Scholarly Opportunities for Medical Students and Residents in Canadian Medical Professional Organizations.

Objectives: Participation in medical specialty organizations can provide medical students and residents with additional research, advocacy, networking, and leadership opportunities. Although past research has looked at individual specialties in the United States, little is known about trainee involvement in Canadian organizations. Therefore, the aim of this study is to review the opportunities available for medical students and residents within Canadian medical specialty organizations. Methods: The websites of 71 Canadian medical specialty organizations were reviewed to assess levels of trainee participation. Results: Of the 71 organizations reviewed, 42 (59%) allow medical students and 67 (94%) allow residents to become members. Most organizations allow trainees to attend their annual conference (83% for students and 93% for residents), and the mean cost of attending the most recent virtual conference was $114 (range: $0-$475) for students and $142 (range: $0-$475) for residents. Twenty-two organizations (31%) have travel awards for students and 37 (52%) have awards for residents. Research grants are available in 41 (58%) of organizations for students and 56 (79%) for residents. Formal mentorship programs exist in 16 (23%) organizations for students and 25 (35%) for residents. Conclusion: To our knowledge, this study highlights for the first time the scholarly opportunities available to trainees within Canadian medical specialty organizations.

Utility of head computed tomography for older adults with suspected delirium in the emergency department: A retrospective observational study.

BACKGROUND: Delirium in older people is associated with significant morbidity and mortality and has life-threatening etiologies making prompt recognition essential. Computed tomography of the head (CT-head) may have a role in determining the cause of delirium; however, inpatient studies suggest it is overused. There is a paucity of emergency department (ED)-based research surrounding the use of CT-head in delirium. This study aims to describe the utility of CT-head in older patients presenting to the ED with symptoms of delirium. METHODS: We conducted a retrospective chart review of patients 65 years and older with symptoms of delirium who visited local EDs over a 3.5-year period (2016-2020). We compared patients who did and did not receive CT-head. Our primary objective was to determine the proportion of acute findings in patients who received CT-head. Our secondary objectives were to describe the proportions of patients who did and did not receive CT-head in terms of their demographics, presenting symptoms, disposition, and indications for and results of CT-head scans. Chi-square tests were utilized for comparisons. RESULTS: A total of 630 encounters were identified through database searching; 526 met inclusion criteria. Thirty-four were excluded for presenting directly to consultants, leaving 492 included encounters. Of those who received a CT-head (n = 279), 13 (4.7%) had acute findings. Of the encounters with acute findings, four (30.77%) had focal neurological deficits (FND), and two (15.38%) had Glasgow Coma Scale (GCS) score < 14. Patients without CT-head (n = 213) were more likely to be discharged (p < 0.01) and less likely to have a FND (p < 0.01). CONCLUSIONS: CT-head is ordered for over half of older ED patients with symptoms of delirium despite infrequent acute findings. Acute findings typically occur in the context of symptoms suggestive of intracranial abnormalities such as FND or GCS < 14. This suggests physicians should be more selective when ordering CT-heads in patients with symptoms of delirium.

Opportunity costs of attending surgical clinic appointments and experiences with telemedicine for follow-up care.

OBJECTIVES: Telemedicine has been rapidly implemented in orthopedics during the coronavirus (COVID-19) pandemic. The purpose of this study was to quantify opportunity costs for patients attending typical in-person appointments and understand their perceptions of telemedicine for follow-up care. METHODS: A cross-sectional study was performed by surveying patients who had elective orthopedic surgery and attended at least one in-person and one phone call appointment. The survey assessed opportunity costs associated with in-person appointments, experience with telemedicine, and preferred type of future appointment. RESULTS: Of the 49 eligible patients, 41 (83.7%) completed the survey. The median travel distance to the clinic was 108 km, and the time spent in the clinic was 60 min. Participants responded "yes" to various forms of opportunity costs associated with attending in-person appointments, including missed work (46.3%), lost income (34.1%), recreational activities (26.8%), home or yard care (14.6%), socializing with friends or family (12.2%), school (2.4%), and childcare (2.4%). In addition, elements of the telemedicine appointment were rated from 1 (least favorable) to 10 (most favorable), and averages were calculated for ease of use (9.2), convenience (8.4), confidence in the doctor's diagnostic ability (8.2), likelihood of using the service again (6.4), and overall satisfaction (8.2). Preferred future appointment types included having the first visit in-person and subsequent visits via telephone (61.0%), in-person only (36.6%), and unsure (2.4%). CONCLUSION: This study identifies various opportunity costs associated with in-person orthopedic appointments and a favorable view toward telemedicine for follow-up care.

Inhibition of Staphylococcus epidermidis biofilms using polymerizable vancomycin derivatives.

BACKGROUND: Biofilm formation on indwelling medical devices is a ubiquitous problem causing considerable patient morbidity and mortality. In orthopaedic surgery, this problem is exacerbated by the large number and variety of material types that are implanted. Metallic hardware in conjunction with polymethylmethacrylate (PMMA) bone cement is commonly used. QUESTIONS/PURPOSES: We asked whether polymerizable derivatives of vancomycin might be useful to (1) surface modify Ti-6Al-4V alloy and to surface/bulk modify PMMA bone cement to prevent Staphylococcus epidermidis biofilm formation and (2) whether the process altered the compressive modulus, yield strength, resilience, and/or fracture strength of cement copolymers. METHODS: A Ti-6Al-4V alloy was silanized with methacryloxypropyltrimethoxysilane in preparation for subsequent polymer attachment. Surfaces were then coated with polymers formed from PEG(375)-acrylate or a vancomycin-PEG(3400)-PEG(375)-acrylate copolymer. PMMA was loaded with various species, including vancomycin and several polymerizable vancomycin derivatives. To assess antibiofilm properties of these materials, initial bacterial adherence to coated Ti-6Al-4V was determined by scanning electron microscopy (SEM). Biofilm dry mass was determined on PMMA coupons; the compressive mechanical properties were also determined. RESULTS: SEM showed the vancomycin-PEG(3400)-acrylate-type surface reduced adherent bacteria numbers by approximately fourfold when compared with PEG(375)-acrylate alone. Vancomycin-loading reduced all mechanical properties tested; in contrast, loading a vancomycin-acrylamide derivative restored these deficits but demonstrated no antibiofilm properties. A polymerizable, PEGylated vancomycin derivative reduced biofilm attachment but resulted in inferior cement mechanical properties. CLINICAL RELEVANCE: The approaches presented here may offer new strategies for developing biofilm-resistant orthopaedic materials. Specifically, polymerizable derivatives of traditional antibiotics may allow for direct polymerization into existing materials such as PMMA bone cement while minimizing mechanical property compromise. Questions remain regarding ideal monomer structure(s) that confer biologic and mechanical benefits.

Distribution and role of Kv3.1b in neurons in the medial septum diagonal band complex.

The medial septum diagonal band complex (MS/DB) projects via cholinergic and GABAergic pathways to the hippocampus and plays a key role in the hippocampal theta rhythm. In the MS/DB we have previously described a population of fast spiking GABAergic neurons that contain parvalbumin and mediate theta frequency activity in vitro. The Kv3.1 potassium channel is a delayed rectifier channel that plays a major role in fast spiking neurons in the CNS, and has previously been localized in the MS/DB. To determine which cell types in the MS/DB express the Kv3.1b ion channel subunit, transgenic mice in which the expression of GABAergic and glutamate markers are associated with the expression of green fluorescent protein (GFP; GAD67-GFP and VGluT2-GFP mice, respectively) were used for immunofluorescence and axonal tract tracing. Electrophysiological studies were also carried out on rat MS/DB slices to examine the role of the Kv3.1 channel in theta frequency oscillations. The results for the MS/DB were as follows: (1) cholinergic cells did not express GFP in either GAD67-GFP or VGluT2-GFP mice, and there was GAD67 immunoreactivity in GFP-positive neurons in GAD67-GFP mice and in a small proportion (6%) of GFP-positive neurons in VGluT2-GFP mice. (2) Kv3.1b immunofluorescence was associated with the somata of GABAergic neurons, especially those that contained parvalbumin, and with a minority of glutamatergic neurons, but not with cholinergic neurons, and with GABAergic axonal terminal-like processes around certain GABAergic neurons. (3) Both Kv3.1b-positive and -negative GABAergic neurons were septo-hippocampal, and there was a minor projection to hippocampus from VGluT2-GFP neurons. (4) Kainate-induced theta oscillations in the MS/DB slice were potentiated rather than inhibited by the Kv3.1 blocker 4-aminopyridine, and this agent on its own produced theta frequency oscillations in MS/DB slices that were reduced by ionotropic glutamate and GABA receptor antagonists and abolished by low extracellular calcium. These studies confirm the presence of heterogeneous populations of septo-hippocampal neurons in the MS/DB, and suggest that presence of Kv3.1 in the GABAergic neurons does not contribute to theta activity through fast spiking properties, but possibly by the regulation of transmitter release from axonal terminals.

Polymerizable vancomycin derivatives for bactericidal biomaterial surface modification: structure-function evaluation.

Surface modification of implantable biomaterials with biologically active functionalities, including antimicrobials, has wide potential for addressing implant-related design problems. Here, four polymerizable vancomycin derivatives bearing either acrylamide or poly(ethylene glycol) (PEG)-acrylate were synthesized and then polymerized through a surface-mediated reaction. Functionalization of vancomycin at either the V(3) or the X(1) position decreased monomeric activity by 6-75-fold depending on the modification site and the nature of the adduct (P < 0.08 for all comparisons). A 5000 Da PEG chain showed an order of magnitude decrease in activity relative to a 3400 Da counterpart. Molecular dynamics computational simulations were used to explore the mechanisms of this decreased activity. Assays were also conducted to demonstrate the utility of a living radical photopolymerization to create functional, polymeric surfaces with these monomers and to demonstrate surface-based activity against Staphylococcus epidermidis . In particular, the vancomycin-PEG-acrylate derivatives demonstrated a 7-8 log reduction in bacterial colony forming units (CFU) with respect to nonfunctionalized control surfaces.

Can community surgeons perform laparoscopic colorectal surgery with outcomes equivalent to tertiary care centers?

BACKGROUND: Laparoscopic colorectal surgery (LCS) performed in tertiary care centers has been well studied. It has been shown to provide improved short-term outcomes and comparable long-term outcomes to the conventional open approach. However, LCS performed in a community hospital setting has not been well studied. In a previous paper, we presented the short-term outcomes of 100 LCS performed by two community surgeons with no formal training in LCS. In this follow-up study, we present both short- and longer-term outcomes for 250 patients who underwent LCS. METHODS: This is a prospective study of 250 consecutive patients who underwent LCS at the North Bay District Hospital (a 200-bed community hospital located 350 km away from the nearest tertiary care center). RESULTS: Between October 2000 and October 2006, 250 consecutive patients (130 women and 120 men, mean age of 64.4 +/- 13.7 years) underwent LCS for benign (N = 129) and malignant (N = 121) disease. Median operating time was 215.0 min (58.0-475.0 min) and the conversion rate was 7.2%. The intraoperative complication rate was 2.8%. There were 20 (8.0%) major postoperative complications and 42 (16.8%) minor postoperative complications. There was no intraoperative mortality. There were six 30-day mortalities due to ischemic bowel (1), stroke (1), myocardial infarction (3), and pneumonia (1). The median length of stay was 4.0 days (2.0-55.0 days). Disease-free survival for stages I-IV colorectal cancer (CRC) was 100, 97.2, 71.4, and 10% for a mean follow-up time of 36.9, 29.3, 27.9, and 21.1 months, respectively. The mean number of resected lymph nodes was 11.5 +/- 8.6. CONCLUSION: We note that both our short and longer-term outcomes are similar to tertiary care centers. We therefore conclude that LCS can be performed in a community hospital setting with both short- and longer-term outcomes similar to tertiary care centers.

Are portable bladder scanning and real-time ultrasound accurate measures of bladder volume in postnatal women?

Real-time ultrasound and portable bladder scanners are commonly used instead of catheterisation to determine bladder volumes in postnatal women but it is not known whether these are accurate. Change in bladder volumes measured by ultrasound and portable scanners were compared with actual voided volume (VV) in 100 postnatal women. The VV was on average 41 ml (CI 29 - 54 ml) higher than that measured by ultrasound, and 33 ml (CI 17 - 48 ml) higher than that measured by portable scanners. Portable scanner volumes were 9 ml (CI -8 - 26 ml) higher than those measured by ultrasound. Neither method is an accurate tool for detecting bladder volume in postnatal women.

Vancomycin derivative photopolymerized to titanium kills S. epidermidis.

Infections in the setting of orthopaedic hardware remain a serious complication. Traditional treatment modalities rely on antibiotic-loaded biomaterials and/or prolonged intravenous therapy, both of which suffer major limitations. We hypothesized a derivatized form of the glycopeptide antibiotic vancomycin could be covalently attached to a Ti-6Al-4V implant alloy to form a bactericidal surface capable of killing bacteria relevant to orthopaedic infections. First, a polymerizable poly(ethylene glycol)-acrylate derivative of vancomycin was synthesized. This monomer was characterized by liquid chromatography, 1H NMR spectroscopy, and MIC and MBC determination. The monomer was subsequently photochemically polymerized to implant grade Ti-6Al-4V alloy. The coating was bactericidal against Staphylococcus epidermidis through initial release of unattached antibiotic species followed by continued surface-contact-mediated bacterial killing by covalently tethered vancomycin. Through this surface-contact mechanism, the number of colony forming units dropped by ca. fivefold from an initial inoculum of 1 x 10(6) cfu/mL over 4 hours and by ca. 100-fold with respect to nonbactericidal control surfaces. An inoculum of 1 x 10(4) cfu/mL was reduced to undetectable levels over 17 hours. This coating method allows a loading dose several thousand times larger than that achieved with monolayer vancomycin coupling approaches and holds promise for the treatment of orthopaedic infections.

The role of telementoring and telerobotic assistance in the provision of laparoscopic colorectal surgery in rural areas.

PURPOSE: The aim of this study was to assess whether telementoring and telerobotic assistance would improve the range and quality of laparoscopic colorectal surgery being performed by community surgeons. METHODS: We present a series of 18 patients who underwent telementored or telerobotically assisted laparoscopic colorectal surgery in two community hospitals between December 2002 and December 2003. Four community surgeons with no formal advanced laparoscopic fellowship were remotely mentored and assisted by an expert surgeon from a tertiary care center. Telementoring was achieved with real-time two-way audio-video communications over bandwidths of 384 kbps-1.2 mbps and included one redo ileocolic resection, two right hemicolectomies, two sigmoid resections, three low anterior resections, one subtotal colectomy, one reversal of a Hartmann operation, and one abdominoperineal resection. A Zeus TS microjoint system (Computer Motion Inc, Santa Barbara CA) was used to provide telepresence for the telerobotically assisted laparoscopic procedures, which included three right hemicolectomies, three sigmoid resections, and one low anterior resection. RESULTS: There were no major intraoperative complications. There were two minor intraoperative complications involving serosal tears of the colon from the robotic graspers. In the telementored cases, there were two postoperative complications requiring reoperation (intra-abdominal bleeding and small bowel obstruction). Two telementored procedures were converted because of the mentee's inability to find the appropriate planes of dissection. One telerobotically assisted procedure was completed laparoscopically by the local surgeon with aid of telementoring because of inadequate robotic arm position. The median length of hospital stay for this series was 4 days. The surgeons considered telementoring useful in all cases (median score 4 out of 5). The use of remote telerobotic assistance was also considered a significant enabling tool. CONCLUSIONS: Telementoring and remote telerobotic assistance are excellent tools for supporting community surgeons and providing patients better access to advanced surgical care.

Comparison of nicardipine versus placebo to control hemodynamic responses during emergence and extubation.

OBJECTIVE: To compare 2 different doses of intravenous nicardipine versus placebo to control heart rate and blood pressure responses to emergence and extubation. DESIGN: Prospective, randomized, double-blind, placebo-controlled. SETTING: University hospital, single-institutional. PARTICIPANTS: Forty-five American Society of Anesthesiologists (ASA) class I through III adult patients. INTERVENTIONS: General endotracheal anesthesia was with oxygen and isoflurane and muscle relaxation. At the end of surgery, with at least 2 twitches present by nerve stimulator and end-tidal isoflurane <0.4%, reversal was accomplished with neostigmine and glycopyrrolate. Two minutes post-reversal, the study drug (nicardipine, 0.015 mg/kg; nicardipine, 0.03 mg/kg; or a saline placebo) was given. Heart rate and blood pressure were measured for every minute up to 10 minutes and at 15 minutes postreversal. MEASUREMENTS AND MAIN RESULTS: There were no significant differences among groups in age, gender, ASA class, weight, or heart rate. The nicardipine groups, 0.015 and 0.03 mg/kg, had lower blood pressure values than the placebo group. There was a significant difference in blood pressure among groups, with greater and more consistent attenuation of blood pressure occurring with the larger nicardipine dose. There were no episodes of hypotension or adverse events. CONCLUSIONS: Compared with placebo, both nicardipine doses attenuated blood pressure but not heart rate responses during emergence and extubation. Greater blood pressure control occurred with the larger nicardipine dose of 0.03 mg/kg.

Orlistat maintains biliary lipid composition and hepatobiliary function in obese subjects undergoing moderate weight loss.

OBJECTIVES: Orlistat, an intestinal lipase inhibitor, has recently been approved by the US Food and Drug Administration for treatment of obesity. The effects of orlistat on hepatobiliary function have not been previously defined. A 4 wk study was performed involving modest weight loss in obese subjects to observe any short-term hepatobiliary responses that occur after initiating treatment with orlistat and a hypocaloric diet. METHODS: A total of 23 obese (BMI 30-41 kg/m2) subjects were randomized to a double blind t.i.d. treatment with 120 mg of orlistat or a placebo in conjunction with a hypocaloric diet (1200-1500 kcal/day). The study was designed to achieve similar modest weight loss in both groups in order to be able to directly assess the effects of orlistat. Cholesterol saturation, bile composition, and gallbladder motility were measured. RESULTS: At the end of the treatment period, mean weight loss of 3.8 kg was achieved in the orlistat group (vs 2.3 kg with placebo, p = NS). Total bile acid concentration decreased significantly with placebo (-18.57 +/- 6.99 mmol/L; 95% CI = -32.26 to -4.87), but not with orlistat. Biliary phospholipid concentration decreased significantly with placebo (-4.38 +/- 1.91 mmol/L; 95% CI = -8.13 to -0.64) but not with orlistat. Mean changes from the baseline in cholesterol saturation index and gallbladder motility were similar in both groups. Microscopy of bile failed to reveal cholesterol microcrystals before or after treatment in either group. CONCLUSIONS: Our findings indicate a primary initial effect of weight loss is a reduction in biliary bile acids and phospholipids. Orlistat blocks these adverse changes in biliary lipid composition and maintains hepatobiliary function. We speculate that the risk of formation of gallstones during weight loss may actually be lowered with orlistat.

Differences in antigen recognition and cytolytic activity of CD8(+) and CD8(-) T cells that express the same antigen-specific receptor.

CD8(+) and CD8(-) T cell lines expressing the same antigen-specific receptor [the 2C T cell receptor (TCR)] were compared for ability to bind soluble peptide-MHC and to lyse target cells. The 2C TCR on CD8(-) cells bound a syngeneic MHC (K(b+))-peptide complex 10-100 times less well than the same TCR on CD8(+) cells, and the CD8(-) 2C cells lysed target cells presenting this complex very poorly. Surprisingly, however, the CD8(-) cells differed little from CD8(+) cells in ability to bind an allogeneic MHC (L(d+))-peptide complex and to lyse target cells presenting this complex. The CD8(+)/CD8(-) difference provided an opportunity to estimate how long TCR engagements with peptide-MHC have to persist to initiate the cytolytic T cell response.

Validation of an XML-based process to automatically web-enable clinical practice guidelines: experience with the smoking cessation guideline.

OBJECTIVES: To validate the ease by which a Clinical Practice Guideline (CPG) can be web-enabled using an XML-based semi-automated process. DESIGN AND IMPLEMENTATION: An XML DTD for Clinical Practice Guidelines and an MS Word authoring template were created in an earlier project. We took an existing guideline, Bedside Smoking Cessation Intervention, placed it into the MS Word template, converted it into XML, and then to HTML for deployment over the Kaiser Permanent intranet. CONCLUSIONS: We were able to use the MS Word authoring template and automatically generate both an XML representation of our guideline, and an HTML representation, which we have deployed on our intranet. The Bedside Smoking Cessation Intervention guideline was automatically merged into the online guidelines collection. Placing it on our intranet allowed for rapid and easy access by physicians and other health care providers throughout the Kaiser Permanente Medical Care Program.

Performance improvement: the organization's quest.

In today's health care marketplace, quality has become an expectation. Stakeholders are demanding quality clinical outcomes, and accrediting bodies are requiring clinical performance data. The Roosevelt Institute's quest was to define and quantify quality outcomes, develop an organizational culture of performance improvement, and ensure customer satisfaction. Several of the organization's leaders volunteered to work as a team to develop a specific performance improvement approach tailored to the organization. To date, over 200 employees have received an orientation to the model and its philosophy and nine problem action and process improvement teams have been formed.

Postmenopausal estrogen therapy selectively stimulates hepatic enlargement in women with autosomal dominant polycystic kidney disease.

The goal of this study was to determine whether use of postmenopausal estrogen (Premarin, Wyeth-Ayerst, Philadelphia, PA) in women with autosomal dominant polycystic kidney disease (ADPKD) increases liver, hepatic cyst, or kidney volume. We also determined whether clinical symptoms correlated with the volume of either the liver or kidneys. Eight women off estrogen (control, C) and 11 others on estrogen (Premarin, E) were studied basally and after 1 year. The two groups were similar in age, weight, age at menarche, and gravida. Volumes of total liver, hepatic cysts, hepatic parenchyma, and total kidney were measured by a validated computed tomography (CT) technique. Estrogen treatment was associated with a selective increase in total liver volume (E vs. C: delta = 7% +/- 12% vs. -2% +/- 8%, P < .03) and no change in kidney volume (E vs. C: delta = 0% +/- 6% vs. -2% +/- 6%, P = NS). Symptoms were common, regardless of estrogen treatment (abdominal pain 60%, shortness of breath 40%, or both 35%). Patients with symptoms of abdominal pain and shortness of breath had significantly increased hepatic volumes (P < .03) but similar kidney volume compared with patients without symptoms. We conclude that estrogen treatment of postmenopausal ADPKD women is associated with selective liver enlargement and that abdominal symptoms in ADPKD patients may be because of extensive hepatic cystic disease.

Quantitative liver function tests define the functional severity of liver disease in early-stage cirrhosis.

Some patients with early-stage cirrhosis preserve hepatic function, whereas others have little hepatic reserve and rapidly deteriorate. The aim of this study was to use quantitative tests of liver function (QLFTs) to define the degree of functional hepatic impairment in patients with early-stage cirrhosis (Child-Pugh score 5-7) and to determine whether the tests predicted subsequent hepatic decompensation. We recruited 10 cirrhotic (Cr) patients and 10 healthy controls (NI), who were well matched for race, age, weight, and gender. Clearances of caffeine (CF) and antipyrine (AP) after oral administration were measured from timed samples of saliva. The clearance of cholate (CA) was measured from serum samples obtained after simultaneous oral ([2,2,4,4-2H]CA) and intravenous ([24-13C]CA) administration. CA shunt was calculated as (Cl i.v./Clo x 100%). CF elimination rate (Cr v NI, mean +/- SD: 0.03 +/- 0.02 v 0.075 +/- 0.018 h-1, P < .0005) and AP clearance (24 +/- 16 v 40 +/- 7 mL/minute, P < .02) were reduced in Cr patients. CA shunt was increased in Cr patients (43 +/- 18 v 18 +/- 7%, P < .002). Five Cr patients decompensated during follow-up and had the worst CA shunts (76%, 66%, 51%, 48%, and 45%). Three subsequently received successful orthotopic liver transplantation, 1 died of hepatoma, and 1 is on the waiting list for transplantation. In conclusion, QLFTs define the degree of functional impairment in early cirrhosis and may identify Cr patients at greatest risk of decompensation who may require transplantation for survival.