Validation of a brief measure of combat exposure among Canadian Armed Forces personnel.

BACKGROUND: Exposure to military combat is associated with mental health problems, including posttraumatic stress disorder (PTSD) and depression. To understand the effects of combat on adverse health outcomes, the sound measurement of combat experiences is required; however, many scales used in past research are lengthy. A brief measure of combat exposure benefits militaries by reducing the burden on respondents as well as administration time in post-deployment settings and large population-based health surveys. DATA AND METHODS: The current study sought to describe the psychometric properties of a brief measure of combat exposure among Canadian Armed Forces (CAF) personnel. Data from post-deployment screening were used to compare the psychometric properties of an 8-item scale with the full scale that it was derived from. RESULTS: The 8-item measure did not fit a one-factor solution well and did not offer a statistically significant improvement in model fit over the full 30-item measure. However, its association with increased odds of a number of health outcomes indicates that it could be useful as a brief measure of combat exposure in settings where using the full scale is not feasible. DISCUSSION: Brief measures of combat exposure are valuable for assessing events experienced during deployment among military personnel. Although the 8-item Combat Exposure Scale assessed in the current study represents a potentially useful measure for CAF personnel, further research is necessary to improve its fit.

Attention Deficit Hyperactivity Disorder Presentations to The Child and Adolescent Mental Health Urgent Consult Clinic.

OBJECTIVE: The objective of the present study is to compare and contrast demographic and clinical characteristics of patients diagnosed with and without ADHD referred to the Child and Adolescent Mental Health Urgent Consult Clinic (CAMHUCC) in order to identify any differences between the patient groups and potentially improve care of these patients in the community. METHODS: This is retrospective cohort study of all children and adolescents, who were referred to the CAMHUCC between 2012 and 2014. Using data routinely collected at the clinic, individuals with ADHD were compared to individuals without ADHD. Data analysis was conducted using frequencies, percentages, means and standard deviations to describe participant demographic and clinical information, and comparisons between individuals with and without ADHD was made using Mann-Whitney U statistics. RESULTS: Of the 803 urgent assessments at the clinic, 367 (45.7%) were diagnosed with ADHD. Individuals with ADHD were statistically significantly more likely to be younger, male, referred for aggression, and not living with both parents. Individuals with ADHD were also more likely to be referred for follow-up than those without ADHD, and were more likely to have had at least one previous admission to the CAMHUCC. CONCLUSIONS: Individuals with ADHD account for a significant proportion of child and adolescent presentations to CAMHUCC. Provision of urgent psychiatric care to young people with ADHD represents a significant utilization of resources on health care in terms of initial assessment, higher rates of follow up care, need for risk assessment and referral to CMHA.

OBJECTIF: L'objectif de la présente étude est de comparer et de contraster les caractéristiques démographiques et cliniques des patients diagnostiqués avec et sans trouble de déficit d'attention avec hyperactivité (TDAH) qui sont adressés à la clinique de consultation d'urgence pour santé mentale d'enfants et d'adolescents (CCUSMEA) afin de distinguer toute différence entre les groupes de patients et de potentiellement améliorer les soins de ces patients dans la communauté. MÉTHODES: C'est une étude de cohorte rétrospective de tous les enfants et adolescents qui ont été aiguillés à la CCUSMEA entre 2012 et 2014. À l'aide des données recueillies régulièrement à la clinique, les personnes souffrant de TDAH ont été comparées avec les personnes sans TDAH. L'analyse des données a été menée à l'aide des fréquences, des pourcentages, des moyennes et des écarts types pour décrire les données démographiques et cliniques des participants, et les comparaisons entre les personnes avec et sans TDAH ont été faites à l'aide du test U statistique de Mann-Whitney. RÉSULTATS: Sur les 803 évaluations d'urgence à la clinique, 367 (45,7 %) ont été diagnostiquées avec le TDAH. Les personnes souffrant du TDAH étaient statistiquement plus significativement susceptibles d'être plus jeunes, de sexe masculin, aiguillées pour une agression, et ne vivant pas avec leurs deux parents. Les personnes souffrant du TDAH étaient également plus susceptibles d'être adressées à un suivi que celles sans TDAH, et étaient plus susceptibles d'avoir eu plus d'une admission précédente à la CCUSMEA. CONCLUSIONS: Les personnes souffrant du TDAH représentent une proportion significative des présentations d'enfants et d'adolescents à la CCUSMEA. L'offre de soins psychiatriques d'urgence aux jeunes gens souffrant du TDAH représente une utilisation significative des ressources des soins de santé en ce qui concerne l'évaluation initiale, les taux plus élevés des soins de suivi, le besoin d'une évaluation de risque et l'aiguillage à CMHA.

Emergency Department Referrals for Adolescent Urgent Psychiatric Consultation: Comparison of Clinical Characteristics of Repeat-presentations and Single-presentation.

OBJECTIVE: a) to examine the demographic and clinical characteristics of repeat-presentations to an adolescent urgent psychiatric clinic, and b) to compare them with single-time presentation. METHOD: This 18-month retrospective study compared repeat-presenters to age and gender matched single-time presenters. Demographic variables included age gender and ethnicity. Clinical variables included reason for referral, family history, diagnosis, recommendations and compliance. Data were analyzed using descriptive statistics, McNemar's Chi-square tests for matched pairs, and conditional logistic regression. RESULTS: Of 624 assessments 24% (N=151) were repeat-presentations. Compared with single-presentation, repeat-presentation group had a higher proportion of Aboriginal youth (X2 (1) = 108.28 p < 0.01), a higher proportion in special educational placement (X2 (1) = 6.82, p < 0.01), a higher proportion with a family history of anxiety disorders (X2 (1) = 10.62, p = 0.01) and substance use disorder (X2 (1) = 18.99, p < 0.01). Conditional logistic regression results suggested that repeat-presentation group had higher odds of past hospital admission (OR: 3.50, p < 0.01) higher odds of family history of mood disorders (OR: 4.86, p < 0.01) and of antisocial disorders (OR: 4.97, p = 0.02), and lower odds of recommendation compliance (OR: 0.10, p < 0.01). CONCLUSION: Repeat-presentations for urgent psychiatric consultation constitute a quarter of referrals to the urgent psychiatric clinic. Identifying and addressing factors that contribute to repeat-presentations may, assist in improving treatment compliance by ensuring focused interventions and service delivery for these youth. In turn, this will improve access to the limited urgent services for other youth.

OBJECTIF: a) Examiner les caractéristiques démographiques et cliniques des visites répétées à une clinique psychiatrique d'urgence pour adolescents et b) les comparer à celles d'une visite unique. MÉTHODE: Cette étude rétrospective sur 18 mois a comparé les visiteurs répétés avec des visiteurs uniques appariés selon l'âge et le sexe. Les variables démographiques comprenaient l'âge, le sexe et l'origine ethnique. Les variables cliniques étaient notamment la raison de l'aiguillage, les antécédents familiaux, le diagnostic, les recommandations et l'observance. Les données ont été analysées à l'aide de statistiques descriptives, de tests du chi carré de McNemar pour paires appariées, et de la régression logistique conditionnelle. RÉSULTATS: Sur les 624 évaluations, 24% (N = 151) étaient des visites répétées. Comparé aux visiteurs uniques, le groupe des visites répétées avait une proportion plus élevée de jeunes autochtones (X2 (1) = 108,28, p < 0,01), une proportion plus élevée de placements en éducation spécialisée (X2 (1) = 6,82, p < 0,01), et une proportion plus élevée de sujets ayant des antécédents familiaux de troubles anxieux (X2 (1) = 10,62, p = 0,01) et de troubles d'utilisation de substances (X2 (1) = 18,99, p < 0,01). Les résultats de la régression logistique conditionnelle suggéraient que le groupe des visites répétées avait des probabilités plus élevées d'hospitalisations passées (RC 3,50, p < 0,01), des probabilités plus élevées d'antécédents familiaux de troubles de l'humeur (RC 4,86, p < 0,01) et de troubles antisociaux (RC 4,97, p = 0,02), et des probabilités plus faibles d'observance des recommandations (RC 0,10, p < 0,01). CONCLUSION: Les visites répétées pour une consultation psychiatrique urgente constituent un quart de l'aiguillage à la clinique psychiatrique d'urgence. Identifier et aborder les facteurs qui contribuent aux visites répétées peut aider à améliorer l'observance du traitement en assurant des interventions ciblées et la prestation de services à ces jeunes. Cela améliorera ensuite l'accès aux services d'urgence limités pour les autres jeunes.

Assessing the iPad as a tool for low-vision rehabilitation.

OBJECTIVE: It has been demonstrated consistently that patients with poor vision have a reduced quality of life and functional status and higher rates of psychologic distress. This study aims to assess whether the iPad has potential as a visual aid in patients with low vision. DESIGN: Qualitative study with key-informant interviews. PARTICIPANTS: Patients who identified as having impaired vision were recruited from a low vision ophthalmology clinic. METHODS: Patients participated in a 4-session iPad training course. The goal of the course was to teach patients with low vision how to operate an iPad, with a particular emphasis on how to optimize iPad settings and accessibility features in response to some of the challenges faced by patients with low vision. Three interviews were conducted with each participant: before the course, immediately after the course, and 3 months after the course. The purpose of the interviews was to gain an understanding of their experience with low vision and to assess if and how the iPad had influenced this experience. A grounded theory qualitative approach was used for analysis. RESULTS: Six patients took part in the study and were divided into 2 separate courses to minimize course size. Participants had favorable views regarding the course. Five of the 6 participants were using the iPad on a daily basis 3 months after the course. Thematic analysis revealed that use of the iPad led to both a heightened sense of independence and improved social connectivity. It is theorized that use of the iPad as a low-vision aid may enhance a patient's sense of self-worth. CONCLUSIONS: With proper training, the iPad has the potential to be a valuable tool for low-vision patients. Its features help patients to gain independence and to stay connected within their social circles. Further research with a larger patient population and quantifiable endpoints should focus on these themes.

New Surgeon Outcomes and the Effectiveness of Surgical Training: A Population-Based Cohort Study.

PURPOSE: Reports have questioned the technical proficiency of newly graduating surgeons. However, objective data supporting these concerns are limited. Surgical outcomes among recent graduates are an important indicator of residency programs' ability to graduate surgeons who are ready to meet the needs of their patients. This study aimed to investigate the association between a surgeon's number of years of independent practice and the risk of surgical adverse events. DESIGN: Population-based cohort study. PARTICIPANTS: All patients 66 years of age or older undergoing isolated cataract operations in Ontario, Canada, between January 1, 1997, and December 31, 2013. METHODS: Cataract surgical outcomes for all operations performed by surgeons commencing practice in the study period were evaluated using linked health care databases. MAIN OUTCOME MEASURES: Four serious complications were evaluated: posterior capsule rupture, dropped lens fragments, retinal detachment, and suspected endophthalmitis. Analyses controlled for patient-, surgeon-, and institution-level covariates. RESULTS: The study evaluated 1 431 320 cataract operations. Surgeons in their first year of independent practice were more than 9 times more likely to have high complication rates (≥2%) than surgeons in their tenth year (odds ratio [OR], 9.3; 95% confidence interval [CI], 2.7-31.9). Each additional year of independent practice was associated with a 10% decrease in the risk of patients experiencing an adverse surgical event (OR, 0.90 per year of surgeon independent practice; 95% CI, 0.87-0.94). CONCLUSIONS: In this population-based study, surgical complications were significantly more likely early in surgeons' careers. Interventions may be needed in postgraduate surgical training and early independent career monitoring and mentoring processes to ensure patient safety while continually renewing the surgical workforce.

Impact of Combination Glaucoma Therapies on ß-Blocker Exposure.

PURPOSE: ß-adrenergic receptor antagonists (ß-blockers) used in the treatment of glaucoma are an often-overlooked source of systemic adverse events. Ophthalmic timolol has been associated with severe systemic adverse events including numerous cases resulting in death. In recent years the number of fixed-dose combination therapies for glaucoma has grown rapidly, and among available combination therapies only the nonselective ß-blocker timolol is used as the ß-blocker component. METHODS: A population-based study was conducted in Ontario, Canada between January 1, 2001 and December 31, 2012 to assess the shift to combination therapies in the management of glaucoma, and to investigate the impact of this shift on the relative use of selective and nonselective ß-blockers in patients with this disease. RESULTS: Between 2001 and 2012 timolol (nonselective ß-blocker) use grew at an average annual rate of 2.2% (P<0.0001), whereas betaxolol (selective ß-blocker) use declined by 14.1% per year (P<0.0001). These changes in the relative use of betaxolol and timolol coincided with changes in the relative use of combination and single-drug therapies. Over the study period, the use of ß-blockers as single-drug therapy decreased by 7.7% annually (P<0.0001). In contrast, the use of combination therapies containing a ß-blocker increased by 7.6% annually (P<0.0001). CONCLUSIONS: The introduction of fixed combination glaucoma therapies has been associated with a significant shift to greater use of nonselective ß-blockers. In vulnerable older populations, this may have an important impact on patient safety that warrants further study.

Effect of cataract surgery volume constraints on recently graduated ophthalmologists: a population-based cohort study.

BACKGROUND: Across Canada, graduates from several medical and surgical specialties have recently had difficulty securing practice opportunities, especially in specialties dependent on limited resources such as ophthalmology. We aimed to investigate whether resource constraints in the health care system have a greater impact on the volume of cataract surgery performed by recent graduates than on established physicians. METHODS: We used population-based administrative data from Ontario for the period Jan. 1, 1994, to June 30, 2013, to compare health services provided by recent graduates and established ophthalmologists. The primary outcome was volume of cataract surgery, a resource-intensive service for which volume is controlled by the province. RESULTS: When cataract surgery volume in Ontario entered a period of government-mandated zero growth in 2007, the mean number of cataract operations performed by recent graduates dropped significantly (-46.37 operations/quarter, 95% confidence interval [CI] -62.73 to -30.00 operations/quarter), whereas the mean rate for established ophthalmologists remained stable (+5.89 operations/quarter, 95% CI 95% CI -1.47 to +13.24 operations/quarter). Decreases in service provision among recent graduates did not occur for services without volume control. The proportion of recent graduates providing exclusively cataract surgery increased over the study period, and recent graduates in this group were 5.24 times (95% CI 2.15 to 12.76 times) more likely to fall within the lowest quartile for cataract surgical volume during the period of zero growth in provincial cataract volume (2007-2013) than in the preceding period (1996-2006). INTERPRETATION: Recent ophthalmology graduates performed many fewer cataract surgery procedures after volume controls were implemented in Ontario. Integrated initiatives involving multiple stakeholders are needed to address the issues facing recently graduated physicians in Canada.

The effects of distress and the dimensions of coping strategies on physicians' satisfaction with competence.

OBJECTIVES: The purposes of this study were to (1) articulate the dimensions of Coping strategies used by physicians, and (2) determine whether Coping strategies alleviated Distress and enhanced Satisfaction with Competence. METHODS: Comprehensive questionnaires on factors associated with Satisfaction with Competence were sent to a stratified sample of 5300 physicians across Canada. The response rate was 57% with negligible bias. Factor analysis was used to articulate the dimensions of Coping strategies. The classic Baron and Kenny regression series was used to establish whether Coping mediates the effects of Distress on Satisfaction with Competence. Years in Practice, Self-Reported Health, and Duties of Physicians were control factors. RESULTS: A reliable 15-item measure of Coping was confirmed (α = .76) with four reasonably reliable dimensions: Collegiality (α = .80), Attitude (α = .63), Managing Work (α = .60), and Self-Care (α = .62). Physicians reported a mean Satisfaction with Competence of (M = 4.26 out of 6.0, standard deviation (SD) = 0.64) with General practitioners reporting slightly lower levels of Satisfaction with Competence than average. Conversely, chronic disease, clinical, and procedural specialists reported higher levels of Satisfaction with Competence. The mean Distress level for all physicians was (M = 3.66 out of 7.0, SD = 0.93). The highest levels of distress were reported by emergency physicians, general practitioners, and surgeons. Clinical specialists, anesthesiologists, and psychiatrists reported the lowest levels of distress. Physicians reported (M = 4.48 out of 7.0, SD = 0.78) as the mean level of Coping ability with clinical specialists and general practitioners reporting lower than average abilities to cope. Laboratory and chronic care specialists reported greater than average coping abilities. Regression analyses established Coping as a mediator of Distress which predicted physicians' Satisfaction with Competence. CONCLUSION: Four groups of coping strategies were significant in relieving the pressures of work: (1) Collegiality, (2) Self-Care, (3) Managing Work, and (4) Positive Attitude.

Modeling factors explaining physicians' satisfaction with competence.

OBJECTIVE: Attention to physician wellness has increased as medical practice gains in complexity. Physician satisfaction with practice is critical for quality of care and practice growth. The purpose of this study was to model physicians' self-reported Satisfaction with Competence as a function of their perceptions of the Quality of Health Services, Distress, Coping, Practice Management, Personal Satisfaction and Professional Equity. METHODS: Comprehensive questionnaires were sent to a stratified sample of 5300 physicians across Canada. This cross-sectional study focused on physicians who examined and treated individual patients for a final study population of 2639 physicians. Response bias was negligible. The questionnaires contained measures of Satisfaction with Competence, Quality of Health Services, Distress, Coping, Personal Satisfaction, Practice Management and Professional Equity. Exploring relationships was done using Pearson correlations and one-way analysis of variance. Modeling was by hierarchical regressions. RESULTS: The measures were reliable: Satisfaction with Competence (α = .86), Quality (α = .86), Access (α = .82), Distress (α = .82), Coping (α = .76), Personal Satisfaction (α = .78), Practice Management (α = .89) and the dimensions of Professional Equity (Fulfillment, α = .81; Financial, α = .93; and Recognition, α = .75) with comparative validity. Satisfaction with Competence was positively correlated with Quality (r = .32), Efficiency (r = .37) and Access (r = .32); negatively correlated with Distress (r = -.54); and positively correlated with Coping strategies (r = .43), Personal Satisfaction (r = .57), Practice Management (r = .17), Fulfillment (r = .53), Financial (r = .36) and Recognition (r = .54). Physicians' perceptions on Quality, Efficiency, Access, Distress, Coping, Personal Satisfaction, Practice Management, Fulfillment, Pay and Recognition explained 60.2% of the variation in Satisfaction with Competence, controlling for years in practice, self-reported health and duties of physicians. CONCLUSION: Satisfaction with Competence could be affected by excessive accumulation of duties, concerns about quality, efficiency, access, excessive distress, inadequate coping abilities, personal satisfaction with life as a physician, challenges in managing practices and persistent inequities among physicians.

Reconceptualizing determinants of health: barriers to improving the health status of First Nations peoples.

Comparing the key determinants of health articulated by the Public Health Agency of Canada (the Agency) with the spiritual and cultural knowledge systems of First Nations peoples, as expressed by the Four Worlds International Institute for Human and Community Development (Four Worlds) and their 14 determinants of well-being and health, reveals differing philosophical perspectives. The key determinants of health can be interpreted as lacking a holistic and inclusive approach to public health services. As a result, many public health programs in Canada marginalize, ignore and suppress the needs of First Nations communities and people. Incorporating the Four Worlds guiding principles and its 14 health determinants model within the context of Canadian public health services geared towards First Nations populations provides the opportunity to develop a deeper understanding of social determinants of health. Therefore, when implementing public health initiatives to address the health status of First Nations people in Canada, it is important that the Agency incorporate the guiding principles of the Four Worlds: Development Comes from Within; No Vision, No Development; Individual and Community Transformations Must Go Hand in Hand; and Holistic Learning is the Key to Deep and Lasting Change. Reconceptualizing the key determinants of health to encompass the worldview expressed by the Four Worlds acknowledges the cultural wisdom of First Nations people and offers the potential to develop more inclusive public health services.