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Purpose: To compare three anxiety scales; the anxiety visual analogue scale (VAS), the anxiety component of the Amsterdam preoperative anxiety and information scale (APAIS), and the state portion of the Spielburger state-trait anxiety inventory (STAI), for assessment of preoperative anxiety levels in same day admission patients., Methods: Patients completed the three anxiety assessment scales both before and after seeing the anesthesiologist preoperatively. The scales used were the STAI, the six-question APAIS, and the VAS. APAIS was further subdivided to assess anxiety about anesthesia (sum A), anxiety about surgery (sum S) and a combined anxiety total (i.e., sum C = sum A + sum S). These scales were compared to one another. Pearson's correlation (pair-wise deletion) was used for validity testing. Cronbach's alpha analysis was used to test internal validity of the various components of the APAIS scale. A correlation co-efficient (r) > or = 0.6 and P < 0.05 were considered significant., Results: Four hundred and sixty three scale sets were completed by 197 patients. There was significant and positive correlation between VAS and STAI r = 0.64, P < 0.001), VAS and APAIS r = 0.6, P < 0.001), sum C and STAI r = 0.63, P < 0.001) and between VAS and sum C r = 0.61, P < 0.001). Sum C and STAI r value were consistent with repeated administration. Cronbach's alpha-levels for the anxiety components of the APAIS (sum C) and desire for information were 0.84 and 0.77 respectively., Conclusion: In addition to VAS, the anxiety component of APAIS (sum C) is a promising new practical tool to assess preoperative patient anxiety levels.

Background: Osteoporosis is a health care issue in which family physicians play a major role. Although awareness of osteoporosis is high, recent studies suggest that application of recent advances in its treatment to the clinical setting may be low. We have developed a problem-based learning intervention for osteoporosis in which paired rheumatologists and family physicians developed nine problem-solving clinical scenarios. An educational matrix was used to link specific case scenarios with individual teaching objectives, developed via a previous needs assessment. Family physicians participated in the workshop, developing best practice responses to the clinical scenarios with a trained facilitator and content expert., Methods: To assess the impact of this intervention, family physicians participated in a pre- and post-test evaluation, using objective structured clinical examinations and standardized patients. Objective structured clinical examination stations tested knowledge, skills, and judgment relating to osteoporosis with respect to risk factors, use of appropriate investigations including bone mineral densitometry (BMD), strategies for the prevention of osteoporosis (both pharmacologic and nonpharmacologic), treatment options for established osteoporosis (bisphosphonates and hormone replacement therapy), and management of recent osteoporosis fracture. Participants were evaluated using a predetermined score generated by their responses to objective structured clinical examinations and standardized patients (max. score = 101). Evaluations were conducted anonymously, although participants had access to their own pre- and post-test results for personal feedback. The impact of the workshop was assessed by comparing pre- and post-test responses by group, by individual, and by station., Results: Participants demonstrated a significant improvement in their post-workshop scores. Of 40 participants, 26 showed improvement in score (> +10), 13 showed modest change (+1 to +10), and 1 showed a marked decrease (> -10). The greatest improvements were seen in the management of the male osteoporosis patient, determination of risk factors for osteoporosis, and the use and interpretation of bone mineral densitometry. Family physicians reported general satisfaction with the content and format of both the workshop and the evaluation process., Implications: We conclude that this type of problem-based learning intervention workshop results in improved knowledge, skills, and judgment in the management of osteoporosis by family physicians as objectively assessed using a pre- and post-test format including objective structured clinical examinations and standardized patients.

Purpose: To clarify the recent perception of shortfalls in anesthesia physician resources, two models were used to assess these resources in Ontario, Canada., Methods: Two models, demand-based and benchmarking, were used. In the demand-based model estimated future supply and attrition were obtained from information on Ontario Ministry of Health funded trainees. Data from the Canadian Residents Matching Service and the Association of Canadian University Departments of Anesthesia were also used. Current demand was identified from a telephone survey of Departments of Anesthesia in ten Ontario cities. The number of anesthesia practitioners in Ontario was estimated from the 1996 Canadian Anesthesiologists' Society Physician Resource Database (CASPRD) in the demand-based model. In the benchmarking model, using Alberta as the closest published analogue to Ontario, the annual specialist growth rate in Ontario since 1986 was calculated in the literature as 2.8%/yr for 1986-1994. The number of anesthesiologists in Ontario from the 1986 CASPRD was used to calculate need based on that growth rate. Results are compared with population to anesthesiologist (P/A) ratios calculated from Statistics Canada population data and physician numbers from CASPRD., Results: A shortfall in the number of anesthesiologists has been identified. The P/A ratio worsened by 17.6% from 1986 to 1996. The demand-based model indicated that the shortfall is increased from a current deficit of 40 to 68 by 2005, using CASPRD. Benchmarking showed that the estimated shortfall in 1994 was 131., Conclusion: This conservative approach indicates that the shortfall in anesthesiologist physician resources will worsen by 2005.

Objective: To develop and evaluate a practice based small group (PBSG) learning intervention on osteoporosis for primary care physicians., Methods: A needs assessment on osteoporosis was performed and objectives for a continuing medical education (CME) program developed by an interdisciplinary advisory committee. Nine clinical cases were developed for evaluation by CME participants with a trained facilitator and content expert using the PBSG format. The effect of the CME intervention was evaluated using a pre and post-test consisting of objective structured clinical examination stations and standardized patients., Results: Fifty-four family physicians participated in 4 pilot PBSG learning sessions. The program format, content, and participant satisfaction was highly rated (> 3.35:4.0). Participants expected the program to have a significant effect on the practices (3:40:4.0). Ninety-eight percent of participants improved their pretest scores, with a mean increase of 13% (range 1-36%)., Conclusion: Based on our experience, we advocate the use of PBSG learning interventions as an effective and acceptable method of providing CME by rheumatologists for their family physician colleagues. This format appears to be associated with a significant effect on knowledge, skills, and behavior as assessed by our study.

Purpose: To report physician resource information from the 1996 national anesthesia physician and residency programme surveys in Canada. The findings are used to discuss the potential effects on availability of future specialist anesthesia services in Canada., Methods: Twenty-six hundred and ninety-three physicians (2,206 specialists, 487 family physicians) providing anesthesia services were surveyed. Information on demographics and patterns of clinical practice were sought. Anesthesia programme directors provided trainee information. Projections of the potential number of practicing anesthesiologists to 2026 were made based on the number of available training positions and age distribution of anesthesiologists., Results: There was a 58.3% response rate to the national survey. Since 1986 there has been a 10% increase in the number of specialist anesthesiologists. Marked regional variations in age distribution and changes in the number of specialist anesthesiologists were noted. Most specialists remain in the region or province of postgraduate training. Sixty percent of specialists were either re-entry trainees or international medical graduates. Changes in anesthesia practice patterns have resulted in 40% of the anesthesiologist's work now occurring outside of the operating room. Anesthesia training positions have decreased by at least 15%. The population of Canada is projected to increase by 33.8% between 1996 and 2026. If current government and position allocation policies continue, it is projected there will be 0% increase in the number of specialist anesthesiologists over the same time period., Conclusions: Changes in anesthesia practices have exacerbated the current shortages of anesthesiologists. These shortages will worsen if the number of, and restrictions to, available residency positions is unchanged.

Most organized physician continuing educational activities are undertaken without assessing their effects on long-term changes in physician practice patterns, patient outcomes or return on investment. Practice audit and practice self-appraisal are two activities that can be used to achieve these objectives. It is recommended that these be promoted from an educational perspective. A series of principles, including the mandatory application of practice audit and practice self-appraisal are proposed to guide the process. The identification of issues relating to learning, diffusion of information and behavioural change required to facilitate this change are briefly discussed.

The issue of mandatory continuing medical education (CME) is controversial. Traditional measures mandate only attendance, not learning, and have no measurable performance end points. There is no evidence that current approaches to CME, mandatory or voluntary, produce sustainable changes in physician practices or application of current knowledge. Ongoing educational development is an important value in a professional, and there is an ethical obligation to keep up to date. Mandating self-audit of the effect of individual learning on physician's practices and evaluation by the licensing authority are effective ways of ensuring the public are protected. The author recommends the use of a personal portfolio to document sources of learning, the effect of learning and the auditing of their applications on practice patterns and patient outcomes. A series of principles are proposed to govern its application.

The purpose of this study was to compare two anaesthetic protocols for haemodynamic instability (heart rate (HR) or mean arterial pressure (MAP) < 80 or > 120% of ward baseline values) measured at one-minute intervals during carotid endarterectomy (CEA). One group received propofol/alfentanil (Group Prop; n = 14) and the other isoflurane/alfentanil (Group Iso; n = 13). Periods of haemodynamic instability were correlated to episodes of myocardial ischaemia as assessed by Holter monitoring (begun the evening before surgery and ceasing the morning of the first postoperative day). In Group Prop, anaesthesia was induced with alfentanil 30 micrograms.kg-1 i.v., propofol up to 1.5 mg.kg-1 and vecuronium 0.15 mg.kg-1, and maintained with infusions of propofol at 3-12 mg.kg-1.hr-1 and alfentanil at 30 micrograms.kg-1.hr-1. In Group Iso, anaesthesia was induced with alfentanil and vecuronium as above, thiopentone up to 4 mg.kg-1 and maintained with isoflurane and alfentanil infusion. Phenylephrine was infused to support MAP at 110 +/- 10% of ward values during cross-clamp of the internal carotid artery (ICA) in both groups. Emergence hypertension and/or tachycardia was treated with labetalol, diazoxide or propranolol. Myocardial ischaemia was defined as ST-segment depression of > or = 1 mm (60 msec past the J-point) persisting for > or = one minute. For the entire anaesthetic course (induction to post-emergence), there was no difference between groups for either duration or magnitude outside the < 80 or > 120% range for HR or MAP. However, when the period of emergence from anaesthesia (reversal of neuromuscular blockade to post-extubation) was assessed, more patients were hypertensive (P = 0.004) and required vasodilator therapy in Group Iso (10/13 vs 5/14; P = 0.038 Fisher's Exact Test). The mean dose of labetalol was greater in Group Iso (P = 0.035). No patient demonstrated myocardial ischaemia during ICA cross-clamp. On emergence, 6/13 patients in Group Iso demonstrated myocardial ischaemia compared with 1/14 in Group Prop (P = 0.029). Therefore, supporting the blood pressure with phenylephrine, during the period of ICA cross-clamping, appears to be safe as we did not observe any myocardial ischaemia at this time. During emergence from anaesthesia, haemodynamic instability was associated with myocardial ischaemia. Under these specific experimental conditions, with emergence, hypertension and myocardial ischaemia were more prevalent with more frequent pharmacological interventions in patients receiving isoflurane.

This study was undertaken with the objective of assessing current sources of information for anaesthesia Physician Resource Planning (PRP). Four major data bases, the annual reports of Health and Welfare Canada (H&W), the education statistics from the Canadian Post-M.D. Education Registry (CAPER), the Royal College of Physicians and Surgeons of Canada (RCPSC) and the Physician Resource Data System of the Canadian Medical Association (PRDS), were examined for the period 1982 to 1991. The ratio of the number of surgical (S) to anaesthesia (A) clinicians decreased over this period despite an increase in the S:A ratios for trainees and certificants. The number of female anaesthetists has progressively increased. A steady decline in the number of rural anaesthetists has occurred. Age distribution of active certified anaesthetists revealed marked inter-regional differences. Little change was noted in the total mean hours worked per week. Each database provided valuable, but limited, data. The PRDS data is useful in assessing trends (age, sex and practice activity). Information provided by H&W tends to underestimate anaesthesia resource information by at least 10%. While information obtained from RCPSC and CAPER is accurate, the current mode of presentation of data limits their usefulness. Integrating data from all the databases appears to provide a meaningful assessment for PRP rather than assessing each database in isolation. Interpretation of the information and its value must take into account the limitations of the data being provided. Assessing present and planning future needs based on the current information structure will prove extremely difficult.

The shift to direct entry into residency training from medical school for all graduates will offer new challenges for anaesthesia training programmes. In this paper we argue that it also offers us an opportunity to re-evaluate our current approach to anaesthesia education. Emphasis in the residency programmes should be to provide trainees with clinical experiences and stimulation that will develop the required traditional competencies. It should also cultivate competency in clinical decision-making, intuition and judgement. Our purpose is to generate discussion by proposing an alternate curriculum model, the experiential curriculum. The basic premise is that learning is a process and outcome is to a large extent related to what the learner does. The process begins with an experience that provides for observation and reflection. Integration of the thoughts provides the basis for executing either existing or new actions. In the experiential curriculum residency training and learning are enhanced by documenting and critically evaluating the experiences to which the resident is exposed. Included within such a structured programme are the methodologies of problem-based and evidence-based learning. Faculty development will be required to help the resident pursue these skills of self-evaluation and efficient learning. We believe that incorporation of an experiential curriculum into the residency training programme will achieve the goals listed above and allow maturation of the process of lifelong learning. It will also allow greater achievement of the application of new information to one's practice.

The ability of continuous infusions of opioids to control hypertension at the end of neurosurgical procedures without compromising prompt emergence was studied in patients undergoing craniotomy for supratentorial tumours. Four infusion regimens were compared in a randomized double-blind fashion; three of alfentanil and one of fentanyl. Low-dose alfentanil was administered to nine patients (35.1 micrograms.kg-1 then a continuous infusion of 16.2 micrograms.kg-1.hr-1); mid-dose alfentanil to eight patients (70.2 micrograms.kg-1 then 32.4 micrograms.kg-1.hr-1); high-dose alfentanil to eight patients (105.3 micrograms.kg-1 then 48.6 micrograms.kg-1.hr-1). Eight additional patients were given fentanyl (8.3 micrograms.kg-1 then 1.6 micrograms.kg-1.hr-1). Using published values for the pharmacokinetic variables of alfentanil and fentanyl, modelling predicted stable concentrations of 60, 120, 180 ng.ml-1 for the alfentanil infusion regimens respectively and 2 ng.ml-1 with the fentanyl regimen. Maintenance anaesthesia comprised the opioid infusion, 50% N2O in O2 and isoflurane titrated to control mean arterial pressure (MAP) within 20% of ward MAP. Isoflurane was discontinued after closure of the dura. Nitrous oxide was discontinued at the same time as reversal of neuromuscular blockade. The opioid infusion was discontinued with closure of the galea. A greater time-averaged isoflurane concentration was required to control MAP within the prescribed limits in the low alfentanil group (ANOVA; P less than 0.05). The PaCO2 at two, five and 30 min after extubation were not different among groups. The times from discontinuing N2O to eye opening and tracheal extubation were not different. The time to follow commands was longer in the low alfentanil group (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Three cases of chlorpropamide overdose are reported. Plasma levels of chlorpropamide, diazoxide, glucose, and insulin are presented for each patient during treatment. The simultaneous analysis of chlorpropamide, hydrochlorothiazide, and diazoxide in plasma by high pressure liquid chromatography (HPLC) is also reported. Although all three cases presented at hospital with potentially lethal plasma levels of chlorpropamide, each was successfully treated with intravenous diazoxide and glucose. Plasma diazoxide concentrations between 50-100 microgram/mL appear to be optimal in achieving therapeutic control of chlorpropamide induced hypoglycemia.

The use of the Esophageal Obturator Airway (EOA) was prospectively studied in 300 cases of prehospital cardiac arrests. Seventy-seven complications were documented in 72 patients. Inadvertent tracheal intubation occurred in 72 patients. Inadvertent tracheal intubation occurred in 13 patients, five unrecognized. No differences were found when initial emergency room rhythm and resuscitation outcome were compared to a previous study using the oral airway (OA). A subgroup of 124 EOA and 55 OA patients were compared. The EOA was effective in reducing the frequency of aspiration (17 vs 34 per cent). Arterial oxygenation was similar, and rose in both groups following tracheal intubation. Esophageal trauma was found in 10 per cent of the EOA patients who underwent autopsy. Although the EOA is useful in prehospital emergency care, the only advantage for this technique in comparison to the OA is the prevention of aspiration of gastric contents. It also appears that other techniques of advanced cardiac life support, i.e. defibrillation, drug therapy, etc. are necessary to improve survival statistics.

Gastric rupture following ventilation during cardiopulmonary resuscitation is a rare occurrence. We report two cases of documented gastric rupture plus two additional cases in which the clinical diagnosis of pneumoperitoneum was made and gastric rupture was assumed to be the mechanism. Review of the literature reveals the lesser curvature of the stomach to be the common site of rupture. This complication emphasizes the necessities of correct positioning of the jaw with mouth-to-mouth ventilation and careful assessment of air entry and chest movement following endotracheal intubation.

Access to an ambulance service trained to provide only basic cardiac life support (BCLS) and adjunctive ventilation with oxygen provided the opportunity to study cardiac rhythms during BCLS in patients with circulatory arrest. Holter monitoring was attempted in 43 patients. Technically adequate traces throughout transport to hospital were obtained in 21. The average monitored time was 11.9 minutes. A tachydysrhythmia (mainly VF/VT) was initially found in 10, heart block or bradycardia in 9, and asystole in 2 persons. During BCLS, six patients with bradycardic rhythms converted temporarily to VF. The first ECG tracing obtained in the hospital revealed, however, that only five were still in a tachydysrhythmia and 15 were asystolic. These data demonstrate that important rhythm changes occur when BCLS is continued for several minutes during circulatory arrest. Although some bradycardic rhythms convert to VF, the VF is not sustained. After an average of 12 minutes, 90% of those initially in bradycardic rhythm and 50% of those initially in VF/VT were asystolic. This study provides further evidence that BCLS does not prevent cardiac deterioration.

Resuscitation outside of hospital of victims of cardiac arrest is a major challenge to our emergency care system. Most cities in Canada do not have a mobile advanced life support service; instead they rely on basic life support outside of hospital. The outcome in such cases and the factors affecting the outcome are largely unknown. Thus, it is difficult to estimate the lifesaving potential of adding advanced life support to the existing measures available for care outside of hospital.A prospective study of all resuscitation attempts begun outside of hospital was conducted during 18 consecutive months in 1977-78 in Winnipeg; at that time only basic life support was available outside of hospital. Resuscitation was attempted 849 times, and 33 patients (4%) survived to be discharged from hospital. Data analysis revealed that: (a) none of the 58% of patients in asystole at the time of arrival at a hospital survived to be discharged, but 11% of the patients with ventricular fibrillation or tachycardia (27% of the entire group) survived; (b) the survival rate was lower when the interval from the emergency telephone call to the patient's arrival at the hospital exceeded 10 minutes; and (c) basic life support was begun immediately in 29% of the patients with ventricular fibrillation or tachycardia, and increased the survival rate fivefold.The training of private citizens in basic life support is a vital component of total emergency cardiac care. A mobile advanced life support service will be effective in saving lives if it reduces the delay before definitive care is instituted, preferably to less than 10 minutes.

This article studies the process of decision making used to arrive at decisions to withdraw treatment in the adult and neonatal intensive care unit. The emerging role of team decision making is described as a cumulative process of dialogue between the health care team and the patient's family (including the patient in some cases).

The use of atracurium during anaesthesia for abdominal hysterectomy in a 37-year-old patient with homozygous plasma cholinesterase [EsEs] deficiency is described. Intubation was achieved utilizing 0.47 mg X kg-1 of atracurium. Subsequent doses of 0.08 mg X kg-1, 0.12 mg X kg-1 and 0.12 mg X kg-1 were given 34, 57 and 78 minutes respectively after the initial dose. At the time of reversal of the residual effects of neuromuscular blockade, 26 minutes after the last dose, spontaneous respiration had resumed. The duration of action of the drug was not different from that described in normal patients. Atracurium would appear to be a safe drug to provide neuromuscular relaxation in patients with plasma cholinesterase deficiency, where surgical procedures of intermediate duration are being undertaken.

The resuscitation experience of a large teaching hospital during 1973-77 was reviewed. Resuscitation was attempted on 2091 victims of cardiac arrest; 261 patients (12.5%) survived to be discharged from hospital.Coronary heart disease caused about one half of all the cardiac arrests, but was associated with a better survival rate (14.4%) than the other causes. Cardiac arrest following multiple trauma had the worst prognosis; only 3% of the patients survived to be discharged from hospital. However, the main factor influencing outcome was the site of arrest. The survival rates of patients on whom resuscitation was initiated in the emergency room or an intensive care area were triple and double the rate for patients in hospital wards, although one third of all the cardiac arrests induced by a coronary event and occurring in hospital were on the wards. Patients whose arrest occurred outside hospital, where only basic life support was available, had a survival rate of just 6.3%, whereas those whose arrest occurred in the emergency room had a survival rate of 31.9%. Since these two patient groups were similar in terms of age and diagnosis, we believe that the potential survival rate for victims of cardiac arrest outside of hospital that are optimally treated is close to 30%.These data suggest that increased survival from cardiac arrest can be expected with extension of the resuscitation services both inside and outside of hospital, but particularly with increased emphasis on emergency cardiac care outside of hospital.

Pre-hospital self-administered analgesia using a 50:50 mixture of nitrous oxide and oxygen (Entonox) was evaluated in 240 patients. Of these, 93.4 per cent experienced either complete or partial relief from traumatic, chest, abdominal or back pain. Drowsiness was the most common side effect noted. No complications occurred during delivery of the mixture. Attention is drawn to the effect of extreme temperatures on the Entonox mixture and recommendations are made with respect to its use below-freezing climates. Because of its ease of use and short duration of action, Entonox appears to be well suited for the treatment of pre-hospital pain by Emergency Medical Technicians.