Canadian Orthopaedic Research Articles

Report from the 2007 AOA North American Traveling Fellowship

The John J. Fahey, MD, Memorial North American Traveling Fellowship (NATF) originated in 1968 at an American Orthopaedic Association (AOA) Executive Committee meeting. In 1969, the committee's proposal to create a fellowship program for orthopaedic surgeons to travel to orthopaedic centers around the United States and Canada was accepted. The tour's purpose is to promote clinical and scientific exchange and fellowship at each orthopaedic program visited. The 2007 tour was organized by Sohail Mirza, MD (University of Washington), and was coordinated by Lesley Coussis of the AOA office and Trinity Wittman of the Canadian Orthopaedic Association. The 2007 fellows, who hailed from diverse areas and orthopaedic specialties, were George Athwal, a shoulder and elbow surgeon from London, Ontario, Canada (University of Western Ontario); Bang Hoang, a musculoskeletal oncologist from Irvine, California (University of California, Irvine); Samir Mehta, a trauma surgeon from Philadelphia, Pennsylvania (University of Pennsylvania); Brett Owens, a sports medicine surgeon from El Paso, Texas (William Beaumont Army Medical Center); and Jennifer Wolf, a hand and elbow surgeon from Denver, Colorado (University of Colorado Health Sciences Center). We began our tour in Charlotte, North Carolina, where we were hosted by Edward Hanley Jr., MD, and Steven Frick, MD, of the Carolinas Medical Center. On October 1, 2007, the inaugural day of the North American Traveling Fellowship, the Department of Orthopaedics hosted an academic program in the morning. Later that day, the fellows had the opportunity to spend time with Dr. Hanley, who gave us many pearls of wisdom, including his philosophy of leadership and management as a chairman. The next day, each fellow spent the morning with members in their specific specialty, followed by a trip to the U.S. National Whitewater Center in Charlotte, where we had a thrilling few rides on the manmade training center's river, complete with …

Orthopaedic Surgeons Prefer to Participate in Expertise-based Randomized Trials

Empiric data and theoretical arguments suggest an alternative randomized clinical trial (RCT) design, called expertise-based RCT, has enhanced validity, applicability, and ethical integrity compared with conventional RCT. Little is known, however, about whether physicians will participate in an expertise-based RCT. In a cross-sectional survey of Canadian orthopaedic surgeons, we evaluated preference for and willingness to participate in an expertise-based versus a conventional RCT if given the opportunity to participate in a trial investigating the effectiveness of high tibial osteotomy versus unicompartmental knee arthroplasty. Using an electronic survey ((c)2005 SurveyMonkey.com), we invited all 767 members of the Canadian Orthopaedic Association (2005) to participate; 276 surgeons completed the questionnaire (37.5% response rate). One hundred two surgeons (53.4%) were willing to participate in an expertise-based RCT compared with 35 surgeons (18.3%) willing to participate in a conventional RCT. Ninety-seven surgeons (52.4%) strongly or moderately preferred the expertise-based design compared with 25 (13.5%) who preferred the conventional design. For the clinical example we presented, the majority of Canadian orthopaedic surgeons were willing to participate in and preferred the expertise-based design. The expertise-based randomized clinical trial design may overcome some of the barriers to conducting clinical trials in orthopaedic surgery and improve the validity of their conclusions.

Comparison of Health-Related Quality of Life Between Patients with End-Stage Ankle and Hip Arthrosis

End-stage ankle arthrosis is one of the leading causes of chronic disability in North America. Information on this condition is limited. The amount of pain and the reduction in health-related quality of life and function have not been quantified with use of universal outcome measures. The purpose of the present study was to compare the extent of pain, loss of function, and health-related quality of life in two cohorts of patients waiting for the surgical treatment of end-stage ankle or hip arthrosis. One hundred and thirty patients with end-stage ankle arthrosis who were awaiting total ankle arthroplasty or ankle arthrodesis were recruited through a Canadian Orthopaedic Foot and Ankle Society multicenter study. All patients prospectively completed the Short Form-36 (SF-36) generic outcome instrument. This cohort was compared with a similar cohort of 130 patients with end-stage hip arthrosis, randomly selected from an existing prospective joint replacement database, who had completed an SF-36 questionnaire prospectively from 2000 to 2005. In both groups, the scores for all SF-36 subscales were approximately two standard deviations below normal population scores. Patients with ankle arthrosis had significantly worse mental component summary scores (p < 0.05), role-physical scores (p < 0.05), and general health scores (p < 0.05). Patients with hip arthrosis reported significantly lower physical function scores (p < 0.05), although the SF-36 physical component summary score was not significantly different between the two groups. The SF-36 physical component summary, bodily pain, vitality, role-emotional, social functioning, and mental health subscale scores were equally affected in both cohorts. The mental and physical disability associated with end-stage ankle arthrosis is at least as severe as that associated with end-stage hip arthrosis.

Methylprednisolone for Acute Spinal Cord Injury: 5-Year Practice Reversal

To re-evaluate practice patterns for methylprednisolone (MP) administration in patients with acute spinal cord injury (SCI) within the spinal surgery community across Canada five years after the publication of practice recommendations. Canadian orthopedic and neurological spine surgeons were surveyed at their respective annual meetings about their practice of steroid administration for acute SCI by means of a questionnaire comprised of the same seven questions posed five years ago plus an additional question related to change of view. Forty-two surgeons and twenty-one residents directly involved in the acute management of SCI completed the questionnaire. Seventy-six percent of spinal surgeons do not prescribe MP for SCI in sharp contrast to 76% who prescribed it five years ago. Of the 24% who use steroids, the NASCIS II dosing regimen is most commonly followed. One third of physicians continue to administer MP because of fear of litigation. Over a five year period there has been a complete reversal in practice patterns of MP administration for SCI, along with an increased familiarity of the published literature. Attendance at meetings, participation in local group discussions, and peer-reviewed publications appear effective in altering practice preferences arising from peer pressure and even fear of litigation.

Fluid lavage in patients with open fracture wounds (FLOW): an international survey of 984 surgeons

BackgroundAlthough surgeons acknowledge the importance of irrigating open fracture wounds, the choice of irrigating fluid and delivery pressure remains controversial. Our objective was to clarify current opinion with regard to the irrigation of open fracture wounds.MethodsWe used a cross-sectional survey and a sample-to-redundancy strategy to examine surgeons' preferences in the initial management of open fracture wounds. We mailed this survey to members of the Canadian Orthopaedic Association and delivered it to attendees of an international fracture course (AO, Davos, Switzerland).ResultsOf the 1,764 surgeons who received the questionnaire, 984 (55.8%) responded. In the management of open wounds, the majority of surgeons surveyed, 676 (70.5%), favoured normal saline alone. Bacitracin solution was used routinely by only 161 surgeons (16.8%). The majority of surgeons, 695 (71%) used low pressures when delivering the irrigating solution to the wound. There was, however considerable variation in what pressures constituted high versus low pressure lavage. The overwhelming majority of surgeons, 889 (94.2%), reported they would change their practice if a large randomized controlled trial showed a clear benefit of an irrigating solution – especially if it was different from the solution they used.ConclusionThe majority of surgeons favour both normal saline and low pressure lavage for the initial management of open fracture wounds. However, opinions varied as regards the comparative efficacy of different solutions, the use of additives and high versus low pressure. Surgeons have expressed considerable support for a trial evaluating both irrigating solutions and pressures.

Achieving the National Quality Forum's “Never Events”

Review the evidence regarding methods to prevent wrong site operations and present a framework that healthcare organizations can use to evaluate whether they have reduced the probability of wrong site, wrong procedure, and wrong patient operations. Operations involving the wrong site, patient, and procedure continue despite national efforts by regulators and professional organizations. Little is known about effective policies to reduce these "never events," and healthcare professional's knowledge or appropriate use of these policies to mitigate events. A literature review of the evidence was performed using PubMed and Google; key words used were wrong site surgery, wrong side surgery, wrong patient surgery, and wrong procedure surgery. The framework to evaluate safety includes assessing if a behaviorally specific policy or procedure exists, whether staff knows about the policy, and whether the policy is being used appropriately. Higher-level policies or programs have been implemented by the American Academy of Orthopaedic Surgery, Joint Commission on Accreditation of Healthcare Organizations, Veteran's Health Administration, Canadian Orthopaedic, and the North American Spine Society Associations to reduce wrong site surgery. No scientific evidence is available to guide hospitals in evaluating whether they have an effective policy, and whether staff know of the policy and appropriately use the policy to prevent "never events." There is limited evidence of behavioral interventions to reduce wrong site, patient, and surgical procedures. We have outlined a framework of measures that healthcare organizations can use to start evaluating whether they have reduced adverse events in operations.

Knee Immobilization in the Immediate Post-Operative Period Following ACL Reconstruction

This study was designed to determine the practice patterns and rationale for knee immobilizer use in immediate post-operative period following an anterior cruciate ligament (ACL) reconstruction. Descriptive cross-sectional survey. Canada. A random sample of 50% of Canadian orthopedic surgeons registered with the Canadian Orthopaedic Association (COA). Self-reported survey responses regarding knee immobilizer use, surgeon characteristics, graft type and type of practice. Complete survey response rate was 36.1% (122/338). There was a lack of consensus regarding knee immobilizer use; 47.7% of responding surgeons use a knee immobilizer in the immediate post-operative period while 52.3% do not. There were no trends in characteristics such as fellowship training, number of years in practice and type of practice between surgeons who use and do not use a knee immobilizer. The reported reasons for immobilization were: pain reduction in the post-operative period (51.6%), graft site protection (38.7%), maintaining full extension (19.4%) and habit (12.9%). The length of time the immobilizer was used ranged from 5-42 days. The lack of consensus reported in the current study and published literature reflects a lack of scientific evidence in the area of post-operative knee immobilization. The need for a randomized clinical trial to assess the efficacy of knee immobilizer use after ACL reconstruction is evident. The authors recommend using peri-operative pain as an outcome measure in future studies investigating immobilization in the immediate post-operative period.

W. Robert Harris (1922–2005)

The Journal of Bone and Joint Surgery. British volumeVol. 88-B, No. 5 ObituaryFree AccessW. Robert Harris (1922–2005)Robert B. SalterRobert B. SalterSearch for more papers by this authorPublished Online:1 May 2006https://doi.org/10.1302/0301-620X.88B5.17811AboutSectionsPDF/EPUB ToolsDownload CitationsTrack CitationsPermissionsAdd to Favourites ShareShare onFacebookTwitterLinked InRedditEmail On 13 December 2005, Canada lost one of its most distinguished academic orthopaedic surgeons with the death of Dr. W. Robert (Bob) Harris from pancreatic cancer. After a private funeral, a splendid Memoral Service in celebration of his life was held in Massey College of the University of Toronto.Born in Canada, he was the son of Professor Robert I. Harris, who was the first Professor of Surgery of the Division of Orthopaedic Surgery of Toronto General Hospital. Bob received his primary, secondary, and tertiary education in Toronto culminating in his graduation with Honours in Medicine in January, 1945. On that occasion he was awarded the Canadian Medical Association Prize in Public Health and became a member of the Alpha Omega Alpha Honour Society. He immediately enlisted in the Royal Canadian Naval Volunteer Reserve (RCNVR) in which he served for one year as a Surgeon-Lieutenant.In 1946 Bob married Barbara Drew-Brook and together in an ideal marriage, they raised four children, Nancy, Janet, Rob and Pam and then came ten grandchildren. He was a loving and much loved husband, father and grandfather.In 1947 he studied histology with Professor Arthur Ham, the author of the classic textbook, to which Bob contributed an important chapter on fracture healing. There followed three years of postgraduate training on the W. E. Gallie Course on Surgical Training. It was during that residency that he was awarded the Reeves Prize.He then spent a year as an Orthopaedic resident in the Massachusetts General Hospital in Boston. In 1952 he won an R. S. McLaughlin Travelling Fellowship that enabled him to continue his orthopaedic education in the United Kingdom, Scandinavia, Italy, and France.As a fully trained orthopaedic surgeon he was appointed in 1953 to the Division of Orthopaedic Surgery at the University of Toronto in which he served with distinction throughout his academic career.In due course he succeeeded Professor F. P. Dewar and was promoted to the rank of full Professor. He developed a number of special interests including slipped capital femoral epiphysis, epiphyses and their transplantation, amputations, and the rehabilitation of injured workers.Bob Harris and I collaborated on a combined research project on injuries involving the epiphyseal plate. He insisted that since his part of the project (basic research) was smaller than mine (clinical research) his name should appear second on the title, hence the Salter-Harris classification of injuries involving the epiphyseal plate. Both he and I were quite young when the classification was published (1963). Indeed, sometimes when being introduced to a foreign orthopaedic surgeon, the statement was made to one, or both of us that “In our country we use the classification that was created by your father(s)”.Bob Harris was elected to the American Orthopaedic Association, the most prestigious orthopaedic association in North America. He was also the President of the Janes’ Surgical Society as well as the Little Club (a Travel Club). He also became an Examiner for the Royal College of Physicians and Surgeons of Canada.In 1968 he was elected the President of the Canadian Orthopaedic Foundation and in 1975 and 1976 he served as the President of the Canadian Orthopaedic Association. It was during the Presidency that he had the honour of representing the Association at the Sixth Combined Meeting of the Orthopaedic Associations of the English Speaking World in London, England. It was during that outstanding meeting that Her Majesty, Queen Elizabeth The Queen Mother, presented to each of the Presidents of their Association a handsome replica of Nicholas Andry’s Orthopaedic Tree.Bob Harris was a quiet and humble man who had a wonderful spirit of generosity and who was never heard to speak ill of anyone. Indeed he was an exemplary role model to his family, his students, and his colleagues.The late Sir Wilfred Grenfell, Founder of the Grenfell Mission in Newfoundland and Labrador, has written that “Life in Medicine is a Field of Service” Certainly the exemplary life of Dr. W. Robert Harris has been one of stellar Service.All of us worldwide who have known him personally and have appreciated his contributions to the field of orthopaedics will be forever grateful to him.FiguresReferencesRelatedDetails Vol. 88-B, No. 5 Metrics History Published online 1 May 2006 Published in print 1 May 2006 InformationCopyright © 2006, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download

A Multicenter Randomized Controlled Trial of Nonoperative and Operative Treatment of Displaced Clavicle Shaft Fractures

Canadian Orthopedic Trauma Society, Royal Columbian Hospital, New Westminster, BC, Canada Canadian Academy of Sport Medicine Annual Scientific Symposium May 10–13, 2006, Edmonton, Alberta, Canada

Special report: highlights of the First Annual Scientific Meeting of the Canadian Orthopaedic Foot and Ankle Society, Winnipeg, Manitoba, October 4, 2003.

Special report: highlights of the First Annual Scientific Meeting of the Canadian Orthopaedic Foot and Ankle Society, Winnipeg, Manitoba, October 4, 2003.

MEDICAL ERRORS IN ORTHOPAEDICS

Bernstein, Adam D. MD; Jazrawi, Laith M. MD; Elbeshbeshy, Basil MD; DellaValle, Craig J. MD; Zuckerman, Joseph D. MD

Preoperative signing of the incision site in orthopaedic surgery in Canada.

Wrong-site surgery is an often catastrophic yet preventable problem. Reports of wrong-site surgery have been on the rise in the United States every year since 19951,2. The number of reported cases has increased from sixteen in 1998 to fifty-eight at the time of writing in 2001. Eleven cases occurred in the month of November 2001 alone1,2. These increases are cause for grave concern. Wrong-site surgery is a concern for every surgical specialty. However, orthopaedic surgery has an inherently higher risk compared with other types of surgery. Orthopaedic surgeons frequently operate on extremities, and many diseases do not have ob-vious external abnormalities. Of the 126 reported cases of wrong-site surgery in the United States, 41% were orthopaedic-related procedures1,2. Operating on the correct site can be ensured through a strict series of checks and rechecks involving the surgeons, nurses, residents, and patients. In 1994, the Canadian Orthopaedic Association (COA) began an educational program intended to prevent such mistakes from occurring. Their recommendations included marking the incision site with a permanent marker prior to entering the operating room3. The rates of wrong-site surgery in orthopaedic procedures in Canada have been declining since 1987 ( Fig. 1 ). Since 1994, the number of cases has been reduced from thirteen cases per year to five cases per year in 20004. Most of the cases involved knee surgery, and, in all but one, the knee had not been marked4. Fig. 1: Graph showing the number of reported occurrences of wrong-site surgery per year in Canada. (Data provided by the Canadian Medical Protective Association.) The purpose of this study was to evaluate the impact that the campaign to promote preoperative signing of the incision site had on Canadian orthopaedic surgeons by …

Orthopaedic Training and Practice in the Canadian Health-Care System

To The Editor: Dr. David Baillargeon and Dr. Stefan Parent painted a rosy picture of life in Canada as orthopaedic surgeons-in-training in “The Canadian Orthopaedic Residency Experience” (2001;83:956-8). The authors described the benefits of a government-funded health-care system that improves the life of its citizens and provides free and unlimited high-quality care. As a native who graduated from a Canadian university, completed my orthopaedic residency in Canada, served on the staff of Canadian teaching hospitals, and trained orthopaedic residents both in Canada and in the United States, I feel compelled to comment. The Canadian health-care system is deplorable. Doctors, who were once the proud standard-bearers of the medical profession, have become civil servants whose livelihood has been severely curtailed and even capped …

The Canadian orthopaedic residency experience.

O Canada! Country of the Great Lakes and the Rockies, with coasts reaching two oceans, a great mix of English and French cultures, embraced diversity, and a healthy economy, Canada can boast of being one of the best places in the world to live in the twenty-first century. In 1945, Dr. J.E. Samson, a well-known orthopaedist from Montreal, along with other colleagues across the country, founded the Canadian Orthopaedic Association. Before that, most Canadians who wished to become orthopaedic surgeons were obligated to travel to England, continental Europe, or the United States for their training. Today’s University of Montreal Orthopaedic Surgery Program still proudly bears Samson’s name. The postwar era also saw the rise of several other orthopaedic surgery programs in Canada. Canada’s government-funded health-care system represents a peculiarity in North America—one that improves the quality of life of its citizens. Canadians enjoy free and unlimited high-quality care, including access to top specialists, in hospitals and public clinics from British Columbia to Newfoundland. In this regard, practicing orthopaedic surgery in Canada is rewarding, as surgeons are expected to give their best expertise equally to every patient on the basis of the challenges of the case, regardless of such bureaucratic issues as the type of insurance-coverage plan that a patient might have. The residency in Canadian orthopaedic programs is thus conducted in this framework of high quality-of-care standards, which are accessible to all. Admission to an orthopaedic residency program is as competitive in Canada as it is in the United States. After completing four to five years of medical school, students may apply to a program within Canada through the Canadian Resident Matching System (CARMS), which allows both residents and program directors to pick their top choice by orderly ranking. Orthopaedic residencies are quite popular; candidates are chosen on the basis …

Management of injuries to the anterior cruciate ligament: results of a survey of orthopaedic surgeons in Canada.

To identify the approaches to management of anterior cruciate ligament (ACL) injury by Canadian orthopedic surgeons. A questionnaire was mailed to 234 physicians randomly chosen from the Canadian Orthopaedic Association directory to obtain the following information: 1) how orthopaedic surgeons diagnose acute hemarthroses; 2) how patients in any of three common ACL injury scenarios would be managed; 3) what variations exist in surgical technique; and 4) how patient variables such as age, gender, and alignment influence the decision-making process. The return rate was 72%, and 56% of respondents were from academic centers. Patients such as those described in the protocol are routinely managed by 80% of the respondents. The diagnosis of acute hemarthrosis is predominantly made by means of clinical examination and radiographs. Magnetic resonance imaging (MRI) is used occasionally by 43% and routinely by 6% of those who responded; arthroscopy is used routinely by 24%. For the competitive athlete with a complete ACL tear, 64% would recommend reconstruction and 33% would recommend bracing and rehabilitation. For reconstruction, 59% would use bone-patellar tendon-bone (B-PT-B) autograft and 32% would use hamstring tendon autograft; 40% would incorporate the ACL stump during reconstruction. Of the respondents, 77% would advocate ACL reconstruction for competitive athletes with chronic ACL injury. Of these, 63% would use B-PT-B autograft and 27% would use hamstring tendons. If bracing and rehabilitation failed, 98% would recommend ACL reconstruction. In ACL reconstruction, synthetic augmentation would be used by 12% in chronic cases and by 16% in acute cases. In making the decision to perform ACL reconstruction, 53% consider limb alignment to be important and 67% consider moderate patellofemoral pain to be important. Seventy-one percent are influenced by patellofemoral pain when choosing a surgical technique, with a trend toward semitendinosis autograft rather than B-PT-B autograft reconstruction. For the 8-year-old child with an acute ACL injury, 63% of the respondents would recommend rehabilitation and bracing. For the 14-year-old, 45% would recommend rehabilitation and bracing and 37% would recommend ACL reconstruction after physeal closure. The results of the survey indicate that, with respect to some of the issues, there is a wide variation in management of acute and chronic ACL injuries among Canadian orthopedic surgeons. Future research and randomized, controlled clinical trials should be directed toward these areas.

Canadian Orthopaedic Association. 34th meeting, in Vancouver, British Columbia, June 11-15, 1978.

Canadian Orthopaedic Association. 34th meeting, in Vancouver, British Columbia, June 11-15, 1978.

Compression Fixation of Peritrochanteric Fractures and Early Weight Bearing

Forty-two patients with peritrochanteric fractures of the femur were treated by open reduction and internal fixation with a 95 degree A-Ocompression plate. In 30 of 42 patients (71%) resumption of weight-bearing was achieved by 4 weeks from the time of surgery. Compressive fixation devices have biomechanical advantages over other types of standard nail-plates.

The Effect of Methylmethacrylate on Fracture Healing

Fractures were created in the femur of dogs by dividing the midshaft with an airdriven saw. Immobilization was achieved with a four-hole compression plate. No methylmethacrylate supplementation was used in the control groups. In the three experimental groups methylmethacrylate was added to the internal fixation by placing it on the endosteal, periosteal, and both surfaces of the bone. Healing of the fractures uniformly failed to occur when methylmethacrylate was apposed to both periosteal and endosteal regions. Histologic, fluorescent, and autoradiographic studies indicated that the bone surface in contact with methylmethacrylate was necrotic and did not incorporate tetracycline or Ca-45. New bone occurred only on the surface which was not in contact with methylmethacrylate.

A History of the Canadian Orthopaedic Association

A History of the Canadian Orthopaedic Association

Report of the Visit of the 1959 North American Traveling Fellows to Great Britain

The orthopaedic problems in Great Britain certainly are similar to those seen in this country, although their handling probably is more uniform because of the orthopaedic organization. The organization of regional orthopaedic centers, which are largely dominated by one institution, naturally reflects the feelings of the institution on the management of specific diseases. Throughout Great Britain we found that arthrodeses are much more commonly carried out on the major joints than they are in this country. Another contrast was the great individual experiences which many orthopaedic surgeons have had in treating particular entities. This is because of the concentration of patients in a given area where they are under the care of a small number of consultants. The number of patients seen and handled by an individual consultant is many times larger than that cared for by an orthopaedic surgeon in a comparable position in the United States and Canada. Tuberculosis is more common in Great Britain than in this country although its incidence is falling rapidly. The anterolateral approach for the drainage of abscesses is frequently utilized in the surgical treatment of tuberculosis of the spine. Time chemotherapeutical treatment in bone and joint tuberculosis varied a great deal throughout the areas visited. Two radically different views on the early management of spinal cord injuries were presented to us, yet the end results were similar. In Great Britain the emphasis is on a spinal injury centers as an integral unit within a general medical and surgical hospital. In the field of children's orthopaedics there still is great emphasis on treatment of congenital dislocation of the hip, an entity that is seen much more frequently in Great Britain than in the United States and Canada. The staff at the Robert Jones and Agnes Hunt Orthopaedic Hospital presented several different concepts in time management of scoliosis, particularly of the infantile or childhood type. They have done a large number of epiphyseal arrests of the convex side of the curve with interbody fusion. Time end results, however, are of too recent duration for clinical evaluation. In conclusion, the Traveling Fellows wish to express their most sincere thanks to The American Orthopaedic Association and The Canadian Orthopaedic Association for sponsoring and arranging this tour. We have made many friendships which we will cherish for the remainder of our lives. On a personal basis the value of this tour to us will grow in the years to come. Although it is impossible to assimilate all the material presented to us in this relatively brief period, we are certain that exchange fellowships are tremendously important in fostering an exchange of information. The British Orthopaedic Association and all of its members were magnificent hosts and treated us with every possible courtesy and kindness. We wish to extend particular thanks to Mr. Norman Capener and Mr. John Crawford Adams for all of their efforts in preparing such an outstanding itinerary for us. Those of us who were privileged to participate in the tour this year sincerely hope that the Traveling Fellowship Exchange Program will be continued between North America and Great Britain.