Workload and patterns of care in the Timmins Family Health Team in Ontario.

OBJECTIVE: To characterize primary care physician and nurse practitioner ("GP") workload and availability, and any relationship with daytime, low-acuity emergency department (ED) and after-hours walk-in clinic (WIC) visit counts. DESIGN: Retrospective database review. SETTING: Timmins, Ont, with 5 family health team (FHT) office sites, 1 after-hours FHT WIC, and 1 ED. PARTICIPANTS: An anonymous data set representing 21 voluntarily enrolled GPs comprising 33 211 office appointments among 15 908 patients, plus 2043 ED visits and 2713 WIC visits, over 18 months. MAIN OUTCOME MEASURES: Roster size corrections for inactive ("dormant") patients, nursing supports, and patient complexity (age and sex). Availability of GPs was defined as the corrected number of office visits per patient per year. Linear and nonlinear relationships between GP availability and each roster's chronic disease burden (congestive heart failure, chronic obstructive pulmonary disease, and diabetes); ED visit count per patient; and WIC visit count per patient. RESULTS: Corrections for dormant patients and then for each of relative nursing support and patient complexity changed roster sizes by a mean (SD) of -8.4% (14.5%), -7.1% to 5.6% (median -1.6%), and 32.0% (18.2%), respectively. Combining these corrections increased effective roster size by a mean (SD) of 18.4% (7.3%). Larger rosters were not proportionately more dormant. In the Timmins FHT, GPs saw unique patients about 2.05 times per year (range 1.39 to 3.81). Availability of GPs did not change with increasing numbers of patients with congestive heart failure, chronic obstructive pulmonary disease, or diabetes in the roster. The ED diversion model had low explanatory power and was likely unreliable. The WIC diversion model was more robust, predicting 0.08 fewer WIC visits per patient per year if GP availability increased from 2.0 to 3.0 visits per patient per year (relative risk reduction of 41%). CONCLUSION: Sampled GPs manage a more complex patient population on average than their uncorrected roster sizes imply. There was no evidence that larger rosters or those with more patients with comorbid conditions reduced GP availability. Increasing physician availability might decrease WIC attendance.

Using blackboard collaborate, a digital web conference tool, to support nursing students placement learning: A pilot study exploring its impact.

Ensuring student nurses, when in clinical placement areas, receive good quality Higher Education Institution (HEI) lecturer support is challenging. This is because conventional HEI placement support, is resource intensive and arguably infeasible with growing student numbers. Evidence suggests, however, that online collaborative learning solutions (e.g., virtual classrooms, web conferencing tools) have the potential to ameliorate resource pressures. To test this idea, an online learning solution called Blackboard Collaborate was piloted. It virtually connected, students and their preceptors to a university lecturer. Its usefulness was explored by obtaining qualitative, focus group data, from the students and preceptor participants. The findings were thematically analysed. Collaborate ensured all three parties were connected. It was a time efficient, easy to use technology. Despite technical glitches, i.e. occasional time delay and audio echo, participants concluded Collaborate was an efficient medium when placement needs were routine. Face-to-face was preferable when more intensive support was required. In today's busy times, HEI's must explore time effective methods of placement collaboration. Online collaborative tools are one solution. Students will, however, need to develop their digital literacy in using this technology. The benefit being when qualified they are more likely to embrace this form of technology to promote their efficiency.

Outcomes of transmastoid resurfacing for superior canal dehiscence using a cartilage overlay technique.

OBJECTIVE: Superior semicircular canal dehiscence is a well-described syndrome with potentially debilitating symptoms. We report on the audiologic and long-term symptom outcomes of 10 patients (12 ears) undergoing a cartilage overlay transmastoid resurfacing technique. METHODS: Retrospective chart review and cross-sectional outcomes recall survey were used. A mailed questionnaire quantifying the effect of surgery on symptom severity and patient satisfaction were used. Nonlinear regression curves of pre-/postoperative air and bone pure-tone audiometric data were used to evaluate postoperative changes in hearing. Surgical failure was defined as requiring revision surgery, and rates were estimated over time using a Kaplan-Meier analysis. RESULTS: Most patients reported improved symptoms postoperatively and were satisfied overall with the surgical outcomes. However, four of 12 ears (33%) had a second (revision) surgery before achieving these results. Postoperatively, hearing through air and bone conduction tended to decrease at frequencies greater than 2500 Hz. The chance of avoiding a re-operation at 36 months (and up to 120 months) was estimated to be 57.1% (95% confidence interval [confidence interval]: 100%, 32.6%). The most common surgical complication was intraoperative cerebrospinal fluid (CSF) leak, encountered exclusively during dural elevation, seen in four of 12 ears (33%). CONCLUSION: Although subjectively successful at reducing symptoms, in our small sample this surgical approach did not provide a long-term stable repair and was frequently associated with intraoperative CSF leak. Offering transmastoid resurfacing to patients should involve a detailed discussion on the potential for revision surgery and risks of diminished hearing and CSF leak. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:2164-2169, 2019.

ResistanceSim: development and acceptability study of a serious game to improve understanding of insecticide resistance management in vector control programmes.

The use of insecticides is the cornerstone of effective malaria vector control. However, the last two decades has seen the ubiquitous use of insecticides, predominantly pyrethroids, causing widespread insecticide resistance and compromising the effectiveness of vector control. Considerable efforts to develop new active ingredients and interventions are underway. However, it is essential to deploy strategies to mitigate the impact of insecticide resistance now, both to maintain the efficacy of currently available tools as well as to ensure the sustainability of new tools as they come to market. Although the World Health Organization disseminated best practice guidelines for insecticide resistance management (IRM), Rollback Malaria's Vector Control Working Group identified the lack of practical knowledge of IRM as the primary gap in the translation of evidence into policy. ResistanceSim is a capacity strengthening tool designed to address this gap. The development process involved frequent stakeholder consultation, including two separate workshops. These workshops defined the learning objectives, target audience, and the role of mathematical models in the game. Software development phases were interspersed with frequent user testing, resulting in an iterative design process. User feedback was evaluated via questionnaires with Likert-scale and open-ended questions. The game was regularly evaluated by subject-area experts through meetings of an external advisory panel. Through these processes, a series of learning domains were identified and a set of specific learning objectives for each domain were defined to be communicated to vector control programme personnel. A simple "game model" was proposed that produces realistic outputs based on player strategy and also runs in real-time. Early testing sessions revealed numerous usability issues that prevented adequate player engagement. After extensive revisions, later testing sessions indicated that the tool would be a valuable addition to IRM training.

Observer aging and long-term avian survey data quality.

Long-term wildlife monitoring involves collecting time series data, often using the same observers over multiple years. Aging-related changes to these observers may be an important, under-recognized source of error that can bias management decisions. In this study, we used data from two large, independent bird surveys, the Atlas of the Breeding Birds of Ontario ("OBBA") and the North American Breeding Bird Survey ("BBS"), to test for age-related observer effects in long-term time series of avian presence and abundance. We then considered the effect of such aging phenomena on current population trend estimates. We found significantly fewer detections among older versus younger observers for 13 of 43 OBBA species, and declines in detection as an observer ages for 4 of 6 vocalization groups comprising 59 of 64 BBS species. Consistent with hearing loss influencing this pattern, we also found evidence for increasingly severe detection declines with increasing call frequency among nine high-pitched bird species (OBBA); however, there were also detection declines at other frequencies, suggesting important additional effects of aging, independent of hearing loss. We lastly found subtle, significant relationships between some species' published population trend estimates and (1) their corresponding vocalization frequency (n ≥ 22 species) and (2) their estimated declines in detectability among older observers (n = 9 high-frequency, monotone species), suggesting that observer aging can negatively bias long-term monitoring data for some species in part through hearing loss effects. We recommend that survey designers and modelers account for observer age where possible.

Widespread reproductive variation in North American turtles: temperature, egg size and optimality.

Theory predicts the existence of an optimal offspring size that balances the trade-off between offspring fitness and offspring number. However, in wild populations of many species, egg size can still vary from year to year for unknown reasons. Here, we hypothesize that among-year variation in population mean egg size of freshwater turtles is partly a consequence of their gonadal sensitivity to seasonal temperatures, a physiological mechanism which principally functions to synchronize reproduction with a favorable time of year. As part of this process, among-year variation in seasonal temperatures modifies the extent of egg follicle development, and this may translate into variation in mean egg size among years (both at the individual and population level). To test this hypothesis, we applied an information-theoretic approach to model relationships between mean egg mass and the temperatures experienced during discrete periods of follicular development in wild populations of three turtle species (Chrysemys picta, Chelydra serpentina, Glyptemys insculpta) over 12 consecutive years. Because follicular development occurs in the fall for C. serpentina and G. insculpta, whereas it occurs both in the fall and spring for C. picta, we expected only fall temperatures would explain egg size variation in C. serpentina and G. insculpta, whereas both fall and spring temperatures would correlate with egg size variation in C. picta. These predictions were upheld. We then compared among-year variation in within-female egg and clutch sizes of each species in order to evaluate whether such variation might still be consistent with some tenets of optimal egg size theory. In all three species, we found that clutch sizes vary more than egg sizes in spite of temperature-induced egg size variation, and this pattern of relatively high clutch-size variation matches theoretical predictions. Future work should explore the roles of direct and indirect (i.e., nutritional) influences of temperature on egg size in natural settings.

Heart failure mortality among older Medicare beneficiaries: association with left ventricular function evaluation and angiotensin-converting enzyme inhibitor use.

BACKGROUND: Left ventricular function evaluation and angiotensin-converting enzyme (ACE) inhibitor use are the two basic indicators of heart failure quality of care. In this retrospective follow-up study, we analyzed the association between these two quality indicators and mortality in elderly hospitalized heart failure patients. METHODS: The patients in our study were older Alabama Medicare beneficiaries discharged with a diagnosis of heart failure in 1994. Cox regression analyses, adjusted for various patient and care characteristics, were performed to estimate the overall mortality rate. RESULTS: The mean age of the 1,090 patients in our study was 79+/-7.5 years. Both left ventricular function evaluation (hazard ratio, 0.83; 95% confidence interval, 0.705-0.976) and ACE inhibitor use (hazard ratio, 0.77; 95% confidence interval, 0.655-0.905) were associated with a lower 3-year mortality rate. Adjustment for various patient and care characteristics did not alter these associations. CONCLUSION: Left ventricular function evaluation and ACE inhibitor use were each associated with increased survival time in older Medicare beneficiaries with heart failure.