safety Handbook. Boca Raton, FL: CRC Press, 1997. 5. Cadario, B. Replace misinformation with facts about herbal medicine. Patient Care Canada, 9(1): 64--87, 1998. 6. lAu BH, et a/. Effect of an odor-modified garlic preparation on blood lipids. utr Res. 1987;7:139-49. 7. Jain AK, eta/. Can garlic reduce leuels of serum lipids? A controlled clinical study. Am I Med. 1993;94:632-5. 8. Mader FH. Treatment of hyperlipidemia with garlic-powder tablets. Arzneim Forsch. 1990;40:1111-6. 9. Barrie SA , eta/. Effects of garlic oil on platelet aggregation, serum lipids mrd blood pressure in humans. J Ortlromol. Med. 1987;2:15-21 . 10. Bordia A. Effect of garlic on blood lipids in patients with coronary heart disease. Am J Clin utr. 1981;34:2100-3. 11 . The Lawrence Review of atural Products . St. Louis, Ml : Fa cts and Comparisons. 12. JAMA 1997;278:1363. 13. Bartolo M. Panel DisciiSsion, Minerva Med 1973;79:4192. 14. Bauer U. Six-month do uble-blind randomized clinical trail of ginkgo biloba extract vs. placebo in huo parallel groups of patients suffering from arterial insufficiency. Arzneim Forsh . 1984;34:716 15. Paick J, Lee f. An experimental study of the effect of ginkgo biloba extract on the lntmm1 and rabbit caverosum tissue. J Uro/1996;156:1876-80. 16. Upton R.(ed.) St.John 's wort monograph. American Herbal Pharmacopoeia. 1997. 17. Tyler VE. Herbs ofCIJOice. ew York: Pham~aceutical Products Press, 1994. 18. Mattei FM et a/. Serenoa repens extract in the medical treatment of benign prostatic hypertrophy. Urologia. 1988;55:547-52. 19. Werbac/1 , M R and Murray, MT . Botanical Influences on Illn ess: a sourcebook of clinical research. Tirird Line Press: Tarzana, CA, 1994. 74-77. 20. Sultan C et a/. Inhibition of androgen metabolism and binding by a liposterolic extract of seronoa repens B in Iutman foreskin fibroblasts. I Steroid Biochem. 1984;20:515-519. 21. Leung AY and FosterS. Encyclopedia of common natural ingredients used in food, drugs and cosmetics. 2nd ed., ew York: John Wiley and Sons, 1996. 22. Jell in, J.M . (ed). Therapeutic uses of Herbs . Prescriber's letter. 1998. Q

Table 2. Herbal interaction with common medical conditions.22

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ANTENATAL PSYCHOSOCIAL HEALTH ASSESSMENT: A BROADER EXPLORATION OF WOMEN'S ANTENATAL HEALTH By Nicole Sikorsky and Kerri English JD is a 20-year old single woman in her first trimester of pregnancy. She is presenting to you for her first antenatal visit. You are concerned about her lack of social supports and her feelings towards the pregnancy. She may have low self-esteem and men tions that her partner has a history of alcohol abuse. You wo nder what impact th ese iss ues w ill have on her postpartum outcome and how to intervene. regnancy is a time w hen the physical health of both the mother and fetus should be closely monitored. However, assessment must go beyond the medical and antenatal care that has become routine in Canada. Recentl y, p ychosocial factors have become an increasingly important con ideration and " the prenatal period provides an opportunity to look beyond pregnancy and delivery and to marshall the re ources essential for further healthy development of mother, infant and family" .1 Studies have shown that prenatal parenting education for women may decrease their chance of experiencing negative consequence if psychosocial risk factors are addressed.2 It is not sufficient to consider only biological risk factors as these have been ineffective in preventing low birth weight babie , which is one indicator of a child's future well being.J Psychosocial risk factor have also been associated with poor po tpartum outcome including child abuse, women abuse, relationship problems, postpartum depression and increased illness. Prenatal care needs to involve screening, education and interventions.Attempts at implementing screening and intervention tools for the identification of psychosocial ri k factors antenatally have not been widely accepted. There are several reasons why previous screening tools have not been used. For instance, the Jack of an evidenceba ed approach to identify ocial risk factors associated with poor postpartum outcome decrea e the perceived va lidity of the potential screening tools. As well, the absence of guidelines for approaching some of these se nsitive topics would make it more difficult to incorporate these tools into clinical practice . The physician's goal when applying a creening tool should be to gain an appreciation of the patient's risk profile, not to have a strict numerical cut-off point to identify those at

ABOUT THE AUTHORS Nicole Sikorsky and Kerri English are both secondyear medical students at the Un iversity of W estern Ontario. Nicole Sikorsky completed a BSc in Biological Sdence at the Un iversity of Alberta. Kerri Eng lish has h er BS c (Bioch em istry) and a minor in Wo m en 's Studies from McMaster University.

risk. A user-friendly format including pre-printed forms and hort answer questions would encourage physicians to include psychosocial risk factors when performing an tenatal assessments. These issues were taken into con ideration in the development of a comprehensive psychosocial health as essment tool - the Antenatal Psychosocial Health As essment (ALPHA) Form. THE A N TENATAL P S YCH O SO C I AL HEAL T H ASSESSMENT The ALPHA project was designed by a team of multidisciplinary health care profe sionals to determine which psychosocial risk factors are associated with poor postpartum outcome . The culmination of the project was the de ign of the ALPHA form, a screening tool to globally as ess a woman's prenatal p ychosocial risk factors.4 U e of this form ma y help standardize the collection of information, remind physicians of these issues and assist in communication between the patient and physician. The development of this form has triggered the inclusion of p ychosocial issues as di cussion topics on the upcoming version of the Ontario Antenatal record. Generation of a list of relevant poor postpartum outcomes was accomplished through a survey of family physicians acros s Ontario . The outcomes identified included child abuse, woman abuse, couple dysfunction, postpartum depression and increased physical illness. A questionnaire was sent to members of the University of Toronto Department of Family and Community Medicine's Survey etwork of Attitudes and Practice (S AP).S Physicians were asked to rate the importance of information gathered antenatally and to evaluate whether an antenatal psy chosocial risk factor assessment form woul_d _be _useful. The gender and practice setting of the phys10an influenced the rated importance of the material. Eighty-five percent of re pondents believed that this form would be useful, while fifteen percent felt the form was not needed and cited that they already knew too much abo ut their patients. Additionally, they mentioned it wo uld increase their workload and could violate confidentiality, depending on the distribution of the information. A literature review was performed to assess which antenatal factors had been previously associated with poor postpartum outcomes.6 Evidence for the correlation was rated as being Class A (good evidence), Class B (fair evidence), and Class C (no evidence of association). Fifteen factors were identified and were grouped into four broad categories: family factors , maternal factors , ub tance abuse and family violence.

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The ALPHA form, the product of research done by the ALPHA team, uses the broad categories mentioned. nder each category, the factors are listed w ith the correla ted outcome (e.g . woman abuse, child abuse, postpar tum depre ssion) and also indicate the strength of the association. Suggested questions to ask the patient about each of the factors identified are listed. There is a column to record the physician's level of concern as "low", "some" or "high" regarding the patient's risk for that pecific factor. The physician can provide individualized comment and plans and is also encouraged to indicate his / her o erall level of concern for the woman and her family. Specific sugges tions for interventions are listed in a checklis t format to prompt ideas and encourage follow-up.

THE IMPACT OF PSYCHOSOCIAL FACTORS The implications of s uch p sychosocial factor are broad and cannot possibly be addressed within the scope of this article. However, woman abuse, substance abuse and postpart u m depression are t h ree topic of considerable interest and significance. Woman abuse can be defined as the use of phy ical force and verbal threats to intimidate another person, w ith whom one has an intimate or other clos e famil y relationship.? The abuse may be physical, psychological, financial or sexual. Woman abu se tends to go unrecognized during all parts of a woman's lifecycle. In a 1993 Statistics Canada Survey, twenty-nine percen t of wome n who had been married or in a common-law rela tionship h ad b een assa u lted b y their partners . Pregnancy does not protect a woman from such abuse; t wen ty -one percen t of women abu ed by a partner reported being assaulted while they were pregnant. Sadly, a woman' s antenatal experience with abuse has shown good association wi th abuse continuing through the postpartum period. The health consequences of women abuse b r ing women to emergency departments with both overt and covert signs of abuse. Abused women may present w ith injuries such as broken bones, internal bleeding and head injuries. However, ab u sed women are more likely to present with o ther common physical symptoms such as chronic pelvic pain, headaches and irritable b o wel syndrome than nonabused women.9, 10, n Yet, the signs and symptoms of the abuse may be very subtle. Women may appear withdrawn, depre s sed or anxiou . A physician must be aware of the possibility of abu e in order to recognize it. Evaluating for woman abuse may be accomplished by using a screening tool such a the Women Abuse Screening Tool (WAST).l2 Determining that a woman is currently being abused raises the issue of safety for both the mother and her unborn child. The association between the use of alcohol and illicit drugs and a tendency towards committing or experiencing woman abuse has been recently reported.13 Male partners who abused women h ad increased rates of cocaine and alcohol abuse compared to men who did not commi t violence towards their female partner.I4 ot only i the u se of drugs associa ted with a propensity tow a rds experiencing or committing woman abuse but substance abuse by the mother, d uring the time of pregnancy, has

been recognized as having profound biological effects. Examples of these effects include both fetal alcoho l yndrome and fetal alcohol effect . The CAGE screening tool has proven to be useful in screening for alcohol abuse and could be applied to women during pregnancy. IS Depression during the pregnancy has shown good association with pos t partum depression. Pos tpartum depression is seen in approximately ten percent of women and its presence leads to an increased risk of a mood disorder16 as well as a fifty percent chance of recurrence in future pregnancies.I7 The ramifications of a moth er's depression extend throughout childhood development. Children and adolescents of depressed mothers sh ow developmental delays both emotionally and socially.l A mother's depression, postpartum or other, has a profound p ychosocial impact on the family.

HIGHLIGHTS O F PSYCHOSOCIAL FACTORS AN D POO R POSTPARTUM OUTCOMES Relationship problems, the issue of compliance with prenatal education and a woman's sense of self efficacy are three factors impacting on the po tpartum outcome for the mother and baby. Relationship difficulties that exist between couple antenatally ha ve shown ev idence of association with postpartum depression, relation hip problems and child and woman abuse after the delivery. Cultural issue will also have an impact on communication between the couple and the roles that develop within the family. Anticipation of the changes that may occur once the baby is born is helpful when considering this topic with the mother. on-compliance with prenatal education, including never attending classes or withdrawal, has shown a n association with child abu e . Any reasons, u ch a financia l, language barriers or unwanted pregnancy should be explored to ee if they migh t be modifi e d . Offering alternatives and discu sing a woman' s concerns may be of help. A woman's sense of elf influences her feelings of elfefficacy. Such feelings may be evident in how a mother views her ability to parent. Low elf-esteem has show n good evidence of association with child ab use and fair association with woman abuse. It is useful to engage the woman in imagining what type of mother she will be. As essing if the lack of self-e teem is related only to certain issues (such as parenting) or if it i global is an important distinction and will help evaluate this risk factor. IMPLEMENTATION The advent of the ALPHA form has facilita ted the assessment of psychosocial risk factors for a woman who has come to discuss her pregnancy. It suggests s pecific questions to assist the physician when inquiring about sensitive issues . However, it also serves to promote thoughts or consideration of a follow- up plan. The tool has yet to be proven as valid and reliable, which may only occ u r with i ts increased use. Incl u sion of these psychosocial discussion topics on the forthcoming Ontario Antenatal Record is a testament to its strong development. Currently, the Ontario An tenatal Record focuses on obtaining essential medical and obstetrical histories and

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Feature functions to chart the progress of the pregnancy. The absence of a consideration of pertinent psychosocial issues is one of the factors prompting the revision of the form . When it is released to Ontario physicians, the modified Antenatal record will include six questions based on the ALPHA form criteria to assess psychosocial health.19 This is an important development for the broader exploration of the antenatal woman's health. FUTURE DEVELOPMENTS Extending screening, education and implementation of risk assessments for psychosocial factors to women in the pre-conception stage is the next step towards reducing poor postpartum outcomes . Often, exposure of the fetus to harmful agents during a crucial time, the first trimester, occu rs before a w oman knows she is pregnant. Also, counselling a woman about contraception if she h as many psychosocial risk factors is an option to reduce poor outcomes postnatally. Utilization of the ALPHA form will work toward s reducing psychosocial risk factors in the antenatal period. It has set the stage for future development of similar tools to be used before a woman conceives. THE CASE

During your first and subsequent visits with JD, you refer to the ALPHA form to identify the psychosocial risks she has that are associated with poor postpartum outcomes. Your assessment reveals that JD and her baby are at risk for such outcomes as child abuse, maternal abuse, postpartum dep ression and couple dysfunction. Your concern is high. For follow-up you recommend additional office visits in both the pre- and postnatal periods so these issues can be monitored and any clu:mges recorded. You also arrange for home visits during the pregnancy and afterwards. Supportive counselling both individually and in a group setting are mentioned which JD feels may be useful. You determine that one reason why she has not attended prenatal and parenting classes is a lack of financial resources and you are able to inform her of places to attend such classes without cost. JD agrees to the suggested recommendlltions and reports three weeks later at your office that she feels more positive about the pregnancy. ACKNO~EDGEMENTS

The a uthors would like to thank Dr. Barbara Lent, Department of Family Medicine, for sharing her extensive knowledge on this topic with us and for reviewing the manuscript. REFERE CES 1. Rosen MG. Cnringfor Our Future: the Cnntent of Prenatal Care: a Report of the Public Health Service Expert Panel on the Content of Prenatal Care. Public Health Seruice. Department of Health and Human Seruices , Washington1989. 2. Mid mer D, Wilson L, Cummings S. A Randomized Controlled Trial of the Influence of Prenatal Parenting Education on Postpartum Anxiety and Marital Adjustment. Family Medicine 1995; 27(3): 200-205. 3. Culpepper L, jack B. Psychosocial Issues in Pregnancy. Primary Cnre 1993; 20(3): 599-619. 4. Midmer D, Biringer A, Carroll jC, Reid Aj, Wilson L, Stewart D, et a/. A Reference Guide for Prouiders: Th e ALPHA -Antenatal Psychosocial Health Assessment Form. Toronto: Department of Family and Community Medicine, University of Toronto; 1995. 5. Carroll jC, Reid Aj, Biringer A , Wilson L, Midmer D. Psychosocial Risk Factors during Pregnancy. Canadian Family Physician 1994; 40:1281-1289. 6. Wilson L, Reid A/, Mid mer D, Biringer A, Carroll JC, Stewart D. Antenatal

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Psychosocial Risk Factors Associated witlz Aduerse Postpartum Family Outcomes. CMA] 1996; 154(6): 785-799. 7. Ontario Medical Association Committee on Wife Assault, A Medical Perspective on Wife Assault, Supplement to Canadian Medical Association Joumal, January 1991 . 8. Statistics Canada. The Daily. Catalogue 11-001E. Nouember 18, 1993. 9. Domino], Haber]. Prior Physical and Sexual Abuse in Women with Chronic Headache: Clinical Correlates. Headadre 1987; 27: 310-314. 10. Drossman D, Lesserman J, Nachman G, et a/. Sexual and Physical Abrtse in Women with Functional or Organic Gastrointestinal Disorders. Annals of Internal Medicine 1990; 113:828-833. 11 . Harrop-Griffiths j, Katorr W, Walker E, et a/. Tire Association between Chronic Peluic Pain, Psychiatric Diagnosis, and Childhood Sexual Abuse. Obstetrics and Gynecology 1988; 71 : 579-595. 12. Brown ]8, Lent 8, Brett PJ, Sas G, Pederson LL. Development of the Woman Abuse Screening Tool for use in Family Practice. Family Medicine 1996; 28(6): 422-428. 13. Grisso fA , Schwarz DF, Hirschinger N, Sammel M , et a/. Violent Injuries among Women in an Urban Area. The New England journal of Medicine 1999; 341(25): 1899-1905. 14. Kyriacou DN, Anglin D, Taliaferro E, StoneS, eta/. Risk Factors for Injury to Womeu from Domestic Violence. The New England journal of Medicine 1999; 341(25): 1892-1898. 15. Lawner K, Doot M, Gausas ], Doot ]. Implementation of CAGE Alcohol Screening in Primary Care Practice. Family Medicine 1997; 29(5): 332-335. 16. Philipps LH, O'Hara MW. Prospective Study of Postpartum Depression: 4 ?-year follaw-up of Women and Children. ]oumal of Abnormal Psydrology 1991; 100(2): 151-155. 17. Wisner KL, Wheeler 58 . Preuention of Recurrent Postpartum Major Depression. Hospital and Community Psychiatry 1994; 45(12): 1191-1196. 17. Fleming AS, Flett GL, Ruble DN, Shaul DL. Postpartum Adjustment in First-Time Mothers: Relations Between Mood, Matemal Attitudes, and Mother-Infant Interactions. Deuelopmental Psydzology 1988; 24(1): 71-81 . 19. Ontario Antenatal Record (99108). Ministry of Health and Long-Term Care in conj unction with tlze Ontario Medical Association. Personal communication witlr Dr. Barbara Lent. Q

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THE IMPORTANCE OF THE G P PSYCHOTHERAPIST IN COMMUNITY MEDICINE By Paul Winston

he primary care physician repre ents the gateway to the health care system. In Ontario more patients pre ent to their family practitioner for their mental health needs than to specialty mental health provider .1 For the physician it is often difficult to separate the physical ailment from its psycho ocial and emotional impact. In a comprehensive qualitative tudy of family physicians in Ontario, Craven et al. found that mental health problems were a major concern. In one focus group a physician related that "Last week I must have had five people in the two days that I wa working in my office who came in with little minor complaints and then were in major tear and their lives were falling apart." 2 The physicians reported that the management of p ycho ocial and p ychiatric problems accounted for 25%-50% of their time. A review by Gail Golden, a London psychologist, reproduced this from numerous studie .3 Thi pre ents a considerable burden for the busy physician, as they mu t cope with providing time for their patients' needs. Craven et al, found that some volume-overloaded physicians may stop themselves from investigating a perceived psychosocial problem out of fear of " taking the lid off of it." Even if they are willing to diligently follow-up on psychosocial issues, the physician may not posses the tools to perceive the problem or make a diagnosis. In their tudy of depression in primary care, Klinkman and others4 cite everal studie which have documented that it has been estimated that up 50-70 % of patients w ith depression are missed by their primary care physician and even if diagnosed they are often given "inadequate" treatment modalities.s Many Canadians who are diagnosed with mental health disorders do not receive treatment. Parikh et al reported, in the Canadian Journal of Psychiatry, that many of these people were nonetheless seeing a family physician. In particular, only half of people diagno ed with major depression were being treated for their condition, even though more than 90% per cent of this population aw their family physician for other health matters . This led to the suggestion that the undertreatment could be helped by treatment intervention by the primary care physician. They also recommended the provision of adequate resources for this treatment. Intervention may consist of medication and or

ABOUT THE AUTHOR Paul Winston is a second-year medical student at UWO. He has a BSc in human biology from the University of Toronto, and an interest in psychotherapy.

counseling by the famil y physician or a referral I consultation to a mental health care specialist. Craven found that most family phy icians felt "comfortable" with the medication aspect. Finding the time for counseling or psychotherapy poses con iderably more of a challenge due to time constraints and lack of kill . otwith tanding, it was found that most physicians will schedule a time to discus a problem raised during a visit. Some physicians offer p ychotherapy or counseling essions of one-half or full hour essions up to 3 to 5 times per week. This was corroborated with a mail survey of Ontario family physician that found that 88% of tho e who replied engaged in at lea tone psychotherapy session per week.6 The physician who uncovers a problem is faced with a deci ion of how to treat. There is much evidence for the efficacy of p ychotherapy. A review by Poon showed that the meta-analysi of patients undergoing psychotherapy (usually long term) re ulted in 80% of the treated patients having an improved outcome over those that did not receive therapy. 7 Poon uggests that many physicians "shy awa y" from counseling due to lack of time and training. He describes short term techniques such as BATHE (Background, Affect, Trouble, Handling, Empathy) and his own model of DIG (Dream -ask the miracle question, Initiate-the fir t question, Get-going). However most physicians rely on their listening, empathy and compassionate skills. Current undergraduate medical education, such as the University of Western Ontario's Patient Centred Model, heavily emphasize the importance of communication in as e ing the patient' s underlying needs and concerns. Lesage and others suggest that this new education emphasis has re ulted in family physicians initiating counseling and therapy and not to onl y "medicalize" their patients' conditions. Craven underline that this adhere well to the international recognition that mental health care should receive a greater role at the primary care level as outlined by the World Health Organization.9 The need for p ychotherapy training was directly addressed by faculty at the University of Toronto Medical School. They have begun a therapeutic communications training program for first and second year students. The students engage in four months of therapy with a patient for forty-five minutes per week. In group of four or five they then meet with a member of the faculty of psychiatry for ninety-minutes a week to receive supervision and to discu s the patient's progress. In addition to the valuable training, the student learn to work with colleague . Dr. Solomon Shapiro, a founder of the program, explains that many doctors work in isolation and "can't express their doubts and concerns to their

U. W . 0 . Medical Journal 70 (2) 2000

Featur e peer ."10 Thi type of tudy group, upervi ion, and peer con ultation are a cornerstone of most psychotherapy training program . The tudents in the program are not all de tined to be psychotherapi t . While corre ponding with Dr. Shapiro he explained that "one of the reason the program wa developed was to help future phy icians develop a better understanding of the ubtletie of the doctor-patient relationship . Thi of cour e includes recognizing their own and their patient ' tran ference and counter-transference and other emotional reaction ." Thus, the tudents are empowered with the skill necessary to better communicate and understand their patients. But where does the need for longer term, or focu ed psychotherapy with trained therapi t fit in? The evidence dearly ugge t that it i needed at the primary care level. Mo t physicians will refer their patients for the e ervice . Unfortunately, Ontario' health care coverage doe not apply to p ychotherapy given by most trained clinical p ychologist and social workers. For tho e that cannot afford to pay that leaves family phy ician and psychiatri ts. Today p ychiatry is moving more toward biological models. In an interview with Dr. Michael Cord, past pre ident of the General Practitioner P ychotherapy A ociation (GPPA), he referred to the fact that only 3% of p ychiatric training i pent on p ychotherapy. While many p ychiatri ts do pursue p ychotherapeutic and p ychoanalytic training while in practice they ju t are not enough to fill the need. According to Dr. Cord, as many patients ee GP p ychotherapi t for their therapy a ee p ychiatri t . He also stre e that "the mental health y tern i under great train becau e of the 50% reduction in inpatient psychiatric beds over the next few years. Furthermore, the underfunding of community re ource to look after these chronically ill patient ha created an urgent need for the mental health care that GP / FP' s provide. The GP p ychotherapist is uniquely placed to offer therapeutic intervention. Many GP / FP's have had a longterm relationship with their patients and can detect when there are change in need of this intervention . Their training in therapy aids in diagno ing and assessing the need for p ychosocial intervention within their own patient population. Patients will receive coverage by OHIP and do not need to be subjected to some of the social tigmas attached to eeing a p ychiatrist or p ychologi t out ide of the primary care etting which can cause a barrier to initiation of therapy . The efficacy of psychotherapy within this etting was tested by Dr . Golden. In her study, p ychologi ts offered p ychotherapy in a primary care setting, but at no co t to the patients. She report that few family phy icians are able to refer for free therapy in their own settings. The purpo e of thi retrospective analy i was to te t if p ychotherap y ses ion resulted in decrea ed visits to the family phy ician for health rea ons. She found a 49% reduction in vi it after the mean of 12.5 es ions were completed and a 23% reduction during the cour e of therapy. GP p ychotherapi t also combine their medical knowledge and pharmacological knowledge with their therapy. Dr. Cord ees many patients for the emotional

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repercussions of organic disea e uch as cancer and AIDS. "You can' t take care of a patient' cancer without dealing with the fear," described one focus group physician.2 Eating disorders, sub tance abuse, anxiety, mood di orders, depression, grief and bereavement, exuality and exual dy function, relationship , inability to cope at work or with family , emotional development and p y cho omatic issue may al o be addre ed with p y chotherapy from within the existing patient population. The unique po ition of the GP p ychotherapi t place them in the ame community as other GP's who need to make a referral but may be unfamiliar with p ychiatri ts, ocial worker and p ychologist in their community who offer therapy. Craven found that many of the physician groups expressed a "frustration" and "anger" with regards to the inadequate relationship that they had with p ychiatri t . In fact, no group "felt that they had good acce to p ychiatric consultation, advice and back-up." Dr. Cord offered in ight into the role of the GP p ychotherapi t. In order to earn the designation the ph y ician mu t meet the requirements of the GPPA . Currently thi involves 50 hours per year in either Continuing Medical Education (CME) or Continuing Collegial Interaction (CGI). Thi latter may con ist of tudy group and conference . A minimum of five hour practice of p ychotherapy per week i also recommended. The GPP may al o become a mentor. This involve 100 hour of CME/CGI plu 25 hour of upervision and an experience of per onal therapy. Many GPP's may enroll in a formalized training program, along ide psychiatrists and other mental health care practitioners at the top of their fields, such as psychologists and ocial worker . Such programs are offered by p ychoanalytic institute , and at the Adler and Ge talt Institutes. Training may be in several therapeutic areas such as, cognitive, p y chodynamic, interper onal, psychoanalytic, brief p ychotherapy, child p ychotherapy etc. The GPPA is working to e tabli h a training program through the Toronto Hospital offering training taught jointly by GPP' and p ychiatrists. The Ontario College of Family Physicians is al o hoping to increa e p ychotherapy skills in rural practice where other counseling profe sional may not exist. GPP' have a wide range of practice with many de ignating 40-60% of their practice to therapy. Some GPP' have a dedicated practice of psychoth erapy exdu ively in their pecial interest area. Dr. Cord explains that a a career option the GP / FP p ychotherapist offer an extension of the existing family practice. It differ from p ychiatry in that the focus is not on categories, diagnostic criteria, and biological cau ation. P y chotherapy offer the proces of narration and formulation of a patient' individual bio-psychosocial hi tory. Many GP / FP's undergo p ychotherapy training as a natural outgrowth of their daily relationship with their patient . There clearly i a need for increa ed mental health intervention in the primary care setting. Psychotherapy is a proven method that helps to improve the quality of a patient's life. Parikh et al, suggest that the need for " collaboration between family phy ician and pecialist

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to enh a nce psychiatric treatment in the primary care etting should be a public health priority." Craven and Kates at McMaster are developing a 'Shared Care' model of collaboration between psychiatrists and primary care in Hamilton to address this need. The GP p ychotherapi t is aptly placed to aid in this intervention. They can pr vide therapy to a population that might not normally seek out care, without incurring patient co t, and withi n our current health care sys tem . For the famil y phy ician (particularly now that medical students must pick their specialty by fourth year) GP p ychotherapy training offers an opportunity to expand and develop skills and it allows for a practice to evolve with patients' needs. Dr. Cord asserts that the Canada Health Act guarantees univer ality of access. The GP p ychotherapist can help to ensur that the need for acce to quality mental health care ism t. (This article has been peer reviewed by William Laurie M.S.W. Dip.CBSc. Mr. Laurie trains and supervises family physicians in psychotherapy and has a private practice in psychotherapy and psychoanalysis in Toronto.)

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REFERE CES 1. Parikh, Lin and Lesage, Mental Health Treatment in Ontario: Selected Comparisons Between the Primary Care and Specialty Sectors .Can f. Psychiatry 1997;42,929-934) 2. Craven, Cohen, Campbell, Williams, Kates, Mental Health Practices of Ontario Family Physician : A Study Using Qualitative Methodology. Can f. Psydriatry 1997;42:943-949. 3. Golden, G.A. Impact of Psycotherapy. Can Fam Phy ician, 1997;43:10981102. 4. Klinkman , Schwenk, Coyne. Depression in Primary Care - More like Asthma Than Appendicitis:The Michigan Deprssion Project . Can J Psychiatry. 1997;42:966-973) 5. Hirsdifield, Keller, Panico, Arons,arlow, Davidoff and others. The ational Depressive and Manic-Depression Association consensus statement on the rmdertreatment of depression . JAMA 1997;277:330-40 6. Swanson, Family physician 's approach to psychotherapy and counselling. Perceptions and practices. Can Fam Physician . 1994;40: 53-59. 7. Poorr. Short counseling techniques for busy family doctors. Can Fam Plry icinn 1997;43:705-n3. 8. Lesage, Goering, Lin . Family Physicians and the mental healt/1 ystem . Report from the Mental Health Supplement to tire Ontario Health Survey. Can Fam Physician. 1997;43:251-256 9. World Health Organization. The introduction of a mental health component into primary health care. Geneva. World Health Organization. 1990 10. Ledrky. Medical students taught to listen in the U o T program. CMA/ 1997;157:563-4 Q

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MANAGEMENT OF BREAST CYSTS By Sandy Widder

INTRODUCTIO N reast cysts tend to occur in approximately 10% of Canadian women, and compose one third of all palpable breast lump in female aged 35 - 54.1 The presence of breast lumps can be anxiogenic as many w omen fear the potential of having breast cancer. One can, however, easily differentiate and treat breast cysts via fine needle aspiration (F A). FNA is a quick, accurate and inexpensive technique which can be done as a simple office procedure. Its sensitivity ranges from 90 97%, but depends greatly on the quality and interpretation of the biopsy.2 Use of F A + I - biopsy with clinical and mammographic findings is widely accepted in the surgical literature as the proper evaluation of breas t lumps3; however, there is little published information which guides family physicians in managing breast lumps.

BREAST CYST ASPIRATION All that is needed for the performance of breast cyst a piration (BCA) is a fine needle (21 - 22 gauge) and a syringe (3 - 5 mL). After the area on the breast has been clea ned, a small amount of air is aspirated into the sy ringe. The operator's dominant hand then holds the syringe and directs the needle into the lesion, while the other hand tabilizes the area. ega tive pressure is applied while the needle is rotated with stabbing motions. After release of negative pre ure, the needle is removed. The sample is then ejected onto a slide, thinly smeared u ing another slide and fixed with a spray fixative.4 ot only are the contents of BCA diagnostic, but the sensation produced when the needle penetrates the breast mass can also be very helpful. In fibrocystic tissue, the tissue is firm and resists needle penetration. A lipoma permits easy access while a fibroadenoma tends to be firm, but mobile on the tip of the needle. A cancer is less mobile and a grittiness may be both felt and heard on needle contact. The complications of BCA are few and minor. Usually individuals complain of some pain and bruising at the site of aspiration. Very rarely, a pneumothorax may be cited as a complication. I EVALUATION OF THE BREAST CYST Many anatomical features in a female can be mistaken for a breast lump, eg prominent ribs. In addition, there are some benign conditions which cause breasts to become

ABOUT THE AUTHOR Sandy Widder is a second-year medical student at the University of Western Ontario who previously completed an HBSc in zoology at the University of Calgary.

lumpy, eg fibrocystic breast disease. Therefore, it is impo rtant to fir s t determine whether a breast lump actually exists. The probability that a breast lump is malignant versus benign depends on other factor uch as: increasi ng age, a personal or family history of breast cancer, a history of atypical breast hyperplasia, lobular or ductal carcinoma in si tu. 5 If a breast lump has been identified, a family physician should go onto a breast cyst aspiration (BCA). The aforementioned is contraindicated if the lesion is clearly malignant, eg presence of peau d'orange or palpable firm axillary nodes.t If the lesion is a cyst that completely disappears and the fluid is not bloody, the fluid may be discarded (Ed note: On the other hand, sending such fluid to pathology may serve to reassure the patient). The patient is then reassessed in 6 - 8 weeks to ensure that the cyst has not recurred.6 In large tudies of fluid specimens, only 1% were found to be carcinomass, 6, 7; in most of the malignant samples, the fluid was hemorrhagic, the cyst failed to collapse completely during aspiration or recurred shortly after aspiration. If on aspiration the lesion is solid, contains bloody aspirate, doe not disappear after aspiration or is s uggestive of cancer (micro calcifications on mammography), the family physician should refer to a surgeon. I CONCLUSION Aspiration of brea t cysts is an easy and accurate way of differentiating breast cysts from other types of breast pathology. BCA is cost effective as little equipment is needed, and the technique is very simple to learn . Complications such as a pneumothorax are very rare, and the benefits certainly outweigh any risks as BCA can reduce patient anxiety and avoid unnecessary referrals or investigations. REFERENCES 1. Heise R, Mahoney L, Watson B. Management of palpable breast lumps: Consensus guidelines for family physicians. Can. Fam . Physician 1999; 45:1926- 1932. 2. Kline TS. Fine Needle Aspiration Biopsy of the Breast. Am. Fam. Physician 1995; 52 (7): 2021 - 2025. 3. Butler fA , Vargas HI, Worthen N, Wilson SE. A ccuracy of combined mammographic-Cytologic diagnosis of dominan t breast masses. Arch. Surg. 1990; 125: 893- 896. 4. Lieu D. Fine Needle Aspiration: Technique and Smear Preparation . Am. Fam. Pllysician 1997; 55 (3): 839- 846. 5. Donegan WL. Evaluation of a palpable breast mass. N. Engl. f. M ed. 1992; 327 (13): 937 -942. 6. Hamed H, Coady C, Chaudry MA, FentimanlS. Follow-up of patient with aspirated breast cysts is necessary. Arch. Surg. 1989; 124: 253- 255. 7. Ciatto 5 , Cariaggi P, Bulgaresi P. Th e va lu e of routine cytologic examination of breast cyst fluids. Acta. Cytol. 1987; 31:301 -304. Q

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DEALING WITH WOMAN ABUSE FAMILY PRACTICE

By Danielle Martin and Sameena Uddin

INTRODUCTIO N he relationship between a primary caregiver and a patient, w_h en ba~ed on trust, confidentiality and long-term mteraction, puts the family physician in a unique position to address issues of woman abuse with her or his patientsl . The physician's role in dealing with domestic violence has been described as a process in Identification, Documentation of injuries, Education of patients, coordination of care and enabling of Acce s to resources, cooperation in the Legal process, and provision of Support (IDEALS)2. In fact, family physicians have a professional duty and a social responsibility to reduce the risk of violence where possible and advocate for the safety of their patients and of women in general3. Domestic violence is more common than hypertension and at least as common as breast cancer4; 1 in 8 Canadian women who live with a partner are beaten at some point in their livess. It is a major determinant of women's health that goes largely undetected and unaddressed in the health care system. It has been estimated that 10-39% of women seeking routine primary care report a history of domestic violence; approximately one-third of those women fear for their ongoing safety. Yet only between 5% and 15% of abused women are identified by their health care provider!, 6, 7_ Domestic violence occurs in women of all racial and socioeconomic backgrounds. It is not more common in minorities or the socioeconomically disadvantaged3, 4. While women with disabilities and pregnant teens are at particularly high risk for abuse, women from all walks of life experience violence. Family physicians must strive to screen adequately for abuse in their patients, to deal appropriately with disclosure, and to participa te in community abuse prevention efforts.

DOMESTIC ABUSE AS A HEALTH ISSUE Abused women use the health care system more often and have more health problems than women who are not abused8. Symptoms are often vague and increase in

ABOUT THE AUTHORS Danielle Martin is a first year medical student at the University of Western Ontario. Ms. Martin graduated from McGill University in 1998 with a B.Sc. Honours in Biochemistry. She has since worked in the health care policy field as it pertains to provincial politics. Sameena Uddin is a first year medical student at the University of Wes tern Ontario. Ms. Uddin is looking toward a career in family medicine. She is currently a volunteer with the Sexual Assault Crisis Line in London and received three phone calls from women in crisis while writing this paper.

intensity with increased violence. Often the woman does not draw any link between her symptoms and the abuse?, 9. If the abuse is not identified, these women can be labelled as hypochondriac or neurotic; abused women are more likely to be prescribed analgesics and minor tranquilizers 4 . When symptoms may be linked to abuse, the physician should not neglect to give medical attention while addressing the abuse concurrently. Table 1 lists some clinical presentations that are more common in abused women than non-abused women. SCREENING FOR ABUSE IN PRIMARY CARE Physicians have long avoided issues of woman abuse, citing the possibility of offending a patient, lack of knowledge of what to do with the information, frustration with outcome, lack of support staff, and time constraints as reasons for not screening4· 12, 13. Physicians may also be affected by their own experience, and can discount the severity of a situation or overidentify and become overly controlling of the situation. However, the potential effectiveness of screening points to a need for doctors to overcome their discomfort and adopt screening techniques as part of their daily interactions with patients. Woman abuse costs more than 4 billion dollars annually, including the costs to health care ($1.5 billion alone), social services, Table 1. WHEN TO SUSPECT ABUSE 4, &, 1,1o, n I. • • • • •

Direct Injuries Fractures, bruises Bums (cigarette, stoves, scalds) Injuries inconsistent with patient's description of mechanism Old untreated injuries (e.g. fractures) STDs, unwanted pregnancies, miscarriages

II. • • • • •

Non-specific Symptoms Chronic pain syndromes, including chronic pelvic pain Irritable bowel syndromes, other gastrointestinal symptoms Headaches Insomnia Syncope, choking sensations, hyperventilation

Ill. • • • • • • •

Psychological Manifestations Depression Eating disorders Drug and alcohol abuse Post-Traumatic Stress Disorder Multiple and Borderline Personality Disorders Dissociation Suicidal ideation

IV.

Other Accompanied by a partner unwilling to leave or who answers questions for the patient Frequent crying Evasiveness Passivity

• • • •

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Feature education, the criminal justice system, and labour and employment14, and consequently should also factor in to the physician's thinking. Moreover, as a caring person sensitive to the needs of people, the ideal family physician will want to address issues of violence in order to help individual patients cope. For a woman in an abusive relationship, many barriers to good health care exist, and the family physician must take a proactive role in addressing them. Access to the health care system may be the initial barrier to getting support from her physician. Lack of transportation can be a factor (her partner may refuse to take her and I or prevent her access to the physician); in rural areas or close-knit communities there may be privacy concerns related to other members of the community discovering the abuse. In urban emergency settings, the impression that the physician is ' too busy' for such a discussion may also impede proper health carets. The most well-meaning physicians often wait for patients to initiate disclosure of abuse before addressing it. This poses a formidable problem, since the barriers to disclosure are enormous for many women. Confidentiality is a major concern for the woman if the abusive partner is also a patient or friend of the same physician 16. Women are also frequently afraid that the physician will not understand, will blame her for the abuse, will dismiss her concerns, or as in some cases, will say that they should "go back home and try again"17. In abusive relationships, the perpetrator takes power away from the woman. On disclosure, the health care system must not take control away from the patient by involving the legal system against her will or breaching confidentiality and discussing the abuse with the abuser. A physician who is clear on her or his supportive role to the patient, as described in the IDEALS philosophy, will be less likely to make these mistakes . As long as cases of abuse go underreported and health concerns go untreated, the possibility for fatal outcomes escalates. It is the physician's responsibility to break down the barriers we ha ve described. Many studies have shown that patients want to be asked about physical and sexual abuset s, s. Screening is effective: the addition of a single question about domestic violence to a self-administered health history form increased the identification from 0% to 11.6%19. At Ottawa General Hospital the addition of a wife assault policy and procedure saw an increase of 1500% in number of identified cases2o. Importantly, several studies have pointed out that abuse victims are less likely to visit their physician for routine, preventive care visits2t. Questions to detect abuse during preventive care visits may miss the atrisk population that underutilizes preventive care. This implies that any opportunity should be used if a physician is committed to learning about a patient's abuse history. How then to screen for abuse? First of all, the aforementioned patient and physician barriers should be decreased or eliminated. Second, approachability must be incorporated into the outward image of the practice by clearly displaying patient education material such as posters, pamphlets, telephone numbers of local shelters, crisis lines and resource centres, in patient waiting areas, examination rooms and washrooms22. Third, a valid and

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reliable screening tool should be used with direct questions that attempt to pin down specifics about the violence, including the current safety of the woman's situation, the frequency and intensity of abuse4. Some screening tools have defined an abused woman as someone who answers yes to questions such as: "Within the past year, have you been hit, slapped, kicked, or otherwise physically hurt by someone?" or "Within the past year, has anyone forced you to have sexual activities?"S Table 2 indicates some approaches to screening. As tools like WAST (Woman Abuse Screening Tool, see table 2) become more widespread, physicians will find it easier to broach the subject of abuse and to help their patients cope. It is vital that screening become a part of both routine and episodic interactions with patients. Finally, it has been noted that there is a difference between screening and misdiagnosis of abuse. "The classic example of recording ' walked into a door' as the cause of an injury that clearly could not have originated from such an event is an instance of failure to diagnose, not failure to screen"24. Table 2. HOW TO SCREEIII FOR ABUSE 19• 22• 23 I. •

Framework for Interviewing Always interview the patient alone, without family members or the partner in the room . If this is not possible, do not ask about domestic violence. • Ask questions in a non-judgmental, unintimidating, and supportive way. • Assure the patient that everything she tells you is confidential and that you care about her health and safety. • Do not push a woman to disclose more than she feels comfortable with. Note: Frequently, survivors will disclose over time, as trust and safety are established. II. • •

•

Specific Questions to Ask "Are you safe in your life right now?" "At any time, has a partner ever hit you, kicked you, or otherwise physically hurt you?" WAST- Woman Abuse Screening Tool23 • In general, would you describe your relationship as having a lot of tension, some tension, or no tension? • Do you and your partner work out disagreements with great difficulty, some difficulty, or no difficulty? • Do arguments result in you feeling down or bad about yourself often, sometimes, or never? • Do arguments result in hitting , kicking , pushing often , sometimes, or never? • Do you feel frightened by what your partner says or does often, sometimes, or never? • Has your partner abused you physically often, sometimes or never? • Has your partner abused you emotionally often, sometimes, or never?

Ill. Statements that can be helpful • "Because domestic violence is a very common occurrence, we ask all women these questions. n • "This must have been very difficult for you ... n • "Is there something you would like to tell me?" • "I believe you ... " • "This is not your fault. ·

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D EALING WITH DISCLOSURE The physician's response to disclosure sets the scene for all future interactions and interventions. Most women are very vulnerable at the time of disclosure and may be fearful, embarrassed, indecisive, in shock, or may try to minimize their situation. The role of the doctor is to support the woman, not to solve all her problems: "You can' t treat it like an infection that will be gone in ten da ys" . Validation of the victim' s feelings a nd a supportive and trusting patient-physician relationship can be as helpful as any single intervention4. Screening methods such as those described above are onl y a first step in assessing abu se, and shou ld be followed immediately with further evaluation. Since women killed by their husbands represent 38% of all adult female homicides25, the level of danger should not be presumed to be small. Assessment should involve a thorough history and physical examination. If the abuser has used weapons, threatened to kill her, has access to guns, manifests extreme jealousy or obsessiveness, or if there has been destruction of property, the r is k of homicide is increased. In all cases of woman abuse, a safety plan should be devised with the woman th at is appropriate for the level of risk. The plan should include routes of escape, places to turn in an emergency, and a list of things to take if she decides to leave (such as money, clothing, jewellery, important documents, medicines, address book, etc.)26. It is vital to document the interaction precisely, as medical records can be used for future legal action and can be helpful to a woman who is referred to a mental health professional4. Photos of any injuries may al s o be appropriate, if the woman does not object. In a court case, the woman should be made aware that signing for release of her medical records will allow her abuser to read them, through his defense lawyeriS. Finally, medical record that support ideas that the woman is hysterical or unstable can adversely affect her credibility in court. The partner should only be involved if the w oman gives her permission because of the principle of confidentiality3. Furthermore, the use of couple counseling has been strongly discouraged because it has been shown to lead to an escalation of the abuse in many cases; it is an attempt to solve the couple' s problems rather than addressing the issues of control and power that are central in abuseJ, 27. Finally, the family physician must recognize that he or she is not solely responsible for dealing with abuse issues. Referral is highly underutilized in many cases of abuse. Local support organizations as well as other health professionals can be very effective. Referrals are often appropriate and helpful as long as the family physician continues to follow the situation and makes it clear that she or he is always available . This is particularly important given the time constraints of a busy practice: abuse issues cannot be dealt with sufficiently in a fifteen minute appointment. Booking a follow-up appointment at the time of disclosure is therefore paramount. Dealing with disclosure can be very difficult for the physician involved, and over time, can lead to burnout2, 24.

The idea that a simple directive or referral will bring the woman to leave an abusive relationship is damaging; the process of leaving can take years or may never happen at all24. While this may be frustrating, it is important to recognize that the famil y physician can help abu sed patients in many ways, even if the woman remains in the relationship. The physician's role as counsellor is an important one, but should not be confused with a role of ' rescuer'. ABUSE PREVENTION AND HEALTH PROMOTION An increase in domestic violence education at the level of health care professionals' training is necessar y. Following the 1996 murder of Arlene May by her partner in Collingwood, Ontario, a Joint Committee on Domestic Abu s e released a strateg y aimed at increa s ing the knowledge of health professionals. Recommendations include d that " substantive, mandatory training on domestic violence should be included as part of the core curriculum for all medical students in Ontario"28, and that licensing and continuing education programs for family physicians include core skill requirements in dealing with woman abuse. The lack of information on woman abuse in medic a l textbooks continues to be a problem 1,29. Encouragingly, medical curricula across North America are incorporating more education on woman abuse. We hope that this trend will continue, and that physicians in all specialties will recognize domestic abuse as a health issue relevant to the practice of medicine. Woman abuse is a complex social problem that requires action on all fronts. In order to address violence against women at its roots, physicians must be more than jus t re sources for indi v idual women; the y must b e advocates for the safety of all women. Participation in community programs, education of colleagues and students, and advocacy for better public policy are all ways that physicians can help prevent abuse along with other members of their communities. Physicians can also help advocate for more funding for organizations that work with abused women. In their role as primary care practitioners, they are in an excellent position to help women in abusive situations; in their role as public health advocates, they can participate in correcting the imbalance of power that causes abusive relationships. ACKNOWLEDGMENTS Our thanks to Drs. Carol Herbert, Barbara Lent, and Jean Marmoreo, for reviewing this paper and provided highly valuable and constructive feedback . REFERÂŁ CES

1. Rovi, Sue, PhD, Charles P. Mouton, MD , MS. Do mestic Violen ce Ed11cation in Fa mily Practice Residencies. Family Medici ne 1999; 31 (6): 398-403. 2. Herbert , Carol P. , M D . Family Violence and Family Physician s Opportunity and Obligation. Canadian Family Physician 1991; 37:385-90. 3. Fe"is, Lo"aine E., PhD, C.Psydt, Peter Norton, Ph D, MD, Earl V. Dunn, MD, Elaine H. Gort, MSc . Clinical Factors Affecting Physician s' Management Decisions in Cases of Female Partner Abuse. Family M edicine 1999; 31(6): 415-25.

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Featur e 4. El-Bayoumi, Gigi, MD, Marie L. Borum, MD, MPH, Yolauda Haywood, MD. Domestic Violence /11 Women . Medical Clinics of North America 1998; 82(2): 391-401 . 5. MacLeod, L. Battered but not beaten ... preventing wife battering in Canada. Canadian AdviS()ry Cauncil on the Status of Women, 1987. 6. Scholle, Sarah Hudson, Dr PH, Kathryn M . Rost, PhD, Jacqueline M. Golding, PhD. Physical Abu e Among Depressed Women. Journal of General Internal Medicine 1998; 13: 607-13. 7. McMauley f., Kern DE, Kolodn er K et a/. The Battering Syndrome: Prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Internal Med 1995; 123:737-46. 8. Me uti, Louise-Anne, Bonnie E. Carlson, Deirdre Gagen , ancy Winterbauer . " Reproductive Violence Screening in Primary Care: Perspectives and Experiences of Patieuts aud Battered Women" JAMWA 1999;54:85-90. 9. Walling MK, RC Reiter, MW O'Hara, AK Milburn, G Lilly, SD Vincent. Abuse history and chronic pain in women I: Prevalences of sexual abuse and physical abuse. Obstetrics and Gynecology 1994; 84:193-99. 10. Weybright, David, ed. Greater Ciucinnati Domestic Violence Initiative Protocol. 11 . Yepez-Millon, Morella. Sexual Abuse and Women's Health. Sexual Assault Ce11tre London1999. 12. aumann, Phyllis, David Langford, Sara Torres, Jacquelyn Campbell, ancy Glass. Woman Battering in Primary Care Practice. Family Practice 1999; 16(4): 343-52. 13. Sugg, K, R Inui, "Primary Care phy ician 's response to domestic violence: ope11ing Pandora's box". JAMA. 1992;267:3157-60. 14. Day, 1995 15. Reynolds, Clzri tine, Anne Schwietzer. Responding to Woma11 Abuse: A Protocol for Health Care Providers. London Battered Women's Advocacy Centre. 16. Ferris, Lorraine, Peter orion, Earl V. Dunn, Elaine H. Gort, au /mba Degani. Guidelines for Managing Domestic Abuse when Male and Female Partners are Patieuts of the Same Physician. JAMA 1997; 278: 851-57. 17. Sullivan-Wilsou, 1994 18. Friedman LS, Samet JH, Roberts MS, Hudlin M, Ha11 P. "Inquiry about victimization experiences: A survey of patient preferences and physician practices. Arc/rives of Internal Medicine 1992;152:1186-90. 19. Freund, Karen M., Sharon M. Bak, Leslie Black/rail. Identifying Domestic Violence in Primary Care Practice. Journal of General Internal Medicine 1996; 11 : 44-46. 20. Social Work Department, Ottawa Ge11eral Hospital, 1989. 21 . Kelso, Elizabetlr B., Raja Jaber. SelectiollS from curreut literature: clinical detection of abuse. Family Practice 1996; 13(4): 408-13. 22. Society of Obstetricia11s and Gynecologists. Policy Statemeut 011 Violence Against Women, 1996. 23. Belle-Browu, Judith, Barbara Lent, Pamela f. Brett, George Sas, Linda L. Pederson. Developmeut of the Womau Abuse Scree11ing Tool for Use i11 Family Practice. Family Medicine 1996; 28:422-8. 24. Thurston , Wilfreda E., Jill Cory, Cathie M . Scott. Building a feminist theoretical framework for screening of wife-battering: key issues to be addressed. Patieut Education and Counselliug 1998; 33: 299-304. 25. Boritclr, He/err. Fallen Womeu : Female Crime and Criminal Justice in Canada. ITP elsou, 1997. 26. Stringham, Peter. Domestic Violence. Mental Health 1999; 26(2): 373-84. 27. Digneffe, Francoise and Callette Parent. LA medintio11 peut-elle devenir une res ource pour les conjointes victime de violence? Canadian Journal of Women and the lAw 1998; 10:293-305. 28. Joint Cammittee on Domestic Violence. A Report to the Attorney General of Ontario - Working Toword a Seamles Community and Justice Response to Domestic Violence: A Five Year Plan for Ontario, 1999. 29. ParsollS, Lynn H., Mary Lou Moore. Family Violence Issues in Obstetrics and Gynecology, Primary Care, and Nursing T exts. Obstetrics and Gynecology 1997; 90: 596-99. Q

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LEARNING ABOUT LEARNING: HOW PRIMARY HEALTH CARE CAN BENEFIT By

physician's assumptions about a patient's ability to understand and remember instructions are inherent in most clinical practices. Thi is especially true for primary care physicians who interact and monitor their patients on a continual basis. Patients with learning disabilities present a challenge to the delivery of adequate care . These disabilities do not require wheelchairs or special devices; they are subtle and may ea ily go unnoticed by the unsuspecting phy ician. Just how prevalent are these learning disabilities? It is predicted that at least 10% of the Canadian population has some form of learning disability - approximately 800,000 people in Ontario alonel. U.S. statistics estimate that 20% of Americans have evere learning disabilitie 2. Although these disabilities permeate our ociety to such an extent, little is truly understood about their etiology. It is known, for instance that learning deficits may arise due to events precipitated during prenatal or childhood development3. Moreover, the fundamental genetic and cellular biology that underlie normal learning and memory are not completely under tood. However, the field of cognitive neuroscience has made r apid advances in the past century in attempting to determine where memory is located in the human brain and what makes up a memory. Recent progress, particularly in the molecular aspects of learning and memory research may provide useful information that could guide future therapies for patients with these types of disabilities. With this in mind, physicians mu t be aware of the deficits incurred by such learning disabilities in order to adequately prevent their detrimental effects on health care delivery. Assuring that a patient with a learning disability understands and retains a physician' s instructions ensures better health care for that individual. Although definitions can vary, most sources agree that learning disabilities are a group of disorder that cause a person to have deficits in reading, wr i ting, reasoning, mathematical skills, attention, understanding or remembering . These deficiencies are due to impairments in the circuitry of the central nervous system

ABOUT THE AUTHORS Nirit Bernhard is a first year medical student at the University of Western Ontario. She attended the University of Toronto where she received an MSc. in Neurobiology in 1999, and an Hon B.Sc. in 1997. Raffaela Profiti is a first year medical student at the University of Western Ontario. She previously completed an Hon B.Sc. in Biology at McMaster University in 1997.

irit Bernhard and Raffaela Profiti

causing an inability to process information the same way as an average person4. Importantly, these learning deficits are not due to primary deficits in vision, hearing or in motor abilities, and do not involve mental retardation, emotional disturbances or environmental disadvantages, (although there may be some co-morbidity with any of the e). It is important to note that despite this disability, the e people still display average to above average intelligence. FROM BASIC RESEARCH... Given the potential effects of learning disabilities on a patient's acces ibility to health care, the understanding of mechanisms that are involved in learning and memory is no less important than understanding the mechanisms underlying hearing loss, or any other disability that would cau e an impedance to receiving adequate health care. Analysis of learning can be broken down into two general categories: systems and moleculess. The first category deals with what a memory actually is, and what brain circuits are important in its storage or retrieval, and the second category deals with the molecular and genetic creation of learning and memory within the nerve cells that make up the circuits. The e questions have been debated by scientist and philosophers for many centuries (for a good review refer to Dudai, 19896). In the last century, many neuroscientists in Canada, such as Wilder Penfield, Donald Hebb, Brenda Milner, and Endel Tulving (to name but a few) have contributed to our understanding of these cognitive questions. In 1949, Donald Hebb7 was instrumental in first proposing that memories are represented as "reverberating activity" in assemblies of interconnected neurons, and went on to suggest that there was no single area for memory processes . Brenda Milner, at the Montreal eurological Institute, expanded on thi concept with her work on the famous patient, H.M . . H.M. had a bilateral resection of his medial temporal lobe structures (including the hippocampus). These lesions presented in an astounding manner: H.M, had severe impairments of recent memories, although his IQ was above normal. Subsequent tests demonstrated that there were some forms of memory that did remain intact: H .M showed improvements in learning skilled motor tasks. Interestingly, he had no recollection of doing the tasks, despite the improvements he demonstrated. Thus, H.M. was able to perceive information but unable to retain that new information at a conscious level. The study of H.M. and subsequent amnesic patients led to the classification system used toda y, where a distinction is made between declarative or conscious memory and nondeclarative or unconscious memory9.

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Feature Simply put, declarative memory i what help your patient remember to take her medication on time, wherea nondeclarative memory is involved in how she remembers ro brush her teeth every morning. ondeclarative memory eems to be intact in amne iacs, and i likely not affected in people with learning di abilitie 10. The medial temporal lobe seems to play the most prominent role in the initial phases of declarative memory. On the other hand, nondeclarative memory is thought to reside in many brain areas, ranging from the striatum (for procedural, habit learning), to reflex pathways (for nonassociative learning). Although the e areas have been broadly delineated, it is very difficult for researchers to tease apart which aspect of memory (acquisition, storage or retriev al) reside in what brain sites. In the past three decades, rapid advances on the molecular level have had a huge impact on current learning theories. Studie in thi regard have been facilitated by using animal model of human learning and memory, especially invertebrate models that demon trate very simple behaviours, and that have a simple anatomy w hich i easily amenable to laboratory manipulations. To thi s end, the u e of invertebrate in tudying the e molecular aspects ha been greatly beneficial. Studies involving fruit flies (drosophila), sea slug (aplysia) and w orm (C. elegans) have allowed for the elucidation of molecular pathway and gene involved in learning and memory11, 12, 13. Much of this understanding came from creating animals with specific genetic lesions that rendered them unable to learn or retain newly acquired information. The e "learning mutants" provided orne of the fir t evidence that it was possible to make the leap from gene to complex behaviour14. Thi molecular approach ha s led to the idea that nondeclarative learning i embedded in the actual neural circuit that produce the behaviour15. The strengthening of the e circuit i under the control of certain genes. Thi differs from declarative memory, which require an entire neural sy tern such as the medial temporal lobe16. The detective work at the molecular level has even allowed researchers to propose different mechani ms for the torage of short term memory (STM) ver u long term memory (LTM). It is thought that STM involve modifications and trengthening of pre-exi ting connections, whereas LTM u e molecules bound in the cell to initiate the synthe i of new proteins that will help in the formation of new connections in the circuit17. Is it possible that specific genes play a role in human learning and memory? At lea t two genes for dyslexia, a pecific reading disability affecting children and adults have been cloned1 , 19. In addition, many single gene disorder and other genetic abnormalitie have been correlated with di order that show high prevalence of learning disabilitie 20, 21 . For example, in neurofibromatosis type 1 (NF1), 30%-45% of patients that lack any other apparent neural pathology have learning disabilitie (Silva et al., 1997). There are orne e timate that the heritability of learning disabilitie i a high as 50%22. Idiopathic learning di abilitie have demonstrated

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average correlations of 0.4 in mono- and dizygotic twin tudie . Although there ha been much controver y over the investigation of the genetic basis of cognitive abilitie 23, 24, the implications for therapy are quite significant. That genetics may underlie many learning di abilitie opens many door to potential therapy - a s urprising concept given the difficulty scienti ts and clinician have come aero in developing gene therapie for other known genetic di ea es. The studies of "learning mutants" demonstrated that the learning deficit of the e animal could be overcome with increased or alternative type of training25, 26. The human equivalent of this kind of extra training may be what we call "special education" . ... TO CLINICAL AWARENESS By interfering with an individual's ability to receive adequate health care a a whole, learning di abilities greatly impact the health care system . Williams and colleague surveyed 3000 patients from two urban ho pita! and found that a high proportion could not function in the health care y tern due to poor reading s kills27. Many were unable to read and understand important information uch as instructions on medication bottle or appointment lips . Many patients had difficultie learning and remembering information and were therefore unable to under tand their condition, let alone comply with a physician' s instruction . This study demon trates the difficulty patients with learning and memory disabilities have following even ba ic in tructions, such as how to follow a low-fat diet or prepare for an upcoming medical exam . Presenting information to patients in written form, as is often done in drug tore regarding medication side effects and contraindications, is yet a further ob tacle patients with learning deficits mu t overcome. The futility of dispensing information in thi manner i obviou for patient who can not read . For tun atel y this obstacle can be overcome through awareness and u e of alte rnate forms of communication. Individuals with learning disabilities may al o have oral language deficit . The y may have difficulty under tanding complex in tructions or they may mi under tand imple words. In the latter ca e, for example, unnecessary side effect may cau e a patient to s top taking a medication because the implication of taking the medication incorrectly were not well under tood. Other patient may have trouble expres ing themselve and would therefore be unable to clearl y define their symptom or time course of illness 2 . Phy ician (and phy ician -in-training) are continuously being reminded that patient are the be t ource of information . Patients w ith learning disabilities can therefore provide unreliable information. Phy ician should keep two key concept in mind w hen dealing with patient with learning di abilitie . Understanding the biology of learning and memory and how it manifests itself as a di ability is key to being aware of the i ue involved. An increa ed awarene will lead to keener ob ervations of the symptoms associated with learning di abilities. Phy icians should be aware that learning di abilities are common and pose a tremendou

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challenge because they are so difficult to detect. In fact, many patients will go to great extents to cover up their disability out of embarrassment or fear of appearing s tupid . However, an awareness of the behavio ural characteristics of individuals with learning disabiliti s can greatly improve the quality of care provided. Symptoms can be observed throughout a patient's visit from the time a patient enters the waiting room to a patient' s final questions. Memory and attention deficits can result in a patient failing to keep appointments, arriving late due to confusion with times or directions, and pacing in waiting rooms. Patients with lea r ning disabilities rarely pick up a magazine or read office pamphlets or posters . They may not fill out form properly, have others do it for them, or claim to have left their glasses at home. Patients with oral language impairments may have small vocabularies, use w ords incorrectly, have disorganized thoughts, or have problems giving a complete history or description of symptoms29. Basic questions by patients about aspects of the visit discussed fully and repeatedly, or a recurrent problem with compliance, should also alert physicians to an underlying problem. Physicians must be cautious not to take any one of these signs in isolation but ins tead consider the whole gestalt of symptoms. When a learning di ability is suspected, a physician can take a number of steps to improve his or her delivery of health care. Assistance should be provided with filling out forms to those with difficulties reading and writing. For patients with comprehensive or expressive difficulties, history taking should involve direct and simple words. Questions requiring yes or no answers are useful in generating accurate information30. Wh e n giving instruction or explanations it is important to present information slowly, simply, and repetitively. Trying to emphasize one point at a time or adjusting one aspect of the patient's regime per v isit, while minimi zing the amount of medical jargon u ed is helpful. An easy way to monitor comprehension is by asking the patient relevant questions or asking him or her to repeat the instructions. For patients who have a poor memory or difficulties reading, a review of written instructions is essential. Providing pictorial instructions can also be u seful. Compliance with instructions and therapies should al o be monitored. This can be done via telephone inquiries, follow up visits, or home visits with a request to see medication bottles or a demonstration of what patients are supposed to do31. Patients with learning disabilities may have a difficulties ranging from reading deficits to remembering vital information. These obstacles interfere with a patient's acce s to adequate health care. That patient often mask this already ' invisible' disability po es a challenge to physicians who may assume their instructions are easily read or have been full y unders tood . Therefore, the importance of being aware of the sy mptoms and recognizing the warning signs m ust be stressed. This will guide health care workers in making the adjustments necessary to greatly improve the quality of care provided to patients with learning disabilitie . A physician's role is to a sure accessible and reliable health care to all patients.

Through a greater awareness and understanding of the details involved in learning and memory and the effects of its di abilities, doctors will be a step closer to reaching this goal. AC KN O~EDG EMENTS

The authors would like to acknowledge V. Tropepe for his thoughtful advice on this manuscript. REFERENCES 1. Learning Disabilities Association of Ontario. Slats from August 1996. For more information see http://www.freenet.toronto.on.ca/iplaa254/ define/fact. txt 2. Kelly MS and Gottesman RL. Adults with Severe Reading and Learning Difficulties: A Challenge for tire Family Physician . f Am Board Fam Pract 1997; 10(3):199-205. 3. Learning Disabilities Association of Ontario. Slats from August 1996. For more information see http://www.freenet.toronto .on .ca/iplaa2541 deft nelfact.txt 4. Koller, HP. I of Ophthalmic Nursing & Technology 1999; 18(1):12-18. 5. Milner B, Squire LR, Kandel ER. Cognitive eurosicence and the study of memory. Neuron 1998; 20(3):445-468. 6. Dudai Y. The neurobiology of memory. Concepts, findings, trends. Toronto: Oxford University Press, 1989. 7. Hebb DO. The organization of behaviour: a neuropsychological theory. New York: Wiley, 1949. 8. Scovil/fe WB and Milner B. Loss of recent memory after bilateral hippocampal lesions. I eurol eurosurg Psychiatry 1957; 20:11-21 . 9. Cohen I and Squire LR . Preserved learning and retention of pattern analyzing skill in amnesia: dissociation of knowing how and knowing that. Science 1980; 210:207-209. 10. Squire LR, Knowlton B and Musen G. The structure and organization of memory. Annu Rev Psyclro/1993; 44:453-495. 11 . Dudai Y, Uzzan A and Zvi S. Abnormal activity of adenylate cyclase in the Drosoplrila memory mutant, rutabaga. Neurosci Lett 1983; 42 :207-212. 12. Kaang B, Kandel ER and Grant SG . Activation of cAMP-responsive genes by stimuli that produce long-term facilitation in Aplysia sensory neurons. euron 1993; 10:427-435. 13. Wen J., Kumar , Mo"ison GE, Runciman S, Rambaldini G, Rousseau 1, and van der Kooy D. Mutations 1/rat prevent a sociative learning in C. elegans. Behav eurosci 1997; 111 (2): 342-353. 14. Quinn WG, Ha"is WA and Berrzer S. Conditioned behavior in Drosophila melanogaster. Proc at/ Acad Sci 1974; 71 :708-712. 15. Thompson RF and Krupa D1. Organization of memory traces in the mammalian brain. Annu Rev Neurosci 1994; 17:519-550. 16. Milner B, Squire LR, Kandel ER. Cognitive eurosicence mrd tire study of memory. euron 1998; 20(3):445-468. 17. Milner B, Squire LR, Kandel ER. Cognitive eurosicence and the study of memory. euron 1998; 20(3):445-468. 18. Cardou IR, Smith SD, Fullmer D , Kimberling, WJ, Penington BF and De Fries IC. Quantitative trait loci for reading disability on chromosome 6. Science 1994; 266:276-278. 19. Fagerlreim T, Raeymaekers P, T_rmessen FE, Pederson M, Trarrebj_rg L and Lubs HA. A new gene (DYX3 ) for dyslexia is located on chromosome 2. 1 Med Genet 1999; 36(9):664-669. 20. Hodgson SV. The genetics of learning disabilities. Develop Med and Child euro/1998; 40(2):137-40. 21 . Thapar A , Gottesman 11, Owen M1, O ' Donovan MC, McGuffin P. The genetics of mental retardation. Brit 1 of Psyclriat 1994; 164:747-58. 22. Tlrapar A , Gottesman 11, Owen M1, O ' Donovan MC, McGuffin P. The genetics of merrtal retardation . Brit J of Psychiat 1994; 164:747-58. 23. l..emonick MD. Smart genes? Time, 1999; 154(11 ):40-44. 24. Plomin R. Gertetic and general cognitive ability. Nature 1999; 402(2 ):C25-

C29. 25. Tully T, Bolwig G, Christensen 1, Connolly 1, Ce/Vecchio M , eta/. A return to genetic dissection of memory in Drosophila. Cold Spring Harbor Symp Quant Bio/1996; 61 :207-218. 26. Silva AI, Frankland PW, Marowitz Z, Friedman E, Lazlo G, eta/., A mouse

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Feature model for the learning and memory deficits associated with neurofibromatosis type 1. Nature Genet 1997; 15(3):281-284. 27. Williams MV, Parker RM, Baker DW, Parikh NS, Pitkin K, et a/. Inadequate functional health literacy among patients at two public hospitals. JAMA 1995; 274:1677-82. 28. Kelly MS and Gottesman R L. Adults with severe reading and learning difficulties: A challenge for the family physician. JABFP 1997; 10(3):199-205. 29. Kelly MS and Gottesman RL. Adults with severe reading and learning difficulties: A challenge for the family physician. JA BFP 1997; 10(3):199-205. 30. Kelly MS and Gottesman R L. Adults with severe reading and learning difficulties: A challenge for the family physician. JABFP 1997; 10(3):199-205. 31 . Kelly MS and Gottesman RL. Adults with severe reading and learning difficulties: A challenge for the family physician. JA BFP 1997; 10(3):199-205.

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U. W.O. Medical Journ al 70 {2) 2000 - - - - - - - - - - - - - - - - - - - - - - - -

F e atur e

Articl e s

UNDERSTANDING

INFANT

By Tammy J. Clifford MSc.(A ), M. Karen Campbell PhD, Kathy

ixon Speechley PhD and Fabian Gorodzinsky MD, FRCPC

INTRODUCTIO N nfant colic is enigmatic despite its long hi tory, relatively frequent occurrence and an abundance of relevant research . Although its existence m ay be trivialized by some, recent work indicates that an episode of colic may adversely affect family life.t-9 Compounding this finding is the uncertainty regarding the success of behavioural and pharmacological intervention strategies .I0-20 Also worth noting is the potential for significant costs to the health care system; United Kingdom data indicate that one in six families eeks medical advice regarding their infant's crying.2t An infant's excessive crying can al o elicit "parental colic," a condition which is "characterized by crying, fatigue, guilt, depression and resentment of the infant."S, 22 Concomitant changes to the parent-child relationship may result in long-term deficits to the infant's menta l and social development.6, 23-26 Moreover, it has been suggested that, for individuals prone to abuse, the stress of caring for a colicky infant may result in shaken baby syndrome.27-30 Society' s understanding of infant colic needs to be improved. A comprehensive review of the relevant literature was undertaken in order to identify gaps in our current understanding of this complex condition. This review explores the definition of colic, discu sses the postulated aetiological factors presented in the literature, note s so me of the methodological shortcomings of previous research and provides recommendations for clinicians. Articles were obtained from MEDLINE searches of the English-language literature from 1966 to present using textwords 'infant colic,' 'excessive crying' and 'i rritable infant.' Bibliographic review of these articles provided works written prior to 1966. A total of 103 articles, including case reports and clinical op inion commentaries, were reviewed with emphasis placed upon those published in peer-reviewed journals.

WHAT IS COLIC? The reported prevalence of colic varies widely,30-43 perhap owing to the fact that it is an ill-defined condition characterized b y excessi ve and inconsolable crying, hypertonicity and wakefulness. The onset of colic usually ABOUT m E AUTHORS Ms. Clifford is a fourth year Doctoral Candidate in the Department of Epidemiology and Biostatistics. She completed a BSc in Physiology and an MSc(A) in Occupational Health at McGill University. Dr. Campbell is an Associate Professor in the Departments of Epidemiology and Biostatistics, Obstetrics and Gynaecology, and Paediatrics. Dr. Speechley is an Associate Professor in the Departments of Paediatrics and Epidemiology and Biostatistics. Dr. Gorodzinsky is a paediatrician in clinical practice in London and an Associate Professor in the Department of Paediatrics.

C0 LI C

occurs between the second and sixth weeks of life and its disappearance, around age three months, is typically sudden and unexplained. The most widely cited criterion for colic, known as the "Rule of Threes," defines such an infant as one who being "otherwise healthy and well-fed, [has] paroxysms of irritability, fussing or crying lasting for a total of three hours per day and occurring more than three days in any one week."32 A difficulty with this definition of colic is the similarity in the crying patterns of all infants. The duration of infants' crying usually increases until the sixth week of life, then decreases to baseline around age four months; the crying tends to exhibit a diurnal rhythm, being clustered in the evening hours.44-46 At its peak, the median amount of crying has been found to be 2.75 hours per day; however, substantial intra- and inter-individual variability exists. 44 - 46-4 Thus, it is unknown whether the "Rule of Threes" describes a clinically meaningful subgroup of crying infants or simply an arbitrary upper limit of the 'normal' frequency distribution of crying.46-48 The " Rule of Threes" also neglects to refer to cry q.uality . Acoustic analyses indicate that differing cucumstances (e.g., hunger, pain, cold) elicit unique cries." Additionally, colicky infants' cries have been found to be qualitatively different from those of controls.st Evidence suggests, however, that parents are able to distinguish the circumstances which prompt their infant's crying.49, s2, 53 PO STULATED ETIOLOGICAL MECHANISMS While most have an opinion as to the cause(s) of colic, the . true origin(s) of colic are unknown. This ma y be attributable to the possibility of multiple aetiologies and, as well, to methodological s hortcomings of previou s research. These methodological shortcomings include inconsistent definitions of colic, an absence of control groups, the use of clinically referred populations, small sample sizes, failure to control for covariates and nonprospective study designs. Although these methodological issues arise, to different degrees, in various published studies, the results of these studies need not be summarily dismissed . The aetiological theories arising from these studies are discussed below. Mother-Child Interaction Less than optimal encounters between mother and child, prompted by a mother's anxiety and / or depression, have been implicated in the development of colic yet the evidence is contradictory.21, 23-25, 31-34, 54-64 A number of mechanisms have been suggested to be responsible for the purported associations between maternal p ychopathology and "difficult" infant behaviour. These mechanisms include increased autonomic/ endocrinologic reactivity, genetic predisposition and differential maternal handling.65, 66 Additionally, it may be that anxious and I or depressed mothers are less tolerant of behaviour problems and / o r report such episodes more frequently.

U. W. 0. Medical Journal 70 (2) 2000

Feature Unfortunately, existing studie do not provide for the direction of causation to be inferred, owing to crossectional or retrospective study design. Thus, it is difficult to interpret whether the arudety I depression preceded the episode of colic or whether an infant's colic potentiated the mother's arudety I depression. D ietary Incompatibilities Some studies have focused on dietary incompatibilities as possible causes of colic. In formula-fed infant , suspected mechanisms include an allergy to cow's milk protein and I or lactose intolerance. Switching an infant' s formula, from cow's milk-based preparations to soy-based and I or hydrolyzed preparations, is frequently undertaken to ameliorate colic and some have suggested that this "should be the first therapeutic approach." 67 everthele s, neither epidemiological nor laboratory evidence implicating an allergic response to protein in cow' s milk formula has led to a consensus.67-74 Significant reductions in the duration of colic symptoms have been found when infants were switche.d from cow's milk formula to soy-based formula .67, 71 -73 It 1s important to note, however, that individuals who have an allergy to cow's milk protein may also react adversely to oy protein and that the Committee on Nu trition of the American Academy of Pediatric also recommends that oy formulas not be used "in the routine management of colic." 75 In order to demonstrate a true food allergy, symptoms must subside after the elimination of the suspected agent from the diet, symptoms must recur within 48 hours after a trial feeding of the agent, three such challenges must be po itive and have similar features and symptoms must s ubside after each challenge reaction.76 Most studies implicating a milk protein allergy in colic' s aetiology have failed to fulfill these criteria. This may be due, in part, to pa rents' and I or clinicians' unwillingness to subject an infant to additional challenges once "relief" has been achieved. This unwillingness is understandable; the lack of scientific rigor, however, may result in the belief that these dietary changes are a "cure" when, in fact, the episode of colic may have subsided on its own, without any outside intervention, due to its natural history. The implication of lactose intolerance in the origins of colic in formula-fed infants is ba ed on the knowledge that mos t infant cannot fully absorb the lactose load in formula during the first several months of life and that unabsorbed lactose in the small intestine is a h y per-peristaltic stimulus J7, 78 Although one study indicated that breath hydrogen excretion, a surrogate measure of incomplete lactose absorption, was found to be significantly elevated in colicky infants,79 no other studies have provided evidence in support of this hypothesis. SO- 2 The experience of colic in breast-fed infants is uggested to result from an allergy to a component of th~ir mothers' milk. While it has been shown that cows' nulk protein can be transferred in the breastmilk of mothers whose diets include cow's milk, or cow's milk products,70, 83, 84 it is debatable whether infants of nursing mothers who avoid cow's milk or other potential dietary allergens such as eggs, wheat and nut products, experience less distress than infants whose mothers did not consume low allergen diets.85-88

Art i cle s

Feeding Schedule While not abundant, the literature relating feeding schedule to the development of colic is also contradictory. For example, under-feeding, overfeeding, and the early introduction of solid foods into infants' diets, have all been suggested to be both causes of, and treatments for, colic.36, Contingent feedings, as opposed to feedings dictated by a schedule, have been shown to reduce fretful cry ing .16, 89, 90 Since the timing of feedings is easily modified and since some fretful crying may stem from an infant's hunger, contingent feedings should be one of the first interventions proposed when colic is suspected. H ormonal Mechanisms Consideration ha also been given to the possibility that colic may originate from al tered hormone levels. While it has been shown that the plasma progesterone levels of colicky and non-colicky infants do not differ,91, 92 it has been demonstrated that colicky infants, from birth, exhibit higher serum levels of motilin.93, 94 Melatonin, the hormone which regulates circadian rhythms, has also been given aetiological consideration in t~e dev~lopment . of colic, but this theory has not been mveshgated w1th adequate scientific rigor.95-99 Cen tral Nervous System Immaturity The final aetiological mechanism proposed in the literature suggests that colicky infants possess abnormally ensitive central nervous systems whereby minimal stimuli result in fussiness and irritability .44, 100 If this hypothesis were true, it may be predicted that preterm infants would be more likely to experience colic; however, this association has not been documented.34 Nevertheless, clinicians should note that premature infants may present with "irritability of prematurity," a condition whose symptoms mimic those of colic but which results from a normal state of brain development in premature infants. DISCUSSION The existing body of literature concerning the aetiology of colic is abundant but inconclusive . The absence of definitive conclusions regarding the aetiology of colic combined with it frequent occurrence, potential lasting impact on mother, child and family and associated costs to the health care system necessitate further research in this area . Future research can address the methodological shortcomings of previous works with relative ease by using prospective methods along with a reliable and valid instrument, such as Barr's "Baby's Day Diary/'101 which would facilitate objective ascertainment of episodes of colic. At present, there is no cure for colic; however, an episode can be managed until it subsides on its own. Differential diagno es, listed in Table I, need to be excluded. 29 Common explanations for crying, such as hunger and cold, should also be explored. Clinicians should be aware of the signs of sh aken baby syndrome, s uch as retinal haemorrhages.29 Parents need to be informed of normal crying behaviour and assured that colic typically remits by the infant's third or fourth month of life and that they are not to blame for their child' s fussiness .I02 Pharmacological therapies must be

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Table 1: Differential Diagnosis for Colic • • • • • • • • •

gastroesophageal reflux constipation seizures corneal abrasion drug withdrawal anatomic (pyloric stenosis, intussusception / hernia) infectious (otitis media, meningitis, urinary tract infection) metabolic (hyponatremia, hypoglycemia) iatrogenic (medications, immunizations)

sc rutinized because of potential side effect and questionable effectivenes . It is likely that colic should be conceptualized as a "product of behavioural and biologic interactions"103 but until research provides us with the answers as to the origins of colic, clinicians need to provide support to parents whose child is experiencing colic. REFER£ CES

1. Forsyth BWC, Leventhal JM, McCarthy PL. Mothers ' perceptions of problems offeeding and crying problems. Am I Dis Child 1985;106:1012-7. 2. Forsyth BWC, McCarthy PL, Leventhal JM . Problems of early mfancy, formula changes and mothers' beliefs about their infants. J Pediatr 1985;106:1012-7. 3. Wikander B. Infantile colic in a psychodynamic and nursing per pective. Scand J Caring Sci 1987;1:103-9. 4. Keefe MR, Froese-Fretz A . Living with an Irritable Infant: Maternal Perspectives. MC 1991;16:255-9. 5. Pinyerd Bf. Infant colic and matemal menta/health: ursing research and practice concenzs. Issues Comp Pediatr urs 1992;15:155-67. 6. Lehtonen L, Korhonen T, Korvenranta H. Temperament and Sleeping Patterns in Colicky Infants during the First Year of Life. J Dev Behav Pediatr 1994;15:416-20. 7. Rautava P, Lehtonen L, Helen ius H, Sillanpaa M . Infantile Colic: Child and Family Three Years Later. Pediatrics 1995;96:43-7. 8. Raiha H, Lehtonen L, Korhonen T, Korvenranta H. Family Life 1 Year After Infantile Colic. Arch Pediatr Ado/esc Med 1996;150:1032-6. 9. St.lames-Roberts I, Conroy S, Wilsher K. Bases for maternal perceptions of infant crying and colic behaviour. Arch Dis Child 1996;75:375-84. 10. Illingworth RS . Evening Colic In Infants: A Double-Blind Trial of Dicyclomine Hydrochloride. Lancet1959;Dec. 19, 1959:1119-20. 11 . Danielsson B, Hwang CP. Treatment for infantile colic with surface active substance (simethicone). Acta Paediatr Scand 1985;74:446-50. 12. Hwang CP, Daniel SOil B. Dicyclomine hydrochloride i11 illfantile colic. Brit Med J- Cli11 Res Ed 1985;291:1014 13. Hunziker UA, Barr RG. Increased carrying reduces infant crying: a randomized controlled trial. Pediatrics 1986;77:641-8. 14. Becker N, Lombardi P, Sidoti E, Katkin LS. My/icon drops in the treatment of colic. Clin Ther 1988;10:401-5. 15. Sethi KS, Sethi JK. Simethicone in the management of infant colic. The Practitioner 1988;232:508 16. Barr RG, Konner M , Bakeman R, Adamson L. Crying in !Kung San Infants: A Test of the Cultural Specificity Hypothesis. Dev Med Child euro/1991;33:601-10. 17. MetcalfTJ, Irons TG, Sizer LD, Young PC. Simethicone ir1 the Treatment of Infant Colic: A Randomized Placebo-Controlled Multicenter Trial. Pediatrics 1994;94:29-34. 18. Oggero R, Garbo G, Savino G, Moster! M . Dietary modification versus dicyclomine hydroclzloride in tire treatment of severe infantile coli . Acta Paediatr 1994;83:222-5.

19. St./ames-Roberts I, Hurry J, Bowyer J, Barr RG. Supplemental Carrying compared with Advice to Increase Responsive Parenting as Interventions to Prevent Persistent Infant Crying. Pediatrics 1995;95:381-8. 20. Merrill Dcnu Phamwceuticals: Bulletin - ew Prescribi11g Informatioll on Bentyl (dicyclomine). ovember 19, 1984. 21. St.lames-Roberts I, Hali/ T . Infant Crying Patterns in the First Year: ormal Commrmity and Clinical Findings. J Child Psycho/ Psychiatr 1991;32:951-68. 22. Pinyerd Bl, Zipf WB. Colic: Idiopathic, Excessive Infant Crying. J Pediatr Nurs 1989;4:147-53. 23. Sloman J, Bellinger DC, Krentzcel CP. Infantile colic and fran ient developmental lag in the fir t year of life. Child Psyclziatr Hum Dev 1990;21:25-35. 24. Beck CT. A Meta-Analysis of the Relationship between Postpartum Depression and Infant Temperame11t. urs Res 1996;45:225-30. 25. Beck CT. Postpartum Depressed Mothers ' Experiences Interacting with their Children. urs Res 1996;45:96-104. 26. Beck CT. The Effects of Postpartum Depression on Maternal-Infant Interaction: A Meta-analy is. urs Res 1995;44:298-304. 27. Frodi AM. Contribution of infant characteristics to child abuse. Am J Ment Def1981;85:341-9. 28. Mortimer P, Kevill F. Frustration and Despair. Community Outlook 1985;19-22. 29. Singer JL, Rosenberg M . A fatal case of colic. Pediatr Emerg Care 1992;8:171-2. 30. American Academy of Pediatrics. Shaken Baby Syndrome: Inflicted Cerebral Trauma. Pediatrics 1993;92:872-5. 31 . Illingworth RS. Three Month 's Colic. Arch Dis Child 1954;29:165-74. 32. Wessel MA, Cobb JC, Jackson EB, Harris GS, Detwiler AC. Paroxysmal Fussing inlnfacy, sometimes called "colic". Pediatrics 1954;14:421-33. 33. Paradi e JL. Maternal and other factors in the etiology of colic. JAMA 1966;197:123-31 . 34. Meyer JE, 11zaler MM. Colic in Low Birthweight Infants. Am f Dis Child 1971;122:25-7. 35. Boulton TJC, Rowley MP. utritional Studies during Early Childhood III. Incidental Observations of Temperament, Habits and Experien ces of Ill-Health. Aust Paediatr J 1979;15:87-90. 36. Hide DW, Guyer BM . Prevalence of Infant Colic. Arch Dis Child 1982;57:559-60. 37. Rubin SP, Prendergast M . Infantile colic: incidence and treatment in a orfolk community. Child care health dev 1984;10:219-26. 38. Stahlberg M. Infantile Colic: occurrence and risk factors. Eur I Pediatr 1984;143:101-11 . 39. Thomas DB. Aetiological associations in infantile colic: an hypothesis. Aust Paediatr J 1981;17:292-5. 40. Hogdall CK, Vestemwrk B, Birch M , Plenov G, Toftager-Larsen K. The significance of pregnancy, delivery and postpartum factors for the development of infantile colic. J Peri nat Med 1991;19:251-7. 41 . Lehtonen L, Korvenranta H. Infantile Colic: seasonal incidence and crying profiles. Arch Pediatr Adolesc Med 1995;149:533-6. 42. Canivet C, Hagander B, Jakobsson I, Lanke f. Infantile colic - less common than previor1sly estimated? Acta Paediatr 1996;85:454-8. 43. Crowcroft S, Strachan DP. The social origins of infantile colic: questionnaire study covering 76 747 infants. BMJ 1997;314:1328 44. Brazleton TB. Crying in infancy. Pediatrics 1962;29:579-88. 45. Rebelsky F, Black R. Crying in Infancy. J Genet Psycho11982;121:49-57. 46. Barr RG. 17ze Nonnal Crying Curve: What do we really know? Dev Med Child Neurol1990;32:356-62 . 47. Barr RG, Rotman A, Yaremko J, Leduc D, Francoeur TE. The Crying of Infants with Colic: A controlled empirical description . Pediatrics 1992;90:14-21. 48. Barr RG. Normality: A Clinically Useless Concept. The Case of Infant Crying and Colic. J Dev Behov Pediatr 1993;14:264-70. 49. Murry T, Hol/ien H, Muller E. Perceptual responses to infant crying: matemal recognition and sex judgments. J Child Lang 1974;2:199-204. 50. Muller E, Hollien H, Murry T . Perceptual responses to infant crying: identification of cry types. J Child Lang 1973;1:89-95. 51 . Fuller BF, Keefe MR, Curtin M . Acoustic Analysis of Cries from orma/" and "Irritable" Infants. West J Nurs Res 1994;16:243-53. 52. Zeskind PS, Barr RG. Acoustic Characteristics of naturally occurring cries of infants with "colic". Child Dev 1997;68:394-403. N

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Feature 53. Zeskind PS, Lester BM. Acoustic Features and Auditory Perception of the Cries of ewborns with Prenatal and Perinatal Complications. Child Dev 1978;49:580-9. 54. Carey WB . Maternal anxiety and infantile colic: is there a relationship? Clin Pediatr 1968;7:590-5. 55. Carey WB. Temperament Risk Factors in Children : A conference report. f Dev Bel1av Pediatr 1990;11:28-34. 56. Spock B. Etiological Factors in Hypertrophic Pyloric Stenosis and Infantile Colic. Psychosom Med 1944;6:162-3. 57. Ottinger DR, Simmons JE . Behavior of Human Neonates and Prenatal Matemal Anxiety. Psycho/ Rep 1964;14:391-4. 58. Miller AR, Barr RD. Matemal Emotional State and Infant Behaviour: Are they Related? Am/ Dis Child 1991; 145:421 . 59. Miller AR , Barr RG , Eaton WO. Crying and Motor Behavior of Six-Week-Old Infants and Postpartum Mat ernal Mood . Pediatrics 1993;92:551-8. 60. Parker Sf, Barrett DE. Maternal Type A Behavior During Pregnancy, eonatal Crying and Early Infant Temperament: Do Type A Women have Type A Babies? Pediatrics 1992;89:474-9. 61. Rautava P, Helenius H, Lehtonen L. Psychosocial predisposing factors for infantile colic. BMJ 1993;307:600-4. 62. Barnett B, Parker G. Possible determinants, correlates and consequences of high levels of anxiety in primiparous mothers. Psycho/ Med 1986;16:177-85. 63. Farber EA, Vaughn B, Egeland B. The relationship of prenatal matemal anxiety to infant behaviour and mother-infant interaction during the first six months of life. Early Human Dev 1981;5:267-77. 64. Whiffen VE, Gotlib I. Infants of Postpartum Depressed Mothers: Temperament & Cognitive Status. J Abn PsydJo/1989;3:274-9. 65. Lederman RP . Relationship of Anxie ty, Stress and Psychosocial Development to Reproductive Health . Beltav Med 1995;21 :101-12. 66. Ledennan RP. Matemal Anxiety in Pregnancy: Relationship to Fetal and ewborn Health Stahts. Ann Rev urs Res 1997;4:3-19. 67. Ia cono G, Carroccio A, Montalto G, Cava taio F, Bragion E, Lorelli D, Balsamo V, Notarbartolo A Severe infantile colic and food intolerance: A Long-Term Prospective Study. J Pediatr Gastroenterol Nutr 1991;12:332-5. 68. Lothe L, Lindberg T. Cow 's Milk Wh ey Protein elicits Symptoms of Infantile Colic in Colicky Formula-Fed Infants: A Double-Blind Crossaver Study. Pediatrics 1989;83:262-6. 69. Harris MJ, Pelts V, Penny R. Cow's Milk Allergy as a Cause of Infantile Colic: Immunofluorescent Studies on jeju nal Mucosa . Aust Pediatr J 1977;12:276-81. 70. Thomas DW, McGillian K, Eisenberg LD, Liebennan HW, Rissman EM. Infantile colic and type of milk feeding . Am J Dis Child 1987;141 :451-3 . 71. Jakobsson I, Lindberg T. A Prospective Study of Cow's Milk Protein Intolerance in Swedish Infants. A cta Paediatr Scand 1979;68:853-9. 72. Lothe L, Lindberg T, fakobsson I. Cow's Milk Formula as a Cause of Infantile Colic: A Double-Blind Study. Pediatrics 1982;70:7-10. 73. Campbell JPM . Dietary treatment of infant colic: a double-blind study. J R Coli Gen Pract 1989;39:11-4. 74. Forsyth BWC. Colic and the effect of changing formulas : a double-blind, multiple cross-over study. J Pediatr 1989;115:521-6. 75. American Academy of Pediatrics - Committee on Nutrition. Soy Protein Formulas: Recommendations for Use in Infant Feeding . Pediatrics 1983;72:359-63. 76. Goldman AS, Anderson DW, Sellers WA, Saperstein S, Kniker WT, Halpern SR. Milk Allergy - Oral Challenge with Milk and Isolated Milk Proteins In Allergic Children. Pediatrics 1963;32:425-39. 77. Barr RG, Hanley J, Patterson DK, Wooldridge f. Breath l1ydrogen excretion in normal newbom infants in response to 11sual feeding patterns: Evidence for "functional lactase insufficiency" beyond the first month of life. J Pediatr 1984;104:257 78. Geertsma MA, Hyams jS. Colic - A Pain Syndrome of Infancy? Pediatr C/in orth Am 1989;36:905-19. 79. Miller JJ, McVeagh P, Fleet GH, Petocz P, Brand JC. Breath hydrogen excretion in infants with colic. Arch Dis Child 1989;64:725-9. 80. Liebman WM. Infantile Colic: Association with Lactose and Milk Intolerance. JAMA 1981;245:732-3. 81 . Stahlberg M , Savilahti E. Infantile colic and feeding. Arch Dis Child 1986;61 :1232-3. 82. Miller /J, McVeagh P, Fleet GH, Petocz P, Brand JC. Effect of yeast lactase mzyme on "colic" in infants fed human milk. J Pediatr 1990;117:261-3.

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Articles

83. Jakobsson I, Lindberg T, Benediktsson B, Hansson B. Dietary Bovine B-Lactoglobulin is Transferred to Human Milk . Acta Paediatr Scand 1985;74:342-5. 84. Clyne PS, Kulczycki A. Human breast milk contains Bovine IgG . Relationship to Infant Colic? Pediatrics 1991;87:439-44. 85. Evans RW, Allardyce RA, Fergusson DM, Taylor B. Matemal diet and infantile colic in breast-fed infants. Lancet 1981;1:1340-2. 86. fakobsson I, Lindberg T . Cow's Milk Proteins cause infantile colic in breast-fed infants: A double-blind crossover study. Pediatrics 1983;71:268-71. 87. Hill DJ, Hudson IL, Sheffield LJ, Shelton MJ, Menahem S, Hosking CS. A low allergen diet is a significant intervention in infantile colic: Results of a COIIIIIllmity-based study. J Allergy Clin Imnumo/1995;96:886-92. 88. Taylor WC. A Study of Infantile Colic. CMAJ 1957;76:458-61 . 89. Barr RG, Elias MF. ursing Interval and Matemal Responsivity: Effect on Early Infant Crying. Pediatrics 1988;81 :529-36. 90. Lee K. The Crying Patterns of Korean Infants and Related Factors. Dev Med Child Neuro/1994;36:601 -7. 91. Clark RL, Ganis FM, Bradford WL. A Study of the Possible Relationship of Progesterone to Colic. Pediatrics 1963;31 :65-71 . 92. Weissbluth M , Green OC. Plasma progesterone concentrations in infmJts: relation to infantile colic. J Pediatr 1983; 103:935-6. 93. Lathe L, Ivarsson SA, Lindberg T. Motilin, Vasoactive Intestinal Peptide and Gastrin in Infantile Colic. Acta Paediatr Scand 1987;76:316-20. 94. Lathe L, Ivarsson SA, Ekman R, Lindberg T. Motilin and Infantile Colic. Acta Paediatr Scand 1990;79:410-6. 95. Weissbluth M , Weissbluth L. Colic, Sleep Inertia , Melatonin and Circannual Rhythms. Med Hypotheses 1992;38:224-8. 96. Weissbluth L, Weissbluth M . The Effect of Serotonin and Melatonin in Circadian Rhythms on the Intestinal Smooth Muscle. Med Hypotheses 1992;39:164-7. 97. Weissbluth L, Weissbluth M . The Photo-Biochemical Basis of Infant Colic: Pin ea l Intracellular Calcium Concentrations Controlled by Light , M elatonin and Serotonin. Med Hypotheses 1993;40:158-64. 98. Seron-Ferre M, Ducsay CA, Valenzuela Gj. Circadian Rhythms during Pregnancy. Endocr Reviews 1993;14:594-609. 99. Kortoglu S, Ha/lac IK, Uzwn K, Coskum A 5-hydroxy-3-indole acetic acid levels in infantile colic: is serotoninergic tonus responsible for this problem? Acta Paediatr 1997; 86:164-165. 100.Holmes, CA. Infantile Colic: A Practitioner's Perspective. Clin Pediatr 1969; 8:566-569. 101. Barr RG, Kramer MS, Boisjoly C, McVey- White L, Pless lB. Parental diary of infant cry and fuss behaviour. Arch Dis Child 1988;63:380-7. 102.Lucassen PLBJ, Assendelft WJJ, Gubbels JW, van Eijk JTM, van Geldrop WJ, Knuistingh even A. Effectiveness of treatments for infantile colic: sys tematic review. BMJ 1998; 316: 1563-1569. 103.Miller AR, Barr RG. Infantile Colic- Is It a Gut Issue? Pediatr Clin North Am 1991;38:1407-23. Q

sc e ll a n e ous

Articl e s

CARDIAC

MYXOMAS By Shafie Fazel

he estimated incidence of heart neoplasms varies between 0.0017% and 0.19% in unselected patients in autopsy series. Tumor metastases to the heart are 2040 times more common than primary heart neoplasms. Of the primary tumors, three quarters are benign, and more than half of these are myxomas. In general, the preferred treatment for all cardiac tumors is surgical excision. Excision of malignant tumors, however, is frequently noncurative due to the aggressive nature of these tumors.l, 2 Recently, orthotopic heart transplantation ha s been attempted in cases of unresectable cardiac tumor with some suggestions of benefit.J

EPIDEMIOLO GY Myxomas occur in either a sporadic or familial pattem.l, 2, 4, 7 Sporadic myxomas tend to occur more often in women between the third and sixth decades of life, and are mostly single, unicentric tumors.4 Familial myxomas generally occur as part of the Carney syndrome,s an autosomal dominant familial multiple neoplasia and lentiginosis syndrome. Recently, however, a case of one famil y with a myxoma has been reported where the myxoma was not associated with manifestations of the Carney syndrome.6 Familial myxomas occur more frequently in young men, and are multicentric ( .g. hiatrial). Upon resection of the tumor, patients with familial myxoma have higher recurrence rates than patients with sporadic myxoma.s PATHOLOGY Macroscopically, myxomas are mostly gelatinous, pedunculated and mobile with areas of hemorrhage and necrosis. The amount of collagen deposition and the length of the stalk determine the mobility of these tumors. Rarely, myxomas may be sessile and villous. The fragile villous extensions of these tumors have a high propensity to break into pieces that embolize.l, 4 Microscopically, myxomas are composed of polygonal cells scattered in a myxoid matrix which is composed of a mucopolysaccharide-rich stroma. Mitotic figures are rare, and invasion of the myocardium has not been reported. Current evidence indicates that the polygonal cells are embryonal remnants of multipotential me enchymal cells that persist following the septation of the heart, and may differentiate into endothelial cells, fibroblasts, angioblasts, and myoblasts.7路 s LOCATIO N Cardiac myxomas u sually develop in the atria, with three-quarters of myxomas arising in the left atrium, mostly at the border of the fossa ovalis on the inter-atrial septum. They may also originate, in descending order of frequency, from the posterior atrial wall, the anterior atrial wall, and the atrial appendage. In less than 10% of the cases, the myxoma may arise in either of the ventricles.t, 2. 4

Despite being histologically benign, these tumors may be lethal because of their strategic location . Di stant metastases are rare, but have been reported .9, 10 These presumably occur as pieces of the tumor break up and embolize through the vascular system. Such metastatic emboli are to be distinguished from thrombotic emboli (see below).l CLINICAL PRESENTATION AND COMPLICATIONS Myxomas in the heart chambers ma y lead to thrombosis and embolism. It is estimated embolism occur in nearly half of the patients. These tend to be systemic emboli, due to the preponderance of myxomas in the left atrium, with subsequent transient or permanent blockage of cerebral, coronary and peripheral arteries. In cases of ventricular myxomas, complete obstruction of the abdominal aorta has been reported.n Clinically evident pulmonary embolization becau e of a right chamber m yx oma is surprisingly rare .l, 2, 4 The presence of peripheral arterial emboli in a patient without known heart disease or aortic aneurysm, therefore, may indicate the pre ence of a cardiac myxoma. The obstruction of blood flow by these tumors may cause syncope, left-sided heart failure or right-sided heart failure . Because these tumors are frequently pedunculated and mobile, the repeated passage of the tumor mass through cardiac valves may result in valvular damage by a "wrecking ball" effect.l Cardiac myxomas may also masquerade as a collagen vascular di ease. Fatigue, weight loss, fever, erythematous rash, arthralgia and myalgia accompany the laboratory findings of elevated CRP, ESR, autoimmune immunoglobulins (ANCA, ANA, anti-histone antibodies, anti-dsDNA antibodies}, anemia (hypochromic or normochromic}, leukocytosis, and thrombocy topenia . Myxomas may also be associated with Raynaud 's phenomenon), 4, 12, 13 In almost all cases, surgical excision of the tumor re ults in the regression of these symptoms and the normalization of laboratory values, thu s confirming that the tumor itself, or substances secreted by the tumor, are responsible for these abnormalities (see below ). Recent findings suggest that the constitutive production of IL-6 by the tumor may be the underlying cause of these constitutional symptoms (see below). Thus, myxomas cause one or more components of the triad of embolism, intra-cardiac obstruction, and constitutional symptoms. Occasionally, these tumors may also be infected, and the patient may present with signs and symptoms of endocarditis. DIAGNO SIS AND EVALUATION On auscultation of the heart, the clinician may hear a loud, widely split Sl. Occasionally, a low-pitched early diastolic sound resembling 53 or an opening snap may be heard as the tumor plops into the ventricles early in

U. W . 0. Medical Journal 70 (2) 2000

M i sce ll a n eo u s dia tole ("tumor plop"). Both ystolic and dia tolic heart murmurs may be present in more than half of the patients depending on the size, location and mobility of the tumor. Systolic murmurs occur if the tumor interferes with valve closure, or has damaged the A-V valves . Diastolic murmurs occur as the tumor interferes with blood flow from the atria into the ventricle . The change in the timing, duration, and quality of the murmurs with a change in po ition of the patients should arouse suspicion of a heart turnor.1, 2, 4 In the vast majority of ca es, echocardiography establishe the diagnosis and additional imaging modalities, such as CT scans or MRI, are not required. The locatio n, size, shape, attachment and mobility of the myxoma also need to be determined pre-operatively. In patients over 40 years of age, coronary angiography is required to as ess the status of the coronary arteries. To minimize the risk of embolization, ventriculograms should be avoided during the angiography procedure. Although the tumor may precipitate a upraventricular or ventricular arrhythmia, EKG findings are nonspecific. Che t X-rays may demonstrate igns of left-heart failure such as pulmonary congestion. Calcification of the tumor is rarely visible on a chest film.1 â&#x20AC;˘,

TREATMENT Treatment of cardiac myxomas is prompt surgical excision. The surgical procedure1, 2, 4, 14 involves: median ternotomy; the institution of cardiopulmonary bypass and cardioplegic cardiac arre t; excision of the tumor, root of the pedicle and full thickness of the adjacent inter-atrial septum; inspection of all cardiac chambers for multi-focal myxoma; repair of the atrial epal defect by suturing or pericardia} patch (depending on size of the defect); and inspection and repair or replacement of damaged valves. Care should be taken to avoid fragmenting the tumor on excision . If pre-operative coronary angiography demonstrated diseased coronary arteries, the affected ve els should be bypas ed. Intra-operative mortality i below 3%, 15, 16 and long-term prognosis is excellent. Recurrence of familial m yxomas or metastases ma y complicate long-term management.17 CARDIAC MYXOMAS AND IL-6 Hirano et al first discovered that cell-lines derived from cardiac myxomas constitutively express IL-6 in v itro.18 IL-6 is a pleiotropic cytokine with important immunological function as both an innate and an adaptive immunity mediator. Its multitude of functions include: i) induction of various acute-phase proteins in liver cells by acting as a hepatocyte-stimulating factor; ii) promotion of hematopoiesis in conjunction with IL-3; and iii) induction of B cell differentiation and production of polyclonal immunoglobulins .19 Thus, Hirano et al postulated that constitutive symp toms of cardiac myxomas and autoantibody production might be due to IL-6 expression by these tumors. This original hypothesis has been tested and verified ub equently by many investigators.20-24 In a study of 17 cardiac myxoma patients, Parissis et al showed that 14 out of the 17 patients who had significa nt autoimmune

Ar ti c l es

disorders, also had high (> 5-6 pg / mL) concentrations of IL-6.20 The RT-PCR analysis of tissue sample indicated the presence of IL-6 mRNA transcripts. Post-operatively, the IL-6 level in the affected 14 patients normalized, and the autoimmune disorders remitted. Autoantibodies, however, may not di appear immediately. One case has been reported in which ANA elevation did not remit for 9 months post-operatively in the absence of SLE or other collagen vascular diseases. 21 The circulating IL-6 levels correlate with the tumor size, as it might be expected, and a certain circulating concentration needs to be reached before constitutional sym ptoms and autoantibodies appear.22 It has recently been hypothesized that elevated IL-6 levels may be important in increasing the risk of metastasis of this tumor. Despite its low malignant potential, Wada et a[10 have reported a cardiac myxoma with high IL-6 expre sian metastasizing to the brain. The postulated mechanism involves the induction of adhesion molecule (e.g. ICAM-1), enhancement of cell-cell interactions, and promotion of the anchoring of embolic meta ta e . As such, control of IL-6 levels may be important in three respects: decreasing the constitutional symptoms; decreasing autoantibody production, autoimmune di orders and controlling their sequealea; and, putatively, decreasing the risk of metastasis which would complicate management. In a report of two cases, Sakamato and colleagues demon trated that dexamethasone inhibited the production of IL-6 in cultured cardiac myxoma cells, presumably at the post-transcriptional leveJ.23 Following this study, Vaughan and colleagues studied the affects of naproxen on a patient who on transthoracic echocardiography had a ventricular mass, which later on was diagnosed histologically as a myxoma. This patient had no abnormalitie on cardiac physical examination, but complained of a one-month history of night sweats, anorexia, arthralgia and weight loss of 31 kg. His IL-6 levels dropped from 155 pg/mL to 20 pg / mL with preoperative naproxen (250 mg BID). This was associated with complete remission of his constitutional symptoms before he received surgery.24 Evidence, thus, supports a causative role for IL-6 in inducing constitutive symptoms and auto-immune disorder in cardiac myxoma patients. The multi-potential mesenchymal cells of the myxoma may differentiate into fibroblasts, endothelial cells, vascular smooth muscle cells,19 etc., that are capable of producing this cytokine. IL6 expression may be controlled with anti-inflammatory agents, and this might prove beneficial in treatment of preoperative cardiac myxoma patients. Nonethele s, surgical excis ion is the mainsta y of treatment and should be performed within days of the diagnosis being made. SUMMARY Despite being histologically benign, cardiac myxomas may be lethal becau e of their strategic location. The morbidity and mortality associated with this disease is very high, and surgery is curative. Hence, prompt diagnosis of this tumor is crucial. In many instances,

U. W.O. Medical Journal 70 (2} 2000 - - - - - - - - - - - - - - - - - - - - - - - -

M i scellaneous

Art i c l es

however, patients with this disease may present without an y cardiac finding s and onl y w ith cons titutional sy mptom s . Cardiac m yx oma, therefore, s ho u ld be included in the differential diagnosis of any con dition presenting with au toimmune features . The role of antiinflammatory agents in the pre-operative treatm ent of patients remains unclear, and such treatment should not dela y prompt s urgical inter v en tion . Al though it is plausible that elevated IL-6 levels may be instrumental in mediating metastasis of this tumor, it will be very difficult to test this h y po the s is becaus e of the r a rity o f the metastases. ACKNO~EDGEMrn NTS

The au thor wishes to thank Dr. R.J. Novick, Ian Ozard, and Jay Adlington for their constructive criticism. REFERENCES 1. Novick RJ, and Dobell ARC. Tumors of the Heart. In Baue AE, Cella AS, Hammond GC, Laks H, Naunheim KS , eds . Glenn's Thoracic and Cardiovascular Surgery. 5th ed. Norwalk, Connecticut: Appleton & Lange, 1991, pp 1989-2002 2. Majano-Lainez RA . Cardiac Tumors: A Current Clinical and Pathological Perspective. Clinical Reviews in Oncogenesis 1997; 8(4):293-303 3. Michler RE, and Goldstein DJ. Treatment of Cardiac Tumors by Orthotopic Cardiac Transplantation . Seminars in Oncology 1997; 24(5):534-9 4. Reynen K. Cardiac Myxomas . The N ew England Journal of Medicine 1995; 333(24):1610-1617 5. Singh SD, and Lansing AM. Familial Cardiac Myxoma : A Comprehensive Review of Reported Cases . Kansas Medical Association Journal1996; 94:96-104 6. Dandolu BR, lyer KS, Das B, and Venugopal P. Nonsyndrome Familial Atrial Myxoma in Two Generations. Journal of Thoracic and Cardiovascular Surgery 1995; 110:8724 7. Tanimura A, Kitazono M, Nagayama K, Tanaka S, and Kosuga K. Cardiac Myxoma: Morphological, Histochemical, and Tissue Culture Studies. Human Pathology 1988; 19(3):316-322 8. Lie JT. The Identity and Histogenesis of Cardiac Myxomas: A Controversy Put to Rest . Archives of Pathology and Lab Medicine 1989; 113:724-6 9. Diflo T, Cantelmo NL, Haudenschild CC, and Watkins MT. Atrial Myxoma With Remote Metastasis : Case Report and Review of the Literature. Surgery 1992; 111 :352-6 10. Wada A, Kanda T, Hayashi R, Imai S, Suzuki T, and Murata K. Cardiac Myxoma Metastasized to the Brain: Potential Role of Endogenous Inter/eukin-6. Cardiology 1993; 83:208-11 11 . Young RD, and Hunter WC. Primary Myxoma of the Left Ventricle with Embolic Occlusion of the Abdominal Aorta and Renal Arteries. Archives of Pathology 1947; 43 :86-91 12. Fitzpatrick AP, Lanham JG, and Doyle DV. Cardiac Tumours Simulating Collagen Vascular Disease. British Heart Journal 1986; 55:592-5 13. Byrd WE, Matthews OP, and Hunt RE. Left Atrial Myxoma Presenting as a Systemic Vasculitis. Arthritis and Rheumatism 1980; 23(2):240-3 14. Poole A V, Breyer RH, Holliday RH, Hudspeth AS, Johnston FR, Cordell AR, and Mills SA. Tumors of the Heart: Surgical Considerations. Journal of Cardiovascular Surgery 1984; 25:511 15. Hanson EC, Gill CC. Razavi M , and Loop FD . The Surg ical Treatment of Atrial Myxomas . Journal of Thoracic and Cardiovascular Surgery 1985; 89:298-303 16. Fang B, Chiang C, Hung J, Lee Y , and Chang C. Cardiac Myxoma -Clinical Experience in 24 Patients. International Journal of Cardiology 1990; 29:33541 17. Gray IR, and Williams WG. Recurring Cardiac Myxoma. British Heart Journal1985; 53:645-9

18. Hirano T, Taga T, Yasukawa K, Nakajima K, Nakano N, Takatsuki F, Shimizu M, Murasl!ima A, Tsunasawa S, Sakiyama F, and Kishimoto T. Human B-cell Differentiation Factor Defined by an Anti-peptide Antibody and its Possible Role in Autoantibody Production . Proceedings of the National Academy of Science USA 1987; 84:228-31 19. Kisl!imoto T, Akira S, and Taga T . Interleukin-6 and its Receptor: A Paradigm for Cytokines. Science 1992; 258:593-7 20. Parissis JT, Mentzikof D, Georgopolou M , Gikopoulos M , Kanapitsas A, Merkouris K, and Kefalas C. Correlation of Inter/eukin-6 Gene Expression to Immunologic Features in Patients with Cardiac Myxoma . Journal of Interferon and Cytokine Research 1996; 16:589-593 21. Wang HJ, Chang HN, Yu CL, Tsai CY, and Shih CM. Prolonged Elevation of Antinuclear Antibodies in a Patient With Atrial Myxoma after Tumor Extirpation. Clinical and Experimental Rheumatology 1995; 13(5):676-7 [Letter] 22. Soeparwata R, Poem/ P, Schmid C, Neuhof H, and Scheid H. Interleukin-6 Plasma Levels and Tumor Size in Cardiac Myxoma. The Journal of Thoracic and Cardiovascular Surgery 1996; 112(6): 1675-1677 23. Sakamoto H, Sakamaki T, Wada A, Nakajima T, Kanda T, and Murata K. Dexamethasone Inhibits Production of Inter/eukin-6 by Cultured Cardiac Myxoma Cells. American Heart Joumal1994; 127(3):704-5 24. Vaughan CJ, Gallagher M , and Murphy MB. Left Ventricular Myxoma Presenting with Constitutional Symptoms and Raised Serum Interleukin-6 both Suppressed by Naproxen. European Heart Journal 1997; 18:703 [Letter]

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