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May 1, 2010 | Editorial 

From the MUMJ Editors 2010

Christine Navarro

Good communication is vital to patient-centered care and, as medical students, we spend a good deal of time refining our interpersonal skills. A number of articles in this year’s issue of the McMaster University Medical Journal (MUMJ) emphasize the importance of
effective communication. A review of medical error in Canada (Butt) indicates that an effective reporting mechanism is needed for health care professionals to discuss, learn
around, and ultimately reduce adverse events. In our Literature, the Arts and Medicine section, conversation about mental illness is encouraged to counter its stigmatization,
through both artwork and written pieces. The need to share perspectives to appreciate the whole clinical picture is depicted in Bryn Ludlow’s graphic “Scrutinized,” featured
on our cover.

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May 1, 2010 | Clinical Review 

Essential Surgical Services: An Emerging Primary Health Care Priority

Julia Pemberton, BSc (Hons), MSc (c), Brian Cameron, MD, FRCS

ABSTRACT

Essential surgical services have been a neglected part of global primary health care priorities. This neglect has not been intentional; rather it is a consequence of the logistical, practical and social challenges unique to surgery. Recent literature demonstrates the vast unmet global surgical need and deconstructs the issues underlying the provision of this essential health service. Surgical conditions such as injury, obstetrical complications, and congenital anomalies contribute to 15% of death and disability worldwide, largely in the most resource-poor countries Yet new evidence confirms that surgical care is more cost-effective than antiretroviral treatment for HIV in preventing death and disability. There has simply been a lack of attention and resources directed at improving the necessary components of surgical care: training of health workers to deliver emergency and essential surgical services, and provision of the necessary ancillary staff, equipment and supplies to provide basic surgical care. Reviewing the current best evidence, this paper reflects on the historical roots of primary health care, and argues that surgical services are an essential component of primary
health care that should be universally accessible and affordable.

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May 1, 2010 | Clinical Review 

Corneal Transplantation: Dental Lamina as Keratoprosthesis

Sourabh Arora, BSc, Taha Bandukwala, BSc

ABSTRACT

Corneal diseases are among the major causes of global blindness, second only to cataracts in overall significance. The etiology of corneal blindness includes various infectious and inflammatory eye diseases that cause corneal scarring, which ultimately leads to functional blindness. Anatomically, the cornea is the outermost layer of the eye and is primarily responsible for light refraction, allowing for central and peripheral vision. In cases where less invasive treatments for corneal disease fail, corneal transplant is indicated, which has the highest success rate of any transplant procedure. The simplest form of corneal transplant, Penetrating Keratoplasty (PKP), is performed by transplanting a donor cornea from a cadaver. The authors review a more complex form of corneal transplant, Osteo-Odonto Keratoprosthesis (OOKP), which is a two stage procedure wherein dental and buccal tissue is auto-transplanted to replace the cornea. This review
comprises relevant anatomy, the procedure, surgical interprofessionalism, indications, contraindications, complications, patient outcomes and future scope of OOKP.

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May 1, 2010 | Clinical Review 

Medical Error in Canada: Issues Related to Reporting of Medical Error and Methods to Increase Reporting

Atif R. Butt, BA, MBA, CHE

ABSTRACT

Medical errors and adverse events have a substantial impact on healthcare outcomes in Canada. Reports including The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada, published in 2004, and Self-reported medical errors in seven countries: Implications for Canada, published in 2009, provide important insight regarding errors. The former study provided the first national
estimate of adverse events in Canadian hospitals, and showed that approximately 37% of total adverse events or 70,000 cases were potentially preventable. This paper reviews these landmark reports and suggests that to prevent future errors, healthcare organizations must first ensure that they have effective reporting mechanisms in place. There are significant issues related to the reporting of errors including a “blame and shame” culture; disagreement on the use of mandatory versus voluntary reporting; lack of central and standardized collection mechanisms; and various human, material, and financial barriers. Organizational, provincial/territorial, and national level strategies can be implemented to increase error reporting. These strategies involve shifting from “blame and shame” to a culture of safety, openness, and trust; focusing on education and communication; investing in information technology; and revising current policy.

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May 1, 2010 | Original Research 

Presenting with Chest or Abdominal Pain: Evaluation of Emergency Department Wait-time Intervals and Factors Influencing Length of Stay

Adnan Qureshi, MSc, Mark Morreale, MSc, Dara Klisowsky, MSc, Joyce Lock, MD, MSc

ABSTRACT

Purpose:
With more than 14 million emergency department visits in Canada each year, there is substantial interest in providing timely access to care. This study investigates Canadian Triage and Acuity Scale (CTAS) level 2 and 3 patients presenting in the emergency department with a chief complaint relating to abdominal or chest pain, a cohort found to experience the longest time from registration to discharge. The purpose of this study was to evaluate the time required for each component of routine care provided to the study population, and to identify independent variables that influence length of stay within the emergency department.
Results:
Patients with chest pain complaints were on average evaluated by a physician 40 minutes before patients with abdominal pain complaints; however, chest pain patients spent an additional 154 minutes within the emergency department. Four factors contributed to increased length of stay for all patients in the study:
(1) emergency department congestion, (2) consultant response time, (3) diagnostic imaging, and (4) repeat laboratory investigations.
Conclusions:
This paper describes sources of delays for patients whose care exceeds 360 minutes. Alleviating congestion can be done by building capacity through resource reallocation or through addition of key human resources. Improvement of consultant response time may be achieved through implementation of time-based performance measures, initiating consultations earlier in the care process, and through acute care models. The
contribution of diagnostic imaging to delaying disposition decisions requires the availability of preliminary results to the treating physicians. Awareness of the necessity of repeating laboratory investigations (e.g., troponin) provides evidence that exceptions are necessary when evaluating emergency department care times.

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May 1, 2010 | Case Report 

Omeprazole Reduces Blood Level of Quetiapine

Rouslan Kotchetkov, MD, PhD, Richard C. Millson, MD, FRCPC

CASE PRESENTATION

Mr. A is a 66-year-old single male with a longstanding history of schizoaffective disorder
(SAD); his first related hospitalization was in 1960. Mr. A was recently admitted to hospital following the deterioration of his mental status and home situation. He was
unable to maintain his apartment after his roommate moved to a nursing home. Prior to the current admission, Mr. A’s SAD had been treated with first generation antipsychotics.
During the present hospitalization, his medication was...

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May 1, 2010 | Case Report 

Diagnosis of Urea Cycle Disorders in Adulthood: Late-Onset Carbamyl Phosphate Synthetase 1 Deficiency

Ryan Yu, BSc, Murray Potter, MD

CASE PRESENTATION

A 44-year-old man presented to hospital with sudden onset of nausea, vomiting, confusion, reduced level of consciousness, and seizures. He was acutely ill for three days, yet continued to experience episodic attacks of similar presentation over the following two years. Magnetic resonance imaging of the brain demonstrated mild to moderate cortical atrophy with numerous small, non-specific foci of increased signal within the subcortical white matter and, to a...

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May 1, 2010 | Case Report 

The Successful Use of ECT for the Treatment of Depression During Pregnancy

Colin White, BSc (Hons), MD, David F. Craig, MD, FRCP

CASE PRESENTATION

A 30-year-old gravida 1, para 0, married female with a six-year history of depression presented at 33 weeks gestation. She reported a five-month history of depressed mood, intense feelings of anxiety, loss of appetite, loss of capacity to enjoy normal activities, terminal insomnia, difficulty concentrating, feelings of guilt and diurnal mood variation.

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May 1, 2010 | Case Report 

Cheek Reconstruction: A Variation on a Bilobed Flap

Colin P. White, MD, Doron Sommer, MD, FRCS(C)

CASE PRESENTATION

An 85-year-old male was referred to the otolaryngology clinic for evaluation of a known recurrence of a large basal cell lesion on his left cheek. The patient complained of increasing irritation to the left side of his face, an area previously treated with radiation for
the basal cell carcinoma (BCC). A scar contracture with some superficial crusting was seen at the left cheek (Figure 1). The abnormal region measured approximately...

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May 1, 2010 | Literature, the Arts & Medcine 

Perspectives on Mental Health

Kathleen Huth, BArtsSc, Jean Wilson, PhD

Highly stigmatized and poorly understood, mental illness is a difficult topic to discuss. Moreover, the risk of being politically incorrect often discourages people from engaging in conversation about it. This year’s section on “Literature, the Arts and Medicine” highlights the struggle of living both with any condition that affects the brain and with the associated stigma. We asked, “What does it mean to have a mental illness?”, and patients and those who are close to them responded through creative expression. This was not a question
for doctors who make the diagnosis; rather, we sought answers from the people who carry that diagnosis...

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May 1, 2010 | Commentary 

Agricultural Productivity, Health, and Climate Change: A Public Health Perspective

Emily Groot, BArtsSc

INTRODUCTION

Anthropogenic climate change poses unprecedented threats to our planet and population. The average global temperature has increased by 0.4°C since the 1970s and is expected to increase by approximately 2 to 6°C by 2100. This change is primarily attributable to human production of greenhouse gases. The evidence for, and mechanism of, this climate change is well-known and well documented and will therefore not be discussed here. Instead, this paper will provide an introduction to the health impacts of climate change;

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May 1, 2010 | Commentary 

Interim Federal Health: A Public Health Perspective

Joshua Wales, BMus

A 34-year-old refugee claimant presents in your office. She escaped from Columbia three years ago and claimed refugee status immediately on arrival to Canada. After being given Interim Federal Health (IFH) insurance coverage, she was unable to find a family physician who would accept it. She went for 18 months without primary care, and had to go to the emergency room several times due to complications of her type 1 diabetes. Still waiting for her refugee status hearing, she recently started receiving care from you at a Community Health Centre. She is now pregnant, and her referrals to obstetricians have been refused several times due to her IFH coverage.

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May 1, 2010 | Commentary 

General Surgery: Who Wants It? Addressing Perceptions and Misconceptions

Song Hon H. Kim, MD, Natalya N. Zhang, MD, Juan J. Russo, BHSc, Ismail K. El-Salfiti, BSc, Marcin Kowalczuk, BHSc, more

General surgeons are vital to maintaining the health of our population. They manage patient care from routine hernia repairs to catastrophic traumas and from simple biopsies to complicated Whipple operations. A general surgeon draws satisfaction from helping patients in a very tangible, concrete way, seeing the results of interventions in a short time. To effectively care for patients, a general surgeon acts as an advocate, communicates with patients and collaborates with peers in other specialties. General surgery is a challenging, rewarding field and entry was once highly competitive. In the last decade, there has been a trend towards fewer medical students applying to general surgery, as well as other surgical subspecialties, with some programs recently having difficulty filling their residency positions...

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May 1, 2010 | Commentary 

MacPLUS Federated Search: A New Era Tool for Evidence-Informed Clinical Decision Making

Oksana Hlyva, MSc, PhD, Chris Cotoi, MEng, MBA, Nicholas Hobson, Dipl T, Rick Parrish, Dipl T, Dawn Jedras, BA, Nancy Wilczynski, PhD, Anthony J. Levinson, MD, MSc, R. Brian Haynes, MD, PhD

INTRODUCTION

With two million biomedical research articles published annually, a clinician reading two articles daily would be 55 centuries behind each year. More recently, it has been recognized that the evidence base for clinical effectiveness has become so vast that it is fundamentally unmanageable for individual providers. Some research indicates that the ineffective employment of this evidence base via electronic information resources may lead physicians to change an initially correct answer to a wrong one. A decade ago, the Institute of Medicine’s To Err is Human identified medical errors as the fifth leading cause...

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May 1, 2010 | Clincal Quiz 

What Are These ECG Diagnoses?

Lucy Lu

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