[Not Available]. / Pratique réflexive et responsabilité sociale en médecine de famille: Les impacts de l'expérience des stages internationaux menés dans les pays en voie de développement.

OBJECTIF: Explorer les retombées perçues d'un stage électif en santé internationale dans le processus d'apprentissage des résidents en médecine de famille. TYPE D'ÉTUDE: Étude qualitative de type collaborative reposant sur des entrevues semi-dirigées. CONTEXTE: Québec. PARTICIPANTS: Un total de 12 résidents en médecine de famille et 9 superviseurs de stages internationaux (N = 21). MÉTHODES: Entrevues semi-dirigées menées auprès de résidents et de superviseurs de stages. PRINCIPALES OBSERVATIONS: Tous les participants ont tiré des avantages tant sur le plan technique que sur le plan relationnel. Sur le plan technique, ils ont renforcé leurs connaissances des pathologies tropicales; ils ont également appris à élargir leur examen clinique. Sur le plan relationnel, ils ont bénéficié d'une expérience riche du point de vue des interactions avec d'autres milieux de soins et avec des populations vivant majoritairement dans des conditions précaires. C'est au niveau des compétences relationnelles (communication, empathie, etc.) avec les patients vulnérables que l'impact du stage a été le plus bénéfique. Tous les participants ont en effet été confrontés à d'autres formes de thérapies locales et à d'autres interprétations de symptômes et d'étiologie des maladies. CONCLUSION: L'impact de cette étude au niveau des retombées pédagogiques est important puisque nous avons pu situer la façon dont les résidents vivaient un tel stage et ce qu'ils en retiraient en matière de compétences médicales et d'approche pédagogique dans la rencontre avec les patients. Une approche collaborative avec des superviseurs de stages nous a permis d'effectuer une triangulation des données et de mieux situer les apports d'un stage international dans la formation universitaire. Enfin, les résultats obtenus permettraient de soutenir et de renforcer les programmes académiques en médecine sociale et préventive et de mieux préparer les futurs médecins de famille à agir dans des contextes socioculturels pluriels.

Reflective practice and social responsibility in family medicine: Effect of performing an international rotation in a developing country.

OBJECTIVE: To explore the perceived effect of an elective international health rotation on family medicine resident learning. DESIGN: Qualitative, collaborative study based on semistructured interviews. SETTING: Quebec. PARTICIPANTS: A sample of 12 family medicine residents and 9 rotation supervisors (N = 21). METHODS: Semistructured interviews of residents and rotation supervisors. MAIN FINDINGS: Residents and supervisors alike reported that their technical skills and relationship skills had benefited. All increased their knowledge of tropical pathologies and learned to expand their clinical examinations. They benefited from having very rich interactions in other care settings, working with vulnerable populations. The rotations had their greatest effect on relationship skills (communication, empathy, etc) and the ability to work with vulnerable patients. All of the participants were exposed to local therapies and local interpretations of disease symptoms and pathogenesis. CONCLUSION: The findings of this study will have a considerable effect on pedagogy. The residents' experiences of their international health rotations and what they learned in terms of medical skills and pedagogic approaches in working with patients are described. Using a collaborative approach with the rotation supervisors, the data were triangulated and the benefits of an international rotation on academic training were more accurately defined. The findings can now be used to enrich academic programs in social and preventive medicine and more adequately prepare future family physicians for work in various social and cultural settings.

Efficacy of supervised Tai Chi exercises versus conventional physical therapy exercises in fall prevention for frail older adults: a randomized controlled trial.

PURPOSE: To compare the effectiveness of supervised Tai Chi exercises versus the conventional physical therapy exercises in a personalized rehabilitation program in terms of the incidence and severity of falls in a frail older population. METHOD: The participants were frail older adults living in the community, admitted to the day hospital program in Sherbrooke, Quebec, Canada (n = 152). They were randomized to receive a 15-week intervention, either by supervised Tai Chi exercises (n = 76) or conventional physical therapy (n = 76). Fall incidence and severity were assessed using both the calendar technique and phone interviews once a month during 12 months following the end of the intervention. Other variables were collected at baseline to compare the two groups: age, comorbidity, balance, sensory interaction on balance, and self-rated health. RESULTS: Both interventions demonstrated a protective effect on falls but Tai Chi showed a greater one (RR = 0.74; 95% CI = 0.56-0.98) as compared to conventional physical therapy exercises. CONCLUSIONS: Supervised Tai Chi exercises as part of a rehabilitation program seem to be a more effective alternative to the conventional physical therapy exercises for this specific population.

The effect of supervised Tai Chi intervention compared to a physiotherapy program on fall-related clinical outcomes: a randomized clinical trial.

PURPOSE: To assess some fall-related clinical variables (balance, gait, fear of falling, functional autonomy, self-actualization and self-efficacy) that might explain the fact that supervised Tai Chi has a better impact on preventing falls compared to a conventional physiotherapy program. METHODS: The participants (152 older adults over 65 who were admitted to a geriatric day hospital program) were randomly assigned to either a supervised Tai Chi group or the usual physiotherapy. The presence of the clinical variables related to falls was evaluated before the intervention (T1), immediately after (T2), and 12 months after the end of the intervention (T3). RESULTS: Both exercise programs significantly improved fall-related outcomes but only the Tai Chi intervention group decreased the incidence of falls. For both groups, most variables followed the same pattern, i.e. showed significant improvement with the intervention between T1 and T2, and followed by a statistically significant decrease at the T3 evaluation. However, self-efficacy was the only variable that improved solely with the Tai Chi intervention (p = 0.001). CONCLUSIONS: The impact of supervised Tai Chi on fall prevention can not be explained by a differential effect on balance, gait and fear of falling. It appeared to be related to an increase of general self-efficacy, a phenomenon which is not seen in the conventional physiotherapy program.

Improving the quality of residential care using goal attainment scaling.

OBJECTIVE: To illustrate the potential of goal attainment scaling (GAS) as a means to improve the quality of care provided by residential care facilities to frail older adults. DESIGN: A pre-test/post-test single-group design. SETTINGS/PARTICIPANTS: Twenty facilities providing inadequate care to at least one resident. These facilities were identified with a case-finding questionnaire followed by a thorough investigation of the quality of care delivered to a sample of frail older adults. INTERVENTION: The 6-month intervention was conducted by three interdisciplinary teams of health professionals experienced in caring for frail older adults. The intervention was tailored to the main quality problems identified at baseline in the facility. The first task of the intervention team was to set weighted priority goals in conjunction with the facility manager. Subsequent monthly on-site visits, interspersed with frequent telephone calls, were devoted to assisting the manager and staff implement permanent changes in the areas of care targeted for improvement. MEASUREMENTS: Pre- and post-intervention GAS scores. RESULTS: Two facilities were lost to follow-up. A total of 81 facility goals were established at the onset of the study. Goals per facility ranged from 2 to 9 (mean = 4.5, SD = 2.04). GAS scores increased significantly between pre- and post-intervention (P < .001). Goal achievement varied with the manager's own rating of the quality of care provided in the facility (P = .008), his/her education level (P = .037), and the intervention team (P = .049). CONCLUSIONS: This study shows that quality improvement objectives established with the manager following a thorough evaluation of the quality of care provided in the facility can, on average, be attained with the help of experienced health professionals. It also provides some insight into the types of facilities where preset objectives are more likely to be achieved.

Using goal attainment scaling to improve the quality of long-term care: a group-randomized trial.

OBJECTIVE: To assess the effect of a 6-month interdisciplinary customized intervention based on goal attainment scaling and aimed at improving the quality of care provided by long-term care facilities to frail older adults. DESIGN: A pair-matched group-randomized trial with quality of care measurements taken before and after the intervention and 6 months later. SETTING: Forty unregulated small-to-medium sized long-term care facilities delivering inadequate care to at least one resident. Facilities were matched on baseline quality of care, health district, and size. One member of each pair was then randomly allocated to the intervention, the other acting as a control. STUDY PARTICIPANTS: The trial involved 201 frail older adults randomly selected from the 40 participating facilities. INTERVENTION: The intervention was tailored to the main quality problems identified at baseline in the facility. The first task of the intervention team was to set weighted quality improvement goals with the facility manager, which were then recorded on a goal attainment follow-up guide. Subsequent monthly on-site visits, interspersed with frequent telephone calls, were meant to assist the manager and staff to implement permanent changes in the areas of care targeted for improvement. Main outcome measure. Quality of care measured with the Quality of Care (QUALCARE) Scale, a multidimensional instrument that uses a 5-point scale to assess six subdimensions of care: environmental, physical, medical management, psychosocial, human rights, and financial. A score greater than 2 is considered indicative of inadequate care. RESULTS: The intervention effect on the overall quality of care was neither clinically nor statistically significant. Change from baseline to the end of the intervention averaged .21 and .22 in the experimental and control conditions, respectively (P = 0.86). CONCLUSION: Attainment of preset quality improvement objectives did not translate into detectable improvements in the care provided to residents.

Improving the quality of residential care using goal attainment scaling.

OBJECTIVE: To illustrate the potential of goal attainment scaling (GAS) as a means to improve the quality of care provided by residential care facilities to frail older adults. DESIGN: A pre-test/post-test single-group design. SETTINGS/PARTICIPANTS: Twenty facilities providing inadequate care to at least one resident. These facilities were identified with a case-finding questionnaire followed by a thorough investigation of the quality of care delivered to a sample of frail older adults. INTERVENTION: The 6-month intervention was conducted by three interdisciplinary teams of health professionals experienced in caring for frail older adults. The intervention was tailored to the main quality problems identified at baseline in the facility. The first task of the intervention team was to set weighted priority goals in conjunction with the facility manager. Subsequent monthly on-site visits, interspersed with frequent telephone calls, were devoted to assisting the manager and staff implement permanent changes in the areas of care targeted for improvement. MEASUREMENTS: Pre- and post-intervention GAS scores. RESULTS: Two facilities were lost to follow-up. A total of 81 facility goals were established at the onset of the study. Goals per facility ranged from 2 to 9 (mean = 4.5, SD = 2.04). GAS scores increased significantly between pre- and post-intervention (P < .001). Goal achievement varied with the manager's own rating of the quality of care provided in the facility (P = .008), his/her education level (P = .037), and the intervention team (P = .049). CONCLUSIONS: This study shows that quality improvement objectives established with the manager following a thorough evaluation of the quality of care provided in the facility can, on average, be attained with the help of experienced health professionals. It also provides some insight into the types of facilities where preset objectives are more likely to be achieved.

Geriatric day hospital: who improves the most?

This study compared the changes in some bio-psychosocial variables (functional independence, nutritional risk, pain, balance and walking, grip strength, general well-being, psychiatric profile, perception of social support, leisure satisfaction, and caregivers' feeling of burden) in four categories of clients during their program at a geriatric day hospital (GDH). The study also evaluated whether or not improvements, if any, were maintained 3 months after discharge. One-hundred-and-fifty-one people, categorized by primary reason for admission, were assessed at the GDH with reliable and valid tools, at admission and at discharge. Three months after discharge, they were reassessed with the same tools. Overall, two categories of clients, stroke / neurological diseases and musculoskeletal disorders / amputations, improved the most. For the gait disorders and falls group, only the functional independence score improved, but not at a clinically significant level. Finally, clients in the cognitive function disorders / psychopathologies group improved the most on their well-being scores and caregivers' burden decreased the most. All gains were maintained up to 3 months after discharge, except for leisure satisfaction. With the exception of clients who attended the GDH because of gait disorders and falls, the improvements and maintenance achieved in each category occurred in the domains where improvement had been hoped for, because of the particular disabilities in question and because of the nature of the GDH services offered.

Modulation of human lymphocyte proliferative response with aging.

Previously, we have demonstrated age-associated alterations in transmembrane signaling. One of the most reproducible alterations found in the immune response with aging is the decrease of lymphocyte proliferation on stimulation with various different mitogens. Here, we confirm that proliferative responses to stimulation with phytohaemagglutin (PHA), recombinant human IL-2, or anti-CD3 monoclonal antibody are all greater in the young (20-25 years) than old (60-87 years) population. We attempted to modulate the proliferative response using various agents acting at different levels of transmembrane signaling (pertussis toxin, cholera toxin, isoproterenol, PMA, Ca ionophore A23187), as well as at the level of the lymphocyte plasma membrane (methyl-beta-cyclodextrin, MBCD), or by using antioxidant vitamins (Vitamin E or C). None of these agents was able to restore effectively the proliferative response of lymphocytes from the aged to the level of young subjects. Even the combination of A23187 and PMA acting directly on calcium metabolism and protein kinase C activity was insufficient to restore the decreased mitogenic capacity of T cells from elderly subjects. Cyclodextrin, which decreases the cholesterol content of the membrane, increased the proliferative response of lymphocytes of elderly subjects, but not to the level of the young. Vitamin E had a very strong inhibitory effect on lymphocyte stimulation in both the age groups, except in combination with MBCD in T cells of the elderly, while Vitamin C had no significant modulatory effect. MAPK ERK and p38 activation was found to be decreased with aging in T cells after anti-CD3 mAb stimulation. Vitamin E but not Vitamin C strongly inhibited MAPK ERK or p38 activation. The direct activation of certain molecules or the modulation of the cholesterol content of the membrane seems to be effective immunomodulatory interventions with aging.