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Background. Overuse of opioids has become a health crisis in the United States and Canada. Opioid prescribing practices have subsequently come under scrutiny, with limited study regarding prescribing patterns of dentists. Methods. A longitudinal analysis was conducted on all adult patients to whom an opioid was dispensed from 2014 through 2017 in Manitoba, Canada. Rates of dental opioid prescribing, milligram morphine equivalents (MMEs) per prescription, and guideline adherence were determined. Additional analyses evaluated the contribution of dentist prescribing to first opioid use and opioid use 90 days before and after first dental opioid prescription. Results. Dentist prescriptions accounted for 3.8% of all opioid prescriptions and 0.58% of total MMEs. Codeine with acetaminophen combinations were the primary opioid prescribed (97.4%), followed by tramadol/acetaminophen (1.7%) and oxycodone with acetaminophen (0.7%). Overall, 30 or less tablets were supplied in 96.1% of prescriptions. Prescriptions were written for 5 or less days in 89.1% of cases and for 7 or less days in 95.2% of cases. In the 90-day before-after analysis, 87.8% of patients received only 1 prescription from their dentist, with an additional 9.8% receiving only 2 prescriptions. Dentists were responsible for 20.6% of first opioid prescriptions, with 5.6% written for 50 or more MMEs per day. Conclusions. Compared with available guidelines, prescribed quantities were mostly appropriate, suggesting that the overall contribution of dentists to opioid overuse is limited. Practical Implications. Dental opioid stewardship can be encouraged through an enhanced regulatory monitoring program with local review to guide efforts to further improve opioid prescribing. Continued efforts are warranted to prescribe smaller quantities and for greater avoidance of opioid use for dental pain. [ABSTRACT FROM AUTHOR]

Introduction: No common or widely accepted criteria exist for physician review of blood films or for reported standards of physician rate of blood film review. Individual institutions generally have internal criteria for physician review of blood films. To better understand how and why blood film reviews are performed at different institutions across Canada, with a specific interest in physician blood film review, we undertook a survey to assess the current practise patterns of physician review of blood films across Canada. Methods: A 15 question survey was developed and sent to 24 academic, large community and corporate laboratories across Canada by e‐mail to laboratory directors of those institutions. Centres were chosen to include all provinces in Canada and most of the major academic centres. Twenty of the 24 centres responded. Results: The mean rate of physician review of blood films as a percentage of all CBCs processed per day was 4.1% (range 0.35%‐13%) and of all blood films made per day was 28.8% (range 1.9%‐66.5%). Data on factors which might affect physician review rates, physician preferences regarding what percentage of physician blood film review rates is reasonable and physician perspectives on the role of physician blood film review are discussed. Conclusion: This survey reveals that there is varying practise patterns and opinions with respect to blood film review by physicians in Canada. [ABSTRACT FROM AUTHOR]

An increase in physical activity has been shown to improve outcomes in many diseases. An estimated 600 000 Canadians receive their primary health care from emergency departments (ED). This study aims to examine physical activity prescription by emergency medicine physicians (EPs) to determine factors that influence decisions to prescribe physical activity. A survey was distributed to EPs via email using the Canadian Association of Emergency Physicians (CAEP) survey distribution protocol. Responses from 20% (n = 332) of emergency physician/residents in Canada were analyzed. Of the EPs, 62.7% often/always counsel patients about preventative medicine (smoking, diet, and alcohol). Only 12.7% (42) often/always prescribe physical activity. The CCFP-trained physicians (College of Family Physicians Canada) were significantly more likely to feel comfortable than CCFP-EM–trained physicians (Family Physicians with Enhanced Skills in Emergency Medicine) prescribing physical activity (p = 0.0001). Both were significantly more likely than the FRCPC-trained EPs (Fellows of the Royal College of Physicians of Canada). Of the EPs, 73.4% (244) believe the ED environment does not allow adequate time for physical activity prescription. Family medicine-trained EPs are more likely to prescribe physical activity; the training they receive may better educate them compared with FRCPC-trained emergency medicine. Further education is required to standardize an approach to ED physical activity prescription. [ABSTRACT FROM AUTHOR]

Sexual and reproductive health is an important component of comprehensive health care for youth. This statement provides guidance for selecting and prescribing contraceptives for youth, including commonly prescribed hormonal contraceptives—the pill, patch, ring and injectable progestin—and long-acting reversible contraceptives (LARCs). LARCs, including subdermal implants (which are not available in Canada) and intrauterine contraceptives (IUCs), are substantially more effective during typical use than hormonal contraceptives. This statement endorses LARCs as the first-line option for contraception for Canadian youth, while emphasizing that providers must collaborate with youth to select a contraceptive method that is acceptable, safe, effective and practical for them. Strategies that eliminate obstacles to initiating and continuing contraception are provided. [ABSTRACT FROM AUTHOR]

An editorial is presented which argues against the antibiotic coverage thresholds that clinicians are willing to accept for the treatment of patients with sepsis of varying disease severity. Topics include the mechanisms explaining poorer clinical outcomes infection occurs due to antibiotic resistant bacteria; and antibiotic resistance and rapid evolution have made efforts to insure the delivery of appropriate therapy.

The article offers information on the efforts for improving paediatric medications for Canadian children and youth. It discusses the policies governing the development, approval and reimbursement of medicines for adult populations; discussions on the need for process redesign for regulatory and reimbursement systems; and the information on the need to expand commercial access for child-friendly formulations.

Background: Healthcare professionals involved in pain management come from different disciplines, which may have different perspectives and training about evidence-based practice (EBP). A common concern for health professionals is pain management. Understanding how different professions involved in pain management view EBP forms the ideal context to study professional differences in EPP, and how this might influence pain management. Purpose: The purpose of this study was to compare different professions with respect to knowledge, attitudes and self-reported behavior toward EBP. Study design: Cross-sectional study. Methods: Physicians, nurses, occupational therapists, physical therapists and psychologists who were involved in pain management (n=675) completed an online survey on a single occasion. The survey included demographic questions and the EBP-knowledge, attitude, behavior questionnaire (EBP-KABQ). This is a 27-item questionnaire that has been validated for use with different health professionals, and measures four constructs related to EBP (knowledge, attitude, behavior and outcome/decision). Differences between professionals were identified using a one-way between groups analysis of variance, with post-hoc testing (statistical significance was set at P value less than 0.05; clinical significance set at a mean difference of 10%). Results: The score on three of the four subscales of the KABQ were statistically different across professions. In general, knowledge scores were high for all professions (83-87%). Nurses demonstrated statistically higher levels of EBP knowledge (87%) when compared with other groups (F=4.79, P=0.001), but the differences were not deemed clinically relevant. Behavior was the lowest subscale and the most variable across professions (37-56%). Physicians had statistically significant (F=25.69; P=0.001), and clinically relevant, higher behavior subscale scores (56%) when compared with other professional groups. Physicians (73%) also had higher outcome/decision subscale scores (F=6.50; P=0.001), but this was only marginally different from other professions (65-73%). The attitude subscale scores were low and were not different across professions (range 57-59%; F=1.65, P=0.16; NS). Conclusion: The current study indicates that physicians and allied health professionals have similar EBP attitudes and knowledge. All professional groups seem to have suboptimal implementation of EBP. The nature of medical decision-making, its evidentiary pool, or longer experience with EBP may contribute to greater implementation amongst physicians. [ABSTRACT FROM AUTHOR]

Little information exists about the patterns of practice of athletic training and therapy (ATT) professionals in different countries. The purpose of this study is to examine similarities in the patterns of practice of ATT professionals in three Mutual Recognition Agreement (MRA) countries--the United States, Canada, and Ireland. We compared the practice frequency of 24 ATT tasks performed by ATT professionals in these countries. Only two tasks, involving emergency care and patient education, were carried out differently in the United States and Canada. Our results therefore suggest that patterns of practice are very similar among ATT professionals in these countries. [ABSTRACT FROM AUTHOR]

Background: Methadone maintenance treatment is an effective way to reduce harms associated with opioid use disorder and, in several countries, is delivered in community-based primary care settings. Expanding methadone into primary care depends, in part, on physicians' willingness and readiness to integrate it into their practices. Objectives: This qualitative study explores factors that primary care physicians consider important when contemplating prescribing methadone to treat opioid use disorder. Methods: In-depth interviews were conducted during 2015 with 20 primary care physicians in various sized communities throughout Nova Scotia, Canada. Participants shared their views and experiences related to prescribing methadone to treat opioid use disorder. Data were analyzed inductively using thematic analysis to identify predominant themes. Results: Participants discussed an interplay of factors as they contemplated prescribing methadone to treat opioid use disorder in primary care. Physician-related factors included access to methadone expertise, support from allied professionals, suitability of skills, and personal experiences. Patient-related factors involved perceptions about methadone users as a difficult patient group with highly complex needs. Practice-related factors encompassed concerns about threats to physicians' careers, surveillance duties, unfair remuneration, safety risks, and practice disruptions. Contextual factors included knowledge deficits about substance use disorders, the generalist nature of primary care, methadone's socio-political context, and opioid prescribing patterns in primary care. Conclusions: Understanding the perspectives of physicians is vital to expanding methadone into primary care. This study identifies factors that should be addressed to attract, support, and retain primary care physicians in prescribing methadone to treat opioid use disorder. [ABSTRACT FROM AUTHOR]

Background: Empirical prescribing of antibiotics to women with symptoms of acute cystitis prior to culture results is common, but subsequent culture results are often negative. A clinical decision aid for prescribing decisions in acute cystitis was previously developed that could reduce these unnecessary antibiotic prescriptions but has not been validated. This study sought to validate this decision aid for empirical antibiotic prescribing decisions in a new cohort of women with suspected acute cystitis. Methods: External validation study of a clinical decision aid in 397 women with symptoms of acute cystitis, involving 230 Canadian family practitioners across Canada between 2009 and 2011. The sensitivity and specificity of the decision aid compared to a gold standard positive urine culture (defined as ≥10² cfu/ml (≥105 CFU/L)) was determined, and compared with physician management, and the earlier development cohort study estimates. Other outcomes assessed were total antibiotic prescriptions, unnecessary antibiotics for negative urine cultures, and recommendations for urine culture testing. Chi-square tests were used for unpaired comparisons, adjusted for physician clustering. McNemar's test was used for paired comparisons. Results: There were 245/397 (61.7%) positive urine cultures. The cystitis aid sensitivity was 202/245 (82.5%, 95% Confidence Interval (CI)) = 77.1%, 86.8%), compared to 167/208 (80.3%) in the previous development cohort (p = 0.54), and 239/245 (97.6%) by family physicians in the current study (p < 0.001). Specificity was low for physicians (10/152, 6.6%) compared to the decision aid (54/152, 35.5%; p < 0.001, resulting in more antibiotic prescriptions by physicians (381/397, 96.0%) than would occur with decision aid recommendations (300/397, 75.6%, p < 0.001). Unnecessary antibiotic prescriptions where urine cultures were negative would be reduced an absolute 11.1% with cystitis aid recommendations (98/397, 24.7%) compared to usual physician care (142/397, 35.8%; p = 0.001). Urine cultures would also be reduced (97/397, 24.4% decision aid vs 351/397, 88.4% physicians; p < 0.001). Conclusions: A 3-item clinical decision aid demonstrated reproducible accuracy in two cohorts of women with acute cystitis symptoms. Clinically important reductions in total and unnecessary antibiotic use, as well as urine culture testing, could result with routine clinical use compared to current empirical physician management practices. [ABSTRACT FROM AUTHOR]

The aim of this study was to assess whether the Harris Hip Score (HHS) and the Oxford Hip Score (OHS) were comparable in normal, healthy, pathology-free individuals of different age, gender, ethnicity, handedness and nationality. The purpose of this study was to establish normal population values for the HHS and OHS using an electronic data collection system.~Background~Background~317 Australian and 310 Canadian citizens with no active hip pain, injury or pathology in the ipsilateral hip corresponding to their dominant arm, were evaluated. Participants completed an electronically-administered questionnaire and were assessed clinically. Chi-square tests, Fisher's exact test and Poisson regression models were used where appropriate, to investigate the association between hip scores, ethnicity, nationality, gender, handedness and age.~Methods~Methods~There was a statistically significant association between the OHS and age (p<0.0001) and the HHS and age (p = 0.0006); demonstrating that as age increased, normal hip scores decreased. There was no statistically significant association between the HHS and gender (p = 0.1389); or HSS and nationality, adjusting for age (p = 0.5698) and adjusting for gender (p = 0.6997). There was no statistically significant association between the OHS and gender (p = 0.1350). Australians reported a statistically significant 4.2% higher overall OHS value compared to Canadians (p = 0.0490). There was no statistically significant association between the OHS and nationality in age groups 18-79 years. Participants >80 years reported a statistically significant association between the OHS and nationality (p<0.0001).~Results~Results~Studies using an electronic control group should consider differences in gender, age, ethnicity and nationality when using the HHS and OHS to assess patient outcomes. This study has established an electronic, normal control group for studies using the HHS and OHS. When using the OHS, the control group should be sourced from the same country of origin. When using the HHS, the control group should be sourced from a pre-established control group within a database, without necessarily being sourced from the same country of origin.~Conclusions~Conclusions [ABSTRACT FROM AUTHOR]

Objective:There has been much attention on appropriate prescribing in older adults in recent years. Recent guidelines favor the use of newer antidepressants over older agents based on their safety profile in this population. This study aimed to examine whether there has been a decline in older antidepressants and an increase in newer antidepressants used by older adults. Method:A retrospective cross-sectional study using administrative databases examined the annual incidence of antidepressant use (per 1000) of community-dwelling adults ≥60 years old between 1997/1998 and 2012/2013 in Manitoba, Canada. Results:The population of Manitoba ≥60 years increased by 25.6% from 188,296 to 236,569 from 1997/1998 to 2012/2013. New antidepressant use peaked to 45.9 per 1000 in 1999/2000, and then decreased steadily to 30.5 per 1000 in 2012/2013 (p< 0.0001). Incident amitriptyline use was high but declined from 15.5 to 7.4 per 1000 (p< 0.001). An increase in incident trazodone, mirtazapine, and venlafaxine use was observed (p< 0.001). Conclusions:There has been an overall decrease in the annual incidence of antidepressant users in older adults over the last 16 years, with a marked decline in new amitriptyline use and an increase in the incidence of newer agents. [ABSTRACT FROM AUTHOR]

Objective. Access to pregabalin via Ontario's public drug insurance program was expanded to an unrestricted model on April 1, 2013, from a prior authorization model. This study aims to identify the effect of expanded access on the rate of pregabalin use by publicly insured persons and to assess the characteristics of new patients initiating pregabalin following this expanded access. Methods. We conducted a cross-sectional time series analysis using the linked health administrative records of residents of Ontario, Canada, with public drug coverage who were dispensed a prescription for pregabalin between April 1, 2006, and December 31, 2014. Results. A total of 108,047 publicly insured persons were dispensed pregabalin over the study period. The overall rate of pregabalin use increased from 1.0 per 1,000 individuals in Q1 of 2013 to 22.0 per 1,000 individuals in Q4 of 2014. Musculoskeletal (81.6%) and neurological (68.1%) conditions were the most prevalent diagnoses in patients who initiated pregabalin following the expansion of access. Past and concomitant use of opioids, nonsteroidal anti-inflammatory drugs, and antidepressants was also common in this population. Conclusions. Formulary changes in Ontario have led to expanded access to pregabalin, which may have led to an increase in off-label use of these products and potential patient risk associated with concomitant use of pregabalin with central nervous system-depressing drugs. [ABSTRACT FROM AUTHOR]

The unilateral withholding and withdrawal of potentially life-sustaining treatment presents a complex issue of law and public policy. The authors examine the current state of this practice and conclude that it is occurring, being challenged in the courts, and is treated differently in different jurisdictions. The authors review the current state of the law in the United Kingdom, Australia, New Zealand, the United States, and Canada. The authors use Canada as a case study to outline a process for pursuing law reform. The authors propose a model for law and policy reform in this area that is both informed and shaped by the fundamental values of Canadian society. [ABSTRACT FROM AUTHOR]

Medical tourism, growing worldwide, includes Canadians coming to the United States for medical treatment. For U.S. healthcare providers to take advantage of the potential economic benefits of cash-paying Canadian medical tourists, they must comply with U.S. federal and state laws governing fraud and abuse, including the federal Stark Law and Anti-Kickback Statute (AKS), and state-level analogs. These laws may restrict the ability of U.S. healthcare providers to compensate foreign medical tourism brokers, who play an important role in the growth of medical tourism by providing patients with assistance arranging travel and medical services. Using a hypothetical arrangement among U.S. healthcare providers and a Canadian medical practice that not only provides the typical broker services, but also serves to identify appropriate cases for referral from a medical perspective, this article demonstrates how to reduce or even eliminate potential fraud and abuse liability, while improving the quality of the experience for both patients and U.S. providers. [ABSTRACT FROM AUTHOR]

Objectives: The Coping Strategies Inventory-Short Form (CSI-SF) measures four coping strategies based on 16 items: 4 items each indicating problem- vs. emotion-focused engagement or disengagement. Here we provide the first assessment of reliability and construct validity of the CSI-SF among hemodialysis patients across 13 countries.Methods: The CSI-SF was completed by patients in 9 languages in phase 4 of the Dialysis Outcomes and Practice Patterns Study (2009-11). Cronbach's alpha was used to assess internal consistency. Exploratory and confirmatory factor analyses were applied to assess the factor structure of the CSI-SF by country and language. CSI-SF data were analyzed from 7201 patients (60% male; median age 62.5 [range 18-96] years).Results: Good internal consistency (α=0.56-0.80) was seen for three scales in English (US, UK, Canada, Australia, New Zealand), German, and Swedish versions. The fourth scale was internally consistent if two items were dropped. In these countries, both exploratory and confirmatory factor analyses indicated a factor structure consistent with the four CSI-SF scales. Other language versions showed a factor structure inconsistent with these four scales.Conclusion: The slightly modified English, German, and Swedish versions of the CSI-SF are reliable and valid instruments for measuring coping strategies in hemodialysis patients. [ABSTRACT FROM AUTHOR]

The article discusses the significance of optimizing the language and format of clinical practice guidelines to improve guideline uptake, along with tips on how to increase guideline uptake. Topics discussed include reasons why clinicians do not use guidelines, the importance of language and format of guidelines, and ways to improve the intrinsic characteristics of guidelines. It also explores the challenge of poor uptake of guidelines across health systems.

Background: Clinical practice guidelines are widely distributed by medical associations and relied upon by physicians for the best available clinical evidence. International findings report that financial conflicts of interest (FCOI) with drug companies may influence drug recommendations and are common among guideline authors. There is no comparable study on exclusively Canadian guidelines; therefore, we provide a case study of authors' FCOI declarations in guidelines from the Canadian Medical Association (CMA) Infobase. We also assess the financial relationships between guideline-affiliated organizations and drug companies.Methods: Using a population approach, we extracted first-line drug recommendations and authors' FCOI disclosures in guidelines from the CMA Infobase. We contacted the corresponding authors on guidelines when FCOI disclosures were missing for some or all authors. We also extracted guideline-affiliated organizations and searched each of their websites to determine if they had financial relationships with drug companies.Results: We analyzed 350 authors from 28 guidelines. Authors were named on one, two, or three guidelines, yielding 400 FCOI statements. In 75.0 % of guidelines at least one author, and in 21.4 % of guidelines all authors, disclosed FCOI with drug companies. In 54.0 % of guidelines at least one author, and in 28.6 % of guidelines over half of the authors, disclosed FCOI with manufacturers of drugs that they recommended. Twenty of 48 authors on multiple guidelines reported different FCOI in their disclosures. Eight guidelines identified affiliated organizations with financial relationships with manufacturers of drugs recommended in those guidelines.Conclusions: This is the first study to systematically describe FCOI disclosures by authors of Canadian guidelines and financial relationships between guideline-affiliated organizations and pharmaceutical companies. These financial relationships are common. Because authoritative value is assigned to guidelines distributed by medical associations, we encourage them to develop formal policies to limit the potential influence of FCOI on guideline recommendations. [ABSTRACT FROM AUTHOR]

Background: Opioid agonist therapy (OAT) has been shown to reduce opioid use and related harms. However, many young people are not accessing OAT. This study sought to explore how young people navigated OAT over time, including periods of engagement, disengagement, and avoidance.Methods: Semi-structured, in-depth qualitative interviews were conducted between January 2018 and August 2020 with 56 young people in Vancouver, Canada who reported illicit, intensive heroin and/or fentanyl use. Following the verbatim transcription of longitudinal interviews, an iterative thematic analysis was used to extrapolate key themes.Results: Young people contemplating OAT expressed fears about its addictiveness. Many experienced pressure from providers and family members to initiate buprenorphine-naloxone, despite a desire to explore other treatment options such as methadone. Once young people initiated OAT, staying on it was difficult and complicated by daily witnessed dosing requirements and strict rules around repeated missed doses, especially for those receiving methadone. Most young people envisioned tapering off OAT in the not-too-distant future.Conclusions: Findings underscore the importance of working collaboratively with young people to develop treatment plans and timelines, and suggest that OAT engagement and retention among young people could be improved by expanding access to the full range of OAT; updating clinical guidelines to improve access to safer prescription alternatives to the increasingly poisonous, unregulated drug supply; addressing treatment gaps arising from missed doses and take-home dosing; and providing a clear pathway to OAT tapering. [ABSTRACT FROM AUTHOR]

• The impact of COVID-19 pandemic on child maltreatment investigators was examined. • The changes in work practices during the pandemic were investigated through a survey. • Child maltreatment investigators experienced greater stress levels during the pandemic. • Workers perceived higher stress levels among children and families receiving services. As cases of child maltreatment become an increasing concern during the COVID-19 pandemic, the perspectives of those charged with protecting and supporting children and families is an important area of inquiry. We sought to examine the experiences of child maltreatment workers during the first wave of the pandemic (i.e., May-July 2020). We specifically aimed to examine child maltreatment experiences related to the following: (1) their work practices during the pandemic, (2) their perceived safety during the pandemic, and (3) their perceptions on the safety of the children and families with whom they work. A total of 106 child maltreatment investigators and forensic interviewers provided responses to a national survey disseminated across Canada. Using a cross-sectional design, data were collected through a survey management program. The survey combined both open-ended and forced choice questions to gather perspectives on respondents' experiences. More than half (67%) reported a reduction in their caseloads during the pandemic (May-July 2020) and continued in-person interviews, with the use of preventative health measures (i.e., PPE, physical distancing, gloves). Most respondents reported elevated stress levels and similarly high stress levels amongst the children and families to whom they provide services. Overall, our findings highlight both how child maltreatment investigators have adapted to preventative measures and the continuing areas of weakness where further supports are required. [ABSTRACT FROM AUTHOR]

Objective To determine the proportion of infants who receive inhaled nitric oxide (iNO), and to characterize the variations in its use by gestational age (GA) and center in infants <34 weeks' gestation. Design Retrospective analysis was performed in infants born at <34 weeks' gestation and admitted to neonatal intensive care units participating in the Canadian Neonatal Network between January 2010 and December 2013. Results Of 19,525 infants, 831 (4.2%) received iNO. A total of 369 infants (44%) received iNO during the first 2 days after birth. The proportion of neonates who received iNO in the 22 to 25, 26 to 29, and 30 to 33 weeks' GA groups was 16.1, 6.0, and 1.3%, respectively. Infants in whom iNO was initiated in the first 2 days of age received it for a shorter duration (median, 3 days; interquartile range [IQR], 2-5) as compared with those who started after 2 days (median, 5 days; IQR, 2-11). The use of iNO varied by center, ranging from 0 to 15.5% (p < 0.001). Conclusion Out of every 25 infants born at <34 weeks' gestation in Canada received iNO, with the highest rate of use in infants born at lower gestation. Further research to identify reasoning, efficacy, and safety of iNO in preterm infants is warranted. [ABSTRACT FROM AUTHOR]

This section offers news briefs on relating to addiction as of June 2016. It announces the implementation of the Cigarettes and Other Tobacco Products (Packaging and Labelling) Amendment Rules 2014 in India. It reports the prescription drug monitoring to be introduced in Victoria to prevent overdoses, as well as the ruling by the Texas Supreme Court upholding a state Supreme Court decision to impose a special tax on cigarette makers.

Background: The Paediatric Chairs of Canada have been proactive in workforce planning, anticipating paediatric job opportunities in academic centres. To complement this, it is important to characterize the practice profiles of paediatricians exiting training, including those working outside of tertiary care centres. Objective: To describe the training paths and the practice patterns of Canadian paediatric residency graduates. Methods: A survey was completed in 2010 to 2011 by Canadian program directors regarding residents completing core paediatrics training between 2004 and 2010. Data collection included training path after completing core paediatrics training and practice type after graduation. Results : Of 699 residents completing their core training in paediatrics, training path data were available for 685 (98%). Overall, 430 (63%) residents completed subspecialty training while 255 (37%) completed general paediatrics training only. There was a significant increase in subspecialty training, from 59% in earlier graduates (2004 to 2007) to 67% in later graduates (2008 to 2010) (P=0.037). Practice pattern data after completion of training were available for 245 general paediatricians and 205 subspecialists. Sixty-nine percent of general paediatricians were community based while 85% of subspecialists were hospital based in tertiary or quaternary centres. Of all residents currently in practice, only 36 (8%) were working in rural, remote or underserviced areas. Conclusions: Almost two-thirds of recent Canadian paediatric graduates pursued subspecialty training. There was a significant increase in the frequency of subspecialty training among later-year graduates. Few graduates are practicing in rural or underserviced areas. Further studies are needed to determine whether these trends continue and their impact on the future paediatric workforce in Canada. [ABSTRACT FROM AUTHOR]

Background: Oral corticosteroids (OCSs) are widely prescribed in Otolaryngology-Head & Neck surgery (OtoHNS). There is evidence in the literature regarding specific dosing regimens. However, it is not known to what extent these recommendations are being implemented in practice. Methods: An anonymous online survey was sent to Canadian Society of Otolaryngology-Head and Neck Surgery members (N = 696). Dosing, frequency and tapering of OCSs were assessed in acute rhino-sinusitis (ARS), chronic rhino-sinusitis with (CRSwP) and without polyps (CRSsP), sudden sensori-neural hearing loss (SSNHL), and idiopathic facial nerve/Bell's palsy (IFN). Participants were asked to complete for conditions treated and results were compared with current guidelines. Development of prescribing habits and observed complications were also explored. Results: 124 surveys (18 %) were completed. In CRSwP (N = 98), the median dose was 50 mg (Range: 10-100 mg) and the average duration was 8 days (Range: 1-21 days). In CRSsP (N= 29), the median dose was 50 mg (Range: 20-80 mg) and the average duration was 8 days (Range: 1-14 days). In SSNHL (N= 118), the median dose was 60 mg (Range: 10-120 mg) and the average duration was 10 days (Range: 1-21 days). In IFN (N= 108), the median dose was 50 mg (Range: 10-100 mg) and the average duration was 10 days (Range: 1-21 days). Tapering dosages were used in treating CRSwP (64 %), CRSsP (62 %), ARS (44 %), SSNHL (60 %) and IFN (53 %). Respondents most frequently perceived "Mentor/Preceptor Guidance" as a source of their prescribing habits. Conclusion: There is significant heterogeneity in OCS prescribing habits despite the availability of fairly consistent evidence in the literature for some of the surveyed conditions. Improvements in standardization should be made with the aim of enhancing outcomes and reducing complications. [ABSTRACT FROM AUTHOR]

The Australian College of Mental Health Nurses directs that mental health nurses must 'enable cultural safety in practice, taking into account age, gender, spirituality, ethnicity and health values'. The present study is a review of the existing literature undertaken in order to identify current knowledge and knowledge gaps regarding the experience of Indigenous women in acute mental health inpatient facilities. In particular, studies that identified environments and practices promoting the development of culturally-safe healing spaces for Indigenous women, and studies that identified women's experience of seclusion, were sought. The results showed that there is little literature directly relevant to Indigenous women's experiences of inpatient mental health units in Australia. The present study consolidates existing knowledge and knowledge gaps, and advances the argument for gender-disaggregated future research. Implications for professional practice and service development are also noted. [ABSTRACT FROM AUTHOR]

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site (www.ismp.org), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org. ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications. [ABSTRACT FROM AUTHOR]

Purpose: To describe current practices for manual wheelchair (MWC) skills training in Canadian rehabilitation centers. Methods: An online survey was sent to practice leaders in occupational (OT) and physical therapy (PT) at 87 Canadian rehabilitation centers. Responses were solicited from individuals who could report about wheelchair skills training at facilities with at least 10 beds designated for rehabilitation. Thirty-four questions asked about: (1) demographics, (2) components of MWC training, (3) amount of MWC skills training, (4) use of validated programs and (5) perceived barriers to using validated programs. Data were analyzed using summary statistics. Results: About 68/87 responses were received primarily from OTs (42/68). Basic MWC skills training (e.g. wheel-locks) was consistently part of clinical practice (45/68), while advanced skills training (e.g. curb-cuts) was rare (8/68). On an average, 1-4 h of training was done (29/68). Validated training programs were used by 16/68, most of whom used them ' rarely' (7/16). Common barriers to using validated programs were lack of time (43/68) and resources (39/68). Conclusions: Learning to use a wheelchair is important for those with ambulation impairments because the wheelchair enables mobility and social participation. Providing opportunities for advanced wheelchair skills training may enhance mobility and social participation in a safe manner. [ABSTRACT FROM AUTHOR]

Objective: It is important to understand how chiropractors practice beyond their formal education. The objective of this analysis was to assess the diagnostic and treatment methods used by chiropractors in English-speaking Canadian provinces. Methods: A questionnaire was created that examined practice patterns amongst chiropractors. This was sent by mail to 749 chiropractors, randomly selected and stratified proportionally across the nine English-speaking Canadian provinces. Participation was voluntary and anonymous. Data were entered into an Excel spreadsheet, and descriptive statistics were calculated. Results: The response rate was 68.0%. Almost all (95.1%) of respondents reported performing differential diagnosis procedures with their new patients; most commonly orthopaedic testing, palpation, history taking, range of motion testing and neurological examination. Palpation and painful joint findings were the most commonly used methods to determine the appropriate joint to apply manipulation. The most common treatment methods were manual joint manipulation/mobilization, stretching and exercise, posture/ergonomic advice and soft-tissue therapies. Conclusions: Differential diagnosis is a standard part of the assessment of new chiropractic patients in English-speaking Canadian provinces and the most common methods used to determine the site to apply manipulation are consistent with current scientific literature. Patients are treated with a combination of manual and/or manipulative interventions directed towards the joints and/or soft-tissues, as well as exercise instruction and postural/ergonomic advice. [ABSTRACT FROM AUTHOR]

Background: While client-centred practice has received wide support, it remains difficult to apply in many practice settings. Identified barriers include constraints on time, resources, and services imposed by healthcare policies. Healthcare professionals' prioritizing of client safety over (other) interests that clients may name may further restrict the application of client-centred practice. Discharge planning is one area where such considerations can conflict. Aim: This paper presents a secondary analysis of data examining the process of discharge in one Canadian rehabilitation setting. It examines how discourses of client-centred practice and of prioritizing safety were reflected in discharge planning with older adults and considers the implications of potential conflicts between these discourses. Method: Taking a critical bioethics perspective informed by relational autonomy theory, microethnographic case studies were used to examine discharge planning from the perspectives of older adult clients and healthcare professionals. Results: Healthcare professionals interpreted client-centred practice to require abiding by client wishes, as long as this was safe; furthermore prioritizing safety took precedence over other considerations in discharge planning. Conclusion and significance: Client-centred practice was not promoted in discharge planning processes in the research setting. Applying a relational autonomy lens to practice could promote approaches that better facilitate client-centred practice. [ABSTRACT FROM AUTHOR]

Background: The Canadian Rhinologic workforce and future needs are not well defined. The objective of this study was to define the current demographics and practice patterns of the Canadian Rhinologic workforce. Outcomes from this study can be used to perform rhinologic workforce needs assessments. Methods: A national survey was administered to all Canadian otolaryngologists who were identified to have a clinical practice composed of >50% rhinology. Results: 42 surgeons participated in the survey (65% response rate). The mean age was 46 (SD 10.1) years and the average age of planned retirement was 66 (SD 4.0). Eighty three percent of respondents had completed a rhinology fellowship and 17% practiced exclusively rhinology. Thirty three percent hold advanced degrees. Forty two percent of surgeons felt their access to operative time was insufficient. Six percent of surgeons reported not having access to image guided surgery. Fourteen percent felt that there were too many practicing rhinologists in Canada while 17% believed there were too few practicing rhinologists. Seventeen percent have advised their residents to pursue other fields due to a perceived lack of future jobs. Overall, 66% of respondents were satisfied with their income, and 83% were satisfied with their careers. Conclusions: This study has demonstrated that there is a perceived mismatch between the current supply of Rhinology labor and the capacity to treat patients in a timely manner. Outcomes from this study will begin to improve Rhinologic workforce planning in Canada and reduce the gap between patient demand and access to high quality care. [ABSTRACT FROM AUTHOR]

Background: Discordant practice patterns may be a consequence of evidence-practice gaps or deficiencies in knowledge translation. We examined the current strategies used by hepato-pancreatico-biliary (HPB) surgeons in Canada for the perioperative management of pancreaticoduodenectomy (PD). Methods: We generated a web-based survey that focused on the perioperative measures surrounding PD. The survey was distributed to all members of the Canadian Hepato-Pancreatico-Biliary Association. Results: The survey was distributed to 74 surgeons and received a response rate of 50%. Many similarities in surgical techniques were reported; for example, most surgeons (86.5%) reconstruct the pancreas with pancreaticojejunostomy rather than pancreaticogastrostomy. In contrast, variable techniques regarding the use of peritoneal drainage tubes, anastomotic stents, octreotide and other intraoperative modalities were reported. Most surgeons (75.7%) reported that their patients frequently required preoperative biliary drainage, yet there was minimal agreement with the designated criteria. There was variability in postoperative care, including the use of epidural analgesia and timing of postoperative oral nutrition. Conclusion: We identified heterogeneity among Canadian HPB surgeons, suggesting a number of evidence-practice gaps within specific domains of pancreatic resections. Focused research in these areas may facilitate technical agreement and improve patient outcomes following PD. [ABSTRACT FROM AUTHOR]

Aim To document current practice by dietitians in Australia and Canada in the nutrition management of Parkinson's disease. This will help identify priority areas for review and development of practice guidelines and direct future research. Methods Current practice in the phases of the Nutrition Care Plan was captured using an online survey distributed to Dietitians Association of Australia members and Practice-Based Evidence in Nutrition subscribers through their email newsletters. The results of the diagnosis, intervention and monitoring phases are presented here. Results Eighty-four dietitians responded. There was consistency in practice for nutrition issues that are encountered in other populations, such as malnutrition and constipation. There was more variation in practice in the nutrition issues that are more specific to Parkinson's disease, such as nutrition and meal interactions with medication. A lack of awareness of emerging treatments, such as deep brain stimulation surgery, appears to exist in the responding dietitians. Conclusions The variation in practice that was present for the nutrition issues specific to Parkinson's disease may reflect the lack of quality evidence and subsequently evidence-based guidelines in these areas. Work to provide background information about treatment options and to translate current evidence for the nutrition issues that are specific to Parkinson's disease into practice recommendations should be completed. [ABSTRACT FROM AUTHOR]

Abstract: Canadian nurse practitioners’ use of physical activity prescriptions is examined. Nurse practitioners use unstructured counseling techniques; have more opportunities with older adults; experience barriers; and want more education. Barriers are lack of time, lack of knowledge, and patient disinterest. Canadian resources are suggested to support physical activity prescriptions. [ABSTRACT FROM AUTHOR]

Children’s musculoskeletal (MSK) injury pain remains poorly managed. This survey of pediatric emergency physicians and orthopedic surgeons assessed analgesia administration practices and discharge advice for children with acute MSK pain; 683 responses were received. Ibuprofen was the most commonly reported analgesic used in the emergency department (52%) and at discharge (68%). Most (85%) reported using oral opioids in the previous 6 months. Codeine use was the most commonly reported opioid used in the emergency department (38%) and at home (51%). For equal levels of pain, younger children received less opioids than older children. Younger physicians and recent graduates chose acetaminophen and codeine more than older and more experienced colleagues, who preferred ibuprofen and non-codeine containing opioid compounds (P < .001 and .006, respectively). Orthopedic surgeons reported less ibuprofen use than pediatric emergency physicians (P < .001). Choice of analgesic agents is heterogeneous among physicians and is influenced by pain severity, child’s age, and physician characteristics. [ABSTRACT FROM PUBLISHER]

Aim To determine the prescribing of and adherence to oral hypoglycaemic agents, insulin, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and statin therapy among South-Asian, Chinese and white people with newly diagnosed diabetes. Methods The present study was a population-based cohort study using administrative and pharmacy databases to include all South-Asian, Chinese and white people aged ≥ 35 years with diabetes living in British Columbia, Canada (1997-2006). Adherence to each class of medication was measured using proportion of days covered over 1 year with optimum adherence defined as ≥ 80%. Results The study population included 9529 South-Asian, 14 084 Chinese and 143 630 white people with diabetes. The proportion of people who were prescribed angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, statin or oral hypoglycaemic agents was ≤ 50% for all groups. South-Asian and Chinese people had significantly lower adherence for all medications than white people, with the lowest adherence to angiotensin-converting enzyme inhibitor treatment (South-Asian people: adjusted odds ratio 0.37, 95% CI 0.34-0.39; P<0.0001; Chinese people: adjusted odds ratio 0.50, 95% CI 0.47-0.54; P<0.0001) and statin therapy (South-Asian people: adjusted odds ratio 0.47, 95% CI 0.41 - 0.53, P < 0.0001; Chinese people: adjusted odds ratio 0.72, 95% CI 0.67 - 0.77; P<0.0001) compared with white people. Conclusion Adherence to evidence-based pharmacotherapy was substantially worse among the South-Asian and Chinese populations. Care providers need to be alerted to the high levels of non-adherence in these groups and the underlying causes need to be investigated. [ABSTRACT FROM AUTHOR]

Recent acceleration in development of computerized neuropsychological tests and test batteries has led to gains in sophistication, intuitiveness, and capability with concomitant opportunities for greater adoption among practitioners. Advantages attributed to computerized methods (e.g., standardization, large-scale screening, measurement of performance attributes inaccessible by traditional means) enhance prospects for growth. Despite technological improvement and potential benefit to neuropsychological assessment, the regularity with which neuropsychologists utilize computer-based methods remains unsettled. As part of a 10-year follow-up study of neuropsychological test usage practices, we surveyed neuropsychologists' utilization of computerized instruments and investigated practice-related factors that influence computerized test adoption. Respondents were 512 doctorate-level psychologists residing in the United States and Canada (26% usable response rate; 54% female) affiliated with the National Academy of Neuropsychology or the International Neuropsychological Society. Of the 693 distinct instruments reported by respondents, only 6% (n = 40) were computerized, and the average respondent reported rarely using computerized tests. We present the top-ranked computerized instruments and results of correlational analyses, which indicate that fewer years practicing and the youth of respondents associates with increased likelihood of computerized test utilization, along with increased utilization of neuropsychological tests with alternative or parallel forms. Implications for existing and emerging technologies in research and clinical settings are considered. [ABSTRACT FROM AUTHOR]

Although breast conservation surgery ( BCS) is commonly performed, several aspects of the procedure remain controversial. We undertook a cross-sectional survey to compare Canadian ( CDN) and American ( AM) general surgeons' reported BCS practice patterns to better understand the cross-border differences in early-stage breast cancer surgery care. A modified Dillman Method survey was mailed to 1,447 AM and 1,443 CDN surgeons. Factors evaluated included preoperative assessment, margin definition, surgical techniques, and re-excision practices. The response rate was 26% and 51% for AM and CDN surgeons, respectively. There was variation in use of preoperative core biopsies. American surgeons required wider margins for invasive cancer and ductal carcinoma in situ, and more often recommend re-excision for invasive cancer with 1 and 2 mm margins (p < 0.05). There was also variability in surgical techniques used for intraoperative margin assessment. Wide variation in BCS practice was observed, with some of this variability related to surgeon country. [ABSTRACT FROM AUTHOR]

We review evidence of determinants contributing to increased opioid-related mortality in the United States and Canada between 1990 and 2013. We identified 17 determinants of opioid-relatedmortality andmortality increases that we classified into 3 categories: prescriber behavior, user behavior and characteristics, and environmental and systemic determinants. These determinants operate independently but interact in complex ways that vary according to geography and population,making generalization from single studies inadvisable. Researchers in this area face significant methodological difficulties; most of the studies in our review were ecological or observational and lacked control groups or adjustment for confounding factors; thus, causal inferences are difficult. Preventing additional opioid-related mortality will likely require interventions that address multiple determinants and are tailored to specific locations and populations. [ABSTRACT FROM AUTHOR]

Despite the importance of diversity variables to the clinical practice of neuropsychology, little is known about neuropsychologists' multicultural assessment practices and perspectives. The current study was the first to survey issues related to neuropsychologists' assessment of minority populations, proficiency in languages other than English, approaches to interpreting the cognitive scores of minorities, and perceived challenges associated with assessing ethnic/racial minority patients. We also surveyed respondents with regard to their own demographic backgrounds, as neuropsychologists who identify as ethnic/racial minorities are reportedly underrepresented in the field. Respondents were 512 (26% usable response rate; 54% female) doctorate-level psychologists affiliated with the International Neuropsychology Society or the National Academy of Neuropsychology who resided in the United States or Canada. Overall, results suggest that lack of appropriate norms, tests, and referral sources are perceived as the greatest challenges associated with assessment of ethnic/racial minorities, that multicultural training is not occurring for some practitioners, and that some are conducting assessments in foreign languages despite limited proficiency. In addition, ethnic/racial minorities appear to be grossly underrepresented in the field of neuropsychology. Findings are discussed in relation to the need for appropriate education and training of neuropsychologists in multicultural issues and the provision of more valid assessments for ethnic/racial minority individuals. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is a common cardiac arrhythmia, and leading cause of ischemic stroke. Despite proven effectiveness, warfarin remains an under-used treatment in atrial fibrillation patients. We sought to study, across three physician specialties, a range of factors that have been argued to have a disproportionate effect on treatment decisions. Methods: Cross-sectional survey of Canadian Family Doctors (FD: n = 500), Geriatricians (G: n = 149), and Internal Medicine specialists (IMS: n = 500). Of these, 1032 physicians were contactable, and 335 completed and usable responses were received. Survey questions and clinical vignettes asked about the frequency with which they see patients with atrial fibrillation, treatment practices, and barriers to the prescription of anticoagulants. Results: Stated prescribing practices did not significantly differ between physician groups. Falls risk, bleeding risk and poor patient adherence were all highly cited barriers to prescribing warfarin. Fewer geriatricians indicated that history of patient falls would be a reason for not treating with warfarin (G: 47%; FD: 71%; IMS: 72%), and significantly fewer changed reported practice in the presence of falls risk (χ2 (6) = 45.446, p < 0.01). Experience of a patient having a stroke whilst not on warfarin had a significant impact on vignette decisions; physicians who had had patients who experienced a stroke were more likely to prescribe warfarin (χ2 (3) =10.7, p = 0.013). Conclusions: Barriers to treatment of atrial fibrillation with warfarin affect physician specialties to different extents. Prior experience of a patient suffering a stroke when not prescribed warfarin is positively associated with intention to prescribe warfarin prescription, even in the presence of falls risk. [ABSTRACT FROM AUTHOR]

Aim To document and compare current practice in nutrition assessment of Parkinson's disease by dietitians in Australia and Canada in order to identify priority areas for review and development of practice guidelines and direct future research. Methods An online survey was distributed to DAA (Dietitians Association of Australia) members and PEN (Practice-based Evidence in Nutrition) subscribers through their email newsletters. The survey captured current practice in the phases of the Nutrition Care Plan. The results of the assessment phase are presented here. Results Eighty-four dietitians responded. Differences in practice existed in the choice of nutrition screening and assessment tools, including appropriate body mass index ranges. Nutrition impact symptoms were commonly assessed, but information about Parkinson's disease medication interactions was not consistently assessed. Conclusions The variation in practice related to the use of screening and assessment methods may result in the identification of different goals for subsequent interventions. Even more practice variation was evident for those items more specific to Parkinson's disease and may be due to the lack of evidence to guide practice. Further research is required to support decisions for nutrition assessment of Parkinson's disease. [ABSTRACT FROM AUTHOR]

The article presents a study survey which discussed trends in antimicrobial prescribing among Canadian physicians. Many respondents did not prescribe amoxicillin, and a substantial proportion underdosed, among those who did. In one scenario, increased proportion of respondents selecting oral cephalosporins or amoxicillin/clavulanate was seen. Macrolides were often prescribed, maybe because they offer excellent coverage of Mycoplasma pneumoniae and Chlamydophila pneumoniae.

Objective: To assess the use of concussion/mild traumatic brain injury (mTBI) guidelines, criteria used in the initiation of return-to-play (RTP) and management of RTP for brain injured children and youth by Canadian paediatricians. Methods: A cross-sectional survey was mailed through the Canadian Paediatric Surveillance Program to ∼2600 paediatric specialists and sub-specialists. Results: Of 809 respondents (31%), 503 encountered newly diagnosed paediatric concussion/mTBI within the past 12 months, reporting ∼6900 cases. Of the respondents, 96.7% (95% CI = 94.7-98.6%) reported using one or more of the presented concussion/mTBI guidelines in the management of their patients. The most frequently reported criteria (>50%) used to determine asymptomatic status were: free from all concussion symptoms, by patient report (92%), by proxy report (76%), normal physical examination (65%), in school full-time, with usual school performance (53%). Most respondents (84.9%) did not initiate RTP immediately after their patients became asymptomatic. The median time waiting before initiating RTP was 7 days. The median duration of the RTP sequence was 7 days, with considerable variation reported. Conclusions: Canadian paediatricians frequently encounter patients with concussion/mTBI. Their concussion/mTBI care appears to be consistent with current guidelines, but also shows practice variation, particularly when current guidelines become less proscriptive. [ABSTRACT FROM AUTHOR]

The purpose of this study was to assess whether antidepressant prescribing during pregnancy decreased following release of U.S. and Canadian public health advisory warnings about the risk of perinatal complications with antidepressants. We analyzed data from 228,876 singleton pregnancies among women (aged 15-44 years) continuously enrolled in Tennessee Medicaid with full pharmacy benefits (1995-2007). Antidepressant prescribing was determined through outpatient pharmacy dispensing files. Information on sociodemographic and clinical factors was obtained from enrollment files and linked birth certificates. An interrupted time series design with segmented regression analysis was used to quantify the impact of the advisory warnings (2002-2005). Antidepressant prescribing rates increased steadily from 1995 to 2001, followed by sharper increases from 2002 to late 2004. Overall antidepressant prescribing prevalence was 34.51 prescriptions [95 % confidence interval (CI) 33.37-35.65] per 1,000 women in January 2002, and increased at a rate of 0.46 (95 % CI 0.41-0.52) prescriptions per 1,000 women per month until the end of the pre-warning period (May 2004). During the post-warning period (October 2004-June 2005), antidepressant prescribing decreased by 1.48 (95 % CI 1.62-1.35) prescriptions per 1,000 women per month. These trends were observed for both selective serotonin reuptake inhibitors (SSRI) and non-SSRI antidepressants, although SSRI prescribing decreased at a greater rate. We conclude that antidepressant prescribing to pregnant women in Tennessee Medicaid increased from 1995 to late 2004. U.S. and Canadian public health advisories about antidepressant-associated perinatal complications were associated with steady decreases in antidepressant prescribing from late 2004 until the end of the study period, suggesting that the advisory warnings were impactful on antidepressant prescribing in pregnancy. [ABSTRACT FROM AUTHOR]

Background: Clinical nurse specialists are recognized internationally for providing an advanced level of practice. They positively impact the delivery of healthcare services by using specialty-specific expert knowledge and skills, and integrating competencies as clinicians, educators, researchers, consultants and leaders. Graduate-level education is recommended for the role but many countries do not have formal credentialing mechanisms for clinical nurse specialists. Previous studies have found that clinical nurse specialist roles are poorly understood by stakeholders. Few national studies have examined the utilization of clinical nurse specialists. Objective: To identify the practice patterns of clinical nurse specialists in Canada. Design: A descriptive cross-sectional survey. Participants: Self-identified clinical nurse specialists in Canada. Methods: A 50-item self-report questionnaire was developed, pilot-tested in English and French, and administered to self-identified clinical nurse specialists from April 2011 to August 2011. Data were analyzed using descriptive and inferential statistics and content analysis. Results: The actual number of clinical nurse specialists in Canada remains unknown. The response rate using the number of registry-identified clinical nurse specialists was 33% (804/2431). Of this number, 608 reported working as a clinical nurse specialist. The response rate for graduate-prepared clinical nurse specialists was 60% (471/782). The practice patterns of clinical nurse specialists varied across clinical specialties. Graduate- level education influenced their practice patterns. Few administrative structures and resources were in place to support clinical nurse specialist role development. The lack of title protection resulted in confusion around who identifies themselves as a clinical nurse specialist and consequently made it difficult to determine the number of clinical nurse specialists in Canada. Conclusions: This is the first national survey of clinical nurse specialists in Canada. A clearer understanding of these roles provides stakeholders with much needed information about clinical nurse specialist practice patterns. Such information can inform decisions about policies, education and organizational supports to effectively utilize this role in healthcare systems. This study emphasizes the need to develop standardized educational requirements, consistent role titles and credentialing mechanisms to facilitate the identification and comparison of clinical nurse specialist roles and role outcomes internationally. [ABSTRACT FROM AUTHOR]

This article examines treatment recommendations in orthopedic surgery consultations and shows how surgery is treated as “omni-relevant” within this activity, providing a context within which the broad range of treatment recommendations proposed by surgeons is offered. Using conversation analysis to analyse audiotaped encounters between orthopedic surgeons and patients, we highlight how surgeons treat surgery as having a special, privileged status relative to other treatment options by (1) invoking surgery (whether or not it is actually being recommended) and (2) presenting surgery as the “last best resort” (in relation to which other treatment options are calibrated, described and considered). This privileged status surfaces in the design and delivery of recommendations as a clear asymmetry: Recommendationsforsurgery are proposed early, in relatively simple and unmitigated form. In contrast, recommendationsnot forsurgery tend to be delayed and involve significantly more interactional work in their delivery. Possible implications of these findings, including how surgeons' structuring of recommendations may shape patient expectations (whether for surgery or some alternative), and potentially influence the distribution of orthopedic surgery procedures arising from these consultations, are considered. [ABSTRACT FROM PUBLISHER]

Introduction Clinical practice guidelines ( CPGs) are an important source of justification for clinical decisions in modern evidence-based practice. Yet, we have given little attention to how they argue their evidence. In particular, how do CPGs argue for treatment with long-term medications that are increasingly prescribed to older patients? Approach and rationale I selected six disease-specific guidelines recommending treatment with five of the medication classes most commonly prescribed for seniors in Ontario, Canada. I considered the stated aims of these CPGs and the techniques employed towards those aims. Finally, I reconstructed and logically analysed the arguments supporting recommendations for pharmacotherapy. Analysis The primary function of CPGs is rhetorical, or persuasive, and their means of persuasion include both a display of their credibility and their argumentation. Arguments supporting pharmacotherapy recommendations for the target population follow a common inductive pattern: statistical generalization from randomized controlled trial ( RCT) and meta-analysis evidence. Two of the CPGs also argue their treatment recommendations for older patients in this style, while three fail to justify pharmacotherapy specifically for the older population. Discussion The arguments analysed lack the auxiliary assumptions that would warrant making a generalization about the clinical effectiveness of medications for the older population. Guidelines reason using simple induction, while ignoring important inferential gaps. Future guidelines should aspire to be well-reasoned rather than simply evidence-based; argue from a plurality of evidence; be wary of hasty inductions; appropriately limit the scope of their recommendations; and avoid making law-like, prescriptive generalizations. [ABSTRACT FROM AUTHOR]