Anxiolysis for laceration repair in children: a survey of pediatric emergency providers in Canada.

OBJECTIVES: Intranasal dexmedetomidine is a potentially effective anxiolytic but its role in pediatric laceration repair is only emerging. Future trials and clinical adoption of intranasal dexmedetomidine depend on understanding pediatric emergency providers' practice patterns surrounding anxiolysis and perceived barriers to intranasal dexmedetomidine for anxiolysis during suture repair in children. Our objectives were to characterize these parameters to inform future research and facilitate clinical adoption. METHODS: We conducted an online survey of pediatric emergency physician members of Pediatric Emergency Research Canada from September to December 2020. Questions pertained to perceptions of anxiolysis for suture repair, with a focus on intranasal dexmedetomidine. The primary outcome was anxiolysis for suture repair. Data were reported using descriptive statistics. RESULTS: The response rate was 155/225 (68.9%). During suture repair, 127/148 (86%) believed that > 25% of young children experience distress requiring physical restraint. 116/148 (78%) would provide anxiolysis, mainly intranasal benzodiazepines (100/148, 68%). Only 6/148 (4%) would provide intranasal dexmedetomidine but 95/148 (64%) would consider it if there was evidence of benefit. The most common perceived barriers to intranasal dexmedetomidine included inadequate personal experience (114/145, 79%) and lack of access (60/145, 41%). CONCLUSIONS: Most Canadian pediatric emergency providers believe that laceration repair in a young child is distressing. Despite questionable efficacy, most would provide intranasal benzodiazepines, but would consider intranasal dexmedetomidine if there was evidence of benefit.

RéSUMé: OBJECTIFS: La dexmédétomidine intranasale est un anxiolytique potentiellement efficace mais son rôle dans la réparation des lacérations en pédiatrie n'est qu'émergent. Les futurs essais et l'adoption clinique de la dexmédétomidine intranasale dépendent de la compréhension des habitudes de pratique des urgentistes pédiatriques en matière d'anxiolyse et des obstacles perçus à la dexmédétomidine intranasale pour l'anxiolyse pendant la réparation des sutures chez les enfants. Nos objectifs étaient de caractériser ces paramètres pour éclairer les recherches futures et faciliter l'adoption clinique. MéTHODES: Nous avons mené un sondage en ligne auprès des médecins urgentistes pédiatriques membres de Recherche en urgence pédiatrique Canada (Pediatric Emergency Research Canada) de septembre à décembre 2020. Les questions portaient sur les perceptions de l'anxiolyse pour la réparation des sutures, en mettant l'accent sur la dexmédétomidine intranasale. Le résultat principal était l'anxiolyse pour la réparation des sutures. Les données ont été rapportées à l'aide de statistiques descriptives. RéSULTATS: Le taux de réponse était de 155/225 (68,9 %). Pendant la suture, 127/148 (86 %) ont estimé que > 25 % des jeunes enfants éprouvent une détresse nécessitant une contention physique. 116/148 (78 %) fourniraient une anxiolyse, principalement des benzodiazépines intranasales (100/148, 68 %). Seulement 6/148 (4 %) fourniraient de la dexmédétomidine intranasale, mais 95/148 (64 %) l'envisageraient s'il y avait une preuve de bénéfice. Les obstacles les plus fréquemment perçus à la dexmédétomidine intranasale étaient une expérience personnelle insuffisante (114/145, 79 %) et un manque d'accès (60/145, 41 %). CONCLUSIONS: La plupart des fournisseurs canadiens de services d'urgence pédiatriques croient que la réparation des lacérations chez un jeune enfant est pénible. En dépit d'une efficacité douteuse, la plupart d'entre eux fourniraient des benzodiazépines intranasales, mais envisageraient la dexmédétomidine intranasale s'il était prouvé qu'elle était bénéfique.

Prevalence of Adult Female Genital Trauma After Acute Sexual Assault: The Need for a Universal Definition of Genital Trauma.

BACKGROUND: Examination of the adult female genitalia after an acute sexual assault may reveal findings interpreted by the examiner as injuries, which may be linked to later legal outcomes. There is no consistent definition in the literature regarding what findings constitute genital trauma after sexual assault. We studied how the prevalence of genital trauma is impacted by the inclusion/exclusion of various genital findings reported in the literature. METHODS: A retrospective descriptive chart review of the sexual assault forensic records from a provincial regional sexual assault treatment center was conducted over a 4-year period and included 67 female patients, 12 years old and over, who reported being sexually assaulted in the previous 72 hours and received a complete forensic examination. We studied the prevalence of genital trauma, using eight definitions of trauma, as well as the percentage of each type of genital finding within this population. RESULTS: The prevalence of genital trauma in this population ranged from 52%, the majority, to 31% of women, depending on the definition of trauma utilized. Forty-one percent of the findings, the greatest number overall, were redness. Bruises, abrasions, and tears (lacerations), the components of blunt force trauma, accounted for 4%, 15%, and 14% of the findings, respectively. INTERPRETATION: A universal definition of what findings constitute genital trauma after acute sexual assault is required if the examiner, as expert witness, is to compare findings in a given case with the broader literature and assist the court in ensuring an informed process of decision making.

Building research culture and capacity in academic family medicine departments: Insights from a simulation workshop.

OBJECTIVE: To use data from a workshop in which various representatives from departments of family medicine (DFMs) aimed to identify strategies to increase research activity, particularly among clinical faculty members. DESIGN: Descriptive qualitative study using data from a workshop in which participants role-played (ie, as clinician-teachers, department chairs, and mentors) and, while in the role-playing scenario, were asked to imagine strategies that would encourage the clinical faculty members to engage in research. SETTING: The 2014 North American Primary Care Research Group Annual Meeting in New York City, NY. PARTICIPANTS: Thirty-two workshop participants who belonged to DFMs and other academic primary care organizations: 18 from Canada, 11 from the United States, 2 from Australia, and 1 from the Netherlands. METHODS: Facilitators recorded the strategies at the workshop. Strategies were organized into themes and vetted by facilitators to ensure that they adequately represented the data. Finalized themes were compared and integrated across scenarios. MAIN FINDINGS: Participants enthusiastically and productively engaged in the role-playing scenarios. The themes that emerged from the workshop discussions indicated that in order to increase clinician-teacher engagement in research, the following factors needed to be attended to: gaining confidence in conducting research; finding research topics that have personal relevance; presenting clarity of expectations; fostering collaborative relationships; using a tailored approach; providing resources, structures, and processes; and having leadership and vision. Finally, it was important to recognize these efforts in the context of the existing research environment of the DFM and the various responsibilities of clinician-teachers. CONCLUSION: The analysis of data arising from this simulation workshop elucidated practical strategies for building and sustaining research in DFMs. There is a clear indication that one size does not fit all with respect to strategies for building a research culture in a DFM; the authors' recommendations guide departments to tailor strategies to their unique context.

Comprehensive practice: Normative definition across 3 generations of alumni from a single family practice program, 1985 to 2012.

OBJECTIVE: To determine the range of services and procedures offered by family physicians who define themselves as comprehensive practitioners and compare responses across 3 generations of alumni of a single family practice program. DESIGN: Cross-sectional survey. SETTING: Western University in London, Ont. PARTICIPANTS: All graduates of the family medicine program between 1985 and 2012. MAIN OUTCOME MEASURES: Self-reported provision of the following types of care: in-office care, in-hospital care, intrapartum obstetrics, housecalls, palliative care, after-hours care, nursing home care, minor surgery, emergency department care, sport medicine, and walk-in care. Sex, training site (urban or rural), size of community of practice, practice model, and satisfaction with practice were also reported. RESULTS: Participants practised in 7 provinces and 1 territory across Canada, but principally in Ontario. A small number were located in the United States. There was a decline in the number of services provided across 3 generations of graduates, with newer graduates providing fewer services than the older graduates. Significant decreases across the 3 groups were observed in provision of housecalls (P = .004), palliative care (P = .028), and nursing home care (P < .001). Non-significant changes were seen in provision of intrapartum obstetrics across the 3 alumni groups, with an initial decline and then increase in reported activity. Most respondents were in a family health organization or family health network practice model and those in such models reported offering significantly more services than those in family health group or salary models (P < .001). CONCLUSION: The normative definition of comprehensive care varies across 3 generations of graduates of this family medicine program, with newer physicians reporting fewer overall services and procedures than older graduates. Greater understanding of the forces (institutional, regulatory, economic, and personal) that determine the meaning of comprehensive primary care is necessary if this foundational element of family medicine is to be preserved.

Patient satisfaction with access and continuity of care in a multidisciplinary academic family medicine clinic.

OBJECTIVE: To determine patient satisfaction with care provided at a family medicine teaching clinic. DESIGN: Mailed survey. SETTING: Victoria Family Medical Centre in London, Ont. PARTICIPANTS: Stratified random sample of 600 regular patients of the clinic aged 18 years or older; 301 responses were received. MAIN OUTCOME MEASURES: Patient satisfaction with overall care, wait times for appointments, contact with physicians, and associated demographic factors. Logistic regression analysis and analysis were used to determine the significance of factors associated with satisfaction. RESULTS: The response rate was 50%. Overall, 88% of respondents were fairly, very, or completely satisfied with care. Older patients tended to be more satisfied. Patients who were less satisfied had longer wait times for appointments (P < .001) and reduced continuity with specific doctors (P = .004). More satisfied patients also felt connected through other members of the health care team. CONCLUSION: Patients were generally satisfied with the care provided at the family medicine teaching clinic. Older patients tended to be more satisfied than younger patients. Points of dissatisfaction were related to wait times for appointments and continuity with patients' usual doctors. These findings support the adoption of practices that reduce wait times and facilitate continuity with patients' usual doctors and other regular members of the health care team.

Learning behaviour and preferences of family medicine residents under a flexible academic curriculum.

OBJECTIVE: To determine family medicine residents' learning behaviour and preferences outside of clinical settings in order to help guide the development of an effective academic program that can maximize their learning. DESIGN: Retrospective descriptive analysis of academic learning logs submitted by residents as part of their academic training requirements between 2008 and 2011. SETTING: London, Ont. PARTICIPANTS: All family medicine residents at Western University who had completed their academic program requirements (N = 72) by submitting 300 or more credits (1 credit = 1 hour). MAIN OUTCOME MEASURES: Amount of time spent on various learning modalities, location where the learning took place, resources used for self-study, and the objective of the learning activity. RESULTS: A total of 72 residents completed their academic requirements during the study period and logged a total of 25 068 hours of academic learning. Residents chose to spend most of their academic time engaging in self-study (44%), attending staff physicians' teaching sessions (20%),and participating in conferences, courses, or workshops (12%) and in postgraduate medical education sessions (12%). Textbooks (26%), medical journals (20%), and point-of-care resources (12%) were the 3 most common resources used for self-study. The hospital (32%), residents' homes (32%),and family medicine clinics (14%) were the most frequently cited locations where academic learning occurred. While all physicians used a variety of educational activities, most residents (67%) chose self-study as their primary method of learning. The topic for academic learning appeared to have some influence on the learning modalities used by residents. CONCLUSION: Residents used a variety of learning modalities and chose self-study over other more traditional modalities (eg, lectures) for most of their academic learning. A successful academic program must take into account residents' various learning preferences and habits while providing guidance and training in the use of more effective learning methods and resources to maximize educational outcomes.

Characteristics of chronic pain patients in a rural teaching practice.

OBJECTIVE: To describe the characteristics of chronic noncancer pain (CNCP) patients taking oxycodone or its derivatives in a rural teaching practice. DESIGN: Characteristics of CNCP patients taking oxycodone over a 5-year period (September 2003 to September 2008) were compared with those of patients not taking opioid medications using a retrospective chart audit. SETTING: A rural teaching practice in southwestern Ontario. PARTICIPANTS: A total of 103 patients taking chronic oxycodone therapy for CNCP and a random sample of 104 patients not taking opioid medication. MAIN OUTCOME MEASURES: Number of visits, health problems, sex, and previous history of addiction and mental illness. RESULTS: Patients with CNCP taking oxycodone had significantly more health problems (P < .001), including drug and tobacco addictions. They had more than 3 times as many clinic visits during the same period of time as patients not taking opioid medication (mean of 39.0 vs 12.8 visits, P < .001). CONCLUSION: Patients with CNCP in this rural teaching practice had significantly more health issues (P < .001) and were more likely to have a history of addiction than other patients were. They created more work with significantly more visits over the same period compared with the comparison group.