Background. Patients facing open-heart surgery have the choice of donating their own blood prior to surgery for their later use (pre-operative autologous donation), or accepting volunteer-donated (allogeneic) blood. A decision aid, consisting of an audiotape and a booklet, was developed to assist patients to make this decision. It defined "blood transfusion", and clarified its role in heart surgery. Non-transfusion alternatives were listed. It described the two transfusion options, their risks and benefits and gave probabilities of complications. A summary chart allowed the patients to compare the pros and cons of each method. Objectives. (1) To evaluate the decision aid's effect on specific outcomes. (2) To evaluate the decision aid's acceptability to heart surgery patients. (3) To assess the importance of others' opinions in making the decision to pre-donate blood before heart surgery. Design. Before-after trial. Setting. Outpatient surgery clinics, Ottawa Heart Institute, University of Ottawa. Participants. A consecutive series of 70 patients who were to have open-heart surgery in the future. Patents were English-speaking and were potential candidates for autologous blood donation. Measurements. Knowledge, values (importance ratings), preference for transfusion method, decisional conflict and risk perception were measured before and after the decision aid was used. Decision aid acceptability and importance of opinions of others were measured after the decision aid.

Abstract not available.

Objective. Two large randomized trials that compared elective EndoVascular Aneurysm Repair (EVAR) with open repair for non-ruptured abdominal aortic aneurysms (AAA) have demonstrated similar long-term mortality rates but increased costs associated with EVAR. Despite these data, the use of EVAR continues to increase in North America. There are currently very limited population-based adjusted data looking at long-term outcomes and resource utilization. Methods. All patients who underwent elective AAA repair between April 2002 and March 2007 in Ontario were identified using data from hospital discharge abstracts. ICD-10-CA and Canadian Classification of health Interventions (CCI) codes were used in a validated algorithm to identify patients who underwent either EVAR or open repair of non-ruptured AAAs. Pre-operative co-morbidities were measured using the Charlson co-morbidity index. Risk stratification into quintiles was performed using propensity score analysis. Results. Overall, 6461 patients underwent treatment of non-ruptured AAAs (N: EVAR 888; open 5573). Patients undergoing EVAR were older and had more comorbidities. The adjusted 30-day mortality was significantly lower in the EVAR group (adjusted OR= 0.34 [0.20-0.59]). The adjusted all-cause long-term mortality was similar in both groups (OR= 0.95 [0.81-1.05]). After adjustment for significant confounders, rates of imaging studies and both urgent and vascular readmissions were statistically higher in the EVAR group. However, the EVAR group had significantly shorter length of stay for the index hospitalization, all subsequent hospitalizations, and the intensive care unit. Discharge to a nursing home or other chronic care facility after the index procedure was also lower in the EVAR group (OR= 0.55 [0.41-0.0.74]). The durability of the repair of EVAR vs. open techniques as indicated by the rate of repeat interventions following the index procedure for EVAR (OR= 1.3 [0.98-1.75]) did not reach statistical significance. Conclusion. After adjusting for pre-operative risk factors, there was no difference in long-term mortality between EVAR and open repair in Ontario. The significantly lower 30-day mortality rate in EVAR patients was not sustained over longer-term follow-up. Although the utilization of imaging studies and hospitalizations was significantly higher in the EVAR group, patients undergoing open repair spent more days in hospital (including readmissions), more time in ICU, and were more likely discharged to a chronic care facility.

The objectives of the thesis were to determine the prevalence of functional capacity outcome measure use among physiotherapists working with post-operative cardiac surgery clients and to develop evidence-based recommendations regarding their use in clinical practice. The thesis consisted of a systematic review of the literature; a survey of outcome measure use in clinical practice; and the development of a clinical practice guideline. Thirty-one functional capacity outcome measures were included in the review. Only 2.6% of survey respondents reported almost always using outcome measures in their clinical practice. The Six Minute Walk Test, the modified Borg Rating Scale of Perceived Exertion and vital signs were recommended for routine use in clinical practice. A variety of outcome measures are available for use in clinical practice however their use in clinical practice continues to be less than optimal. There is a need for continued training in outcome measure use in clinical practice.

Objectives: 1) To identify laparoscopic colorectal surgery practice patterns in Canada, 2) To systematically review the literature comparing hand assisted laparoscopic surgery to conventional laparoscopic surgery and 3) To design a randomized controlled trial protocol comparing conventional laparoscopic to hand assisted laparoscopic colorectal resections. Methods: A national cross sectional study was undertaken of Canadian General Surgeons with respect to their practice patterns specific to laparoscopic colorectal surgery. A systematic review comparing Conventional laparoscopic to Hand-Assisted Laparoscopic colorectal resections. A randomized controlled trial protocol with methodological discussions regarding issues in surgical trials was written. Results: The majority of Canadian General Surgeons are offering laparoscopic colorectal resections although the volume per surgeon appears to be low. The main barriers to adoption are operating time and lack of formal minimally invasive surgery training. There were two trials identified for inclusion in the systematic review with a total of 94 subjects with some methodological weaknesses. A potential trend towards decreased conversion to open surgery in the hand assisted group was identified. A protocol is presented for a trial comparing hand assisted to conventional laparoscopic colorectal surgery. Conclusion: A large percentage of Canadian surgeons perform laparoscopic colorectal resections although many perform less than one case per month. The limited number of trials performed and their associated methodological weaknesses and heterogeneity does not allow a reliable assessment of the relative benefits of hand-assisted and conventional laparoscopic resections for colorectal disease. Additional adequately powered and methodologically sound trials are needed to determine if there is a clinically important difference in perioperative outcomes.

<p> This dissertation provides an ethical justification of surgical weight loss interventions for the treatment of obesity. Situating obesity as not merely a public health concern but also fundamentally a problem of clinical medicine confronting individual patients and physicians, the dissertation argues that the time frame of public health interventions is too long for individuals presently facing obesity and its deleterious physical and social co-morbidities. It argues that failure to address weight loss on an individual level, and specifically to consider the clinical appropriateness of weight loss surgery (WLS), raises serious questions about failure to respect autonomy and promote patient welfare. Moreover, social skepticism or rejection of WLS as a treatment option raises concerns about fairness, as this failure indicates that obesity is not regarded in relevantly similar ways to other life-threatening and health-impairing conditions. </p><p> The dissertation examines various reasons that obesity and its myriad interventions, including WLS, are inadequately addressed in the clinical setting. It argues that considerations with cultural and ethical valence play a critical role in obesity's different and unfair treatment within clinical medicine. Gendered and theologically informed attributions of blame, self-blame, shame, and self-stigma influence the attitudes and actions of both patients and clinicians with regard to addressing obesity. Inappropriate and conceptually confused ascriptions of responsibility impede social acceptance of, and access to, WLS. The dissertation's criticism and subsequent reconceptualization of these ascriptions of responsibility from a perspective informed by feminist epistemology and ethics provide the foundation upon which to consider reform of current clinical practices surrounding treatment of obesity. This dissertation concludes that WLS is both ethically and clinically justified.</p>

Allogeneic Hematopoietic Stem Cell Transplantation is applied in the management of cancer. It involves myeloablative chemoradiotherapy followed by infusion of donor stem cells. The characteristics of the donor stern cells influences transplant outcomes which itself, is dependent on the donor characteristics. The purpose of this thesis was to explore preferences over donor characteristics. A systematic review was performed to identify all donor characteristics associated with outcome. Eight traditional and 5 non-traditional characteristics were identified. The results of the review were used to inform a survey of the Canadian Bone Marrow Transplant Group which primarily includes transplant physicians. An online survey and conjoint analysis of Canadian Bone Marrow Transplant Group members was performed to define relative importance of donor characteristics. Canadian Bone Marrow Transplant Group members, including transplant physicians caring for adults strongly indicate preference for donors related to recipients (HR 2.97) over the donor's age, gender and cytomegalovirus compatibility.

<p> Objective: Under-reporting of surgical errors inhibits development of knowledge and strategies that can lead to lower error rates. Mandatory error reporting programs have proliferated among states as one means of reducing the incidence of errors. Evidence suggests that errors are under-reported. Little is known of the perceptions of states regarding the risk of under-reporting, their responses to it and the ways they use reported data to improve patient safety. A qualitative study was conducted to assess the perceptions of state managers regarding the risk of under-reporting and the role of enforcement, analysis and feedback in current and ideal error reporting programs. </p><p> Methods: 24 state medical error reporting programs were surveyed for characteristics and perceptions of surgical error reporting compliance. A key informant sample of 11 states explored perceptions of barriers and facilitators to reporting, and current and ideal strategies for enforcement and data use. Qualitative data were coded for themes and key findings. A plan for change responds to the conclusions. </p><p> Results: 52% of states had discovered surgical errors through means other than required reporting by health care institutions. 76% of states reported that it was impossible to know whether all required reports were made. Some managers did not have adequate resources to enforce reporting, analyze data or engage the health care industry to improve patient safety. State managers understood most of the same reasons given by the health care industry in the literature for failure to report, except lack of program usefulness and feedback. Most managers valued using error data analysis in collaboration with the health care industry to reduce the incidence of surgical errors, but only 37.5% of states use data this way. </p><p> Conclusion: Most state managers do not know whether their programs receive all required surgical error reports, and most do not have the resources to use data the way they would like to. Managers did not understand lack of program value and feedback as an important barrier. A plan for change provides education to states and recommendations that include standardization of reporting requirements, data sharing, and new requirements for error reporting.</p>

<p>The research question answered by this qualitative, narrative design study is how some couples maintained continued marital intimacy and well-being after prostate cancer surgery. It was directed to a purposeful, critical, and criterion based sampling of 5 heterosexual participant couples between the ages of 52 and 65 years old, who had been married for an average of 29 years and who experienced the disruption in their marriage of prostate cancer and its surgical remedy. The research question created a frame for evaluating literature which provided a basic understanding of the physiology associated with prostate cancer and its treatment options, while recognizing and giving appropriate voice through semi-structured interviews to the compromising and potentially traumatic effects of that surgery on couples&rsquo; relationships. In addition to the stresses introduced by a prostate cancer diagnosis, a complexity of emotional and physical concerns is realized with existing treatments, often leading to difficult adjustments and long-term consequences. Although extensive volumes of research attest to the vexing interruption to marital intimacy after prostate cancer surgery, there is a lack of direct, narrative inquiry from long-term married couples addressing instead the question of how they prevailed over those profound challenges. This study subsequently positioned itself to the telling of the participants&rsquo; stories, before and after surgery, and to the positive inquiry of how they learned from their lived experiences and demonstrated that learning as resilience, resourcefulness, and a determination to maintain a mutually acceptable level of intimacy and well-being in their enduring marriages. Attributes of a fulfilling marriage were also explored as characterizing a committed and happy long-term relationship which supports wellness of mind, body, and spirit. In addition, inquiry was made into the transpersonal aspects and significance of marital well-being and shared practices which help to sustain it. </p>

<p> This study is a qualitative exploration of the lived experience of five active Canadian women from 40-70 years of age who underwent a first time total hip replacement (THR). The extensive literature search drew out numerous issues related to recovery, which were categorized under operative factors, social factors, and personal factors. Aware that the vast majority of studies evaluating the preparation and recovery from a total hip replacement had used scales, clinical scoring systems, health measures, and patient satisfaction ratings (Bayley, et al., 1995; Siggeirsdottir, et al., 2005, Yoon et al., 2010), the author sought a method to allow the patient's voice to come through (Lane-Carlson, 2011). </p><p> The grounded theory approach allowed concepts to emerge from the experiential data, which included in-depth individual interviews, participant journals, field observations, and researcher reflective notes. Data were gathered approximately one week pre and four weeks post surgery, followed by a group interview when analysis was nearly completed. Analysis utilized coding, categorizing and thematic conceptualization. Results conceptualized two patterns, one described three major components which supported the patient in recovery: The character qualities of the patient, the personal support system and the medical system, while the other examined the reality of the experiential process though which the patient passed i.e. pain and loss, delay, decision, confusion, preparation, delivery and reclaiming self along with posttraumatic growth. The author considered a variety of perspectives emerging from the data, one of the most vexing ones being uneven leg lengths, a complication of THR requiring more research in order to assure leg length equality after THR. Another influential discovery was the benefit of a participant group meeting after the recovery, and participants felt this should be pursued. A significant contribution was the age-range of this group, which embraced the Baby Boomers, and the implications concomitant with that. This process suggested a unique metaphor of a woman having her first baby. Hence the substantive grounded theory offered was "Rebirth, Regaining a Level Playing Field."</p>