How Would We Know Whether Joint Replacements Are Successful if We Do Not Ask Patients?

Joint replacements are among the most effective and most frequently performed surgeries in Canada. Patient-reported outcome measures (PROMs) are measurement instruments completed by patients about aspects of their health status, including pain and function. PROMs data from three provinces show that approximately nine in 10 patients report higher PROM scores after joint replacement surgery. These data can help identify factors that lead to better care and opportunities to further understand what contributes to a patient's perception of surgical success. Expanding the collection of PROMs to more patients and more provinces is needed to help healthcare planners and clinicians understand these important outcomes.

New mental health indicators provide a snapshot on performance of the mental health system in Canada.

Although the general hospital remains an important place for stabilizing crises, most services for mental illnesses are provided in outpatient/community settings. In the absence of comprehensive data at the community level, data that are routinely collected from general hospitals can provide insights on the performance of mental health services for people living with mental illness or poor mental health. This article describes three new indicators that provide a snapshot on the performance of the mental health system in Canada: self-injury hospitalization rate, 30-day readmission rate for mental illness and percentage of patients with repeat hospitalizations for mental illness. Findings suggest a need for the early detection and treatment of mental illnesses and for optimal transitions between general hospitals and community services.

Comparing estimates of influenza-associated hospitalization and death among adults with congestive heart failure based on how influenza season is defined.

BACKGROUND: There is little consensus about how the influenza season should be defined in studies that assess influenza-attributable risk. The objective of this study was to compare estimates of influenza-associated risk in a defined clinical population using four different methods of defining the influenza season. METHODS: Using the Studies of Left Ventricular Dysfunction (SOLVD) clinical database and national influenza surveillance data from 1986-87 to 1990-91, four definitions were used to assess influenza-associated risk: (a) three-week moving average of positive influenza isolates is at least 5%, (b) three-week moving average of positive influenza isolates is at least 10%, (c) first and last positive influenza isolate are identified, and (d) 5% of total number of positive isolates for the season are obtained. The clinical data were from adults aged 21 to 80 with physician-diagnosed congestive heart failure. All-cause hospitalization and all-cause mortality during the influenza seasons and non-influenza seasons were compared using four definitions of the influenza season. Incidence analyses and Cox regression were used to assess the effect of exposure to influenza season on all-cause hospitalization and death using all four definitions. RESULTS: There was a higher risk of hospitalization associated with the influenza season, regardless of how the start and stop of the influenza season was defined. The adjusted risk of hospitalization was 8 to 10 percent higher during the influenza season compared to the non-influenza season when the different definitions were used. However, exposure to influenza was not consistently associated with higher risk of death when all definitions were used. When the 5% moving average and first/last positive isolate definitions were used, exposure to influenza was associated with a higher risk of death compared to non-exposure in this clinical population (adjusted hazard ratios [HR], 1.16; 95% confidence interval [CI], 1.04 to 1.29 and adjusted HR, 1.19; 95% CI, 1.06 to 1.33, respectively). CONCLUSION: Estimates of influenza-attributable risk may vary depending on how influenza season is defined and the outcome being assessed.

Understanding and using the hospital standardized mortality ratio in Canada: challenges and opportunities.

In 2005, the Canadian Institute for Health Information (CIHI) began a methodological journey to develop a Canadian version of the hospital standardized mortality ratio (HSMR). For two years, CIHI worked with hospitals, regional authorities and measurement experts to define the most appropriate methodology given Canadian datasets and systems of care. In November 2007, we made the findings publicly available for regional health authorities and larger facilities. In their lead article, Penfold et al. discuss their views regarding some methodological issues and potential limitations of the HSMR to monitor quality of care and, in particular, as a patient safety indicator. Here we respond to their specific concerns and maintain that the HSMR remains an important tool in the arsenal of information hospitals can use to focus the discussion of patient safety/quality improvement, monitor the provision of care over time and identify opportunities for improvement.

The fusion of IGF I with stromal cell-derived factor I or alpha1 proteinase inhibitor alters their mitogenic or chemotactic activities while keeping their ability to inhibit HIV-1-gp120 binding.

It has been previously reported that insulin-like growth factor I (IGF I) decreases in AIDS patients with wasting, a condition that is partially prevented by combined IGF I growth hormone therapy. By generating bifunctional proteins of IGF I and stromal cell-derived factor 1alpha (SDF-1alpha) or alpha1 proteinase inhibitor (API), two proteins known to prevent HIV infection, it may be possible to improve the therapeutic effectiveness of these compounds for the treatment of AIDS-mediated wasting. SDF-1alpha or the M351E-M358L mutant of API were attached at the C-terminal end of IGF I and synthesized by a stable insect cell expression technique. The IGF I-SDF-1alpha chimera reduced the enhancement of thymidine incorporation into bovine fetal erythroid cells observed in the presence of insect cell produced IGF I alone. It also decreased the SDF-1 and IGF I-stimulated hematopoietic cell migration, without losing the capacity to compete with the binding of HIV-1 (IIIB)-surface glycoprotein gp120. The IGF I-API chimera displayed the same mitogenic activity and a similar, but lower chemotactic activity than IGF I in the assays mentioned above. It had a comparable anti-elastase activity to that observed with a previously described IGF II-API fusion protein with the single mutation M351E. The binding of gp120 to a murine hematopoietic cell line was stimulated by human neutrophil elastase (25-100 nM) and inhibited by IGF I-API. In conclusion, the linkage of IGF I with SDF-1 or API can alter some biological functions of the single components of the chimera while keeping their ability to compete with HIV-1-gp120 binding.

Insect cell production of a secreted form of human alpha(1)-proteinase inhibitor as a bifunctional protein which inhibits neutrophil elastase and has growth factor-like activities.

alpha(1)-proteinase inhibitor (API) is a potential therapeutic agent in all diseases in which elastase released by neutrophils has to be effectively neutralized. We ligated the cDNA of human API to the C-terminal section of an insulin-like growth factor II analogue (BOMIGF), known to be properly folded and secreted in insect cells using the baculovirus expression system. The BOMIGF-API chimera was recovered from the incubation medium of the infected cells. It shared the properties of both IGFs and API. It inhibited neutrophil elastase and formed SDS-stable complexes with the enzyme. The attachment of the large API protein to the C-terminal end of the 10 kDa IGF analogue did not destroy the IGF-mediated stimulation of thymidine incorporation into bovine fetal erythroid cells. We tested the capacity of the chimera to affect fibronectin-dependent TF-1 cell migration. BOMIGF-API significantly restored TF-1 cell migration in the presence of elastase, which is the enzyme of burn wound fluid most probably involved in fibronectin degradation. Some of the beneficial uses for this chimera may include all instances for which inhibition of elastase-mediated extracellular matrix destruction as well as stimulation of cell migration and proliferation are required for tissue repair.

Nursing home residents and Enterobacteriaceae resistant to third-generation cephalosporins.

Limited data identify the risk factors for infection with Enterobacteriaceae resistant to third-generation cephalosporins among residents of long-term-care facilities. Using a nested case-control study design, nursing home residents with clinical isolates of Enterobacteriaceae resistant to third-generation cephalosporins were compared to residents with isolates of Enterobacteriaceae susceptible to third-generation cephalosporins. Data were collected on antimicrobial drug exposure 10 weeks before detection of the isolates, facility-level demographics, hygiene facilities, and staffing levels. Logistic regression models were built to adjust for confounding variables. Twenty-seven case-residents were identified and compared to 85 controls. Exposure to any cephalosporin (adjusted odds ratio [OR] 4.0, 95% confidence interval [CI] 1.2 to 13.6) and log percentage of residents using gastrostomy tubes within the nursing home (adjusted OR 3.9, 95% CI 1.3 to 12.0) were associated with having a clinical isolate resistant to third-generation cephalosporins.