Robert Thivierge

Canadian Pediatric Asthma Consensus Guidelines, 2003 (updated to December 2004): Introduction

Background: Although guidelines for the diagnosis and management of asthma have been published over the last 15 years, there has been little focus on issues relating to asthma in childhood. Since the last revision of the 1999 Canadian asthma consensus report, important new studies, particularly in children, have highlighted the need to incorporate this new information into asthma guidelines. Objectives: To review the literature on asthma published between January 2000 and June 2003 and to evaluate the influence of new evidence on the recommendations made in the Canadian Asthma Consensus Report, 1999 and its 2001 update with a major focus on pediatric issues. Methods: Diagnosis of asthma in young children, prevention strategies, pharmacotherapy, inhalation devices, immunotherapy and asthma education were selected for review by small expert resource groups. In June 2003, the reviews were discussed at a meeting under the auspices of the Canadian Network For Asthma Care and the Canadian Thoracic Society. Data published up to December 2004 were subsequently reviewed by the individual expert resource groups. Results: This report evaluates early life prevention strategies and focuses on treatment of asthma in children. Emphasis is placed on the importance of an early diagnosis and prevention therapy, the benefits of additional therapy and the essential role of asthma education. Conclusion: We generally support previous recommendations and focus on new issues, particularly those relevant to children and their families. This guide for asthma management is based on the best available published data and the opinion of health care professionals including asthma experts and educators.

Learning and Caring in Communities of Practice: Using Relationships and Collective Learning to Improve Primary Care for Patients with Multimorbidity

We introduce a primary care practice model for caring for patients with multimorbidity. Primary care for these patients requires flexibility and ongoing coordination, and it often must be tailored to individual circumstances. Such complex and flexible care could be accomplished within communities of practice, whose participants are willing to learn from their shared practice, further each other’s goals, share their stories of success and failure, and promote the continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use an iterative approach to care improvement that integrates what they learn and do collectively over time. Clinicians in these communities would define common goals, cocreate care plans, and engage in reflective case-based learning. As community members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a mix of methods, future research should explore the conditions that are necessary for collective learning within communities of clinicians who care for patients with multimorbidity and who develop new knowledge in practice. By understanding these conditions, we can foster the development of collective learning and improve primary care for these patients.

Benzodiazepine poisoning. Clinical and pharmacological considerations and treatment.

SummaryBenzodiazepines are among the most frequently prescribed drugs worldwide. This popularity is based not only on their efficacy but also on their remarkable safety. Pure benzodiazepine overdoses usually induce a mild to moderate central nervous system depression; deep coma requiring assisted ventilation is rare, and should prompt a search for other toxic substances. The severity of the CNS depression is influenced by the dose, the age of the patient and his or her clinical status prior to the ingestion, and the coingestion of other CNS depressants. In severe overdoses, benzodiazepines can occasionally induce cardiovascular and pulmonary toxicity, but deaths resulting from pure benzodiazepine overdoses are rare.Quantitative determinations of benzodiazepines are not useful in the clinical management of intoxicated patients since there is no correlation between serum concentrations and pharmacological and toxicological effects.Benzodiazepine overdoses occurring during pregnancy rarely induce serious morbidity in mothers or fetuses, although large doses administered near delivery can induce respiratory depression in neonates. The teratogenic potential of benzodiazepines remains controversial, but is probably small if it exists at all.There is clear evidence that the prolonged use of even therapeutic doses of benzodiazepines will lead to dependence. The risk of developing significant withdrawal symptoms is related to dosage and duration of treatment.Prevention of gastrointestinal absorption should be initiated in all intentional benzodiazepine overdoses. Forced diuresis and dialysis techniques are not indicated since they will not significantly accelerate the elimination of these agents. Intravenous administration of flumazenil, a pure benzodiazepine antagonist, effectively reverses benzodiazepine-induced CNS depression.

Training family physicians in shared decision making for the use of antibiotics for acute respiratory infections: a pilot clustered randomized controlled trial.

Background  Experts estimate that the prevalence of antibiotics use exceeds the prevalence of bacterial acute respiratory infections (ARIs).

Cardiac Monitoring Of Children With Household Electrical Injuries

STUDY OBJECTIVE Because death has occurred with injury involving voltage as low as 50 to 60 V (probably the result of arrhythmias), we wanted to evaluate the necessity of cardiac monitoring in children sustaining electrical injuries with 120 or 240 V. DESIGN The charts of 151 children who presented to the emergency department between April 1, 1989, and March 31, 1992, were reviewed. SETTING A tertiary care pediatric teaching hospital. RESULTS A total of 141 patients presented with 120-V electrical injuries. An ECG or a rhythm strip was performed in 93 patients (66%), and no arrhythmias were believed to have resulted from the electrical injury. Cardiac monitoring was done in 113 patients (80%) for a mean duration of 7.4 +/- 6.6 hours (median, 4 hours), and no arrhythmias were observed. Creatine phosphokinase levels were measured in 62 patients (44%) with a mean of 137 +/- 154 U/L (median, 96 U/L). The levels were elevated in 8 patients (12%), with no clinical significance. Follow-up was done in 112 patients (77%), and no significant adverse outcome was reported. There were only 10 patients in the 240-V group; no arrhythmias or adverse outcomes had occurred. CONCLUSION On the basis of our findings, initial cardiac evaluation (ECG) and monitoring do not appear to be necessary in children sustaining household electrical injuries (120 and 240-V); however, the significance of loss of consciousness, tetany, wet skin, or current flow that crossed the heart region could not be determined in our investigation. Therefore, cardiac monitoring should be performed if one of these factors is present.

Interprofessional learning in the trenches: fostering collective capability.

The greatest resource for improving interprofessional learning and practice is the knowledge, wisdom, and energy of professionals who adapt to challenging situations in their everyday work. We call collective capability the ability of a group of professionals to balance two interdependent levels of organization of practice: what professionals know and what they do collectively over time. Organizing what professionals know links the relational value – caring for patients – to the knowledge value of practice. Organizing what professionals do includes human and organizational factors that facilitate collective work and learning: technical skills for care delivery, institutional support, and a complex mix of emotional, ethical and moral factors involved in social decision-making. Performance gaps can result from a lack of an integrated knowledge framework or from a disembodied knowledge that is not anchored in practice. Opportunities for continuous learning can be seized by documenting the source of the performance gap, and providing the relevant resources to establish the balance between the organization of knowledge and the organization of work.

Home environmental factors associated with poor asthma control in Montreal children: a population-based study.

Background. Home environmental exposures may aggravate asthma. Few population-based studies have investigated the relationship between asthma control in children and home environmental exposures. Objective: Identify home environmental exposures associated with poor control of asthma among asthmatic children less than 12 years of age in Montreal (Quebec, Canada). Methods. This cross-sectional population-based study used data from a respiratory health survey of Montreal children aged 6 months to 12 years conducted in 2006 (n = 7980). Asthma control was assessed (n = 980) using an adaptation of the Canadian asthma consensus report clinical parameters. Using log-binomial regression models, prevalence ratios (PRs) with 95% confidence intervals (95% CIs) were estimated to explore the relationship between inadequate control of asthma and environmental home exposures, including allergens, irritants, mold, and dampness indicators. Subjects with acceptable asthma control were compared with those with inadequate disease control. Results. Of 980 children with active asthma in the year prior to the survey, 36% met at least one of the five criteria as to poor control of their disease. The populations characteristics found to be related with a lack of asthma control were younger age, history of parental atopy, low maternal education level, foreign-born mothers, and tenant occupancy. After adjustments, children living along high-traffic density streets (PR, 1.35; 95% CI, 1.00–1.81) and those with their bedroom or residence at the basement level (PR, 1.30; 95% CI, 1.01–1.66) were found to be at increased risk of poor asthma control. Conclusions. Suboptimal asthma control appears to be mostly associated with traffic, along with mold and moisture conditions, the latter being a more frequent exposure and therefore having a greater public health impact.

Feasibility of a randomised trial of a continuing medical education program in shared decision-making on the use of antibiotics for acute respiratory infections in primary care: the DECISION+ pilot trial

BackgroundThe misuse and limited effectiveness of antibiotics for acute respiratory infections (ARIs) are well documented, and current approaches targeting physicians or patients to improve appropriate use have had limited effect. Shared decision-making could be a promising strategy to improve appropriate antibiotic use for ARIs, but very little is known about its implementation processes and outcomes in clinical settings. In this matter, pilot studies have played a key role in health science research over the past years in providing information for the planning, justification, and/or refinement of larger studies. The objective of our study was to assess the feasibility and acceptability of the study design, procedures, and intervention of the DECISION+ program, a continuing medical education program in shared decision-making among family physicians and their patients on the optimal use of antibiotics for treating ARIs in primary care.MethodsA pilot clustered randomised trial was conducted. Family medicine groups (FMGs) were randomly assigned, to either the DECISION+ program, which included three 3-hour workshops over a four- to six-month period, or a control group that had a delayed exposure to the program.ResultsAmong 21 FMGs contacted, 5 (24%) agreed to participate in the pilot study. A total of 39 family physicians (18 in the two experimental and 21 in the three control FMGs) and their 544 patients consulting for an ARI were recruited. The proportion of recruited family physicians who participated in all three workshops was 46% (50% for the experimental group and 43% for the control group), and the overall mean level of satisfaction regarding the workshops was 94%.ConclusionsThis trial, while aiming to demonstrate the feasibility and acceptability of conducting a larger study, has identified important opportunities for improving the design of a definitive trial. This pilot trial is informative for researchers and clinicians interested in designing and/or conducting studies with FMGs regarding training of physicians in shared decision-making.Trial RegistrationClinicaltrials.Gov NCT00354315

Bedside ultrasound training using web-based e-learning and simulation early in the curriculum of residents

BackgroundFocused bedside ultrasound is rapidly becoming a standard of care to decrease the risks of complications related to invasive procedures. The purpose of this study was to assess whether adding to the curriculum of junior residents an educational intervention combining web-based e-learning and hands-on training would improve the residents’ proficiency in different clinical applications of bedside ultrasound as compared to using the traditional apprenticeship teaching method alone.MethodsJunior residents (n = 39) were provided with two educational interventions (vascular and pleural ultrasound). Each intervention consisted of a combination of web-based e-learning and bedside hands-on training. Senior residents (n = 15) were the traditionally trained group and were not provided with the educational interventions.ResultsAfter the educational intervention, performance of the junior residents on the practical tests was superior to that of the senior residents. This was true for the vascular assessment (94% ± 5% vs. 68% ± 15%, unpaired student t test: p < 0.0001, mean difference: 26 (95% CI: 20 to 31)) and even more significant for the pleural assessment (92% ± 9% vs. 57% ± 25%, unpaired student t test: p < 0.0001, mean difference: 35 (95% CI: 23 to 44)). The junior residents also had a significantly higher success rate in performing ultrasound-guided needle insertion compared to the senior residents for both the transverse (95% vs. 60%, Fisher’s exact test p = 0.0048) and longitudinal views (100% vs. 73%, Fisher’s exact test p = 0.0055).ConclusionsOur study demonstrated that a structured curriculum combining web-based education, hands-on training, and simulation integrated early in the training of the junior residents can lead to better proficiency in performing ultrasound-guided techniques compared to the traditional apprenticeship model.

Cardiac monitoring of high-risk patients after an electrical injury: a prospective multicentre study.

Objective: To report our experience monitoring patients with previously identified theoretical risk factors of significant electrical injury. Methods: Patients who presented to one of 21 emergency departments between October 2000 and November 2004 were eligible to be enrolled in a prospective observational cohort study if after an electric shock they had one of several risk factors (transthoracic current, tetany, loss of consciousness or voltage source ⩾1000 V) and therefore needed cardiac monitoring. Results: Of the 134 patients enrolled, most were monitored because of transthoracic current (n = 60), transthoracic current and tetany (n = 39), tetany (n = 10), or voltage ⩾1000 V (n = 10). There were 15/134 (11%) patients with abnormal initial ECGs. No patient developed potentially lethal late arrhythmia during the 24 hours of cardiac monitoring. Conclusion: Although only patients deemed at risk of late arrhythmias were monitored, none developed potentially lethal late arrhythmias. Asymptomatic patients with transthoracic current and/or tetany and a normal initial ECG do not require cardiac monitoring after an electrical injury with voltage <1000 V and no loss of consciousness.