Michael Allen

Effect of catecholamines and methylprednisolone on carbohydrate metabolism of dogs

Abstract Rates of glucose and of lactate production, and of gluconeogenesis from lactate were measured in unanaesthetized dogs with indwelling arterial and venous catheters. 2-t-glucose, l (+)-lactate-14C, or the mixture of the two were used as tracers according to the primed, constant infusion technique. Norepinephrine infusion had virtually no effect on carbohydrate metabolism. In the normal dog, epinephrine caused increases in plasma glucose levels (about 50%) and in glucose production (35%); lactate turnover increased nearly fourfold, and gluconeogenesis from lactate increased proportionally, thereby almost tripling the lactate contribution to glucose production. There was a logarithmic correlation between plasma lactate level and lactate turnover and a straight line correlation between lactate turnover and the rate of formation of glucose from lactate. The increase of lactate turnover after lactate infusion alone, and combined with norepinephrine, and after methylprednisolone treatment fitted the straight line correlation. It was therefore concluded that in vivo the lactate mobilization limits gluconeogenesis from this source. methylprednisolone pretreatment greatly potentiated the effect of epinephrine. Plasma glucose was increased to 300–600 mg 100 ml . Glucose production rose to four to eight times normal, and gluconeogenesis from lactate rose to eight to ten times the normal values.

Facilitating interpersonal interaction and learning online: Linking theory and practice

Introduction: An earlier study of physicians perceptions of interactive online learning showed that these were shaped both by program design and quality and the quality and quantity of interpersonal interaction. We explore instructor roles in enhancing online learning through interpersonal interaction and the learning theories that inform these. Methods: This was a qualitative study using focus groups and interviews. Using purposive sampling, 50 physicians were recruited based on their experience with interactive online CME and face‐to‐face CME. Qualitative thematic and interpretive analysis was used. Results: Two facilitation roles appeared key: creating a comfortable learning environment and enhancing the educational value of electronic discussions. Comfort developed gradually, and specific interventions like facilitating introductions and sharing experiences in a friendly, informative manner were helpful. As in facilitating effective small‐group learning, instructors thoughtful use of techniques that facilitated constructive interaction based on learners needs and practice demands contributed to the educational value of interpersonal interactions. Discussion: Facilitators require enhanced skills to engage learners in meaningful interaction and to overcome the transactional distance of online learning. The use of learning theories, including behavioral, cognitive, social, humanistic, and constructivist, can strengthen the educational design and facilitation of online programs. Preparation for online facilitation should include instruction in the roles and techniques required and the theories that inform them.

Videoconferencing for Practice-Based Small-Group Continuing Medical Education: Feasibility, Acceptability, Effectiveness, and Cost.

Introduction: Small‐group, practice‐based learning is an effective and well‐accepted method of continuing medical education (CME). However, one limitation is that many physicians work in communities with fewer than the minimum number recommended for an effective learning group. Videoconferencing has the potential to remove this limitation. The purpose of this study was to evaluate the feasibility, acceptability, effectiveness, and cost of conducting practice‐based, small‐group CME learning by videoconference. Methods: Through a videoconferencing link, 10 learners in three communities were guided through four practice‐based learning modules by a trained facilitator at a fourth site. Data were collected through evaluation questionnaires, direct observation by the research team, pre‐ and post‐knowledge tests, a focus group, and an interview. Results: A total of 31 learners participated in the four modules. Videoconferencing was generally well accepted by learners. The facilitator and research team observers noted that muting microphones, video quality, audio quality, and audio lag all somewhat hindered discussion. Overall, the facilitator found moderating by videoconference only slightly more difficult than a face‐to‐face session. There was evidence of knowledge gain, with post‐test scores being 20% higher than pretest scores (p = .006). Learners reported nine practice changes from taking the modules. At commercial rates, telecommunications costs per videoconferenced module were approximately CAN

Interactive on-line continuing medical education: Physicians' perceptions and experiences

1,200. Discussion: Videoconferencing has the potential to bring the benefits of small‐group, practice‐based learning to many physicians; however, strict attention to videoconferencing techniques is required. Cost is also an important consideration.

Physician perceptions of the effect of telemedicine on rural retention and recruitment.

Introduction: Although research in continuing medical education (CME) demonstrates positive outcomes of on‐line CME programs, the effectiveness of and learners satisfaction with interpersonal interaction in on‐line CME are lower. Defined as faculty‐learner or learner‐learner interpersonal interaction, this study explores physicians perceptions of and experiences in interactive on‐line CME and factors influencing these. Methods: Focus groups and interviews were undertaken by three Canadian universities. Using purposive sampling, we recruited physicians based on their experiences with interactive on‐line CME. Content analysis was applied first, followed by a comparative analysis to confirm themes and findings. Results: Physicians based their perceptions of interactive on‐line CME by comparing it with what they know best, face‐to‐face CME. Although perceptions about access and technical competency remained important, two other themes emerged. The first was the capacity of on‐line CME to meet individual learning preferences, which, in turn, was influenced by the quality of the program, the degree of self‐pacing or self‐direction, opportunity for reflection, and educational design. The second was the quality and quantity of interpersonal interaction, which was shaped by perceptions of social comfort, the educational value of interactions, and the role of the facilitator: Prior experience with on‐line CME moderated perceptions. Discussion: The extent that on‐line CME programs reflected characteristics of high‐quality CME and individual learning preferences appeared to shape perceptions about it. It is important to incorporate the characteristics of effective CME into the design and implementation of interactive on‐line programs, considering diverse learning preferences, providing faculty development for on‐line facilitators, and grounding this work in learning theory.

Family physicians' perceptions of academic detailing: a quantitative and qualitative study.

We conducted a postal survey of 140 family and community specialist physicians in a predominantly rural area which had received clinical telemedicine services and videoconferenced continuing medical education (CME) for two years. The questionnaire contained 46 items. The response rate was 47%. Most respondents (83%) reported having attended videoconferenced CME sessions and 45% reported having referred patients for teleconsultation. Physicians in more rural areas used these services more frequently. Ratings of two statements assessing the value of telemedicine in community support were significantly and positively correlated with the number of videoconferenced CME sessions attended and the number of telemedicine services used. In relation to their decision to stay in their community for at least one year, respondents rated telemedicine lower in importance than all but one of 17 other factors expected to influence physician recruitment and retention in rural communities. The influences on physician rural recruitment and retention are complex. However, telemedicine was used more frequently by the more rural physicians, and there was a relationship between higher usage and higher ratings of its value as a community support.

Helping family physicians improve their cardiac auscultation skills with an interactive CD-ROM.

BackgroundThe efficacy of academic detailing in changing physicians knowledge and practice has been the subject of many primary research publications and systematic reviews. However, there is little written about the features of academic detailing that physicians find valuable or that affect their use of it. The goal of our project was to explore family physicians (FPs) perceptions of academic detailing and the factors that affect their use of it.MethodsWe used 2 methods to collect data, a questionnaire and semi-structured telephone interviews. We mailed questionnaires to all FPs in the Dalhousie Office of Continuing Medical Education database and analyzed responses of non-users and users of academic detailing. After a preliminary analysis of questionnaire data, we conducted semi-structured interviews with 7 FPs who did not use academic detailing and 17 who did use it.ResultsOverall response rate to the questionnaire was 33% (289/869). Response rate of non-users of academic detailing was 15% (60/393), of users was 48% (229/476). The 3 factors that most encouraged use of academic detailing were the topics selected, the evidence-based approach adopted, and the handout material. The 3 factors that most discouraged the use of academic detailing were spending office time doing CME, scheduling time to see the academic detailer, and having CME provided by a non-physician. Users of academic detailing rated it as being more valuable than other forms of CME. Generally, interview data confirmed questionnaire data with the exception that interview informants did not view having CME provided by a non-physician as a barrier. Interview informants mentioned that the evidence-based approach adopted by academic detailing had led them to more critically evaluate information from other CME programs, pharmaceutical representatives, and journal articles, but not advice from specialists.ConclusionUsers of academic detailing highly value its educational value and tend to view information from other sources more critically because of its evidence-based approach. Non-users are unlikely to adopt academic detailing despite its high educational value because they find using office time for CME too much of a barrier. To reach these physicians with academic detailing messages, we will have to find other CME formats.

Videoconferencing for continuing medical education: from pilot project to sustained programme.

Introduction: There have been few studies of the cardiac auscultation skills of residents and family physicians. This study assessed a group of family physicians cardiac auscultation skills and use of a computerized self‐instructional program to improve these skills. Methods: Forty‐two volunteer family physicians participated in an initial assessment of cardiac auscultation skills using test recordings of 12 common heart sounds. They were provided with a CD‐ROM instructional program and were asked to devote 15 hours of self‐study to the program and to return in 9 months for reassessment. Results: The 42 family physicians in the initial assessment identified 39% of the heart sounds. Twenty‐one returned for reassessment and showed significant improvement. Their initial mean score was 4.3 of 12 (35%), and their final mean score was 8.0 of 12 (67%). They found the CD‐ROM program to be a valuable resource. The feature most liked was the unlimited opportunity to review sounds, cases, and tutorials. Most frequent problems related to computer access or skills. Eleven respondents reported using the program to resolve patient problems in their clinical practices. Discussion: The cardiac auscultation skills of group of volunteer family physicians showed low initial scores that improved significantly after self‐study with a CD‐ROM instructional program. The program was a valuable self‐instructional aid, and physicians used it as a resource in clinical practice. However, only 50% of the initial group completed the self‐study and returned for final assessment. Providing more support and assistance in the initial phase, especially computer uses, may enable completion of similar computerized self‐study programs.

Associations of sexual risk-taking with having intercourse before 15 years in adolescent females in Cape Breton, Nova Scotia, Canada

Videoconferencing has been used to provide distance education for medical students, physicians and other health-care professionals, such as nurses, physiotherapists and pharmacists. The Dalhousie University Office of Continuing Medical Education (CME) has used videoconferencing for CME since a pilot project with four sites in 1995–6. Since that pilot project, videoconferencing activity has steadily increased; in the year 1999–2000, a total of 64 videoconferences were provided for 1059 learners in 37 sites. Videoconferencing has been well accepted by faculty staff and by learners, as it enables them to provide and receive CME without travelling long distances. The key components of the development of the videoconferencing programme include planning, scheduling, faculty support, technical support and evaluation. Evaluation enables the effect of videoconferencing on other CME activities, and costs, to be measured.

Primary Care Physicians and Coronary Heart Disease Prevention: A Practice Model.

BACKGROUNDnThis study was carried out to determine whether having first vaginal intercourse before 15 years of age is independently associated with sexual risk behaviours in Canadian female adolescents aged from 15 to 19 years.nnnMETHODSnSelf-completion surveys which included questions about sexual risk behaviours were carried out at three high schools in Cape Breton, Nova Scotia, Canada, in May 2006. The survey also contained questions asking about socioeconomic status, substance use and depression. Associations of early intercourse with risk behaviours were assessed using unadjusted and adjusted logistic regression.nnnRESULTSnThe survey response rate was 92.5%. Of the 797 females aged 15-19 years responding, 475 had had vaginal intercourse in the previous year; 132 of these (27.8%) had intercourse before the age of 15 years. In adjusted analysis, early vaginal intercourse was associated with not using a condom at last intercourse (odds ratio (OR) 2.22; 95% confidence interval (CI) 1.40-3.54), unplanned intercourse in the previous year due to substance use (OR 2.45; 95% CI 1.49-4.04), having a casual partner at last intercourse (OR 2.10; 95% CI 1.23-3.56) and having three or more partners for vaginal intercourse in the previous year (OR 5.11; 95% CI 2.86-9.14).nnnCONCLUSIONSnA history of having first intercourse before 15 years is associated with subsequent sexual risk-taking behaviours in adolescent females. These associations have clinical importance because the occurrence of early intercourse can alert health care providers to the possible presence of these risk behaviours. They also underscore the need to develop and assess programs which can delay the onset of sexual debut.