Community group practices in Canada: are they ready to reform their practice?

INTRODUCTION: Governments and healthcare organizations in Canada are reforming the clinical practice structures and policies to deliver primary care to the population. A key component of primary healthcare reform is the establishment of an interdisciplinary, community-based team approach to patient care. This study was undertaken to provide in-depth insight regarding primary healthcare providers' beliefs and attitudes in regard to their current group practice, what changes they believe are occurring and those necessary to reform group practice settings, their willingness to embrace changes, and the challenges they face to realize the proposed reform. METHODS: This study employed a mixed-method research design (qualitative and quantitative data collection techniques) through day-long focus groups of primary healthcare professionals (eg, family physicians, specialists, dieticians, psychologists) from across Canada. RESULTS: There is considerable variation in the composition of primary care group practices across Canada. Respondents report that group practices are little more than an economic convenience to facilitate sharing of resources. Even when a practice is composed of several disciplines, there is little to no organized or systematic interaction among healthcare professionals aimed at improving patient care, lack of clarity as to identified leaders/managers of the team, and inconsistencies in the model of care provided to patients. However, there is a perception of value and benefit in working in a cohesive group practice to improve patient care. DISCUSSION: Findings revealed that although healthcare providers report themselves ready to make the necessary changes and willing to move to interdisciplinary team-based practices, there are substantive challenges that impede a movement to truly effective interdisciplinary team practice and functioning. These challenges include the type and allocation of funding, interprofessional healthcare provider education, changing the healthcare provision model, and barriers among healthcare professionals regarding shared and equitable team accountability for patient health outcomes.     

How Does Aging Affect Presentation and Management of Biliary Stones?

Common bile duct (CBD) stones are common in elderly adults, but the effect of aging on the presentation of CBD stones remains to be evaluated. Recent studies have demonstrated that the clinical presentation of CBD stones may vary with age. Younger adults may present with classical biliary colic symptoms, whereas elderly adults may have no unapparent clinical features. Younger adults with CBD stones were significantly more likely to have abnormal liver function tests than those without. The sensitivity and accuracy of transabdominal ultrasound scans in screening for CBD stones increases with age. Antibiotic agents should be promptly administered to individuals with CBD stones complicated by cholangitis, but the effects of pharmacotherapy on renal function should be considered in elderly adults. Endoscopic retrograde cholangiopancreatography (ERCP) is considered to be first‐line treatment for CBD stones, and endoscopic biliary sphincterotomy (EST) or endoscopic papillary balloon dilation (EPBD) along with ERCP is an adequate biliary drainage method in individuals with CBD stones. EPBD has a lower bleeding risk but higher post‐ERCP risk of pancreatitis than EST. Longer‐duration (>1 minute) EPBD may be preferred over EST because it is associated with a comparable risk of pancreatitis but a lower rate of overall complications, although recurrent cholangitis or unfavorable outcomes will increase during CBD dilation or in the presence of residual CBD stones.     

Diurnal regulation of the gastrin-releasing peptide receptor in the mouse circadian clock

In mammals, circadian rhythms are generated by the suprachiasmatic nuclei (SCN) of the hypothalamus. SCN neurons are heterogeneous and can be classified according to their function, anatomical connections, morphology and/or peptidergic identity. We focus here on gastrin-releasing peptide- (GRP) and on GRP receptor- (GRPr) expressing cells of the SCN. Pharmacological application of GRP in vivo or in vitro can shift the phase of circadian rhythms, and GRPr-deficient mice show blunted photic phase shifting. Given the in vivo and in vitro effects of GRP on circadian behavior and on SCN neuronal activity, we investigated whether the GRPr might be under circadian and/or diurnal control. Using in situ hybridization and autoradiographic receptor binding, we localized the GRPr in the mouse SCN and determined that GRP binding varies with time of day in animals housed in a light-dark cycle but not in conditions of constant darkness. The latter results were confirmed with Western blots of SCN tissue. Together, the present findings reveal that changes in GRPr are light driven and not endogenously organized. Diurnal variation in GRPr activity probably underlies intra-SCN signaling important for entrainment and phase shifting.     

Alpha-II-spectrin after controlled cortical impact in the immature rat brain

Proteolytic processing plays an important role in regulating a wide range of important cellular functions, including processing of cytoskeletal proteins. Loss of cytoskeletal proteins such as spectrin is an important characteristic in a variety of acute central nervous system injuries including ischemia, spinal cord injury and traumatic brain injury (TBI). The literature contains extensive information on the proteolytic degradation of alpha-II-spectrin after TBI in the adult brain. By contrast, there is limited knowledge on the characteristics and relevance of these important processes in the immature brain. The present experiments examine TBI-induced proteolytic processing of alpha-II-spectrin after TBI in the immature rat brain. Distinct proteolytic products resulting from the degradation of the cytoskeletal protein alpha-II-spectrin by calpain and caspase 3 were readily detectable in cortical brain parenchyma and cerebrospinal fluid after TBI in immature rats.     

The evolving role of selective neck dissection for head and neck squamous cell carcinoma

Neck dissection is an important part of the surgical treatment of head and neck squamous cell carcinoma (HNSCC). The historical concept of neck dissection implied the removal of all lymph node-bearing tissue in the neck, which began in the late nineteenth century. However, more conservative variations of neck dissection have been performed and promoted as well. Anatomic, pathologic, clinical investigations, and prospective studies have demonstrated that the lymphatic dissemination of HNSCC occurs in predictable patterns. Supported by these studies, selective neck dissection (SND), which consists of the removal of select levels of lymph nodes in the neck that have the highest risk of harboring undetected metastases, has become widely accepted in the treatment of the clinically uninvolved neck. More recently, evidence supports using SND in a therapeutic setting in selected cases of HNSCC with limited metastatic disease. Additionally, even more targeted dissections referred to as super-selective neck dissection have been explored for selected patients undergoing elective node dissection for supraglottic cancer and as an adjuvant therapy for salvage of residual lymphadenopathy confined to a single neck level following chemoradiation. In the future, the trend to tailor treatment to individual patients and to limit toxicity and morbidity may further increase the use of SND. The indications have to be guided by further research, in relation with non-surgical treatment options while optimizing oncological effectiveness.     

Neuromonitoring of the laryngeal nerves in thyroid surgery: a critical appraisal of the literature

One of the most significant complication of thyroid surgery is injury of the recurrent laryngeal nerve. Injury of the external branch of the superior laryngeal nerve is a less obvious but occasionally significant problem. Recently, neuromonitoring during thyroidectomy has received considerable attention because of literature encouraging its use, but there is no consensus about its advantages and utility. A critical assessment of the literature on neuromonitoring was conducted in order to define its effectiveness, safety, cost-effectiveness and medical-legal impact. Available data does not show results superior to those obtained by traditional anatomical methods of nerve identification during thyroid surgery. Data about cost-effectiveness is scarce. The literature shows inconsistencies in methodology, patient selection and randomization in various published studies which may confound the conclusions of individual investigations. The current recommendation for use in “high risk” patients should be assessed because definition heterogeneity makes identification of these patients difficult. As routine use of neuromonitoring varies according to geography, its use should not be considered to be the standard of care.