Postpartum haemorrhage in rural Indigenous women: scoping review of a global obstetrical challenge.

We conducted a scoping review to determine incidence and risk factors for postpartum haemorrhage (PPH) in rural Indigenous women. We systematically searched PubMed (Medline), EMBASE, and CINAHL for all peer-reviewed articles and grey literature regarding Indigenous ethnicity, rural settings, and PPH incidence, risk factors, or maternal outcomes published from inception to 11 January 2021. Eleven articles were deemed relevant after screening and quality assessment using the National Institutes of Health scoring system for mixed study reviews. Of these, 3 articles were good quality, 1 was fair, and 7 were poor. Nine possible risk factors were recorded. The outcomes studied were transfusion, hysterectomy and mortality. PPH research in rural Indigenous women is scarce, mostly low quality and fails to represent most Indigenous cultures and countries. Women from Indigenous groups in rural Canada, Australia and the USA are at higher risk for PPH but specific risk factors are unknown. While widely differing populations made the data difficult to synthesise, this inaugural scoping review highlights a need for further research and increased obstetrical resources in areas where rural Indigenous women reside.

Assessing a research training programme for rural physicians.

INTRODUCTION: To assess the effect of a training programme called 6for6 (the programme) on research competency and productivity amongst rural physicians. The programme develops the research skills of six rural physicians over six weekends. Physicians learn about various research methods and writing techniques through blended learning components. METHODS: We conducted a quasi-experimental study, comparing research competency and productivity between intervention and non-equivalent control groups and over time through a repeated measures design. Generalized linear mixed model (GLMM), ANOVA, and Cochran Q tests were conducted. The intervention was provided to five groups of 6 rural physicians each between 2014 and 2019. Main outcome measures: self-assessed research competency (knowledge, attitudes and skills) and productivity (publications, grants and presentations of research-related work at conferences) were our primary and secondary outcomes, respectively. We measured the outcomes before, during and after the programme. Controls: Rural physicians who expressed interest in the programme and later enrolled. RESULTS: This study shows that, amongst its thirty participants, overall research competency was significantly different between intervention and control groups (65.7% ± 37.6% and 58.6% ± 14.4%, P < 0.05 for GLMM). The percentage of participants who were productive before, during and after the programme was 26.7%, 16.7% and 50.0%, respectively. Overall, productivity rates were significantly different between intervention and control groups (rate difference was 72.2/100 person-years, P < 0.05 for GLMM). CONCLUSION: This study suggests that the programme improves research competency and productivity for rural physicians. Rural physicians who wish to improve their research competency would benefit from participating in similar programmes.

Résumé Introduction: Évaluer l'effet d'un programme de formation intitulé 6for6 (le programme) sur les compétences en recherche et la productivité parmi les médecins des régions rurales. Le programme permet à six médecins en région rurale d'acquérir des compétences en recherche durant six fins de semaine. Les médecins apprennent diverses méthodologies de recherche et techniques de rédaction par l'entremise d'un programme d'apprentissage mixte. Méthodologie: Nous avons réalisé une étude quasi-expérimentale, qui comparait les compétences en recherche et la productivité entre des groupes non-équivalents intervention et témoin, et dans le temps, par une méthodologie à mesures répétitives. Un modèle linéaire à effets mixtes généralisé (GLMM), un modèle d'analyse de variance, et des tests Q de Cochran ont été réalisés. L'intervention a été appliquée à 5 groupes de 6 médecins en région rurale, entre 2014 et 2019 dans tous les cas. Paramètre d'évaluation: compétences en recherche évaluées par l'apprenant (connaissances, attitudes et compétences) et productivité (publications, subventions et présentation des travaux de recherche aux congrès) étaient respectivement nos paramètres d'évaluation principal et secondaire. Nous avons mesuré les paramètres avant, durant et après le programme. Les médecins en région rurale ayant manifesté de l'intérêt à l'égard du programme ont été inscrits. Résultats: L'étude montre que parmi les 30 participants, les compétences générales en recherche étaient significativement différentes entre les groupes intervention et témoin (65,7 ± 37,6% et 58,6 ± 14,4%, P < 0,05 pour le GLMM). Le pourcentage de participants qui étaient productifs avant, durant et après le programme était respectivement de 26,7, 16,7 et 50,0%. Dans l'ensemble, la productivité était significativement différente entre les groupes intervention et témoin (différence des taux: 72,2 par 100 années-personnes, P < 0,05 pour le GLMM). Conclusion: Cette étude laisse penser que le programme améliore les compétences en recherche et la productivité chez les médecins en région rurale. Les médecins en région rurale qui souhaitent améliorer leurs compétences en recherche bénéficieront de programmes semblables. Mots-clés: Compétences en recherche, programme de formation en recherche, santé en région rurale, communautés rurales.

Rural health research capacity building: an anchored solution.

Rural physicians face many challenges with providing rural health care, which often leads to innovative solutions. Despite their creativity with overcoming barriers, there is a lack of support for rural health research - an area of health care where research makes great impacts on small communities. Rural research capacity building (RRCB) is essential to support rural physicians so that they can conduct relevant research, but RRCB programs are sparse. Thus, our team at Memorial University of Newfoundland, Canada, has created an RRCB ecosystem through the 6for6 and Rural360 programs, which outline a pathway for rural physicians to make meaningful contributions to their communities through research. This article describes the RRCB ecosystem and explains how the 6for6 and Rural360 programs address the need for RRCB. Designed to train six rural physicians over six sessions per year, 6for6 fosters learning of research practices through a conceptual framework that envelops complexity science, systems thinking, and anchored instruction. The use of this framework allows the learning to be grounded in issues that are locally relevant for each participant and follows guiding principles that enable many types of learning. Rural360 continues the pathway by providing an in-house funding opportunity with an iterative review process that allows participants to continue developing their research skills and, ultimately, secure funding for their project. This anchored delivery model of RRCB programming is made possible through many support systems including staff, librarians, instructors, the university, and other stakeholders. It has successfully helped form communities of practice, promotes collaboration both between learners and with third parties, encourages self-organization with flexibility for learners outside of the in-house sessions, and ultimately drives social accountability in addressing local healthcare issues.

Evaluation plan of the 6for6 research skills program for rural and remote physicians.

Overwhelming issues and barriers often prevent rural and remote physicians (RRPs) from pursuing the many socially accountable research questions they encounter on a daily basis. Although research training programs can empower RRPs to rise to these challenges, there is a lack of evidence on how they should be developed and refined. At Memorial University, a faculty development program (FDP) called 6for6 has been helping RRPs surmount their research quagmires and engage in scholarship since 2014. After an initial three-year (2014-17) pilot, we prepared a detailed plan to evaluate the 6for6 research FDP for RRPs and inform future years of delivery. Using a modified Delphi method and participatory action model a group of program team members, stakeholders and evaluation experts developed an evaluation plan including a logic model and an evaluation matrix addressing five key themes. To our knowledge, this is the first evaluation plan for a research-focused FDP targeting RRPs. While this plan was developed specifically for the 6for6 FDP, our approach to its development may be useful to any institution interested in evaluating an FDP with limited resources.

SurgeCon: Priming a Community Emergency Department for Patient Flow Management.

INTRODUCTION: Canadian emergency departments (ED) are struggling to provide timely emergency care. Very few studies have assessed attempts to improve ED patient flow in the rural context. We assessed the impact of SurgeCon, an ED patient-management protocol, on total patient visits, patients who left without being seen (LWBS), length of stay for departed patients (LOSDep), and physician initial assessment time (PIA) in a rural community hospital ED. METHODS: We implemented a set of commonly used methods for increasing ED efficiency with an innovative approach over 45 months. Our intervention involved seven parts comprised of an external review, Lean training, fast track implementation, patient-centeredness approach, door-to-doctor approach, performance reporting, and an action-based surge capacity protocol. We measured key performance indicators including total patient visits (count), PIA (minutes), LWBS (percentage), and LOSDep (minutes) before and after the SurgeCon intervention. We also performed an interrupted time series (ITS) analysis. RESULTS: During the study period, 80,709 people visited the ED. PIA decreased from 104.3 (±9.9) minutes to 42.2 (±8.1) minutes, LOSDep decreased from 199.4 (±16.8) minutes to 134.4(±14.5) minutes, and LWBS decreased from 12.1% (±2.2) to 4.6% (±1.7) despite a 25.7% increase in patient volume between pre-intervention and post-intervention stages. The ITS analysis revealed a significant level change in PIA - 19.8 minutes (p<0.01), and LWBS - 3.8% (0.02), respectively. The change over time decreased by 2.7 minutes/month (p< 0.001), 3.0 minutes/month (p<0.001) and 0.4%/month (p<0.001) for PIA, LOSDep, and LWBS, after the intervention. CONCLUSION: SurgeCon improved the key wait-time metrics in a rural ED in a country where average wait times continue to rise. The SurgeCon platform has the potential to improve ED efficiency in community hospitals with limited resources.

Rural360: incubating socially accountable research in the Canadian North.

People in Northern Newfoundland and Coastal Labrador (NNCL), Canada, face major challenges obtaining accessible and contextually-relevant healthcare. Rural360 is a socially accountable research incubator that provides funding for NNCL physicians to research solutions to these issues. NNCL graduates of the adjoined 6for6 research training program for rural physicians are invited to submit the research project they have conceptualised as part of that initiative as a letter of intent, and subsequently as a research proposal, to Rural360. These submissions are reviewed by relevant subject matter experts as part of the Rural360 adjudication process. This process is iterative and strives to guide and assist participants in refining their submission. The overarching objective of Rural360 is to collaborate with rural physicians to conduct, disseminate or otherwise catalyze unsupported community-based research in NNCL. In so doing, it is highly socially accountable, empowering participants to become change-makers who investigate contextually important health issues that emerge from NNCL communities.

Laparoscopic cholecystectomy for ultrasound normal gallbladders: Should we forego hepatobiliary iminodiacetic acid scans?

INTRODUCTION: Hepatobiliary iminodiacetic acid (HIDA)-radionuclear scans are used to diagnose biliary dyskinesia, the treatment for which is a laparoscopic cholecystectomy (LC). However, the predictive value of the HIDA scan for LC candidacy is debated. CASE: A physical, ultrasound, and blood test for a 53-year-old woman with biliary dyskinesia-like symptoms were normal, contradicting a textbook history. A HIDA-scan was ordered but the results suggested she was not eligible for a LC. The patient insisted on receiving the procedure and gave informed consent to undergo an elective LC. RESULTS: Six-weeks post-surgery, the patient's symptoms had ceased besides one short episode of abdominal pain. CONCLUSION: A LC relieved the patient's symptoms, suggesting that negative HIDA-scans can mislead correct decisions to perform a LC. Surgeons who receive inconclusive HIDA scan results should consult their patients, and when necessary and agreed-upon, take an informed risk together in an attempt to improve the patient's quality of life.

Introduction: La scintigraphie hépatobiliaire avec acide iminodiacétique (HIDA) radionucléaire sert au diagnostic de dyskinésie biliaire, qui est traitée par cholécystectomie par laparoscopie. La valeur prédictive de l'HIDA pour identifier les candidats à la cholécystectomie par laparoscopie fait cependant l'objet d'un débat. Cas: L'examen physique, l'échographie et les analyses sanguines d'une femme de 53 ans qui présentait des symptômes évoquant la dyskinésie étaient normaux, ce qui contredisait l'anamnèse modèle. Une scintigraphie HIDA a été réalisée, mais les résultats ont laissé croire que la patiente était inadmissible à la cholécystectomie par laparoscopie. La patiente a insisté pour subir l'intervention et a donné son consentement éclairé pour subir une cholécystectomie par laparoscopie non urgente. Résultats: Six semaines après l'intervention, les symptômes de la patiente étaient disparus, à l'exception d'un épisode de douleur abdominale. Conclusion: La cholécystectomie par laparoscopie a soulagé les symptômes de la patiente, ce qui laisse croire que la scintigraphie HIDA négative peut entraîner des erreurs de décision pour réaliser une cholécystectomie par laparoscopie. Les chirurgiens qui reçoivent des résultats inconcluants à la scintigraphie HIDA doivent consulter leurs patients, et lorsque nécessaire et entendu, prendre ensemble un risque éclairé pour tenter d'améliorer la qualité de vie des patients. Mots-clés: Dyskinésie biliaire, scintigraphie HIDA, cholécystite alithiasique, cholécystite chronique sans lithiases, dysfonctionnement biliaire, vésicules biliaires symptomatiques échographie normale.

Fishhook injury in Eastern Newfoundland: Retrospective review.

INTRODUCTION: The Canadian island of Newfoundland has a long history of fishing; however, no study to date has developed a regional profile of fishhook injuries on its east coast. METHODS: To this end, we conducted a retrospective review of fishhook injuries at all Newfoundland East coast emergency departments from 2013 to 2015. Patient presentations were reviewed for the date of arrival, sex of the patient, location of fishhook injury, tetanus immunisation status, anaesthetic utilisation, diagnostic imaging, antibiotic management and technique of removal. RESULTS: Information was retrieved for 165 patients. Most injuries occurred to the hand (80.6%), and out of five documented techniques, "advance and cut" was the most common extraction method (55.5%). There was a high percentage of prophylactic oral antibiotics prescribed (57%) and X-ray imaging (20%) utilised. Consultation was required for 4.2% of the fishhook injuries including consultation to a local fire department service. CONCLUSIONS: On the east coast of Newfoundland, fishhook injuries are addressed inconsistently, with potentially suboptimal methods for removal, coupled with unnecessary imaging and antibiotics. We believe that there is a role for education and other initiatives to improve the care delivered.

Blessures d'hameçons dans l'est de Terre-Neuve: Un examen rétrospectif Résumé Introduction: L'île canadienne de Terre-Neuve a une longue histoire de pêche. Cependant, à date, aucun profil régional sur les blessures d'hameçons de la côte est à été décrit. Méthodes: À cette fin, nous avons mené une étude rétrospective sur les blessures d'hameçons répertoriées de 2013 à 2015 dans l'ensemble des départements d'urgence de la côte est de Terre-Neuve. Les données retenues dans cette étude incluent la date d'arrivée, le sexe du patient, lieu deblessure d'hameçon, l'état de l'immunisation antitétanique, l'utilisation d'anesthésie, l'utilisation d'imagerie, la gestion des antibiotiques et les techniques utilisées pour retirer l'hameçon. Résultats: Les informations ont été répertoriées sur 165 patients. La plupart des blessures s'est produites aux mains (80,6%) et sur cinq techniques documentées, la méthode d'extraction " Avancer et couper " a étéla plus couramment utilisée (55,5%). Il y a eu un pourcentage élevé de prescriptions d'antibiotiques oraux données par prophylaxie (57%) ainsi que et de radiographies (20%) faites. Une consultation était requise pour 4,2% des blessures d'hameçons, incluant une consultation auprès d'un service d'incendie local. Conclusion: Sur la côte est de Terre-Neuve, les blessures d'hameçons semblent être géréesde manière inconsistante, avec des méthodes d'extraction potentiellement sous-optimales et surutilisation d'antibiotiques et d'imagerie. Nous estimons qu'il y a un rôle d'éducation ainsi que d'autres initiatives pour améliorer les soins octroyés aux patients ayant des blessures d'hameçon. Keywords: Retrait d'hameçon, hameçon accroché, blessures d'hameçons.

Minipig and Human Metabolism of Aldehyde Oxidase Substrates: In Vitro-In Vivo Comparisons.

The importance of aldehyde oxidase (AOX) is becoming increasingly recognized in the prediction of human pharmacokinetic parameters from animal data. The objectives of these studies were to ascertain whether an in vitro-in vivo correlation existed in the clearance and metabolic pathways of AOX substrates and to establish whether the minipig represented an appropriate non-rodent model for man in the pre-clinical development of drugs metabolized by AOX. Using the AOX substrates carbazeran, 6-deoxypenciclovir and zaleplon, clearance was estimated from in vitro depletion experiments with minipig and human liver cytosol and microsomes and scaled before comparison with data generated in parallel in vivo studies in minipigs. In vitro and in vivo metabolic pathways were characterized by LC-MS/MS. Scaling of in vitro metabolism data to predict in vivo clearance underestimated in vivo values, although the rank order of clearance for the three compounds was preserved. Prediction of human in vivo clearance from scaled minipig in vivo data produced results which correlated well with published clinical values. Overall, this study is the first to compare minipig in vitro metabolism data with in vivo pharmacokinetic data for compounds metabolized by AOX and provides a scientific rationale for the selection of this species as a model for humans in the development of drugs which are substrates of AOX.

Curriculum development of 6for6: Longitudinal research skills program for rural and remote family physicians.

PROBLEM ADDRESSED: To address barriers challenging the engagement of rural and remote family physicians (RRFPs) in research, Memorial University of Newfoundland in St John's has developed a longitudinal faculty development program (FDP) called 6for6. OBJECTIVE OF PROGRAM: To establish and evaluate a longitudinal FDP that promotes a foundation of research activity. Program description Informed by a needs assessment in phase 1, phase 2 saw the 6for6 curriculum designed, developed, and implemented to reflect the unique needs of RRFPs. Preliminary evaluations have been conducted and results will be presented after year 1 of the program. CONCLUSION: The 6for6 FDP has been positively received by participants, and it is evident that they will serve as champions of rural research capacity building. It is anticipated that by April 2017, 18 RRFPs will be equipped with the research and leadership skills required to foster research networks within and outside their communities.

Needs assessment for development of 6for6: Longitudinal research skills program tailored to rural and remote family physicians.

PROBLEM ADDRESSED: Rural and remote family physicians (RRFPs) face greater barriers to research engagement than their urban colleagues and have access to fewer faculty development programs (FDPs) to foster their research skills. OBJECTIVE OF PROGRAM: To identify and prioritize skills and services that RRFPs need to engage in research. PROGRAM DESCRIPTION: Memorial University of Newfoundland in St John's used a needs assessment as the foundation for developing an FDP for RRFPs. The assessment comprised a systematic literature review and environmental scan, key informant interviews (n = 10), a focus group with RRFPs (n = 15), expert group meetings (n = 2), and needs assessment surveys (n = 19). CONCLUSION: The assessment identified barriers to RRFPs engaging in research, priority considerations for the development of a research FDP for RRFPs, and research areas to be included in the program curriculum. This information was used to inform phases 2 and 3 of program development, which are further discussed in a companion article.

Dissociation of conditioned taste avoidance from conditioned disgust reactions induced by wheel running in rats.

It is well established that wheel running in rats produces conditioned taste avoidance; that is, rats that run in wheels after consuming a novel-tasting solution later consume less of that solution than rats that do not run. In experiment 1, we found that wheel running also produces conditioned disgust reactions, indicated by gapes elicited by both the taste and context that were experienced before running. Experiment 2 showed that the conditioned disgust reactions were likely not due to running itself but to a by-product of running, the rocking of the wheel that occurs when the running stops. When rocking was reduced, the disgust reactions were also reduced, but consumption of the taste solution was not changed, showing dissociation of conditioned taste avoidance and disgust. These findings indicate that the taste avoidance induced by wheel running itself is more like the taste avoidance produced by rewarding drugs than that produced by nausea-inducing drugs.