bluuebunny/crossref_metadata_2025 huggingface dataset:
Distance and Transportation as Barriers to Cardiac Rehabilitation in Urban and Rural Coronary Artery disease Outpatients
Authors: Brual Janette , Gravely-Witte Shannon , Kayaniyil Sheena , Stewart Donna E. , Grace Sherry L.
Published: May 2017

Background: Cardiac rehabilitation (CR) is a proven means to reduce morbidity and mortality among cardiac outpatients but is grossly under-utilized. Transportation, distance and travel time are frequently cited barriers to participation. The purpose of this study was to compare CR participation rates between urban and rural cardiac outpatients and examine perceived distance and transportation barriers.

Methods: 255 cardiac outpatients (mean age 68+11 years; 76%(194) male) of 97 Ontario cardiologists completed a survey within an on-going prospective study. The second digit of A0A in the postal code designated rural status and was verified with Statistics Canada 2001 Census. Using a 5-point Likert scale outpatients indicated the degree to which transportation and distance were barriers and self-reported travel time to CR and percentage of sessions attended.

Results: 87% (223) of outpatients lived in an urban area, while 13% (32) were rural. Overall, 44%(113) participated in CR, with 46% (102) urban and 34% (11) being rural (P > 0.05). Transportation barriers were significantly related to CR participation (P < 0.01), whereas distance was not. Data were split by geographic area and transportation was only significantly related to CR participation among urban outpatients (P < 0.01). Urban outpatients reported a mean travel time of 25±18 minutes compared to 68±53 for rural outpatients (P < 0.0001). The mean percentage of CR sessions participated in was 84±28%, which did not differ by geographic status.

Conclusions: Contrary to previous research, living in a rural area and perceived distance were not related to CR participation. However data collection is ongoing. Rural outpatients had longer travel times yet perceived no distance or transportation barriers. Transportation barriers for urban outpatients may be related to population density and traffic delays. Efforts to reduce transportation-related barriers in urban areas such as improving public transportation or increasing home-based CR provision may be warranted.
Impact of Beta-Blocker Treatment and the Nutritional Status on Glycemic Response During Exercise in Type 2 Diabetic Patients
Authors: Ferland A. , Brassard P. , Croteau S. , Lemieux S. , Bergeron J. , Lacroix S. , Fournier L. , Poirier P.
Published: May 2017

Background/Objective: More than 60% of type 2 diabetic individuals present with hypertension and have higher risk of cardiac complications. In addition to behavioural modifications, such as healthy food choices and regular physical activity, beta-blocker (BB) treatment may be considered in order to reduce morbidity and mortality especially following a cardiovascular event. However, this medication is generally associated with a deleterious impact on glucose metabolism. To assess the impact of a BB treatment on glucose response in type 2 diabetic patients exempt of cardiovascular complications.

Methods: Six sedentary men, treated with diet and/or a hypoglycemic agent performed four exercise sessions at 60% of their VO2 peak, in the fasted state or 2 hours after a standardized breakfast, with and without BB (Atenolol 100 mg id for five consecutive days). Blood samples were assayed during the resting period, at 15-minutes intervals during the exercise session and the recovery period.

Results: A reduction of blood glucose levels was observed following the exercise session performed in the postabsorptive state (41% and 37% reduction with and without BB treatment respectively; P < 0.01). One hour of exercise performed in the fasted state had minimal impact on glucose and insulin levels, with or without BB. BB treatment was not associated with increased baseline blood glucose or insulin levels in the fasted or the postabsorptive situation.

Conclusion: These results suggest that the nutritional status has a more important impact on plasma glucose and insulin modulation than short-term use of BB per se.
Interpreting Changes in Endurance Shuttle Walking Performance
Authors: Brouillard Cynthia , Pepin Véronique , Singh Sally , Revill Sue , Lacasse Yves , Maltais François
Published: May 2017

Rationale: The endurance shuttle walk has recently been shown to be highly responsive to both bronchodilation and pulmonary rehabilitation. The degree to which changes in endurance shuttle walking performance are perceptible to patients is unknown.

Objective: To evaluate the relationship between objective and subjective measures of change in endurance shuttle walking performance.

Methods: 129 comparison points were obtained from 69 patients with COPD (FEV1: 47±16%) who completed two or more endurance shuttle walking tests as part of a bronchodilation study. Patients were asked to rate their performance of the day in comparison to their previous performance on a 7&S209; point scale ranging from -3 (large deterioration) to +3 (large improvement). These ratings were related to changes in walking distance and endurance time, expressed both as delta and percent change.

Results: Patient ratings of change were significantly correlated with delta walking distance (r=0.44, P < 0.001), delta endurance time (r=0.46, P < 0.001), percent change in walking distance (r=0.54, P < 0.001), and percent change in endurance time (r=0.55, P < 0.001). Deteriorations in walking performance were perceived in 34% of cases, while improvements were detected in 81% of cases.

Conclusion: Changes in endurance shuttle walking performance, especially improvements, are well perceived by patients with COPD. From this set of data, it should be possible to identify the smallest change in walking performance with a high likelihood of being perceived by the patients (MCID).
Is Prolonged and Repeated Exercise-Induced Myocardial Ischemic Training Deleterious?
Authors: Noël Martin , Jobin Jean , Marcoux Audrey , Boyer Luce , Dagenais Gilles R. , Bogaty Peter
Published: May 2017

Background: In patients with ischemic heart disease (IHD), the current guidelines on exercise prescription recommend that exercise training intensity be 10 beats/min below the heart rate at which there is >1 mm ST-segment depression (ischemic threshold). However, it is not well established that exercise training above the ischemic threshold is harmful.

Methods: Twenty-two patients with angiographically documented IHD (>70% stenosis) were randomized to exercise training either at a target intensity that induced myocardial ischemia (ischemic group) or that adhered to current guidelines (control group). Training was progressively increased to 60 min under continuous ECG monitoring. Cardiac troponin T (cTnT) was measured at regular intervals. Ambulatory ECG monitoring was performed before and after 6 wkof training and left ventricular function was evaluated by echocardiography in the ischemic group after at least 6 wk of training.

Results: The ischemic training sessions were very well tolerated. The ischemic group had myocardial ischemia during the first 20, 40, and 60 min exercise sessions for 12.3 ± 6.8 min, 29.0 ± 12.9 min and 49.8 ± 2.2 min, respectively, with ST-segment depression ranging from 1.0 to 2.1 mm. The estimated myocardial work (as expressed by RPP) during the training session was also higher in the ischemic than in the control group for the first 20 min (17 354 ± 6 528 vs 13 355 ± 2 936 beats/min • mmHg, respectively; P=0.08), 40 min (16 329 ± 5 407 vs 12 452 ± 2 330 beats/min • mmHg, respectively; P=0.04), and 60 min training sessions (18 750 ± 5 698 vs 13 352 ± 2 947 beats/min • mmHg, respectively; P=0.02) No patient in either group demonstrated significant arrhythmias nor increased cTnT. The measured cTnT stayed below the detectable values of the essay (>0.01μg/l) for all patients at all times. Left ventricular function remained unchanged in the ischemic group.

Conclusion: In patients with IHD, prolonged and repeated ischemic training sessions up to 60 min can be well tolerated without evidence of myocardial injury, significant arrhythmias or left ventricular dysfunction. Thus exercising at or above the ischemic threshold does not appear deleterious under this kind of supervision.
Comparison of Respiratory and Circulatory Responses to 1-Leg, 2-Leg Knee Extension Exercise and Cycling in Patients with COPD
Authors: Baril Jacinthe , Robillard Julie , Laurin David , Rossi Amanda , Boushel Robert , Taivassalo Tanya , Comtois Alain , Sheel William Andrew , Deschênes Julie , Bourbeau Jean , Perrault Hélène
Published: May 2017

Background: The mass-specific work rates at which peripheral circulatory blood flow (BF) may become compromised in COPD due to a “respiratory steal” phenomenon was examined using one leg (1-leg KE), two-leg knee extension (2-leg KE) and cycling.

Methods: Eleven COPD patients (age: 66 yr ± 8; FEV1= 45% predicted ± 14) did three steady states of cycling, 1-leg KE and 2-leg KE at 20, 40 and 65% of peak power (SS20%; SS40%; SS65%). Ventilation, VO2, arterial blood gas and dye dilution cardiac output were measured at rest and during exercise. Inspiratory capacity (IC) was used to monitor operating lung volume responses and determine dynamic hyperinflation.

Results: Preliminary data show higher VO2 (L•min-1) during cycling than 1-leg KE and 2-leg KE (SS65% 1.0 ± 0.2 vs 0.5 ± 0.1 vs 0.6 ± 0.1). Despite the smaller muscle mass involvement of 1-leg KE, breathing frequency during SS65% was not different from that of cycling at SS65% (27 ± 5 vs 28 ± 5). During 1-leg KE, a plateau in tidal volume (0.8L ± 0.1) was achieved at SS20% while during cycling, tidal volume increased up to 1.4L ± 0.3 at SS65%. Similar falls in pH from baseline and similar PCO2 measures were seen with cycling (baseline: pH 7.43 ± 0.02; PaCO2 mmHg 39 ± 2 to SS65%: 7.38 ± 0.03; 40 ± 3) and 1-leg KE (baseline: pH 7.41 ± 0.03; PaCO2 mmHg 39 ± 2 to SS65%: 7.39 ± 0.02; 40 ± 3) although SaO2 was maintained with 1-leg KE, but not with cycling or 2-leg KE (95 to 93% at SS65%). IC (in % total lung capacity) was similarly reduced from baseline in 1-leg KE (30 ± 2 to 23 ± 3) and during cycling (30 ± 2 to 24 ± 3).

Conclusion: These data suggest that ventilatory and gas exchange responses depend on the relative symptom-limited exercise intensity and not exercise modality.
Evaluation by Dipirydamole MRI of the effects of cardiac rehabilitation after myocardial infarction
Authors: Blanc P. , Douard H. , Courregelongue M. , Perron J. M. , Roudaut R. , Broustet J. P.
Published: May 2017

Background: The effects of exercise training (ET) on myocardial perfusion after myocardial infarction have been well studied with scintigraphy whereas cardiac MRI seems a better technique which was not used yet in the literature in this indication.

Methods: 11 patients after a first myocardial infarction were left again in 2 groups: a 20 session-ET program (T, n=6) and a control group (C, n=5). All patients underwent a dipirydamole MRI and a cardiopulmonary test at entry and after 3 months.

Results At 3 months, improvements in work capacity (P < 0,05), peak VO2 (P < 0,05) were observed in T but not in C. Ejection fraction and left ventricular (LV) volumes were unchanged in T and C. Myocardial perfusion assessed by MRI was comparable at rest and after dipirydamole in each group. The recuperation of the segmentary kinetics was inversely proportional to the delayed enhancement given by MRI and was better for T than for C (P < 0,02).

Conclusions: This is a preliminary study. Cardiac MRI makes it possible to apprehend perfusion in a reliable and reproducible way. ET has no detrimental effects on LV volumes and function; rather, it improves recovery of infarcted segments.
Impact of Beta-Blockade on Exercise Capacity in Subjects with Type 2 Diabetes
Authors: Brassard Patrice , Ferland Annie , Croteau Sara , Fournier Lison , Jobin Jean , Poirier Paul
Published: May 2017

Background: Beta-blockers are prescribed to subjects with type 2 diabetes with coronary disease to reduce all-cause mortality. However, this medication reduces exercise capacity in non diabetic individuals. The purpose of this study was to evaluate the impact of beta-blockade on exercise capacity in diabetic subjects free of coronary disease.

Methods: Ten sedentary men with type 2 diabetes participated in this study. Subjects were treated with oral hypoglycemic agents and/or diet. Exercise capacity was evaluated using an incremental protocol performed on a cycle ergometer. Subjects were evaluated without (WBB group) and following the use of a beta-blocker (Atenolol 100 mg, id) for 5 consecutive days (BB group).

Results: Per study design, subjects were their own control. The BB situation was characterized by a lower resting heart rate (HR) (54±4 vs 74±12 bpm; P < 0.001) and a trend toward a lower resting systolic blood pressure (SBP) (123±11 vs 131±14 mmHg; P=0.1) compared to the WBB evaluation. Even with comparable peak workload achieved (193±27 vs 200±22 watts), there was a 13 % reduction in relative and absolute values of peak oxygen uptake (25.8±3.4 vs 29.7±4.1 ml·kg-1·min-1; P < 0.05 and 2.5±0.5 vs 2.9±0.6 L·min-1 respectively; P < 0.001), a 35 % reduction in peak HR (110±9 vs 169±14 bpm; P < 0.001) and a 21 % reduction in peak SBP (167±24 vs 211±20 mmHg; P < 0.001) in the BB compared to the WBB situation. Also, the BB situation showed a lower peak minute-ventilation (97±15 vs 120±24 L/min; P < 0.05) compared with WBB.

Conclusion: These results suggest that in subjects with type 2 diabetes free of coronary disease, the use of a beta-blockers impedes cardio-respiratory function at peak exercise beyond compensatory mechanisms leading to a decreased exercise capacity.
Test-retest Reproducibility of Constant Rate Step and Shuttle Walk Test for the Assessment of Exertional Dyspnea in patients with COPD
Authors: Henophy S. , Rycroft A. , Baril J. , Nadreau Éric , Bourbeau J. , Perrault H. , Maltais F.
Published: May 2017

Background: Alternatives for laboratory exercise testing are needed to better reflect symptoms of physical activities of daily living in chronic disease. Such a tool should accurately set the exercise intensity and show good reproducibility. This study examined the reproducibility of constant rate walking (CRWT) and stepping tests (CRST) to assess exertional dyspnea in patients with COPD.

Methods: Stable COPD patients (n=43; 65 ± 6.5 yr; FEV1= 49 ± 16% pred.) equipped with a portable Jaeger Oxycon Mobile® metabolic system completed both the CRWT and the CRST. Each test included four 3-min constsant rate stages separated by a 10-min rest period on two occasions separated by 7 to 14 days. For both exercise modalities the selected rates targeted intensities between 25 and 80% VO2 peak for moderately-severe COPD patients. Ventilation (VE) and gas exchange were obtained during the third minute and the Borg dyspnea score at the end of each exercise bout.

Results: An equal proportion of patients (35%) completed stage 4 of the CRWT and of the CRST. The test-retest correlation coefficients for dyspnea scores ranged from 0.79 to 0.95 for stages 1 through 4 for theCRWTand from 0.88 to 0.85 for the CRST while those for VE (L·min-1) ranged from 0.95 to 0.98 and 0.91 to 0.95 respectively.

Conclusion: These results show both the CRWT and the CRST to be highly reproducible for the assessment of exertional dyspnea in patients with moderate-severe COPD. However, a better linearity in VE and VO2 with exercise stages was seen for the CRST than for the CRWT since patients complied more easily to the imposed external load with stepping than with walking.
Quality Assurance and the Service Domain in Cardiac and Pulmonary Rehabilitation
Authors: Hoberty P. D.
Published: May 2017

Background: Little is known about the quality assurance methods used on cardiac and pulmonary rehabilitation. Also, little is known as to what extent the service domain is evaluated and what methods are employed. Knowledge of what is being done in these regards may facilitate programs effectively and efficiently measuring these outcomes.

Methods: A survey was mailed to 1/3 of the programs (approximately 400) in both cardiac and pulmonary rehabilitation listed in the AACVPR Program Guide 2004. The survey included questions that would add to the knowledge of what is the extent of practice and methods. 12 components of quality assurance were listed and 14 components of patient satisfaction were assessed as to the frequency of use. It was pilot tested and revised.

Results: The usable return rate was 48%. Program directors of both types of programs claimed daily formal assessment of most of the 12 areas listed for quality assurance. The three highest being assessment of adverse events, safety, and patient satisfaction. The three lowest use was in the area of efficiency, timeliness and continuity of care. The service domain was assessed as comparable to the other three: health, clinical and behavioral domains. Patient satisfaction was the most commonly assessed component of the service domain with more than 90% of both types of programs measuring program effectiveness, overall program quality and friendliness of the staff. Managers most commonly cited the acquisition of new equipment as the endpoint as the end results of patient satisfaction assessment.

Conclusions: There was surprising similarity in results from programs in cardiac and pulmonary rehabilitation. Quality assurance is very frequently assessed in both. Concern for adverse events, safety, and patient satisfaction predominate.
Fatigability of Lower Limb Muscles during Walking in Chronic Obstructive Pulmonary Disease
Authors: Marquis Nicole , Bouyer Laurent , Debigare Richard , Laviolette Louis , Brouillard Cynthia , Saey Didier , Maltais Francois
Published: May 2017

Background: Patients with chronic obstructive pulmonary disease (COPD) perceive much less quadriceps fatigue during walking compare to cycling. Whether other lower limb muscles could develop fatigue during walking is unknown. The purpose of this study was to assess the electrical activity of five lower limb muscles during a 6-minute walking test in 11 healthy subjects and in 10 patients with COPD matched for age and activity level.

Methods: Surface electromyographic (EMG) data were recorded in five muscle groups (soleus, gastrocnemius (GM), tibialis anterior, vastus lateralis and rectus femoris) of the right leg during the walking test. The EMG median frequency of all contractions at minute 2 and 6 were averaged for each muscle group. Ventilation, oxygen consumption and CO2 production were also continuously measured throughout the test.

Results: Although the walking distance (494 ± 116 vs. 625 ± 50 m; P < 0.01) and the walking speed (1.7 ± 0.4 vs. 2.1 ± 1.2 m·s-1; P < 0.01) were reduced in COPD compared with controls, patients worked at a higher percentage of their estimated maximum voluntary ventilation during the test (118 ± 32 % vs. 51 ± 14 %; P < 0.01). The time course of the EMG median frequency from minute 2 to 6 differed between patients with COPD and healthy controls for the soleus, GM and tibialis anterior suggesting the occurrence of a muscle fatiguing profile in COPD.

Conclusions: Evidences of a fatiguing profile was found in three lower limb muscle groups during walking in COPD despite a slower walking speed compared to healthy controls.
Leg Muscle Blood Flow During 1 and 2-leg Knee Extension Exercise in Patients with COPD and Aged-Controls
Authors: Robillard Julie , Momoh Fatihat , Baril Jacinthe , Sheel Andrew William , Boushel Robert , Laurin David , Rossi Amanda , Deschenes Julie , Bourbeau Jean , Taivassalo Tanja , Perrault Helene
Published: May 2017

Background: In chronic obstructive pulmonary disease (COPD), leg muscle blood flow may be compromised during dynamic exercise due to the competing influence of respiratory muscle work for available cardiac output. This study examined the flow demand limits of skeletal muscle flow in varying muscle mass recruitment. It employed one leg knee extension (1L-KE) and two-leg knee extension (2L-KE) to examine the mass-specific work rates at which peripheral circulatory function may become compromised due to elevated respiratory demands.

Methods: Three male COPD patients (70 ± 5 yr; FEV1 /FVC = 42 ± 11%) and two aged-controls (74 ± 1 yr; FEV1/FVC = 76 ± 5%) completed three sets of 7-minute steady state 1L-KE and 2L-KE at 20, 40 and 65% (SS20%; SS40%; SS65%) of previously determined ergometer-specific peak power, separated by rest periods of 15 min. Leg muscle blood flow (BF) was determined using pulsed Doppler sonography of the femoral artery during incremental exercise loads and post-exercise. ECG, blood pressure, ventilatory parameters and VO2 were obtained continuously, and dye dilution cardiac output was measured at rest and during exercise.

Results: Preliminary data showed that, for each exercise intensity, the required VO2 is similar in both groups. However, the workloads in COPD are between 60% and 82% of the control group workloads. During 1L-KE and 2L-KE, BF is consistently higher in COPD compared to controls. For 1L-KE, the increase in BF from rest (mean ± SD in ml/min; COPD vs controls) are SS20%: 763 ± 244 vs 105 ± 34; SS40%: 1157 ± 597 vs 310 ± 97; SS65%: 1493 ± 348 vs 424 ± 45. BF relative to workload is at least 3-fold higher in COPD compared to controls for all exercise intensities.

Conclusions: These data suggest that mean muscle blood flow may not be compromised during knee-extensor exercise in COPD patients, and ongoing data will clarify whether this is a compensatory response to altered peripheral muscle metabolic function.
Improvement in Quadriceps Muscle Strength and Fucntional Capacities after a 3-month home-based Endurance Training in Lung Transplant Recipients
Authors: Vivodtzev Isabelle , Pison Christophe , Mezin Paulette , Guerrero Karen , Borel Jean-Christian , Levy Patrick , Wuyam Bernard
Published: May 2017

Background: Peripheral muscle dysfunction and reduced exercise capacity are well recognized in lung transplant recipients (LTR) in spite of improved lung function. However, the effect of exercise training in this specific population is still poor studied. We investigated the benefits of training on muscle function and cardio-ventilatory response during exercise in LTR.

Methods: Twelve patients after lung transplantation (FEV1: 74 ± 24 % of predicted value) and 12 healthy subjects (C) were studied before and after a 3-month home-based endurance training. Quadriceps strength and fatigability were assessed by maximal twitch tension (TwQ) using magnetic stimulation of the femoral nerve and fiber diameters were obtained after biopsy of the vastus lateralis. Cardio-ventilatory responses were measured during both maximal and constant workload (W) cycle exercise and quality of life was assessed by the Chronic Respiratory Questionnaire.

Results: At baseline, LTR had lower percentage of type I fibers, TwQ, Wmax, VO2max, VEmax and endurance time than C (< 50% of C each). After training, significant improvement in TwQ (+44 ± 26 N), Wmax (+13 ± 19 W), endurance time (+11.5 ± 11.1 min) and dyspnea score (CRQdyspnea: +3.1 ± 4.4 points) were observed in LTR (p < 0.05). Furthermore, VE was reduced at submaximal (VE at ventilatory threshold: -4.5 ± 6.8 L/min) and constant (65% Wmax) exercise (-6.4 ± 5.2 L/min) (P < 0.05). Decrease in exercise-induced fatigability correlated with decrease in VE at initial maximal workload in LTR (r = 0.72, P = 0.06) and in LTR + C (r = 0.56, P = 0.02) and increase in TwQ correlated to increase in CRQdyspnea in LTR (r = 0.74, P = 0.04).

Conclusion: Gains in exercise capacity and in quadriceps strength were observed after endurance training in LTR. The latter may have been involved in improving exercise ventilatory response and dyspnea, supporting the benefit of peripheral muscle strength improvement in exercise tolerance in LTR and even the larger field of chronic respiratory diseases.
Clinical research lags behind biomedical, population-based health, and health services research at multiple levels
Authors: Raghavan Malathi , Sandham J. Dean
Published: May 2017

Purpose: Concerns regarding a decline in clinical research have been raised internationally. In this study, research initiatives and competitiveness of investigators seeking funding for clinical research were compared with those for three other health research themes in Canada, namely, biomedical, population-based, and health services research.

Methods: A retrospective, multi-level descriptive study was conducted using administrative data from the Canadian Institutes for Health Research (CIHR) research grants program. Annual growth rates in numbers of proposals submitted since year 2000 (level I of comparison), success rates of submissions (level II), and growth rates in funding received since fiscal-year 1999-00 (level III) were compared across themes.

Results:

Proposal submission (Level I): The average annual rate of growth in proposal submissions for biomedical, clinical, population-based and health services research was 11.8%, 6.3%, 105.0% and 43.2%, respectively.

Success rate (Level II) was lower in clinical research (24%; P-value < 0.001) compared with biomedical (34%), population-based (29%), and health services (28%) research.

Funding (Level III) grew at an average rate of 16.1% per year for biomedical, 28.2% for clinical, 65.9% for population-based, and 86.2% for health services research. However, the median amount funded for clinical projects (CAD $154,535) was less (P-value < 0.0001) than that for biomedical projects ($225,346).

Conclusion: The overall growth of research activities in clinical theme was slower than with research in other themes—fewer proposals were submitted and lower proportion of submissions was successful. Smaller amounts of funding were received for clinical projects compared with biomedical projects, but a handful of large-scale clinical projects influenced the growth rate in funding for all clinical research. This report underscores the concern that multi-level problems plague clinical research.
3. Interactive online software documenting and corroborating exposure to CanMEDS Roles
Authors: Lamarche Y. , Perrault L. P. , Beauchamp G. , Renaud J.-F. , Lamarche S. , Carrier M.
Published: May 2017

Residents are exposed to various situations contributing to the development of their CanMEDS roles. Exposure to different clinical scenarios and teaching situations contributing to the development of the CanMEDS roles could be identified, documented by residents and corroborated by staff supervisors retrospectively. A rapid and thorough method to assess this exposure is not available and could help to monitor a programs strengths and weaknesses.

Daily activities developing specific CanMEDS roles where identified initially by the program director and residents. An internet based automatic survey generator (residentevaluation.com) was built to interrogate residents on a weekly basis on their exposure these clinical activities, linked to the seven CanMEDS roles. The surveys where automatically directed to supervisors for corroboration and comments. Periodic and annual reports where sent to the program director.

The study group was composed of the Université de Montréal cardiac surgical trainees (n=6). Weekly surveys were sent from July 2006 to March 2007 (Ongoing). Participation rose from 42% to 79% in trainees and was 70% among supervisors. Time to fill the weekly survey was less than 1 minute for trainees and supervisors. The majority of residents documented development of all seven CanMEDS roles on a weekly basis. The trainees were exposed on a weekly basis to a reflection on the development of their CanMEDS competences.

Cardiac surgical trainees at Université de Montréal are exposed and develop their CanMEDS roles over their regular training. The residentevaluation.com program allows a rapid weekly assessment and documentation of exposure to CanMEDS roles. The tool provides periodic and annual reports for program directors to quantify this exposure and adjust the program objectives. This software could be used in other programs to assess its efficiency in different cohorts.

Frank, JR, ed. 2005. The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. Ottawa: The Royal College of Physicians and Surgeons of Canada

Frank JR, Jabbour M, Fréchette D, Marks M, Valk N, Bourgeois G, eds. Report of the CanMEDS Phase IV Working Groups. Ottawa: The Royal College of Physicians and Surgeons of Canada. March, 2005.
4. Leadership in postgraduate medicine: Results from the first annual chief resident leadership workshop
Authors: Verma S. , Zulla R. , Mikhael J. , Natsheh A. , Takahashi S. Glover , Muharuma L. , McIlory J.
Published: May 2017

In the spring of 2006, chief and senior residents were surveyed to determine how they prepared for their senior administrative/leadership role, what topics should be included in a leadership workshop and how this workshop should be delivered. Overall, 32.3% had no prior contact with the previous chief resident. Among those prepared, 46% consulted previous chiefs/seniors and/or program directors. Eighty-five percent agreed that a leadership workshop would be beneficial for future chiefs.

Using the results from this environmental scan, a planning committee was formed to design the First Annual Chief Resident Leadership Workshop, held in August 2006, to identify and develop leadership skills while providing them with the resources to ease their transition into this senior administrative role. Seven sessions were offered: Your Role as Chief Resident, Mentorship, overview of the residents’ work/education contract, Personality Inventory (i.e. Myers-Briggs), Anti-Racism and Harassment, Resident Wellness and Public Speaking. A keynote address on leadership in academic medicine was given by a well-known Canadian clinician leader. To reinforce the experience, a resource binder and handbook was distributed to all participants.

Quality and content of each session was evaluated using on a 5-point Likert scale. Mean scores were calculated. Mentorship scored the highest in terms of quality (4.46) and content (4.47), followed by Leadership in Academic Medicine (4.43 and 4.62, respectively). Over 90 % agreed that a leadership program is necessary. Parallel to our earlier findings, many chief residents use multiple sources to prepare for their role, primarily the pairing of contact with the previous chief resident and the Program Director. The results indicate that a formal, centralized leadership workshop/seminar is valued and should highlight the necessary skills set and provide key resources.

Susman J, Gilbert C. Family practice residency directors’ perceptions of the position of chief resident. Academic Medicine 1992; 67(3):212-213.

Awad JJ, Levenson SM, Osman CH, James S. The impact of a novel resident leadership training curriculum. The American Journal of Surgery 2004; 188:481-484.

Kasuya RT, Nip IL. A retreat on leadership skills for residents. Academic Medicine 2001; 76(5):554.
5. A needs assessment for a CanMEDS-based curriculum in ambulatory care for internal medicine residents in Canada
Authors: Wong R. , Roff S.
Published: May 2017

In Canada, graduates of internal medicine training programs should be proficient in ambulatory medicine and practice. Before determining how to improve education in ambulatory care, a list of desired learning outcomes must be identified and used as the foundation for the design, implementation and evaluation of instructional events. The Delphi technique is a qualitative-research method that uses a series of questionnaires sent to a group of experts with controlled feedback provided by the researchers after each round of questions. A modified Delphi technique was used to determine the competencies required for an ambulatory care curriculum based on the CanMEDS roles.

Four groups deemed to be critical stakeholders in residency education were invited to take part in this study: 1. Medical educators and planners, 2. Members of the Canadian Society of Internal Medicine (CSIM), 3. Recent Royal College certificants in internal medicine, 4. Residents currently in core internal medicine residency programs. Panelists were sent questionnaires asking them to rate learning outcomes based on their importance to residency training in ambulatory care. Four hundred and nineteen participants completed the round 1 questionnaire that was comprised of 75 topics identified through a literature search. Using predefined criteria for degree of importance and consensus, 19 items were included in the compendium and 9 were excluded after one round. Forty-two items for which the panel that did not reach consensus, as well as 3 new items suggested by the panel were included in the questionnaire for round 2. Two hundred and forty participants completed the round 2 questionnaire; consensus was reached for each of the 45 items.

After two rounds, 21 items were included in the final compendium as very high priority topics (“must be able to”). An additional 26 items were identified as high priority topics (“should be able to”). The overall ratings by each of the four groups were similar and there were no differences between groups that affected the selection of items for the final compendium. To our knowledge this is the first time a Delphi-process has been used to determine the content of an ambulatory care curriculum in internal medicine in Canada. The compendium could potentially be used as the basis to structure training programs in ambulatory care.

Barker LR. Curriculum for Ambulatory Care Training in Medical residency: rationale, attitudes and generic proficiencies. J Gen Intern Med 1990; 5(supp.):S3-S14.

Levinsky NG. A survey of changes in the proportions of ambulatory training in internal medicine clerkships and residencies from 1986-87 to 1996-97. Acad Med 1998; 73:1114-1115.

Linn LS, Brook RH, Clarke VA, Fink A, Kosecoff J. Evaluation of ambulatory care training by graduates of internal medicine residencies. J Med Educ 1986; 61:293-302.
7. Présentation d'un portfolio électronique pour la formation et l'évaluation des compétences CanMEDS en obstétrique-gynécologie
Authors: Dupuis M.-J. , Girardot D.
Published: May 2017

Bien que les objectifs d’apprentissage et fiches d’évaluation de stage tiennent compte des sept compétences CanMEDS, il est difficile d’intégrer celles ci dans l’apprentissage et l’évaluation. Le portfolio, lorsque utilisé dans une approche réflexive, favorise l’apprentissage des compétences. Le développement et l’utilisation du portfolio visent une meilleure intégration des rôles CanMEDS dans l’apprentissage et une évaluation authentique des compétences.

Notre programme adopte le portfolio comme outil d’apprentissage et d’évaluation. Pour chaque compétence CanMEDS, le portfolio comprend 6 sections : 1) Critères spécifiques pour la compétence, 2) Description par le résident d’une bonne et d’une mauvaise performance, 3) Description d’un incident critique (un par année) ayant transformé sa formation, 4) Auto évaluation, 5) Rétroaction.

A chaque trimestre, le résident rencontre son tuteur et présente son auto évaluation. Celle-ci est comparée à l’évaluation que les superviseurs font du résident, compilée et présentée au résident par son tuteur. Annuellement, le résident fournit la preuve de sa progression pour une compétence donnée. Pour ce faire, il complète son portfolio régulièrement en cours d’année pour documenter l’analyse de sa progression à l’aide d’exemples tirés de son portfolio.

Après une année d’implantation, nous évaluerons l’impact sur la perception de l’intégration des compétences CanMEDS aux niveaux des apprentissages et des évaluations, et le degré de satisfaction des résidents et des tuteurs.

Naccache N, Samson L, Jouquan J. Le portfolio en éducation des sciences de la santé: un outil d’apprentissage, de développement professionnel et d’évaluation. Pédagogie médicale, 2006; 7: 110-27.

Tardif J. L’évaluation des compétences: documenter le parcours de développement, 2006

Kjaer NK, Maagaard R, Wied S. Using an online portfolio in postgraduate training. Medical Teacher, 2006; 8:708-712
9. Innovation in research instruction: Pilot testing of team learning to promote peer reviewed grantwriting by clinician trainees
Authors: Warnock F. , Sibley J.
Published: May 2017

We piloted the combination of Team-Based Learning (TBL) with interactive in-class instruction in grantsmanship to test its effectiveness in preparing clinician trainees to produce a national (CIHR) peer reviewed operating grant in a small class setting. The approach was integrated into a university graduate quantitative method and design course delivered to five trainees in 12 weekly 4hr sessions. Outcomes to assess knowledge acquisition, retention and application included percentage scores in seven TBL individual and student team tests (each containing 15-20 multiple-choice items), student participation in a mock peer review and student own submission of an operating grant (using CIHR peer review evaluation criteria to assess methodological coherency and soundness of the research design and plan, feasibility, relevancy and innovativeness). Also assessed were student perception of the approach on their learning (7 item questionnaire) and two peer teaching evaluations.

In seven consecutive testing sessions, percentage scores for the individual tests were 80, 72, 76, 71, 83, 75 and 80 and corresponding team scores were 96, 96, 83, 100, 95, 97, and 97 suggesting an 18% increase in individual knowledge with team testing. Overall, student achievements were 93% for mock peer review and 78% for grant production. Trainees rated TBL and the interactive in-class activities as effective in consolidating knowledge and promoting complex research design decision making. Evaluations of the teaching were 4.7 and 4.8 out of 5. Findings suggest students mastered course content, that team learning increased individual knowledge and that trainees linked theory to successfully produce a CIHR operating grant. These pilot findings call for larger prospective studies to test the combined approach in larger classes and with other populations of clinician trainees.

The clinician scientist: yesterday, today and tomorrow. Canadian Institutes of Health Research. http://www.cihr-irsc.gc.ca/e/pdf_22084.htm. Accessed February 25, 2007.

Ringel SP. Steiner JF, Vickrey BG, Spencer SS. Training clinical researchers in neurology: We must do better. Neurology 2001; 57:388-392.

Haidet P, O’Malley KJ, Boyd R. An initial experience with “Team Learning’ in medical education. Academic Medicine 2002; 77: 40-41.
12. Disclosure of medical errors: A view through a global lens
Authors: Kalra J. , Neufeld H. , Mulla A.
Published: May 2017

There are ongoing efforts worldwide to minimize the occurrence of medical errors. However, the issue of honest disclosure of a medical error to the patient or their family has been relatively unattended. We have previously reported the Canadian provincial initiatives encouraging open disclosure of a critical event and have suggested its integration into a ‘no-fault’ model. In the absence of uniform policies directing appropriate disclosure of a medical error, substantial scope exists for breaching the patient’s trust if errors during the process of care are not disclosed. We reviewed the various medical error disclosure initiatives across the globe to analyze the progress made in this key area. In 2001, the United States (US) Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandated an open disclosure of any critical event during care to the patient or their families. This was deemed as an essential accreditation standard for the institution. In Australia, the Australian Council for Safety and Quality in Health Care integrates the disclosure process with a risk management analysis towards investigating the critical event. In New Zealand, the patients suffering a medical error are rehabilitated and compensated through a no-fault, state-funded compensation scheme. The National Health Services (NHS) of the United Kingdom directs the doctors and managers to inform a patient of an act of negligence or omission that causes harm. The NHS scheme offers a remedial package to the patient including an apology and financial compensation in return for the patients waiving their right to litigate. The Canadian provincial initiatives, though similar in content, remain isolated because of their non-mandatory nature and absence of federal or provincial laws on disclosure. In Conclusion, we suggest that a uniform national policy centered on addressing errors in a non-punitive manner and respecting the patient’s right to an honest disclosure be implemented.

Kalra J, Massey KL, Mulla A. Disclosure of medical error: policies and practice. Journal of the Royal Society of Medicine 2005; 98(7): 307-09.

Hebert PC, Levin AV, Robertson G. Bioethics for clinicians: 23. Disclosure of medical error. CMAJ 2001; 164(4):509-13.

Mazor KM, Simon SR, Gurwitz JH. Communicating with patients about medical errors: a review of the literature. Arch Intern Med. 2004; 164(15):1690-7.
13. The impact of government regulation of ambulatory surgical facilities on access to elective surgical procedures
Authors: Fric-Shamji E. , Shamji M.
Published: May 2017

Advances in medical technology have made free-standing ambulatory surgery centres a cost-effective method of delivering health care in the United States. One: Rapid expansion of such centres and duplication of services have raised concerns over rising health care costs, two: leading to government regulation of facilities via a Certificate of Need (CON) law in many states. Three: Such regulation may decrease access to elective procedures.

This study investigates access to elective surgical procedures in selected states with and without CON laws. Results of the Health Care Utilization Project were analyzed. Per capita rates of elective carpal tunnel release (CTR) and lumbar discectomy were evaluated in 16 states with CON laws and 5 states without CON laws over the years 2004-2005. Distribution of CTR and lumbar discectomy were analyzed by facility ownership and teaching status, using rates of emergent procedures as a control. Student’s t-tests compared rates of CTR and discectomy as a function of CON legislation. Two-factor ANOVA extended this analysis to account for teaching environment and facility ownership.

Fewer CTR cases were performed in states with CON laws (p=0.014), specifically in government-owned (p=0.012) and non-teaching facilities (p=0.01). No difference was observed in lumbar discectomy rates in states with respect to CON regulation. Distribution of both procedures among teaching and non-teaching centers was independent of CON laws. Facility ownership predicts fraction of these cases performed at an institution,(p < 0.01) and this distribution is influenced by CON regulation, increasing fractions of both types of procedures performed at private, not-for-profit centers (p=0.001, p=0.003 respectively).

We conclude that CON laws restrict access to certain procedures, specifically in government-owned and non-teaching facilities. These laws may limit the supply of surgical care, notably by redistributing away from government and for-profit centres. Potential solutions include reinvestigating the need for CON laws, or examining the CON methodology to accurately reflect need.

Small NC, Bert JM. Office Ambulatory Surgery Centers: Creation and Management. J Am Acad Orthop Surg 2003; 11:157-62.

Casalino LP, Devers KJ, Brewster LR. Focused Factories? Physician-Owned Specialty Facilities. Health Affairs 22(6):56-67.

Lanning JA, Morrisey MA, Ohsfeldt RL. “Endogenous hospital regulation and it’s effects on hospital and non-hospital expenditures” Journal of Regulatory Economics1991 (June); 3(2):137-54.
15. Meeting challenges in the delivery of surgical care
Authors: Sigurdson L.
Published: May 2017

Canadian surgeons are faced with looming demographic challenges. Shortages in surgical manpower cannot be addressed expediently due to 14-year university requirements. A potential solution is to increase the efficiency of surgeons already in practice. Physician assistants (PA’s), may play a role in this regard by allowing surgeons to concentrate on their core competency, namely operating. The purposes of this investigation are to explore the inefficiencies in a current Canadian surgeon’s practice, examine the feasibility of PA employment and evaluate the financial impacts.

The study was performed in 3 parts. In part 1, operating room plastic surgery Surgiserver® data for 10 years leading up to 2005 were analyzed to determine daily operating time actually used. In part 2, 4 months of detailed time series data were captured prospectively for every patient care event. The data was analyzed using SPSS (ver. 11.5) to determine the percentage and types of events that could be delegated to a PA. In part 3, PA hiring scenarios were developed using formal business case analyses.

Over 3,635 days, mean operating time used in a 10-hour surgical day was 5.93 hours. Of the 806 patients seen in 13 clinics, 53.5% could have been cared for by a PA. In the minor procedure area, 48.8 % of surgical time was spent performing non-essential, PA compatible work. In the main OR, 25.9% of surgical time was PA compatible. Considering the weekly mix of activities, a PA could increase surgical productivity by 36.7%. Hiring a PA was neutrally cost effective at the 37% productivity increase level. However, much greater discounted incremental cash flows, internal rates of return (IRR) and return on investments (ROI) were achieved when PA hiring allowed one surgeon to run 2 OR’s simultaneously.

Employing PA’s, in conjunction with increasing OR capacity, have the potential to markedly increase the capability of surgeons to deal with lengthy wait lists in a cost effective manner.

McKibbin RC. Cost-effectiveness of physician assistants: A review of recent evidence. Pa J 1978; 8(2):110-115.

Maxfield RG. Use of physician's assistants in a general surgical practice. Am J Surg 1978; 131(4):504-508.

Kaissi A, Kralewski J, Dowd B. Financial and organizational factors affecting the employment of nurse practitioners and physician assistants in medical group practices. J Ambul Care Manage 2003; 26(3):209-216.
16. Postgraduate training and its effect on practice location, career choice and practice profile: Tracking 10 years of output from the University of Toronto
Authors: Abrahams C. , Verma S. , Glazier R. , Jaakkimainen L. , Shultz S.
Published: May 2017

The purpose of this study is to investigate the relationship between location and specialty of training and practice characteristics such as type of practice (i.e. community versus academic), socio-demographic profile of patients and their complexity, hospital/health facility affiliations and workload/productivity.

The analysis required an extraction of registrant data from the University of Toronto Postgraduate Web Evaluation and Registration (POWER) system for a cohort of exiting residents and fellows from 1993 to 2003. The data extract was linked to several administrative databases held by ICES, including physician practice and billing information from the Ontario Health Insurance Plan (OHIP) and anonymized patient demographic data from the Registered Persons Database (RPDB).

Results of this study will inform workforce policy issues such as the overall contribution made by Toronto graduates to Ontario, other Canadian provinces and international practice pool of physicians, trends regarding medical career choice, similarities and differences between career choices of International Medical Graduates versus Canadian Medical Graduates, impact of location/program of training, impact of length of training and profile/geography of patients served by graduates of Toronto. The study will aim to create a methodology/template for analysis that can be applied to other medical schools and catchment areas in human health resource planning.

Chan B, Willett J. Factors Influencing Participation in Obstetrics by Obstetrician-Gynecologists. 2004; 103(3):493-498.

Noble J, Baerlocher MO. Future Practice Profiles of Canadian Medical Trainees. Clinical and Investigative Medicine 2006; 29(4):288-289.

Watson DE, Katz A, Reid RJ, Bogdanovic B, Roos N. Family Physician Workloads and Access to Care in Winnipeg: 1991 to 2001. Canadian Family Physician 2004; 171(4):339-342.