Vancomycin-dependent Enterococcus faecium vanA: characterization of the first case isolated in a university hospital in Brazil

In this study, we report the characterization of a strain of Enterococcus faecium vanA, which grows only in the presence of vancomycin (VDEfm-UEL). The bacterium was isolated from the feces of a female patient who had undergone surgical treatment of Reinke’s edema and was receiving intravenous vancomycin therapy for infection with methicillin/oxacillin-resistant Staphylococcus aureus, a postoperative complication. Antimicrobial dependence was further confirmed by the vancomycin E-test. VDEfm-UEL was also shown to be resistant to ampicillin, ciprofloxacin, chloramphenicol, erythromycin, levofloxacin, penicillin, rifampicin, and teicoplanin. The putative virulence genes efaA, gelE and esp were detected by PCR. The ddl gene from VDEfm-UEL was cloned and sequenced. Vancomycin dependence seems to be associated with the insertion of a nucleotide in that sequence, which results in a frame-shift mutation, introducing a premature stop codon. This is the first report of vancomycin-dependent E. faecium isolation in a university hospital in Brazil.

Characterization and analysis of the outcome of adults with acute myeloid leukemia treated in a Brazilian University hospital over three decades

We evaluated the outcome of 227 patients with acute myeloid leukemia during three decades (period 1 - 1980’s, N = 89; period 2 - 1990’s, N = 73; period 3 - 2000’s, N = 65) at a single institution. Major differences between the three groups included a higher median age, rates of multilineage dysplasia and co-morbidities, and a lower rate of clinical manifestations of advanced leukemia in recent years. The proportion of patients who received induction remission chemotherapy was 66, 75, and 85% for periods 1, 2, and 3, respectively (P = 0.04). The median survival was 40, 77, and 112 days, and the 5-year overall survival was 7, 13, and 22%, respectively (P = 0.01). The median disease-free survival was 266, 278, and 386 days (P = 0.049). Survival expectation for patients with acute myeloid leukemia has substantially improved during this 30-year period, due to a combination of lower tumor burden and a more efficient use of chemotherapy and supportive care.

Study of the comprehension of the scientific method by members of a university health research laboratory

In Brazil, scientific research is carried out mainly at universities, where professors coordinate research projects with the active participation of undergraduate and graduate students. However, there is no formal program for the teaching/learning of the scientific method. The objective of the present study was to evaluate the comprehension of the scientific method by students of health sciences who participate in scientific projects in an academic research laboratory. An observational descriptive cross-sectional study was conducted using Edgar Morin complexity as theoretical reference. In a semi-structured interview, students were asked to solve an abstract logical puzzle - TanGram. The collected data were analyzed using the hermeneutic-dialectic analysis method proposed by Minayo and discussed in terms of the theoretical reference of complexity. The students’ concept of the scientific method is limited to participation in projects, stressing the execution of practical procedures as opposed to scientific thinking. The solving of the TanGram puzzle revealed that the students had difficulties in understanding questions and activities focused on subjects and their processes. Objective answers, even when dealing with personal issues, were also reflected on the students’ opinions about the characteristics of a successful researcher. Students’ difficulties concerning these issues may affect their scientific performance and result in poorly designed experiments. This is a preliminary study that should be extended to other centers of scientific research.

Clinical outcome of protein-energy malnourished patients in a Brazilian university hospital

Protein-energy malnutrition (PEM) is a treatable disease with high prevalence among hospitalized patients. It can cause significant increases in the duration of hospitalization and costs. PEM is especially important for health systems since malnourished patients present higher morbidity and mortality. The objective of the present study was to assess the evolution of nutritional status (NS) and the effect of malnutrition on clinical outcome of patients at a public university hospital of high complexity in Brazil. Patients hospitalized in internal medicine (n = 54), oncology (n = 43), and infectious diseases (n = 12) wards were included. NS was evaluated using subjective global assessment up to 48 h after admission, and thereafter at intervals of 4-6 days. On admission, patients (n = 109) were classified as well-nourished (n = 73), moderately malnourished or at risk of malnutrition (n = 28), and severely malnourished (n = 8). During hospitalization, malnutrition developed or worsened in 11 patients. Malnutrition was included in the clinical diagnosis of only 5/36 records (13.9% of the cases, P = 0.000). Nutritional therapy was administered to only 22/36 of the malnourished patients; however, unexpectedly, 6/73 well-nourished patients also received commercial enteral diets. Complications were diagnosed in 28/36 malnourished and 9/73 well-nourished patients (P = 0.000). Death occurred in 12/36 malnourished and 3/73 well-nourished patients (P = 0.001). A total of 24/36 malnourished patients were discharged regardless of NS. In summary, malnutrition remains a real problem, often unrecognized, unappreciated, and only sporadically treated, even though its effects can be detrimental to the clinical course and prognosis of patients. The amount of public and private funds unnecessarily dispersed because of hospital malnutrition is significant.

Basic life support knowledge of first-year university students from Brazil

We aimed to evaluate knowledge of first aid among new undergraduates and whether it is affected by their chosen course. A questionnaire was developed to assess knowledge of how to activate the Mobile Emergency Attendance Service - MEAS (Serviço de Atendimento Móvel de Urgência; SAMU), recognize a pre-hospital emergency situation and the first aid required for cardiac arrest. The students were also asked about enrolling in a first aid course. Responses were received from 1038 of 1365 (76.04%) new undergraduates. The questionnaires were completed in a 2-week period 1 month after the beginning of classes. Of the 1038 respondents (59.5% studying biological sciences, 11.6% physical sciences, and 28.6% humanities), 58.5% knew how to activate the MEAS/SAMU (54.3% non-biological vs 61.4% biological, P=0.02), with an odds ratio (OR)=1.39 (95%CI=1.07-1.81) regardless of age, sex, origin, having a previous degree or having a relative with cardiac disease. The majority could distinguish emergency from non-emergency situations. When faced with a possible cardiac arrest, 17.7% of the students would perform chest compressions (15.5% non-biological vs 19.1% biological first-year university students, P=0.16) and 65.2% would enroll in a first aid course (51.1% non-biological vs 74.7% biological, P<0.01), with an OR=2.61 (95%CI=1.98-3.44) adjusted for the same confounders. Even though a high percentage of the students recognized emergency situations, a significant proportion did not know the MEAS/SAMU number and only a minority had sufficient basic life support skills to help with cardiac arrest. A significant proportion would not enroll in a first aid course. Biological first-year university students were more prone to enroll in a basic life support course.

Prevalence of child malnutrition at a university hospital using the World Health Organization criteria and bioelectrical impedance data

Malnutrition constitutes a major public health concern worldwide and serves as an indicator of hospitalized patients’ prognosis. Although various methods with which to conduct nutritional assessments exist, large hospitals seldom employ them to diagnose malnutrition. The aim of this study was to understand the prevalence of child malnutrition at the University Hospital of the Ribeirão Preto Medical School, University of São, Brazil. A cross-sectional descriptive study was conducted to compare the nutritional status of 292 hospitalized children with that of a healthy control group (n=234). Information regarding patients’ weight, height, and bioelectrical impedance (i.e., bioelectrical impedance vector analysis) was obtained, and the phase angle was calculated. Using the World Health Organization (WHO) criteria, 35.27% of the patients presented with malnutrition; specifically, 16.10% had undernutrition and 19.17% were overweight. Classification according to the bioelectrical impedance results of nutritional status was more sensitive than the WHO criteria: of the 55.45% of patients with malnutrition, 51.25% exhibited undernutrition and 4.20% were overweight. After applying the WHO criteria in the unpaired control group (n=234), we observed that 100.00% of the subjects were eutrophic; however, 23.34% of the controls were malnourished according to impedance analysis. The phase angle was significantly lower in the hospitalized group than in the control group (P<0.05). Therefore, this study suggests that a protocol to obtain patients’ weight and height must be followed, and bioimpedance data must be examined upon hospital admission of all children.

The implications of being an international medical graduate (IMG) in Canadian society : a qualitative study of foreign-trained physicians' resettlement, sense of identity and health status

This qualitative research study used grounded theory methodology to explore the settlement experiences and changes in professional identity, self esteem and health status of foreign-trained physicians (FTPs) who resettled in Canada and were not able to practice their profession. Seventeen foreign-trained physicians completed a pre-survey and rated their health status, quality of life, self esteem and stress before and after coming to Canada. They also rated changes in their experiences of violence and trauma, inclusion and belonging, and racism and discrimination. Eight FTPs from the survey sample were interviewed in semi-structured qualitative interviews to explore their experiences with the loss of their professional medical identities and attempts to regain them during resettlement. This study found that without their medical license and identity, this group of FTPs could not fully restore their professional, social, and economic status and this affected their self esteem and health status. The core theme of the loss of professional identity and attempts to regain it while being underemployed were connected with the multifaceted challenges of resettlement which created experiences of lowered selfesteem, and increased stress, anxiety and depression. They identified the re-licensing process (cost, time, energy, few residency positions, and low success rate) as the major barrier to a full and successful settlement and re-establishment of their identities. Grounded research was used to develop General Resettlement Process Model and a Physician Re-licensing Model outlining the tasks and steps for the successfiil general resettlement of all newcomers to Canada with additional process steps to be accomplished by foreign-trained physicians. Maslow's Theory of Needs was expanded to include the re-establishment of professional identity for this group to re-establish levels of safety, security, belonging, self-esteem and self-actualization. Foreign-trained physicians had established prior professional medical identities, self-esteem, recognition, social status, purpose and meaning and bring needed human capital and skills to Canada. However, without identifying and addressing the barriers to their full inclusion in Canadian society, the health of this population may deteriorate and the health system of the host country may miss out on their needed contributions.

An assessment of autism knowledge in the medical field

Once thought to be rare, pervasive developmental disorders (PDDs) are now recognized as the most common neurological disorders affecting children and one of the most common developmental disabilities (DD) in Canada (Autism Society of Canada, 2006). Recent reports indicate that PDDs currently affect 1 in 150 children (Centre for Disease Control and Prevention, 2007). The purpose of this research was to provide an understanding of medical resident and practicing physicians' basic knowledge regarding PDDs. With a population of children with PDDs who present with varying symptoms, the ability for medical professionals to provide general information, diagnosis, appropriate referrals, and medical care can be quite complex. A basic knowledge of the disorder is only a first step in providing adequate medical care to individuals with autism and their families. An updated version of Stone's (1987) Autism survey was administered to medical residents at four medical schools in Canada and currently practicing physicians at three medical schools and one community health network. As well, a group of professionals specializing in the field ofPDDs, participating in research and clinical practice, were surveyed as an 'expert' group to act as a control measure. Expert responses were consistent with current research in the field. General findings indicated few differences in overall knowledge between residents and physicians, with misconceptions evident in areas such as the nature of the disorder, qualitative characteristics of autism, and effective interventions. Results were also examined by specialty and, while pediatricians demonstrated additional accurate 11 knowledge regarding the nature of the disorder and select qualitative impairments, both residents and practicing physicians demonstrated misconceptions about PDDs. This preliminary study replicated the findings of Stone (1987) and Heidgerken (2005) concerning several misconceptions of PDDs held by residents and practicing physicians. Future research should focus on additional replications with validated measures as well as the gathering of qualitative information, in order to inform the medical profession of the need for education in PDDs at training and professional levels.

Opioid poisoning and availability of specialized medical care in Ontario, 2002-2006

The prescription of opioid analgesics has risen sharply in North America over the past two decades. This increase has been accompanied by a rise in overdoses. The present study draws on administrative data collected from emergency department contacts to describe the epidemiology of opioid overdose in Ontario b~tween 2002 and 2006 and to examine the role of regional variation in availability of specialist care. The number of poisonings increased from 1250 (10.9 per 100,000) in FY2002 to 1816 (15.2 per 100,000) in FY2005. Local concentration of specialist physicians was significantly associated with the incidence of opioid overdose, inversely at most levels of availability, but positively at very high levels. Regional variation in incidence was also associated with demographics, median family income, and the rate of other drug poisonings. Policy options for limiting opioid-related harms are limited, but improvements in monitoring and clinical management may prove valuable.

Office of the University President Sous fonds: Dr. James A. Gibson

Dr. James A. Gibson was born in Ottawa on January 29, 1912 to John W. and Belle Gibson. At an early age the family moved to Victoria, B.C. where John W. Gibson was a director of the Elementary Agricultural Education Branch, Department of Education. Gibson received his early education in Victoria, receiving a B.A. (honours) at UBC in 1931. In 1931 he was awarded the Rhodes scholarship and received his B.A., M.A., B.Litt and D. Phil at New College, Oxford. This was to be the beginning of a long and dedicated relationship with the Rhodes Scholar Association. Upon his return to Canada, Dr. Gibson lectured in Economics and Government at the University of British Columbia. In 1938 he was married to Caroline Stein in Philadelphia, and the same year joined the staff of the Department of External Affairs as a Foreign Service officer. Within twenty minutes of his arrival he was seconded to the Office of the Prime Minister and Secretary of State for External Affairs, W. L. Mackenzie King in charge of War Records and Liaison Officer. This was a critical time in the history of Canada, and Dr. Gibson experienced firsthand several milestones, including the Royal Visit of King George VI and Queen Elizabeth in 1939. Dr. Gibson was present at the formation of the United Nations in San Francisco in 1945, being part of the Prime Minister’s professional staff as well as attending conferences in Washington, Quebec and London as an advisor to the Canadian delegation. Gibson contributed many articles to the publication bout de papier about his experiences during these years. After his resignation in 1947, Gibson joined the staff of the fledgling Carleton College, as a lecturer. In 1949 he was appointed a professor and in 1951 became Dean of Arts and Sciences. Dr. Gibson acted as President from 1955 to 1956 upon the sudden death of Dr. MacOdrum. In 1963 Dr. Gibson accepted the invitation of the Brock University Founders’ Committee, chaired by Arthur Schmon, to become the founding president. Dr. Gibson guided the new University from a converted refrigeration plant, to an ever expanding University campus on the brow of the Niagara Escarpment. Dr. Gibson remained firmly “attached” to Brock University. Even after official retirement, in 1974, he retained the title President Emeritus. Gibson’s final official contribution was an unpublished ten year history of the University. In retirement Gibson remained active in scholarly pursuits. He was a visiting scholar at the Center of Canadian Studies, University of Edinburgh; continued his ongoing research activities focusing on W. L. Mackenzie King, the Office of the Governor General of Canada, and political prisoners transported to Van Dieman’s Land. He remained active in the Canadian Association of Rhodes Scholars, becoming editor from 1975 to 1994 and was appointed Editor Emeritus and Director for Life in 1995 in honour of his dedicated and outstanding service. In 1993 he was awarded one of Canada’s highest achievements, the Order of Canada. Gibson retained close ties with Brock University and many of its faculty. He maintained an office in the Politics Department where he became a vital part of the department. In 1996 Brock University honoured Gibson by naming the University Library in his honour. James A. Gibson Library staff was instrumental in celebrating the 90th birthday of Gibson in 2002, with a widely attended party in the Pond Inlet where many former students, including Silver Badgers. The attendees also included former and current colleagues from Brock University, Canadian Rhodes Scholars Association, family and friends. Gibson was later to remark that the highlight of this event was the gift of his original academic robe which he had personally designed in 1964. In 2003 Dr. Gibson moved to Ottawa to be near some of his children and the city of his birth and early career. In that year “two visits to Brock ensued: the first, to attend a special celebration of the James A. Gibson Library; his late to attend the 74th Convocation on Saturday, October 18, 2003. A week later, in Ottawa, he went for a long walk, returned to his residence, Rideau Gardens, went into the lounge area, took off his coat and folded it up, put it on the back of his chair, sat down, folded his hands in his lap, closed his eyes, and died”. With sources from: Carleton University The Charlatan, Gibson CV, and Memorial Service Programme

Understanding Continuance Intentions of Physicians with Electronic Medical Records (EMRS): An Expectancy-Confirmation Perspective

This thesis examines physicians’ satisfaction with electronic medical records (EMRs) in the post-adoption phase. More specifically, the study examines how physicians’ satisfaction with EMRs impacts on their intention to continue using as well as extend their adoption of additional functions of EMRs. Expectation-confirmation theory is used with the incorporation of perceived risk as the theoretical framework. The extended theoretical model is used to formulate eight hypotheses to aid in the understanding of physicians’ continuance intentions. A field survey of 135 Canadian physicians that utilize EMRs was performed to test the model empirically. The study found that physicians are willing to continue using and adopting additional components of EMRs. In addition, the empirical results suggest that physicians’ perceived usefulness and perceived risk impacts satisfaction, which in turn influences physicians’ continuance intentions. As well, perceived risk has an influence on physicians’ continuance intentions directly.

A Narrative Study of Patient Encounter Accounts of Physicians, Nurses, and Medical Receptionists after Two Decades of a Paradigm of Patient-Centered Care

Despite recent well-known advancements in patient care in the medical fields, such as patient-centeredness and evidence-based medicine and practice, there is rather less known about their effects on the particulars of clinician-patient encounters. The emphasis in clinical encounters remains mostly on treatment and diagnosis and less on communicative competency or engagement for medical professionals. The purpose of this narrative study was to explore interactive competencies in diagnostic and therapeutic encounters and intake protocols within the context of the physicians’, nurses’, and medical receptionists’ perspectives and experiences. Literature on narrative medicine, phenomenology and medicine, therapeutic relationships, cultural and communication competency, and non-Western perspectives on human communication provided the guiding theoretical frameworks for the study. Three data sets including 13 participant interviews (5 physicians, 4 nurses, and 4 medical receptionists), policy documents (physicians, nurses, and medical receptionists) and a website (Communication and Cultural Competency) were used. The researcher then engaged in triangulated analyses, including N-Vivo, manifest and latent, Mishler’s (1984, 1995) narrative elements and Charon’s (2005, 2006a, 2006b, 2013) narrative themes, in recursive, overlapping, comparative and intersected analysis strategies. A common factor affecting physicians’ relationships with their clients was limitation of time, including limited time (a) to listen, (b) to come up with a proper diagnosis, and (c) to engage in decision making in critical conditions and limited time for patients’ visits. For almost all nurse participants in the study establishing therapeutic relationships meant being compassionate and empathetic. The goals of intake protocols for the medical receptionists were about being empathetic to patients, being an attentive listener, developing rapport, and being conventionally polite to patients. Participants with the least iv amount of training and preparation (medical receptionists) appeared to be more committed to working narratively in connecting with patients and establishing human relationships as well as in listening to patients’ stories and providing support to narrow down the reason for their visit. The diagnostic and intake “success stories” regarding patient clinical encounters for other study participants were focused on a timely securing of patient information, with some acknowledgement of rapport and emapathy. Patient-centeredness emerged as a discourse practice, with ambiguous or nebulous enactment of its premises in most clinical settings.

Conflict of Interest Policies at Canadian Universities and Medical Schools: Some Lessons from the AMSA PharmFree Scorecard

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