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1.  A brief tool to assess capacity to consent for medical care among homeless individuals with problematic substance use: study protocol 
Archives of Public Health  2013;71(1):11.
Background
Public health care increasingly uses outreach models to engage individuals who are marginalized, many of whom misuse substances. Problematic substance use, together with marginalization from the health care system, among homeless adults makes it difficult to assess their capacity to consent to medical care. Tools have been developed to assess capacity to consent; however, these tools are lengthy and unsuitable for outreach settings. The primary objective of this study is to develop, validate, and pilot a brief but sensitive screening instrument which can be used to guide clinicians in assessing capacity to consent in outreach settings. The goal of this paper is to outline the protocol for the development of such a tool.
Methods/Design
A brief assessment tool will be developed and compared to the MacArthur Competency Assessment Tool for Treatment (MacCAT-T). As list of 36 possible questions will be created by using qualitative data from clinician interviews, as well as concepts from the literature. This list will be rated by content experts according to the extent that it corresponds to the test objectives. The instrument will be validated with 300 homeless adult volunteers who self-report problematic substance use. Participants will be assessed for capacity using the MacCAT-T and the new instrument. A combination of Classical Test Theory and advanced psychometric methods will be used for the psychometric analysis. Corrected Item-Total correlation will be examined to identify items that discriminate poorly. Guided exploratory factor analysis will be conducted on the final selection of items to confirm the assumptions for a unidimensional polytomous Rasch model. If unidimensionality is confirmed, an unstandardized Cronbach Alpha will be calculated. If multi-dimensionality is detected, a multidimensional Rasch analysis will be conducted. Results from the new instrument will be compared to the total score from the MacCAT-T by using Pearson’s correlation test. The new instrument will then be piloted in real-time by street outreach clinicians to determine the acceptability and usefulness of the new instrument.
Discussion
This research will build on the existing knowledge about assessing capacity to consent and will contribute new knowledge about assessing individuals whose judgment is impaired by substance use.
doi:10.1186/0778-7367-71-11
PMCID: PMC3651044  PMID: 23651056
Capacity to consent; Substance use; Psychometric instruments; Vulnerable populations
2.  The use of thoracoscopy to enhance medical students’ interest and understanding of thoracic anatomy 
Annals of Thoracic Medicine  2012;7(3):145-148.
AIM:
To develop a video-based educational tool designed for teaching thoracic anatomy and to examine whether this tool would increase students’ stimulation and motivation for learning anatomy.
METHODS:
Our video-based tool was developed by recording different thoracoscopic procedures focusing on intraoperative live thoracic anatomy. The tool was then integrated into a pre-existing program for first year medical students (n = 150), and included cadaver dissection of the thorax and review of clinical problem scenarios of the respiratory system. Students were guided through a viewing of the videotape that demonstrated live anatomy of the thorax (15 minutes) and then asked to complete a 5-point Likert-type questionnaire assessing the video's usefulness. Apart from this, a small group of entirely different set of students was divided into two groups, one group to view the 15-minute video presentation of thoracoscopy and chest anatomy and the other group to attend a 15-minute lecture of chest anatomy using radiological images. Both groups took a 10-item pretest and post-test multiple choice questions examination to assess short-term knowledge gained.
RESULTS:
Of 150 medical students, 119 completed the questionnaires, 88.6% were satisfied with the thoracoscopic video as a teaching tool, 86.4% were satisfied with the quality of the images, 69.2% perceived it to be beneficial in learning anatomy, 96.2% increased their interest in learning anatomy, and 88.5% wanted this new teaching tool to be implemented to the curriculum. Majority (80.7%) of the students increased their interest in surgery as a future career. Post-test scores were significantly higher in the thoracoscopy group (P = 0.0175).
CONCLUSION:
Incorporating live surgery using thoracoscopic video presentation in the gross anatomy teaching curriculum had high acceptance and satisfaction scores from first year medical students. The video increased students’ interest in learning, in clinically applying anatomic fact, and in surgery as a future career.
doi:10.4103/1817-1737.98847
PMCID: PMC3425046  PMID: 22924072
Medical students; thoracic anatomy; thoracoscopy
3.  Strategic faculty recruitment increases research productivity within an academic university division 
Canadian Journal of Surgery  2009;52(5):401-406.
Background
Research is an important mandate for academic surgical divisions. However, there is widespread concern that the current health care climate is leading to a decline in research activity. A University of British Columbia (UBC) academic surgical division attempted to address this concern by strategically recruiting PhD research scientists to prioritize research and develop collaborative research programs. The objective of our study was to determine whether this strategy resulted in increased research productivity.
Methods
We reviewed the UBC Department of Surgery database to assess research funding obtained by the Division of General Surgery for the years 1994–2004. We searched MEDLINE for peer-reviewed publications by faculty members during this period.
Results
Research funding increased from a mean of Can$417 292 per year in the 5 years (1994/95–1998/99) before the recruitment of dedicated PhD scientists to a mean of Can$1.3 million per year in the 5 years following the recruitment strategy (1999/2000–2003/04; p = 0.012). Funding for the initial 5 years was Can$2.1 million, including 1 Canadian Institutes of Health Research (CIHR) grant. Funding increased to Can$6.8 million, including 22 CIHR grants over the subsequent 5 years (p < 0.001). Collaborative research led to the awarding of multidisciplinary grants exceeding Can$4 million with divisional members as principle or coprinciple investigators. From 1994/05 to 1998/99, the total number of peer-reviewed publications was 116 (mean 23.2, standard deviation [SD] 7 per year), increasing to 144 from 1999/2000 to 2003/04 (mean 28.8, SD 13 per year). The trend was for publications in journals with higher impact factors in the latter 5-year period.
Conclusion
Strategic recruitment resulted in increased and sustained research productivity. Interactions between research scientists and clinicians resulted in successful program grant funding support. These results have implications for sustaining the research mission within academic departments of surgery.
PMCID: PMC2769093  PMID: 19865575
4.  Empyema: An increasing concern in Canada 
BACKGROUND:
Empyema is a suppurative infection of the pleural space. Without prompt treatment, it can result in significant hospital stays, more invasive treatments as it progresses, and substantial morbidity and mortality.
OBJECTIVES:
The primary objective of the present study was to evaluate whether there has been an increasing incidence of empyema in Canada. A secondary objective was to investigate whether this increase disproportionately affects any age group.
METHODS:
The Discharge Abstract Database of the Canadian Institute for Health Information was used to evaluate national empyema data.
RESULTS:
There were 11,294 patients identified with empyema over the nine-year period of the present study, of whom 31% were women. The mean (± SD) length of stay was stable throughout the study at 21.82±33.88 days, and 63.4% were discharged home. The incidence rate ratio (IRR) was defined as the ratio of the incidence rate of medical empyema in 2003 divided by the incidence rate in 1995. Medical empyema increased significantly (IRR 1.30, 95% CI 1.20 to 1.41; P<0.001), as did empyema of unknown cause (IRR 1.29, 95% CI 1.08 to 1.54; P=0.005), while surgical empyema did not appear to increase (IRR 1.17, 95% CI 0.97 to 1.43; P=0.114). A Poisson regression showed an increase in the indirect age-standardized IRR during the study period (IRR 1.025, 95% CI 1.018 to 1.032; P<0.001). The IRR for patients younger than 19 years of age from 1995 to 2003 was 2.20 (95% CI 1.56 to 3.10), while the IRR in patients older than 19 years was 1.23 (95% CI 1.14 to 1.34).
CONCLUSIONS:
The present study demonstrates the increasing rate of empyema in Canada and shows a change in pattern of disease. The disproportionate rate change in the pediatric population suggests a high-risk group that needs to be addressed. In the adult population, while cause is unknown, it is necessary to continually educate front-line physicians to confront both the increased burden of this disease, caused by an aging population, and the underlying increasing rate of empyema in Canada.
PMCID: PMC2677840  PMID: 18354748
Empyema; Infection; Parapneumonic effusion; Pleural effusion
5.  The demographics of significant firearm injury in Canadian trauma centres and the associated predictors of inhospital mortality 
Canadian Journal of Surgery  2008;51(3):197-203.
Objective
Our primary objective was to evaluate demographic and causal factors of inhospital mortality for significant firearm-related injuries (i.e., those with an Injury Severity Score [ISS] > 12) in Canadian trauma centres.
Methods
We analyzed data submitted to the Canadian Institute for Health Information (CIHI) in the National Trauma Registry for all firearm-injured patients for fiscal years 1999–2003. Univariate and bivariate adjusting for ISS and multivariate logistic regression were performed.
Results
Men accounted for 94% of the 784 injured. In all patients, the percentages of self-inflicted, intentional, unintentional and unknown injuries were 27.8%, 60.3%, 6.1% and 5.7%, respectively. The inhospital fatality rate was 39.8%, with 83% of fatalities occurring on the first day. Two-thirds of patients were discharged home. Univariate and adjusted analysis found that ISS, first systolic blood pressure (BP), first systolic BP under 100, first Glasgow Coma Scale (GCS) score, age over 45 years, self-inflicted injury, intentional injury and injury at home significantly worsened the odds ratio of death in hospital and that police shooting was relatively beneficial. BP under 100, age over 45 years and a low GCS score had an adjusted odds ratio of death of 4.12, 1.99 and 0.64 per point increase, respectively. The multivariate model showed that ISS, BP under 100, first GCS score, sex and self-inflicted injury were significant in predicting inhospital death.
Conclusion
A predominance of young men are injured intentionally with handguns in Canada, whereas older patients suffer self-inflicted injuries with long guns. The significant number of firearm deaths, largely in the first day, highlights the importance of preventative strategies and the need for rapid transport of patients to trauma centres for urgent care.
PMCID: PMC2496605  PMID: 18682765
6.  The practice of thoracic surgery in Canada 
Canadian Journal of Surgery  2004;47(6):438-445.
The objective of the consensus conference of the Canadian Association of Thoracic Surgeons (CATS) was to define the scope of thoracic surgery practice in Canada, to develop standards of practice, to define training and resource requirements for the practice of thoracic surgery in Canada and to determine appropriate waiting times for thoracic surgery care. A meeting of the CATS membership was held in September 2001 to address issues facing thoracic surgeons practising in Canada. The discussion was facilitated by an expert panel of surgeons and supplemented by a survey. At the end of the meeting, consensus was reached by the membership regarding the issues outline above.
The membership agreed that the scope of practice includes diagnosis and management of conditions of the lungs, mediastinum, pleura and foregut. They agreed that appropriate training in thoracic surgery included completion and certification in general or cardiac surgery prior to completing a 2-year program in thoracic surgery. The membership supported the Canadian Society of Surgical Oncology recommendations for management of cancer patients that new patients should be seen within 2 weeks of referral and cancer therapy initiated within 2 weeks of consultation. Thoracic surgical care is best delivered by 2 or 3 fully certified thoracic surgeons, in regional centres linked to a cancer centre and trauma unit. The establishment of a critical mass of thoracic surgeons in each centre would lead to improved quality and delivery of care and allow for adequate coverage for on-call and continuing medical education.
PMCID: PMC3211597  PMID: 15646443
7.  The effect of clinical academic service contracts on surgeon satisfaction 
Canadian Journal of Surgery  2007;50(3):175-180.
Objective
The purpose of this study was to determine the satisfaction of members of an academic department who are funded by a Clinical Academic Service Contract (CASC), compared with those who are not.
Methods
We mailed a satisfaction questionnaire designed to examine surgeons' perceived effect of CASCs on their participation in their division or department and on professional activities (research, teaching, clinical) to members of the surgery department who perform operative interventions. We analyzed responses from CASC and non-CASC members, using t tests for continuous variables and chi-square tests for categorical variables.
Results
Four of 9 operative divisions (cardiac, thoracic, neurosurgery, pediatric surgery) are CASC-funded, and 5 are not (general, plastic, otolaryngology, urology, vascular). The response rate after 3 mailings was 59%. CASC responders agreed on the need for the following: improved focus and resolution of issues (p < 0.001, p < 0.02); focus on developmental and future planning (p < 0.001); flexibility to change the level of participation in research, teaching and clinical activities (p < 0.001); recognition for academic and administrative activities (p < 0.002); opportunities to achieve career path goals (p < 0.002); more autonomy in research (p < 0.04); compensation for professional activities (p < 0.001); and increased leisure time (p < 0.004). Responders disagreed that morale was low (p < 0.001). They were satisfied with the following: professional activities (p < 0.019), increased research activities (p < 0.001), quality of research (p < 0.001), more presentations (p < 0.025), increased teaching time (p < 0.004) and ability to care for their patients (p < 0.001).
Conclusion
CASC responders were significantly more satisfied with their professional activities and more optimistic in their divisional roles than were non-CASC responders. Based on these results, all departmental members who perform operative interventions should consider being on a CASC.
PMCID: PMC2384291  PMID: 17568488

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