Cesarean Section Delivery Is Not a Risk Factor for Development of Inflammatory Bowel Disease: A Population-based Analysis.

BACKGROUND & AIMS: Mode of birth affects development of the intestinal microbiota, and microbial dysbiosis has been associated with inflammatory bowel disease (IBD). We performed a population-based analysis to determine whether mode of delivery (cesarean section vs. vaginal delivery) affects risk of IBD. METHODS: We collected data from the University of Manitoba IBD Epidemiology Database, which contains records on all Manitobans diagnosed with IBD from 1984 through 2010. Starting in 1970, 6-digit family health registration numbers were used in Manitoba to link mothers with their offspring. Maternal health records, including dates and modes of delivery and siblings of individuals with IBD, were identified. RESULTS: We obtained data on 1671 individuals with IBD and 10,488 controls (individuals without IBD, matched by age, sex, and area of residence at IBD diagnosis) linked to mothers' obstetrical records. Higher proportions of urban than rural residents were delivered by cesarean section for IBD cases (12.8% vs. 9.7%, P = .05) and controls (13.3% vs. 9.4%, P < .0001). A higher percentage of men with Crohn's disease than women with Crohn's disease were born via cesarean section (13.5% vs. 8.4%, P = .01). Overall, there was no difference in the percentage of IBD cases born by cesarean section (11.6%) vs. controls (11.7%, P = .93). In multivariate analysis, birth by cesarean section was not associated with an increased risk of subsequent IBD, controlling for age, sex, urban residence, and income (odds ratio, 1.04; 95% confidence interval, 0.89-1.23). Persons with IBD were no more likely to have been born by cesarean section than their siblings without IBD (1740 siblings from 1615 families) (11.6% vs. 11.3%; odds ratio, 1.14; 95% confidence interval, 0.72-1.80; P = .79). CONCLUSIONS: People with IBD were not more likely to have been born via cesarean section than controls or siblings without IBD. These findings indicate that events of the immediate postpartum period that shape the developing intestinal microbiome do not affect risk for IBD.

Maternity Outcomes in Manitoba Women: A Comparison between Midwifery-led Care and Physician-led Care at Birth.

BACKGROUND: Registered midwives, obstetricians/gynecologists, and general or family practice physicians (GPs) provide maternity care across Canada. Few North American studies have assessed whether maternity outcomes differ across these three groups. This study compared maternal and neonatal outcomes of low-risk pregnant women whose birth was attended by registered midwives, obstetricians/gynecologists, and family practice physicians in Winnipeg, Manitoba from 2001/02 to 2012/13. METHODS: Descriptive statistics and logistic regression were used to examine differences in types of intervention, mode of delivery, and outcomes by provider type among low-risk women. Logistic regression models controlled for socio-demographic and birth-related covariates. RESULTS: Low-risk births comprised 83,774 (48.7%) of total births (n = 171,910). The adjusted odds ratio (aOR), (95% confidence interval) for midwife vs OB/GYN showed women who had a midwife attend the birth had reduced odds of having an episiotomy 0.47 (0.40-0.54), epidural 0.25 (0.23-0.27), and cesarean delivery 0.13 (0.10-0.16) and their infants had less Neonatal Intensive Care Unit admissions 0.28 (0.18-0.43). The aOR for GP versus OB/GYN showed women who had a GP had reduced odds of having an epidural/spinal 0.83 (0.79-0.88) and cesarean delivery 0.44 (0.40-0.48). CONCLUSIONS: The effectiveness of Manitoba maternity services can be improved with increased use of integrated midwifery services. Future research should examine how midwifery and physician-led models of care differ, and the influence of these differences on birth outcomes and cost-effectiveness to the health care system. Improvement of data tracking systems is also needed.

A Second Slice of FPIES: A Single-Center Reappraisal of Pediatric FPIES.

BACKGROUND: Food protein-induced enterocolitis syndrome (FPIES) is being increasingly recognized as a non-IgE-mediated food allergy; however, it remains unclear if and how the presentation, diagnosis, and management of this disease has changed in recent years. OBJECTIVE: To reappraise the FPIES cohort at a large US pediatric tertiary referral center. METHODS: We performed a retrospective chart review of pediatric patients with FPIES (International Classification of Diseases, Tenth Revision code K52.21) diagnosed in our allergy/immunology clinics between 2018 and 2022. RESULTS: There were 210 children diagnosed with FPIES. Most were White (73.8%), non-Hispanic (71.4%), and male (54.3%) with private insurance (77.6%). Cow's milk was the most common food trigger (35.2%), with the earliest median age of onset of 5 months. The atypical FPIES rate was 13.8%. FPIES was accurately diagnosed in 54.3% at the first medical contact. The oral food challenge pass rate was 73.5%. The rate of trigger resolution at 36 months was 77%. CONCLUSIONS: By comparing trends from a previous and current FPIES cohort, we were able to assess the potential impact of various guidelines and practice changes on the diagnosis and management of FPIES at our center. Milk and oat surpassed rice as the most common FPIES triggers; peanut and egg emerged as new FPIES triggers; there was a shorter time to diagnosis and an increased rate of atypical FPIES. Our findings reflect earlier recognition of FPIES and prompt allergy/immunology referral from community physicians, implementation of recent medical society guidelines for infant feeding practices, and growing clinical expertise of allergists at our center.

Quality of Outpatient Pediatric Palliative Care Telehealth: A Retrospective Chart Review.

CONTEXT: Studies suggest the feasibility and acceptability of telehealth in outpatient pediatric palliative care. However, there is a need for data that describes the implementation and quality of telehealth, relying on objective and validated measures. OBJECTIVE: We sought to compare the provision of pediatric palliative care by delivery method. METHODS: We conducted a retrospective electronic health record review of patients seen by our outpatient palliative care team over a two-year period. Demographic, diagnostic, and health utilization data as well as encounter characteristics were compared between patients seen in person (IP), through telehealth (TH), and both (IP/TH). RESULTS: Three hundred ninety-four patients were evaluated with 889 outpatient pediatric palliative care encounters. Non-English speaking patients were less likely to receive palliative care through TH, as were patients without active patient portals. Median follow-up time was longer for patients seen through TH or IP/TH. Patients with malignancies were seen more frequently IP while children with neurologic diagnoses, technology dependence, and a higher number of complex chronic conditions were seen more frequently via TH. Health outcomes, end of life quality metrics, and encounter-level quality indicators were similar across care delivery methods. Review of systems, pain, and mood management, and advance care planning happened more frequently IP while goals of care discussions and medical decision-making happened more through TH. CONCLUSION: Despite differences in patients seen and palliative interventions provided in person compared to telehealth, health outcomes, and quality indicators were similar across care delivery methods. These data support the continued practice of telehealth in palliative care and highlight the need for equity in its evolution.

Dietary Sodium and Potassium Patterns in Adults with Food Insecurity in the Context of Hypertension Risk.

Background: Food insecurity (FIS), characterized by the lack of consistent access to nutritious food, is associated with hypertension and adverse health outcomes. Despite evidence of a higher prevalence of hypertension (HTN) in patients living with FIS, there is limited data exploring the underlying mechanism. Methods: We conducted a cross-sectional analysis of 17,015 adults aged 18-65 years, using dietary recall data from the National Health and Nutrition Examination Survey (2011-2018). Univariate and multivariable analyses were used to examine the association between FIS, HTN, and dietary sodium and potassium levels. Results: Individuals reporting FIS had a significantly lower mean intake of potassium (2.5±0.03 gm) compared to those in food-secure households (2.74±0.02 gm). No significant difference was found in the mean dietary sodium intake based on food security status. Non-Hispanic Black participants showed a high prevalence of HTN and FIS. While Non-Hispanic White and Hispanic participants had a high prevalence of FIS, it did not appear to influence their risk of HTN. Conclusions: Adults with FIS and HTN were more likely to report a lower dietary potassium intake. Increasing access to healthy foods, particularly potassium-rich foods, for individuals facing FIS, may contribute to reducing the HTN prevalence and improving cardiovascular outcomes.

OralOpioids: Harnessing R Programming and Data Science to Combat Opioid Misuse.

Aims: This study aims to introduce the OralOpioids R package, a novel research tool for the in-depth study and analysis of opioid prescriptions in Canada, which reports a significant per-capita pharmaceutical opioid consumption. Methods: The OralOpioids R package employs data from Health Canada's Drug Product Database (DPD), focusing on authorized oral opioids. It systematically filters drug identification numbers (DINs) by narcotic schedules and administration routes. Moreover, it calculates the morphine equivalent dose (MED) for each DIN using the CDC table. Core functions include MED calculation for specific drugs, brand name retrieval, opioid content extraction, and unit computations based on Canadian MED guidelines. Results: When juxtaposed against renowned opioid calculators such as MDCalc, Oregon Pain, and Ohio Pain, the OralOpioids package exhibited a near-perfect correlation, with R-squared values consistently at 0.99. Conclusions: The OralOpioids package, distinctively tailored for research, marks a significant stride in understanding and monitoring Canada's opioid milieu. By encompassing data on discontinued opioids, it fosters a nuanced comprehension of the opioid panorama, enabling historical insight and post-marketing watchfulness. Primarily targeting researchers, its scope extends to healthcare providers, insurers, and administrative boards, all of whom can leverage its potent capabilities for informed decision-making. Although currently centered on Canadian opioids, its flexible design is primed for future expansion, potentially capturing a global audience and catalyzing efforts against the opioid crisis.

Does Point of Care Ultrasound Improve Resuscitation Markers in Undifferentiated Hypotension? An International Randomized Controlled Trial From The Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Series.

Introduction Point of Care Ultrasound (PoCUS) protocols are commonly used to guide resuscitation for patients with undifferentiated hypotension, yet there is a paucity of evidence for any outcome benefit. We undertook an international multicenter randomized controlled trial (RCT) to assess the impact of a PoCUS protocol on key clinical outcomes. Here we report on resuscitation markers.  Methods Adult patients presenting to six emergency departments (ED) in Canada and South Africa with undifferentiated hypotension (systolic blood pressure (SBP) <100mmHg or a Shock Index >1.0) were randomized to receive a PoCUS protocol or standard care (control). Reported physiological markers include shock index (SI), and modified early warning score (MEWS), with biochemical markers including venous bicarbonate and lactate, at baseline and four hours.  Results A total of 273 patients were enrolled, with data collected for 270. Baseline characteristics were similar for each group. Improvements in mean values for each marker during initial treatment were similar between groups: Shock Index; mean reduction in Control 0.39, 95% CI 0.34 to 0.44 vs. PoCUS 0.33, 0.29 to 0.38; MEWS, mean reduction in Control 2.56, 2.22 to 2.89 vs. PoCUS 2.91, 2.49 to 3.32; Bicarbonate, mean reduction in Control 2.71 mmol/L, 2.12 to 3.30 mmol/L vs. PoCUS 2.30 mmol/L, 1.75 to 2.84 mmol/L, and venous lactate, mean reduction in Control 1.39 mmol/L, 0.93 to 1.85 mmol/L vs. PoCUS 1.31 mmol/L, 0.88 to 1.74 mmol/L. Conclusion We found no meaningful difference in physiological and biochemical resuscitation markers with or without the use of a PoCUS protocol in the resuscitation of undifferentiated hypotensive ED patients. We are unable to exclude improvements in individual patients or in specific shock types.

Does Point-of-care Ultrasound Use Impact Resuscitation Length, Rates of Intervention, and Clinical Outcomes During Cardiac Arrest? A Study from the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Investigators.

Introduction This third study in the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) series examined potential relationships between point-of-care ultrasound (PoCUS) use and the length of resuscitation, the frequency of interventions, and clinical outcomes during cardiac arrest. Methods A health records review was completed for adult patients (>19 years, without a do not resuscitate (DNR) order) who presented to a tertiary emergency department in cardiac arrest between 2010 and 2014. Patients were grouped based on PoCUS use and findings for cardiac activity. Data were analyzed for length of resuscitation, frequency of interventions, return of spontaneous circulation (ROSC), survival to hospital admission (SHA), and survival to hospital discharge (SHD). Results Of the 223 patients who met inclusion criteria, 180 (80.7%) received assessment by PoCUS during cardiac arrest management in the emergency department (ED). In the PoCUS group, 21 (11.6%) demonstrated cardiac activity and 159 (88.4%) did not. Patients with activity on PoCUS had longer mean resuscitation times (27.3; 95% confidence interval 17.7-37.0 min) than patients with no activity (11.51; 10.2-12.8 min) and patients who did not receive a PoCUS exam (14.36; 9.89-18.8 min). Patients with cardiac activity on PoCUS were more likely to receive endotracheal intubation (ET; 95.23%; 86.13-104.35%) and epinephrine (Epi; 100%; 100-100%) than patients with no activity (ET: 46.54%; 38.8-54.3%; Epi: 82.39%; 76.50-88.31%) and those with no PoCUS (ET: 65.11%; 50.87-79.36%; Epi: 81.39%; 69.76-93.03%). Those with no cardiac activity on PoCUS were much less likely to achieve ROSC (19.5%; 13.4-25.6), SHA (6.9%; 2.97-10.86%) and SHD (0.6%; -0.5-1.8%) compared to those with cardiac activity on PoCUS (ROSC; 76.19%; 57.97-94.4%), SHA (33.3%; 13.2-53.5%), SHD (9.5%; -3-22.07%), and those with no PoCUS (ROSC 39.5%; 24.9-54.1%; SHA 27.9%; 14.5- 41.3%, and SHD 6.9%; -0.6-14.59). Conclusions Emergency department cardiac arrest patients with cardiac activity on PoCUS received longer resuscitation with higher rates of intervention as compared to those with negative findings or when no PoCUS was performed. Patients with cardiac activity on PoCUS had improved clinical outcomes as compared with patients not receiving PoCUS, and patients with no activity on PoCUS.

Do combined ultrasound and electrocardiogram-rhythm findings predict survival in emergency department cardiac arrest patients? The Second Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED2) study.

OBJECTIVES: Point-of-care ultrasound (POCUS) is used increasingly during resuscitation. The aim of this study was to assess whether combining POCUS and electrocardiogram (ECG) rhythm findings better predicts outcomes during cardiopulmonary resuscitation in the emergency department (ED). METHODS: We completed a health records review on ED cardiac arrest patients who underwent POCUS. Primary outcome measurements included return of spontaneous circulation (ROSC), survival to hospital admission, and survival to hospital discharge. RESULTS: POCUS was performed on 180 patients; 45 patients (25.0%; 19.2%-31.8%) demonstrated cardiac activity on initial ECG, and 21 (11.7%; 7.7%-17.2%) had cardiac activity on initial POCUS; 47 patients (26.1%; 20.2%-33.0%) achieved ROSC, 18 (10.0%; 6.3%-15.3%) survived to admission, and 3 (1.7%; 0.3%-5.0%) survived to hospital discharge. As a predictor of failure to achieve ROSC, ECG had a sensitivity of 82.7% (95% CI 75.2%-88.7%) and a specificity of 46.8% (32.1%-61.9%). Overall, POCUS had a higher sensitivity of 96.2% (91.4%-98.8%) but a similar specificity of 34.0% (20.9%-49.3%). In patients with ECG-asystole, POCUS had a sensitivity of 98.18% (93.59%-99.78%) and a specificity of 16.00% (4.54%-36.08%). In patients with pulseless electrical activity, POCUS had a sensitivity of 86.96% (66.41%-97.22%) and a specificity of 54.55% (32.21%-75.61%). Similar patterns were seen for survival to admission and discharge. Only 0.8% (0.0-4.7%) of patients with ECG-asystole and standstill on POCUS survived to hospital discharge. CONCLUSION: The absence of cardiac activity on POCUS, or on both ECG and POCUS together, better predicts negative outcomes in cardiac arrest than ECG alone. No test reliably predicted survival.

OBJECTIF: On a de plus en plus recours à l'échographie au chevet (EC) durant les manœuvres de réanimation. L'étude visait donc à déterminer si l'association de l'EC et de l'électrocardiogramme (ECG) pour analyse du rythme avait une meilleure valeur prévisionnelle que l'ECG seul quant à l'issue durant les manœuvres de réanimation cardiorespiratoire au service des urgences (SU). MÉTHODE: Il s'agit d'un examen de dossiers médicaux de patients en état d'arrêt cardiaque qui ont été soumis à une EC au SU. Les principaux critères d'évaluation étaient le retour à la circulation spontanée (RCS), la survie en cours d'hospitalisation et la survie après le congé de l'hôpital. RÉSULTATS: Une EC a été effectuée chez 180 patients; la présence d'activité électrique a été observée à l'ECG initial chez 45 d'entre eux (25,0%; 19,2­31,8%) et à l'EC initiale chez 21 d'entre eux (11,7%; 7,7­17,2%). Quarante-sept patients (26,1%; 20,2­33,0%) ont connu un RCS, 18 (10,0%; 6,3­15,3%) ont survécu à l'hospitalisation et 3 (1,7%; 0,3­5,0%) ont survécu au congé de l'hôpital. L'ECG a révélé une sensibilité de 82,7% (intervalle de confiance à 95% : 75,2%−88,7%) et une spécificité de 46,8% (32,1­61,9%) à l'égard de la valeur prévisionnelle du non-retour à la circulation spontanée. Dans l'ensemble, l'EC avait une sensibilité supérieure (96,2%; [(91,4­98,8%]) mais une spécificité comparable (34,0%; [(20,9­49,3%]) à celles de l'ECG. Chez les patients présentant une asystole à l'ECG, l'EC avait une sensibilité de 98,18% (93,59­99,78%) et une spécificité de 16,00,% (4,54­36,08%). Quant aux patients ayant une activité électrique sans pouls, l'EC avait une sensibilité de 86,96% (66,41­97,22%) et une spécificité de 54,55% (32,21­75,61%). Des résultats comparables ont été obtenus en ce qui concerne la survie en cours d'hospitalisation ainsi qu'après le congé de l'hôpital. Enfin, seulement 0,8% (0,0­4,7%) des patients présentant une asystole à l'ECG et un arrêt des contractions du cœur à l'EC ont survécu au congé de l'hôpital. CONCLUSION: L'absence d'activité électrique cardiaque à l'EC seule ou à l'association de l'ECG et de l'EC a une meilleure valeur prévisionnelle que l'ECG seul quant à l'issue défavorable des.

Is point-of-care ultrasound a reliable predictor of outcome during atraumatic, non-shockable cardiac arrest? A systematic review and meta-analysis from the SHoC investigators.

AIMS: To evaluate the accuracy of PoCUS in predicting return of spontaneous circulation (ROSC), survival to hospital admission (SHA), and survival to hospital discharge (SHD) in adult non-traumatic, non-shockable out-of-hospital or emergency department cardiac arrest. METHODS: Medline, EMBASE, Cochrane, CINAHL, ClinicalTrials.gov and the World Health Organization Registry were searched for eligible studies. Data analysis was completed according to PRISMA guidelines. A random-effects meta-analysis model was used with I-squared statistics for heterogeneity. RESULTS: Ten studies (1486 participants) were included. Cardiac activity on PoCUS had a pooled sensitivity of 60.3% (95% confidence interval 38.1%-78.9%) and specificity of 91.5%(80.8%-96.5%) for ROSC. The sensitivity of cardiac activity on PoCUS for predicting ROSC was 26.1%(7.8%-59.6%) in asystole compared with 76.7% (61.3%-87.2%) in PEA. Cardiac activity on PoCUS, compared to absence, had odd ratios of 16.90 (6.18-46.21) for ROSC, 10.30(5.32-19.98) for SHA and 8.03(3.01-21.39) for SHD. Positive likelihood ratio (LR) was 6.87(3.21-14.71) and negative LR was 0.27(0.12-0.60) for ROSC. CONCLUSIONS: Cardiac activity on PoCUS was associated with improved odds for ROSC, SHA, and SHD in non-traumatic, non-shockable cardiac arrest. We report a lower sensitivity and higher negative likelihood ratio, but greater heterogeneity compared to previous systematic reviews. PoCUS may provide valuable information in the management of non-traumatic PEA or asystole, but should not be viewed as the sole predictor in determining outcomes.

Does Point-of-care Ultrasonography Change Emergency Department Care Delivered to Hypotensive Patients When Categorized by Shock Type? A Post-Hoc Analysis of an International Randomized Controlled Trial from the SHoC-ED Investigators.

Introduction Our previously reported randomized-controlled-trial of point-of-care ultrasound (PoCUS) for patients with undifferentiated hypotension in the emergency department (ED) showed no survival benefit with PoCUS. Here, we examine the data to see if PoCUS led to changes in the care delivered to patients with cardiogenic and non-cardiogenic shock. Methods A post-hoc analysis was completed on a database of 273 hypotensive ED patients randomized to standard care or PoCUS in six centres in Canada and South Africa. Shock categories recorded one hour after the ED presentation were used to define subcategories of shock. We analyzed initial intravenous fluid volumes, as well as rates of inotrope use and procedures. Results  261 patients could be classified as cardiogenic or non-cardiogenic shock types. Although there were expected differences in the mean fluid volume administered between patients with non-cardiogenic and cardiogenic shock (p-value<0.001), there was no difference between the control and PoCUS groups (mean non-cardiogenic control 1881mL (95% CI 1567-2195mL) vs non-cardiogenic PoCUS 1763mL (1525-2001mL); and cardiogenic control 680mL (28.4-1332mL) vs. cardiogenic PoCUS 744mL (370-1117mL; p= 0.67). Likewise, there were no differences in rates of inotrope administration nor procedures for any of the subcategories of shock between the control group and PoCUS group patients. Conclusion Despite differences in care delivered by subcategory of shock, we did not find any difference in key elements of emergency department care delivered between patients receiving PoCUS and those who did not. This may help explain the previously reported lack of outcome differences between groups.

Do Electrocardiogram Rhythm Findings Predict Cardiac Activity During a Cardiac Arrest? A Study from the Sonography in Cardiac Arrest and Hypotension in the Emergency Department (SHoC-ED) Investigators.

Introduction Electrocardiographic (ECG) rhythms are used during advanced cardiac life support (ACLS) to guide resuscitation management. Survival to hospital discharge has been reported to be better for patients with pulseless electrical activity (PEA) than asystole in out-of-hospital arrests. Despite this, treatment for these two (non-shockable) rhythms is combined in ACLS guidelines. This study examines if the recorded cardiac rhythm of asystole or PEA during ACLS accurately predicts mechanical cardiac activity as determined by point-of-care ultrasound (PoCUS). Methods A database review was completed for patients (> 19 years without a do not resuscitate (DNR) order) who presented to a tertiary emergency department in PEA or asystolic cardiac arrest between 2010 and 2014. Patients were separated into two groups: those with electrical cardiac activity (PEA) and those without (asystole). We compared ECG rhythm and PoCUS-documented cardiac activity results (both initial and any) for each case. Results  A total of 186 patients met the study criteria. The 46 patients with PEA on ECG were more likely to have cardiac activity than the 140 patients with asystole (odds ratio 7.22 (95% confidence intervals 2.79-18.7) for activity on initial PoCUS; odds ratio 5.45 (2.49-12.0) for activity on any PoCUS during arrest). ECG alone was poorly sensitive for initial cardiac activity (63.64%; 40.66% to 82.80%) and any cardiac activity (54.29%; 36.65% to 71.17%), with specificity marginally better at 80.49% (73.59% to 86.25%) for initial and 82.12% (75.06% to 87.87%) for any activity. Conclusion Our results suggest that ECG rhythm alone is not an accurate predictor of cardiac activity. This supports the use of PoCUS during cardiac arrest, in addition to ECG, to identify patients with ongoing mechanical cardiac activity and to help determine appropriate treatment for this group.

Changes in self-directed learning readiness in dental students: a mixed-methods study.

The purpose of this study was to identify changes in dental students' self-directed learning (SDL) readiness during their education. Guglielmino's SDL readiness scale (SDLRS) was completed at admission by dental students at the University of Saskatchewan and at the end of each year of training. The response rates varied from year to year. Between twenty-seven and thirty students completed the questionnaire each year at admission (93-100 percent of the entering class). The numbers of participants were lower in succeeding years: numbers used for analysis ranged from eleven to twenty-six; years in which fewer than eleven students participated were not included in the analysis. At admission, the students' mean SDLRS score was 228.98 (on a scale from 58 to 290, with 290 the highest); this score was higher than that of the average adult population (214±25.59). There was no significant effect of years of predental education, prior unsuccessful applications to dental school, interview scores, age, or admission test scores. There was a significant drop in SDLRS scores at the end of the first year for most of the cohorts (p<0.001). In addition to the questionnaire part of the study, two instructors and five first- and second-year students participated in focus groups. Those results showed that the individuals defined SDL narrowly and had similar perceptions of curricular factors that affect SDL readiness. The drop in scores one year after admission and lack of change with increased training suggests that current educational interventions may require re-examination and alteration to those that promote self-direction.

Does medical training promote or deter self-directed learning? A longitudinal mixed-methods study.

PURPOSE: The School of Medicine, University of Saskatchewan curriculum promotes self-direction as one of its learning philosophies. The authors sought to identify changes in self-directed learning (SDL) readiness during training. METHOD: Guglielmino's SDL Readiness Scale (SDLRS) was administered to five student cohorts (N = 375) at admission and the end of every year of training, 2006 to 2010. Scores were analyzed using repeated-measurement analysis. A focus group and interviews captured students' and instructors' perceptions of self-direction. RESULTS: Overall, the mean SDLRS score was 230.6; men (n = 168) 229.5; women (n = 197) 232.3, higher than in the average adult population. However, the authors were able to follow only 275 students through later years of medical education. There were no significant effects of gender, years of premedical training, and Medical College Admission Test scores on SDLRS scores. Older students were more self-directed. There was a significant drop in scores at the end of year one for each of the cohorts (P < .001), and no significant change to these SDLRS scores as students progressed through medical school. Students and faculty defined SDL narrowly and had similar perceptions of curricular factors affecting SDL. CONCLUSIONS: The initial scores indicate high self-direction. The drop in scores one year after admission, and the lack of change with increased training, show that the current educational interventions may require reexamination and alteration to ones that promote SDL. Comparison with schools using a different curricular approach may bring to light the impact of curriculum on SDL.