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Introduction: Despite the public health imperative that all medical practitioners serving reproductive-aged women know the components of abortion care and attain competency in nondirective pregnancy options counseling, exposure to abortion care in US medical school education remains significantly limited., Methods: Florida International University Herbert Wertheim College of Medicine offers an opt-in clinical exposure to abortion care during the obstetrics and gynecology clerkship. During clerkship orientation, students watched a recorded presentation reviewing components of abortion care and emphasizing that participating students may increase or decrease involvement at any time without explanation. Students opting in completed a form specifying their desired level of involvement for each component as "yes," "no," or "not sure.", Results: Of 350 clerkship students over 23 6-week rotations, 98 (28%) chose to opt in, with opt-in form data available for 90 students. Ninety students chose to observe counseling for first- and second-trimester surgical abortion and medical abortion. Seven students used the option "no" for history taking and examine second trimester fetal parts. Twenty-four students marked "not sure" for participating in evacuation of first-trimester pregnancy., Discussion: This educational intervention proved feasible and offers an opportunity for students to have experiential learning about abortion care in an inclusive, respectful manner. This experience may be incorporated into undergraduate and graduate medical education. Providing learners the opportunity for exposure to abortion care improves their overall medical education and will impact the care they provide as future clinicians., (© 2021 by the Society of Teachers of Family Medicine.)

Background: Emergency general surgery patients are at an increased risk for morbidity and mortality compared to their elective surgery counterparts. The complex nature of emergency general surgery conditions can challenge community hospitals, which may lack appropriate systems and personnel. Outcomes related to transfer have not been well-established. We aimed to compare postoperative outcomes of patients who were transferred from another hospital to a center with dedicated acute care surgery services with patients admitted directly to the acute care surgery centers., Methods: We performed a secondary analysis of a national, multicenter review of emergency general surgery patients undergoing complex emergency general surgery at 5 centers across Canada. The primary outcome was the development of any complication. The adjusted odds of postoperative complication was assessed using logistic regression, controlling for age, comorbidities, duration of stay before transfer, American Society of Anesthesiologists classification, and booking priority., Results: A total of 1,846 patients were included in the study, and 176 (9.5%) were transferred. Of these 21% (n = 37) underwent an operative procedure, and 15% (n = 27) underwent an operation at the transferring center. Transferred patients were more likely to have at least 1 comorbidity (68% vs 57%; P = .004), were classified as greater urgency on arrival (<2 hours booking priority, 43% vs 17%; P < .001), had a greater American Society of Anesthesiologists classification (American Society of Anesthesiologists ≥3 = 81% vs 65%; P < .001), a greater duration of operation (119 vs 110 minutes; P = .004), and were more likely to undergo a second operation (28% vs 14%; P < .001) compared to patients directly admitted to an acute care surgery center. On univariate analysis, transferred patients had greater rates of complications (48% vs 31%; P < .001), mortality (14% vs 7%; P = .005), and admission to the intensive care unit (22% vs 12%; P < .001). Transfer status remained an independent predictor of complication (odds ratio 1.9 [95% confidence interval 1.3-2.7]; P < .001) and intensive care unit admission (odds ratio 1.9 [95% confidence interval 1.2-3.0]; P = .007), but not mortality (odds ratio 1.1 [95% confidence interval 0.6-1.9]; P = .79) on regression analysis., Conclusion: Complex emergency general surgery patients transferred to acute care surgery centers may have worse outcomes and greater use of resources compared to those admitted directly. This finding has clinically and financially important implications for the design and regionalization of acute care surgery services as well as resource allocation at acute care surgery centers., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Competing Interests: Conflicts of interest: There are no conflicts of interest to declare.

Objectives: To explore UK clinicians' beliefs and behaviours around recommending e-cigarettes as a smoking cessation aid for patients with cancer., Design: Cross-sectional online survey., Setting: England, Wales, Scotland and Northern Ireland., Participants: Clinicians involved in the care of patients with cancer., Primary and Secondary Outcomes: Behavioural Change Wheel capability, opportunity and motivation to perform a behaviour, knowledge, beliefs, current practice around e-cigarettes and other smoking cessation practices., Method: Clinicians (n=506) completed an online survey to assess beliefs and behaviours around e-cigarettes and other smoking cessation practices for patients with cancer. Behavioural factors associated with recommending e-cigarettes in practice were assessed., Results: 29% of clinicians would not recommend e-cigarettes to patients with cancer who continue to smoke. Factors associated with recommendation include smoking cessation knowledge (OR 1.56, 95% CI 1.01 to 2.44) and e-cigarette knowledge (OR 1.64, 95% CI 1.06 to 2.55), engagement with patients regarding smoking cessation (OR 2.12, 95% CI 1.12 to 4.03), belief in the effectiveness of e-cigarettes (OR 2.36 95% CI 1.61 to 3.47) and belief in sufficient evidence on e-cigarettes (OR 2.08 95% CI 1.10 to 4.00) and how comfortable they felt discussing e-cigarettes with patients (OR 1.57 95% CI 1.04 to 2.36)., Conclusion: Many clinicians providing cancer care to patients who smoke do not recommend e-cigarettes as a smoking cessation aid and were unaware of national guidance supporting recommendation of e-cigarettes as a smoking cessation aid., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Summary: In single-stage hernia repair in the setting of contaminated fields there is a high rate of infection following mesh repair. New strategies to decrease infection in this challenging patient population are needed. Stimulan calcium sulfate antibiotic beads (CSAB) are a biodegradable material that deliver high concentrations of antibiotics locally to a site of insertion. Their use in the prevention of infection has not been described in hernia graft implantation. Here we describe our use of CSAB in a series of 11 patients with modified Ventral Hernia Working Group class III and Centers for Disease Control and Prevention class II-IV wounds undergoing single-stage incisional ventral hernia repair. We found that implantation of CSAB in single-stage hernia repair in the setting of contaminated fields was feasible with low systemic antibiotic levels. Further research should be undertaken to investigate the efficacy of this novel tool in hernia repair.

Background: Most of the literature on emergency general surgery (EGS) has investigated appendiceal and biliary disease; however, EGS surgeons manage many other complex conditions. This study aimed to describe the operative burden of these conditions throughout Canada., Methods: This multicentre retrospective cohort study evaluated EGS patients at 7 centres across Canada in 2014. Adult patients (aged ≥ 18 yr) undergoing nonelective operative interventions for nonbiliary, nonappendiceal diseases were included. Data collected included information on patients' demographic characteristics, diagnosis, procedure details, complications and hospital length of stay. Logistic regression was used to identify predictors of morbidity and mortality., Results: A total of 2595 patients were included, with a median age of 60 years (interquartile range 46-73 yr). The most common principal diagnoses were small bowel obstruction (16%), hernia (15%), malignancy (11%) and perianal disease (9%). The most commonly performed procedures were bowel resection (30%), hernia repair (15%), adhesiolysis (11%) and débridement of skin and soft tissue infections (10%). A total of 47% of cases were completed overnight (between 5 pm and 8 am). The overall inhospital mortality rate was 8%. Thirty-three percent of patients had a complication, with independent predictors including increasing age ( p = 0.001), increasing American Society of Anesthesiologists score (p = 0.02) and transfer from another centre ( p = 0.001)., Conclusion: This study characterizes the epidemiology of nonbiliary, nonappendiceal EGS operative interventions across Canada. Canadian surgeons are performing a large volume of EGS, and conditions treated by EGS services are associated with a substantial risk of morbidity and mortality. Results of this study will be used to guide future research efforts and set benchmarks for quality improvement.

Objectives: Physicians frequently treat patients struggling with addiction, including alcohol abuse. The Society of Teachers of Family Medicine's National Clerkship Curriculum lists necessary learning for all future physicians and includes several core objectives related to identifying community resources, the role of support groups in treating patients, and identifying and managing substance abuse., Methods: During the family medicine clerkship at the Florida International University Herbert Wertheim College of Medicine, students learn about resources for treating alcohol abuse by attending a 12-step Alcoholics Anonymous (AA) meeting and answering brief reflective questions about the experience. For the 2018-2019 academic year, students completed an anonymous, optional, computer-based, pre-/postactivity survey to assess the students' perceived impact of attending an AA meeting., Results: After the AA meeting, there was an increase in the percentage of students who agreed or strongly agreed that AA meetings are a useful resource. Students perceived that they would be likely to refer a patient with alcohol abuse to AA in the future, were confident in their ability to explain AA to a patient, were knowledgeable about community resources for patients with alcohol addiction, and were confident in their ability to assess patients for alcohol abuse., Conclusions: Attendance at a single AA meeting increased students' awareness of community resources, including AA, for patients who abuse or misuse alcohol. Because students also reported increased perceived self-confidence regarding explaining AA to patients and assessing patients for alcohol addiction, attendance at an AA meeting has the potential to affect future patient care.

The comparative efficacy of ceftazidime-avibactam and meropenem-vaborbactam for treatment of carbapenem-resistant Enterobacteriaceae (CRE) infections remains unknown. This was a multicenter, retrospective cohort study of adults with CRE infections who received ceftazidime-avibactam or meropenem-vaborbactam for ≥72 hours from February 2015 to October 2018. Patients with a localized urinary tract infection and repeat study drug exposures after the first episode were excluded. The primary endpoint was clinical success compared between treatment groups. Secondary endpoints included 30- and 90-day mortality, adverse events (AE), 90-day CRE infection recurrence, and development of resistance in patients with recurrent infection. A post hoc subgroup analysis was completed comparing patients who received ceftazidime-avibactam monotherapy, ceftazidime-avibactam combination therapy, and meropenem-vaborbactam monotherapy. A total of 131 patients were included (ceftazidime-avibactam, n  = 105; meropenem-vaborbactam, n  = 26), 40% of whom had bacteremia. No significant difference in clinical success was observed between groups (62% versus 69%; P  = 0.49). Patients in the ceftazidime-avibactam arm received combination therapy more often than patients in the meropenem-vaborbactam arm (61% versus 15%; P  < 0.01). No difference in 30- and 90-day mortality resulted, and rates of AE were similar between groups. In patients with recurrent infection, development of resistance occurred in three patients that received ceftazidime-avibactam monotherapy and in no patients in the meropenem-vaborbactam arm. Clinical success was similar between patients receiving ceftazidime-avibactam and meropenem-vaborbactam for treatment of CRE infections, despite ceftazidime-avibactam being used more often as a combination therapy. Development of resistance was more common with ceftazidime-avibactam monotherapy., (Copyright © 2020 American Society for Microbiology.)

Background: Single-stage repair of incisional hernias in contaminated fields has a high rate of surgical site infection (30-42%) when biologic grafts are used for repair. In an attempt to decrease this risk, a novel graft incorporating gentamicin into a biologic extracellular matrix derived from porcine small intestine submucosa was developed., Methods: This prospective, multicenter, single-arm observational study was designed to determine the incidence of surgical site infection following implantation of the device into surgical fields characterized as CDC Class II, III, or IV., Results: Twenty-four patients were enrolled, with 42% contaminated and 25% dirty surgical fields. After 12 months, 5 patients experienced 6 surgical site infections (21%) with infection involving the graft in 2 patients (8%). No grafts were explanted., Conclusions: The incorporation of gentamicin into a porcine-derived biologic graft can be achieved with no noted gentamicin toxicity and a low rate of device infection for patients undergoing single-stage repair of ventral hernia in contaminated settings., Trial Registration: The study was registered March 27, 2015 at www.clinicaltrials.gov as NCT02401334.

Background: Acute care surgery (ACS) and emergency general surgery (EGS) services must provide timely care and intervention for patients who have some of the most challenging needs. Patients treated by ACS services are often critically ill and have both substantial comorbidities and poor physiologic reserve. Despite the widespread implemention of ACS/EGS services across North America, the true postoperative morbidity rates remain largely unknown., Methods: In this prospective study, inpatients at 8 high-volume ACS/EGS centres in geographically diverse locations in Canada who underwent operative interventions were followed for 30 days or until they were discharged. Readmissions during the 30-day window were also captured. Preoperative, intraoperative and postoperative variables were tracked. Standard statistical methodology was employed., Results: A total of 601 ACS/EGS patients were followed for up to 30 inpatient or readmission days after their index emergent operation. Fifty-one percent of patients were female, and the median age was 51 years. They frequently had substantial medical comorbidities (42%) and morbid obesity (15%). The majority of procedures were minimally invasive (66% laparoscopic). Median length of stay was 3.3 days and the early readmission (< 30 d) rate was 6%. Six percent of patients were admitted to the critical care unit. The overall complication and mortality rates were 34% and 2%, respectively. Cholecystitis (31%), appendicitis (21%), bowel obstruction (18%), incarcerated hernia (12%), gastrointestinal hemorrhage (7%) and soft tissue infections (7%) were the most common diagnoses. The morbidity and mortality rates for open surgical procedures were 73% and 5%, respectively., Conclusion: Nontrauma ACS/EGS procedures are associated with a high postoperative morbidity rate. This study will serve as a prospective benchmark for postoperative complications among ACS/EGS patients and subsequent quality improvement across Canada., Competing Interests: Anthony MacLean received a stipend to serve as a faculty member at an Ethicon colorectal surgery bootcamp for the Canadian colorectal surgery fellows. No other competing interests were declared., (© 2020 Joule Inc. or its licensors)

Background and Objectives: Many medical schools assess student clinical knowledge using the National Board of Medical Examiners (NBME) subject examinations. The Family Medicine Clinical Science Mastery Series (CSMS) self-assessments, which are made up of former Family Medicine NBME examination questions, became available in September 2017. They provide students with realistic practice questions and immediate performance feedback. To further assess the utility of various study tools available to our students, this study investigated the impact of the CSMS self-assessments for family medicine on the NBME family medicine subject examination performance., Methods: Data analysis was conducted to compare student performance on the end-of-rotation NBME Family Medicine Clinical Subject Examination before and after the introduction of the CSMS family medicine self-assessments. The effect size was measured using a Cohen d analysis. We conducted an independent t-test analysis to determine the effect the NBME Family Medicine CSMS self-assessments had on end-of-rotation clinical subject examination scores., Results: The analysis revealed statistically significant improvement in students' clinical subject examination scores after the release of the CSMS in September 2017 (n=90) compared to the students' scores prior to the availability of the CSMS (n=95)., Conclusions: Student scores improved with the introduction of the NBME CSMS family medicine self-assessment. These results support recommending student use of the CSMS as a study tool for their end-of-clerkship NBME subject examinations.

Introduction: Technology provides a platform to help address individualized training needs for community preceptors who are separated from the campus and pressured to achieve clinical productivity goals. This study explores technology use and support for delivering faculty development to community preceptors., Methods: This cross-sectional study was part of the 2017 Council of Academic Family Medicine's (CAFM) Educational Research Alliance (CERA) annual survey of family medicine clerkship directors in the United States and Canada., Results: The majority of respondents (n=62, 68.9%) agreed or strongly agreed that "using technology is critical to the successful delivery of faculty development to community preceptors." Only one-third (n=31) agreed or strongly agreed that their institution offers them adequate support to create and deliver technology-mediated faculty development or offers adequate support to community preceptors for accessing and using technology., Conclusions: Clerkship directors need institutional support to provide effective faculty development to preceptors via technology. The opportunity exists for institutions, national organizations, and professions to collaborate across disciplines and health professions on technology-based faculty development to support a level of quality and engagement for faculty development that is consistent with the levels we bring to student education., (© 2019 by the Society of Teachers of Family Medicine.)

Background: In situ trauma simulations allow for the trauma team and emergency department to practise team dynamics, resuscitation and logistics in a safe environment. The goal of this investigation was to show the feasibility of an in situ trauma simulation program at a Canadian level 1 trauma centre., Methods: We performed a retrospective review of in situ simulations (maximum 20 min, followed by a 10-min debriefing session) at a level 1 trauma centre from 2015 to 2017. Errors were categorized according to the National Patient Safety Agency risk assessment matrix by 3 independent raters and assigned consequence scores (assessing potential harm) and likelihood scores (assessing the likelihood of potential harm). A risk score was calculated as the product of the mean consequence and likelihood scores. Errors per simulation and the number of simulations required for error resolution were recorded., Results: We reviewed 8 in situ simulations and identified 54 errors, of which 7 were related to medications, 20 to equipment, 21 to environment/staffing and 6 to training. The mean consequence score was 2.85/5 (standard deviation [SD] 0.75, intraclass correlation coefficient [ICC] 28%), indicating minor to moderate harm. The mean likelihood score was 2.82/5 (SD 0.55, ICC 41%), indicating unlikely to possible. The mean risk score was 8.42/25 (SD 3.19, ICC 43%). One error (2%) was low risk, 23 (43%) were moderate risk, 26 (48%) were high risk, and 4 (7%) were extreme risk., Conclusion: In situ trauma simulations are feasible in a Canadian centre and provide a safe environment to identify and rectify errors., Competing Interests: None declared., (© 2019 Joule Inc. or its licensors)

Background and Objectives: Medical schools are increasingly challenged to recruit and retain community-based preceptors. Physicians experience various incentives and deterrents to teaching medical students while providing patient care. Self-determination theory (SDT) posits people act in response to internal and external motivations and suggests autonomy, competence, and relatedness are basic psychological needs for well-being and integrity. The applicability of SDT to explain why physicians become or remain a preceptor is uncertain. This study explores physicians' motivations for precepting medical students within the framework of SDT., Methods: Focus groups were conducted at seven institutions chosen to represent national diversity using a semistructured interview guide based on SDT. Community-based family physicians discussed benefits and barriers to precepting. Interviews were recorded, transcribed, and coded using open codes. Thematic analysis was performed utilizing the conceptual framework of SDT emphasizing the domains of autonomy, competence, and relatedness., Results: Feeling competent about their medical practice and teaching skills, reporting connectedness to the institution and students, and having autonomy over their teaching increased preceptor motivation to teach. Concerns about clinical workload demands, negative teaching experiences, and institutional bureaucracy decreased motivation., Conclusions: Preceptors choose to become and remain preceptors based on a combination of intrinsic motivating factors and effective external motivators. SDT appears to be a useful framework for assessing and responding to the needs of community-based family medicine preceptors and may be a useful guide for medical educators and policy makers seeking to identify and implement effective strategies to recruit and retain community preceptors to work with medical students.

Introduction: National Board of Medical Examiners (NBME) subject examinations are used by many schools to assess student clinical knowledge. Studies indicate that mean scores on NBME examinations improve as the clinical year progresses. Literature review revealed no studies investigating changes in individual student scores when end-of-block examinations were repeated at the end of the clinical year. This study investigated NBME family medicine subject examination score changes for students who opted to repeat the examination at the end of the academic year., Methods: In 2014, students on a 4-week family medicine block clerkship took the NBME subject examination at the end of their clerkship block and were offered the opportunity to repeat this examination at the end of that clinical year; 25 of 80 students voluntarily repeated the examination. Paired t -tests were used to compare performance outcomes between the exam means at the end of the clerkship blocks to the means on the exam administration at the end of the academic year., Results: Results showed a statistically significant improvement in scores between the first and second examination administration. Examinations given immediately after the students' clinical experience yielded scaled scores ranging from 60 to 80 compared to the national mean of 71.9. Examinations given at the end of the clinical year yielded scaled scores ranging from 57 to 90 ( t [24]=-2.66, P =0.0006)., Conclusion: Repeating the NBME subject examination at the end of the year led to slightly increased scores, suggesting that time spent during clerkships influences examination performance., (© 2019 by the Society of Teachers of Family Medicine.)

Background: Emergency general surgery (EGS) services are gaining popularity in Canada as systems-based approaches to surgical emergencies. Despite the high volume, acuity and complexity of the patient populations served by EGS services, little has been reported about the services' structure, processes, case mix or outcomes. This study begins a national surveillance effort to define and advance surgical quality in an important and diverse surgical population., Methods: A national cross-sectional study of EGS services was conducted during a 24-hour period in January 2017 at 14 hospitals across 7 Canadian provinces recruited through the Canadian Association of General Surgeons Acute Care Committee. Patients admitted to the EGS service, new consultations and off-service patients being followed by the EGS service during the study period were included. Patient demographic information and data on operations, procedures and complications were collected., Results: Twelve sites reported resident coverage. Most services did not include trauma. Ten sites had protected operating room time. Overall, 393 patient encounters occurred during the study period (195/386 [50.5%] operative and 191/386 [49.5%] nonoperative), with a mean of 3.8 operations per service. The patient population was complex, with 136 patients (34.6%) having more than 3 comorbidities. There was a wide case mix, including gallbladder disease (69 cases [17.8%]) and appendiceal disease (31 [8.0%]) as well as complex emergencies, such as obstruction (56 [14.5%]) and perforation (23 [5.9%])., Conclusion: The characteristics and case mix of these Canadian EGS services are heterogeneous, but all services are busy and provide comprehensive operative and nonoperative care to acutely ill patients with high levels of comorbidity.

Background and Objectives: Students on their family medicine clerkship at Herbert Wertheim College of Medicine get little clinical exposure to obstetric care, which is not commonly provided by family physicians in urban settings. To address this, we added to our clerkship didactic curriculum a 2-hour session involving a standardized patient (SP). The SP is collectively interviewed by the student group during four simulated prenatal visits, each of which present a different complication of pregnancy. The goal of this study was to evaluate the students' perception of this session's utility, the session's ability to increase student self-confidence regarding obstetric issues, and perceived relevance of obstetrics to family medicine., Methods: During the 2016-2017 academic year, we evaluated this educational intervention using anonymous, immediate postsession surveys containing both Likert scale and open-ended questions. Qualitative answers were analyzed using a thematic analysis approach, with development of a codebook by consensus., Results: Students overwhelmingly found this session to be pertinent to their learning needs and reported an increase in their self-confidence level regarding obstetrical care. Continuity of care, comprehensive care, and an emphasis on health prevention were identified themes relating how obstetrics embodies the principles of family medicine., Conclusions: We developed this prenatal standardized patient experience to expose our clerkship students to full-spectrum family medicine, including primary care obstetrics. Our data suggests that this session increased students' self-confidence with obstetrics management, filled in gaps in their clinical exposure to full-spectrum family medicine, and addressed a perceived learning need.

Purpose: Community-based faculty play a large role in training medical students nationwide and require faculty development. The authors hypothesized that positive relationships exist between clerkships paying preceptors and requiring faculty development, and between protected clerkship directors' time and delivering face-to-face preceptor training, as well as with the number or length of community-based preceptor visits. Through under standing the quantity, delivery methods, barriers, and institutional support for faculty development provided to community-based preceptors teaching in family medicine clerkships, best practices can be developed., Method: Data from the 2015 Council of Academic Family Medicine's Educational Research Alliance survey of Family Medicine Clerkship Directors were analyzed. The cross-sectional survey of clerkship directors is distributed annually to institutional representatives of U.S. and Canadian accredited medical schools. Survey questions focused on the requirements, delivery methods, barriers, and institutional support available for providing faculty development to community-based preceptors., Results: Paying community-based preceptors was positively correlated with requiring faculty development in family medicine clerkships. The greatest barrier to providing faculty development was community-based preceptor time availability; however, face-to-face methods remain the most common delivery strategy. Many family medicine clerkship directors perform informal or no needs assessment in developing faculty development topics for community-based faculty., Conclusions: Providing payment to community preceptors may allow schools to enhance faculty development program activities and effectiveness. Medical schools could benefit from constructing a formal curriculum for faculty development, including formal preceptor needs assessment and program evaluation. Clerkship directors may consider recruiting and retaining community-based faculty by employing innovative faculty development delivery methods.

Objective: To further the validity of a tool to assess nondirective pregnancy options counseling skills., Methods: Using a cross-sectional design, we explored four sources of construct validity evidence for an objective structured clinical examination for training and assessment of nondirective pregnancy options counseling: content, response process, internal structure, and relations to other variables. Content of the previously developed tool was enhanced through input from five family medicine educators. The objective structured clinical examination was implemented in a family medicine clerkship with third-year medical students from 2014 to 2015 using trained raters. Response process was addressed after a pilot round. Three new raters evaluated videotapes of 46 performances. Cronbach's alpha, intraclass correlation coefficients, and Spearman's rho were estimated with 95% confidence intervals., Results: The content validity was affirmed. Cronbach's alpha was 0.71. According to Landis and Koch's criteria, all but two items unique to the clinical situation of pregnancy options counseling generated substantial to perfect agreement (0.62-1.00). Relations to other variables within the checklist were strong, ranging from 0.66 to 0.87., Discussion: This tool for assessing pregnancy options counseling skills has excellent content and strong internal structure. Further work to improve the Global Rating Scale may be necessary for summative use.

Community health workers (CHWs) collaborating with health care teams improve health outcomes. The feasibility of employing CHWs to support behavioral health in primary care is unknown. We offered experienced CHWs a 48-hour behavioral health training and placed them at health centers. Supervisors received technical assistance to support integration. We interviewed team members to explore CHW interactions with patients and team members. There was evidence of CHW integration. Major CHW roles included care coordination, outreach, and screening. It may be feasible to integrate behavioral health-focused CHWs into primary care settings. Both CHWs and supervisors need ongoing training and support.

Background: The open abdomen is an increasingly used technique that is applied in a wide variety of clinical situations. The ABThera Open Abdomen Negative Pressure Therapy System is one of the most common and successful temporary closure systems, but it has limited ability to close the fascia in approximately 30% of patients. The abdominal reapproximation anchor system (ABRA) is a dynamic closure system that seems ideal to manage patients who may not achieve primary fascial closure with ABThera alone. We report on the use of the ABRA in conjunction with the ABThera in patients with an open abdomen., Methods: We retrospectively analyzed patients with an open abdomen managed with the ABThera and ABRA between January 2007 and December 2012 at the Halifax Infirmary, QEII Health Science Centre, Halifax, Nova Scotia., Results: Sixteen patients had combination therapy using the ABRA and ABThera systems for treatment of the open abdomen. After removing patients who died prior to closure, primary fascial closure was achieved in 12 of 13 patients (92%)., Conclusion: We observed a high rate of primary fascial closure in patients with an open abdomen managed with the ABThera system in conjuction with the ABRA. Applying mechanical traction in addition to the ABThera should be considered in patients predicted to be at high risk for failure to achieve primary fascial closure.

Methylene blue (MB) has been used with some success as a treatment for the vasoplegia of vasopressor-refractory septic shock. The putative mechanism of action of MB is the inhibition of endothelial nitric oxide within the microvasculature and improved responsiveness to endogenous catecholamines (norepinephrine (NE)). However, to date, no study has demonstrated the microcirculatory effect of methylene blue in septic shock. The objective of this randomized, controlled, animal study was to show, in an experimentally-induced, septic shock model in rats, the effects of MB and NE on global hemodynamics and the microcirculation. Mean arterial pressure (MAP) was drastically reduced following bacterial endotoxin (lipopolysaccharide, LPS) administration in animals not receiving vasopressors. Only the combination of NE + MB restored MAP to control levels by the end of the three hour experiment. Intravital microscopy of the microcirculation was performed in the terminal ileum in order to examine functional capillary density in intestinal muscle layers and the mucosa, as well as leukocyte activation in venules (rolling, adhesion to the endothelium). Untreated LPS animals showed a significant increase in leukocyte adhesion and a decrease in capillary perfusion in the intestinal microcirculation. In groups receiving NE or NE+MB, we observed a significant decrease in leukocyte adhesion and improved functional capillary density, indicating that microvasculature function was improved. This study suggests that methylene blue may be able to improve hemodynamics while preserving microvascular function in septic shock.

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Purpose: Methylene blue (MB) has been advocated for the treatment of refractory hemodynamic instability in patients with septic shock. However, the use of MB infusions in septic shock is not considered standard treatment, and the available literature describes infusions of short duration, typically less than six hours., Clinical Features: We report a case of septic shock in a 67-yr-old male who required maximal vasopressor support with norepinephrine, epinephrine, and vasopressin. Despite standard protocols for the treatment of septic shock, the patient's hemodynamic status was refractory 80 hr post admission. However, initiation of a MB infusion resulted in the rapid restoration of hemodynamic stability and a subsequent decrease in vasopressor requirements. Multiple attempts to discontinue the MB infusion resulted in immediate and repeated increases in vasopressor requirements, necessitating a continuous infusion with a slow taper of MB for 120 hr. Ultimately, the patient survived the illness and was discharged home. We observed no adverse events that could be attributed to the use of MB., Conclusion: In our patient, the use of MB resulted in hemodynamic stability unattained with standard vasopressor support. Further research is warranted on the use of MB in patients with septic shock.

Objective: The Paducah Gaseous Diffusion Plant (PGDP) became operational in 1952; it is located in the western part of Kentucky. We conducted a mortality study for adverse health effects that workers may have suffered while working at the plant, including exposures to chemicals., Materials and Methods: We studied a cohort of 6820 workers at the PGDP for the period 1953 to 2003; there were a total of 1672 deaths to cohort members. Trichloroethylene (TCE) is a specific concern for this workforce; exposure to TCE occurred primarily in departments that clean the process equipment. The Life Table Analysis System (LTAS) program developed by NIOSH was used to calculate the standardized mortality ratios for the worker cohort and standardized rate ratio relative to exposure to TCE (the U.S. population is the referent for ageadjustment). LTAS calculated a significantly low overall SMR for these workers of 0.76 (95% CI: 0.72-0.79). A further review of three major cancers of interest to Kentucky produced significantly low SMR for trachea, bronchus, lung cancer (0.75, 95% CI: 0.72-0.79) and high SMR for Non-Hodgkin's lymphoma (NHL) (1.49, 95% CI: 1.02-2.10)., Results: No significant SMR was observed for leukemia and no significant SRRs were observed for any disease. Both the leukemia and lung cancer results were examined and determined to reflect regional mortality patterns. However, the Non-Hodgkin's Lymphoma finding suggests a curious amplification when living cases are included with the mortality experience., Conclusions: Further examination is recommended of this recurrent finding from all three U.S. Gaseous Diffusion plants.

Background: Few studies have addressed the quality of dictated operative reports (ORs). This study documents changes in resident dictation after the introduction of a standardized OR template., Methods: Twenty residents dictated an OR based on a surgical procedure video. Residents were randomized to receive an OR template or no intervention. Residents dictated another report 3 months later. Outcomes measures were dictation quality using a previously validated tool and resident comfort with dictation., Results: There was no overall difference in quality in the intervention group as measured by the Structured Assessment Form (SAF) (28.6 vs 30.0, P = .36) and Global Quality Ratings Scale (GQRS) (21.7 vs 21.8, P = .96). However, junior resident subgroup analysis revealed an improvement in the intervention group on both the SAF (23.2 vs 28.3, P = .02) and GQRS (17.1 vs 20.4, P = .02). Subjective comfort level improved in the intervention group (P = .02)., Conclusions: The operative dictation template can significantly improve resident comfort level with dictation and has the potential to improve the quality of junior resident dictations., (Copyright 2010 Elsevier Inc. All rights reserved.)

The purpose of this study was to determine whether an index of self-reported attention deficits predicts the pattern of visual field asymmetries observed in behavioral measures of attention. Studies of "normal" subjects do not present a consistent pattern of asymmetry in attention functions, with some studies showing better left visual field (LVF) performance, others showing no asymmetry or even a right visual field (RVF) advantage. Here we found that a participant variable (a measure of self-reported attention problems) may help to explain these inconsistencies. We used Conners' Adult ADHD Rating Scales to measure self-reported attention problems in a group of 36 normal (non-ADHD) subjects, and we used two behavioral tasks to directly measure their attentional abilities: a lateralized Attention Network Task (ANT) and a visual search task. Comparing subjects with relatively Low versus High scores on the attention-deficit (AD) scale, we found that subjects with High scores were less efficient in orienting attention to the left visual field. When LVF targets were preceded by a valid spatial cue, response times were positively correlated with AD scores, indicating slower covert-attention shifts as attention-deficit scores increased. Right visual field data showed a different pattern of results. Subjects with High AD scores were at least as efficient as those with Low AD scores in orienting attention to the RVF. This study provides evidence that visual field asymmetries in orienting attention vary across individuals, and that level of self-reported attention problems correlates with behavioral deficiencies in orienting attention to the left visual field., (Copyright 2009 Elsevier Inc. All rights reserved.)

Background: This study tested the effectiveness and perceived value of a palliative/end-of-life (P/EOL) curriculum for junior residents implemented during an intensive care unit (ICU) rotation., Methods: Residents rotating through the ICU over a 6-month period completed pre- and post-curriculum surveys evaluating their self-assessed efficacy in providing P/EOL care and attitudes towards P/EOL care. Scores were analyzed using a paired Student t test., Results: Seventeen of 19 (90%) residents completed both the pre- and post-curriculum evaluations. The P/EOL curriculum increased self-assessed efficacy ratings in the domains of pain management (P = .04), psychosocial knowledge (P = .001), communicator knowledge (P = .001), professional knowledge (P = .002), and manager knowledge (P < .001). The rotation was rated as being valuable in preparing residents to care for patients near the end-of-life (P < .05), with surgery residents indicating it to be the most valuable rotation in their training program for learning about P/EOL care., Conclusions: An ICU P/EOL curriculum improves self-assessed efficacy scores across multiple domains in P/EOL care and is seen as a valuable educational experience.

Background: Despite its multifaceted importance, no validated or reliable tools assess the quality of the dictated operative note. This study determined the construct validity, interrater reliability, and internal consistency of a Structured Assessment Format for Evaluating Operative Reports (SAFE-OR) in general surgery., Methods: SAFE-OR was developed by using consensus criteria set forth by the Canadian Association of General Surgeons. This instrument includes a structured assessment and a global quality rating scale. Residents divided into novice and experienced groups viewed and dictated a videotaped laparoscopic sigmoid colectomy. Blinded, independent faculty evaluators graded the transcribed reports using SAFE-OR., Results: Twenty-one residents participated in the study. Mean structured assessment scores (out of 44) were significantly lower for novice versus experienced residents (23.3 +/- 5.2 vs 34.1 +/- 6.0, t = .001). Mean global quality scores (out of 45) were similarly lower for novice residents (25.6 +/- 4.7 vs 35.9 +/- 7.6, t = .006). Interclass correlation coefficients were .98 (95% confidence interval, .96-.99) for structured assessment and .93 (95% confidence interval, .83-.97) for global quality scales. Cronbach alpha coefficients for internal consistency were .85 for structured assessment and .96 for global quality assessment scales., Conclusions: SAFE-OR shows significant construct validity, excellent interrater reliability, and high internal consistency. This tool will allow educators to objectively evaluate the quality of trainee operative reports and provide a mechanism for implementing, monitoring, and refining curriculum for dictation skills.

Psychosocial and behavioral factors may be strong predictors of adherence to medications in a wide variety of diseases. Newly emerging antiretroviral medications for HIV have been shown to be effective but require near perfect adherence to offer clinically significant benefits. There is currently great interest in deriving patient factors that may predict optimal medication adherence in HIV-positive persons. In this study, we examined the association of psychosocial and behavioral characteristics using the Millon Behavioral Medicine Diagnostic (MBMD; Millon, Antoni, Millon, Meagher, & Grossman, 2001) and adherence to highly active antiretroviral therapy (HAART) among 117 HIV-positive individuals on HAART regimens. Specific indexes of the MBMD were associated with HAART adherence as assessed through patient interview, at baseline assessment, and at 3-month follow-up at a point after which participants had received medication adherence training. As hypothesized, the Medication Abuse scale of the MBMD was uniquely associated with overall adherence at baseline assessment and also predictive of adherence at 3-month follow-up. Additional MBMD scales were also related to overall adherence as well as specific adherence behaviors such as missed doses, following specific instructions, and overmedicating, although the Medication Abuse scale emerged as the most consistent predictor of adherence in the study. These results suggest that the MBMD can be used to predict adherence to HAART medication in a sample of HIV-positive men and women and may subsequently be used to identify those in need of adherence counseling at the point when medications are initiated.

Background: Studies examining AF recurrences post-PVAI base recurrence on patient reporting of symptoms. However, whether asymptomatic recurrences are common is not well known., Objective: To assess the incidence of atrial tachycardia/fibrillation post-PVAI as detected by a PPM and whether these recurrences correlate to symptomatic recurrence., Methods: Eighty-six consecutive patients with symptomatic AF and PPMs with programmable mode-switch capability underwent PVAI. Mode switching was programmed post-PVAI to occur at an atrial-sensed rate of >170 bpm. Patients were followed with clinic visits, ECG, and PPM interrogation at 1, 3, 6, and 9 months post-PVAI. The number and duration of mode-switching episodes (MSEs) were recorded at each visit and is presented as median (interquartile range)., Results: The patients (age 57 +/- 8 years, EF 54 +/- 10%) had paroxysmal (65%) and persistent (35%) AF pre-PVAI. Sensing, pacing, and lead function were normal for all PPMs at follow-up. Of the 86 patients, 20 (23%) had AF recurrence based on symptoms. All 20 of these patients had appropriate MSEs detected. Of the 66 patients without symptomatic recurrence, 21 (32%) had MSEs detected. In 19 of these patients, MSEs were few in number, compared with patients with symptomatic recurrence (16 [4-256] vs 401 [151-2,470], P < 0.01). The durations were all <60 seconds. All of these nonsustained MSEs occurred within the first 3 months post-PVAI, gradually decreasing over time. The other 2 of 21 remaining patients had numerous (1,343 [857-1,390]) and sustained (18 +/- 12 minutes) MSEs that also persisted beyond 3 months (1 beyond 6 months). Therefore, the incidence of numerous, sustained MSEs in asymptomatic patients post-PVAI was 2 of 66 (3%)., Conclusions: Detection of atrial tachyarrhythmias by a PPM occurred in 30% of patients without symptomatic AF recurrence. Most of these episodes were <60 seconds and waned within 3 months. Sustained, asymptomatic episodes were uncommon.