Introduction: The recruitment and retention of family physicians in rural and remote communities has been the topic of many reviews; however, a lack of consensus among them with regard to which factors are most influential makes it difficult for setting priorities. We performed a systematic review of reviews which helped to establish an overall conclusion and provided a set of fundamental influential factors, regardless of the consistency or generalisability of the findings across reviews. This review also identified the knowledge gaps and areas of priority for future research.Methods: A literature search was conducted to find the review articles discussing the factors of recruitment or retention of rural family physicians. Results were screened by two independent reviewers. The number of times that each factor was mentioned in the literature was counted and ordered in terms of frequency.Results: The literature search identified 84 systematic reviews. Fourteen met the inclusion criteria, from which 158 specific factors were identified and summarised into 11 categories: personal, health, family, training, practice, work, professional, pay, community, regional and system/legislation. The three categories referenced most often were training, personal and practice. The specific individual factors mentioned most often in the literature were 'medical school characteristics', 'longitudinal rural training' and 'raised in a small town'.Conclusion: The three most often cited categories resemble three distinct phases of a family physician's life: pre-medical school, medical school and post-medical school. To increase the number of physicians who choose to work in rural practice, strategies must encompass and promote continuity across all three of these phases. The results of this systematic review will allow for the identification of areas of priority that require further attention to develop appropriate strategies to improve the number of family physicians working in rural and remote locations.

INTRODUCTION:Developing a comprehensive cohort of people living with HIV (PLHIV) to help improve healthcare has long been the vision of researchers, clinicians and decision makers. The development of this kind of database is challenging and requires strict adherence to privacy and confidentiality policies. We explored procedures, activities and events in database development.OBJECTIVES:To understand processes of developing a database with sensitive health information in Newfoundland and Labrador (NL), and to investigate procedures and activities to develop the database within its environmental context.METHODS:A narrative case study was used to explain the challenges and procedures involved in developing a database for our population. The development of the PLHIV cohort in NL is provided as an example to demonstrate the complexity of the process. We linked three datasets that included patient-level data for PLHIV: 1. laboratory data; 2. HIV clinic data; 3. health administrative data, which allowed for the creation of a large database containing many variables describing the PLHIV cohort in the province.RESULTS:We developed a de-identified cohort of 251 PLHIV that contained 178 variables. Our case study showed database development is an iterative process. The main challenges were ensuring patient privacy and data confidentiality are not compromised and working with multi-custodian data. These challenges were addressed by establishing a data governance team.CONCLUSIONS:It is important that policy be implemented to merge siloed data sources in order to provide researchers with accurate and complete data that is required to conduct sound and precise research with maximum benefits for treatment and policy-making to improve health outcomes.

Background: HIV care that has been predominantly specialty based can often be managed in primary care settings. The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) database is a rich source of electronic medical records of primary care practices. A case definition for HIV using CPCSSN allows the examination of epidemiology and healthcare utilization of people living with HIV (PLHIV) whose records are in this database and assists us to better understand the primary care of PLHIV. The objective of this study was to develop a case definition for HIV applicable to the CPCSSN database. Methods: Electronic medical record data from CPCSSN was used to develop a retrospective cohort between 2009 and 2017. We identified all possible records of PLHIV in the CPCSSN dataset based on the presence of HIV codes, keywords and medications. Multiple combination of codes, keywords and medications were analyzed to see which resulted in the most accurate definition of PLHIV. To assess the validity, we linked the data to external references (a Newfoundland and Labrador (NL) PLHIV cohort and Nine Circles HIV clinic in Manitoba) and an internal reference (a random sample of the CPCSSN database which was reviewed by two experts to confirm HIV status). Results: We found that the presence of an HIV keyword along with either an ICD code or taking 3 or more HIV medications concurrently was the most accurate algorithm for predicting PLHIV with a sensitivity of 95%, 97.9% and 88.9%, specificity of 63.5%, 100% and 100% for the NL PLHIV cohort, Nine Circles HIV clinic data and internal reference, respectively. Conclusion: To our knowledge, this is the first study to develop an algorithm for identifying people with HIV applicable to the Canadian Primary Care Sentinel Surveillance Network database. This algorithm-based case definition will support future research investigating the utilization of primary healthcare by PLHIV and facilitate improvements in primary care for PLHIV.

Introduction: Canadian emergency departments (ED) are struggling to provide timely emergency care. Very few studies have assessed attempts to improve ED patient flow in the rural context. We assessed the impact of SurgeCon, an ED patient-management protocol, on total patient visits, patients who left without being seen (LWBS), length of stay for departed patients (LOSDep), and physician initial assessment time (PIA) in a rural community hospital ED. Methods: We implemented a set of commonly used methods for increasing ED efficiency with an innovative approach over 45 months. Our intervention involved seven parts comprised of an external review, Lean training, fast track implementation, patient-centeredness approach, door-to-doctor approach, performance reporting, and an action-based surge capacity protocol. We measured key performance indicators including total patient visits (count), PIA (minutes), LWBS (percentage), and LOSDep (minutes) before and after the SurgeCon intervention. We also performed an interrupted time series (ITS) analysis. Results: During the study period, 80,709 people visited the ED. PIA decreased from 104.3 (±9.9) minutes to 42.2 (±8.1) minutes, LOSDep decreased from 199.4 (±16.8) minutes to 134.4(±14.5) minutes, and LWBS decreased from 12.1% (±2.2) to 4.6% (±1.7) despite a 25.7% increase in patient volume between pre-intervention and post-intervention stages. The ITS analysis revealed a significant level change in PIA – 19.8 minutes (p<0.01), and LWBS – 3.8% (0.02), respectively. The change over time decreased by 2.7 minutes/month (p< 0.001), 3.0 minutes/month (p<0.001) and 0.4%/month (p<0.001) for PIA, LOSDep, and LWBS, after the intervention. Conclusion: SurgeCon improved the key wait-time metrics in a rural ED in a country where average wait times continue to rise. The SurgeCon platform has the potential to improve ED efficiency in community hospitals with limited resources.

Background People living with the human immunodeficiency virus (PLHIV) have ongoing healthcare needs as HIV has become a chronic condition for those in treatment. With the success of antiretroviral (ARV) medications, AIDS-related illnesses are no longer the biggest threat to PLHIV, rather, emerging complications and ARV toxicities are of concern. For this reason, HIV care is now transitioning to primary care. To be able to assess the quality of HIV care in these settings a valid case definition is required. Our objective was to develop and validate a case definition for HIV applicable to the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) database. Methods Electronic Medical Record data from CPCSSN (exclusively primary care data) was used to develop a retrospective cohort between 2009 and 2016. We identified all possible records of HIV in the dataset based on the presence of HIV codes, keywords and ARVs. Every combination of codes, keywords and ARVs were analyzed to see which resulted in the most accurate definition of PLHIV. To assess the validity, we linked the data to a LHIV cohort (external reference standard) in Newfoundland and Labrador; and, a random sample of the CPCSSN database which was reviewed by two experts to confirm HIV status (internal reference standard). Sensitivity, specificity and predictive values were measured. Results It was determined that the presence of an HIV keyword in the EMR along with either an ICD code or taking 3 or more ARV drugs was the most accurate algorithm for predicting PLHIV. Compared to internal and external references, the algorithm showed (97.1% and 95.0% sensitivity, 100% and 80% specificity), respectively. Conclusion This is the first Canada-wide study investigating the utilization of primary healthcare by PLHIV. This case definition will contribute to future research and improvements in providing care to PLHIV in a primary care setting. Disclosure No significant relationships.

Background In Newfoundland and Labrador (NL), people living with HIV (PLHIV) primarily receive care through an interdisciplinary HIV specialty clinic, however, HIV care has been transitioning to primary healthcare elsewhere. Developing a comprehensive cohort of PLHIV to help improve healthcare has long been the vision of researchers, clinicians and decision makers. The objective of this study was to develop a de-identified cohort of PLHIV in NL, to be used to inform policy and prioritize healthcare system changes to optimize HIV healthcare in NL and to address gaps in care for PLHIV. Methods Data was collected from a number of different databases and PLHIV were identified as having HIV from three sources: 1. NL Public Health Laboratory data; 2. HIV Clinic data; 3. Medical Administration data. Results The finalized dataset included 317 people who had been diagnosed with HIV in NL as of 1994 and 251 were still alive at the end of data collection. The final database contained a total of 178 variables describing PLHIV health and health care utilization. Only 7% of PLHIV were identified by all three sources suggesting no single provincial HIV data custodian captures all those living with HIV in the province. Conclusion It is important that policy be implemented to merge siloed data sources in order to provide researchers, clinicians and decision makers with the accurate and complete data that is required to conduct sound and precise research, provide appropriate care and allocate resources to health initiatives that can improve the quality of life for PLHIV. Disclosure No significant relationships.

Background: Point of Care Ultrasound (PoCUS) is well established within emergency medicine, however, the availability of formal training for other clinical disciplines is limited. Memorial University has established a cost-efficient, multidisciplinary PoCUS training program focusing on training residents’ discipline-specific ultrasound skills. This study evaluates the skills, knowledge, and attitudes of residents who participated in the program.Methods: Analysis was conducted using a mixed-methods, sequential exploratory approach. Initially, a focus group of seven first year residents was conducted to generate themes that were used to guide development of a survey administered to residents over a two-year period.Results: Thirty residents responded to the survey (response rate 63.8%) with 53.3% meeting the training requirements for focused assessment using sonography in trauma, 43.3% for pleural effusion, 40.0% for aortic aneurysms, and 40.0% for cardiac scans. Early pregnancy assessment was the skill of least interest with 46.6% not interested. Over half the residents (53.6%) agreed or strongly agreed that a multidisciplinary program met their needs while 21.4% disagreed. The focus group found the multidisciplinary approach adequate.Conclusions: A single PoCUS curriculum has been shown to meet the needs and expectations of a majority of residents from multiple disciplines. It can enhance collaboration and bridge gaps between increasingly compartmentalized practices of medicine.

ObjectivesMethodsTelemedicine technology contributes to the teaching of point-of-care ultrasound (US); however, expensive equipment can limit its deployment in resource-challenged settings. We assessed 3 low-cost telemedicine solutions capable of supporting remote US training to determine feasibility, acceptability, and effectiveness. We also explored the value of instructional videos immediately before telementoring. Thirty-six participants were randomly assigned to receive US mentoring in 1 of 3 telemedicine conditions: multiple fixed cameras, a smartphone, and traditional audio with a live US stream. Participants were then asked to perform a standardized US examination of the right upper quadrant under remote guidance. We measured observer's global ratings of performance along with the mentor's and student's rating of effort and satisfaction to determine which of the 3 approaches was most feasible, acceptable, and effective. During the second phase, students were randomized to watch an instructional video or not before receiving remote coaching on how to complete a subxiphoid cardiac examination. Effort, satisfaction, and performance from the independent observer's and student's perspective were surveyed. ResultsConclusionsThere was no significant difference between the different telemedicine setups from the observer's perspective; however, the mentor rated the smartphone significantly worse (P=.028-.04) than other technologies. Platforms were rated equivalent from the student's perspective. No benefit was detected for watching an instructional video before the mentored task. Remote US skills can be taught equally effectively by using a variety of telemedicine technologies. Smartphones represent a viable option for US training in resource-challenged settings.

Newfoundland and Labrador (NL), the most eastern province of Canada, is characterized by a unique topography and pattern of settlement. The current population is descended from a small founding population of indigenous Innu, Inuit and Mi'kmaq and an estimated 28,000 settlers. These settlers originated from Southwest England and Southeast Ireland and came to invest and work in one of the world's richest fisheries. They settled in bays, coves and islands off the coast, in small settlements called out-ports. These isolated communities developed unusual patterns of genetic disease including an unusual prevalence of some extremely rare Hereditary Bleeding Disorders (HBD). This study was designed to document the prevalence of these rare disorders, at a snapshot in time, using our provincial HBD registry. These diagnoses were verified by reviewing the original initial diagnostic coagulation results to confirm or refute each diagnosis. When available, we also recorded the underlying mutation. Population based prevalence rates were then compared with data published from the World Federation of Hemophilia (WFH) Global Registry. The results are striking. Using the WFH data the per capita prevalence in NL of Hemophilia A, Factors V, XI, and XIII Deficiency are higher than that of mainland Canada minus Labrador by a factor of 2.89, 4.54, 5.44 and 9.22, respectively. The increased prevalence of mild Hemophilia A is explained by a founder effect of the Val 2016 Ala mutation. All the severe FXIII deficient patients are homozygotes for c.691-1 G > A mutation. These results show that NL's unique geography and population distribution led to a genetic drift that increased the prevalence of some rare factor deficiencies. This comparatively high prevalence provides a potential pool of patients for genotype/phenotype research.

DESIGN We conducted a randomized, parallel, unblinded, superiority trial of a laboratory reporting intervention designed to reduce antibiotic treatment of asymptomatic bacteriuria (ASB). METHODS Results of positive urine cultures from 110 consecutive inpatients at 2 urban acute-care hospitals were randomized to standard report (control) or modified report (intervention). The standard report included bacterial count, bacterial identification, and antibiotic susceptibility information including drug dosage and cost. The modified report stated: “This POSITIVE urine culture may represent asymptomatic bacteriuria or urinary tract infection. If urinary tract infection is suspected clinically, please call the microbiology laboratory … for identification and susceptibility results.” We used the following exclusion criteria: age <18 years, pregnancy, presence of an indwelling urinary catheter, samples from patients already on antibiotics, neutropenia, or admission to an intensive care unit. The primary efficacy outcome was the proportion of appropriate antibiotic therapy prescribed. RESULTS According to our intention-to-treat (ITT) analysis, the proportion of appropriate treatment (urinary tract infection treated plus ASB not treated) was higher in the modified arm than in the standard arm: 44 of 55 (80.0%) versus 29 of 55 (52.7%), respectively (absolute difference, −27.3%; RR, 0.42; P = .002; number needed to report for benefit, 3.7). CONCLUSIONS Modified reporting resulted in a significant reduction in inappropriate antibiotic treatment without an increase in adverse events. Safety should be further assessed in a large effectiveness trial before implementation TRIAL REGISTRATION. clinicaltrials.gov#NCT02797613 Infect Control Hosp Epidemiol 2018;814–819

Background: Antimicrobial stewardship is the promotion of responsible antimicrobial use to reduce antimicrobial resistance, antimicrobial toxicity and cost, and to reduce the incidence of nosocomial infections. Our objectives were to measure antibiotic use rate in 10 long-term care facilities (LTCF) during a 1-year period, and to determine the appropriateness of antimicrobial prescriptions. Methods: Antibiotic prescriptions from 10 long-term care facilities, between January 2015 and January 2016, were collected from a pharmacy database. A sample of500 prescriptions was randomly selected for chart review to determine the appropriateness of the prescribed antibiotic based on published guidelines. Results: We analyzed 3,148 prescriptions for 1,313 residents (2.40 prescriptions/patient/year, median duration 7 days). Antibiotic use rate was 21.16 Defined Daily Doses/1,000 patient-days/year, or 5.42 antibiotic days/1,000 patient-days/month. Of the 500 randomly selected prescriptions, 448 were analyzed for appropriateness. Mean age of included residents was 82.5 (SD 12.1 years). 288/448 (64.3%) were female, with an average activities of daily living (ADL) score of 19.3 (SD 8.5). Urinary tract infection was the most common indication for antibiotics (177/448, 39.5%), followed by lower respiratory tract infection (144/448, 32.1%) and skin and soft-tissue infection (76/448, 17.0%). 259/448 (57.8%) of prescriptions were inappropriate, including 115/163 (70.5%) given for urinary tract infection, 78/140 (55.7%) given for lower respiratory tract infection, and 15/68 (22.0%) given for skin and soft-tissue infection. Inappropriateness varied by long-term care facility (LTCF) between 18/41 (43.9%) and 15/21 (71.4%), and by drug class between 0/5 (0%) among penicillinase-resistant penicillins and 29/38 (76.3%) among macrolides. Conclusions: Antimicrobial use rate is high, and 57.8% of prescriptions are inappropriate. The least appropriate prescriptions are given for urinary tract infections. Appropriateness is highly variable by LTCF, indication, and drug class.

Commercial point-of-care (POC) diagnostic tests for Group A Streptococcus, Streptococcus pneumoniae, and influenza virus have large potential diagnostic and financial impact. Many published reports on test performance, often funded by diagnostics companies, are prone to bias. The Standards for Reporting of Diagnostic Accuracy (STARD 2015) are a protocol to encourage accurate, transparent reporting. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool evaluates risk of bias and transportability of results. We used these tools to evaluate diagnostic test accuracy studies of POC studies for three respiratory pathogens. For the 96 studies analysed, compliance was <25% for 14/34 STARD 2015 standards, and 3/7 QUADAS-2 domains showed a high risk of bias. All reports lacked reporting of at least one criterion. These biases should be considered in the interpretation of study results.

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Traditionally, rural areas in many countries are limited by a lack of access to health care due to the inherent challenges associated with recruitment and retention of healthcare professionals. Telemedicine, which uses communication technology to deliver medical services over distance, is an economical and potentially effective way to address this problem. In this research, we develop a new telepresence application using an Augmented Reality (AR) system. We explore the use of the Microsoft HoloLens to facilitate and enhance remote medical training. Intrinsic advantages of AR systems enable remote learners to perform complex medical procedures such as Point of Care Ultrasound (PoCUS) without visual interference. This research uses the HoloLens to capture the first-person view of a simulated rural emergency room (ER) through mixed reality capture (MRC) and serves as a novel telemedicine platform with remote pointing capabilities. The mentor's hand gestures are captured using a Leap Motion and virtually displayed in the AR space of the HoloLens. To explore the feasibility of the developed platform, twelve novice medical trainees were guided by a mentor through a simulated ultrasound exploration in a trauma scenario, as part of a pilot user study. The study explores the utility of the system from the trainees, mentor, and objective observers' perspectives and compares the findings to that of a more traditional multi-camera telemedicine solution. The results obtained provide valuable insight and guidance for the development of an AR-supported telemedicine platform.

AbstractMost excavated material generated from tunnelling projects ends up being deposited on land. The EU funded project “DRAGON” aims to develop technologies to analyse and characterise this material so that the potentially usable fraction can be easily separated from non‐usable material. Increasing use of this material by external industries will improve resource efficiency while reducing landfill quantities and disposal costs. One of the project goals is to assess the potential environmental benefits/costs of applying DRAGON technology to planned future EU tunnelling projects. A three stage approach has been adopted to meet this goal. Firstly, the potential for diverting material from landfill must be assessed. To account for the diversity of tunnelling projects, this will be based on an average of 54 recent tunnelling projects. Secondly, a life cycle assessment (LCA) model will be created to allow each of these tunnelling projects to be analysed and the potential benefits of using DRAGON technology will be compared against the ‘business as usual’ case. These results will then be averaged to give the expected environmental costs/benefits per t excavated material. Finally, these costs/benefits will be scaled up to account for the expected amount of material from future European tunnelling projects ‐ expected to be around 800 m. t.

Integrated circuits for wireless sensor nodes (WSNs) targeting the Internet-of-Things (IoT) paradigm require ultralow-power consumption for energy-harvesting operation and low die area for low-cost nodes. As the IoT calls for the deployment of trillions of WSNs, minimizing the carbon footprint for WSN chip manufacturing further emerges as a third target in a design-for-the-environment (DfE) perspective. The SleepWalker microcontroller is a 65-nm ultralow-voltage SoC based on the MSP430 architecture capable of delivering increased speed performances at 25 MHz for only 7 μW/MHz at 0.4 V. Its sub-mm 2 die area with low external component requirement ensures a low carbon footprint for chip manufacturing. SleepWalker incorporates an on-chip adaptive voltage scaling (AVS) system with DC/DC converter, clock generator, memories, sensor and communication interfaces, making it suited for WSN applications. An LP/GP process mix is fully exploited for minimizing the energy per cycle, with power gating to keep stand-by power at 1.7 μW. By incorporating a glitch-masking instruction cache, system power can be reduced by up to 52%. The AVS system ensures proper 25-MHz operation over process and temperature variations from -40 °C to +85 °C, with a peak efficiency of the DC/DC converter above 80%. Finally, a multi-V t clock tree reduces variability-induced clock skew by 3 × to ensure robust timing closure down to 0.3 V.