By H. Raid. Ottawa University.
There was also a group of patients with sinonasal polyposis that had no evidence of allergic disease generic cilostazol 50 mg on line spasms foot. Consequently buy 100mg cilostazol with visa muscle relaxant neck pain, it was concluded that there is no causal relationship between allergy (positive skin tests buy cilostazol 100 mg free shipping spasmus nutans, family history of atopy generic cilostazol 100mg visa muscle relaxant parkinsons disease, eosinophils in nasal secretions or in nasal polyps) and polyps. It has been reported that 46% of patients with allergic rhinitis have clinical and radiologic evidence of sinonasal polyposis ( 32). It also has been reported that the incidence of asthma in patients with polyps is 20%, and that up to 32% of the asthmatic patients have nasal polyps. The triad of aspirin intolerance, nasal polyposis, and bronchial asthma is well documented ( 33). Regardless of the etiologic factors, the imaging appearance of polyposis is quite dramatic ( Fig. Rounded masses are seen filling the nasal cavities (unilateral or bilateral), often extending into and filling the adjacent sinuses. The bony walls may be thinned and at times appear eroded, making the possibility of a malignant mass a differential consideration. Following administration of contrast, however, the polypoid mucosa does not enhance homogenously as would malignancy ( 6,32). Coronal computed tomography images viewed at a wide/bone window (A) and a narrow/soft tissue window (B) in a patient with sinonasal polyposis. Soft tissue windows suggest central high attenuation of the proteinaceous secretions ( small black arrows) in the maxillary sinus. Polypoid ethmoid mucocele is a process that involves bilaterally all the ethmoid cells, with diffuse expansion of the sinus. Its appearance is similar to the diffuse sinus abnormality seen with polyposis, except that the polypoid mucocele preserves the ethmoid septa and lamina papyracea. Acute or fulminant invasive fungal sinusitis is a rapidly progressive disease seen in the immunocompromised host. Chronic or indolent invasive fungal sinusitis occurs in an immunocompetent patient; the fungus proliferates in the sinus cavity and penetrates the mucus. A mycetoma or fungal ball is also seen in immunocompetent nonatopic individuals; the fungus is found in the secretions without penetration of the mucosa. Lastly, allergic fungal sinusitis occurs when the fungi colonize the sinus of an atopic immunocompetent host and act as an allergen, eliciting an immune response. The inflammation results in obstruction of the sinus, stasis of secretions, and further fungal proliferation. The diagnostic criteria for fungal sinusitis are as follows: the presence of allergic mucin at endoscopy; identification of fungal hyphae within the allergic mucin; absence of fungal invasion of the submucosa, blood vessels, or bone; immunocompetency; and radiologic confirmation ( 35,36 and 37). The air-fluid levels associated with acute bacterial sinusitis are less common in fungal sinusitis; in fact, the absence of fluid levels is suggestive of fungal disease. In this same study it was noted that 96% of the patients had more than one sinus involved by the disease process. If more than one sinus is involved, it may difficult to distinguish fungal sinusitis from sinonasal polyposis. This is felt to be secondary to the presence of calcium, heavy metals (iron and manganese), and inspissated secretions ( 36,38). A similar appearance may occur with the inspissated secretions in chronic bacterial sinusitis. However, one study ( 39) demonstrated that the calcifications seen in fungal sinusitis are more commonly central in location and more likely to be punctate in morphology. The calcifications in nonfungal sinusitis are more likely at the periphery (near the wall) of the sinus. Nonfungal calcifications are often smoothly marginated with a round or eggshell appearance. Unfortunately, calcifications that are noted to be nodular or linear in shape can be seen with either process. A T2-weighted image from a brain magnetic resonance image (A) shows opacification of the sphenoid sinus ( large white arrows). The majority of the secretions are isointense, but centrally there are serpiginous, linear areas of signal void ( small white arrows). A computed tomographic examination of the sinuses was subsequently obtained (B narrow/soft tissue window and C wide/bone window). The sphenoid sinus (large black arrows) is completely opacified with central areas of linear calcification ( small black arrows). As a result of the presence of calcification or paramagnetic ions within the inspissated secretions, T2-weighted images show a markedly low signal and often a signal void ( 38). A mycetoma, or fungus ball, may resemble a calcification or concretion within an opacified sinus. Fungal sinusitis may cause areas of bone erosion from pressure remodeling ( 36,38). Often it is this aggressive nature that identifies the sinus process as more complicated than bacterial/inflammatory disease. This occurs prior to bone destruction, and may be an early sign of an invasive process. Invasive fungal sinusitis demonstrates an enhancing mass with bone erosion that extends beyond the sinus walls to involve the superficial soft tissues, orbit, or intracranial contents. Imaging of sinonasal neoplasms is no exception, although some generalizations can be made. Hydrated secretions and hypertrophic mucosa are generally more hyperintense on T2-weighted imaging. Neoplasms often demonstrate homogenous enhancement, but sinusitis does not; this is a key finding. Normal mucosa also enhances, but an obstructed sinus demonstrates more peripheral mucosal enhancement with central low signal intensity. However, in a small sinus cavity where the walls are apposed, the appearance of sinusitis may still suggest a solid lesion ( 16). The problem with using bone destruction and extension to surrounding structures as a distinguishing feature is apparent, because this may be seen in aggressive nonneoplastic processes as well. Inverted papilloma is an epithelial tumor that occurs in individuals 50 to 70 years of age. This tumor is unusual in that the epithelium grows (inverts) into the underlying stroma, rather than growing exophytically. It is usually a unilateral mass that arises from the lateral nasal wall adjacent to the middle turbinate, and commonly extends into the maxillary sinus. There is an association between inverted papilloma and malignancy; the prevalence ranges from 2% to 56%. The malignancy may arise directly from the inverted papilloma, adjacent to the papilloma (synchronous tumor) or in the same anatomic site as a previously resected papilloma (metachronous tumor) ( 41,42,43 and 44). Juvenile angiofibroma begins as a unilateral mass that arises in the nasal vault, near the choana and sphenomaxillary fissure. This tumor presents in the second decade of life in men, often with epistaxis or nasal obstruction. It commonly extends into and widens and destroys the pterygopalatine fossa and the pterygoid plates as it extends into the nasopharynx. When they do occur they most often involve the maxillary sinus, then the ethmoid sinuses, and finally the nasal cavity. Olfactory neuroblastoma, also known as esthesioneuroblastoma, is a neural crest tumor that arises from the olfactory epithelium of the nasal cavity. There is a bimodal age distribution affecting teenagers and individuals in their sixth decade of life. The imaging findings are not unique other than the characteristic location of this tumor in the superior aspect of the nasal cavity, adjacent to the cribriform plate (46,47). Melanotic tumors are hyperintense on T1-weighted images and hypointense on T2-weighted images ( 16).
Further investigations consist of a search for a cause or associated conditions and a deci- sion whether a lung biopsy is warranted quality cilostazol 100mg spasms medication. Bronchoscopic biopsies are too small to be rep- resentative or useful in this situation generic cilostazol 100mg with mastercard muscle relaxant esophageal spasm, and a video-assisted thoracoscopic biopsy would be the usual procedure purchase cilostazol 100mg overnight delivery xanax muscle relaxant dose. It would usually be appropriate to obtain histology of the lung in someone of this age cheap cilostazol 50mg on line muscle relaxant for bruxism. There is some evidence that anti-oxidants such as acetylcysteine improve the outlook and these may be combined with the steroids and azathioprine. In a patient of this age, lung transplantation might be a consideration as the dis- ease progresses. Progression rates are variable and an acute aggressive form with death in 6 months can occur. A subendocardial inferior myocardial infarction was diagnosed and he was treated with thrombolytics and aspirin. This showed severe triple-vessel disease not suitable for stenting, and coronary artery bypass grafting was performed. He is attending a cardiac rehabilitation clinic and he has had no further angina since his surgery. He has a strong family history of ischaemic heart disease, with his father and two paternal uncles having died of myocardial infarctions in their 50 s; his 50-year-old brother has angina. He has bilateral corneal arcus, xanthelasmata around his eyes and xanthomata on his Achilles tendons. He has many clinical features to go with the high cholesterol and prema- ture vascular disease. The homo- zygous condition is rare and affected individuals usually die before the age of 20 years due to premature atherosclerosis. Corneal arcus, xanthelasmata and xanthomata on Achilles tendons and the exten- sor tendons on the dorsum of the hands develop in early adult life. The other major causes of hypercho- lesterolaemia are familial combined hyperlipidaemia and polygenic hypercholesterol- aemia. Familial combined hyperlipidaemia differs from familial hypercholesterolaemia by patients having raised triglycerides. Patients with polygenic hypercholesterolaemia have a similar lipid profile to familial hypercholesterolaemia but they do not develop xanthomata. Hypercholesterolaemia may commonly occur in hypothyroidism, diabetes mellitus, nephrotic syndrome and hepatic cholestasis. This patient is at extremely high risk for further vascular events and especially occlusion of his coronary artery bypass grafts. His risk depends on the combination of his risk fac- tors, and all of these need attention. He should be advised to stop smoking, reduce his alcohol intake (which is also affecting his liver as judged from the raised gamma-glutamyl transpeptidase), take more exercise and eat a strict low-cholesterol diet. He should have pharmacological treatment with a statin but may need combined treatment for this level of hyperlipidaemia. His children should have their lipid profile measured so that they can be treated to prevent premature cor- onary artery disease. There is clear evidence from clinical trials that primary prevention of coronary artery disease can be achieved by lowering serum cholesterol. In patients who have evidence of cardiovascular disease secondary prevention is even more important, aiming for a cho- lesterol level as low as possible. He has a 12-year history of chronic cough and sputum production, but she thinks that these symptoms may have increased a little over the last 8 weeks. He has smoked 20 cigarettes daily for the last 50 years and he drinks around 14 units of alcohol per week. Two years ago he became depressed and was treated with an antidepressant for 6 months with good effect. There are no abnormalities to find in the cardiovascular, respiratory or abdominal systems. Addison s disease might be linked with respiratory problems through adrenal involvement by metastases or tuberculosis. This can be confirmed by measurement of serum and urine osmolarities to show serum dilution while the urine is concentrated. Fluid restriction to 750 mL daily produced an increase in serum sodium to 128 mmol/L with improvement in the confusion and weakness. Such treatment often produces a response in terms of shrinkage of the tumour, improved quality of life and increased survival. Small-cell undifferentiated carcinomas of the lung are fast-growing tumours, usually unresectable at presentation. Her 20-year-old son has asthma and she has tried his salbutamol inhaler on two or three occasions but found it to be of no real benefit. She has tested herself on her son s peak flow meter at home and she has obtained values of about 100 L/min. On direct question- ing she says that the shortness of breath tends to be worse on lying down but there are no other particular precipitating factors or variations through the day. There is a generalized wheeze heard all over the chest but no other abnormalities. It is similar in both inspiration and expiration as shown in the flow volume loop (Fig. The spirometry trace of volume against time in such cases shows a straight line of the same reduced flow right up to the vital capacity. On examination, this airway narrowing is likely to produce a single monophonic wheeze which may be heard over a wide area of the chest. Differential diagnosis of rigid large-airway obstruction The situation may easily be confused with asthma if the peak flow and the wheezing are accepted uncritically. The wheezing in asthma comes from many narrowed airways of different calibre and mass, and the wheezes are often described as polyphonic. The fixed flow in inspiration and expiration in this case suggest a rigid large-airway nar- rowing. If the narrowing can vary a little with pressure changes, then the pattern will depend on the site of the narrowing (Figs 99. If it is outside the thoracic cage, as in a laryngeal lesion, it will be more evident on inspiration. Large-airway narrowing can be caused by inflammatory conditions such as tuberculosis or Wegener s granulomatosis, damage from prolonged endotracheal intubation or by extrinsic pressure such as a retrosternal goitre. The great majority of symp- tomatic lung tumours are visible on plain chest X-ray but central lesions in large airways may not be seen. In this case, fibre-optic bronchoscopy showed a carcinoma in the lower trachea reducing the lumen to a small orifice. Treatment was by radiotherapy with oral steroids to cover any initial swelling of the tumour which might increase the degree of obstruction in the trachea. She has had two previous admissions to hospital within the last 6 months, once for an overdose of heroin and once for an infection in the left arm. The heart sounds are normal and there are no abnormal findings on examination of the respiratory system. The respiratory rate is18/min, jugular venous pressure is not raised, there are no new heart murmurs and oxygen saturation is 97 per cent on room air. This complication is not unusual in intravenous drug users and can be associated with sepsis although there was no sign of this on the initial investigations. She has been treated for the thrombosis and for alcohol withdrawal and her opiate use. The deep vein thrombosis would have predisposed her to a pulmonary embolus, but the normal respiratory rate, lack of elevation of jugular venous pressure and normal oxygen saturation make this unlikely.
Results: In practice generic cilostazol 50mg amex muscle relaxant topical cream, fewer than 1% of the respondents disagreed with the medical literature 50 mg cilostazol with amex muscle relaxant usage, an objective evidence of compliance with this clinical alert was 32% cilostazol 100 mg free shipping muscle relaxant 8667. We do not anticipate significant unintended consequences from the implantation of the measure order 50mg cilostazol with mastercard spasms vitamin deficiency. Nonrheumatic atrial fibrillation, the predominant form in the United States, occurs in nearly 6% of persons 65 years of age or older. Atrial fibrillation is an independent risk factor for stroke, increasing the annual risk by fivefold and accounting for approximately 15% of all strokes in the United States. Over the past decade, multiple randomized trials have demonstrated that warfarin therapy can reduce the average annual risk for ischemic stroke by two thirds, from 4. However, recent data suggest that these dramatic findings have not been adequately implemented in clinical practice. Temporal trend data reveal an increase in warfarin use among outpatients with atrial fibrillation, from 7% in 1980-1981 (before the publication of randomized trials demonstrating the efficacy of anticoagulation) to 33% to 50% in 1996. This reduction was similar for both primary and secondary prevention and for both disabling and nondisabling strokes. By on-treatment analysis (excluding patients not undergoing oral anticoagulation at the time of stroke), the preventive efficacy of oral anticoagulation exceeded 80%. Among residents with an indication for anticoagulant therapy, the absolute estimated crude differences indicated that residents of color were less likely than non-Hispanic whites to receive warfarin. After controlling for confounding, Asian/Pacific Islanders, blacks, and Hispanics eligible for anticoagulant therapy received warfarin less often than non-Hispanic white residents. Four of these trials were placebo controlled; of the 2 that were double blinded with regard to anticoagulation, one was stopped early because of external evidence that oral anticoagulation was superior to placebo, and the other included no female subjects. Anticoagulation with a vitamin K antagonist is recommended for patients with more than 1 moderate risk factor. Results: We found that of the 400 members who satisfied the denominator, 360 were in the numerator, indicating a compliance rate of 90%. Methods: The performance measure is similar in message to a clinical alert that has been operational since 2006. No If other describe: (2a, 2h) Identification of stratification variable(s): Stratification Details (Definitions, codes with description): 8 Risk Adjustment Does the measure require risk adjustment to account for differences in patient 1 Example of measure description: Percentage of adult patients with diabetes aged 18-75 years receiving one or more A1c test(s) per year. Conclusion Significant disparities in the rate of utilization of three common vascular surgical procedures exist between Hispanic patients and the general population. In addition, Hispanics appear to present with more advanced disease and have worse outcomes in some cases. Reasons for these disparities must be determined to improve these results in the fastest growing segment of our society. Citations for evidence: Disparities in the treatment and outcomes of vascular disease in Hispanic patients. There is good evidence that abdominal ultrasonography, performed in a setting with adequate quality assurance (i. There also is good evidence of important harms of screening and early treatment, including an increased number of surgeries with associated clinically significant morbidity and mortality and short-term psychologic harms. The natural history of arterial aneurysms is distinguished by gradual and/or sporadic expansion in their diameter and by the accumulation of mural thrombus caused by turbulent blood flow at their periphery. Aneurysm size remains the single most important predictor not only for aneurysm rupture but also for unrelated death from other cardiopulmonary events (280,281). Data suggest that the eventual risk for rupture is approximately 20% for aneurysms larger than 5. Female first- degree relatives appear to be at similar risk, but the data are less certain. Aortic diameter can be measured accurately by ultrasound imaging in more than 97% of subjects 3The strength of the body of evidence for the specific measure focus should be systematically assessed and rated, e. Screening by this method has the potential to reduce the incidence of aortic rupture. Level of Evidence B: Data derived from a single randomized trial or nonrandomized studies. Results: We found that of the 590 members who satisfied the denominator, 272 were in the numerator, indicating a compliance rate of 46%. Compliance to the clinical alert is measured using an analysis of subsequent claims and patient derived data, in this case the appearance of medical claims or patient derived data for abdominal imaging. Results: In practice, fewer than 1% of the respondents disagreed with the medical literature, and upto 25% show objective evidence of compliance. Describe how could these potential problem s be audited: The inclusion of patient-derived data from a personal health record or through a disease management program may be used to confirm the presence or absence of a test; ultimately the data sources may be tested against a sample of medical charts. The additional use of supporting information for certain diagnostic conditions (e. Note: A 3 month time window has been added to certain timeframes in order to account for the inherent delay in the acquisition of administrative claims data. No If other describe: (2a, 2h) Identification of stratification variable(s): Stratification Details (Definitions, codes with description): 1 Example of measure description: Percentage of adult patients with diabetes aged 18-75 years receiving one or more A1c test(s) per year. High rates of obesity are also reported among Mexican American men and women (33% and 38%, respectively) and among white women with lower levels of education (37%). These risk factor profiles translate into significantly higher rates of stroke in African Americans and heart failure in African Americans, Hispanics, and Native Americans compared with whites. Overall, ischemic heart disease and stroke incidence are inversely related to education and income levels. Trends and disparities in coronary heart disease, stroke and other cardiovascular diseases in the United States: findings of the National Conference on Cardiovascular Disease Prevention. In each of these high risk categories, the absolute benefits substantially outweighed the absolute risks of major extracranial bleeding. Aspirin was the most widely studied antiplatelet drug, with doses of 75-150 mg daily at least as effective as higher daily doses. Clopidogrel reduced serious vascular events by 10% (4%) compared with aspirin, which was similar to the 12% (7%) reduction observed with its analogue ticlopidine. Addition of dipyridamole to aspirin produced no significant further reduction in vascular events compared with aspirin alone. Collaborative meta-analysis of randomized trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. Aspirin as a Therapeutic Agent in Cardiovascular Disease : A Statement for Healthcare Professionals From the American Heart Association Circulation 96: 2751-2753. Specific guideline recommendation: Start aspirin 75 to 162 mg/d and continue indefinitely in all patients unless contraindicated. Rationale for using this guideline over others: Nationally recognized guideline in cardiology 22 Controversy/Contradictory Evidence Summarize any areas of controversy, contradictory evidence, or 3The strength of the body of evidence for the specific measure focus should be systematically assessed and rated, e. The increased use of aspirin in these patients may decrease this risk and reduce subsequent complications and costs. Methods to identify statistically significant and practically/meaningfully differences in performance: Compliance to the performance measure is measured using an analysis of the claims data; in this case looking for evidence of a lipid lowering agent. Compliance to the clinical alert is measured using an analysis of subsequent claims, in this case the appearance of pharmacy claims for an antithrombotic agent. Results: In practice, fewer than 1% of the respondents disagreed with the medical literature, and more than 15% show objective evidence of compliance. The low compliance rate may reflect the absence of claims data for aspirin from over-the-counter use. If Antiplatelet Agent Contraindications is Confirmed for the member (see below) e. Executive Summary: American College of Chest Physicians Evidence- th Based Clinical Practice Guidelines (8 Edition): Antithrombotic and Thrombolytic Therapy.
Residents who demonstrate increased unprofessional behaviours are prone to making more medical At this point cilostazol 100mg spasms of pain from stones in the kidney, the resident needs to reconnect with the errors than the average and to providing suboptimal patient core values and beliefs that led to the decision to become care (West and Shanafelt 2007) purchase 100mg cilostazol overnight delivery muscle relaxant rx. Attending academic half-days on physician the development of active coping skills positively infuence self-care or workshops that offer active coping strategies the well-being of trainees on many levels (Shapiro et al 2000) order cilostazol 100 mg with visa muscle relaxant without drowsiness. Such reconnection will purchase cilostazol 50mg without prescription muscle spasms 72885, in turn, foster of the faculty role models they work with every day, (e. Few medical schools a survey examining resident physician satisfaction both within have wellness programs to support their faculty, not only in and outside of residency training and mental health in Alberta. Sources of stress for residents and recom- temic aspect of the hidden curriculum, and this also infuences mendations for programs to assist them. The infuence of personal and environmental factors on professionalism in medical edu- Strategies to promote a healthy working and learning environ- cation. Some faculties of medicine have done just this by developing innovative, bottom-up, relational-centred care and teaching models that are transforming the environment in which all physicians and health care teams function. They emphasize mentorship, communication and compassion, and increased face time between residents and faculty in order to promote healthy role modelling and reduce trainee distress (Mareiniss 2005, and Cottingham et al 2008). In addition, postgraduate Case medical education offces have taken steps to develop health A third-year resident who provides on-call services at a and safety policies specifcally for their trainees, presumably to mid-sized community hospital is called to the emergency delineate appropriate local responses to identifed inadequacies room to consult on a patient. Environmental health risks include accidents confrmed the resident s confdence in their expanding and exposures to hazardous agents such as chemicals and knowledge and skills. Occupational risks include exposures to blood and other bodily fuids and to respiratory pathogens. Personal safety The triage nurse directs the resident to the room where the risks include exposure to violence perpetrated by patients or patient is waiting and closes the door behind her. In addition, programs traditionally offer orientation in working safely with hazardous materials and in communicable Many minutes later, when the resident manages to calm disease precautions and protocols. Individual programs that the patient to the point where the resident can make a safe involve specifc and frequent environmental exposures (e. Although they discuss the appropriate man- training to minimize risks of special relevance to these residents. These include but are not limited to exposures A further challenge of preparing residents to protect their own to hazardous materials and communicable pathogens, aggres- safety is that some risks are not immediately apparent, or may sive and violent patients, and repetitive strain injuries. Many of same time, elements of postgraduate training put residents at these are related to the number of hours spent in the health care additional risk of which trainees and their programs or institu- setting, very often at the least secure times. On-call residents tions may not be suffciently aware and so may not adequately and their nursing colleagues are frequently in the position of address. This, combined with their relative inexperience in identifying when a situation is getting out of hand, can increase their risk of assault by a patient. Like many mid-level residents, this resident is trying to bal- ance the confdence gained from working more indepen- These incidents can be extremely stressful to residents, who dently with the limitations of their experience. Residents may feel inadequately trained to deal with them on their own may not consider that they will be placed in situations that and may be unfamiliar with reporting protocols. Accreditation could cause them harm, and therefore rely on hospital poli- visits routinely examine the physical layout where residents cies and procedures to ensure their safety needs are met. In train to ensure they are properly equipped, for example by this case, such procedures were fawed. The resident was means of alarms and proximity to support staff, to prevent focused on making a proper diagnosis and management violent assaults by patients. However, these assessments might plan, rather than on assessing the risk of the situation. The not examine other less controllable settings were residents resident began the patient encounter without considering see patients, such as community clinics and patients homes. Additionally, the resident may not have had the skills Where specifc education and training programs exist to and training to calm an increasingly agitated patient, and manage workplace violence, residents and students are more did not have a supervisor present to review the situation likely to report incidents and get the support they need. Intimidation and harassment by faculty, staff and colleagues can present safety risks that An additional risk for this resident was inherent in the residents are, generally speaking, reluctant to disclose. Protecting Residents are aware that certain risks are associated with the the safety of medical students and residents [editorial]. Trainee miss out on a great learning opportunity, or fear of repercus- safety in psychiatric units and facilities: The position of the sion if they appear too hesitant or dependant, residents may Canadian Psychiatric Association. A pilot survey that residents are trained in risk assessment and in policies and of patient-initiated assaults on medical students during clinical procedures to follow when breaches occur. In different parts of the world, including our own, health and Case education systems have struggled with the issue of resident One of the nurses has made a complaint about a senior work hours. The Europe and the United States, considerable attention has been resident requests a meeting with the program director, paid to resident work hours on a larger scale; this has had the who notes they look exhausted. The resident indicates that beneft of bringing increased awareness of and attention to all the residents are exhausted. The resident explains that patient safety and outcome management from the perspective they are working maximum call; a number of residents of health professional fatigue. Because training systems dents primarily teaching each other topics as part of their and trainees alike can ignore the boundaries set by a collective preparation for certifcation examination); and a bus strike agreement, the challenge is to create a culture of dual account- has contributed to lengthy commutes. Particularly areas of they are doing what they can to demonstrate their abilities workplace safety such as fatigue management, collective agree- as a resident but admits to being exhausted. Embedding safety as a core work- place and educational value can have a positive and sustainable Introduction infuence if it is genuine, explicit and promoted. Handover is a particularly vulner- On-call shifts of 24 consecutive hours or more are associated able time for errors in patient care. Written and oral handover with practices that are interdisciplinary and team-oriented have been a sevenfold increase in the incidence of preventable shown to reduce such errors. In addition, handover is increas- medical errors, ingly being recognized as a skill that requires formal training, a 35 per cent increase in the risk of committing a serious evaluation and revision. Work-hour double the risk of having a motor vehicle accident reductions in the United States and Europe have been associ- during the post-call commute, and ated with unusual and innovative practices. Using shift-work performance impairment similar to that induced by a models familiar in the world of emergency medicine but less blood alcohol level of 0. Increasingly, programs are developing poli- human resource issues that, she readily admits, are more cies to minimize the use of pagers. The pro- gram director also begins to shift educational sessions to Invest in other human resources. By optimizing the involve- models that allow for ready digitization and remote access ment of physician assistants, nurse practitioners, phlebotomists, by residents. These professionals can help ensure medical errors, adverse events, and attentional failures. Extended work shifts and the risk of motor indeed, all hospital professionals) are particularly vulnerable vehicle crashes among interns. Many other practical and comprehensive solutions to the bur- den of excessive work hours during residency, as described by Ulmer and colleagues can be considered in a Canadian context. As we continue to improve patient safety, quality outcomes and excellence in residency training and education, we will need to be open to more systemic interventions targeting fatigue management. First and foremost, they expect that their physicians may confict with those of their training pro- physician will be competent. They ex- Case pect to be trusted because it is diffcult to carry out the healing A fnal-year surgical resident has been the lead doctor function in the absence of trust. They wish to be given suf- treating a 62-year-old widow with carcinoma of the colon. They The resident carried out the surgical procedure with the expect patients to accept some responsibility for their own assistance of the attending surgeon.