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PubMedDate not supplied

[A model for monitoring drug prescribing in general practice].

When prescribing drugs, general practitioners at the same should satisfy the requirements of medical science and their vocation, being aware of their task of a rational disposal of the limited resources allocated for health care. The aim of the paper was to determine the characteristics of monitoring model for drug prescription in general practice, taking into consideration the characteristics of the population, morbidity, drugs and physicians. A prospective monitoring of prescribing drug during one month was carried out in six doctor's offices of general practice/family medicine at the Dugave-Travno Health Station of the Novi Zagreb Health Center. In processing data on patients, drugs and physicians the following were used: distribution description and analysis, pair's tests and General Factorial Anova. Out of 3397 patients who visited the above mentioned doctor's offices, 2320 (68.3%) patients were prescribed 4796 prescriptions--an average of 2.07 prescriptions per patient (from 2.00 to 2.42). The total cost of drug prescription was 360,117.33 kunas (from 43,632 to 77,910 kunas). The number of prescriptions and the cost of prescribed drugs increased significantly in terms of statistics with the age of patients (Spearman's correlation coefficient 0.2263; p < 0.001). By General Factorial Anova statistically significant difference was determined in the cost variable among the physicians with the impact of covariate age and number of prescriptions. Professionally, the most appropriate and most rational prescribing was observed among physicians who had the highest educational level and the longest experience in practice. In order to analyze and assess the appropriatness of drug prescription in general practice, the first essential step is to collect data on what is being prescribed, for whom it is being prescribed, and to enable access to data for physicians. This paper has indicated some of the characteristics of a monitoring model for drug prescription in general practice. Formulation and implementation of this model would considerably promote the professional appropriateness and rationality in drug prescription in general practice.

Adolescent↗
PubMed2000

An investigation of patient management methods used for orthodontic extractions by general dental practitioners in north west England.

OBJECTIVE: To quantify the patient management methods used by dental practitioners for orthodontic extractions and to determine what factors influence their choice of method. DESIGN: Practitioners working in the General Dental Service in the area of the former North West Regional Health Authority were randomly sampled and sent a postal questionnaire. SETTING: General Dental Service in the North West of England. SUBJECTS: 204 completed questionnaires were returned; a response rate of 71.1%. INTERVENTIONS: Practitioners were asked about the patient management methods that they used for orthodontic extractions and what factors were important in choosing to use a general anaesthetic. OUTCOME MEASURES: The mean percentages of patients treated with local anaesthetic alone, general anaesthesia and inhalation sedation with local anaesthesia were calculated for the sample. Factors influencing the choice of method used were scored by the practitioners on a ten point scale. RESULTS: Local anaesthesia alone was used for two thirds of orthodontic extraction patients and general anaesthesia for one third. Inhalation sedation was rarely used. Poor patient cooperation and a nervous patient were the most important factors in choosing a general anaesthetic. CONCLUSIONS: Local anaesthesia is used for the majority of orthodontic extractions. However there remains an overuse of general anaesthesia and an underuse of inhalation sedation.

Anesthesia, Dental↗
PubMed1998

Are generalized and localization-related epilepsies genetically distinct?

BACKGROUND: Whether the genetic influences are distinct for generalized and localization-related epilepsies or whether some susceptibility genes raise the risk for both types of epilepsy is uncertain. OBJECTIVE: To evaluate genetic heterogeneity in epilepsy. METHODS: We used Cox proportional hazards analysis to compute rate ratios (RRs) for generalized and localization-related idiopathic or cryptogenic epilepsy in the first-degree relatives of 1498 adult probands with idiopathic or cryptogenic epilepsy ascertained from voluntary organizations. The reference group comprised the first-degree relatives of 362 probands from the same study with postnatal symptomatic epilepsy in whom the genetic contributions appear to be minimal. RESULTS: In the parents and siblings, the risk for all idiopathic or cryptogenic epilepsy was greater if the proband's epilepsy was generalized than if it was localization-related (RR, 4.7 vs 2.4). However, in the parents and siblings of each group of probands, the increased risk was not restricted to the same type of epilepsy as in the proband. The results differed in offspring, with a greater risk for all types of epilepsy if the proband's epilepsy was localization-related than if it was generalized (RR, 4.2 vs 1.6) and a greater risk for localization-related epilepsy than for generalized epilepsy (RR, 7.8 vs 1.8) if the proband's epilepsy was localization-related. CONCLUSIONS: These findings in parents and siblings suggest that some susceptibility genotypes raise the risk for both generalized and localization-related epilepsies but are more common in persons affected with generalized epilepsy. The different findings in offspring may reflect a different influence on susceptibility in that subgroup.

Adolescent↗
PubMed1999

Laparoscopic gastrostomy and jejunostomy: safety and cost with local vs general anesthesia.

BACKGROUND AND HYPOTHESIS: General anesthesia is used for laparoscopic enteral access because pneumoperitoneum requires relaxation of the abdominal muscles. We wanted to determine whether these procedures could be performed with similar results and cost under local anesthesia. DESIGN: Randomized controlled study with 30-day follow-up including a cost-benefit analysis. SETTING: University-affiliated hospitals. PATIENTS: Forty-eight patients (32 men, 16 women; mean age, 67 years) undergoing laparoscopic gastrostomies (n = 32) and jejunostomies (n = 16). INTERVENTION: Twenty-four patients underwent laparoscopic gastrostomy (n = 15) and jejunostomy (n = 9) under local anesthesia with intravenous conscious sedation and monitored anesthesia care. Twenty-four patients had general anesthesia. MAIN OUTCOME MEASURES: Conversion to general anesthesia, complications, and cost. RESULTS: Ten patients under local anesthesia had periods of deep sedation and 1 required conversion to general anesthesia. One patient under general anesthesia required conversion to open gastrostomy. No patients had intraoperative aspiration; however, 4 aspirated after the procedure. One patient died of myocardial infarction during the 30-day follow-up. We found no significant difference in the total mean cost and actual procedure time. The surgeon's fee accounted for 31% of the total cost. CONCLUSIONS: Some patients undergoing laparoscopic enteral access may require deep sedation and a rare patient may require general anesthesia. Clinical conditions and surgeon preference, therefore, should determine whether local anesthesia is suitable for laparoscopic gastrostomies and jejunostomies, and in what setting, since there is no difference in success rate or complications when compared with general anesthesia. Potential savings are possible from the operating room (26% of total cost) or anesthesiologist (12% of total cost) if these procedures are performed in an endoscopy suite without monitored anesthesia care.

Aged↗
PubMed2002

The state of general surgery residency in the United States: program director perspectives, 2001.

HYPOTHESIS: Current demographic patterns and lifestyle factors of general surgery residents may contribute to recent changes in recruitment patterns. DESIGN: Survey addressing the characteristics of general surgery residency, including demographic data, 3-year recruitment and retention trends, and working conditions of general surgery residents. PARTICIPANTS: A convenience sample of all residency program directors in attendance at the 2001 Surgical Education Week was given the opportunity to voluntarily complete the survey. RESULTS: A total of 109 program directors responded to the survey. Women constitute 25% of all current general surgery residents: 66% of the program directors perceived a decline in the number of applicants for general surgery residency. Recruitment patterns differ significantly between small (< or =4 categorical residents per year) and large (>4 categorical residents per year) residency programs. Residents at large programs averaged a 95-hour workweek, whereas those at small programs averaged an 88-hour workweek (P =.01). The mean 1-year attrition rate for general surgery residents was 20.2% in 2000, and attrition showed no relationship to program size, gender composition, or working conditions. CONCLUSIONS: Women remain underrepresented in general surgery residency. Recruitment and match statistics show some variation, but the relevance of a shrinking applicant pool to these changes is unclear. Resident working conditions remain a difficult issue, and attrition rates continue to be significant. A substantial research agenda remains in graduate surgical education.

Attitude of Health Personnel↗
PubMed1999

Effects of stimulus preexposure on the generalization of conditioned taste aversions in infant rats.

Generalization of a conditioned taste aversion in infant rats and how this is affected by stimulus preexposure was investigated in a series of experiments. In Experiment 1 generalization of a conditioned aversion between two tastes (sweet and salty) was found, and the effect of tastes preexposure was a reduction in generalization (Experiment 2). However, when these tastes were combined with a common taste (acid) that was less (Experiment 3) or more intense (Experiment 3b), the effect of stimulus preexposure was a stronger generalization of the conditioned aversion. In this case, a reduction on generalization was again observed by increasing the number of preexposure trials to the taste compounds (Experiment 4). In all cases the generalization levels were directly related to the effect of stimulus preexposure on the acquisition rate of conditioning. It can be concluded that, with the appropriate parameters, a reduction of generalization of a conditioned taste aversion can be obtained after taste exposure in preweanling rats.

Animals↗
PubMed2002

Intensity generalization: physiology and modelling of a neglected topic.

I briefly review empirical data about the generalization of acquired behaviour to novel stimuli, showing that variations in stimulus intensity affect behaviour differently from variations in characteristics such as, for instance, visual shape or sound frequency. I argue that such differences can be seen already in how the sense organs react to changes in intensity compared to changes in other stimulus characteristics. I then evaluate a number of models of generalization with respect to their ability to reproduce intensity generalization. I reach three main conclusions. First, realistic stimulus representations, based on knowledge of the sense organs, are necessary to account for intensity effects. Models employing stimulus representations too remote from the sense organs are unable to reproduce the data. Second, the intuitive notion that generalization is based on similarities between stimuli, possibly modelled as distances in an appropriate representation space, is difficult to reconcile with data about intensity generalization. Third, several simple models, in conjunction with realistic stimulus representations, can account for a wide array of generalization phenomena along both intensity and non-intensity stimulus dimensions. The paper also introduces concepts which may be generally useful to evaluate and compare different models of behaviour.

Animals↗
PubMed1985

General hospital psychiatry: are its roles and functions adjunctive or pivotal?

General hospital psychiatric divisions are an important part of the mental health care delivery system; however, in Canada and the United States, their role and function have not been well defined. In most places, the general hospital is peripheral to the mental hospital, and is thus an adjunctive element in the resulting two-tier mental health care delivery system. The adjunctive type of general hospital psychiatric division provides brief treatment to highly selective types of patients, and is relatively inaccessible to a wide variety of patients. In contrast, the general hospital can be central to the mental health care delivery system--in a pivotal position to patients, other mental health facilities, and community agencies. Important features of the pivotal type are: defined catchment areas, broad admitting criteria and effective discharge planning, linkages with extramural and community programs, staff reorientation, appropriate architectural features, and the ability to hear and respond to the needs of the community. The pivotal type of general hospital psychiatric division can provide appropriate levels of inpatient care, as well as the linkages and backup to extramural and community programs for the long-term mentally ill. The mental hospital would no longer be used as a backup for general clinical disorders, involuntary patients, or patients usually rejected by adjunctive hospitals. There would be collaboration with other agencies in developing programs for special clinical groups (low prevalence disorders), as well as for alcoholism, psychogeriatrics, and adolescent disorders. This article reviews the current polemic on the role and function of the general hospital psychiatric division, as part of the mental health care delivery system.

Canada↗
PubMed2006

Does gastroschisis reduction require general anesthesia? A comparative analysis.

BACKGROUND: Outcome after gastroschisis repair without general anesthesia is controversial, and published conclusions are variable with no comparative studies. AIM: The aim of this study was to present a comparative study evaluating outcome after gastroschisis repair with and without general anesthesia. METHODS: An ambispective nonrandomized study of a cohort of 51 neonates born with gastroschisis between July 1998 and December 2003 was performed. Twenty-four neonates (group 1) had conventional reduction under general anesthesia, and 27 (group 2) cotside minimal intervention reductions were without general anesthesia. RESULTS: Groups were comparable regarding gestational age, birth weight, and quality of eviscerated bowel. Statistical significance (P < .05) was seen between groups 1 and 2 with regard to age at reduction of gastroschisis (5.6 +/- 2.5 vs 3 +/- 1 hours) and time taken for completion of gastroschisis reduction (58.1 +/- 15 vs 49 +/- 14 minutes). No statistical significance (P > .05) was seen with respect to start of feeds (10.4 +/- 3.6 vs 10.9 +/- 4.1 days), duration of total parenteral nutrition (21.5 +/- 7.3 vs 22.4 +/- 6.8 days), and total hospital (stay 29 +/- 10 vs 30 +/- 13 days). Admission to the intensive care unit was required in 92% in group 1 for 1 to 6 days vs 7% in group 2 for 3 to 6 days. There was 1 death in group 1 (4%). Total hospital cost in group 1 was 12,283 pounds sterling +/- 2438 pounds sterling vs 6208 pounds sterling +/- 2120 pounds sterling in group 2 (P = .013). CONCLUSIONS: Neonates with gastroschisis, whose bowel was reduced without general anesthesia, have similar outcomes to those whose bowel was reduced under general anesthesia. Both approaches appear to be safe and effective, but reduction without general anesthesia was cost-effective.

Anesthesia, General↗
PubMed1998

Endoscopic retrograde cholangiopancreatography under general anesthesia: indications and results.

BACKGROUND: Conscious sedation is usually used during endoscopic retrograde cholangiopancreatography (ERCP). Little is known about the indications and outcomes for ERCP in patients who cannot undergo conscious sedation and therefore require general anesthesia. We retrospectively evaluated the indications and outcome for patients undergoing ERCP who required general anesthesia at four teaching hospitals over a 2-year period. METHODS: Of 1200 ERCPs performed over a 2-year period, 65 patients required general anesthesia. Retrospective chart analysis was undertaken to determine indications and outcomes of ERCP performed under general anesthesia. Eleven patients underwent sphincter of Oddi manometry. RESULTS: The major indication for general anesthesia was substance abuse. Therapeutic intervention was successful in 45 of 48 patients; 6 of the 63 patients had complications, all mild and not related to the anesthesia. Sphincter of Oddi manometry was normal in 7 patients; 4 patients had elevated basal pressures. CONCLUSIONS: ERCP under general anesthesia may be considered when conscious sedation fails to achieve a satisfactory level of sedation for a successful and safe ERCP. Procedure-related complication rates appear to be comparable if not lower with general anesthesia.

Adolescent↗
PubMedDate not supplied

Response generalization in apraxia of speech treatments: taking another look.

The purpose of the present paper is to present a critical review and reanalysis of response generalization effects in studies of treatment efficacy in apraxia of speech (AOS). Response generalization takes two forms: generalization of treatment effects to untrained exemplars of trained behaviors and generalization to untrained (i.e., novel) behaviors. In the past, response generalization has not been extensive and typically has been restricted to untrained exemplars of trained behaviors. Reasons for these findings are discussed with reference to recent advances in our understanding of the nature of AOS and to theories of speech motor control and teaming. The discussion focuses on the influence of the theoretical basis used to develop hypotheses and select behaviors to test predictions, the complexity of the treatment task/s, and patient characteristics. Suggestions for future directions in treatment efficacy research are offered. Learner outcomes: (1) An understanding of the nature of AOS, based on recent experimental analyses. (2) An understanding of the efficacy of current treatments for AOS in the area of response generalization. (3) An understanding of how theories of speech motor control might be applied to develop hypotheses for testing and increase effectiveness in treatment studies. (4) An understanding of how theories of speech motor control might guide selection of behaviors to test treatment effects and response generalization.

Apraxias↗
PubMed2000

Mechanisms of generalization in perceptual learning.

Learning in many visual perceptual tasks has been shown to be specific to practiced stimuli, while new stimuli have to be learned from scratch. Here we demonstrate generalization using a novel paradigm in motion discrimination where learning has been previously shown to be specific. We trained subjects to discriminate directions of moving dots, and verified the previous results that learning does not transfer from a trained direction to a new one. However, by tracking the subjects' performance across time in the new direction, we found that their speed of learning doubled. Therefore, we found generalization in a task previously considered too difficult to generalize. We also replicated, in a second experiment, transfer following training with 'easy' stimuli, when the difference between motion directions is enlarged. In a third experiment we found a new mode of generalization: after mastering the task with an easy stimulus, subjects who have practiced briefly to discriminate the easy stimulus in a new direction generalize to a difficult stimulus in that direction. This generalization depends on both the mastering and the brief practice. The specificity of perceptual learning and the dichotomy between learning of 'easy' versus 'difficult' tasks have been assumed to involve different learning processes at different cortical areas. Here we show how to interpret these results in terms of signal detection theory. With the assumption of limited computational capacity, we obtain the observed phenomena--direct transfer and acceleration of learning--for increasing levels of task difficulty. Human perceptual learning and generalization, therefore, concur with a generic discrimination system.

Discrimination, Psychological↗
PubMed1991

Clinical oncology services to district general hospitals: report of a working party of the Royal College of Radiologists.

We conducted a survey of multidisciplinary non-surgical cancer services in district general hospitals without departments of radiotherapy and oncology. All consultants in clinical oncology (radiotherapy and oncology) in the United Kingdom were sent a questionnaire. This report is based on the analysis of information on 235 district general hospitals, which have an average of 450 acute or general beds. Non-surgical medical care for cancer patients at these hospitals is mainly provided by consultants in clinical oncology based at cancer centres. Initial assessment and follow-up, and some investigations and drug treatment, are organized at the district general hospitals, but radiotherapy and a substantial proportion of cytotoxic chemotherapy is administered at the cancer centres. The principal finding of the survey is that the average total weekly commitment of consultants in clinical oncology at district general hospitals is just under two sessions. We estimate that for each session at present provided at these hospitals there are five new cancer patients who would benefit from a specialized oncological opinion. For each new patient consultation there is a need for 5-10 times as many follow-up consultations. It is clear that the time available for cancer patients at district general hospitals, which on average are 22 miles away from the cancer centres, is far from adequate. We believe that it is correct to continue to base cancer services at cancer centres. This helps to ensure the maintenance of high standards and continuity of care. There is no need to alter the system, but there is a need to increase substantially specialist oncological presence at district general hospitals through the appointment of additional visiting consultants.

Hospitals, General↗
PubMed2002

How much colorectal surgery do general surgeons do?

BACKGROUND: Surgical subspecialization has croded the traditional domain of the general surgeon. The purpose of this study was to assess the volume and distribution of colon and rectal cases performed by general surgeons. STUDY DESIGN: The American Board of Surgery database was queried to identify and categorize the number of colorectal cases performed yearly by "generalists" (general surgeons) recertified between 1995-1997. RESULTS: There were 2,434 general surgeons (those with a basic certificate only) recertified. The mean number of large bowel cases was 33 (range 0-243). Thirty-one cases represented the 70th percentile and 60 cases represented the 90th percentile. The mean number of anorectal cases was 12.3 (range 0-185). The 70th percentile was 15 cases, and the 90th percentile was 26 cases. Seventy-five percent of general surgeons perform > or = 17 large intestine cases each year, whereas, only 25% perform > 16 total anorectal cases. CONCLUSION: General surgeons perform a substantial number of colon resections and relatively few anorectal cases. It is unclear whether this is an issue of anorectal training in general surgery programs or referral patterns.

Colorectal Surgery↗
PubMed2000

Antibiotic prescribing for dental conditions: general medical practitioners and dentists compared.

OBJECTIVE: To compare the level of prescribing and types of antibiotics prescribed for dental problems by general medical practitioners and dentists. DESIGN: Secondary analysis of standard consultation data and prescription records from four different settings. SETTING: 30 participating general practices in the General Practice Morbidity Database for Wales in 1996. SUBJECTS: 1,185 attendances for tooth-related problems, at 30 participating practices in the General Practice Morbidity Database for Wales in 1996. Standard consultation records from a GDP emergency dental rota, and two weekend emergency dental clinics: one in a health centre, the other in a dental hospital. RESULTS: More than two thirds (68%) of attendances at general medical practices for tooth-related problems resulted in a prescription for antibiotics. In contrast less than a third (28%) of patients seen by a GDP rota, about half (52%) of patients at a weekend emergency clinic in a health centre, and just more than a third (38%) of patients attending the dental hospital clinic received antibiotics. General medical practitioners were also more likely to prescribe broad-spectrum antibiotics than dentists. CONCLUSION: For acute dental problems general medical practitioners are more likely to prescribe antibiotics than dentists. There also appear to be inter-professional differences in the tendency to prescribe broad spectrum antibiotics. Initiatives to rationalise prescribing for dental conditions may need to target doctors as well as dentists.

Anti-Bacterial Agents↗
PubMed2000

The provision of primary care dental general anaesthesia and sedation in the north west region of England, 1996-1999.

AIM: To investigate trends in the provision of primary care dental general anaesthesia (DGA) and sedation following the new guidance from the General Dental Council. DESIGN: Cross-sectional analysis of data about the provision of DGA in the General Dental Service and Community Dental Service from 1996/97 to 1998/99. SETTING: The North West Health Region of England. METHOD: The numbers of DGAs in the General Dental Service (GDS) and Community Dental Service (CDS) for the three financial years, 1996/97, 1997/98 and 1998/99 were examined. In addition General Dental Service quarterly information about the numbers of general anaesthetics, sedations requiring another dentist or doctor, and claims for conscious sedation or inhalation sedation from April 1997 to December 1999 was requested from the Dental Practice Board. RESULTS: The numbers of DGAs declined by 24 per cent between 1996/97 and 1998/99. Those in the GDS fell from 14,550 in the first quarter of 1997/98 to 3,527 in the first quarter of 1999/2000. The number of claims for sedation, which required another dentist or doctor, increased from 712 in the first quarter of 1997/98 to 2,989 in the same quarter of 1999/2000, while the number of claims for conscious sedation and inhalation sedation increased slightly from 2,847 to 2,963 over the same period. CONCLUSIONS: The revised General Dental Council guidance has reduced the numbers of DGAs being carried out in both GDS and CDS. The number of sedations involving another dentist or doctor has increased considerably but the new guidance seems to have had little effect on the numbers of patients receiving operated administered conscious sedation and inhalation sedation.

Adolescent↗
PubMedDate not supplied

The use of general anaesthesia for tooth extraction in children in London: a multi-centre study.

Following publication of the Poswillo report, the continued use of general anaesthesia in dentistry became the subject of a major debate. In particular, the provision of general anaesthetic services by general dental practitioners in order to carry out simple extractions for child patients has been called into question. Other authors have strongly supported the continued need for general anaesthesia and insist that for some patients it remains the technique of choice. There is, however, little evidence of current patterns of attendance from which argument may be advanced to support or refute the differing views. In this study data was drawn from three London dental teaching hospitals providing out-patient general anaesthesia for extractions. During the 12-month period investigated 7852 general anaesthetics had been administered for child patients. There was evidence of an increase in numbers at one centre when results were compared to those of a previous study and some evidence of a change in pattern of referral with time at the same centre, with an increase in the numbers of patients referred by general dental practitioners. Eighty-three per cent of the anaesthetics had been given for the extraction of carious primary teeth, with an average of 3.3 being extracted per child. Nearly one-third of the anaesthetics were for children under the age of 5 years.

Analysis of Variance↗
PubMed2001

Training general surgery residents in pediatric surgery: A Canadian survey.

BACKGROUND/PURPOSE: The training of general surgeons in pediatric surgery is an important educational role of pediatric surgeons (PS). The authored surveyed this training process and the related expectations and perceptions of competence. METHODS: The authors surveyed all practicing members of the Canadian Association of Paediatric Surgeons (CAPS) in Canada, all general surgery program directors (PD), and all final year general surgery residents (GS). Questions included exposure to pediatric surgery, expected and perceived competence in managing common pediatric general surgical problems, and trainee practice intentions. RESULTS: Response rate to date was 51% from PS, 69% from PD, and 19% from GS. Sixty-seven percent of PS considered the exposure to pediatric surgery satisfactory, yet only 1 of 7 residents planning on pursuing general surgery felt adequately prepared. Trainees were expected to be competent in the conditions polled by 65% of PS and 74% of PD, yet only 38% of the trainees actually felt competent in them. The largest discrepancies were found for infant hernia, newborn colostomy, and cryptorchidism. Presence of a fellowship program and size of training program had no impact on perceived competence. CONCLUSIONS: Training of general surgeons in pediatric surgery varies across Canadian programs. Perceived resident competence often lags behind program and faculty expectations. These data can be used for directing educational priorities in general surgery programs.

Attitude of Health Personnel↗