The use of Escherichia coli strain Nissle 1917 shows promise for improving gastrointestinal and urinary health in dogs.

OBJECTIVES: To investigate the probiotic Escherichia coli Nissle 1917 (EcN) in canine idiopathic diarrhea and urinary tract infections. ANIMALS/SAMPLES: The utility of EcN was explored in a 3-phase study from March 2017 to June 2020. Eighty-nine dogs with idiopathic diarrhea were included in phase 1, 3 healthy dogs were included in phase 2, and uropathogenic E coli (UPEC) isolates from 38 dogs with urinary tract infections were included in phase 3. PROCEDURES: In phase 1, dogs with diarrhea were prospectively enrolled in a randomized study to receive EcN (108 EcN bacteria/mL; < 10 kg received 5 mL/dose, 10 to 25 kg received 10 mL/dose, or > 25 kg received 15 mL/dose) or placebo for 3 days, followed by a 15-day observation phase. In phase 2, healthy dogs received EcN as described in phase 1, with feces analyzed for E coli populations and microbiome composition at days 0, 3, and 7. In phase 3, EcN efficacy was tested by in vitro plate assay against UPEC isolates. RESULTS: Median duration of abnormal stool consistency, time to response, and duration of diarrhea were shorter for dogs that received EcN (5.0, 3.0, and 2.0 days, respectively) versus the placebo (7.0, 5.0, and 4.0 days, respectively) (P = .21, P = .05, and P = .039, respectively). EcN induced shifts in E coli diversity in healthy dogs while having minimal impact on overall microbiome structure. Furthermore, 68% of the canine UPEC isolates were susceptible to EcN in vitro. CLINICAL RELEVANCE: EcN improved the treatment of idiopathic diarrhea, colonized the gastrointestinal tract during the trial, and displayed in vitro competition with UPEC.

Strategies Australian junior doctors use to maintain their mental, physical and social well-being: a qualitative study.

OBJECTIVES: This study aimed to uncover the strategies that junior doctors implement to maintain their mental, physical and social well-being, and the barriers they experience in practising these strategies. PARTICIPANTS: Fifteen junior doctors in their postgraduate year 1 or 2 currently practising in Australia were recruited. OUTCOME MEASURES: Semistructured interviews were conducted, and the transcripts underwent thematic analysis. RESULTS: Three key themes emerged from thematic analysis, namely: well-being strategies, barriers to well-being and and future interventions. Exercise, a healthy and balanced diet, quality sleep, and workplace organisations were frequently reported well-being strategies. High workload, unpredictable routines, lack of familiarity with the healthcare system and ongoing stigma surrounding mental health were seen as barriers to well-being. Suggested interventions included increased control over rosters, subsidised access to facilities such as gyms and increased internship preparedness programmes organised by the medical schools. CONCLUSIONS: The findings from this study may assist in developing more personalised and targeted methods to help junior doctors maintain their mental, physical and social well-being. Future studies may address the structural and systemic changes required to develop a workforce that fosters the well-being of junior doctors and reduces the institutional barriers to practising well-being strategies.

Natural and Synthetic Suppressor Mutations Defy Stability-Activity Tradeoffs.

Thermodynamic stability represents one important constraint on protein evolution, but the molecular basis for how mutations that change stability impact fitness remains unclear. Here, we demonstrate that a prevalent global suppressor mutation in TEM ß-lactamase, M182T, increases fitness by reducing proteolysis in vivo. We also show that a synthetic mutation, M182S, can act as a global suppressor and suggest that its absence from natural populations is due to genetic inaccessibility rather than fundamental differences in the protein's stability or activity.

Barriers to cervical cancer screening faced by immigrant women in Canada: a systematic scoping review.

BACKGROUND: The objective of this scoping study is to review the published literature and summarize findings related to barriers experienced by immigrant women in Canada while accessing cervical cancer screening. METHODS: Electronic databases of peer-reviewed articles and grey literature were searched using comprehensive sets of keywords, without restricting the time period or language. Articles were selected based on the following criteria: (a) the study population consisted of Canadian immigrant women and healthcare providers and other stakeholders serving immigrant women, (b) the research focused on the barriers to accessing cervical cancer screening, and (c) the study was conducted in Canada. RESULTS: Extracted data were grouped and analyzed, resulting in barriers comprised of six themes: economic barriers, cultural barriers, language barriers, healthcare system-related barriers, knowledge-related barriers, and individual-level barriers. Lack of education, low income, preference for a female physician, lack of knowledge, lack of effective communication, and embarrassment were some of the most common barriers mentioned. CONCLUSIONS: Immigrant access to health services, including cervical cancer screening, is a complex issue concerning a wide range of barriers. Our findings offer insights into barriers to cervical cancer screening in immigrant communities in Canada that can be used to assist policymakers, healthcare providers, and researchers enhance the health and well-being of these populations by mitigating barriers and improving screening.

The Impact of a National Competency-Based Medical Education Initiative in Family Medicine.

PURPOSE: Triple C is the Canadian competency-based medical education (CBME) initiative for family medicine. The authors report on a study exploring the impacts Triple C has had across Canada. METHOD: A multi-institutional team conducted a realist study to explore the impact of Triple C implementation in different programs across Canada. Data were collected between March and June 2016 from interviews and focus groups with key medical school stakeholders. Data were analyzed using thematic and template analysis techniques. RESULTS: Data were acquired from 16 of the 17 Canadian medical schools from a combination of program leaders, educators, and trainees. Triple C was implemented in different ways and to different extents depending on context. Newer sites tended to have a more comprehensive implementation than established sites. Urban sites afforded different opportunities to implement Triple C from those afforded by rural sites. Although it was too early to assess its impact on the quality of graduating residents, Triple C was seen as having had a positive impact on identifying and remediating failing learners and on energizing and legitimizing the educational mission in family medicine. Negative impacts included greater costs and tensions in the relationships with other specialties. A principles-based approach to CBME offered flexibility to programs to incorporate variation in their interpretation and implementation of Triple C. Although there was a degree of normalization of practice, it was not standardized across sites or programs. CONCLUSIONS: Triple C has been successfully implemented across Canada but in differing ways and with different impacts.

Social determinants of access to minimally invasive hysterectomy: reevaluating the relationship between race and route of hysterectomy for benign disease.

BACKGROUND: Racial and socioeconomic disparities exist in access to medical and surgical care. Studies of national databases have demonstrated disparities in route of hysterectomy for benign indications, but have not been able to adjust for patient-level factors that affect surgical decision-making. OBJECTIVE: We sought to determine whether access to minimally invasive hysterectomy for benign indications is differential according to race independent of the effects of relevant subject-level confounding factors. The secondary study objective was to determine the association between socioeconomic status and ethnicity and access to minimally invasive hysterectomy. STUDY DESIGN: A cross-sectional study evaluated factors associated with minimally invasive hysterectomies performed for fibroids and/or abnormal uterine bleeding from 2010 through 2013 at 3 hospitals within an academic university health system in Philadelphia, PA. Univariate tests of association and multivariable logistic regression identified factors significantly associated with minimally invasive hysterectomy compared to the odds of treatment with the referent approach of abdominal hysterectomy. RESULTS: Of 1746 hysterectomies evaluated meeting study inclusion criteria, 861 (49%) were performed abdominally, 248 (14%) vaginally, 310 (18%) laparoscopically, and 327 (19%) with robot assistance. In univariate analysis, African American race (odds ratio, 0.80; 95% confidence interval, 0.65-0.97) and Hispanic ethnicity (odds ratio, 0.63; 95% confidence interval, 0.39-1.00) were associated with lower odds of any minimally invasive hysterectomy relative to abdominal hysterectomy. In analyses adjusted for age, body mass index, income quartile, obstetrical and surgical history, uterine weight, and additional confounding factors, African American race was no longer a risk factor for reduced minimally invasive hysterectomy (odds ratio, 0.82; 95% confidence interval, 0.61-1.10), while Hispanic ethnicity (odds ratio, 0.45; 95% confidence interval, 0.27-0.76) and Medicaid enrollment (odds ratio, 0.59; 95% confidence interval, 0.38-0.90) were associated with significantly lower odds of treatment with any minimally invasive hysterectomy. In adjusted analyses, African American women had nearly half the odds of receiving robot-assisted hysterectomy compared to whites (adjusted odds ratio, 0.57; 95%, confidence interval 0.39-0.82), while no differences were noted with other hysterectomy routes. Medicaid enrollment (compared to private insurance; odds ratio, 0.51; 95% confidence interval, 0.28-0.94) and lowest income quartile (compared to highest income quartile; odds ratio, 0.57; 95% confidence interval, 0.38-0.85) were also associated with diminished odds of robot-assisted hysterectomy. CONCLUSION: When accounting for the effect of numerous pertinent demographic and clinical factors, the odds of undergoing minimally invasive hysterectomy were diminished in women of Hispanic ethnicity and in those enrolled in Medicaid but were not discrepant along racial lines. However, both racial and socioeconomic disparities were observed with respect to access to robot-assisted hysterectomy despite the availability of robotic assistance in all hospitals treating the study population. Strategies to ensure equal access to all minimally invasive routes for all women should be explored to align delivery of care with the evidence supporting the broad implementation of these procedures as safe, cost-effective, and highly acceptable to patients.

Virtual patient activity patterns for clinical learning.

BACKGROUND: Virtual patients are software tools that present learners with patient case situations and tasks. Some virtual patients take the learner through a guided case scenario, whereas others require learners to make diagnostic and therapeutic decisions. Much attention has been paid to the design of virtual patients and their use as standalone activities, but rather less attention has been paid to their use in broader educational activities. This article describes a series of activity patterns that make use of virtual patients. CONTEXT: The article describes five patterns of clinical teaching activities that make use of virtual patients: independent study activities; collaborative group activities; blended activities; bridging activities; and reference activities. These patterns were developed inductively from the authors' teaching practices over a number of years. These are not the only activity patterns and designs that can make use of virtual patients but they are ones that have been found to be particularly useful over time and in many different contexts. INNOVATION: Although the design of educational artifacts such as virtual patients is important, clinical teachers also need to consider the ways in which they are used. Different kinds of activity can employ different kinds of virtual patients of varying levels of complexity. An activity focus can allow clinical teachers to make more effective and broader use of virtual patients. IMPLICATIONS: Virtual patients can be used for more than independent study. Clinical teachers are encouraged to explore the multitude of uses that virtual patients can be put to, and the ways in which activities can be constructed around them. Different kinds of activity can employ different kinds of virtual patients, of varying levels of complexity.

FM POD: an evidence-based blended teaching skills program for rural preceptors.

BACKGROUND AND OBJECTIVES: The University of Calgary's Rural Integrated Community Clerkship anchors final-year medical student education in 9 months of family medicine. The purpose of this pilot study was to evaluate the Family Medicine Preceptor Online Development (FM POD) program, designed to meet the faculty development needs of rural preceptors facing challenges of geographical distribution and time constraints. METHODS: The theoretically based program used a blended learning approach, beginning with a face-to-face workshop to strengthen participants' social presence during online interactions to follow. Asynchronous narrated presentations supplied foundational knowledge prior to facilitated synchronous web conferences, where participants shared experiences and co-constructed new knowledge. The program was evaluated using mixed methods, including surveys and focus group discussion. RESULTS: Evaluation tools generated data with high internal consistency reliability; focus group information substantiated and enriched the quantitative survey data. Participants enjoyed collaborating with colleagues and rated their learning experiences highly, reporting meaningful and statistically significant increases in mean comfort with all the precepting skills taught: giving effective feedback, using questions to teach, teaching communications skills, helping learners in difficulty, and making teaching time-efficient. All effect sizes were large. Increased comfort with distance learning technologies was a positive consequence. CONCLUSIONS: Results support the applicability of principles of social constructivism, experiential learning, and reflective learning in these participants. The program was highly rated and effectively increased participants' comfort with teaching skills, offering practical off-the-peg modular faculty development in basic teaching skills for distributed faculty. Participants appreciated the flexible delivery format, which course developers found readily adaptable for additional topics.