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Kasperski M.J.,Toronto East General Hospital | Weston W.W.,University of Western Ontario | Weston W.W.,Institute for Healthcare Communication
Canadian Family Physician | Year: 2011

Problem being addressed: Currently, dementia care provided by family physicians is suboptimal and access to specialist resources is limited. With the aging population, there is a need for system-wide, programmatic interventions to improve the diagnosis and management of patients with memory difficulties. The development of primary care memory clinics addresses this need. Objective: The Memory Clinic Training Program aims to develop highly functioning interprofessional memory clinics that assist family physicians in providing improved care for patients with dementia and other forms of cognitive impairment. Program description: The interprofessional training program consists of a 2-day case-based workshop, 1 day of observership and clinical training at the Centre for Family Medicine Memory Clinic, and 2 days of on-site mentorship at each newly formed memory clinic. Conclusion: The Memory Clinic Training Program is an accredited, comprehensive program designed to assist family practice groups with developing primary care memory clinics. These clinics aim to transform the current limited practice capability of individual family physicians into a systematic, comprehensive, interprofessional health care service that improves capacity and quality of primary care for patients with cognitive impairment and dementia.


Blackwood B.,Center for Infection and Immunity | Clarke M.,Queen's University of Belfast | McAuley D.F.,Center for Infection and Immunity | McAuley D.F.,Royal Hospitals | And 6 more authors.
American Journal of Respiratory and Critical Care Medicine | Year: 2014

Systematic reviews have considerable potential to provide evidencebased data to aid clinical decision-making. However, there is growing recognition that trials involving mechanical ventilation lack consistency in the definition and measurement of ventilation outcomes, creating difficulties in combining data for meta-analyses. To address the inconsistency in outcome definitions, international standards for trial registration and clinical trial protocols published recommendations, effectively setting the "gold standard" for reporting trial outcomes. In this Critical Care Perspective, we review the problems resulting from inconsistent outcome definitions and inconsistent reporting of outcomes (outcome sets). We present data highlighting the variability of the most commonly reported ventilation outcome definitions. Ventilation outcomes reported in trials over the last 6 years typically fall into four domains: measures of ventilator dependence; adverse outcomes;mortality; and resource use. We highlight the need, first, for agreement on outcome definitions and, second, for a minimum core outcome set for trials involving mechanical ventilation. A minimum core outcome set would not restrict trialists from measuring additional outcomes, but would overcome problems of variability in outcome selection, measurement, and reporting, thereby enhancing comparisons across trials. Copyright © 2014 by the American Thoracic Society.


Charlebois A.,University of Toronto | Charlebois A.,St Michaels Hospital | Lee L.,University of Toronto | Lee L.,St Michaels Hospital | And 4 more authors.
Journal of Viral Hepatitis | Year: 2012

While the majority of cases of hepatitis C virus (HCV) in developed countries occur among illicit drug users, HCV antiviral treatment uptake is poor in this population. Several studies have shown that patients can successfully be treated for HCV in the context of methadone maintenance programmes, but little evidence exists evaluating HCV treatment models for substance users where methadone maintenance is not indicated. This retrospective cohort study involved 129 persons participating in psycho-educational support groups and integrated, interprofessional, community-based health services focused on the treatment for HCV among marginalized populations with high rates of crack cocaine use and mental health comorbidities. We sought to identify the factors associated with antiviral treatment uptake. Group participation improved access to health care. While 19% had previously seen an HCV specialist prior to group initiation, 59% saw an HCV specialist during the group. Half of the participants were nonimmune to hepatitis A or B at baseline, and 80% of these patients received immunization through the programme. The programme treated 24 patients with pegylated interferon and ribavirin and achieved a sustained virologic response (SVR) rate of 91% for genotype 2 or 3 and 54% for genotype 1. Stable housing was independently associated with initiation of treatment, and there was a nonsignificant trend towards lower rates of treatment initiation among women. SVR rates for those who had used crack or injection drugs in the month prior to joining the programme did not differ significantly from those who had abstained. © 2012 Blackwell Publishing Ltd.


Wang T.,University of Toronto | Hsieh E.T.,University of Toronto | Hsieh E.T.,Sunnybrook Health science Center | Henry P.,University of Toronto | And 7 more authors.
Human Pathology | Year: 2014

In advanced gastric and gastroesophageal junction (GEJ) adenocarcinomas that overexpress human epidermal growth factor receptor 2 (HER2), treatment with trastuzumab confers a survival benefit. To select patients for treatment, HER2 status is evaluated by immunohistochemistry (IHC) and in situ hybridization. Gastric and GEJ adenocarcinomas demonstrate heterogeneity in HER2 expression. Nonetheless, testing is often performed on biopsies alone, which raises the issue of nonrepresentative sampling. We investigated the correlation of HER2 status between matched biopsy and resection specimens and the role of tumor heterogeneity in contributing to discrepancy. A total of 128 patients with gastric or GEJ adenocarcinoma had tissue available from a biopsy and subsequent resection. HER2 IHC was performed and evaluated by the criteria used in the Trastuzumab for Gastric Cancer clinical trial. In situ hybridization was performed if IHC was equivocal (2+) in either the biopsy or resection and in discrepant cases. Tumor heterogeneity was defined as 3+ or 2+ staining in 10% to 60% of tumor cells. Overall, HER2 was overexpressed in 18 tumors (14%), with a biopsy-resection concordance of 96.1%. Five cases were discrepant; 2 were positive on biopsy only, and 3 were positive on resection only. Tumor heterogeneity was seen in 80% of discrepant biopsies and resections, compared with 24% of concordant cases (P =.016). Our study demonstrates strong concordance between biopsy and resection specimens for HER2 overexpression in gastric cancer. Discordance was correlated with tumor heterogeneity. Overall, both biopsy and resection specimens are appropriate for HER2 testing, but generous sampling for biopsy specimens is necessary to ensure accurate assessment. © 2014 Elsevier Inc. All rights reserved.


Rose L.,University of Toronto | Rose L.,Toronto East General Hospital | Rose L.,Li Ka Shing Knowledge Institute | Dainty K.N.,Li Ka Shing Knowledge Institute | And 3 more authors.
American Journal of Critical Care | Year: 2014

Background: Weaning from mechanical ventilation is influenced by patient, clinician, and organizational factors. Objective: To identify factors that may influence weaning and adoption of weaning strategies and tools, clinicians' perceptions of weaning strategies, and weaning experiences of patients and patients' families. Method: A scoping review of indexed and nonindexed publications (1990-2012) was done. Qualitative studies of health care providers, patients, and patients' families involved in weaning were included. Two investigators independently screened 8350 publications and extracted data from 43 studies. Study themes were content analyzed to identify common categories and themes within the categories. Results: The study sample consisted of nurses in 15 studies, nurses and patients in 1 study, various health care providers in 11, patients in 10, and physicians in 4. Categories identified were as follows: for nurses, role or scope of practice, informing decision making, and influence on weaning outcome; for health care providers, factors influencing weaning decisions or use of protocols, role or scope of practice related to weaning, and organizational structure or practice environment; for patients, experience of mechanical ventilation and weaning, experience of the intensive care environment, psychological phenomena, and enabling success in weaning; and for physicians, tools or factors to facilitate weaning decisions and perceptions of nurses' role and scope of practice. Conclusions: Important issues identified were perceived importance of interprofessional collaboration and communication, need to combine subjective knowledge of the patient with objective clinical data, balancing of weaning systematization with individual needs, and appreciation of the physical and psychological work of weaning. © 2014 American Association of Critical-Care Nurses.


Zia M.I.,Schulich Heart Center | Zia M.I.,Toronto East General Hospital | Ghugre N.R.,Schulich Heart Center | Connelly K.A.,Li Ka Shing Knowledge Institute | And 5 more authors.
Circulation: Cardiovascular Imaging | Year: 2012

Background-Accurate characterization of the longitudinal trends of myocardial edema and hemorrhage has been previously limited by subjective qualitative methods. We aimed to prospectively characterize the evolution of myocardial edema and hemorrhage post acute myocardial infarction using quantitative measures. Methods and Results-Sixty-two patients were enrolled post primary percutaneous coronary intervention and underwent cardiovascular magnetic resonance on a 1.5-T scanner at 48 hours, 3 weeks, and 6 months. Myocardial edema and hemorrhage were assessed by T2 and T2* mapping, respectively, in both infarct segment (IS) and remote segment (RS). At 48 hours, T2 is higher in IS compared with RS (56.7 ms versus 43.4 ms; P <0.01). At 3 weeks T2 remains higher in IS compared with RS (51.8 ms versus 39.5 ms; P <0.01), and subsequently equalizes by 6 months (39.8 ms versus 39.5 ms; P=nonsignificant). T2 is also increased in RS at day 2 versus 3 weeks (43.4 ms versus 39.5 ms; P <0.01). At 48 hours T2* was reduced in IS compared with RS (32.4 ms versus 37.4 ms; P <0.01). At 3 weeks (IS, 37.7 ms versus RS, 38.4 ms; P=nonsignificant) and 6 months (IS, 37.3 ms versus RS, 38.2 ms; P=nonsignificant), T2* values were equal in both segments. Conclusions-Quantification of myocardial edema and hemorrhage by T2 and T2* mapping is feasible post acute myocardial infarction and demonstrates that hemorrhage resolves faster than edema. Noninfarcted segments can also demonstrate edema in the acute phase possibly due to global hyperemia. © 2012 American Heart Association, Inc.


Dimitropoulos G.,University of Toronto | Tran A.F.,University of Toronto | Agarwal P.,Toronto East General Hospital | Sheffield B.,Vancouver General Hospital | Woodside B.,University of Toronto
International Journal of Eating Disorders | Year: 2012

Objective: This study aims to conduct qualitative research on the perspectives of service providers regarding the transition process from pediatric to adult specialized eating disorder tertiary care programs. Method: Two focus groups with a diverse group of clinicians in pediatric and adult eating disorder programs and five qualitative interviews with clinicians in the community were conducted. Results: Three themes were identified as challenges during the transition process: (1) illness related factors (ambivalence and denial); (2) the interruption of normative adolescent developmental processes by the illness; and, (3) the impact of decreased parental involvement in the adult compared to pediatric eating disorder programs. Discussion: These themes were compared with empirical evidence on other chronic mental or physical health concerns for the purpose of identifying ways to facilitate a more successful service transition for young adults with anorexia nervosa. Future research and clinical implications are delineated. © 2011 by Wiley Periodicals, Inc.


Wright S.,Toronto East General Hospital | Wright S.,Center for Ambulatory Care Education
Advances in Health Sciences Education | Year: 2015

Students from state schools are underrepresented in UK medical schools. Discussions often focus on deficient academic and motivational traits of state school students, rather than considering the effects of student support during the admissions process. This qualitative study explored student experiences of support from schools and families during the medical school admissions process with particular focus on the personal statement. Interviews were conducted with thirteen medical students at a British medical school who had each attended a different secondary school (classified as private or state funded). A thematic analysis was performed. Bourdieu’s concepts of capital and field were used as a theoretical lens through which to view the results. Interviews revealed substantial differences in support provided by private and state funded schools. Private schools had much more experience in the field of medical school admissions and had a vested interest in providing students with support. State schools were lacking by comparison, offering limited support that was often reactive rather than proactive. Students from private schools were also more likely to have social contacts who were knowledgeable about medical school admissions and who could help them gain access to work experience opportunities that would be recognised as legitimate by selectors. While medical schools endeavour to make fair admissions policies, there is an unintended link between a student’s access to capital and ability to demonstrate commitment and motivation on personal statements. This helps explain why academically capable but financially or socially challenged students are less likely to be recognised as having potential during the admissions process. Medical schools need to be challenged to review their admissions policies to ensure that the do not inadvertently favour cultural privilege rather than student potential. © 2014, Springer Science+Business Media Dordrecht.


Newman D.E.,Toronto East General Hospital
Rural and remote health | Year: 2010

The Department of Loreto, one of the poorest regions of Peru, has an insufficient number of physicians, particularly specialists, needed to provide adequate health care for its population. The majority of Loreto physicians are GPs who have completed a one-year internship after medical school, followed by a mandatory year of rural service, with no subsequent training. Currently there are no residency training programs available in Loreto. The Loreto Ministry of Health recognizes the value in retaining its own medical school graduates and is, therefore, considering building residency programs in the 4 'basic specialties': internal medicine, pediatrics, general surgery, and obstetrics/gynecology. The objectives of this study were to: (1) characterize the population of currently practicing GPs in Iquitos and Requena in terms of demographics, current medical practice, and educational goals; (2) determine the obstacles faced by general physicians in Loreto, Peru in pursuing residency training; (3) provide baseline information to be used by medical academic institutions to develop specialization programs in Loreto. A survey of 55 questions was created in Spanish encompassing demographics, current medical practice, education, training, and professional goals. Of the total 416 GPs in Loreto, 55 were identified in 2 locations: Iquitos and Requena. The goal was to administer the survey to each of these 55 physicians. Consent was given verbally, and 49 surveys were self-administered. Survey responses were translated into English, data were entered in EpiData and analyzed using SPSS software (SPSS Inc; Chicago, IL, USA). A total of 49 surveys were completed by GPs in Iquitos and Requena. Of the respondents, 84% were male, the majority were either married or in common-law relationships, with at least one child. Their average age was 37.6 years. Sixty-five percent were born in Loreto and most currently lived in Iquitos. Almost all respondents reported that they intended to pursue further training, the majority (59%) intending to pursue residency. Of those intending to complete a residency in the future, 40% specified a desired specialty from among the basic four, 22% a more specialized residency, and 37% did not specify any. The location of training sites, cost of moving to and living in Lima, and/or personal or family reasons were each identified by approximately 50% of respondents as obstacles to their pursuit of residency. Less common obstacles were: not passing the entrance exam, lack of job stability, and not knowing English. Fifty percent of the respondents only identified one obstacle, while 35% identified two and 15% identified three. Cost and location were the most significant factors preventing physicians from pursuing residency; overall, 83% of the physicians surveyed identified one or both of these as a factor that prevented them from pursuing residency. This suggests that there would be interest among the local physician population in residency programs established in Loreto.


Kell J.S.,Toronto East General Hospital
The Canadian journal of urology | Year: 2010

Prostate cancer is a highly prevalent malignancy. Using serum prostatic-specific antigen (PSA) levels to screen for prostate cancer has led to a greater detection of this cancer, at earlier stages. However, screening for prostate cancer by determining PSA levels remains controversial. Concerns include the risk of overdiagnosis and conversely, the failure to detect all prostate cancers. This article, aimed at primary care practitioners, reviews the characteristics of an ideal screening test, in relation to the characteristics of the PSA test. It then discusses the implications of recent findings from two large, randomized, prospective screening trials: the American Prostate, Lung, Colorectal and Ovarian Cancer (PLCO) screening trial and the European Randomized Study of Screening for Prostate Cancer (ERSPC) trial. The latter trial demonstrated a modest survival benefit from PSA screening. Lastly, the article summarizes recommendations from recently updated guidelines about PSA testing from the American Urological Association (AUA), and it discusses when a primary care practitioner might refer a patient to a urologist.

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