College of Medicine - Master of Physician Assistant Studies Capstone Projects

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Open Access
Virtual Delivery of Medical Education: A Physician Assistant Program Literature Review
(0002-05-15) Kasper, Laural
Introduction: In the past few years of the Corona virus (COVID-19) we have seen a significant shift in the delivery of education that incorporates more online components. A virtual model of teaching has been adopted in many institutions worldwide. In the context of training physician assistants (PAs), the question remains if virtual medical teaching is effective enough to be continued as an educational strategy. Purpose: The purpose of this study was to analyze the evidence regarding the application and efficacy of virtual teaching (VT), with the aim of program improvement for PA students. This was done by reviewing emerging literature for evidence to determine if a virtual approach to PA education is effective. Methods: A comprehensive literature review of peer reviewed articles within North America from the year 2000-2023 was conducted. Electronic databases such as PubMed and the Journal of Physician Assistant Education (JPAE) were searched using key terms “physician assistant” AND “virtual” AND “education”. Inclusionary and exclusionary criteria were determined and applied to a total of 108 articles, which were screened by title and abstract. Full-text screening was completed on an eligible 27 articles. Data extraction was done on the final 12 articles, which were utilized in this literature review. Results: The outcomes of the 12 studies reviewed were organized utilizing the Kirkpatrick model of program evaluation. This model was used to compare advantages, disadvantages, student responses, effects of learning, behavioural changes, and organizational benefits. Overall, most pilot virtual programming was well-received and reviewed in the above comparative categories. Conclusion: Virtual education increases access to programs and can be an effective and cost-efficient method to teach PA students. Virtual education should be considered in current program curricula and further studied to determine long-term outcomes.
Open Access
The Effects of Vitamin D Supplementation on Fall Reduction in the Elderly: A Critical Appraisal
(2015-04) Martens, Jillian
BACKGROUND: Falls in the elderly is a significant public health problem due to their high prevalence of 30% in those over 65, many of which result in fractures and soft tissue injuries, longstanding pain, functional impairment, reduced quality of life, and increased mortality. The elderly population is more at risk for vitamin D deficiency, and there is increasing evidence for supplementation and reduction in the rates of falls and fractures. OBJECTIVE: The objective of this paper is to critically appraise five keys articles with the aim to answer the question: ‘What are the effects of vitamin D supplementation and fall reduction in the elderly?’ METHODS: A literature search of PubMed, EMBASE and CINAHL was conducted and five key articles were selected based on relevance and date of publication. Study findings were also considered when selecting articles so as to provide a complete depiction of the variability of results on this topic. RESULTS: Out of the five key studies, the first showed a positive correlation between vitamin D serum concentrations and fall reduction, as well as increased cognition. The second identified a positive role of vitamin D in balance control, which may be a risk factor for falls in the elderly. A third study showed a positive association between serum 25 hydroxyvitamin D levels and physical performance in the elderly. The fourth study found positive associations between vitamin D insufficiency and impairments in factors which predispose the elderly to fall. Finally, the last study identified the effect of oral and parenteral megadose vitamin D supplementation in the elderly, and showed prevention of falls and improvement of functional mobility. Based on these findings as well as the quality of study designs and methods it would appear as though vitamin D supplementation in the elderly plays an important role in fall prevention.
Open Access
Quality of life in prostate cancer: active surveillance versus radical prostatectomy
(2015-04) Woloshyn, Angela
Introduction: This purpose of this review is to summarize current literature surrounding quality of life research in men with prostate cancer who choose either active surveillance (AS) or radical prostatectomy (RP), targeting anxiety, urinary and sexual symptoms. Methods: A PUBMED search on anxiety, urinary, and sexual symptoms in active surveillance and prostatectomy in prostate cancer was performed using MESH search terms. Literature in English from 2005 to 2015 was included, and augmented with relevant articles found amongst reference lists. Thirteen original research articles were selected for review. Results: Men in AS vs RP groups do not significantly differ in terms of anxiety, depression or distress. A higher proportion of men have difficulty achieving erections firm enough for intercourse and higher rates of urinary incontinence after RP. No data was found comparing urinary obstructive symptoms in RP and AS, though obstructive symptoms are known to be higher in watchful waiting. Conclusion: Active surveillance is advantageous in having lower rates of erectile dysfunction and urinary incontinence, and is not associated with higher rates of anxiety. There are few studies comparing health related quality of life in active surveillance to radical prostatectomy, and more literature is required to fully understand the quality of life outcomes of each treatment choice.
Open Access
Current Treatment of DKA: A Review and Approach to Establishing a Best Practice Protocol
(2015-04) Qually, Max
Diabetic ketoacidosis (DKA) is a life threatening complication of diabetes, with profound implications for patients and the healthcare system. Effective treatment of DKA depends on early diagnosis and initiation, followed by timely and accurate monitoring of the disease process. Emphasis was placed on how to manage DKA efficiently, to decreased patient length of stay, without compromising patient safety. This article addresses the underutilization of point of care beta-hydroxybuteric acid (βOHB) meters for diagnostic and treatment guidance. The use, and safety, of point of care βOHB meters for diagnostic and treatment guidance are examined. Improved utilization of such devices may present an opportunity to improve patient outcomes and decrease patient lengths of stay. Methods: Using Scopus, PubMed, and Google Scholar search engines, a review of English, peer reviewed literature of the past 10 years on the diagnosis and management of DKA was constructed. Careful consideration has allowed recommendations presented here to be in agreement with the Canadian Diabetic Association's Clinical Practice Guidelines. A best practice protocol order set was produced; ready for implementation at WRHA community hospitals. Results and Recommendations: Effective treatment of DKA requires early diagnosis, fluid and electrolyte repletion, insulin therapy, and constant monitoring. Treatment strategies have been researched with the goal of diminishing patient length of stay without compromising patient safety. Conclusion: Recommended DKA treatments presented here are optimized when such treatments involve the use βOHB meters for diagnosis and management of DKA. As well it is recommended that treatment strategies be directed via up to date best evidence protocol order sets. There is evidence that such order sets in conjunction with the use of such meters will provide a cost and safety benefit to hospitals and patients respectively.
Open Access
Access Barriers to Primary Health Care: Indigenous People and the Role of the Physician Assistant in Northern Manitoba
(2015-04) Barnes, Christopher
This capstone project compares Manitoba and Alaska health care reform policy in the context of northern Indigenous Health. Additionally, this paper compares northern Manitoba and Alaska Physician Assistant utilization rates. Two questions are investigated: (i) ) Will the current primary care reform policy improve access barriers to primary care for northern and remote Indigenous communities in Manitoba and if not, what other options might be available? (ii) Are Physician Assistants utilized within northern and remote Indigenous communities in Manitoba to address current service delivery challenges? Indigenous people in Manitoba experience significant health inequities as reflected in health indicators published in government documents and academic papers. Despite Manitoba’s primary care reform policy and in light of a recent Auditor-General’s report on northern health care, current systems do not appear to be addressing these issues and access barriers exist. A review of the literature using internet search engines by key words was performed. Important government and health websites were reviewed. Key informants were sought who had expertise in Indigenous health care, health system reform and current Physician Assistant policy and training. The topics examined were: Indigenous sociopolitical perspective, the effects of racism and colonization on Canadian Indigenous people, current health care issues and health care reform initiatives in Manitoba. The following are four significant findings of this study: (i) it is not yet known if current primary health care reform policy will improve access barriers for northern and remote Indigenous communities in Manitoba due in part to the complexity of the federal/provincial/Indigenous peoples arrangement and because there is no pre or post data for the selected health indicator (ii) an option called the “Nuka System of Care” exists, is culturally relevant, is structured to address access barriers related to jurisdictional discrepancies and staffing shortages and has resulted in better health for the Alaska Natives (iii) there is evidence that Physician Assistants are underutilized to address service delivery challenges within northern and remote Indigenous communities in Manitoba (iv) both the “Nuka” system and Physician Assistants could help address access barriers and service delivery challenges for northern and remote Indigenous communities in Manitoba if adopted but further research and evaluation would be needed before policy change could occur.
Open Access
Do non-nutritive sweeteners affect the metabolic health of infants and children? A systematic review of randomized controlled trials and prospective cohort studies
(2015-04) Reid, Ashleigh
Background: Non-nutritive sweeteners (NNS) have recently gained enormous popularity due to their perceived health benefits in weight loss and management; however, their long-term impact on human health is unknown, particularly when exposure occurs during early development. We conducted a systematic review of prospective cohort studies and randomized controlled trials (RCTs) to evaluate the association between NNS exposure in the prenatal period, infancy and childhood (age < 12 years) and metabolic health outcomes. Methods: A comprehensive peer-reviewed search strategy was used to search the Medline (OVID) database from inception to December 2014. Citations were screened in duplicate to identify RCTs and prospective cohort studies evaluating metabolic outcomes after NNS exposure during gestation or childhood. The primary outcomes were change in weight-for-length (WFL) z-score in infants and change in body mass index (BMI) z-score in children; secondary outcomes included growth velocity, birth weight, incidence of overweight/obesity, change in central and total adiposity, and incidence of adverse metabolic effects. Results: From 4591 citations reviewed, 12 studies met our inclusion criteria; 3 RCTs and 9 prospective cohort studies (total n = 83,426 participants). Studies were heterogeneous in the type and duration of NNS exposure and outcomes reported. Two of the nine prospective cohort studies identified significant associations between NNS exposure and increase in BMI or fat mass in children, yet six studies reported no association. Two RCTs evaluated NNS exposure in children and found significant but contradictory associations with weight gain. In two prenatal studies, NNS exposure was not associated with infant birth weight; however, no subsequent metabolic outcomes were evaluated. No studies reported on incidence of metabolic syndrome, insulin resistance, or type 2 diabetes mellitus. Conclusions: There is limited and inconsistent evidence for the metabolic effects of early-life NNS exposure. Further research is required to fully understand the impact of NNS exposure during gestation, infancy, and childhood.
Open Access
Physician Assistants Making a Difference: A Retrospective Study on Discharge Times in Community Orthopedics
(2015-04) Smook, Troy
Intro: Physician Assistants (PAs) have been key components to health care teams around the world for quite some time now. In Canada PAs have been utilized very effectively in the Canadian Forces (CF) and are now transitioning to become integral members in civilian health care across the country, with Manitoba and Ontario leading the way. Doctors are seeing the many potential benefits of PAs but it is not always clear how best to utilize their unique skill sets and talents. Looking at how discharge times are affected is one way to analyze their effectiveness in practice. The purpose of this was paper was to look at a community orthopedic surgery service and investigate how hiring a PA affected discharge times postoperatively. Methods: 120 systematic chart reviews were completed at the health records office of the community health care center. Dates ranged from 6 months prior and 1 year after the PA was hired. To keep the sample size simple, one surgeon was chosen who specialized in total hip arthroplasties and total knee arthroplasties, with no bias being given to age or sex of the patient. Results: The first data set looked at 6 months prior to the PA starting. 45 cases were reviewed and the total length of stay for all cases was averaged and found to be 8.2 days postop. The next data set looked at 75 cases up to 1 year after the PA was hired. The average length of stay again was averaged and found to be 5.2 days postop. This shows that with the addition of one PA to the orthopedic team, they were able to decrease length of stay by, on average, 3 days. Conclusion: This data set proves that PAs are an effective member of the health care team and when used successfully, have dramatic positive benefits to the patients and the health care system as a whole. Not only do they increase effectiveness and efficiency of their supervising physicians, but also with reducing discharge times they are able to reduce costs to the medical system associated with longer hospital stays and associated medical resources.
Open Access
DOES INTRAVENOUS MAGNESIUM REDUCE HOSPITAL ADMISSION RATES IN ADULTS WITH SEVERE ACUTE ASTHMA?
(2015-04) Hall, Steven
Introduction: Asthma is a chronic respiratory disease characterized by bronchial hyper-responsiveness, airflow obstruction, and inflammation that presents with symptoms of cough, dyspnea, chest tightness, wheezing, and sputum production. Symptoms of asthma can range from mild to severe, resulting in hospitalization, intubation, and even death. In addition to inhaled beta agonists, nebulized ipratropium, oxygen, and systemic corticosteroids, magnesium sulfate has been used as an adjunctive treatment of acute severe asthma exacerbations. However, despite its use, its effectiveness has been inconclusive and controversial, with previous studies showing the greatest benefit in those having severe exacerbations. This literature review was conducted to determine if magnesium sulfate administration reduces hospital admission rates in adults with acute, severe exacerbations. Methods: A literature search was conducted for research studies of adult patients who presented with an acute, severe asthma exacerbation and were treated with intravenous magnesium sulfate. Study dates were limited to the years 1989-2014, and were identified through PubMed, Scopus, Embase, and Google Scholar, with further studies identified through the search of reference lists of published articles. A total of 11 studies were found using the sources above. Of these 11 studies, 5 double blind, randomized, placebo controlled trials were selected for this review. Results: Results from the five randomized controlled trials selected were mixed, with two studies showing a decrease in admissions (one had weak evidence of a decrease), and three studies showing no difference in admission rates. Conclusion: Intravenous magnesium sulfate does not appear to decrease admission rates in adult asthmatics having a severe exacerbation.
Open Access
Donepezil in Severe Alzheimer’s disease: A Review of Treatment Considerations with Disease Progression
(2015-04) Neuendorff, Melanie
Introduction: Alzheimer's disease (AD) is a progressive neurodegenerative disorder that affects 35 million people worldwide, with the prevalence expecting to double by 2030. Patients with severe AD (Mini-Mental State Examination (MMSE) score <10) require extensive help with daily activities, show severe memory impairment, and exhibit major personality and behavioral changes. Donepezil is one of only two drugs currently approved by the US Food and Drug Administration (FDA) and Health Canada for use in severe AD. The drug is currently available in 5mg, 10mg, and a controversial more recently FDA approved 23mg daily dose. This review will provide a brief background on AD, and discuss the risks, benefits, and current recommendations for donepezil use in severe disease, with an emphasis on Canadian and US practices. Methods: Randomized Controlled Trials (RCTs) concerning the efficacy and safety of various doses of donepezil (Aricept) use in severe AD were identified using PubMed. Three original double blind, parallel-group, placebo-controlled, randomized studies, one post-hoc analysis, and one sub-group analysis were selected for review. Results: Donepezil benefits patients with severe AD in areas of cognition and global function. Increased benefits of treatment correlated with escalading dose in patients with more advanced baseline disease, as measured by Severe Impairment Battery (SIB) scores. However, more patients assigned to donepezil discontinued their treatment due to an adverse event (AE) than placebo, and AEs occurred more frequently and with increasing severity as dose increased. Conclusion: Donepezil treatment shows small but measurable benefits in severe AD. Clinicians must weigh these benefits against the possible AEs when determining the appropriate course of therapy, as recommendations for discontinuation of cholinesterase inhibitors in advanced AD remain unclear.
Open Access
Food Diversity in the First Year of Life and the Development of Allergic Disease in High-Risk Children
(2015-04) Hirst, Cheryl
Mounting evidence suggests that delaying the introduction of solid food may promote allergic disease, leading to recent changes in infant feeding guidelines. We investigated the association of food diversity during the first year of life and the subsequent risk of asthma, atopy and atopic dermatitis.
Open Access
Clinical Efficacy and Timing of Influenza Immunization in Cancer Patients Receiving Chemotherapy
(2015-04) Patterson, Curtis
Background: Cancer patients who are immunocompromised due to the nature of their malignancy or treatment with chemotherapy, are at increased of developing complications related to influenza infections. While the influenza vaccination has been shown to be safe in immunocompromised patients, recommendations regarding when to vaccinate patients with cancer are inconsistent, and there are currently no guidelines in place to guide clinical decision-making. This review seeks to assess the efficacy of the influenza vaccine and the proper timing of its administration to immunocompromised adult patients due to cancer. Methodology: A literature search was done of studies that assessed humoral seroconversion after vaccination and clinical effectiveness of the influenza vaccination in immunocompromised cancer patients. The studies included patients with solid tumors, hematological malignancies, and those who were post hematopoietic stem cell transplant. Results: The literature indicates chemotherapy patients generally showed decreased immune response to vaccination, when compared to healthy patients who had not been treated with chemotherapy. However, the aforementioned cancer patients did show adequate seroconversion and patients vaccinated early in their chemotherapy cycle (Day 4-5) as opposed to later (Day 16) had a greater serological response to the influenza vaccinate. Conclusion: The influenza vaccine has been confirmed to produce adequate overall antibody response in 3 chemotherapy patients and to be safe and effective. However, literature indicates it should generally be given early in relation to the chemotherapy cycle to achieve maximum effectiveness. The data supporting this assertion is limited, and the topic requires further study. In view of this, clinicians should consider the potential benefits of influenza immunization for patients being treated with chemotherapy.
Open Access
The Distribution of Gastroschisis in Manitoba
(2015-04) Brezinski, Leah
Introduction: There is a reported increase in prevalence of gastroschisis worldwide. In addition, there are a significant number of hot spots identified in the current literature. The etiology for this increase is largely unknown at this time. It is postulated that one of these notable hot spots is in Northern Manitoba where the prevalence of gastroschisis is higher when compared to the rest of the province and country. Methods: We conducted a retrospective cohort study and identified cases of gastroschisis through provincial databases and medical records. They were referenced with postal codes and birth rates according to region. Results: The results demonstrate a 2 to 3 fold increase in prevalence of gastroschisis in the Northern regions of Manitoba when compared to rates in Southern Manitoba. Conclusion: We successfully identified hot spots in Manitoba that have an increased prevalence of gastroschisis. A variety of risk factors have been identified as etiologies for gastrocschisis. Future research efforts will include further investigations in the population of Northern Manitoba and analysis of specific maternal and geographic considerations that could explain the increase in prevalence.
Open Access
A survey designed study on cost effectiveness of Amnisure: Should Amnisure replace Ferning and Nitrazine as the test of choice for diagnosis of rupture of membranes?
(2015-04) Yang, Lu Ting
Rupture of membrane (ROM) is most commonly diagnosed clinically with physical examination; however, approximately 20% of women present very subtly, thus, making diagnosis difficult. An accurate diagnosis is important as it will influence subsequent management and care plan. The current diagnostic standard uses ferning and/or nitrazine, which performs at very low cost but with a low specificity value. This is a survey-designed study, information collected are used to estimate cost in introducing Amnisure in a selective fashion and for every patient with query PROM, to inform better decision making when using in triage unit at The Women's Hospital. Methods- From March 14, 2015-April 14 2015, data will be gathered from triage unit in Women’s Hospital including women that presents with query SROM. An assessment by medical staff if an Amnisure kit would have been useful in establishing diagnosis Results- We determined from this study that approximately 25%-37.5% of PROM would benefit from Amnisure use in diagnosis of PROM. The cost of Amnisure per year is $7192.8-$10,789.2 in selective use and $28,171.8 in standard use. Conclusion- Amnisure is an accurate method for diagnosing rupture of fetal membranes with high sensitivity, specificity, negative predictive and positive predictive values. Amnisure also concluded in this study to be cost effective.
Open Access
Ixodes scapularis, fighting back, a clinician's guide to lyme disease testing in Manitoba: A critical appraisal of current and proposed testing methods
(2016) Paulson, Elizabeth
Background: Lyme disease, a tick borne illness caused by Borrelia burgdorferi, is an increas-ingly prevalent infectious disease in Canada. In 2009, there were 128 cases of Lyme disease re-ported across Canada. In 2015, there were over 700 cases, 35 of those cases in Manitoba. Due to rising temperatures the geographic range of I. scapularis, the primary vector of Lyme disease in Manitoba, is enlarging. This will most likely cause an increase in incidence of human infection. As incidence increases it is important to have a full understanding of Lyme disease presentation, testing and treatment. Much of the current research of Lyme disease focuses on testing. Testing for Lyme disease provides useful assistance in diagnosis, however weaknesses exist including insensitivity to early disease and inability to differentiate from active infection or treated infec-tion. This paper will provide a quantitative critical appraisal of current and proposed research for Lyme disease testing. Methods: A comprehensive Pub Med and Google Scholar database search for “Lyme disease” and “testing” in the last 10 years was conducted. Articles met inclusion criteria if they evaluated any of the testing methods recommended by Infectious Disease Society of America or new pro-posed methods including: ELISA/whole cell sonicate immunosorbent assay, C6, PCR, iPCR, Western blot, and V1sE. Testing methods had to evaluate serum samples collected from patients with known Lyme disease by symptomatology and confirmatory testing. These articles were re-viewed for sensitivity and specificity of testing methods. Results: In early Lyme disease, standard 2 tier testing was 38-40% sensitive. iPCR hybrid anti-gen was 55% sensitive. First tier testing C6 ELISA was most sensitive at 64.6%. In early disseminated Lyme disease, standard 2 tier testing sensitivity increased to 80-88%. PCR and culture decreased to 29% sensitivity. 2 tier ELISA algorithm provided 100% sensitivity and single C6 ELISA provided 90% sensitivity. In late disseminated Lyme disease, standard 2 tier testing was 92-100% sensitive. Single C6 ELISA was 98.2 % sensitive. iPCR was 92% sensitive and 2 tier ELISA was 100% sensitive. Convalescent samples of serum from patients treated with antibiotics continued to have sensitivi-ty of 87-100% in C6 ELISA. Specificity of standard 2 tier testing, single C6 ELISA, iPCR and 2 tier ELISA testing was simi-lar ranging from 97-100%. Specialty labs A and B in the U.S. had 37.8% and 42.5% sensitivity with standard 2 tier testing. Specialty lab B sensitivity changed to 70. 3% when using in-house criteria for interpretation of western blot and specificity decreased from 100% to 72.5%. Conclusion: Lyme disease testing methods continue to be insensitive to early Lyme disease. Newer methods such as iPCR hybrid antigen provided similar sensitivity to early Lyme disease as current recommend methods. Standard 2 tier testing to disseminated Lyme disease is sensitive and specific. Proposed 2 tier ELISA, first tier C6 ELISA and new iPCR hybrid antigen provide similar sensitivity and sensitivity to disseminated Lyme disease. These methods could potentially be used as alternatives to Western blot to avoid inter-laboratory subjectivity.
Open Access
A history of patients' perception and satisfaction with Physician Assistants in primary care
(2016) Piotrowski, Steven
Background: There are greater than four million Canadians that are unable to find a family physician or access immediate care for minor health problems. One solution has been the introduction of Physician Assistants (PA). In order to integrate PAs successfully into the health care system they must provide a high quality of medical care and be accepted by patients. Therefore, this project will examine the history of patients’ perception and satisfaction towards PAs working in primary care. Methods: A review was performed from 1973 to 2015 using the databases of Ovid MEDLINE, Google Scholar, and PubMed. Key search terms included “physician assistants,” “primary health care,” and “patient satisfaction.” Additional information was obtained by manually searching through journals, Internet resources, and bibliographies of retrieved articles. Results: A total of 9 papers were analyzed and reviewed. Patients are satisfied with primary care PAs and consider them a valuable member of the healthcare team. Physician Assistants are viewed as competent, intelligent, friendly, and responsible. No significant difference is observed regarding patient satisfaction and type of provider. Patient’s demographics have the potential to influence their perception of a PA. In addition, the greater number of visits a patient has with a PA, the greater their acceptance of the PA role. Conclusion: It has been demonstrated that patients’ are willing to be treated by primary care PAs and are satisfied with the health care they receive. Furthermore, the greater number of interactions an individual has with a PA the more willing they are to get treated for variety of conditions and are more open to PAs performing complex procedures.
Open Access
The rural incentive: Why do Physician Assistants choose to work in rural medicine and what makes them stay?
(2016) Taylor, Danika
Introduction: Access to healthcare in rural and underserved communities has been a longstanding concern in the Manitoba healthcare system. One way to help alleviate this shortage may be the use of physician assistants in rural communities. Currently 24% of University of Manitoba MPAS graduates practice in rural locations. Objective: The purpose of this review was to identify the benefits and difficulties of physician assistant practice in rural locations in order to understand how rural communities in Manitoba can maximize the recruitment and retention of physician assistants. Methods: A comprehensive review of online databases Embase, PubMed, Google Scholar and Medline for survey and questionnaire based studies of physician assistants. Five American articles were identified and analyzed. Results: Rural physician assistants identified increased autonomy, wider scope of practice and good supervising physician relationships as reasons why they choose rural practice. Community factors such as recreational and cultural amenities, desire for rural living and working in an underserved community were also influential. Increased workload, long hours and salary were identified as difficulties. Conclusion: Rural health employers in Manitoba looking to recruit physician assistants should highlight the benefits of working rurally such as more autonomy and more varied job duties as well as the community specific amenities and attractions. Employers should also address the difficulties such as workload and hours in order to increase retention in the long run.
Open Access
Does the use of hyaluronic acid viscosupplementation prolong the viability of a patient's knee with oseteoarthritis, delaying the need for surgical management? A systematic review of the literature
(2016) Andres, Kristian
Introduction: Osteoarthritis of the knee is a very common complaint in the aging population and a significant burden on not only the patient, causing pain, decreased mobility and a lowered quality of life, but also the healthcare system with frequent primary care visit associated with its symptoms. We investigated the use of viscosupplementation with hyaluronic acid and how long improvement was sustained, preventing the need for costly total knee arthroplasty. Methods: Using Medline (OVID) search strategy from 1946 until February 2016 was developed with they guidance of library personnel trained in research. We searched for studies that looked specifically at the amount of time that a patient would be able to continue using their knee with appropriate level of function and pain before the gold-standard of treatment via total knee arthroplasty would need to be performed. Titles and abstracts of articles were read to determine if appropriate and four articles met the inclusion criteria which meant the articles must look specifically at how long the use of viscosupplementation prevented the need for total knee arthroplasty. Results: In all four articles the time to total knee arthroplasty was increase over no treatment. In all the studies they calculated average time to total knee arthroplasty based on the point in which half the knees treated by viscosupplementation required surgical intervention. The range in these studies saw a prolongation between 370 to 919 days over the control groups which were patients whom did not receive viscosupplementation. It was also found that in patients who were considered positive responders, the more courses of viscosupplementation received, the longer the delay of surgical intervention. Conclusion: Based on the research reviewed it can be said that the use of viscosupplementation vs. no treatment or failed conservative treatment delays the need for total knee arthroplasty in patient with knee osteoarthritis. Further research must be done with more high quality studies using controls to improve the accuracy of this information. Also, further research should be done to determine if these positive results would in turn lead to savings for the Canadian healthcare system and how best to implement them.
Open Access
Mindfulness based stress reduction for generalized anxiety disorder: A review of the current literature
(2016) Moore, Lisa
Introduction: Anxiety disorders are widespread and often debilitating conditions that can impair social, occupational and educational performance, resulting in lower quality of life for affected individuals and their families. Generalized Anxiety Disorder (GAD) has a lifetime prevalence of 5.7 and is characterized by six months or more of frequent, poorly-controlled worry and anxiety about multiple events or issues that negative affect sleep, mood, concentration and can result in a broad variety of somatic complaints. While both drug and psychotherapeutic treatments are widely available, GAD is often resistant to treatment, with a long and relapsing-remitting course. Mindfulness Based Stress Reduction (MBSR) is an 8-week stress relief group program that includes meditation, body awareness and yoga components developed by Jon Kabat-Zinn and first utilized in a clinical context at the University of Massachusetts Medical School in 1979. MBSR integrates contemplative spiritual practices including Zen Buddhism with secular concepts of health and wellness with the goal of reducing the effects of stress on patients. In recent years MBSR and other mindfulness practices have become widely available via Internet, books and structured programs. MBSR is now routinely promoted as effective and safe method with which to reduce stress, depression and anxiety. Methods: To answer the clinical question: in adults with generalized anxiety disorder, what is the efficacy of a MBSR program in relieving anxiety from baseline/pre-treatment? The current medical literature (published from 2006-2016) was surveyed to identify studies focused on the MBSR program and its effectiveness in alleviating symptoms of GAD. Using SCOPUS, Pubmed and Google Scholar databases, nine unique studies were located from 2006-2016 using search terms “generalized anxiety disorder”, “mindfulness based stress reduction”, “MBSR” and “GAD”. Results: Four recent studies were identified that specifically addressed the useful of MBSR program in treating GAD. All four studies concluded that MBSR likely has value in reducing symptoms of GAD. However, all four studies were small in size, with MBSR groups ranging from 16 to 79 participants. A number of methodological issues also problematize the real world value of the studies findings in the majority of the studies. Conclusions: Few current studies specifically evaluate the effectiveness of MBSR in treating GAD. Existing studies are generally small and the majority lack robust designs and long term follow up components, which limits their ability to confidently evaluate the real life usefulness of MBSR in treating GAD. While good evidence exists to support the use of MBSR as a low-cost, low-risk treatment for depression, chronic pain and other conditions, further research is needed to determine the usefulness of MBSR in treating GAD and how MBSR could be used confidently in practice to improve outcomes for GAD patients.
Open Access
The use of nicotine replacement therapy (NRT) for pregnant women who smoke: A narrative review of placebo controlled randomized controlled trials to evaluate efficaacy and safety
(2016) Christian, Mathew
Background: The use of tobacco during pregnancy is considered to be the most important preventable cause of pregnancy complications including pre-term labor and fetal growth restriction (3,9,10). Despite the potential for harmful effects, 10.5-23% of Canadian women smoke during pregnancy (4,5). While there is strong evidence that nicotine replacement therapy (NRT) is highly effective in reducing tobacco use in the general population (17), data supporting the use of NRT in pregnancy is limited. Objective: We conducted a narrative review of placebo-controlled randomizedcontrolled trials (RCTs) to evaluate the safety and efficacy of NRT use for pregnant women who smoke. Methods: A comprehensive review of the literature was performed using the Embase and Ovid MEDLINE database records from 1946 to December 2015. Articles were included if they were placebo-controlled RCTs testing the use of NRT in pregnant women who smoke. Primary outcome measures were daily tobacco use, cessation rates, and pregnancy complications. Results: Of the 407 articles retrieved, five met the inclusion criteria (total n = 1,926 participants). All included RCTs provided cessation counseling to study participants in addition to NRT or placebo. In the RCTs that found a significant difference between NRT and placebo, NRT was associated with a significantly larger reduction in daily tobacco use (cigarettes/day), as well as a significant increase in mean birth weight and a reduced incidence of pre-term birth. NRT use did not have a significant effect on cessation rates, NICU admissions, or the incidence of fetal demise. There were no significant adverse effects associated with NRT use. Conclusions: While additional research is still needed, the results of this narrative review suggest that NRT use may result in greater reductions in tobacco use than counseling alone. There is no evidence from this review that NRT increases the risk of fetal growth restriction, pre-term delivery, or NICU admissions.
Open Access
Meeting the health needs of Winnipeg's most vulnerable population
(2016) Luchka, Karlene
Introduction: The health of Winnipeg’s homeless population continues to be one of the poorest in the province. Although some community services are reaching out to this population, these people continue to have decreased access to non-judgemental, primary care services that are unique to their needs. This approach leaves this population to use emergency services when manageable ailments worsen and become serious, acute or chronic conditions. This in turn makes this population’s journey and their cycle of homelessness even more challenging. A proposed model for a physician assistant run mobile medical clinic is put forth as a unique medical service that brings quality care to this vulnerable population, and caters to their unique health needs. In all, this model will strive to increase the health status of this population and help end homelessness in Winnipeg. Methods: A qualitative and exploratory research study on current mobile clinics for the homeless was performed using Medline and PubMed search engines. Identifying community resources for the homeless in Winnipeg was achieved and accessed through online websites and personal communication. Results: Through detailed research, a proposed model for a mobile medical clinic regularly staffed by a physician assistant, a social worker and/or a mental health worker and outreach workers that provide primary care, diagnostic, counseling and social work services is presented. The potential scheduling, location, supervision, funding, advertising, and safety are discussed and described. Conclusions: The project concluded that a mobile medical clinic catering to the health needs of the homeless population of Winnipeg would help increase their access to quality, non-judgemental primary care services. It would also serve as an access point for these individuals to enter into the health care system and have better access to specialty services they require. Patient-focused primary care services will not only improve their health status and help end their cycle of homelessness but will also benefit Manitoba’s healthcare system as a whole.