[Can we increase the availability of decision aids in French-speaking Switzerland?]

Models of shared decision making recommend the use of patient decision aids. Hundreds of such aids exist worldwide but scaling up of their use in French-speaking Switzerland requires their translation to French and their adaptation to the clinical context. We review seven sources of tools that we assume relevant for French-speaking Switzerland. A short survey on a selection of three decision aids of general practitioners in the canton of Vaud confirmed their general interest in using such tools. They preferred a limited amount and a simple presentation of information in the decision aids to facilitate integration in clinical practice. Given the complexity of the required translations and adaptations, the medical community should develop a collaborative approach to lift this important task.

Canadian Older Adults' Intention to Use an Electronic Decision Aid for Housing Decisions: Cross-sectional Web-Based Survey

BACKGROUND

Older adults with disabilities such as loss of autonomy face the decision of whether to stay at home or move to a health care facility such as a nursing home. Therefore, they may need support for this difficult decision.

OBJECTIVE

We assessed the intention of Canadian older adults to use an electronic decision aid (eDA) to make housing decisions and identified the factors that influenced their intention.

METHODS

We conducted a cross-sectional study using a web-based survey targeting older adults across 10 Canadian provinces and 3 territories. We included respondents from a web-based panel who were aged ≥65 years, understood English or French, had access to an electronic device with an internet connection, and had made a housing decision over the past few months or were planning to make a decision in the coming year. We based the web-based survey on the Unified Theory of Acceptance and Use of Technology (UTAUT). We adapted 17 UTAUT items to measure respondents' intention to use the eDA for housing decisions, as well as items measuring 4 intention constructs (performance expectancy, effort expectancy, social influence, and facilitating conditions). We also assessed eHealth literacy using both subjective and objective scales. We used descriptive statistics and multivariable linear regression analyses to identify the factors influencing the intention to use the eDA.

RESULTS

Of the 11,972 invited panelists, 1176 (9.82%) met the eligibility criteria, and 1000 (85.03%) respondents completed the survey. The mean age was 72.5 (SD 5.59) years. Most respondents were male (548/1000, 54.8%), White (906/1000, 90.6%), English speakers (629/1000, 62.9%), and lived in Ontario or Quebec (628/1000, 62.8%) and in urban areas (850/1000, 85%). The mean scores were 27.8 (SD 5.88) out of 40 for subjective eHealth literacy and 3.00 (SD 0.97) out of 5 for objective eHealth literacy. In our sample, the intention score was 4.74 (SD 1.7) out of 7. The mean scores of intention constructs out of 7 were 5.63 (SD 1.28) for facilitating conditions, 4.94 (SD 1.48) for performance expectancy, 5.61 (SD 1.35) for effort expectancy, and 4.76 (SD 1.59) for social influence. In the final model, the factors associated with intention included mother tongue (β=.30; P<.001), objective eHealth literacy (β=-.06; P=.03), performance expectancy (β=.55; P<.001), social influence (β=.37; P<.001), and facilitating conditions (β=.15; P<.001).

CONCLUSIONS

Findings from this pan-Canadian web-based survey on Canadian older adults suggest that their intention to use the eDA to make housing decisions is similar to the findings in other studies using UTAUT. The factors identified as influencing intention were mother tongue, objective eHealth literacy, performance expectancy, social influence, and facilitating conditions. These will guide future strategies for the implementation of the eDA.

Enabling Healthy Aging to AVOID Frailty in Community Dwelling Older Canadians

The Canadian population is aging. With aging, biological and social changes occur increasing the risk of developing chronic conditions and functional loss leading to frailty. Older adults living with frailty are more vulnerable to minor stressors, take longer to recover from illness, and have difficulty participating in daily activities. The Canadian Frailty Network's (CFN) mission is to improve the lives of older adults living with frailty. In September 2019, CFN launched the Activity & Exercise, Vaccination, Optimization of medications, Interaction & Socialization, and Diet & Nutrition (AVOID) Frailty public health campaign to promote assessing and reducing risk factors leading to the development of frailty. As part of the campaign, CFN held an Enabling Healthy Aging Symposium with 36 stakeholders from across Canada. Stakeholders identified individual and community-level opportunities and challenges for the enablement of healthy aging and frailty mitigation, as part of a focused consultative process. Stakeholders ranked the three most important challenges and opportunities at the individual and community levels for implementing AVOID Frailty recommendations. Concrete actions, further research areas, policy changes, and existing resources/programs to enhance the AVOID Frailty campaign were identified. The results will help inform future priorities and behaviour change strategies for healthy aging in Canada.

Technology implementation in care practices for community-dwelling older adults with mild cognitive decline: Perspectives of professional caregivers in Quebec and Brussels

OBJECTIVE

As worldwide population aging is accelerating, innovative technologies are being developed to support independent living among community-dwelling older adults with mild cognitive decline. However, the successful implementation of these interventions is often challenging. Until now, literature on implementation issues related to the specific context of older adults with mild cognitive decline is lacking and the few studies available do not focus specifically on the perspective of professional caregivers. Yet the perspective of these caregivers is important as they can be considered a key facilitator for technology implementation among this population. Therefore, this study was the first to examine technology implementation among community-dwelling older adults with mild cognitive decline from the broader perspective of professional caregivers.

METHODS

In this qualitative study, two focus groups consisting of a heterogeneous pool of professional caregivers were conducted: one in Quebec (Canada, n = 6) and one in Brussels (Belgium, n = 8). Braun and Clarke' method for thematic analysis, guided by a qualitative descriptive approach was applied to inductively identify themes from the data.

RESULTS

We identified factors influencing technology implementation in older adults with mild cognitive decline on three levels: an individual level (e.g., characteristics of older adults with mild cognitive decline and professional caregivers' attitude), an organizational level (e.g., lack of training among professional caregivers) and a level referring to the broader context (e.g., ethical considerations).

CONCLUSIONS

This study contributes to the research gap in knowledge on the needs of professional caregivers to facilitate technology implementation among the population of older adults with cognitive decline. Future directions for research, practice, and policy are given, more specifically to improve knowledge among caregivers and on the development of decision support to retrieve safe and effective technologies that suit patient-centered care.

Discontinuation of bisphosphonates in seniors: a systematic review on health outcomes

PURPOSE

Bisphosphonates are used to treat osteoporosis. Despite their benefits on bone mineral density (BMD) and fractures, they have shown adverse effects, sometimes severe, during chronic use. Taken for several years, they achieve long-term bone retention, making deprescribing feasible. This review aimed to synthesize evidence on the success and health outcomes of deprescribing of bisphosphonates in seniors, aged over 60 years.

METHODS

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including articles in English, French, or German published before July 2020. Eligible studies included seniors having discontinued bisphosphonates and reported on health outcomes; some allowed meta-analyses on fracture risk.

RESULTS

The review included 9 RCTs and 9 cohort studies of moderate quality. Bisphosphonates were discontinued after 2 to 7 years of use, and BMD or fractures were assessed during follow-up of 0.5 to 5 years. A significant reduction in BMD after discontinuation was observed in 9 of 10 studies. Results on fracture risk after discontinuation are mitigated: 6 RCT extensions showed no increase in the risk of any osteoporotic fractures after discontinuation. Meta-analyses including 4 RCTs showed an increased odds ratio of vertebral fractures of 2.04 (95% CI, 1.39-2.99) among discontinuers. Results from 2 large cohort studies showed no increased risks of any osteoporotic or vertebral fractures, while 2 studies found increased fracture risks.

CONCLUSION

Bisphosphonates have successfully been discontinued low overall fracture risk after at least 3 years of use, but a risk for decreased BMD and increased vertebral fractures remained.

The Effectiveness of e-Health Solutions for Aging With Cognitive Impairment: A Systematic Review

Background and Objectives

e-Health solutions are an innovative approach to support aging with cognitive impairment. Because technology is developing at a fast pace, the aim of this review was to present an overview of the research regarding the effectiveness of these solutions. Moreover, the availability of these solutions was examined.

Research Design and Methods

Systematic searches were conducted in 7 databases. Full texts of potentially relevant references were assessed by 2 reviewers, and discrepancies were solved through discussion. Data on study characteristics, technology type, application domain, availability, outcomes, and effects were extracted. A categorization exercise and narrative synthesis were conducted.

Results

In total, 72 studies describing 70 e-Health solutions were identified. The majority of solutions comprised cognitive training for older adults, followed by educational and supportive web platforms for caregivers. Outcomes included mainly measures of cognition, psychosocial functioning, caregiving processes, caregiver–care receiver relationship, and activities of daily living. Positive effects of cognitive training technologies were observed on cognitive functioning of older adults, as well as those of supportive web platforms on behavioral and psychological symptoms of dementia and caregiver self-efficacy. The effects of these solutions on depression in both target groups were inconclusive. The methodological quality of the studies was moderate to good. However, some important limitations were observed.

Discussion and Implications

The review identified cognitive training solutions and supportive web platforms as the most effective on a limited number of outcomes. Although other solutions seem promising, further research has to overcome methodological issues. Furthermore, solutions for leisure and reminiscence and outcomes specifically related to independent living deserve more attention.

Printed educational materials: effects on professional practice and healthcare outcomes

BACKGROUND

Printed educational materials are widely used dissemination strategies to improve the quality of healthcare professionals' practice and patient health outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines. This is the fourth update of the review.

OBJECTIVES

To assess the effect of printed educational materials (PEMs) on the practice of healthcare professionals and patient health outcomes. To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on healthcare professionals' practice and patient health outcomes.

SEARCH METHODS

We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and EPOC Register from their inception to 6 February 2019. We checked the reference lists of all included studies and relevant systematic reviews.

SELECTION CRITERIA

We included randomised trials (RTs), controlled before-after studies (CBAs) and interrupted time series studies (ITSs) that evaluated the impact of PEMs on healthcare professionals' practice or patient health outcomes. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. Any objective measure of professional practice (e.g. prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included.

DATA COLLECTION AND ANALYSIS

Two reviewers undertook data extraction independently. Disagreements were resolved by discussion. For analyses, we grouped the included studies according to study design, type of outcome and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where data were available, we re-analysed the ITS studies by converting all data to a monthly basis and estimating the effect size from the change in the slope of the regression line between before and after implementation of the PEM. We reported median changes in slope for each outcome, for each study, and then across studies. We standardised all changes in slopes by their standard error, allowing comparisons and combination of different outcomes. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format. We assessed the risks of bias of all the included studies.

MAIN RESULTS

We included 84 studies: 32 RTs, two CBAs and 50 ITS studies. Of the 32 RTs, 19 were cluster RTs that used various units of randomisation, such as practices, health centres, towns, or areas. The majority of the included studies (82/84) compared the effectiveness of PEMs to no intervention. Based on the RTs that provided moderate-certainty evidence, we found that PEMs distributed to healthcare professionals probably improve their practice, as measured with dichotomous variables, compared to no intervention (median absolute risk difference (ARD): 0.04; interquartile range (IQR): 0.01 to 0.09; 3,963 healthcare professionals randomised within 3073 units). We could not confirm this finding using the evidence gathered from continuous variables (standardised mean difference (SMD): 0.11; IQR: -0.16 to 0.52; 1631 healthcare professionals randomised within 1373 units ), from the ITS studies (standardised median change in slope = 0.69; 35 studies), or from the CBA study because the certainty of this evidence was very low. We also found, based on RTs that provided moderate-certainty evidence, that PEMs distributed to healthcare professionals probably make little or no difference to patient health as measured using dichotomous variables, compared to no intervention (ARD: 0.02; IQR: -0.005 to 0.09; 935,015 patients randomised within 959 units). The evidence gathered from continuous variables (SMD: 0.05; IQR: -0.12 to 0.09; 6,737 patients randomised within 594 units) or from ITS study results (standardised median change in slope = 1.12; 8 studies) do not strengthen these findings because the certainty of this evidence was very low. Two studies (a randomised trial and a CBA) compared a paper-based version to a computerised version of the same PEM. From the RT that provided evidence of low certainty, we found that PEM in computerised versions may make little or no difference to professionals' practice compared to PEM in printed versions (ARD: -0.02; IQR: -0.03 to 0.00; 139 healthcare professionals randomised individually). This finding was not strengthened by the CBA study that provided very low certainty evidence (SMD: 0.44; 32 healthcare professionals). The data gathered did not allow us to conclude which PEM characteristics influenced their effectiveness. The methodological quality of the included studies was variable. Half of the included RTs were at risk of selection bias. Most of the ITS studies were conducted retrospectively, without prespecifying the expected effect of the intervention, or acknowledging the presence of a secular trend.

AUTHORS' CONCLUSIONS

The results of this review suggest that, when used alone and compared to no intervention, PEMs may slightly improve healthcare professionals' practice outcomes and patient health outcomes. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

User-Centered Design for Promoting Patient Engagement in Chronic Diseases Management: The Development of CONCERTO

Multimorbidity increases care needs among people with chronic diseases. In order to support communication between patients, their informal caregivers and their healthcare teams, we developed CONCERTO+, a patient portal for chronic disease management in primary care. A user-centered design comprising 3 iterations with patients and informal caregivers was performed. Clinicians were also invited to provide feedback on the feasibility of the solution. Several improvements were brought to CONCERTO+, and it is now ready to be implemented in real-life setting.

e-Health interventions for healthy aging: a systematic review

BACKGROUND

Healthy aging (HA) is a contemporary challenge for population health worldwide. Electronic health (e-Health) interventions have the potential to support empowerment and education of adults aged 50 and over.

OBJECTIVES

To summarize evidence on the effectiveness of e-Health interventions on HA and explore how specific e-Health interventions and their characteristics effectively impact HA.

METHODS

A systematic review was conducted based on the Cochrane Collaboration methods including any experimental study design published in French, Dutch, Spanish, and English from 2000 to 2018.

RESULTS

Fourteen studies comparing various e-Health interventions to multiple components controls were included. The target population, type of interventions, and outcomes measured were very heterogeneous across studies; thus, a meta-analysis was not possible. However, effect estimates indicate that e-Health interventions could improve physical activity. Positive effects were also found for other healthy behaviors (e.g., healthy eating), psychological outcomes (e.g., memory), and clinical parameters (e.g., blood pressure). Given the low certainty of the evidence related to most outcomes, these results should be interpreted cautiously.

CONCLUSIONS

This systematic review found limited evidence supporting the effectiveness of e-Health interventions, although the majority of studies show positive effects of these interventions for improving physical activity in older adults. Thus, better quality evidence is needed regarding the effects of e-Health on the physiological, psychological, and social dimensions of HA.

SYSTEMATIC REVIEW REGISTRATION

The review protocol was registered in PROSPERO (registration number: CRD42016033163).

A computerized and innovative tool to guide interdisciplinary assessment: Exploring the feasibility of the implementation of the Competency Assessment Tool (CAT)

An electronic tool, the Competency Assessment Tool (CAT), was developed in order to guide interdisciplinary teams through clinical competency assessment.

OBJECTIVES

To support the implementation and perpetuation of the CAT, the objectives were: 1) document health and social service professionals' needs in order to support the use of the CAT; 2) identify the facilitating factors and those hindering the implementation of the CAT in a healthcare establishment; 3) identify strategies favoring the use of the CAT.

PARTICIPANTS

Health and social service professionals and doctors were recruited.

METHODS

A qualitative study was realized by conducting focus groups with health and social service professionals and individual interviews with doctors.

RESULTS

The results allowed us to bring to light the CAT's advantages, the issues associated with its implementation (facilitators and obstacles) and the needs to support its use. A number of avenues of intervention were identified and could be put in place to encourage the use of the CAT.

CONCLUSION

This study will support the implementation of the CAT and ultimately, this will allow for the assurance that the decisions taken on the need for protection of vulnerable individuals will be just, rigorous and the fruit of a concerted ethical reflection.

Supporting early academic family medicine careers with the clinician scholar enhanced-skills program

CONTEXT

The Clinician Scholar Program (CSP) is an enhanced-skills (R3) residency program to train clinician researchers/educators/leaders for academic family practice. This article intends to share Laval University's CSP development and evaluation strategy, and provide recommendations for similar innovations in other disciplines/settings.

METHODS

This article uses Kern's model to present the program development, and a program-oriented approach for program evaluation, carried from 2011 to 2017 using descriptive data. Questionnaires, reflexive texts and an Objective Structured Teaching Exam supported data collection.

RESULTS

Seven CSP graduates and 14 controls participated in the program evaluation. Residents were highly satisfied with the program, nevertheless they suggested to allow physicians to come back for training later in career. The CSP enriched knowledge, skills and attitudes about academic practice. CSP increased residents' entrustment level about academic competencies. All graduates joined an academic practice within five years of program completion.

CONCLUSION

Key recommendations to implement similar programs include academic medicine core training, project- based learning with learner-centered objectives, relevant and authentic learning and assessment, and multi-level program evaluation approach. Programs should consider concomitant graduate studies and opportunity to offer such training after a few years of clinical practice to meet other needs at a timely stage of career.

Optimising patient active role with a user-centred eHealth platform (CONCERTO+) in chronic diseases management: a study protocol for a pilot cluster randomised controlled trial

INTRODUCTION

Multimorbidity increases care needs and primary care use among people with chronic diseases. The Concerto Health Program (CHP) has been developed to optimise chronic disease management in primary care services. However, in its current version, the CHP primarily targets clinicians and does not aim to answer directly patients' and their informal caregivers' needs for chronic disease management. Various studies have shown that interventions that increase patient activation level are associated with better health outcomes. Furthermore, educational tools must be adapted to patients and caregivers in terms of health literacy and usability. This project aims to develop, implement and evaluate a user-centred, multifunctional and personalised eHealth platform (CONCERTO+) to promote a more active patient role in chronic disease management and decision-making.

METHODS AND ANALYSIS

This project uses a collaborative research approach, aiming at the personalisation of CHP through three phases: (1) the development of one module of an eHealth platform based on scientific evidence and user-centred design; (2) a feasibility study of CONCERTO+ through a pilot cluster randomised controlled trial where patients with chronic diseases from a primary healthcare practice will receive CONCERTO+ during 6 months and be compared to patients from a control practice receiving usual care and (3) an analysis of CONCERTO+ potential for scaling up. To do so, we will conduct two focus groups with patients and informal caregivers and individual interviews with health professionals at the two study sites, as well as health care managers, information officers and representatives of the Ministry of Health.

ETHICS AND DISSEMINATION

This study received ethical approval from Ethics Committee of Université Laval. The findings will be used to inform the effectiveness of CONCERTO+ to improve management care in chronic diseases. We will disseminate findings through presentations in scientific conferences and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03628963; Pre-results.

Design and implementation of the Competency Assessment Tool (CAT): user experience usability study

The decision on patients' competency to manage their affairs and take care of themselves requires a rigorous evaluation process and consistency among practice settings. Research indicates there is a lack of resources to guide healthcare and social service professionals in the interprofessional decision-making process that such an evaluation requires. A web-based tool, the Competency Assessment Tool (CAT), was designed to assist professionals in that process. The authors conducted a usability study with a beta version of the CAT. The objectives of this study were to: (1) explore what is needed to support its use in community-based and specialized settings; and (2) identify barriers to and facilitators of implementation. A major concern was the perceived onerous nature of the tool. Participants indicated a need for different versions of the tool, depending on the complexity of the evaluation. They want to be directed to areas in the tool based on their field of expertise and want adjustments to functionalities related to collaborative work. This study highlights the importance of the awareness of User Experience (UX) considerations at the outset of the design process, to limit the impact of required modifications and facilitate implementation in the workplace.

The OptimaMed intervention to reduce inappropriate medications in nursing home residents with severe dementia: results from a quasi-experimental feasibility pilot study

BACKGROUND

Medication regimens in nursing home (NH) residents with severe dementia should be frequently reviewed to avoid inappropriate medication, overtreatment and adverse drug events, within a comfort care approach. This study aimed at testing the feasibility of an interdisciplinary knowledge exchange (KE) intervention using a medication review guidance tool categorizing medications as either "generally", "sometimes" or "exceptionally" appropriate for NH residents with severe dementia.

METHODS

A quasi-experimental feasibility pilot study with 44 participating residents aged 65 years or over with severe dementia was carried out in three NH in Quebec City, Canada. The intervention comprised an information leaflet for residents' families, a 90-min KE session for NH general practitioners (GP), pharmacists and nurses focusing on the medication review guidance tool, a medication review by the pharmacists for participating residents with ensuing team discussion on medication changes, and a post-intervention KE session to obtain feedback from team staff. Medication regimens and levels of pain and of agitation of the participants were evaluated at baseline and at 4 months post-intervention. A questionnaire for team staff explored perceived barriers and facilitators. Statistical differences in measures comparing pre and post-intervention were assessed using paired t-tests and Cochran's-Q tests.

RESULTS

The KE sessions reached 34 NH team staff (5 GP, 4 pharmacists, 6 heads of care unit and 19 staff nurses). Forty-four residents participated in the study and were followed for a mean of 104 days. The total number of regular medications was 372 pre and 327 post-intervention. The mean number of regular medications per resident was 7.86 pre and 6.81 post-intervention. The odds ratios estimating the risks of using any regular medication or a "sometimes appropriate" medication post-intervention were 0.81 (95% CI: 0.71-0.92) and 0.83 (95% CI: 0.74-0.94), respectively.

CONCLUSION

A simple KE intervention using a medication review guidance tool categorizing medications as being either "generally", "sometimes" or "exceptionally" appropriate in severe dementia was well received and accompanied by an overall reduction in medication use by NH residents with severe dementia. Levels of agitation were unaffected and there was no clinically significant changes in levels of pain. Staff feedback provided opportunities to improve the intervention.

Decisional needs assessment of patients with complex care needs in primary care: a participatory systematic mixed studies review protocol

INTRODUCTION

Patients with complex care needs (PCCNs) often suffer from combinations of multiple chronic conditions, mental health problems, drug interactions and social vulnerability, which can lead to healthcare services overuse, underuse or misuse. Typically, PCCNs face interactional issues and unmet decisional needs regarding possible options in a cascade of interrelated decisions involving different stakeholders (themselves, their families, their caregivers, their healthcare practitioners). Gaps in knowledge, values clarification and social support in situations where options need to be deliberated hamper effective decision support interventions. This review aims to (1) assess decisional needs of PCCNs from the perspective of stakeholders, (2) build a taxonomy of these decisional needs and (3) prioritise decisional needs with knowledge users (clinicians, patients and managers).

METHODS AND ANALYSIS

This review will be based on the interprofessional shared decision making (IP-SDM) model and the Ottawa Decision Support Framework. Applying a participatory research approach, we will identify potentially relevant studies through a comprehensive literature search; select relevant ones using eligibility criteria inspired from our previous scoping review on PCCNs; appraise quality using the Mixed Methods Appraisal Tool; conduct a three-step synthesis (sequential exploratory mixed methods design) to build taxonomy of key decisional needs; and integrate these results with those of a parallel PCCNs' qualitative decisional need assessment (semistructured interviews and focus group with stakeholders).

ETHICS AND DISSEMINATION

This systematic review, together with the qualitative study (approved by the Centre Intégré Universitaire de Santé et Service Sociaux du Saguenay-Lac-Saint-Jean ethical committee), will produce a working taxonomy of key decisional needs (ontological contribution), to inform the subsequent user-centred design of a support tool for addressing PCCNs' decisional needs (practical contribution). We will adapt the IP-SDM model, normally dealing with a single decision, for PCCNs who experience cascade of decisions involving different stakeholders (theoretical contribution). Knowledge users will facilitate dissemination of the results in the Canadian primary care network.

PROSPERO REGISTRATION NUMBER

CRD42015020558.

Decision aids that support decisions about prenatal testing for Down syndrome: an environmental scan

BACKGROUND

Prenatal screening tests for Down syndrome (DS) are routine in many developed countries and new tests are rapidly becoming available. Decisions about prenatal screening are increasingly complex with each successive test, and pregnant women need information about risks and benefits as well as clarity about their values. Decision aids (DAs) can help healthcare providers support women in this decision. Using an environmental scan, we aimed to identify publicly available DAs focusing on prenatal screening/diagnosis for Down syndrome that provide effective support for decision making.

METHODS

Data sources searched were the Decision Aids Library Inventory (DALI) of the Ottawa Patient Decision Aids Research Group at the Ottawa Health Research Institute; Google searches on the internet; professional organizations, academic institutions and other experts in the field; and references in existing systematic reviews on DAs. Eligible DAs targeted pregnant women, focused on prenatal screening and/or diagnosis, applied to tests for fetal abnormalities or aneuploidies, and were in French, English, Spanish or Portuguese. Pairs of reviewers independently identified eligible DAs and extracted characteristics including the presence of practical decision support tools and features to aid comprehension. They then performed quality assessment using the 16 minimum standards established by the International Patient Decision Aids Standards (IPDASi v4.0).

RESULTS

Of 543 potentially eligible DAs (512 in DALI, 27 from experts, and four on the internet), 23 were eligible and 20 were available for data extraction. DAs were developed from 1996 to 2013 in six countries (UK, USA, Canada, Australia, Sweden, and France). Five DAs were for prenatal screening, three for prenatal diagnosis and 12 for both). Eight contained values clarification methods (personal worksheets). The 20 DAs scored a median of 10/16 (range 6-15) on the 16 IPDAS minimum standards.

DISCUSSION

None of the 20 included DAs met all 16 IPDAS minimum standards, and few included practical decision support tools or aids to comprehension.

CONCLUSIONS

Our results indicate there is a need for DAs that effectively support decision making regarding prenatal testing for Down syndrome, especially in light of the recently available non-invasive prenatal screening tests.

Printed educational materials: effects on professional practice and healthcare outcomes

BACKGROUND

Printed educational materials are widely used passive dissemination strategies to improve the quality of clinical practice and patient outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines.

OBJECTIVES

To assess the effect of printed educational materials on the practice of healthcare professionals and patient health outcomes.To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on professional practice and patient outcomes.

SEARCH METHODS

For this update, search strategies were rewritten and substantially changed from those published in the original review in order to refocus the search from published material to printed material and to expand terminology describing printed materials. Given the significant changes, all databases were searched from start date to June 2011. We searched: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and the EPOC Register.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-randomised trials, controlled before and after studies (CBAs) and interrupted time series (ITS) analyses that evaluated the impact of printed educational materials (PEMs) on healthcare professionals' practice or patient outcomes, or both. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. There was no language restriction. Any objective measure of professional practice (e.g. number of tests ordered, prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included.

DATA COLLECTION AND ANALYSIS

Two review authors undertook data extraction independently, and any disagreement was resolved by discussion among the review authors. For analyses, the included studies were grouped according to study design, type of outcome (professional practice or patient outcome, continuous or dichotomous) and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where the data were available, we re-analysed the ITS studies and reported median differences in slope and in level for each outcome, across outcomes for each study, and then across studies. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format.

MAIN RESULTS

The review includes 45 studies: 14 RCTs and 31 ITS studies. Almost all the included studies (44/45) compared the effectiveness of PEM to no intervention. One single study compared paper-based PEM to the same document delivered on CD-ROM. Based on seven RCTs and 54 outcomes, the median absolute risk difference in categorical practice outcomes was 0.02 when PEMs were compared to no intervention (range from 0 to +0.11). Based on three RCTs and eight outcomes, the median improvement in standardised mean difference for continuous profession practice outcomes was 0.13 when PEMs were compared to no intervention (range from -0.16 to +0.36). Only two RCTs and two ITS studies reported patient outcomes. In addition, we re-analysed 54 outcomes from 25 ITS studies, using time series regression and observed statistically significant improvement in level or in slope in 27 outcomes. From the ITS studies, we calculated improvements in professional practice outcomes across studies after PEM dissemination (standardised median change in level = 1.69). From the data gathered, we could not comment on which PEM characteristic influenced their effectiveness.

AUTHORS' CONCLUSIONS

The results of this review suggest that when used alone and compared to no intervention, PEMs may have a small beneficial effect on professional practice outcomes. There is insufficient information to reliably estimate the effect of PEMs on patient outcomes, and clinical significance of the observed effect sizes is not known. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

Development of PRIDe: a tool to assess physicians' preference of role in clinical decision making

OBJECTIVE

To develop and evaluate items for inclusion in PRIDe (Preferred Role in Decision Making), a new tool to assess changes of role preference among professionals exposed to training in shared decision making (SDM).

METHODS

This study was part of a pilot trial to evaluate the effectiveness of SDM training on the doctors' prescription of antibiotics for acute respiratory infections. Thirty-nine family physicians were randomized to immediate exposure to training or to delayed exposure. Potential items for PRIDe and a questionnaire about physicians' intention to engage in SDM were administered at baseline and at follow-up.

RESULTS

Following analysis, we retained five items that captured a change in physicians' preference. The items' scores were pooled and the resulting tool showed limited internal consistency (Cronbach's alpha = 0.41) but significant test-retest reliability (immediate group: P = 0.03; delayed group: P = 0.008) and acceptable discriminant validity, with patients involved in decision making more actively after training than before (Fisher's test, P = .02).

CONCLUSION

This initial step to develop an evaluation tool to assess changes in doctors' preference of role in decision making following SDM training shows promising results. The next step is to develop more clinical vignettes followed by questions inspired from this analysis.

PRACTICE IMPLICATIONS

The PRIDe instrument can be used in the assessment of health professionals' attitude towards shared decision making after training in shared decision making. Additional research is needed to evaluate its validity before it can be recommended for use.

Interventions to improve continuity of care in the follow-up of patients with cancer

BACKGROUND

Care from the family physician is generally interrupted when patients with cancer come under the care of second-line and third-line healthcare professionals who may also manage the patient's comorbid conditions. This situation may lead to fragmented and uncoordinated care, and results in an increased likelihood of not receiving recommended preventive services or recommended care.

OBJECTIVES

To classify, describe and evaluate the effectiveness of interventions aiming to improve continuity of cancer care on patient, healthcare provider and process outcomes.

SEARCH METHODS

We searched the Cochrane Effective Practice and Organization of Care Group (EPOC) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, CINAHL, and PsycINFO, using a strategy incorporating an EPOC Methodological filter. Reference lists of the included study reports and relevant reviews were also scanned, and ISI Web of Science and Google Scholar were used to identify relevant reports having cited the studies included in this review.

SELECTION CRITERIA

Randomised controlled trials (including cluster trials), controlled clinical trials, controlled before and after studies and interrupted time series evaluating interventions to improve continuity of cancer care were considered for inclusion. We included studies that involved a majority (> 50%) of adults with cancer or healthcare providers of adults with cancer. Primary outcomes considered for inclusion were the processes of healthcare services, objectively measured healthcare professional, informal carer and patient outcomes, and self-reported measures performed with scales deemed valid and reliable. Healthcare professional satisfaction was included as a secondary outcome.

DATA COLLECTION AND ANALYSIS

Two reviewers described the interventions, extracted data and assessed risk of bias. The authors contacted several investigators to obtain missing information. Interventions were regrouped by type of continuity targeted, model of care or interventional strategy and were compared to usual care. Given the expected clinical and methodological diversity, median changes in outcomes (and bootstrap confidence intervals) among groups of studies that shared specific features of interest were chosen to analyse the effectiveness of included interventions.

MAIN RESULTS

Fifty-one studies were included. They used three different models, namely case management, shared care, and interdisciplinary teams. Six additional interventional strategies were used besides these models: (1) patient-held record, (2) telephone follow-up, (3) communication and case discussion between distant healthcare professionals, (4) change in medical record system, (5) care protocols, directives and guidelines, and (6) coordination of assessments and treatment.Based on the median effect size estimates, no significant difference in patient health-related outcomes was found between patients assigned to interventions and those assigned to usual care. A limited number of studies reported psychological health, satisfaction of providers, or process of care measures. However, they could not be regrouped to calculate median effect size estimates because of a high heterogeneity among studies.

AUTHORS' CONCLUSIONS

Results from this Cochrane review do not allow us to conclude on the effectiveness of included interventions to improve continuity of care on patient, healthcare provider or process of care outcomes. Future research should evaluate interventions that target an improvement in continuity as their primary objective and describe these interventions with the categories proposed in this review. Also of importance, continuity measures should be validated with persons with cancer who have been followed in various settings.

Effect of dietary organic and inorganic selenium on antioxidant status, embryo development, and reproductive performance in hyperovulatory first-parity gilts

This project aimed to determine the effect of Se as inorganic Na-selenite (MSe) or organic Se-yeast (OSe) on antioxidant status, hormonal profile, reproductive performance, and embryo development in first-parity gilts. Forty-nine gilts were allocated to 1 of the 3 dietary treatments starting at first pubertal estrus and lasting up to 30 d after AI: control [CONT: basal diet (Se = 0.2 mg/kg) without added Se; n = 16], MSe (CONT + 0.3 mg/kg of MSe; n = 16), and OSe (CONT + 0.3 mg/kg of OSe; n = 17). Blood was collected from all gilts on the day after each onset of estrus and on d 30 after AI. Blood was also collected daily from d -4 to d +4 of the third onset of estrus (d 0) in 8 CONT, 9 MSe, and 8 OSe cannulated gilts. Gilts had received, after d 14 and 15 of their third estrus, a hormonal challenge to induce super-ovulation. At slaughter, embryos and corpora lutea (CL) were weighed and measured. Blood Se was less (P < 0.01) in CONT than in Se gilts and greater in OSe than in MSe (P < 0.01) from the first estrus until d 30 of gestation. At the same time, blood Se-dependent glutathione peroxidase (GSH-Px) decreased for CONT gilts, whereas it increased for both Se groups. The increase was greater in MSe than in OSe gilts (treatment × time, P = 0.02). Plasma 3,3',5-triiodothyronine and thyroxine concentrations for MSe tended to be less than for OSe gilts (P < 0.06). In cannulated gilts, plasma FSH tended to change among treatments (treatment × time, P = 0.06), and plasma estradiol-17β (E(2)) was less (P = 0.01) for MSe than for OSe. There was no treatment effect on mean litter size or embryonic antioxidant status. The Se content of individual embryos was greater for Se-treated than for CONT gilts (P = 0.03), and Se content of individual embryos and total litter was greater for OSe than for MSe gilts (P < 0.01). The length, weight, and protein content of embryos were greater in OSe than in MSe gilts (P < 0.05). There was no treatment effect on weight, length, Se content, and ferric reducing antioxidant power of CL, but GSH-Px in CL was greater for Se than for CONT gilts (P = 0.02). In summary, the Se status response of gilts to dietary Se was affected by both the quantity and the source of Se dietary supplements. Moreover, the uterine transfer of Se to embryos was improved with OSe as compared with MSe, and this was concomitant with an enhanced development of embryos.

Barriers and facilitators to the dissemination of DECISION+, a continuing medical education program for optimizing decisions about antibiotics for acute respiratory infections in primary care: a study protocol

Background

In North America, acute respiratory infections are the main reason for doctors' visits in primary care. Family physicians and their patients overuse antibiotics for treating acute respiratory infections. In a pilot clustered randomized trial, we showed that DECISION+, a continuing medical education program in shared decision making, has the potential to reduce the overuse of antibiotics for treating acute respiratory infections. DECISION+ learning activities consisted of three interactive sessions of three hours each, reminders at the point of care, and feedback to doctors on their agreement with patients about comfort with the decision whether to use antibiotics. The objective of this study is to identify the barriers and facilitators to physicians' participation in DECISION+ with the goal of disseminating DECISION+ on a larger scale.

Methods/design

This descriptive study will use mixed methods and retrospective and prospective components. All analyses will be based on an adapted version of the Ottawa Model of Research Use. First, we will use qualitative methods to analyze the following retrospective data from the pilot study: the logbooks of eight research assistants, the transcriptions of 15 training sessions, and 27 participant evaluations of the DECISION+ training sessions. Second, we will collect prospective data in semi-structured focus groups composed of family physicians to identify barriers and facilitators to the dissemination of a future training program similar to DECISION+. All 39 family physicians exposed to DECISION+ during the pilot project will be eligible to participate. We will use a self-administered questionnaire based on Azjen's Theory of Planned Behaviour to assess participants' intention to take part in future training programs similar to DECISION+.

Discussion

Barriers and facilitators identified in this project will guide modifications to DECISION+, a continuing medical education program in shared decision making regarding the use of antibiotics in acute respiratory infections, to facilitate its dissemination in primary care on a large scale. Our results should help continuing medical educators develop a continuing medical education program in shared decision making for other clinically relevant topics. This will help optimize clinical decisions in primary care.

Patients' perceptions of the quality of care after primary care reform: Family medicine groups in Quebec

OBJECTIVE

To evaluate how a primary care reform, which aimed to promote interprofessional and interorganizational collaborative practices, affected patients' experiences of the core dimensions of primary care.

DESIGN

Before-and-after comparison of patients' perceptions of care at the beginning of family medicine group (FMG) implementation (15 to 20 months after accreditation) and 18 months later.

SETTING

Five FMGs in the province of Quebec from various settings and types of practice.

PARTICIPANTS

A random sample of patients was selected in each FMG; a total of 1046 participants completed both the baseline and follow-up questionnaires.

MAIN OUTCOME MEASURES

Patients' perceptions of relational and informational continuity, organizational and first-contact accessibility, attitude and efficiency of the clinic's personnel and waiting times (service responsiveness), physician-nurse and primary care physician-specialist coordination, and intra-FMG collaboration were assessed over the telephone, mostly using a modified version of the Primary Care Assessment Tool. Additional items covered patients' opinions about consulting nurses, patients' use of emergency services, and patients' recall of health promotion and preventive care received.

RESULTS

A total of 1275 patients were interviewed at the study baseline, and 82% also completed the follow-up interviews after 18 months (n = 1046). Overall, perceptions of relational and informational continuity increased significantly (P < .05), whereas organizational and first-contact accessibility and service responsiveness did not change significantly. Perception of physician-nurse coordination remained unchanged, but perception of primary care physician-specialist coordination decreased significantly (P < .05). The proportion of participants reporting visits with nurses and reporting use of FMGs' emergency services increased significantly from baseline to follow-up (P < .05).

CONCLUSION

This reorganization of primary care services resulted in considerable changes in care practices, which led to improvements in patients' experiences of the continuity of care but not to improvements in their experiences of the accessibility of care.

[Using psychostimulants in end-of-life patients with hypoactive delirium and cognitive disorders: A literature review]

OBJECTIVE

To review the research about psychostimulant effects on cognitive functions in end-of-life patients diagnosed with hypoactive delirium or cognitive disorders.

METHOD

The MEDLINE (1966-March 2008), Embase (1974-March 2008), PsycINFO (1806-March 2008), IPA (1970-March 2008), CINAHL (1982-March 2008), ISI Web of Science (1945-March 2008), Current Contents (March 2007-March 2008), Access Medicine (2001-March 2008), and ProQuest Dissertations & Theses (1980-March 2008) databases were searched with keywords related to delirium, cognition, psychostimulants, and palliative care for French or English articles in a dementia-free and hyperactive delirium-free end-of-life population. Cognitive functions had to be assessed before and after initiation of the psychostimulant treatment. Moreover, treatment had to be initiated after the onset of cognitive impairments.

RESULTS

A total of 173 studies were screened. Five studies on methylphenidate and 1 study on caffeine met inclusion criteria and were included in this review. Two studies were case reports, 2 were open-label trials, and 2 were double-blind, crossover randomized placebo-controlled trials. Three studies were conducted with hypoactive delirium patients and all studies were conducted in an advanced cancer patient population.

CONCLUSIONS

The reviewed studies support the use of methylphenidate to improve end-of-life patient cognitive functions, particularly in the case of hypoactive delirium. Caffeine seems to have beneficial effects on psychomotor activity. Further well-designed studies are needed to consolidate these findings.

Effect of feed texture, meal frequency and pre-slaughter fasting on behaviour, stomach content and carcass microbial quality in pigs

In this study, behaviour in lairage, weight and composition of stomach contents and carcass microbial contamination were studied in 96 barrows assigned to the following treatments: feed texture (FT; mash vs. pellets), meal frequency (MF; 2 vs. five meals per day) and fasting time (WT; 4, 14 and 24 h) according to a 2 × 2 × 3 factorial design. Pigs fed two meals had heavier stomach weights at slaughter than those fed five times per day (P = 0.01). An interaction was found between WT and FT (P = 0.002) for stomach weight. With respect to the contamination of the mouth, total aerobic mesophilic counts were higher than 104 cfu cm-2 but not significantly different between treatments. Coprophagy behaviour in lairage was not correlated with mouth contamination at slaughter. The treatment resulting in the lowest Escherichia coli counts on the thoracic area was feeding the pigs pellets five times per day followed by a 24-h fast. In contrast, the highest E. coli counts were observed in pigs fed mash five times per day followed by a 4-h fast. Comparison a posteriori of these two extreme scenarios yielded a P value of 0.03. Key words: Animal behaviour, carcass hygiene, fasting, feeding, pigs, stomach

Effects of concentrations of cyanocobalamin in the gestation diet on some criteria of vitamin B12 metabolism in first-parity sows1,2

In swine nutrition, little is known about the role of vitamin B(12) in the reproductive processes. The current study was undertaken to obtain information on the dose-response pattern of different metabolic criteria related to the homeostasis of vitamin B(12) and homocysteine in gestating sows receiving various concentrations of dietary vitamin B(12) (cyanocobalamin). Homocysteine is a detrimental intermediate metabolite of the vitamin B(12)-dependent remethylation pathway of Met. Forty nulliparous (Large White x Landrace) sows were randomly assigned during gestation to dietary treatments containing 5 concentrations of cyanocobalamin (0, 20, 100, 200, or 400 microg/kg). During lactation, a diet containing 25 microg of cyanocobalamin/kg (as-fed) was given to all sows. During gestation, plasma vitamin B(12) increased as concentrations of dietary cyanocobalamin increased (linear and quadratic, P < 0.01) and the effect persisted during lactation (21 d postpartum) both in plasma (linear and quadratic, P < 0.05) and the liver (linear and quadratic, P < 0.04). Plasma homocysteine decreased with concentrations of cyanocobalamin provided to sows during gestation (linear, quadratic, and cubic, P < 0.01). At parturition, vitamin B(12) in colostrum increased as concentrations of cyanocobalamin increased (linear and quadratic, P < 0.01), but the treatment effect persisted (linear, P = 0.01) only up to 1 d postfarrowing. However, in piglets there was no treatment effect (P = 0.59) on plasma vitamin B(12) before colostrum intake, but a linear effect of concentrations of cyanocobalamin (P = 0.04) was observed 1 d later. Plasma homocysteine in piglets during lactation decreased with increasing concentrations of cyanocobalamin given to sows in gestation (linear and quadratic, P < 0.01). Based on a broken-line regression model, the concentrations of dietary cyanocobalamin that maximized plasma vitamin B(12) and minimized plasma homocysteine of sows during gestation were estimated to be 164 and 93 microg/kg, respectively. The maximal residual responses in sows and piglets during lactation were observed with treatments of 100 or 200 microg of cyanocobalamin/kg. The dietary cyanocobalamin concentration necessary to optimize the response of these metabolic criteria remains to be refined within lower and narrower ranges of cyanocobalamin concentrations (i.e., <200 mg/kg). Moreover, the biological significance of such concentrations of cyanocobalamin needs to be validated with performance criteria by using greater numbers of animals during several parities.

[The systematic evaluation of instruments designed to assess pain in persons with limited ability to communicate]

Chronic pain is often underdetected and undertreated in long-term care facilities. The use of self-report measures of pain (such as the visual analogue scale) is often problematic for older adults residing in long-term care because of the high prevalence of visual and auditory deficits and severe cognitive impairment. Observational measures of pain have been developed to address this concern. A systematic grid designed to assess the properties of existing observational measures of pain was used for seniors with dementia. The grid focused on the evaluation of content validity (12 items), construct validity (12 items), reliability (13 items) and clinical utility (10 items). Among the 24 instruments that were evaluated, several were deemed to be promising in the assessment of pain among older persons with severe dementia. Nonetheless, additional research is needed before their routine integration in the practices of long-term care settings.

Effects of flaxseed supplementation on endometrial expression of ISG17 and intrauterine prostaglandin concentrations in primiparous dairy cows submitted to GnRH-based synchronized ovulation

The objective of the experiment was to determine the effects of feeding whole flaxseed on ovarian function and uterine concentration of prostaglandins on the 17th day post-ovulation. Fortyeight primiparous Holstein cows averaging 550 kg of body weight (BW) were allotted at 2 wk postpartum to two groups of 24 animals: a control diet with no added fat (CON) or a diet with 9% whole flaxseed (FLA). At 6 wk postpartum cows were subjected to a Presynch-Ovsynch protocol with and without artificial insemination on day 0. Real-time transrectal ultrasonography and plasma progesterone concentrations were used to evaluate ovarian function. On day 17, uterine flushings and biopsies of uterine endometrium were collected. Synchronized ovulation rates based on low and high plasma progesterone concentrations on days 0 and 7, respectively, were the same for cows fed CON and those fed FLA (87.5 vs. 87.5%). The 13,14-dihydro-15-keto-PGF2α (PGFM) to prostaglandin E metabolite (PGEM) ratio in uterine flush was significantly higher for non-inseminated cows fed CON (32.0) than for non-inseminated cows fed FLA (17.5) and there was no difference between pregnant cows fed CON (12.2) and those fed FLA (12.0). Feeding flaxseed before breeding may contribute to increased fertility by improving uterine conditions for embryo survival. Key words: Flaxseed, dairy cattle, ovarian function, prostaglandins

Some aspects of the pyridoxine (vitamin B6) requirement in weanling piglets

Four trials were carried out to determine the optimal level of dietary pyridoxine (vitamin B6) and its interaction with riboflavin (vitamin B2) in early-weaned piglets. In Trial 1, twelve piglets were tube-fed graded supplements of B6, 0, 10, 50 or 100 mg/kg. The level of 50 mg/kg maximized B6in red blood cells (P<0·05). In Trial 2, thirty-six piglets were tube-fed with four combinations of B6(0v. 50 mg/kg) and B2(0v. 25 mg/kg). The B6supplement increased (P<0·01) B6in red blood cells. C-peptide and insulin responses to intravenous glucose tended (P<0·08) to or decreased (P<0·03) with B2while no effect was observed on glucose. After gastro-enteral glucose, dietary B2depressed C-peptide and insulin responses in B6-unsupplemented piglets and increased them in B6-supplemented piglets (P<0·03). The glucose response tended to be higher in B6-supplemented piglets (P<0·06). Trials 3 and 4 were carried out in commercial conditions using either B6and/or B2supplements given during 2 weeks after weaning (Trial 3) or a B6supplement alone (50 mg/kg) given between 2 (weaning) and 10 weeks of age. Despite a marked and persistent increase (P<0·01) of B6in red blood cells in B6-supplemented piglets, the effect on growth performance was either none (P>0·39; Trial 3) or marginally lower (<−2 %;P<0·03; Trial 4). In conclusion, it appears that a dietary supplement of 50 mg/kg B6saturated the red blood cell pool in B6and influenced, along with B2, the glucose homeostasis through the entero-insular axis. Nevertheless, such metabolic effects are not reflected on growth performance.

The effects of handling and group size on welfare of pigs in lairage and their influence on stomach weight, carcass microbial contamination and meat quality

At unloading and on the way to stunning, 800 barrows were exposed to either gentle handling (GH: slowly with a plastic board or whip) or rough handling (RH: quickly with an electric prod). Pigs were kept in large or small groups (30 or 10 pigs) during lairage. Compared with GH, RH increased climbing (P < 0.05), slipping (P < 0.01) and turning around (P < 0.001) behaviours during unloading, and climbing (P < 0.05) on the way to stunning. RH also reduced drinking behaviour during lairage (P < 0.01). Pigs kept in large groups were observed more often standing (P < 0.05) and fighting (P < 0.001) than pigs kept in small groups, but, in contrast, had a slightly lower level of urinary cortisol at slaughter. Stomach weight and microbial contamination at slaughter were not affected by treatments. RH tended to increase skin bruise score on the carcass (P < 0.06) and produced more exudative meat (P < 0.05). In conclusion, the response of pigs to the two specific stressors applied prior to slaughter in this study did not seem to contribute to stomach weight variation at slaughter, but it did influence pork quality. Key words: Pigs, pre-slaughter handling, group size, stress, stomach weight, microbial contamination, behaviour, meat quality

Impact of an Educational Program on Pain Management in Patients With Cancer Living at Home

PURPOSE/OBJECTIVES

To assess the effect of an educational homecare program on pain relief in patients with advanced cancer.

DESIGN

Quasi-experimental (pretest post-test, nonequivalent group).

SETTING

Four community-based primary care centers providing social and healthcare services in the Quebec City region of Canada.

SAMPLE

80 homecare patients with advanced cancer who were free of cognitive impairment, who presented with pain or were taking analgesics to relieve pain, and who had a life expectancy of six weeks or longer.

METHODS

The educational intervention included information regarding pain assessment and monitoring using a daily pain diary and the provision of specific recommendations in case of loss of pain control. Pain intensity data were collected prior to the intervention, and reassessments were made two and four weeks later. Data on beliefs were collected at baseline and two weeks. All data were collected by personal interviews.

MAIN RESEARCH VARIABLES

Patients beliefs about the use of opioids; average and maximum pain intensities.

FINDINGS

Patients beliefs regarding the use of opioids were modified successfully following the educational intervention. Average pain was unaffected in the control group and was reduced significantly in patients who received the educational program. The reduction remained after controlling for patients initial beliefs. Maximum pain decreased significantly over time in both the experimental and control groups.

CONCLUSIONS

An educational intervention can be effective in improving the monitoring and relief of pain in patients with cancer living at home.

IMPLICATIONS FOR NURSING

Homecare nurses can be trained to effectively administer the educational program during their regular homecare visits.

Effectiveness of a clinical intervention in improving pain control in outpatients with cancer treated by radiation therapy

PURPOSE

To determine the effectiveness of a multicomponent clinical intervention to reduce pain in outpatients with cancer.

METHODS AND MATERIALS

Sixty-four patients were randomly assigned to receive either a clinical intervention including an information session, the use of a pain diary, and the possibility to contact a physician to adjust the pain medication, or the usual treatment of pain by the staff radiation oncologist. All patients reported their average and worst pain levels at baseline and 2 and 3 weeks after the start of the intervention.

RESULTS

The study groups were similar with respect to their baseline characteristics and pain levels at randomization. After 3 weeks, the average and worst pain experienced by patients randomized to the clinical intervention group was significantly inferior to the average pain experienced by patients in the control group (2.9/10 vs. 4.4/10 and 4.2/10 vs. 5.5/10, respectively). Results showed that the experimental group patients decreased their pain levels more than the control group patients did over time.

CONCLUSION

An intervention including patient education, a pain diary, and defining a procedure for therapeutic adjustments can be effective to improve pain relief in outpatients with cancer.

Sub-cellular partitioning of cadmium, copper, nickel and zinc in indigenous yellow perch (Perca flavescens) sampled along a polymetallic gradient

Sub-cellular metal distributions were studied in indigenous yellow perch (Perca flavescens) collected from eight lakes located along a cadmium (Cd), copper (Cu), nickel (Ni) and zinc (Zn) concentration gradient. Ambient dissolved metal concentrations were measured to evaluate exposure and total hepatic metal concentrations were determined as a measure of metal bioaccumulation. Metal partitioning among potentially metal-sensitive fractions (cytosolic enzymes, organelles) and detoxified metal fractions (metallothionein) was determined after differential centrifugation of fish liver homogenates. Major proportions of hepatic Cd and Cu were found in the heat-stable cytosolic peptides and proteins fraction (HSP), a fraction including metallothioneins, whereas the potentially metal-sensitive heat-denaturable proteins fraction (HDP) was the largest contributor to the total Ni and Zn burdens. The concentrations of Cd, Cu and Ni (but not Zn) in each sub-cellular fraction increased along the metal contamination gradient, but the relative contributions of each fraction to the total burden of each of these metals remained generally constant. For these chronically exposed fish there was no threshold exposure concentration below which binding of Cd or Ni to the heat-denaturable protein fraction did not occur. The presence of Cd and Ni in the HDP fraction, even for low chronic exposure concentrations, suggests that metal detoxification was imperfect, i.e. that P. flavescens was subject to some metal-related stress even under these conditions.

Cadmium-handling strategies in two chronically exposed indigenous freshwater organisms--the yellow perch (Perca flavescens) and the floater mollusc (Pyganodon grandis)

Laboratory experiments on a variety of aquatic organisms suggest that metallothionein-like proteins (MT) play an important role in the regulation of essential metals, and in the sequestration and detoxification of non-essential metals (e.g., Cd). However, the importance of metallothionein production relative to alternative strategies of metal detoxification, and its effectiveness in metal detoxification, remain largely unexplored in field situations. In the present study we explored metal-handling strategies in an adult benthic bivalve (Pyganodon grandis) and in juvenile yellow perch (Perca flavescens), exposed to Cd in their natural habitat. The two biomonitor species were collected from lakes located along a Cd concentration gradient. Ambient dissolved Cd concentrations were determined by in situ dialysis as a measure of metal exposure. Sub-cellular Cd partitioning was determined in target tissues (bivalve gills and digestive gland; perch liver) by differential centrifugation, and metallothionein was measured independently by a mercury-saturation assay in the bivalve tissues. Malondialdehyde concentrations were measured as a potential indicator of oxidative stress. Ambient dissolved Cd concentrations ranged from 0.06 to 0.57 nM in the nine lakes from which bivalves were collected, and from < 0.3 to 6.7 nM in the eight lakes from which yellow perch were sampled. Bioaccumulated Cd also varied from lake to lake, more so for the bivalve than for the yellow perch; the [Cd]max/[Cd]min ratios for the various tissues decreased in the order: bivalve gill Cd 28 > bivalve digestive gland Cd 18 > perch hepatic Cd 14. In the two lakes that were common to both the bivalve and perch studies, i.e. lakes Opasatica and Vaudray, accumulated Cd concentrations were consistently higher in the bivalve than in the perch. Cadmium-handling strategies were similar in the bivalve digestive gland and perch liver, in that Cd was mainly associated with the heat-stable protein (HSP) fraction. Furthermore, in these organs the contributions from the "mitochondria" and "lysosomes + microsomes" fractions were consistently higher than in the gill tissue. In the bivalve gill, the HSP fraction could only account for a small proportion (10+/-3%) of the total Cd burden, and the metal was instead largely sequestered in calcium concretions (58+/-13%). Along the Cd-exposure gradient, Cd detoxification appeared to be reasonably effective in the bivalve gill and digestive gland, as judged from the protection of the heat-denaturable protein (HDP) fraction. However, in both organs Cd concentrations did increase in potentially metal-sensitive organelles (mitochondria), and malondialdehyde concentrations increased along the exposure gradient in the gills (but not in the digestive gland). Cadmium detoxification seemed less effective in juvenile yellow perch. As total hepatic Cd increased, Cd concentrations increased in all sub-cellular fractions, including the HDP fraction that was well protected in the bivalve. The relative proportions of Cd in the various fractions did not vary appreciably along the exposure gradient and there was no evidence of a threshold exposure concentration below which sensitive metal pools were protected.

Sub-cellular partitioning of metals (Cd, Cu, Zn) in the gills of a freshwater bivalve, Pyganodon grandis: role of calcium concretions in metal sequestration

Indigenous unionid molluscs, Pyganodon grandis, were collected from nine lakes in the Rouyn-Noranda area (Quebec, Canada) along a polymetallic concentration gradient (Cd, Cu, Zn). After excision, the gills were gently homogenised and the cellular compartments were separated by a differential centrifugation procedure that yielded the following particulate fractions: "nuclei + cellular debris", "mitochondria", "lysosomes + microsomes" and "granules". The supernatant remaining after the final ultracentrifugation step, i.e., the operationally-defined cytosol, was separated into a "heat-denaturable proteins" (HDP) fraction and a "heat-stable proteins" (HSP) fraction containing metallothionein (MT). The Cd, Cu and Zn content of each particulate and cytosolic fraction was determined and gill metallothionein was quantified independently by a mercury saturation assay. Cytosolic Cd concentrations were significantly related to the dissolved Cd concentrations at each site, but cytosolic Cu and Zn (essential metals) were not related to their respective ambient dissolved metal concentrations. Metallothionein concentrations increased along the metal contamination gradient and were related to cytosolic Cd (and Zn) in a concentration-dependent manner. However mass balance calculations showed that binding to metallothionein could only account for a small proportion of total gill metal ( approximately 10% Cd; approximately 3% Cu; approximately 1% Zn). Under these chronic exposure conditions, the three metals (Cd, Cu and Zn) were mainly located in calcium concretions present in the gills (respectively 58 +/- 13% of the total gill Cd, 64 +/- 6% of the total gill Cu and 73 +/- 6% of the total gill Zn). The overall contribution of granules to the total gill dry weight remained relatively constant among the different lakes, suggesting that lake-to-lake variations in granule synthesis were independent of the metal contamination gradient, i.e., these constituent elements of unionid gills act as non-inducible metal sinks at the cellular level. Metal concentrations increased proportionally in both the granules and the MT pool along the polymetallic gradient, suggesting a constant partitioning between these two compartments. Overall, despite an increase in Cd in the "mitochondria" fraction, metal sequestration mechanisms seem to be reasonably effective in detoxifying cadmium: in the cytosol, Cd concentrations in the potentially metal-sensitive HDP fraction remained relatively low and constant, even in specimens collected from the most contaminated lakes.

Metal-induced stress in bivalves living along a gradient of Cd contamination: relating sub-cellular metal distribution to population-level responses

The use of biomarkers to assess the impacts of contaminants on aquatic ecosystems has noticeably increased over the past few years. Few of these studies, however, have contributed to the prediction of ecologically significant effects (i.e., at the population or community levels). The present field study was designed to evaluate the potential of metallothionein (MT) and sub-cellular metal partitioning measurements for predicting toxic effects at higher levels of the biological organization in freshwater bivalves (Pyganodon grandis) chronically exposed to Cd. For that purpose, we quantitatively sampled P. grandis populations in the littoral zone of nine lakes on the Precambrian Canadian Shield during two consecutive summers (1998 and 1999); lakes were characterized by contrasting Cd levels but similar trophic status. We tested relationships between the population status of P. grandis (i.e., growth parameters, density, biomass, secondary production, turnover ratio and cumulative fecundity) and (i) ambient Cd concentrations, (ii) sub-organismal responses (MT concentrations in the gill cytosol of individuals and Cd concentrations in three metal-ligand pools identified as M-HMW, the high molecular weight pool, M-MT, the metallothionein-like pool and M-LMW, the low molecular weight pool) and (iii) ecological confounding factors (food resources, presence of host fishes for the obligatory parasitic larval stage of P. grandis). Our results show that littoral density, live weight, dry viscera biomass, production and cumulative fecundity decreased with increasing concentrations of the free-cadmium ion in the environment (Pearson's r ranging from -0.63 to -0.78). On the other hand, theoretical maximum shell lengths (L( infinity )) in our populations were related to both the dissolved Ca concentration and food quality (sestonic C and N concentrations). Overall, Cd concentrations in the gill cytosolic HMW pool of the individual molluscs were the biomarker response that was most frequently and most strongly correlated with the population variables (Pearson's r ranging from -0.58 to -0.80). Our findings demonstrate, however, the difficulty of currently assigning to sub-cellular metal partitioning measurements (mainly Cd bound to the HMW fraction) any predictive role for population health, notably because of the influence of ecological confounding variables (e.g., the cumulative number of degree-days in the littoral zone, as is the case here). Metal contamination of our lakes has decreased markedly in the past 10 years and consequently we believe that the toxic effects of metals may have been replaced by some natural factors as the main agent for structuring the clam populations in these lakes.

Steady-state distribution of metals among metallothionein and other cytosolic ligands and links to cytotoxicity in bivalves living along a polymetallic gradient

The present study was designed to assess the environmental effects of metals in a field setting. We explored exposure-->bioaccumulation-->effects relationships in freshwater molluscs exposed to metals in their natural habitat. Indigenous floater mussels (Pyganodon grandis) were collected from ten limnologically similar lakes located along a Cd, Cu and Zn gradient. Ambient free-metal ion concentrations were estimated as a measure of metal exposure. Metallothionein (MT) was measured in mussel gills and metal partitioning among the various cytosolic protein pools was determined by size exclusion chromatography. Various biomarkers were also measured, including malondialdehyde (MDA) concentrations in the gills and in the digestive gland, glutathione-peroxidase and glutathione-reductase activities in the digestive gland, and lipid concentrations in the gonad. Cadmium and MT concentrations in the gill cytosol increased along the contamination gradient, but Cu and Zn levels were independent of the ambient free-metal ion concentrations. The distribution of Cd among the various cytosolic complexes remained quite constant: 80% in the MT-like pool, 7% in the low molecular weight pool (LMW<1.8 kDa) and 13% in the high molecular weight pool (HMW>18 kDa). For these chronically exposed molluscs there was thus no threshold exposure concentration above which spillover of Cd occurred from the MT pool to other cytosolic ligands. However, the presence of Cd in the LMW and HMW fractions suggests that metal detoxification was imperfect, i.e. that P. grandis was subject to some Cd-related stress at low chronic exposure concentrations. Consistent with this suggestion, MDA concentrations, an indicator of oxidative stress, increased with gill cytosolic Cd. In the digestive gland, MDA concentrations were unrelated to any of the measured metals, but glutathione-peroxidase and glutathione-reductase activities increased with gill cytosolic copper. We speculate that cytosolic Cu catalyses the production of reactive oxygen species, to which the organism reacts by increasing activities of the two enzymes, thus preventing the accumulation of reactive oxygen species. Lipid concentrations in the gonad did not decrease with any of the measured toxicological parameters, suggesting that energy reserves for reproduction were not compromised in the metal-contaminated mussels. The results of the present study, where chronically exposed bivalves were collected from their natural habitat along a metal contamination gradient, contrast markedly with what would have been predicted on the basis of experimental metal exposures, and clearly demonstrate the need to study metal exposure-->bioaccumulation-->effects relationships in natural populations.

Effect of dietary fat sources on systemic and intrauterine synthesis of prostaglandins during early pregnancy in gilts

The present experiment was conducted to determine the influence of dietary fatty acids C18:2n-6 and C18:3n-3 on the modulation of intrauterine synthesis of prostaglandin E2 (PGE2) and F2alpha (PGF2alpha) during early pregnancy in pigs. Prostaglandin E2 in uterine fluid has been previously reported to be associated with embryo survival and development. Thirty-two Yorkshire-Landrace nulliparous gilts were randomly allocated to four diets containing 5% supplemental fat. The four dietary treatments were: HT, hydrogenated tallow (26.5% C16:0 and 54.8% C18:0); SO, sunflower oil (61.3% C18:2n-6); LO, linseed oil (50.4% C18:3n-3); and SO(CLA), a mixture of sunflower oil and conjugated linoleic acids to provide 20% CLA. Treatments started 2 d after the first pubertal estrus (d -21) and lasted for 36 d (slaughter), which was 15 d after the second estrus (d 0; insemination). Fatty acids and PGE2 were measured in the peripheral blood plasma on d -19, d -7, d 0, and d 14. Fatty acids in endometrial tissues and PGE2 and PGF2alpha in the uterine fluid collected on d 15 were also measured. Concentrations of fatty acids in the plasma reflected the content of fatty acids in the diet as early as d -7. From d -7, PGE2 concentrations in the plasma were higher in gilts fed SO compared with HT (P < 0.05). Plasma PGE2 concentrations were lower (P < 0.01) on d 14 in gilts fed LO compared with HT. Total PGF2alpha contents in the uterine fluid of gilts fed LO were more than 70% lower (P < 0.05) than for the HT group. A similar trend was observed for total PGE2 content and for the ratio PGF2alpha:PGE2, but the effect (LO vs HT) was less marked (P < 0.07 and P < 0.10, respectively). There was no effect of SO or SO(CLA) on total PGE2 contents in the uterine fluid. Dietary enrichment in C18:2n-6 and/or C18:3n-3 for early pregnant gilts can influence fatty acids in plasma and endometrial tissue and can modulate circulatory and intrauterine prostaglandins.

Erythrocyte glutathione reductase activity and riboflavin nutritional status in early-weaned piglets

The reliability of erythrocyte glutathione reductase activity (EGRAC) as an indicator of riboflavin (vitamin B2) status was determined in 36 piglets weaned at two weeks of age. Total B2 metabolites determined by high-performance liquid chromatography (HPLC) in plasma, red blood cells, and liver were used as reference values. There was no correlation between EGRAC values and total B2 metabolites either in circulation (r < 0.15, p > 0.08) or in liver (r < 0.01, p > 0.95). EGRAC does not appear to be a reliable biochemical indicator of vitamin B2 status in the pig.

Effect of folic acid and glycine supplementation on embryo development and folate metabolism during early pregnancy in pigs

The present work aimed to determine if different levels of prolificacy either by parity or by genetic origin are linked to folate metabolism. Nulliparous Yorkshire-Landrace (YL) and multiparous YL, and multiparous Meishan-Landrace (ML) sows were randomly assigned to two treatments: 0 ppm or 15 ppm folic acid+0.6% glycine. Supplements were given from the estrus before mating until slaughter on d 25 of gestation. At slaughter, embryo and endometrial tissues were collected to determine concentrations of DNA, protein, and homocysteine. Allantoic fluid samples were also collected to determine concentrations of folates, vitamin B12 and amino acids. Blood samples were taken at first estrus, at mating, and on d 8, 16, and 25 of gestation to determine serum concentrations of folates, vitamin B12, and relative total folate binding capacity (TFBC). Over the entire experiment, multiparous YL sows had higher average serum concentrations of folates than nulliparous YL sows (P < 0.05) but had similar serum concentrations of relative TFBC. Concentrations of folates and relative TFBC averaged higher in ML measured over the entire experiment than in multiparous YL sows (P < 0.05). Concentrations of serum vitamin B12 were higher in multiparous YL than in ML sows or YL nulliparous sows (P < 0.05) over the entire experiment. In allantoic fluid, folates, vitamin B12, and essential amino acids contents were significantly lower in ML than in YL multiparous sows (P < 0.05). The folic acid+glycine supplement increased concentrations of serum folates, but the increase was more marked in nulliparous YL sows (nulliparous x folic acid+glycine, P < 0.05). The folic acid+glycine supplement had no effect on litter size and embryo survival, but it tended to increase embryo DNA in multiparous YL sows (P = 0.06) but not in ML and nulliparous YL sows. Homocysteine was decreased by folic acid+glycine supplement in embryos from all sows, but in endometrium, the folic acid+glycine effect was dependent on parity (nulliparous x folic acid+glycine, P < 0.05). The effects of folic acid+glycine on litter size and embryo development and survival and some aspects of folate metabolism suggest that the basal dietary content of folic acid+glycine was adequate for ML and nulliparous YL sows but not to optimize embryo development in YL multiparous sows.

Cadmium accumulation and metallothionein synthesis in freshwater bivalves (Pyganodon grandis): relative influence of the metal exposure gradient versus limnological variability

The relative influence of limnological confounding factors on cadmium (Cd) bioaccumulation and metallothionein (MT) synthesis was quantified in natural populations of freshwater bivalves (Pyganodon grandis) living in lakes along a Cd concentration gradient. During the ice-free period, we measured 15 environmental variables in the water compartment and determined total concentrations of Cd and MT in the gills of bivalves at 37 littoral stations in 20 lakes distributed across the mining area of Rouyn-Noranda in northwestern Quebec. A multiple linear regression model including pH (+), dissolved Ca concentrations (-) and free Cd2+ concentrations at the sediment-water interface (+) explained 74% of the variability in Cd concentrations in the bivalve gills. Dissolved Ca (-) and free Cd2+ (+) together explained 62% of the variation in MT concentrations in the bivalve gills. Partial linear regression analyses indicated that the limnological factors' pure and shared effects together accounted for 48 and 45% of the total variation in Cd and MT concentrations in the gills, respectively. A lake selection procedure that could be applied in monitoring programs is proposed to minimise the relative influence of these confounding variables.

Reproductive performance and uterine prostaglandin secretion in gilts conditioned with dead semen and receiving dietary supplements of folic acid

The effects of dietary supplements of folic acid at 0 (F−) or 15 ppm (F+) and of conditioning the uterus (C+) or not (C−) with an intrauterine infusion of dead semen on embryonic survival and prostaglandin E2 (PGE2) concentrations in the allantoic fluid on day 30 of gestation were studied. Sixty-four F1 crossbred gilts (Yorkshire × Landrace) were used in a 2 × 2 factorial design. The initiation of folate supplementation and the intrauterine infusion of dead semen were done at the estrus preceding the fertile mating. Folate status in serum was lower in F+ gilts than in F− gilts during the estrus cycle (folic acid × period interaction, P ≤ 0.007). Conditioning increased ovulation rate in F− gilts while it tended to decrease it in F+ gilts (interaction folic acid × conditioning, P ≤ 0.03). A similar interaction (P ≤ 0.02) was observed on the number of presumably live embryos at 30 d of gestation. Mean PGE2 concentration in the allantoic fluid was not affected by treatments (P ≥ 0.44), but the frequency of sows having elevated allantoic PGE2 (> 4 ng mL−1) tended to be higher (P ≤ 0.06) in F+ sows. Overall values of PGE2 were correlated with total litter weight (R2 = 0.54). In conclusion, there was no synergism between folic acid supplements and conditioning of the uterus with dead semen on the reproductive performance or on the secretion of allantoic PGE2 at 30 d of gestation. The secretion of allantoic PGE2 appears as an important factor involved in the control of litter size and weight. Key words: Folic acid, artificial insemination, semen, gilts, conditioning, embryo mortality

Evaluation of gastric emptying function in clinical practice

In this retrospective analysis, we compared different methods to evaluate gastric emptying function, aiming to improve the sensitivity and the clinical availability of our diagnostic testing. In the first study, we compared, in 72 patients clinically suspected of gastroparesis, the emptying of a meal containing two solid nutrients with different disintegration rates: 111In-labeled scrambled eggs and 99Tc-labeled liver cubes. Gastric emptying of 111In-labeled egg was delayed in 12 of our patients and the evacuation of the 99Tc-labeled liver was prolonged in 19 patients. The choice of the nutrient was not important for the identification of diabetic gastroparesis (43% vs 57%; NS), but it was determinant in the case of patients suspected of idiopathic gastroparesis (12% were positive with the egg and 25% with the liver; P < 0.05). In the second study, we compared two different diagnostic methods in 46 patients: a simple radiological detection of the gastric emptying of radiopaque pellets, and the scintigraphic emptying of a solid meal containing 99Tc-labeled liver cubes. Both tests correlated perfectly in 78% of our patients. In 15% of the population (six of these seven patients were diabetics suspected of gastroparesis) the scintigraphic method was normal, while the evacuation of radiopaque pellets was delayed. For clinical purposes, we therefore propose: (1) the scintigraphic method should use liver rather than egg as a radiolabeled tracer in order to improve the sensitivity of the test for detection of gastroparesis; and (2) the radiological detection of radiopaque markers is a reliable and convenient method for the detection of gastroparesis in clinical practice. It is possibly more sensitive than scintigraphy.