Ted Xenodemetropoulos

Adaptation following intestinal resection: mechanisms and signals

The intestine has an inherent ability to adapt morphologically and functionally in response to internal and external environmental changes. The functional adaptations encompass modifications of the brush border membrane fluidity and permeability, as well as up- or down-regulation of carrier-mediated transport. Intestinal adaptation improves the nutritional status following the loss of a major portion of the small intestine, following chronic ingestion of ethanol, following sublethal doses of abdominal irradiation, in diabetes, in pregnancy and lactation, with ageing, and with fasting and malnutrition. Following intestinal resection, morphological and functional changes occur depending upon the extent of the intestine removed, the site studied, and the lipid content of the diet. Therefore, intestinal adaptation has important implications in the survival potential and welfare of the host. An understanding of the mechanisms of, and signals for, intestinal adaptation in the experimental setting forms the basis for the use of management strategies in humans with the short-bowel syndrome.

The impact of fragility fracture on health-related quality of life : the importance of antifracture therapy.

Both general and specific health status instruments can be utilised in evaluating health-related quality of life (HR-QOL) deficits resulting from osteoporotic fractures. Osteoporotic hip, vertebral and wrist fractures significantly decrease HR-QOL in most HR-QOL domains investigated. The presence of multiple vertebral fractures leads to larger decrements in HR-QOL. More research needs to be completed with these HR-QOL tools to better assess the true burden of osteoporotic fractures, particularly in the case of hip fractures, as the burden is surely being underestimated without recognition of HR-QOL. Only when the burden of fragility fractures is understood, inclusive of HR-QOL, will the value of proven antifracture prevention and treatment therapies be appreciated. Information collected by HR-QOL instruments may provide new insight as to how to improve quality of life for patients with fractures and how to properly allocate healthcare spending.

Dabigatran-induced acute hepatitis.

In the March of 2010, a 71-year-old man with a history of chronic atrial fibrillation presented to our institution with a 2-week history of progressive painless icterus, fatigue, and anorexia. He had been initiated on off-label dabigatran for stroke prevention 1 month prior to his hospital admission. Dabigatran was discontinued at the time of admission to hospital. There had been no other recent change to medications or exposure to hepatoxins. He had no premorbid history of hepatic disease. On examination, he had prominent scleral and dermal icterus in the absence of general stigmata of chronic hepatic disease. There was no asterixis. The abdomen was nontender with no palpable masses or visceromegaly. Biochemical investigations during admission demonstrated an aspartate aminotransferase of 667 IU/L (normal 5 times the upper limit of normal). There were no cases of significant hepatic dysfunction or associated morbidity or mortality. Reviewing the Health Canada database on dabigatran, there have been 5 cases of elevated liver enzymes that may have been associated with dabigatran use. Given this information, our case is important in that it identifies a patient who presented with clinically severe hepatic dysfunction that onsets with dabigatran use, in the absence of another identifiable cause and that resolved with only withdrawal of dabigatran. Although not meeting all criteria for Hy’s Law of drug-induced liver injury, the relationship between drug and side effect seems quite distinct. As such, it points to the need for ongoing monitoring of patients receiving this drug for rare cases of drug-induced hepatic dysfunction, especially in patients on other potentially hepatotoxic medications.

Effectiveness of Test‐Enhanced Learning in Continuing Health Sciences Education: A Randomized Controlled Trial

Background: Increasing concerns over the effectiveness and quality of continuing medical education (CME) programs has encouraged educators to use theoretically driven empirical research to improve the educational value of these activities. Within cognitive psychology, theories of learning and knowledge acquisition, such as test‐enhanced learning (TEL), may be used to enhance the effectiveness of CME protocols and delivery. The present study examined whether the pedagogical benefits of testing can be observed in practicing physicians. Methods: A total of 83 physicians were recruited following an education session on constipation management and were randomized to either (a) the test condition (n = 43), where learners wrote a short test consisting of 10 short‐answer questions (SAQs), or (b) the study condition (n = 40), where learners studied the same information. Four weeks later, 56 (68%) physicians completed a final test with 10 new SAQs, with 27 being from the initial test condition and 29 belonging to the initial study condition. Results: Performance on the final SAQ test was equivalent for both test (42.5%) and study‐only (41.2%) conditions (p = .71). Discussion: The null findings in the present study are inconsistent with previous research showing the pedagogical benefits of testing relative to studying. Given that most TEL research focuses on novice learners, who lack strong associative memory networks, it is possible that TEL is specific to novices and not generalizable to experts. Alternative explanations focus on the importance of repeated, distributed testing with feedback.

Domperidone Prescribing Practices Exposed Patients to Cardiac Risk despite a "Black Box" Warning: A Canadian Tertiary Care Center Study.

Background. In 2012, Health Canada released a warning regarding domperidone use, based on associations with life-threatening arrhythmias and death. Objective. This study aimed to compare the appropriateness of domperidone prescribing patterns before the advisory to those afterward. Methods. Two retrospective reviews were conducted for patients prescribed domperidone during quarters in 2005 and 2012. Outcomes included appropriateness of indication, dosing regimens, monitoring of electrolytes, baseline electrocardiogram performance and characteristics, presence of left ventricular dysfunction, and coprescription of QT-prolonging medications. Univariable and multivariable logistic regression analyses were performed. p values < 0.05 were considered significant. Results. 290 and 287 patients were analyzed in 2005 and 2012, respectively. Domperidone initiation in hospital decreased from 2005 to 2012 (71.4% versus 39.4%, p < 0.0001) as did prescriptions for nonapproved indications (84.8% versus 58.2%, p < 0.0001). In-hospital initiation predicted prescription for nonapproved indications (OR = 7.01, 95% CI 4.52–10.87, p < 0.0001). Use of domperidone as the sole GI drug predicted nonapproved indications (OR = 2.51, 95% CI 1.38–4.55, p = 0.002). Conclusions. The advisory was associated with more appropriate domperidone initiation and compliance with recommended dosages. Our study suggests the need for increased awareness of the dosing and monitoring of domperidone to ensure patient safety.

Value Stream Mapping in Lean Healthcare: A Brief Introduction and Application

The Lean approach espouses the elimination of sources of waste throughout a process, so that only value-added activities that address the desires of the customer should be implemented. Originating in manufacturing, Lean has been applied to healthcare, being used to address waste in this sector, for the benefit of patients and other healthcare actors. A central technique for identifying sources of waste is value stream mapping. This technique involves the creation of diagrams that depict workflow and its associated waste, and future state processes with waste reduced or eliminated, all occurring within an overarching series of activities that sees process improvements implemented. This chapter highlights the creation and use of value stream maps (VSMs) in the context of a Lean Healthcare initiative. A case example proposes current state and future state VSMs for medical coding and billing processes, which entail the capture of patient encounter information by the physician for the purpose of receiving remuneration from a healthcare system payer.

The RCQ Model: Conceptualizing Inter-Clinician Relationships, Communities of Practice and Quality Improvement in Healthcare

As society moves into the age of active knowledge management and sharing, inter-clinician relationships and communities of practice can be directed to support quality improvement efforts within healthcare organizations. It is argued that successful adoption of the processes that are critical to quality improvement is necessary for durable improvements in quality. Knowledge sharing is necessary for supporting the skills in performing activities associated with practice audit, change management and use of the associated technology. This paper introduces the Relationships, Communities, Quality RCQ model, which provides a framework for the purpose of conceptualizing how quality improvement in healthcare can be sustained. A variance model is proposed for the evaluation of communities of practice for their value in quality improvement in healthcare.

ChargeMed: Development of a Mobile Application for Medical Coding and Billing within the Ontario Healthcare Environment

Traditional processes involved in coding and billing for medical services performed by physicians present many inherent challenges in complete charge capture, accurate coding and entry as well as timely submission for reimbursement. Process improvement facilitated by the adoption of mobile electronic billing management systems has demonstrated the potential for considerable financial benefit. This paper outlines the conceptual and technical architecture for a mobile coding and billing application facilitating physician remuneration for practices in Ontario, including a description of the relevant contextual background, potential mechanisms for the functional evaluation of this tool and a discussion of possible evolutionary modifications of the proposed application.