The harvesting of a local bone graft from the lumber vertebral body adjacent to an anterior interbody fusion was suggested, to avoid secondary morbidity associated with iliac bone harvest. Instrumentation using a cannulated core drill was developed and assessed in an anatomic safety study. The biomechanical implications of plug removal were assessed in single vertebra and multisegment models. Plug removal using the tools developed was considered safe. The removal of a cylinder bone plug from the vertebral body affected flexion/compression load significantly. The yield strength of the vertebra could be restored effectively using the filler materials studied.

Regular use of the emergency department is associated with a patient's inability to identify a regular primary care physician. Continuity of the physician-patient relationship is largely determined by patient satisfaction, which in turn is influenced by the physician's communication and interpersonal skills. The objective of this study was to estimate the relationship between the communication competency of newly licensed family physicians and the ambulatory health care utilization behaviour of their regular emergency department users. It was hypothesized that physicians with higher levels of competency in patient communication would be the providers of a greater proportion of their patients' ambulatory care than physicians with poorer communication abilities. Consequently, these patients would rely on the emergency department for a smaller proportion of their ambulatory care than patients of physicians with lower levels of communication competency. / In total, 474 newly licensed family physicians and 42 113 regular ED user patients were included in the study population. Analysis was conducted at the level of the physician and patients were attributed to the practice populations of the first study physician they saw. (Abstract shortened by UMI.)

Transplantation of the small intestine is technically feasible, and the only potentially curative method for patients with short gut syndrome. However this procedure is still infrequent, partially because there is still no reliable method to preserve the small bowel (SB) for a reasonable period of time between removal from the donor and transplantation. In search of a suitable medium for SB preservation, we evaluated different solutions which have been successfully used for preservation of other human organs (Eurocollins (EC), University of Wisconsin (UW) and lactated Ringer's (LR)) and tried to improve their effectiveness by adding superoxide dismutase and catalase or verapamil. The adequacy of preservation was assessed by evaluating the physiological properties of the intestine in vitro, using either the rat syngeneic model of intestinal transplantation, or human intestine obtained from organ donors. / LR is a simple, inexpensive and universally available solution, and when supplemented with verapamil, it was as effective as the more complex EC and UW as a protectant against ischemic damage during cold storage of rat ileum. Studies on human intestine validated the rat as an experimental model since the relative effectiveness of the different solutions was similar, however, the human bowel appeared more vulnerable to ischemic and mechanical damage. The results indicate that creation of an effective preservation solution for the small intestine should be possible through appropriate modification of currently available preparations.

Biomedicine evolved from art to science. Based on the science, biomedicine built its culture. The scientific biomedical culture cannot cope with individual needs expressed during a consultation. The doctor-patient relationship, more than a simple encounter where biomedicine can flex its muscles against a disease, is the expected moment where the patient's illness will be alleviated. The scientific construct "disease" has no correlation with the social construct "illness". Doctor and patient are, therefore, not in opposing fields but in different universes. It is time for a paradigm shift.

The Surgery Collagen Incontinence Trial (SCIT) is a randomized controlled trial evaluating the comparative efficacy of surgery versus collagen injection to treat female stress urinary incontinence (SUI). This thesis investigated two issues from SCIT: (1) the trial investigators' use of a consensus estimate that assumed collagen would be preferred as a first line treatment if it was at most 20% less efficacious than surgery; and (2) the cost-effectiveness of surgery and collagen. / A physician survey was conducted to help verify the SCIT investigators' consensus estimate. Respondents on average believed surgery was more efficacious than collagen, and they generally had stronger beliefs in the ability of surgery to meet their requirements for remaining the first line treatment for SUI. However, on average, respondents indicated a willingness to use collagen if it was at most approximately 23% less efficacious than surgery. The survey also provided baseline data for future research into how SCIT's results may or may not play a role in changing the views of clinicians. / The cost-effectiveness analysis was based on a risk-benefit model (decision-tree) that delineated the success rates, side-effects and complication rates of both surgery and collagen. Probabilities from the physician survey and the published literature were used in the model. Collagen was found to be less costly than surgery, but also less efficacious. Until more is known about collagen's long-term durability, the injection material will probably not gain coverage under Canada's provincial health insurance plans.

Angiogenesis is essential for reproduction, inflammation, development and wound repair. During these physiological processes, angiogenesis is tightly regulated. However, many pathological diseases, such as tumor growth and metastases, are driven by persistent deregulated angiogenesis. The integrin vitronectin receptor alphavbeta3 has been shown to mediate endothelial cell migration and proliferation and thus, plays a key role in angiogenesis. In the present study, the effect of alphav antisense phosphorothioate oligodeoxynucleotides (ODN) on alphavbeta3 expression, and on cellular migration and proliferation was assessed using human umbilical vein endothelial cells (HUVEC). We found that alphav antisense phosphorothioate ODN reduced alphavbeta3expression in some endothelial cell cultures and this resulted in a dose-dependent decrease in endothelial cell migration and proliferation. These results suggest that alpha v antisense phosphorothioate ODN could potentially be used as a novel class of angiogenesis inhibitors.

Objectives. (1) To measure the responsiveness of SLAM-R and SLEDAI to meaningful changes in SLE activity; (2) to determine how strongly activity in specific organ systems affects SLAM-R and SLEDAI responsiveness. / Methods. A secondary analysis was performed on blinded data of SLE patients. Sensitivity of SLAM-R and SLEDAI to change were assessed with traditional measures. Also, perceived change in disease activity was modelled as a function of change in overall instrument scores, and of change in organ system subscores. / Results. Both SLAM-R and SLEDAI were responsive to changes perceived by physicians. However, only SLAM-R was sensitive to changes reported by patients. The relevance of type of organ involvement depended on whether the assessor was the patient or the physician. / Conclusion. The differences between the type of change relevant to physicians and patients may account for SLAM-R's better ability to reflect patients' judgments.

We used decision analysis to determine the factors that influence the decision of whether or not to extubate and to evaluate the usefulness of testing with the RR/Vt ratio. A questionnaire was also distributed to experienced critical care specialists. We showed that the rate of improvement in the patient condition had the greatest influence on the decision to extubate. When the rate of improvement was high, the best decision was to continue with mechanical ventilation unless the probability of tolerating extubation was greater than 0.95. However, when there was little or no chance of further improvement with ongoing mechanical ventilation, the best decision was always to extubate. These results appeared to be counter-intuitive to experienced clinicians who were more likely to extubate when patients were improving and less likely when patients were stable. Testing with the RR/Vt ratio was of little benefit when deciding to extubate.

Background. Septic patients produce increased nitric oxide (NO). We postulated increased exhaled nitric oxide (exNO) in SIRS after cardiopulmonary bypass surgery (CPB). / Methods. Forty-two intubated patients were studied postoperatively and at two-hour intervals for eight hours or until extubated. Hemodynamic indices, including indexed systemic vascular resistance (SVRi) and cardiac index (CI) were measured. ExNO was analyzed by ozone chemiluminescence. / Results. Six patients (14%) Manifested SIRS, defined as SVRI <1800 dynes&middot;sec/cm5/m2. ExNO indexed by expired volume of minute ventilation and body surface area (exNO&middot; V&dot;Ei) was less in SIRS patients at each interval. Overall, normal exNO&middot;V&dot;Ei was 4.3 +/- 0.4 nL/min/m2 with a Cl of 2.56 +/- 0.05 L/min/m 2 and an SVRI of 2488 +/- 62 dynes&middot;sec/cm5/m 2, whereas in SIRS exNO&middot;V&dot;Ei was 0.7 +/- 0.3 (p < 0.001) with a Cl of 2.97 +/- 0.09 (p < 0.001) and an SVRi of 1826 +/- 86 (p < 0.001). / Conclusions. Pulmonary production of NO in post-CPB SIRS differs from sepsis and may not be reflective of systemic levels. Increased pulmonary blood flow may scavenge lung production of NO thereby decreasing exhaled levels.

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