Search

Background: There are no established guidelines for transfusing platelets in the setting of traumatic brain injury (TBI)-related intracranial hemorrhage for patients on pre-injury antiplatelet medications (APT). Existing literature has produced mixed results regarding the effectiveness of platelet transfusion in containing bleed size or avoiding craniotomy. We compared outcomes of patients on APT with an intracranial bleed due to trauma, between those who did and who did not receive routine platelet transfusion., Materials and Methods: This retrospective cohort study included patients on APT with TBI-associated intracranial hemorrhage treated at a level II trauma center between 1/1/2014 and 7/31/2018: before March 2017, patients received routine platelet transfusion during initial management ("old protocol"). From March 2017 patients received platelets only if needing craniotomy ("new protocol"). Primary outcome was need for operative management. APT type, intracranial bleed type, bleed size and shift on CT scans, demographic and clinical variables were obtained., Results: Patients were in their mid-70's and most had sustained a fall. Old protocol patients were more likely to be on clopidogrel (32.5% vs. 18.2% for new protocol, p  = 0.016) and had larger bleeds on initial CT (10.1 vs. 6.9 for new protocol, p  = 0.038). When stratifying by aspirin only and clopidogrel±aspirin, old protocol and new protocol patients did not differ on need for operative management (aspirin only p  = 1.0; clopidogrel p  = 0.55), change in bleed size (aspirin only p  = 0.37, clopidogrel p  = 0.068), or other outcomes., Conclusions: We found no evidence that restricting platelet transfusion to patients needing operative management increased the risk of poor outcomes among patients on APT with TBI-associated intracranial hemorrhage., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Author(s).)

Medical education is increasingly delivered at distributed sites away from Academic Health Sciences Centres. The Council of Ontario Faculties of Medicine recommends schools develop resources and metrics to foster regional campus scholarly activity. Opportunities for distributed program trainees must support learning core skills in research and critical appraisal to comply with medical school accreditation standards and to develop their interests and skills in scholarly work for their future medical careers. We describe a scholarly activity program that is a template for distributed campuses or regional teaching sites seeking to increase learner and faculty engagement and research productivity., Competing Interests: The authors have no conflicts of interest to report due to financial and personal relationships that could potentially bias their work., (© 2022 Bell, Khemani, Weera, Henderson, Chambers; licensee Synergies Partners.)

Background: Undergraduate medical students seek as much information as possible as to how residency programs select candidates. The Canadian Residency Matching Service (CaRMS) website is one of their primary sources of information. Students may be more competitive in the match if they know whether scholarly activity is used in the selection process by their preferred programs, as described on the CaRMS website., Methods: For all 17 Canadian faculties of medicine, 2019 R1 entry internal medicine, family medicine and pediatrics program descriptions were reviewed on the CaRMS website looking for keywords related to scholarly activity., Results: Forty-one percent of family medicine, 65% of internal medicine and 71% of pediatric programs explicitly stated having interest in applicants with scholarly experience. In Western Canada, 80% of internal medicine and 60% of pediatrics programs included scholarly activity in their CaRMS description of criteria considered in ranking applications. Similarly, in Ontario, 66% of internal medicine and 83% of pediatrics programs mentioned scholarly activity as a valuable quality. In Quebec 100% of family medicine and 50% of pediatrics programs include scholarly activity in their descriptions. Pediatrics and family medicine programs (100%) in Atlantic Canada mentioned scholarly activities but neither of the two Atlantic Canada internal medicine programs mentioned scholarly activities., Conclusion: Undergraduate medical students can use this project to prioritize extracurricular activities and scholarly work to be competitive for application to family medicine, internal medicine and pediatrics residency programs., Competing Interests: Conflict of Interest: The authors have no conflicts of interest to report due to financial and personal relationships that could potentially bias their work., (© 2020 Lukings, Bell, Stobbe, Basha, Brazier, Dragomir, Glibbery, Kearney, Knapp, Levin, Tucker, Weera, Chambers; licensee Synergies Partners.)

Objective: Efforts to achieve balance between effective pain management and opioid-related adverse events (ORAEs) have led to multimodal analgesia regimens. This study compared opioids delivered via patient-controlled analgesia (PCA) plus liposomal bupivacaine, a long-acting local anesthetic with potential to be an effective component of such regimens, to opioids delivered through PCA alone or PCA plus subcutaneous bupivacaine infusion (ONQ), following laparotomy., Design: Prospective, randomized controlled trial., Setting: Single, tertiary-care institution., Patients: One hundred patients undergoing nonemergent laparotomy., Interventions: Patients were randomly assigned to one of three study treatments: PCA only (PCAO), PCA with ONQ, or PCA with injectable liposomal bupivacaine suspension (EXP)., Main Outcome Measures: Cumulative opioid use, daily mean patient-reported pain scores, and ORAEs through 72 hours postoperatively., Results: On average, the EXP (n = 31) group exhibited less than 50 percent of the total opioid consumption of the PCAO (n = 36) group, and less than 60 percent of that for the ONQ (n = 33) group. Postoperative days 1 and 3 pain scores were significantly lower for the EXP group as compared to the ONQ and PCAO groups (p ≤ 0.005). Fewer patients in the EXP group (19.4 percent) experienced ORAEs compared to the PCAO (41.1 percent) and ONQ (45.5 percent) groups (p = 0.002)., Conclusions: Laparotomy patients treated with liposomal bupivacaine as part of a multimodal regimen consumed less opioids, had lower pain scores, and had fewer ORAEs. The role of liposomal bupivacaine in the postoperative care of laparotomy patients merits further study.

Objectives: To engage persons with dementia, friends, family, caregivers, and health and social care providers to identify and prioritize their questions for research related to living with dementia and prevention, diagnosis, and treatment of dementia., Design: The Canadian Dementia Priority Setting Partnership (PSP) followed James Lind Alliance PSP methods. Results were compared with the World Health Organization research prioritization exercise and the United Kingdom Dementia PSP., Setting: Canada., Participants: In the first survey, 1,217 individuals and groups from across Canada submitted their questions about dementia. 249 participated in the interim prioritization. For the final prioritization workshop, the 28 participants included persons with dementia, friends, family, caregivers, health and social care providers, Alzheimer Society representatives, and members of an organization representing long-term care home residents., Results: The Canadian Dementia PSP top 10 priorities relate to health, quality of life, societal issues, and dementia care. Five priorities overlap with one or both of the other two prioritization initiatives., Conclusion: These results provide researchers and research funding agencies with topics that individuals with personal or professional experience of dementia prioritize, but they are not intended to preclude research into other aspects of dementia., (© 2018 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society.)

Objective: The Accreditation Council for Graduate Medical Education requires accredited residency programs to implement competency-based assessments of medical trainees based upon nationally established Milestones. Clinical competency committees (CCC) are required to prepare biannual reports using the Milestones and ensure reporting to the Accreditation Council for Graduate Medical Education. Previous research demonstrated a strong correlation between CCC and resident scores on the Milestones at 1 institution. We sought to evaluate a national sampling of general surgery residency programs and hypothesized that CCC and resident assessments are similar., Design: Details regarding the makeup and process of each CCC were obtained. Major disparities were defined as an absolute mean difference of ≥0.5 on the 4-point scale. A negative assessment disparity indicated that the residents evaluated themselves at a lower level than did the CCC. Statistical analysis included Wilcoxon rank sum and Sign tests., Setting: CCCs and categorical general surgery residents from 15 residency programs completed the Milestones document independently during the spring of 2016., Results: Overall, 334 residents were included; 44 (13%) and 43 (13%) residents scored themselves ≥0.5 points higher and lower than the CCC, respectively. Female residents scored themselves a mean of 0.08 points lower, and male residents scored themselves a mean of 0.03 points higher than the CCC. Median assessment differences for postgraduate year (PGY) 1-5 were 0.03 (range: -0.94 to 1.28), -0.11 (range: -1.22 to 1.22), -0.08 (range: -1.28 to 0.81), 0.02 (range: -0.91 to 1.00), and -0.19 (range: -1.16 to 0.50), respectively. Residents in university vs. independent programs had higher rates of negative assessment differences in medical knowledge (15% vs. 6%; P = 0.015), patient care (17% vs. 5%; P = 0.002), professionalism (23% vs. 14%; P = 0.013), and system-based practice (18% vs. 9%; P = 0.031) competencies. Major assessment disparities by sex or PGY were similar among individual competencies., Conclusions: Surgery residents in this national cohort demonstrated self-awareness when compared to assessments by their respective CCCs. This was independent of program type, sex, or level of training. PGY 5 residents, female residents, and those from university programs consistently rated themselves lower than the CCC, but these were not major disparities and the significance of this is unclear., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: The Alzheimer Society embarked on a project to improve ways that the 60 provincial and local Societies in Canada can work with local researchers to support recruitment of volunteers to clinical trials and studies. A Guide to assist these offices was produced to design ethical recruitment of research volunteers within their client populations., Methods: Consultations with individuals from provincial and local Societies, as well as researchers and leaders from health-related organizations, were conducted to identify in what ways these organizations are involved in study volunteer recruitment, what is and is not working, and what would be helpful to support future efforts. The Guide prototype used scenarios to illustrate study volunteer recruitment practices as they have been or could be applied in Societies. An implementable version of the Guide was produced with input from multiple internal and external reviewers including subject-matter experts and target users from Societies., Results: Society staff reported that benefits of using the Guide were that it served as a catalyst for conversation and reflection and identified the need for a policy. Also, it enabled Society readiness to respond to requests by persons with dementia and their caregivers wishing to participate in research. A majority (94%) of participating Society staff across Canada agreed that they would increase their capacity to support research recruitment., Discussion: Charitable organizations that raise funds for research have a role in promoting the recruitment of persons with dementia and their caregivers into clinical trials and studies. The Guide was produced to facilitate organizational change to both create a positive culture regarding research as well as practical solutions that can help organizations achieve this goal.

Paragangliomas of the mediastinum are rare, with only approximately 150 cases reported in the literature. Surgical excision is the treatment of choice; however, these tumors often lie near critical vascular structures. Here we present the case of a patient with a mediastinal paraganglioma discovered during a diagnostic procedure., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: This study was conducted to assess the effectiveness of a newly implemented electronic web-based review system created at our institution for evaluating resident performance relative to established milestones., Design: Retrospective review of data collected from a survey of general surgery faculty and residents., Setting: Tertiary care teaching hospital system and independent academic medical center., Participants: A total of 12 general surgery faculty and 17 general surgery residents participated in this study. The survey queried the level of satisfaction before and after the adoption of QuickNotes using several statements scored on a 5-point scale, with 1 being the lowest rating as "not satisfied," and 5 being the highest rating as "completely satisfied.", Results: The weighted average improvements from pre- to post-QuickNotes implementation for the faculty responding to the survey ranged from 10% to 40%; weighted average improvements for the residents responding to the survey ranged from 5% to 73%. For the survey of faculty, both sets of weighted averages tended to be higher than the weighted average for the resident's survey responses. The highest rated topic was the faculty's level of satisfaction with the "frequency to provide feedback" with a post-QuickNotes implementation weighted average of 4.25, closely followed by the residents' level of satisfaction with the "evaluation includes positive feedback" with a post-QuickNotes implementation weighted average of 4.24. The most notable increases in weighted averages from preimplementation to postimplementation were noted for "overall satisfaction" (20% increase for faculty, 37% for residents), "reflects actual criteria that matter" (36% increase for faculty, 73% for residents), faculty "opportunity for follow-up" (increase of 40%), resident "reflects overall trends" (increase of 37%), and resident "provides new information about my performance" (increase of 37%)., Conclusions: Our institutional adoption of QuickNotes into the resident evaluation process has been associated with an overall increased level of satisfaction in the evaluation process by both faculty and residents. The design of QuickNotes facilitates its integration into the resident training environment, as it is web based, easy to use, and has no additional cost over the standard New Innovations subscription. Although it is designed to capture snapshots of trainee behavior and performance, monthly reports through QuickNotes can be used effectively in conjunction with the more traditional end-of-rotation evaluations to show trends, identify areas of strength that should be reinforced, demonstrate areas needing improvement, allow for a more tailored individual education plan to be developed, and permit a more accurate determination of milestone progression., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Despite efforts to raise awareness and develop guidelines for care of individuals with dementia, reports of poor detection and inadequate management persist. This has led to a call for more identification of people with dementia, that is, screening individuals who may or may not complain of symptoms of dementia in both acute settings and primary care. The following should be considered before recommending screening for dementia among individuals in the general population. Dementia Tests . Low prevalence reduces positive predictive value of tests and screening tests will miss people who have dementia and identify people who do not have dementia in substantial numbers. Clinical Issues . The clinical course of dementia has not yet been shown to be amenable to intervention. Misdiagnosis and overdiagnosis can have significant long-term effects including stigmatization, loss of employment, and autonomy. Economic Issues . Health systems do not have the capacity to respond to increased demand resulting from screening. In conclusion, at present attention to life-course risk reduction and support in the community for frail and cognitively impaired older adults is a better use of limited healthcare resources than introduction of unevaluated dementia screening programs.

Background: To study the feasibility of down stage the borderline resectable pancreatic cancer (BRPC) to resectable disease, we reported our institutional results using an intensity-modulated radiation therapy (IMRT) simultaneous integrated boost (SIB) dose escalation approach to improve R0 resectability., Methods: We reviewed our past 7 years of experience of using neoadjuvant induction chemotherapy with Gemcitabine followed by concurrent chemoradiaiton for BRPC. During the concurrent, chemo was 5-FU and radiation were IMRT with SIB technique to target the key areas with dose escalation to 5600 in 28 fractions. The key areas were defined by PET positive area. This was followed by restaging imaging to rule out distant metastases before resection., Results: 25 finished dose escalation protocol. 2 of the 25 cases developed distant metastases, 23 (92%) patients without distant metastases underwent pancreatectomy. Among the those received pancreatectomy, 22 (95%) achieved negative margin (R0). The gastrointestinal toxicity > grade 2 was 8% and there was no grade 4 toxicity., Conclusion: Neoadjuvant Gemcitabine-based induction chemotherapy followed by 5-FU-based IMRT-SIB is a feasible option in improving the likelihood of R0 resection rate in BRPC without compromising the organs at risk for toxicity., Competing Interests: The authors have declared that no competing interests exist.

Background: Worldwide, there is concern that increases in the prevalence of dementia will result in large demands for caregivers and supportive services that will be challenging to address. Previous dementia projections have either been simple extrapolations of prevalence or macrosimulations based on dementia incidence., Methods: A population-based microsimulation model of Alzheimer's and related dementias (POHEM:Neurological) was created using Canadian demographic data, estimates of dementia incidence, health status (health-related quality of life and mortality risk), health care costs and informal caregiving use. Dementia prevalence and 12 other measures were projected to 2031., Results: Between 2011 and 2031, there was a projected two-fold increase in the number of people living with dementia in Canada (1.6-fold increase in prevalence rate). By 2031, the projected informal (unpaid) caregiving for dementia in Canada was two billion hours per year, or 100 h per year per Canadian of working age., Conclusions: The projected increase in dementia prevalence was largely related to the expected increase in older Canadians, with projections sensitive to changes in the age of dementia onset.

Unlabelled: Knowledge translation (KT) involves implementation of evidence-based strategies and guidelines into practice to improve the process of care and health outcomes for patients. Findings from pragmatic trials may be used in KT to provide patients, healthcare providers and policymakers with information to optimize healthcare decisions based on how a given strategy or intervention performs under the real world conditions. However, pragmatic trials have been criticized for having the following problems: i) high rates of loss to follow-up; ii) nonadherence to study intervention; iii) unblinded treatment and patient self-assessment, which can potentially create bias; iv) being less perfect experiments than efficacy trials; v) sacrificing internal validity to achieve generalizability; and vi) often requiring large sample sizes to detect small treatment effects in heterogeneous populations. In this paper, we discuss whether these criticisms hold merit, or if they are simply driven by confusion about the purpose of pragmatic trials. We use the Cardiovascular Health Awareness Program (CHAP) trial--a community randomized pragmatic trial designed to assess whether offering a highly organized, community-based CHAP intervention compared to usual care can reduce cardiovascular disease-related outcomes--to address these specific criticisms and illustrate how to reduce this confusion., Trial Registration: Current controlled trials ISRCTN50550004 (9 May 2007).

Background: Healthcare personnel influenza immunization rates remain sub-optimal. Following multiple studies and expert consultations, the "Successful Influenza Immunization Programs for Healthcare Personnel: A Guide for Program Planners" was produced. This trial assessed the impact of the Guide with facilitation in improving healthcare personnel influenza immunization rates in Canadian healthcare organizations., Methods: A sample of 26 healthcare organizations across six Canadian provinces (ON, MB, NS, BC, SK, NL) was randomized to Intervention (n=13) or Control groups (n=13). Baseline influenza immunization rates were obtained for 2008-2009; the study groups were followed over two subsequent influenza seasons. The Intervention group received the Guide, facilitation support through workshops for managers and ongoing support. The Control groups conducted programs as usual. The Groups were compared using their reported influenza healthcare personnel influenza immunization rates and scores from a program assessment questionnaire., Findings: Twenty-six organizations agreed to participate. 35% (9/26) of sites were acute care hospitals, 19% (5/26) continuing care, long-term care organizations or nursing homes, and 46% (12/26) were mixed acute care hospitals and long-term care or regional health authorities. The median rate of influenza immunization among healthcare personnel for the Intervention group was 43%, 44%, and 51% at three points in time respectively, and in the, Control Group: 62%, 57%, and 55% respectively. No significant differences were observed between the groups at the three points in time. However, there was a 7% increase in the median rates between the Baseline Year and Year Two in the Intervention group, and a 6% decrease in the CONTROL GROUP over the same time period, which was statistically significant (0.071 versus -0.058, p < 0.001)., Interpretation: This pragmatic randomized trial of the Guide with facilitation of its implementation improved healthcare personnel immunization rates, but these rates continued to be sub-optimal and below rates achievable in programs requiring personnel to be immunized., Trial Registration: ClinicalTrials.gov NCT01207518.