A quantitative day in the life of a Saskatchewan rural physician.

INTRODUCTION: Rural family physicians are often required to meet a wide variety of medical service demands that are otherwise the responsibility of specialty physicians in urban centres. However, many rural physicians enjoy the practice variety and ability to meet patients' medical needs through this wider spectrum of care. We aimed to quantify and summarize the workload and clinical disorders seen by rural family physicians in Saskatchewan relative to urban family physicians. METHODS: We used Saskatchewan Ministry of Health billing data for 2015/16 to compare rural and urban care provision. The data were summarized in a graphic 1-month format to portray a typical month in the life of a rural physician in the province. RESULTS: In the office setting, rural family physicians saw 16.8% more cardiac presentations in adults over 65 years of age than did urban family physicians; otherwise, there were no significant differences in the top office diagnosis categories seen by the 2 groups. Differences were apparent, however, in the hospital setting: urban family physicians saw more patients presenting with pain and, reflective of centralization of obstetric delivery services, performed more deliveries than did rural physicians. CONCLUSION: There are differences in the clinical presentations seen by rural and urban family physicians, and these need to be considered by new physicians considering rural practice. Our simple visual depiction of average workload, vacation and activity levels of rural physicians can further inform medical residents on the realities of working in rural Saskatchewan as a family physician. A more complete understanding of clinical workload expectations may promote recruitment of resident physicians.

INTRODUCTION: Les médecins de famille en milieu rural sont souvent appelés à fournir des services médicaux très variés qui sont par ailleurs la responsabilité des médecins spécialistes, en milieu urbain. Cela dit, beaucoup de médecins en milieu rural apprécient la variété et la capacité de répondre aux besoins médicaux des patients dans ce contexte de soins plus étendu. Nous avons tenté de quantifier et de résumer la charge de travail ainsi que les troubles cliniques des patients reçus par les médecins de famille en milieu rural en Saskatchewan par rapport aux médecins de famille en milieu urbain. METHODS: Nous avons utilisé les données de facturation du ministère de la Santé de la Saskatchewan pour 2015­2016 afin de comparer la prestation des soins en milieu rural et urbain. Les données ont été résumées sous forme de graphique représentant un mois typique dans la vie d'un médecin exerçant en milieu rural dans la province. RESULTS: En cabinet, les médecins de famille en milieu rural ont reçu 16,8 % plus de patients de 65 ans atteints d'une cardiopathie que les médecins de famille en milieu urbain. Par ailleurs, il n'y avait pas de différences significatives dans les principales catégories de diagnostics en cabinet entre les deux groupes. Toutefois, des différences étaient évidentes en milieu hospitalier : les médecins de famille en milieu urbain ont reçu plus de patients présentant une douleur et ont pratiqué un nombre plus élevé d'accouchements que les médecins en milieu rural, ce qui reflète la centralisation des services obstétriques. CONCLUSION: Les troubles cliniques des patients reçus par les médecins de famille en milieu rural et urbain diffèrent et doivent être pris en compte par les nouveaux médecins qui envisagent la pratique en milieu rural. Notre représentation visuelle simple de la charge de travail, des vacances et du taux d'activité moyen des médecins en milieu rural peut éclairer les médecins résidents sur les réalités de la pratique du médecin de famille en région rurale en Saskatchewan. Une compréhension plus complète des attentes en matière de charge clinique pourrait favoriser le recrutement des médecins résidents.

Improved quality and more attractive work by applying EBM in disability evaluations: a qualitative survey.

BACKGROUND: The uptake of evidence in practice by physicians, even if they are trained in the systematic method of evidence-based medicine (EBM), remains difficult to improve. The aim of this study was to explore perceptions and experiences of physicians doing disability evaluations regarding motivators and preconditions for the implementation of EBM in daily practice. METHODS: This qualitative study was nested in a cluster randomized controlled trial (Trial registration NTR1767; 20-apr-2009) evaluating the effects of training in EBM. The 45 physicians that participated received a comprehensive 6-months training program in EBM of which the last course day included audio-recorded interviews in groups. During these interviews participating physicians discussed perceptions and experiences regarding EBM application in daily practice. In an iterative process we searched for common motivators or preconditions for the implementation of EBM. RESULTS: Three main concepts or themes emerged after analyzing the transcriptions of the discussions: 1) improved quality of physicians' actions, such as clients benefiting from the application of EBM; 2) improved work attractiveness of physicians; and 3) preconditions that have to be met in order to work in an evidence-based manner including professional competence, facilitating material conditions and organizational support and demands. CONCLUSIONS: Physicians trained in EBM are motivated to use EBM because they perceive it as a factor improving the quality of their work and making their work more attractive. In addition to personal investments and gains, organizational support should further facilitate the uptake of evidence in practice.

[Every physician should know how to take an occupational history: the importance of teaching occupational medicine in medical school]. / Iedere arts moet arbeidsanamnese uitvragen: belang van 'arbeid en gezondheid' in de medische opleiding.

Working and participating in society are important for one's health and wellbeing. This also works the other way around: in order to work or participate, one has to be healthy. Every doctor should learn about this reciprocal relationship during their medical training. In a survey undertaken by the Netherlands Society of Occupational Medicine, the amount of time spent on occupational medicine in the curriculum of eight Dutch medical faculties was examined. The study showed vast differences between faculties in the amount of time spent on occupational medicine, in the learning methods employed and also in the number of students who participate in internships. The situation in the Netherlands compares favourably with that in other European countries. Sufficient specific attention to subjects related to health and work during undergraduate education is important for all doctors and a prerequisite to increase the number of medical students who subsequently choose a career in occupational health medicine.

A clinically integrated post-graduate training programme in evidence-based medicine versus 'no intervention' for improving disability evaluations: a cluster randomised clinical trial.

BACKGROUND: Although several studies have shown that teaching EBM is effective in improving knowledge, at present, there is no convincing evidence that teaching EBM also changes professional behaviour in practice. Therefore, the primary aim of this study was to evaluate the effectiveness of a clinically integrated post-graduate training programme in EBM on evidence-based disability evaluation. METHODS AND FINDINGS: In a cluster randomised controlled trial, fifty-four case-based learning groups consisting of 132 physicians and 1680 patients were randomly assigned to the intervention or control groups. A clinically integrated, post-graduate, 5-day training programme in evidence-based medicine, consisting of (home) assignments, peer teaching, interactive training in searching databases, lectures and brainstorming sessions was provided to the intervention group. The control group received no training. The primary outcome was evidence-based disability evaluation, as indicated by the frequency in use of evidence of sufficient quality in disability evaluation reports. There are no general EBM behaviour outcome measures available. Therefore, we followed general guidelines for constructing performance indicators and defined an a priori cut-off for determination of sufficient quality as recommended for evaluating EB training. Physicians trained in EBM performed more evidence-based disability evaluations compared to physicians in the control group (difference in absolute proportion 9.7%, 95% CI 3.5 to 15.9). The primary outcome differences between groups remained significant after both cluster-adjusted analysis and additional sensitivity analyses accounting for subjects lost to follow-up. CONCLUSIONS: A EBM programme successfully improved the use of evidence in a non-hospital based medical specialty. Our findings support the general recommendations to use multiple educational methods to change physician behaviour. In addition, it appeared important that the professional context of the intervention was very supportive in the sense that searches in databases, using and applying guidelines and other forms of evidence are considered standard practice and are encouraged by colleagues and management.

Annual incidence of occupational diseases in economic sectors in The Netherlands.

OBJECTIVE: To report the annual incidence of occupational diseases (ODs) in economic sectors in The Netherlands. METHODS: In a 5-year prospective cohort study (2009-2013), occupational physicians were asked to participate in a sentinel surveillance system for OD notification. The inclusion criteria for participation were (1) covering a population of employees, (2) reporting the economic sectors and the size of their employee population and (3) willingness to report all diagnosed ODs. In this study, an OD was defined as a disease with a specific clinical diagnosis that was predominantly caused by work-related factors. The economic sectors (n=21) were defined according the NACE (Nomenclature des Activités Économiques dans la Communauté Européenne) classification. RESULTS: In a total working population of 514,590 employees, 1782 ODs were reported over 12 months in 2009. The estimated annual incidence for any OD was 346 (95% CI 330 to 362) per 100,000 worker-years. Of all the ODs, mental diseases were reported most frequently (41%), followed by musculoskeletal (39%), hearing (11%), infectious (4%), skin (3%), neurological (2%) and respiratory (2%) diseases. The four economic sectors with the highest annual incidences per 100,000 workers were construction (1127; 95% CI 1002 to 1253), mining and quarrying (888; 95% CI 110 to 1667), water and waste processing (832; 95% CI 518 to 1146) and transport and storage (608; 95% CI 526 to 690). CONCLUSION: ODs are reported in all economic sectors in The Netherlands. Up to 91% of all ODs are mental, musculoskeletal and hearing diseases. Efforts to increase the effective assessment of ODs and compliance in reporting activities enhance the usability of incidence figures for the government, employers and workers.

Solid-state structural characterization of cutinase-ECE-pincer-metal hybrids.

The first crystal structures of lipases that have been covalently modified through site-selective inhibition by different organometallic phosphonate-pincer-metal complexes are described. Two ECE-pincer-type d(8)-metal complexes, that is, platinum (1) or palladium (2) with phosphonate esters (ECE = [(EtO)-(O=)P(-O-C(6)H(4)-(NO(2))-4)(-C(3)H(6)-4-(C(6)H(2)-(CH(2)E)(2))](-); E = NMe(2) or SMe) were introduced prior to crystallization and have been shown to bind selectively to the Ser(120) residue in the active site of the lipase cutinase to give cut-1 (platinum) or cut-2 (palladium) hybrids. For all five presented crystal structures, the ECE-pincer-platinum or -palladium head group sticks out of the cutinase molecule and is exposed to the solvent. Depending on the nature of the ECE-pincer-metal head group, the ECE-pincer-platinum and -palladium guests occupy different pockets in the active site of cutinase, with concomitant different stereochemistries on the phosphorous atom for the cut-1 (S(P)) and cut-2 (R(P)) structures. When cut-1 was crystallized under halide-poor conditions, a novel metal-induced dimeric structure was formed between two cutinase-bound pincer-platinum head groups, which are interconnected through a single mu-Cl bridge. This halide-bridged metal dimer shows that coordination chemistry is possible with protein-modified pincer-metal complexes. Furthermore, we could use NCN-pincer-platinum complex 1 as site-selective tool for the phasing of raw protein diffraction data, which shows the potential use of pincer-platinum complex 1 as a heavy-atom derivative in protein crystallography.

Active-site architecture and catalytic mechanism of the lipid A deacylase LpxR of Salmonella typhimurium.

The lipid A portion of lipopolysaccharide, the major component of the outer leaflet of the outer membrane of gram-negative bacteria, is toxic to humans. Modification of lipid A by enzymes often reduces its toxicity. The outer-membrane protein LpxR from Salmonella typhimurium is a lipid A-modifying enzyme. It removes the 3'-acyloxyacyl moiety of the lipid A portion of lipopolysaccharide in a Ca(2+)-dependent manner. Here, we present the crystal structure of S. typhimurium LpxR, crystallized in the presence of zinc ions. The structure, a 12-stranded beta-barrel, reveals that the active site is located between the barrel wall and an alpha-helix formed by an extracellular loop. Based on site-directed mutagenesis and modeling of a substrate on the active site, we propose a catalytic mechanism similar to that of phospholipase A2, in which a Ca(2+) forms the oxyanion hole and a histidine activates a water molecule (or a cascade of two water molecules) that subsequently attacks the carbonyl oxygen of the scissile bond.

Evaluation of a workshop on evidence-based medicine for social insurance physicians.

BACKGROUND: Evidence-based medicine (EBM), a comprehensive method to support clinical decision making by using evidence, has been instrumental in clinical specialties but not yet in insurance medicine. AIMS: We developed and evaluated a workshop on EBM for Dutch social insurance physicians who perform disability evaluations. METHODS: Sixty-six social insurance physicians followed a 1-day introductory workshop that focused on teaching two EBM core skills: to ask answerable questions and to search for the best evidence. All outcomes were measured before, immediately after and 3 months after the workshop by means of self-assessment. The primary outcomes were knowledge, skills, attitude and intention to apply EBM in practice. The secondary outcomes were social influence, self-efficacy and behaviour. RESULTS: Immediately after the workshop, a marked and significant improvement was seen in self-assessed skills (mean difference 4.2, 95% CI 3.7-4.6) and in self-efficacy to apply EBM (mean difference 0.7, 95% CI 0.6-0.8). For attitude, knowledge and intention, the improvements were small. Three months after the workshop, the improvements in skills (mean difference 2.3, 95% CI 1.8-2.9) and self-efficacy (mean difference 0.5, 95% CI 0.3-0.6) remained significant. CONCLUSIONS: The workshop improved self-assessed EBM skills and self-efficacy both in the short and long term. The workshop also resulted in limited short-term improvements in self-assessed knowledge and in the intention to apply EBM in practice. The EBM approach can be successfully taught to social insurance physicians working in the field of disability evaluation.

Alzheimer's presenilin-1 mutation potentiates inositol 1,4,5-trisphosphate-mediated calcium signaling in Xenopus oocytes.

Perturbations in intracellular Ca2+ signaling may represent one mechanism underlying Alzheimer's disease (AD). The presenilin-1 gene (PS1), associated with the majority of early onset familial AD cases, has been implicated in this signaling pathway. Here we used the Xenopus oocyte expression system to investigate in greater detail the role of PS1 in intracellular Ca2+ signaling pathways. Treatment of cells expressing wild-type PS1 with a cell surface receptor agonist to stimulate the phosphoinositide second messenger pathway evoked Ca2+-activated Cl- currents that were significantly potentiated relative to controls. To determine which elements of the signal transduction pathway are responsible for the potentiation, we used photolysis of caged inositol 1,4,5-trisphosphate (IP3) and fluorescent Ca2+ imaging to demonstrate that PS1 potentiates IP3-mediated release of Ca2+ from internal stores. We show that an AD-linked mutation produces a potentiation in Ca2+ signaling that is significantly greater than that observed for wild-type PS1 and that cannot be attributed to differences in protein expression levels. Our findings support a role for PS1 in modulating IP3-mediated Ca2+ liberation and suggest that one pathophysiological mechanism by which PS1 mutations contribute to AD neurodegeneration may involve perturbations of this function.