This research used human factors methods to investigate the relationship between no fault found (NFF) incident frequency and device usability. NFF reporting occurs when a medical device sent for repair is found to be operating normally. NFF incidents are one of the most recurrent failure modes, and therefore have considerable impact on cost, dependability and safety. An analysis of medical equipment maintenance data was conducted and six devices with a high NFF reporting frequency were identified. Semi-structured interviews and heuristics evaluations revealed that usability issues likely caused many of the NFF incidents. Other factors suspected to contribute to increased NFF reporting include accessory issues, intermittent faults and environmental issues. Finally, in order to validate the results, usability testing was conducted on three of the devices. 23 usability-related design flaws were identified. Therefore devices containing latent usability-related design flaws can be identified through analysis of medical equipment maintenance data.

Objective: determine whether accreditation through Accreditation Canada is associated with more favorable resident safety in Ontario LTC homes and which facility characteristics are predictive of accreditation. Methods: logistic regression was used to determine predictors of accreditation. To examine the association between accreditation and safety, safety was operationalized as five MDS-RAI quality indicators: prevalence of falls, restraints, catheters, pressure ulcers, and infections. Separate multivariable models were developed for each indicator. Results: the odds of accreditation were approximately six times smaller for municipal (p < 0.001) and non-profit facilities (p < 0.001) relative to for-profits; three times greater for chains relative to non-chains (p < 0.001); and twice as large for urban relative to rural facilities (p = 0.04). Of the five quality indicators examined, only one (falls) was associated with accreditation. After adjusting for confounders, accredited homes were estimated to have 8% lower fall rates than non-accredited homes (p = 0.01).

Although androgens are known to exert anabolic effects in skeletal muscle, overexpression of androgen receptor (AR) selectively in this tissue causes androgen dependent motor deficits and muscular atrophy. The cellular and subcellular changes underlying this phenotype are unknown. Therefore, this study aimed to elucidate the ultrastructural and histologic changes accompanying myopathy and to determine the importance of androgens and overexpression level for myopathic features. Transmission electron microscopy revealed augmented mitochondrial content and reduced myofibril width in androgen exposed transgenics. Additionally, male transgenics demonstrated increased glycogen content. Histochemical analyses confirmed sex-specific changes in glycogen content and revealed a surprising loss in the proportion of oxidative fibers in symptomatic animals. However, increased mitochondrial content was confirmed by the presence of ragged red fibers. Overexpression of AR in muscle fiber results in mitochondrial pathology and dysregulation of glycogen metabolism, possibly reflecting normal but exaggerated function of androgens in skeletal muscle fibers.

Many healthcare providers are at risk of compassion fatigue and burnout from prolonged occupational stress, which can adversely affect workers, patients, and the healthcare system. This qualitative research project inquired into eight female healthcare providers’ experiences of sustaining their own wellbeing. Participants (27 to 60 years old) engaged in semi-structured interviews and participant observation of a self-care activity. Themes were found relating to the variety of self-care strategies used, challenges and supports in the work context, and the important role of authenticity in health promotion practice. Self-care strategies included: social support, pacing, taking breaks, exercise, nutrition, emotional self-care, adapting self-care routines over time, goal setting and prioritization. Supports to wellbeing included: flexible scheduling, taking personal responsibility for wellness, workplace wellness programs, and positive relationships with supervisors, colleagues, friends and family. This arts-informed research project is presented in graphic novel form to enhance its accessibility.

Communication of hospital discharge instructions between patient and provider is an important component of hospital discharge to ensure that patients have the information they need to manage their post-acute care. Patient perception of this interaction is a key indicator of the quality of services provided. This study examined whether there is a correlation between hospital continuity and transition scores (a measure of patient perceptions of hospital discharge instructions) and hospital readmissions in Ontario. The final regression model for the outcome of all medical readmissions within three days of hospital discharge, showed a significant positive relationship (coefficient=0.0090, p=0.011). The estimate was smaller and not significant once the data was restricted to only community hospitals located outside of Toronto (coefficient=0.0085, p=0.060), and when restricted to urban community hospitals outside of Toronto (coefficient=0.0041, p=0.384). For the outcome of specific medical readmissions within 28 days of hospital discharge, no statistically significant relationship was found.

Programs that use the arts to engage older people promote health, foster community, and give voice and legacy to participants. Creative practice in health care settings facilitates emotional, mental, and physical wellness for participants and staff, while improving the culture of care. Yet there is resistance to arts-in-medicine as a legitimate tool of health care. The predominant biomedical paradigm privileges quantitative assessment methods over qualitative studies which may accept anecdotal, arts-informed, or “common sense” evidence. Successful creative programs face challenges translating their benefits when evaluated inappropriately. This arts-informed inquiry uses creative writing to address multiple dimensions of knowing, integrating autoethnographical insights from work as a caregiver, artist, educator, and administrator of collaborative art. Serendipity and imagination in research were employed to explore how collaborating artists can facilitate creative engagement for elders, embodying preventative, community-based medicine to successfully address and transform myriad challenges and opportunities as the population continues to age.

This research used human factors methods to investigate the relationship between no fault found (NFF) incident frequency and device usability. NFF reporting occurs when a medical device sent for repair is found to be operating normally. NFF incidents are one of the most recurrent failure modes, and therefore have considerable impact on cost, dependability and safety. An analysis of medical equipment maintenance data was conducted and six devices with a high NFF reporting frequency were identified. Semi-structured interviews and heuristics evaluations revealed that usability issues likely caused many of the NFF incidents. Other factors suspected to contribute to increased NFF reporting include accessory issues, intermittent faults and environmental issues. Finally, in order to validate the results, usability testing was conducted on three of the devices. 23 usability-related design flaws were identified. Therefore devices containing latent usability-related design flaws can be identified through analysis of medical equipment maintenance data.

Acute demyelination in children may be a monophasic illness or the sentinel attack of multiple sclerosis (MS) – a chronic inflammatory neurodegenerative demyelinating disease. MS risk is largely determined during childhood and vitamin D may protect against MS. The primary objective of this thesis was to evaluate vitamin D status in children presenting with acute demyelinating syndromes (ADS) as a potential contributor to MS outcome. The LIAISON “25 OH Vitamin D TOTAL” assay was validated to assess the biomarker of vitamin D status – serum 25-hydroxyvitamin D (25(OH)D) concentrations. Consecutive patients (<16 y) were enrolled at presentation with ADS and prospectively evaluated at 23 Canadian centres. MS was defined by a second clinical demyelinating event or by MRI evidence of new lesions over time. Cox proportional hazards regression models assessed risk of MS outcome as a function of serum 25(OH)D tertiles, accounting for factors associated with either MS risk or vitamin D status – age, sex, season, and HLA-DRB1*15 status. Of 211 children with 25(OH)D measured in sera obtained a median of 9 days from onset (interquartile range, 5 – 17 d; maximum 36 days), 20% (n = 41) were diagnosed with MS after 3.7 mos. (3.1 – 7.3 mos.). Risk of MS was lower in children with 25(OH)D levels in the highest tertile (≥ 74 nmol/L) at ADS versus those in the lowest tertile (<50 nmol/L) (HR 0.41; 95% CI 0.18 to 0.97, adjusted model). Children with higher circulating 25(OH)D concentrations at ADS have a lower risk of MS. Further evidence for a role of vitamin D insufficiency during childhood and adolescence contributing to MS risk comes from three MS patients with suboptimally managed pseudo-vitamin D deficiency rickets. Finally, a sun exposure questionnaire was validated in the latter part of this thesis for use in future research into determinants of vitamin D status and their association with risk of MS.

This qualitative research study examined the patient education experience from the point of view of health care professionals, namely doctors of chiropractic in the Greater Toronto Area practicing for up to ten years. Health care professionals’ views and beliefs of this important aspect of health care have not been well studied. Patient education is defined as, “the process by which patients learn or acquire knowledge about his/her health status or condition and may involve learning in the cognitive, affective, and/or psychomotor domains.” The study explored eight participants’ views on the nature of patient education in their early and current practices by examining their feelings, beliefs, and use of patient education, its role in their practices, as well as the perceptions of their roles as patient educators. Two semi-structured interviews were conducted with each of the participants. The transcribed interviews underwent detailed qualitative analysis to determine response trends and consensus. The key findings revealed that the participants felt that, while they were well prepared in their undergraduate curricula to diagnose and treat patients, they were not as well prepared to be effective patient educators when they entered practice. Early in their careers, they did not understand or appreciate patient education’s importance and value as a component of their practice. Over time, their beliefs and understanding of patient education changed and participants reported that with experience, they began to value patient education to a greater extent. Changing values reflected changing behaviours. For example, participants increased their time and efforts related to patient education with increased clinical experience. A variety of teaching aids were used with wall charts/posters, three dimensional anatomical models, printed materials and images from textbooks being among the most common. Most of the teaching described by the participants would be characterized as transmission with a one-way flow of information from the doctor to the patient. To a great extent, patient education involved speaking with individual patients. Participants reported encountering, throughout their careers, intrinsic and extrinsic barriers that interfered with the effectiveness of their patient education. The findings suggest that curricular planners for health care professional programs, and specifically for chiropractors, might consider developing content aimed at improving students’ patient education knowledge and skills.

Des décisions médicales en fin de vie sont souvent prises pour des patients inaptes. Nous avons souhaité connaître les argumentations éthiques entourant ces décisions difficiles. Notre objectif était de pouvoir comprendre et apprécier ces lignes d’argumentation. Pour atteindre cet objectif, nous avons répertorié et analysé les lignes argumentatives présentes dans des articles scientifiques, incluant les sections de correspondance et commentaires des journaux savants. Afin d’éviter que les résultats de notre analyse soient trop influencés par les caractéristiques d’un problème médical spécifique, nous avons décidé d’analyser des situations cliniques distinctes. Les sujets spécifiques étudiés sont la non-initiation du traitement antibiotique chez des patients déments souffrant de pneumonie, et l’euthanasie de nouveau-nés lourdement hypothéqués selon le protocole de Groningen. Notre analyse des lignes d’argumentation répertoriées à partir des débats entourant ces sujets spécifiques a révélé des caractéristiques communes. D’abord, les arguments avancés avaient une forte tendance à viser la normativité. Ensuite, les lignes d’argumentation répertoriées étaient principalement axées sur les patients inaptes et excluaient largement les intérêts d’autrui. Nous n’avons trouvé aucune des lignes d’argumentation à visée normative répertoriés concluante. De plus, nous avons trouvé que l’exclusion catégorique d’arguments visant l’intérêt d’autrui des considérations entrainait l’impossibilité d’ évaluer leur validité et de les exclure définitivement de l’argumentaire. Leur présence non-explicite et cachée dans les raisonnements motivant les décisions ne pouvait alors pas être exclue non plus. Pour mieux mettre en relief ces conclusions, nous avons rédigé un commentaire inspiré par les argumentaires avancés dans le contexte de l’arrêt de traitement de Terri Schiavo, patiente en état végétatif persistant. Nous pensons que l’utilisation d’un argumentaire qui viserait davantage à rendre les actions intelligibles, et sans visée normative immédiate, pourrait contribuer à une meilleure compréhension réciproque des participants au débat. Une telle argumentation nous semble aussi mieux adaptée à la complexité et l’unicité de chaque cas. Nous pensons qu’elle pourrait mieux décrire les motivations de tous les acteurs participant à la décision, et ainsi contribuer à une plus grande transparence. Cette transparence pourrait renforcer la confiance dans l’authenticité du débat, et ainsi contribuer à une meilleure légitimation de pratiques cliniques. / Medical decision making is often occurring at the end of life of inapt patients. We wished to learn about and appreciate the ethical arguments concerning these difficult decisions. Our objective was to understand and evaluate these lines of argument. To reach this objective, we have listed and analyzed lines of argument as they were presented in scientific articles, including the sections correspondence and commentary of scholarly journals. In order to avoid that our results are too much influenced by the specifics of one given clinical problem, we decided to analyze distinct clinical settings. The specific subjects studied are the non-initiation of antibiotic treatment for demented patients suffering from pneumonia, and active euthanasia of severely affected newborns following the Groningen protocol. Our analysis of the indexed lines of arguments from debates dealing with these specific subjects has revealed common characteristics. First, the issued argumentations had a strong normative tendency. Second, the indexed argumentation was principally oriented towards the patient himself, while largely excluding the interests of others. We found that none of the indexed normative lines of argument was compelling. Moreover, we found that the systematic exclusion of arguments based on the interests of others entailed the impossibility to evaluate them, and potentially to exclude them definitively from the considerations. It was thus also impossible to evaluate their potentially concealed persistence as a driving force motivating the decisions made. In order to illuminate these conclusions, we have written a commentary inspired by the lines of arguments evoked in the context of the treatment withdrawal of Terri Schiavo, a patient in persistently vegetative state. We believe that the use of lines of argument that render decisions intelligible, without however aiming at immediate normativity, could contribute to a better mutual understanding between the participants of such debates. Such argumentation also seems, in our opinion, more adapted to take the complexity and uniqueness of each single clinical case into account. We believe that such argumentation could better describe the respective motivations of the participants in the decision, and thus increase its transparency. Increased transparency would reinforce the confidence in the authenticity of the debate, and thus better legitimate clinical practice.