Identifying Primary Care Physicians Continuing Education Needs by Examining Clinical Practices, Attitudes, and Barriers to Screening Across Multiple Cancers.

Population-based cancer screening for cervical, breast, and colorectal cancers improves patient outcomes, yet screening rates remain low for some cancers. Despite studies investigating physician perceptions and practices for screening, many have focused on individual cancers and lack primary care physicians' (PCPs) realities around screening for multiple cancers. We surveyed 887 PCPs in British Columbia (BC) to examine practices, beliefs, barriers, and learning needs towards cancer screening across breast, cervical, colorectal, prostate, as well as hereditary predisposition to cancer. Survey results identified differences in PCPs belief in the benefit of screening for recommended and non-recommended routine cancer screening, PCPs adherence to screening guidelines for some cancers and physician comfort and patient testing requests related to physician gender for gender sensitive tests. Further, across cancers, screening barriers included patients with multiple health concerns (41%), limited time to discuss screening (36%), and lack of physician financial compensation to discuss screening (23%). The study highlighted the need for more physician education on screening programs, referral criteria, follow-up processes, and screening guidelines. Conferences (73%), self-directed (46%), small group workshops (42%), hospital rounds (41%), and online CME/CPD (39%) were highly preferred (4+5) for learning about cancer screening. The results suggest a need to improve awareness and adherence to screening guidelines and recommended practices, as well as to provide educational opportunities which address knowledge and practice gaps for physicians.

Understanding how emergency medicine physicians survive and thrive in rural practice: a theoretical model.

INTRODUCTION: The challenges facing emergency medicine (EM) services in Canada reflect the limitations of the entire healthcare system. The emergency department (ED) is uniquely situated in the healthcare system such that shortcomings in hospital- and community-based services are often first revealed there. This is especially true in rural settings, where there are additional site-specific barriers to the provision of EM care. Existing studies look at the factors that influence rural EM physicians in isolation. This study uses a qualitative approach and generates a theoretical model that describes the complex interplay between major factors that influence the experience of rural EM physicians. METHODS: Eight focus groups were conducted with 39 physicians from rural British Columbia, Canada. Semi-structured focus group protocols were designed to leverage the diversity of the focus groups, which included rural generalists, full-time EM practitioners, physicians from very small and remote communities, locums, international medical graduates, physicians new to practice, and physicians who no longer practice rural EM. Following the principles of grounded theory, interview probes were adjusted iteratively to reflect emerging findings. Transcripts were analysed to identify codes and major themes, which served as the basis for the theoretical model. RESULTS: The theoretical model reveals how the causal conditions (a lack of medical and human resources, and the isolation of rural communities due to topography, distance, and inclement weather) contribute to physicians' common experience of feeling fearful and under-supported at work. Two core phenomena emerge as important needs: supportive professional relationships, and healthcare system adaptability. Contextual factors such as remuneration and continuing medical education funding, and the intervening conditions of physicians' rural exposure during formative years, also have an effect. Physicians create innovative solutions to address the challenges that arise in the practice of rural EM. Ultimately, the ability to manage the pressures of rural EM leads physicians to either thrive in or leave rural EM practice. CONCLUSIONS: The theoretical model provides a more complex view of the realities of rural EM care than has been previously described. It identifies factors that enable and hinder rural EM physicians in their practice, and provides an understanding of the strategies they employ to navigate challenges. Some elements of the theoretical model have been previously identified. For example, existing work has found that many rural physicians experience fear and anxiety in their practice. The challenges posed by the variation in rural practice environments have also been previously identified as an important influence. Other elements of the theoretical model, and the common need for practitioners to creatively respond to barriers arising from the healthcare system's inability to respond to local needs, have not been previously identified. This work finds these factors to be a common experience for participants, and as such, more widespread recognition of the importance of these factors could lead to system improvements. Future research is needed to test the hypotheses proposed in this study and explore the generalizability of the findings.

Fluid replacement and heat stress during exercise alter post-exercise cardiac haemodynamics in endurance exercise-trained men.

It has been reported that endurance exercise-trained men have decreases in cardiac output with no change in systemic vascular conductance during post-exercise hypotension, which differs from sedentary and normally active populations. As inadequate hydration may explain these differences, we tested the hypothesis that fluid replacement prevents this post-exercise fall in cardiac output, and further, exercise in a warm environment would cause greater decreases in cardiac output. We studied 14 trained men (VO2,peak 4.66 +/- 0.62 l min(-1)) before and to 90 min after cycling at 60% VO2,peak for 60 min under three conditions: Control (no water was consumed during exercise in a thermoneutral environment), Fluid (water was consumed to match sweat loss during exercise in a thermoneutral environment) and Warm (no water was consumed during exercise in a warm environment). Arterial pressure and cardiac output were measured pre- and post-exercise in a thermoneutral environment. The fall in mean arterial pressure following exercise was not different between conditions (P = 0.453). Higher post-exercise cardiac output (Delta 0.41 +/- 0.17 l min(-1); P = 0.027), systemic vascular conductance (Delta 6.0 +/- 2.2 ml min(-1) mmHg(-1); P = 0.001) and stroke volume (Delta 9.1 +/- 2.1 ml beat(-1); P < 0.001) were seen in Fluid compared to Control, but there was no difference between Fluid and Warm (all P > 0.05). These data suggest that fluid replacement mitigates the post-exercise decrease in cardiac output in endurance-exercise trained men. Surprisingly, exercise in a warm environment also mitigates the post-exercise fall in cardiac output.

CPD and KT: Models Used and Opportunities for Synergy.

The two fields of continuing professional development (CPD) and knowledge translation (KT) within the health care sector, and their related research have developed as somewhat parallel paths with limited points of overlap or intersection. This is slowly beginning to change. The purpose of this paper is to describe and compare the dominant conceptual models informing each field with the view of increasing understanding and appreciation of the two fields, how they are similar and where they differ, and the current and potential points of intersection. The models include the "knowledge-to-action" (KTA) cycle informing KT, models informing CPD curriculum design and individual self-directed learning, and the Kirkpatrick model for evaluating educational outcomes. When compared through the perspectives of conceptual designs, processes, and outcomes, the models overlap. We also identify shared gaps in both fields (eg, the need to explore the influence of the context in which CPD and KT interventions take place) and suggest opportunities for synergies and for moving forward.

Effects of pseudoephedrine on maximal cycling power and submaximal cycling efficiency.

PURPOSE: To study the effects of a therapeutic dose of pseudoephedrine on anaerobic cycling power and aerobic cycling efficiency. METHODS: Eleven healthy moderately trained males (VO (2peak) 4.4 +/- 0.8 L x min(-1) participated in a double-blinded crossover design. Subjects underwent baseline (B) tests for anaerobic (Wingate test) and aerobic (VO (2peak) test) cycling power. Subjects ingested either 60 mg of pseudoephedrine hydrochloride (D) or a placebo (P) and, after 90 min of rest, a Wingate and a cycling efficiency test were performed. During the cycling efficiency test, heart rate (HR) and VO(2) were averaged for the last 5 min of a 10-min cycle at 40% and 60% of the peak power achieved during the VO (2peak) test. RESULTS: There were no significant differences in peak power (B = 860 +/- 154, D = 926 +/- 124, P = 908 +/- 118 W), total work (B = 20 +/- 3, D = 21 +/- 3, P = 21 +/- 3 kJ), or fatigue index (B = 39 +/- 8, D = 45 +/- 5, P = 43 +/- 5%). There were no significant differences in HR at 40% power (D = 138 +/- 10, P = 137 +/- 10 beats.min-1) or 60% power (D = 161 +/- 11, P = 160 +/- 11 beats x min(-1). There were no significant differences in cycling efficiency at 40% power (D = 18.8 +/- 1.8, P = 18.5 +/- 1.8%) or 60% power (D = 20.3 +/- 2.0, P = 20.1 +/- 2.1%). CONCLUSION: A therapeutic dose of pseudoephedrine hydrochloride does not affect anaerobic cycling performance or aerobic cycling efficiency.

CPD and KT: models used and opportunities for synergy.

The two fields of continuing professional development (CPD) and knowledge translation (KT) within the health care sector, and their related research have developed as somewhat parallel paths with limited points of overlap or intersection. This is slowly beginning to change. The purpose of this paper is to describe and compare the dominant conceptual models informing each field with the view of increasing understanding and appreciation of the two fields, how they are similar and where they differ, and the current and potential points of intersection. The models include the "knowledge-to-action'' (KTA) cycle informing KT, models informing CPD curriculum design and individual self-directed learning, and the Kirkpatrick model for evaluating educational outcomes. When compared through the perspectives of conceptual designs, processes, and outcomes, the models overlap. We also identify shared gaps in both fields (eg, the need to explore the influence of the context in which CPD and KT interventions take place) and suggest opportunities for synergies and for moving forward.

Potential benefit from an H1-receptor antagonist on postexercise syncope in the heat.

PURPOSE: H1-receptors mediate the early portion (i.e., first 30 min after exercise) of postexercise hypotension. Immediately after exercise, syncope can occur due to an exaggerated form of postexercise hypotension. Therefore, we hypothesized that orthostatic hypotension occurring immediately after exercise would be attenuated with an H1-receptor antagonist. METHODS: We studied 15 endurance exercise-trained men and women in an environmental chamber set at 35 degrees C and 30.0% humidity. Subjects were studied in the supine position before a 45-min bout of treadmill running at 50% of VO2max. Immediately after exercise, measurements were taken in the supine position before the subjects were moved from a supine to a 60 degrees head-up tilt. Measurements included arterial pressure, heart rate, and brachial and cutaneous blood flow on a control and an H1-receptor antagonist (blockade) day. RESULTS: Mean arterial pressure was reduced 1 min into the tilt compared with preexercise values on the control day (76.2 +/- 0.5 vs 74.2 +/- 0.5 mm Hg; P < 0.05). This reduction was not seen on the blockade day (75.2 +/- 0.3 vs 75.0 +/- 0.5 mm Hg; P > 0.41). There were no differences in brachial vascular conductance (calculated as flow/pressure) in response to the head-up tilt between the study days (P > 0.23). The length of the head-up tilt was compared between study days for each subject. When contrasting this difference, the blockade lengthened the mean tilt time by 94 s (P = 0.098). CONCLUSION: These data suggest that an H1-receptor antagonist could potentially benefit postexercise syncope in a hot environment.

Effects of the menstrual cycle and sex on postexercise hemodynamics.

Factors associated with the menstrual cycle, such as the endogenous hormones estrogen and progesterone, have dramatic effects on cardiovascular regulation. It is unknown how this affects postexercise hemodynamics. Therefore, we examined the effects of the menstrual cycle and sex on postexercise hemodynamics. We studied 14 normally menstruating women [24.0 (4.2) yr; SD] and 14 men [22.5 (3.5) yr] before and through 90 min after cycling at 60% .VO2(peak) for 60 min. Women were studied during their early follicular, ovulatory, and mid-luteal phases; men were studied once. In men and women during all phases studied, mean arterial pressure was decreased after exercise throughout 60 min (P < 0.001) postexercise and returned to preexercise values at 90 min (P = 0.089) postexercise. Systemic vascular conductance was increased following exercise in both sexes throughout 60 min (P = 0.005) postexercise and tended to be elevated at 90 min postexercise (P = 0.052), and femoral vascular conductance was increased following exercise throughout 90 min (P < 0.001) postexercise. Menstrual phase and sex had no effect on the percent reduction in arterial pressure (P = 0.360), the percent rise in systemic vascular conductance (P = 0.573), and the percent rise in femoral vascular conductance (P = 0.828) from before to after exercise, nor did the pattern of these responses differ across recovery with phase or sex. This suggests that postexercise hemodynamics are largely unaffected by sex or factors associated with the menstrual cycle.