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Most medical schools in Canada have, over the last few years, introduced Problem Based Learning (PBL) into their undergraduate curricula. In contrast to some other schools which have radically transformed their entire curricula, the University of Western Ontario approach has been more cautious, setting aside 20 per cent of the time during the first two years of the curriculum to PBL, more traditional, didactic methods being used otherwise. The main challenges have been to integrate the underlying values of the two different approaches to teaching and learning to develop valid and reliable examination and evaluation procedures, and to sustain the enthusiasm and interest of a large, mostly voluntary, group of faculty members, continually improving their skills as tutors. The most beneficial results of this curricular change have been an increased interest in medical education reform in general, and an increased recognition of the importance of teaching in relation to appointments and promotions. Students have appreciated the break from a never ending stream of lectures, and many have welcomed the challenged to explore in depth areas of special interest.

Television is, arguably, the most influential mass medium and "prime time" viewing attracts the largest audiences. To assess the type, number and nutritional content of foods advertised on TV, commercial breaks during "prime time" (7:00 to 11:00 p.m.) on five Canadian channels (CBC-English, CBC-French, CTV, CFPL, Much Music) were recorded and analyzed. A similar analysis of Saturday morning children's TV commercials was also performed. Commercials for foods and food products constituted between 24-35% of all commercials, the largest advertising output for any group of products. The combination of food presented in commercials reflected average current consumption patterns. Of special concern was the emphasis on low nutrition beverages, especially beer, as well as snacks and candy on Much Music. While further government intervention to restrict advertising practices may be an impractical option, there is scope for increasing the alternative promotion of healthy dietary choices.

The focus of this discussion has been on achieving a distribution of health care professionals that meets the objective of making health services available to the total population. The need for a systematic approach to planning, not only for the health care work force, but for the system in general, has been recognized as the highest priority for the health care systems of industrialized countries for over a decade. Overall, the goal of health care work force planning the world over is "to provide the right type of education and training for the right number and type of people needed to render effectively and safely the right types of service when and where required by the population." What is needed is a readiness to evaluate existing service delivery models, to retain those found to be effective and efficient, and to re-direct resources from outdated or ineffective strategies into new approaches found to better meet this goal. We need to envision the health care work force as a whole; work toward making it as efficient as possible, and thereby maintain our national commitment to universal health care.

Patients who receive a kidney transplant that does not function immediately have more complications and decreased graft survival than patients whose allografts function immediately. To determine the causes of initial nonfunction (INF), the authors reviewed 188 consecutive cadaveric kidney transplants performed between 1985 and 1988 at the University Hospital, London, Ont. Data were collected on 16 putative risk factors for INF, which were divided into three categories: donor, recipient and technical. INF was defined as the need for dialysis within 7 days of transplantation. Forty-eight (26%) of the 188 allografts had INF, 6 of which never functioned. Univariate analysis identified five variables associated with increased risk of INF: no donor dopamine use, back-table flush, single-organ retrieval, exchanged kidney and prolonged cold ischemic time. Multivariate analysis, however, identified only three variables associated with INF: cerebrovascular accident as the cause of donor death, no donor dopamine use and single-organ retrieval. The authors recommend (a) low-dose dopamine therapy for all donors and (b) multiorgan retrieval to produce quality kidneys for transplantation.

Critical to health services management in today's economic climate is efficient utilization of our costly and sometimes limited supply of health care professionals. This two-part article gives an overview of current issues in health care work force planning in Canada. In Part I, the problems of estimating current supply are discussed. Needs-based and demand-based forecasting are contrasted. Comprehensive needs-based planning is recommended and changes needed in order to move toward this type of planning are discussed. In Part II, the maldistribution of health care professionals and various corrective measures within the context of needs-based comprehensive planning are discussed.

This article discusses a very early clinical trial from the Old Testament. One of Daniel's and his companions' tribulations in Babylonia is explicated within the framework of the modern clinical trial. Even if many, or maybe even most, guidelines for good clinical trial practice are violated (it can even be argued that this is not really a clinical trial), a discussion of this biblico-historical episode in, for example, a problem-based course in (clinical) epidemiology or a course in the critical appraisal of the literature, can be a useful (and possibly entertaining) exercise.

This article describes crack cocaine and its adverse clinical and public health effects. Although crack cocaine does not yet constitute a major drug problem in the Nordic countries, heed should be paid to North America where crack cocaine has developed into a serious and widespread problem only a few years after its introduction. In spite of highly publicized efforts to limit its spread, after a small decline in 1990, the use of crack cocaine is once again increasing. Strong efforts should therefore be made to keep this substance away from the Nordic countries.

Despite the importance of statistical concepts to health professionals, the teaching of statistics to students from this field has generally been unrewarding. We feel that a few central concepts are crucial to all statistical thinking and that, for most health professionals, the communication of these is more important than learning about complex mathematical models. A device for demonstrating the parallels between a criminal legal trial and statistical hypothesis testing is presented. We feel that it can facilitate the learning of this central statistical concept.

In Oregon, an important new mechanism for prioritizing health care resources is about to be introduced. It is based on a relatively simple cost/benefit formula, the best of available scientific knowledge as well as public opinion and sentiment. The formula is based on three factors: the cost of each treatment or procedure, the improvement in quality of life by giving the treatment and how long a patient would be healthy after treatment. The Oregon experiment may influence the delivery of health care not only in the United States. In modified form this approach may have even more wide-ranging implications in the Scandinavian countries where most of the health services are publicly funded.

Within the sphere of health and welfare, Canada has more in common with the Scandinavian countries than with the United States. This article describes and discusses the unique role of the College of Family Physicians of Canada and the education and training for family medicine, both on the undergraduate and postgraduate levels in Canada. The development of the Master of Clinical Science in Family Medicine degree programme at the University of Western Ontario is considered to be an important vehicle for strengthening academic family medicine in Canada. The amalgamation of current knowledge not only from clinical sciences and educational research, but also from the social sciences, is seen as fundamental to the continued improvement of this discipline.

The importance of avoiding mismatches (MM) at Class I and Class II HLA antigens in cyclosporine-treated renal allograft patients is controversial. In order to assess the role of HLA, 200 consecutive cadaveric renal allografts over a 4-year period were analysed. All patients received cyclosporine/predinisone immunosuppression and 75% were induced with ALG. Minimum follow-up period was one year. HLA A, B, DR, DQ, and DRw52/53 typing were available on 77-100% of allografts. A beneficial effect was noted at the HLA A locus. One-year survival was 87.2% in the 0 and 1 HLA A MM group combined vs 73.8% in the 2 HLA A MM group (p less than 0.05). The mean creatinine level at one year was also lower in the 0 plus 1 MM vs 2 MM group: 152.8 mumol/L vs 184.8 mumol/L, respectively (p less than 0.05). Significantly fewer rejection episodes occurred in the 0 and 1 HLA DQ MM group combined vs the 2 MM group. Steroid-resistant rejection episodes (SRRE) were not associated with the number of HLA MM. Patients who had an SRRE had significantly higher mean current and historical peak panel reactive antibodies (PRA) than patients who did not have SRRE. These results indicate that avoiding mismatches at the HLA A locus may improve renal allograft survival, and matching at HLA DQ may predispose patients to a more quiescent post-transplant course. The degree of preoperative sensitization may be an important etiologic factor in SRRE.

Most universities and major research institutions in North America, Western Europe and around the Pacific are connected via computer communication networks. The authors have used these networks' accessible, low cost, electronic mail system to develop a network of public health researchers and teachers. Current and potential uses of this network are discussed. These networks can not only facilitate international cooperation within public health; they also make it possible to conduct international collaborative research projects that would be too cumbersome and time consuming to initialize and conduct without this communication facility. One participant from Hungary has been able to participate in the network by using telefax. This has some drawbacks compared to electronic mail. In this era of rapid change in Eastern Europe, we urge that electronic communication be made freely available to colleagues in Eastern Europe.

The major Canadian universities are connected via a computer communications network called `Netnorth'. We have used Netnorth's accessible, low-cost, electronic mail system to develop a network of academic Family Medicine users (Famnet). We then tested Famnet's utility for conducting rapid surveys. Famnet shows promise of being a useful means of undertaking regular inter-departmental communication. This system may also increase collegiality among Canadian Departments of Family Medicine and facilitate international communication in family medicine.

Medical expert systems have been developed for more than 20 years, in particular in the United States. Most existing systems are prototypes, and only a few commercial systems are available. The prototypes are generally limited in scope or functions (and have not been transferred to other users). However, in the near future we can expect useful applications to appear in special areas of medicine. In Norway we probably do not have the resources required to develop large commercial medical expert systems. If we want to develop medical expert systems, we should concentrate on limited areas. We must prepare the ground for future use of such systems in Norway. An important first step is to give health personnel basic education in the use of computers.

The prevalence and 14 year incidence of clinical gout and its precursors were investigated in the Polynesian population of Tokelauans living in the Pacific basin, non-migrant Tokelauans living in their isolated atoll homeland being compared with migrant Tokelauans living in urban New Zealand. The age standardised prevalence of gout in Tokelauan men in New Zealand was higher than that in non-migrant Tokelauan men, being 21.0 and 19.5/1000 subjects at the beginning of the study and 51.0 and 14.6/1000 at the end of study, respectively. Migrant men in New Zealand aged under 55 had higher mean serum uric acid concentrations than non-migrant men of the same age. The prevalence of gout was low in women in both environments. The age standardised relative risk of developing gout between 1968 and 1982 was 9.0 times higher in the migrant men than in the non-migrant men. Age, serum uric acid concentration, serum cholesterol concentration, and self reported alcohol consumption at entry to the study were the best set of predictors of gout in men. Preventive strategies to change body mass, diet, and patterns of alcohol use need to be developed in this population.

This article gives an overview of North American electronic networks and on-line databanks containing medical and health-related information. It discusses costs and benefits for physicians and other health care personnel. The article concludes with practical information on ways to connect a Norwegian medical practice to these networks and databanks.

This article describes an extramural university course in epidemiology and medical statistics taught using a computer conferencing system, microcomputers and data communications. Computer conferencing was shown to be a powerful, yet quite easily mastered, vehicle for distance education. It allows health personnel unable to attend regular classes due to geographical or time constraints, to take part in an interactive learning environment at low cost. This overcomes part of the intellectual and social isolation associated with traditional correspondence courses. Teaching of epidemiology and medical statistics is well suited to computer conferencing, even if the asynchronicity of the medium makes discussion of the most complex statistical concepts a little cumbersome. Computer conferencing may also prove to be a useful tool for teaching other medical and health related subjects.

Patient-administrative systems are becoming increasingly accepted in general practice. The market is now more mature than before. Many physicians are now purchasing computer systems for general practice the second time. Due to national characteristics of the health services the market for these systems is not truly international. In Norway this market is dominated by two makes: Infodoc and Profdoc. In future more physicians will use systems for general practice, and more functions will be added, although the usefulness of these may be a matter for discussion. Furthermore, the importance of telecommunications is expected to increase, and similarly, integration with other services. This development would be furthered by central government action for the purpose of harmonizing and standardizing data, systems and possibly user-interface.

The migration of Tokelauans from a traditional atoll in the Pacific to urban New Zealand is associated with an increased prevalence and incidence of Type 2 (non-insulin-dependent) diabetes mellitus over the period 1968-1982. During the same period, a lesser but definite increase is seen among non-migrants in Tokelau. The age standardised prevalence rates rose from 7.5 and 11.7 to 10.8 and 19.9 per 100 respectively in the male and female migrants compared with an increase from 3.0 and 8.7 to 7.0 and 14.3 per 100 in the non-migrant males and females respectively. The incidence of diabetes is shown to be consistently higher in the migrants compared to the non-migrants giving relative risks of 1.5 in males and 1.9 in females. The factors most likely contributing to this difference, are changes to a higher calorie, high protein diet, higher alcohol consumption, a greater weight gain and altered levels of physical activity in the migrants. A number of populations in the Pacific have been shown to have a low rate of diabetes in their traditional setting, but may have a genetic predisposition for diabetes which responds to factors in the urban industrialised environment and life-style. The social and economic changes taking place in Tokelau are also clearly increasing the risk of diabetes. To reverse these trends and prevent the development of complications of Type 2 diabetes, it will be important to institute preventive programmes and to follow up the population in both environments for long-term outcomes, including mortality.

This article proposes the establishment of a central, on-line information bank for the Norwegian health services. The article discusses the potential content and functions of the information bank. It is concluded that, in addition to increasing the availability of health-related information, such an information bank might also improve communication at several levels of the health care system.

Prevalence rates for three hepatitis B virus (HBV) markers in two groups of personnel within the Canadian Armed forces (1848 incoming recruits and 210 crew members from a destroyer) were determined. Blood specimens for analysis were provided twice. The initial prevalence rates fell at the lower end of the spectrum when compared with those found in United States military personnel, Canadian military health personnel, and certain Canadian civilian populations. Eleven recruits and one destroyer crew member seroconverted for at least one of the markers between the first and the second testing. Their serological profiles are discussed in detail. No transmission of HBV between individuals in the group of recruits studied was established. However, evidence was found for a probable limited transmission of HBV between two crew members of HMCS Margaree. These findings combined with the high cost of the hepatitis B vaccine indicate that mass immunization for HBV in the Canadian Forces population cannot be justified on the basis of this study.