bluuebunny/crossref_metadata_2025 huggingface dataset:
Treadmill Running Induces a Detrimental Metabolic Adaptation in the Diabetic Mouse
Authors: Broderick Tom L. , Sennott Jackie , Morrissey Joseph , Standley Paul
Published: May 2017

Background: Regular exercise is generally recommended for the treatment of type 2 diabetes. Exercise reduces body weight, increases insulin sensitivity, and improves glycemic control. The present study was designed to determine the impact of voluntary wheel and forced treadmill running on the metabolic state in the db/db mouse, a model of type 2 diabetes. Our hypothesis is that exercise training improves the metabolic status such that a reduction in body weight, blood glucose and insulin are observed, resulting in improved insulin sensitivity.

Methods: Male diabetic db/db mice were assigned to sedentary (DS), voluntary wheel running (DV), and treadmill running (DT) running groups for 12 weeks. Nondiabetic heterozygote littermates served as control (CN).

Results: After 12 weeks of training, DV and DT mice ran a total of 4.24 ± 0.18 km and 11.8 km, respectively. Data are expressed as mean ± SEM for 10-12 mice in each group. * P < 0.05 vs CN, † P < 0.05 vs DS

*** Table in Full Text PDF. ***

Conclusions: Voluntary exercise training is beneficial in reducing body weight and blood glucose in the db/db mouse, but this effect is minor. Forced treadmill running, however, did not improve body weight, blood glucose and the hyperinsulinemic state remained. These results suggest that forced treadmill exercise training may actually worsen the metabolic state in this model of diabetes.
Study of the Relation between Hypoxia and Muscle Atrophy
Authors: Caron Marc-André , Paré Marie-Ève , Maltais François , Debigaré Richard
Published: May 2017

Background : Skeletal muscle atrophy is an important feature of chronic obstructive pulmonary disease (COPD) and it is recognized to have considerable clinical impacts. Unfortunately, factors contributing to muscle wasting in COPD are poorly understood. Hypoxemia is typical in COPD and several evidences link hypoxic conditions and protein breakdown. We propose that hypoxia participate to muscle atrophy by increasing Ubiquitin-Proteasome (UP) system activity and by decreasing the activity of IGF/PI3K/Akt synthesis pathway.

Methods: To test this hypothesis, L6 muscle myotubes were either exposed to hypoxia (1% O2) or normoxia (21% O2).

Results: After 24 hours of hypoxic exposure, we found a significant rise in the chymotrypsin and caspase-like 20S proteasome activities. Proteolysis was confirmed by an accumulation of a 14 kDa actin fragment during hypoxia. An elevation of Atrogin-1 mRNA expression was also observed in similar conditions. A decline in Akt phosphorylation was noticed in hypoxia. These changes were attenuated by insulin treatment.

Conclusion: Proteolysis is accentuated in myotubes exposed to hypoxia and the UP system appears to be involved. In addition, protein synthesis seems to be affected as a lower Akt activity was observed. However, the IGF/PI3K/Akt pathway can still be stimulated by a suitable signal suggesting that therapies targeting this pathway are conceivable.
Blood Pressure Measurement in Morbid Obesity: Comparison between Forearm and Intra-Arterial Assessment of Blood pressure
Authors: Croteau Sara , Vallière Caroline , Martin Julie , Bussières Jean , Boudreault Jean-Roch , Biron Simon , Marceau Simon , Hould Frederic-Simon , Lebel Stefane , Poirier Paul
Published: May 2017

Background: Obesity is associated with high blood pressure. Measurement of blood pressure (BP) in morbid obesity with a larger cuff bladder may be erroneous due to the anatomy of their upper limb and/or a nonsuitable cuff bladder. The objective of the study was to compare a non-invasive technique of BP measurement on the forearm with an appropriate standard blood cuff bladder to an invasive method (intra-arterial measurement in the radial artery) in two groups of subjects; non obese (NO) and morbidly obese (MO).

Methods: Twenty-seven NO subjects with a mean body mass index (BMI) of 25,6 ± 2,7 kg/m2 were evaluated using two different techniques for blood pressure measurement. Measures were performed, in a supine position, at the forearm level with a standard cuff bladder (Welch Allyn, NY, USA) and on the opposite forearm using an intra-arterial access. The NO group was compared to 20 MO subjects with a mean BMI of 5,1 ± 8,7 kg/m2. The MO group was evaluated during a bariatric surgery procedure, with regular intervals (10 to 15 min) using the same two methods described above.

Results: A difference was observed between the two techniques of blood pressure measurements (P < 0.05 and P < 0.01 intra-arterial vs. cuff bladder for the NO and the MO groups respectively) (see Table). Correlations between the two techniques were observed in the NO group (P < 0.001) for the systolic BP (r=0,823) and the diastolic BP (r=0,769). Similar correlations were also observed in the MO group for the systolic BP (r=0,792, P < 0,001) and the diastolic BP (r=0,830, P < 0,001; Table).

*** Table in Full Text PDF. ***

Conclusion: Although different, BP measurements at the forearm level in MO subjects seems to be clinically valid. This technique may be used in this specific population as an alternative for the measurement of BP.
The Infrequency of Spirometry Use in Medical Clinics
Authors: De Dios Jose Angelo A. , Diez Luis , ZuWallack Richard , Lahiri Bimalin
Published: May 2017

Background: Spirometry is advocated for adults with obstructive lung disease such as asthma or chronic obstructive lung disease (COPD), for individuals with risk factors such as cigarette smoking, and for patients with chronic respiratory symptoms. This record review study was performed to determine how frequent medical residents order spirometry for the above indications.

Methods: Outpatient general medical clinic records from 337 patients followed in the medical clinics of a large, teaching hospital in an urban setting were reviewed. Inclusion criteria for review included age > 45 yr and one of the following: 1) a diagnosis of asthma and/or COPD, 2) either current or previous cigarette smoking, 3) one or more of the following chronic respiratory symptoms: dyspnea, cough, sputum production.

Results: The mean (SD) age was 57 + 10 yr. Of this group, only 31% had spirometry or an order for spirometry documented in the outpatient record.

Conclusion: This finding underscores the under-utilization of spirometry as a diagnostic tool, even in an academic setting.
Locus of Symptom Limitation and Exercise Response to Bronchodilation in Chronic Obstructive Pulmonary Disease
Authors: Deschênes Dominic , Pepin Véronique , Saey Didier , LeBlanc Pierre , Maltais François
Published: May 2017

Background: We previously reported that the occurrence of contractile fatigue of the quadriceps during exercise in patients with COPD reduced the likelihood of acute bronchodilation to improve the endurance time to constant work rate exercise. The purpose of the present study was to assess whether the perception of dyspnea and leg fatigue during exercise could be used to predict the exercise response to acute bronchodilation in this population.

Methods: Sixty-eight patients with COPD performed either two constant work-rate cycling exercises or two endurance shuttle walking tests. These tests were preceded by nebulization of placebo or 500 mg ipratropium bromide. Changes in FEV1 and in the endurance time with bronchodilation were measured. The changes in quadriceps twitch force after exercise were evaluated. In addition, we assessed dyspnea and perception of leg fatigue on Borg scale as well as the locus of exercise limitation (dyspnea, leg fatigue, or both).

Results: The locus of symptom limitation was useful to predict the exercise response to bronchodilation; patients stopping exercise because of leg fatigue or due to a combination of dyspnea/leg fatigue showed a smaller improvement in endurance time to constant work rate exercise with bronchodilation compared with those stopping because of dyspnea. Subjective and objective evidences of fatigue were related: patients who stopped exercising because of leg fatigue showed a larger fall in quadriceps twitch force compared to patients who stopped for dyspnea.

Conclusion: The assessment of the locus of symptom limitation during constant work rate exercise is useful to predict the improvement in endurance time following acute bronchodilation in patients with COPD.
Individualized Intervention Model Aiming to Permanently Change Life Habits which Have an Impact on Modifiable Risk Factors
Authors: Duchaine Lucie , Parent Linda
Published: May 2017

Background: A great challenge for clinicians working in a rehabilitation or prevention setting is to succeed in getting their clients to be physically active and to make them change their life habits. Five years ago at Centre de Réadaptation Lucie Bruneau, an interdisciplinary rehabilitation team took that challenge. This team is specialized in stroke rehabilitation and, in the last 5 yr, it has noticed a decline in the health condition, quality of life and social participation of its patients. Here are some statistics that illustrate the situation: 57% are < 49 yr old, 24% have 3 modifiable risk factors, another 24% have four or more and 18% have five; 35% have associated heart, vascular problems or diseases; for most of them, there’s a 20% chance of having another stroke.

Methods: From these observations, an innovative concept of intervention was born. It is a part of the rehabilitation process and is based on research in a variety of fields: the transtheoric model of Prochaska and DiClemente, the person centered neurodynamic approach; the ecological, psycho-biological (affordance) and pedagogical approaches. The team systematically identifies the risk factors in an individualized intervention plan which is based on the “handicap production process” model. From the start to the end of the rehabilitation program and according to his needs, the patient will be brought to understand, adopt and integrate new life habits in the following spheres: food, smoking, and physical activity.

Results: This global responsibilization optimizes and strengthens their long term commitment. Concerning physical activity, results obtained from a pilot study show us that 70% of our patients maintain their level three months after their discharge.

Conclusion: This type of intervention could be used in other type of settings (rehabilitation or prevention): hospital, school, CLSC’s and community centers.
An Incremental Shuttle Walk Test to Estimate Maximal Aerobic Functional Capacity
Authors: Duvergé Sébastien , Leone Mario , Kalinova Émilia , Le Cren Frédéric , Boucher Jean P. , Comtois Alain S.
Published: May 2017

Background: The goal of the present study was to compare the maximum walking speed and peak oxygen consumption (VO2 peak) obtained during the 6-min walk test (6 MWT) and an incremental shuttle walking test (ISWT) in a trained older population.

Methods: A total of 22 older adults (16 female and 6 male) with a group mean age of 70±5.8 yr (range 58 to 79) completed the 6 MWT and ISWT within a 2 wk period. Heart rate (HR) and VO2 peak were measured during each test with a portable metabolic cart (Cosmed, K4B2). The VO2 peak, the maximum walking speed and the total distance walked measured during both tests (6 MWT and ISWT) were compared.

Results: A total of 110 recordings for the VO2 peak were obtained and analyzed. Strong correlations were found for the VO2 peak and the walking speed (r=0.91 and r=0.89, respectively, for 6 MWT and ISWT). VO2 peak values obtained with the ISWT were significantly greater (P < 0.05) than with the 6 MWT (21.6 ± 5.3 vs 18.9 ml/kgmin ± 4.5, respectively). There was no difference between sexes. In addition, the maximum heart rate as predicted from age during the ISWT was reached by all participants while it was not during the 6 MWT.

Conclusion: Thus, the ISWT appears to a better tool to assess the maximal aerobic functional capacity in older healthy adults based on the higher VO2 peak values obtained in comparison to the 6 MWT.
Development of a Constant Rate Step Test to Assess Exertional Dyspnea in the Primary Care Setting in Patients with COPD Ashley Rycroft
Authors: Henophy Sara , Baril Jacinthe , Nadreau Éric , Bourbeau Jean , Maltais François , Perrault Hélène
Published: May 2017

Background: There is a need to develop a field test to evaluate exertional dyspnea in the primary care setting. This study examined the applicability of a 3-minute constant rate step test in patients with COPD.

Methods: This test involved 4 stepping rates (18, 22, 26, 32 steps.min-1) equivalent to approximately 4.5, 5.3, 6.0, and 7.2 MET with the ultimate goal that in its final development, the assessment will be made a single stepping rate based on disease severity. Stable COPD patients (N= 43; 65 ± 6.5 years; FEV1= 49 ± 16% pred.; SpO2 (%) rest: 95± 2) were equipped with a portable Jaeger Oxycon Mobile® metabolic system and followed an audio signal for stepping up and down a single 20 cm step for 3 minutes. Borg dyspnea scores were obtained at the end each stepping bout. A 10-min rest was given between each stepping bout.

Results: O f the 43 patients, 80% completed stages 1 and 2, 74 and 37% stages 3 and 4 while no patient of MRC class 4 or 5 (n=8) completed stage 1. Breathing frequency (breaths.min-1) spanned from 26.5± 4.1 to 39.0±6.4 but VT (L) remained unchanged (1.4± 0.3 vs. 1.5±0.4) from stage 1 to 4 while Borg scores were 3 ± 1, 4 ± 1, 5 ± 2, 6 ± 3 respectively and SpO2 (%) were 92±5, 91±4, 91±4 and 90±4.

Conclusions: Preliminary findings indicate that a 3-min constant rate step test may present a feasible alternative to laboratory testing to assess exertional dyspnea in moderately severe COPD. In this population, a stepping rate of 26 steps·min-1 could be sustained by the majority of patients while producing a level of dyspnea potentially amenable to therapy.
Use of Preparatory Stability Exercises with Chronic Obstructive Pulmonary Disease Patients (COPD) to Prevent Iatrogenic Injuries during Rehabilitation
Authors: Holly Janet T. , Lavallee Lyne G.
Published: May 2017

Background: The increasing incidence of injuries sustained by clients during pulmonary rehabilitation, created a need to develop a prevention strategy. A pre-pulmonary rehabilitation stability exercise class was created based on best practice principles from the orthopaedic literature. It has been discussed in the literature that patients who have COPD have poor stability strategies based on the dominance of the need to drive the respiratory system. If successful, it was felt that this program would decrease the incidence of injury, decrease length stay and help to optimize outcomes.

Methods: Six months of data recording the incidence and severity of injuries from participants in the pulmonary rehabilitation program was collected in order to obtain comparative statistics and demonstrate the need for this program. A literature review was performed to determine the risk of injury in this population. In a 6 month period, 17% of COPD clients admitted to the Rehabilitation Centre for pulmonary rehabilitation have had musculoskeletal issues that proved a significant enough barrier to rehabilitation to require treatment or pulmonary rehabilitation modification. Wait list clients for pulmonary rehabilitation were assessed using the PSFS, NPRS, the 6-minute walk test, the Active Straight Leg Raise, Sitting Arm Lift and the non-stop walk test. Clients participated in six one-hour group exercise sessions. The exercises included neck stabilizers, pelvic floor muscles, trunk stabilizers, and scapular stabilizers derived from published literature.

Results: Clients were re-evaluated using the same outcome tools as well as noting any injuries sustained and capacity to participate. This data was compared with historical data.

Conclusion: The data will help With patient selection for participation in the exercise class as well as refinement of the outcome tools and exercise protocol. This project illustrates the opportunities that exist to share and transfer knowledge from one area of physiotherapy expertise to another to meet the needs of practice. It is essential that this integrated approach to treatment be fostered by clinicians, educators and researchers alike to improve the overall outcomes for the clients.
Times to Treatment in Patients Undergoing Primary Percutaneous Coronary Intervention at Laval Hospital
Authors: Lachance Philippe , Garceau Patrick , Déry Jean-Pierre
Published: May 2017

Background:Current guidelines for ST-elevation myocardial infarction (STEMI) recommend performing primary percutaneous coronary intervention (PCI) within 90 min of hospital arrival. However, recent data suggest that, in a real-world setting, median door-to-balloon (DTB) time is closer to 180 minfor transferred patients with no more than 4 % of patients treated within 90 min. We conducted this retrospective observational study to assess time to treatment in patients undergoing primary PCI at Quebec Heart and Lung Institute (QHLI).

Methods: Consecutive lytic-eligible patients undergoing primary PCI at QHLI for STEMI between April 2004 and March 2004 were included in the present analysis. The primary evaluation was DTB time measured from arrival at the first hospital to first balloon inflation. Clinical outcomes consisted of in-hospital death, reinfarction and bleeding. DTB times and hospital outcomes of patients transferred from referring hospitals were compared to patients presenting directly to QHLI.

Results: During the study period, 203 lytic-eligible patients were treated with primary PCI and included in the present analysis. Sixty-nine patients presented directly to QHLI and 134 were transferred from other Quebec City hospitals. The median DTB time was 114 min in transferred patients, compared with 87 min for patients presenting directly to QHLI [P < 0.001]. DTB time was
Persistent Elevation of Vascular Endothelial Growth Factor and Prostacyclin Following Cardiopulmonary Maladaptation to High Altitude: A Pilot study
Authors: Le Vy-Van , White Michel , Touyz Rhian , Ross Heather , Tessier Yves , Sirois Martin G.
Published: May 2017

Background: Exposure to hypobaric hypoxemia causes acute mountain sickness (AMS) in 40% of subjects acutely exposed to an altitude of 4,000 m. Vascular endothelial growth factor (VEGF) and cytokines appear to play a role in AMS in model systems. The objective of this pilot study was to explore the change in VEGF, the vasodilatory prostacyclin PGI-2, interleukin-6 and thiobarbituric acid reactive substances (TBARS) levels following prolonged exposure to hypobaric hypoxemia on Bolivian Altiplano. The secondary objective was to investigate the relationship between these markers with good versus poor adaptation to high altitude.

Methods: The study population consisted of 7 climbers aged 24-64 yr. One cardiac transplant and one kidney transplant recipients participated in this study. Aerobic capacity was assessed on a treadmill using a RAMP protocol with gas exchange analyses. Blood samples were harvested within 48 hr of departure and within 24 hr returning to sea level.

Results: Selected biochemisty parameters are presented in the table:

*** Table in Full Text PDF. ***

Data are mean ±SD. CP= cardiopulmonary. Both cardiac and Tx recipients did not experience AMS. Maximum altitude achieved: ∗6120-6522; †5680; ‡5300 meters.

Conclusions: Pulmonary maladaptation to high altitude results in a 2-fold elevated VEGF and PGI-2 without concomitant increase of markers of inflammation or oxidative stress. VEGF does not appear to increase in cerebral maladaptation to high altitude. Further investigations are needed to better understand the role of VEGF and other biomarkers during the process of adaptation or maladaptation to high altitude.
Sexuality and Chronic Respiratory Disease
Authors: Ludwig M. , Poulain M. , Fernandes N. , Cals C. , Brun A. , Cotxet A. , Abbate C. , Andre L. , Desnot P. , Desplan J. , Ninot G.
Published: May 2017

Background: At the admission in rehabilitation program, some patients with chronic respiratory disease were asked by a health professional to to answer a questionnaire about their sexuality. The objectives of the study were 1) to determine if sexual problems occurred in patients with respiratory chronic disease ; 2) to assess if these survey problems were linked to respiratory disease; 3) to explore the motivation to speak about sexuality during rehabilitation program.

Methods: 52 consecutive respiratory disease subjects (58.3 ± 9 yr; FEV1 = 65.5 ± 21 % predicted, mean ± SD) answered a sexuality questionnaire survey with rehabilitation team (psychologists, nurses, physiotherapists). This group comprised 26 men and 26 women.

Results: 70% of patients estimated that respiratory disease had an impact on their sexuality. A visual analog scale showed that 62% of patients were not satisfied. The severity of obstruction (FEV1) was not correlated to satisfaction (r=.017, P=0.90), or frequency (r=.08, P=0.55). Breathlessness was the most important factor of discomfort in sexual activity (61.5%). Tiredness and cough came second (32% and 21% respectively). 63% of respiratory patients never spoke about their sexuality with a health professional. 60% would like the health professional to begin to talk about their sexuality. 36% of patients spoke about it with a professional. In this group, 94% of patients told the professional about their sexual activity on their own initiative.

Conclusion: More than one of two chronic respiratory disease patients (77%) participating in a rehabilitation program want sexuality to be taken into consideration during their program.
Pulmonary Rehabilitation Results in Significant Effect on Physical Outcomes: Preliminary Data from the Saint John Regional Hospital, New Brunswick, Canada
Authors: Mundle Stephen J. , Blanchard Christopher M.
Published: May 2017

Background: Current guidelines claim that pulmonary rehabilitation is a cost effective method for increasing exercise tolerance, decreasing hospitalization, and improving knowledge and quality of life in patients with chronic obstructive pulmonary disease. The purpose of the present study was to examine the changes in physical and psychological outcomes during and after completion of a pulmonary program.

Methods: Between September 2004 and April 2006, 27 patients attended pulmonary rehabilitation. All patients were referred by a Respirologist and had moderate to severe respiratory impairment on pulmonary function testing. They attended 3 supervised exercise sessions per week for 10 weeks under the supervision of a nurse and physiotherapist. Education modules were provided by the physiotherapist and respiratory therapist to increase knowledge and independence with disease management. Data was collected pre and post program, and at 3 month and 6 month follow up visits. There were 16 patients (59.3%) who had complete data and attended all follow-up appointments. Outcomes included the six minute walk test (6MWT) and chronic respiratory questionnaire (CRQ). Follow up visits also assessed exercise adherence and readmissions for respiratory problems.

Results: Repeated measures analysis of variance showed improvement in 6MWT and average metabolic equivalent (MET) from pre to post program (P < .05) which remained stable up to 6 months follow-up. The same analysis did not show improvement for any of the variables measured in the CRQ. Exercise routine, as reported by patients at 6 months, was 4.7 days per week for 28 minutes per session. Readmissions for pulmonary problems were reported by 3 patients, 2 at the 3 month assessment and 1 at the 6 month.

Conclusions: Preliminary program results show improvement in physical outcomes and impressive exercise adherence at 6 months follow-up. The small sample size is an obvious limitation, but being an ongoing program, future data will reveal if these initial findings persist.
Role of Functional Indicators in the Multifactorial Pathologies in Cardiopulmonary Rehabilitatiion
Authors: Pulici Sergio , Schiavoni Piergiorgio
Published: May 2017

Background: Patients in cardiopulmonary rehabilitation often complain of exercise intolerance. While ventilatory limitation is often present, other factors are also important: cardiovascular deconditioning, respiratory muscle dysfunction, gas exchange abnormalities and ventricular dysfunction.

Methods: Forty patients, hospitalized for a consecutive 6 month-period, with persistent exercise intolerance due to cardiopulmonary pathologies were included. 90% were COPD II to IV GOLD stage; 5% had chronic cardiac decompensation; 5% had undergone surgery for coronary bypass and/or cardiac valve prosthesis. Patients were excluded who were clinically unstable, unable to cooperate correctly, had arrythmia due to atrial fibrillation and/or receiving beta-blocking therapy. We have, furthermore, measured parameters of ventilatory dysfunction (ventilatory reserve, dynamic inspiratory capacity), the parameters of cardiovascular limitation (peak heart rate and recovery heart rate at the first minute), parametes of respiratory muscles dysfunction (maximal inspiratory pressure and at the end of the 6 min walking test). Afterwards we classified patients into three groups: ventilatory-limited, cardiovascular-limited, respiratory muscles-limited.

Results: Exercise performance limitation resulted from ventilatory limitation in 60% of the patients, second by cardiovascular limitation in 30% of the patients and also by respiratory muscle limitation in 10% of the patients.

Conclusions: Based on admission diagnosis of 40 patients, 90% were defined as subject to pulmonary rehabilitation and in 10% were receiving cardiac rehabilitation. They divided into three specific functional recovery programs: ventilatory function recovery program (60%), cardiac function recovery program (30%), respiratory muscles recovery program (10%).
A Written Action Plan for Early Treatment of COPD Exacerbations: An Important Component to the Reduction of Hospitalizations
Authors: Sedeno Maria F. , Nault Diane , Hamd Dina H. , Bourbeau Jean
Published: May 2017

Background: This study explored the role of a written action plan in reducing hospitalizations as a component of a COPD self-management program in a recent multi-centre RCT.

Methods: Patients were randomly allocated into 2 groups: intervention or usual care. The intervention group had access to a self-management education program Living Well with COPD, the support of a case manager, and a written action plan with a self-administered prescription of antibiotics and prednisone. Patients were instructed to start both antibiotics and prednisone in case of exacerbation with a change in 2 or more symptoms (increased dyspnea, increased sputum volume and/or purulent sputum) for at least 24 hr.

Results: One hundred and sixty six patients with COPD presented with one exacerbation or more in the 12-month study period. Exacerbations (608) were confirmed by a change in at least one symptom; 429 (70.6%) by a change in 2 or more. Antibiotics were used in 61.3% of the exacerbations and prednisone in 47.7%. The combination of antibiotics and prednisone was used more often by the intervention group in exacerbations presenting changes in 2 or more symptoms (52.97% vs. 34.8%, P < 0.001). This difference was driven by a higher use of prednisone in the intervention group (55.7% vs. 44.3%, P < 0.001) consistent with dyspnea deterioration. In the intervention group, exacerbations treated with antibiotics and prednisone had less risk of requiring an hospitalization than those occurring in the control group (16.5% vs. 35.1%, P < 0.001).

Conclusions: Improved access to treat exacerbations provided by the written action plan plays an important role in reducing hospitalization risk.
Investigation of sources of potential bias in laboratory surveillance for anti-microbial resistance
Authors: Laupland Kevin B. , Ross Terry , Pitout Johann D. D. , Church Deirdre L. , Gregson Daniel B.
Published: May 2017

Purpose: There are a number of biases that may influence the validity of laboratory-based surveillance for antimicrobial resistance. Our objective was to evaluate the potential magnitude of bias in reporting of etiologic agents and their resistance rates associated with inclusion of multiple patient samples and non-random timing and location of sampling.

Methods: All urine cultures submitted to a regional laboratory in the Calgary Health Region during 2004 and 2005 were studied. Comparisons were then made using either the overall cohort or different subgroups compared with the “reference” or gold standard population where only the first isolate per patient per year per species was included.

Results: Overall 56,897 organisms were cultured at ≥104 cfu/mL from 53,548 samples from 35,890 patients; 39,835 organisms were included in the reference cohort. Escherichia coli was reported in 37,246 (65.5%) of overall cohort and 28,257 (70.9%) of the reference cohort. Therefore, the overall cohort resulted in a relative underestimation of the importance of E. coli as the principal cause of urinary tract infections by 8%. Similarly, reported rates of resistance to antimicrobial agents most notably ciprofloxacin [6,480/52,544 (12.3%) vs. 2,647/37,086 (7.1%)], gentamicin [2,991/48,070 (6.2%) vs. 1,567/34,608 (4.5%)], and ceftriaxone [1,737/44,922 (3.9%) vs. 889/32,745 (2.7%)] were higher in the overall than in the reference cohorts. There were large differences in both the distribution of organisms and rates of resistance associated with sampling during different times of the day, week, and year as well as from acute care hospitals and outpatient clinics (P≤0.001).

Conclusions: Reports from laboratory-based surveillance studies may be biased depending on the population studied and method of sampling employed. Care must be taken in interpreting results of surveillance studies that do not protect from these major sources of bias.
1. Communication skills training in orthopaedics
Authors: Lundine K. , Lockyer J. , Hutchison C. , Buckley R.
Published: May 2017

Communication skills have been identified as a key component of medical education by the CanMEDS Project. The objectives of this study were to identify the perceived key components of communication skills from the perspectives of both orthopaedic residents and their program directors, and to understand how these skills are currently taught.

This study utilized a mixed methods design. Quantitative data was collected using a 30-item questionnaire, which was distributed to all Canadian orthopaedic residents. Qualitative data was collected through focus groups with orthopaedic residents and semi-structured interviews with orthopaedic program directors.

One hundred and nineteen out of three hundred and twenty-five questionnaires were completed (response rate = 37%), twelve residents participated in two focus groups, and 9/16 program directors from across the country were interviewed. The questionnaire reliability had an internal consistency of Cronbach’s alpha = 0.72. An ANOVA of the questionnaire data showed gender and International vs. Canadian medical graduate status to be independent variables to several item responses (P < 0.01). The factor analysis produced a five-factor model accounting for 50% of the variance.

Both program directors and residents identified communication skills as being the accurate and appropriate use of language (ie, content skills), not how the communication was presented (ie, process skills). Perceived barriers to communication included time constraints and the need to adapt to the many personalities and types of people encountered daily in the hospital. Residents lack explicit communication skill training, but value developing communication skills in the clinical environment through experiential learning and role modeling. Resident education should focus on developing residents’ process skills in communication. Care should be taken to avoid large-group didactic teaching sessions, which are perceived as ineffective.
2. Use of a health advocacy essay to improve competence
Authors: Borgaonkar M. , Pace D. , Jeon P.
Published: May 2017

We set out to determine if essay writing on health advocacy could improve scores on a Health Advocacy observed structured clinical exam (OSCE) station.

A Health Advocacy station was used as one of ten stations at the annual resident OSCE in 2006. Subsequently, residents were instructed to write an essay regarding their actions as a health advocate, either in general or relating to a specific situation. For the 2007 OSCE, a different Health Advocacy station was used that was similar to the previous year in terms of the issues that residents needed to address and the scoring structure. The results on the OSCE stations between the two years were compared using Student’s T-test. Regression analysis was used to identify any predictors for a higher score.

The number of residents taking the OSCE in 2006 and 2007 were 17 and 13, respectively. Nine residents completed the OSCE in both years. The number of PGY-1’s taking the OSCE for the first time in 2006 and 2007 were 8 and 4, respectively. Compliance with the essay writing was 100%. The mean score on the Health Advocacy station was significantly higher in 2007 compared to 2006 (53.0 ± 14.6 compared to 65.6 ± 10.0 vs. 53.0 ± 14.6; p=0.01). The mean score of PGY-1’s in 2007 tended to be higher than PGY-1’s in 2006 (67.5 ± 11.4 vs. 54.5 ± 12.3; p=0.11), suggesting the improvement was not due to having taken the OSCE previously. Regression analysis did not identify and other predictors of higher score on the OSCE station.

These results suggest that essay writing by residents about actions they have taken as health advocates improves knowledge about the CanMEDS competency of Health Advocacy, as measured in an OSCE station. The non-randomized design of the study does not exclude the possibility of other factors influencing the improvement in score.

Oandasan I, Barker K. Educating for Advocacy: Exploring the Source and Substance of Community-Responsive Physicians. Acad Med 2003; 78(1):S16-S19.

Frank J, Langer B. Collaboration, Communication, Management, and Advocacy: Teaching surgeons new skills through the CanMEDS project. World J Surg 2003; 27:972-978.

Verma S, Flynn L, Seguin R. Faculty’s and residents’ perceptions of teaching and evaluating the role of health advocate: A study at one Canadian university. Acad Med 2005; 80:103-108.
6. CanMEDSification: The role of postgraduate medicine office in supporting the learning and teaching of CanMEDs Roles
Authors: Takahashi S. Glover , Verma S. , Muharuma L. , Zulla R.
Published: May 2017

The Postgraduate Medical Education Office at the University of Toronto has implemented a range of faculty development initiatives targeted at supporting the full implementation of CanMEDS roles and competencies in the day to day learning, teaching and evaluation of residents across the highly distributed postgraduate medicine training programs. In October 2005, the Royal College of Physicians and Surgeons of Canada (RCPSC) released a revised version of the CanMEDS roles. In June 2006, the RCPSC accreditation standards for postgraduate medicine changed some standards which result in an increased expectation of implementation of the CanMEDS roles in teaching and evaluation of residency programs.

From 2005 to 2007, there have been numerous initiatives by the Postgraduate Medical Education Office to support the understanding and implementation of the CanMEDS roles into the learning, evaluation and outcomes of postgraduate training at the University of Toronto. The PGME Office supported the ‘CanMEDSification’ or integration of the CanMEDS framework by: 1) Supporting the development of teacher/faculty teaching and evaluation resources; 2) Providing faculty development in the understanding of these competencies; 3) Providing explicit program feedback through the Internal Review process

The CanMEDS roles have been widely integrated into teaching and evaluation at the University of Toronto. The high attendance rates at workshops and positive workshop evaluations indicate the value of centralized faculty development initiatives and also indicate an increasing confidence in using CanMEDS. The workshop evaluations also indicate a need for additional faculty development in evaluating the non Medical Expert roles.

Shorter E. Oxford English Dictionary (5th ed.). Oxford, UK: Oxford University Press, 2002.

Harris, IB. Deliberative inquiry: The arts of planning. in E.C. Short (ed.), Forms of curriculum inquiry. Albany: State University of New York Press, 1991; 285-307.

Harris, IB. New expectations for professional competence. In L. Curry & J. F. Wergin (Eds.), Educating professionals: Responding to new expectations for competence and accountability. San Francisco: Jossey-Bass, 1993; 17-52.
8. Modelling and teaching collaboration: The interprofessional education in geriatric care project
Authors: Grymonpre R. , Boustcha E. , Nelson M. , Booth A. , De Jaeger A. , Jensen F. , Sullivan T. , Swinamer J. , Weinberg L.
Published: May 2017

The Interprofessional Education in Geriatric Care (IEGC) project is an Interprofessional Education for Collaborative Patient-centred Practice Initiative (Health Canada) funded project that was launched in June 2005 and ends March 2008. The goal of the IEGC project is to develop a sustainable clinical experience that models and teaches the core concepts of patient centred collaboration (goal directedness, leadership, flexibility, team dynamics, conflict resolution, communication, and disciplinary articulation) which directly reflect the enabling competencies of the “Collaborator Role” outlined in the 2005 CanMEDS Framework.

The primary learners are Internal Medicine/Family Medicine residents and senior students in nursing, occupational therapy, physiotherapy, and pharmacy. The interprofessional education occurs at three geriatric day hospitals where collaborative patient-centred care of community dwelling older clients is the standard of practice, and clinicians traditionally accept students for clinical placements. The IEGC project identified instances that learners from two or more disciplines were at Day Hospital simultaneously for approximately three weeks. During this time, experiential learning activities emphasizing the skills needed for effective collaboration were added to typical preceptor based teaching.

Feedback early in the project from students and preceptors indicated that the original design, (practice simulations and didactic small group sessions), were not meeting clinical learning objectives. In response, the clinical teams initiated team led discussions regarding core concepts and students were given the opportunity to assess and develop care plans for “student team” designated patients. In addition structured team observations, directed readings, self-reflective exercises and “ice-breakers” are utilized. Informal feedback from participants has suggested that this is more effective, and relevant way to teach patient centred collaborative practice. The IEGC project has extensive research and evaluation methods based on the JET’s modification of Kirkpatrick’s Model of Educational Outcomes which will assess the effectiveness and viability of the IEGC educational approach.

The Interprofessional Joint Evaluation Team. (2002). A Critical Review of Evaluations of Interprofessional Education. http://www.health.heacademy.ac.uk/publications/ occasionalpaper/occasionalpaper02.pdf/view. Accessed September 9, 2005.

Frank JR, Jabbour M, et al. Eds. Report of the CanMEDS Phase IV Working Groups.

Ottawa: The Royal College of Physicians and Surgeons of Canada. March, 2005.
10. Designing an online curriculum supporting risk management and patient safety
Authors: Gondocz T. , Wallace G.
Published: May 2017

The Canadian Medical Protective Association (CMPA) is a not for profit mutual defence organization with a mandate to provide medico-legal assistance to physician members and to educate health professionals on managing risk and enhancing patient safety. To expand the outreach to its 72,000 member physicians, the CMPA built an online learning curriculum of risk management and patient safety materials in 2006. These activities are mapped to the real needs of members ensuring the activities are relevant.

Eight major categories were developed containing both online courses and articles. Each course and article is mapped to the RCPSC's CanMEDS roles and the CFPC's Four Principles.

This poster shares the CMPA’s experience in designing an online patient safety curriculum within the context of medico-legal risk management and provides an inventory of materials linked to the CanMEDS roles.

Our formula for creation of an online curriculum included basing the educational content on real needs of member physicians; using case studies to teach concepts; and, monitoring and evaluating process and outcomes.

The objectives are to explain the benefits of curricular approach for course planning across the continuum in medical education; outline the utility of the CanMEDS roles in organizing the risk management and patient safety medical education curriculum; describe the progress of CMPA's online learning system; and, outline the potential for moving the curriculum of online learning materials and resources into medical schools.
14. Influences on choice of a generalist career in general surgery, general internal medicine and general pediatrics
Authors: Chung C. , Nickell L.
Published: May 2017

We performed a literature review to summarize the primary influences that encourage or discourage the pursuit of careers in General Surgery (GS), General Internal Medicine (GIM), and General Pediatrics (GP). Relevant studies were identified through a PUBMED and MEDLINE search from 1982 to 2006. All included studies were peer-reviewed and pertained to factors influencing career choice in GS, GIM, GP, and their respective subspecialties. The identified literature was analyzed based on demography, the curriculum, and the nature of the discipline, etc. Consistent factors influencing career choice were established a priori as those supported by ≥2 independent studies or reviews without contradictory findings reported to date. The top two factors favoring the choice of residency in GS are positive clerkship experiences and exposure to positive role models, whereas the top factors discouraging interest in GS are lifestyle issues and the length of residency. As for GIM, influences that favor the specialty include the female gender and preference for GIM upon entry into medical school. Factors that discourage the choice of GIM are high income expectations, the widening salary gap between generalist and specialist, negative clerkship experience and the type of patients in internal medicine. In pediatrics, the top two influences that favor GP are female gender and a predisposition for GP upon entry into medical school. A consistent factor that negatively influences career choice in GP is a favorable attitude towards research. To summarize, the main influences on the choice of a generalist career include gender, role modeling, clerkship experience, lifestyle issues, and financial compensation. Medical schools can encourage the pursuit of generalist careers by enhancing student exposure to positive role models and by providing a positive clerkship experience in GS, GIM, and GP.

Kirkham JC, Widmann WD, Leddy D, Goldstein MJ, Samstein B, El-Tamer M, Harari A, Arnell TD, John R, Hardy MA. Medical student entry into general surgery increases with early exposure to surgery and to surgeons. Current Surgery 2006 (Nov-Dec); 63(6):397-400.

Arora V, Wetterneck TB, Schnipper JL, Auerbach AD, Kaboli P, Wachter RM, Levinson W, Humphrey HJ, Meltzer D. Effect of the inpatient general medicine rotation on student pursuit of a generalist career. Journal of General Internal Medicine 2006 (May); 21(5):471-475.

Cochran A, Melby S, Neumayer LA. An internet-based survey of factors influencing medical student selection of a general surgery career. American Journal of Surgery 2005; 189:742-746.
17. Boundaries or overlap: An examination of the community-oriented clinical practice of community medicine specialists and family/general practitioners
Authors: Russell M. L. , McIntyre L.
Published: May 2017

We compared the work settings and “community-oriented clinical practice” of Community Medicine (CM) specialists and family physicians/general practitioners (FP).

We conducted secondary data analysis of the 2004 National Physician Survey (NPS) to examine main work setting and clinical activity reported by 154 CM (40% of eligible CM in Canada) and 11,041 FP (36% of eligible FP in Canada). Text data from the specialist questionnaire related to “most common conditions that you treat” were extracted from the Master database for CM specialists, and subjected to thematic analysis and coded.

CM specialists were more likely than FP to engage in “community medicine/public health” (59.7% vs 15.3%); while the opposite was found for primary care (13% vs. 78.2%). CM specialists were less likely to indicate a main work setting of private office/clinic/community health centre/community hospital than were FP (13.6% vs. 75.6%). Forty-five percent of CM provided a response to “most common conditions treated” with the remainder either leaving the item blank or indicating that they did not treat individual patients. The most frequently named conditions in rank order were: psychiatric disorders; public health program/activity; respiratory problems; hypertension; and metabolic disorders (diabetes).

There is some overlap in the professional activities and work settings of CM specialists and FP. The “most commonly treated conditions” suggest that some CM specialists may be practicing primary care as part of the Royal College career path of “community-oriented clinical practice.” However the “most commonly treated conditions” do not specifically indicate an orientation of that practice towards “an emphasis on health promotion and disease prevention” as also specified by the Royal College for that CM career path. This raises questions about the appropriateness of the current training requirements and career paths as delineated for CM specialists by the Royal College of Physicians & Surgeons of Canada.

Bhopal R. Public health medicine and primary health care: convergent, divergent, or parallel paths? J Epidemiol Community Health 1995; 49:113-6.

Pettersen BJ, Johnsen R. More physicians in public health: less public health work? Scan J Public Health 2005; 33:91-8.

Stanwell-Smith R. Public health medicine in transition. J Royal Society of Medicine 2001; 94(7):319-21.
18. The future of Canadian residency education: The core competency project
Authors: Frank J. , Nagle J. , Ramsarin R. , Danoff D. , Rainsberry P.
Published: May 2017

The Core Competency Project (CCP) is an initiative to reexamine fundamental recurring issues in Canadian medical education, including: (1) premature career decision making by medical students, (2) barriers to changing career disciplines by residents and practicing physicians, (3) lack of clarity on the role of “generalism” in medical training, and (4) the optimal structure and function of the PGME system. The CCP is a collaborative national endeavour of The Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada. From 2005 to 2007, the CCP employed four primary methods, including: (1) a systematic review of relevant literature, (2) a series of commentary papers by leaders in medicine and medical education, (3) a series of focus groups across Canada involving medical students, residents, and practicing physicians, and (4) a national survey of stakeholders. This was supplemented by consultations with key groups in the medical profession. We describe the findings of these studies and the implications for medical education policy in Canada and around the world. The CCP is an unprecedented national medical education policy initiative.