Using focus groups to inform a peer health navigator service for people who are transgender and gender diverse in Saskatchewan, Canada.

BACKGROUND: This study investigated healthcare access and quality for people who are transgender and gender-diverse (PTGD) in Saskatchewan (SK), Canada, to inform a larger project that was piloting two peer health navigators for PTGD. METHODS: Two online focus groups were held. Nineteen participants were recruited to represent a broad range in age, gender and location in SK. Transcripts of the focus groups were analyzed using a thematic approach. RESULTS: The core theme that was identified was participants' desire for culturally safe healthcare. This core theme had two component themes: (1) systemic healthcare factors and (2) individual healthcare provider (HCP) factors. The healthcare system primarily acted as a barrier to culturally safe healthcare. HCPs could be either barriers or facilitators of culturally safe care; however, negative experiences outweighed positive ones. CONCLUSIONS: PTGD in SK face discrimination, with delays and barriers to care at all levels of the healthcare system. Peer health navigators can address some of these discrepancies; however, greater support is required for PTGD to be able to access culturally safe healthcare. PATIENT OR PUBLIC CONTRIBUTION: People with lived experience/PTGD were involved in all stages of this project. They were included on the team as community researchers and co-developed the research project, conducted the focus groups, participated in the analyses and are co-authors. As well, both navigators and all the participants in the focus groups were also PTGD.

A Retrospective Cost-Effectiveness Analysis of Mifepristone-Misoprostol Medical Abortions in the First Year at the Regina General Hospital.

OBJECTIVE: In July 2017, mifepristone-misoprostol (mife/miso) became available for medical abortion at the Regina General Hospital's Women's Health Centre (RGH WHC). We investigated whether the proportion of abortions performed medically changed as a result of the introduction of mife/miso, whether using mife/miso instead of the surgical alternative would result in cost savings to the health care system, and whether abortion type differed between patients residing in and outside of Regina. METHODS: We conducted a retrospective chart review of all 306 medical abortions from the RGH WHC between July 1, 2017 and June 30, 2018. We obtained medical and surgical abortion information from that year and the preceding one from an administrative database. Statistical methods were used to calculate the costs of mife/miso, methotrexate-misoprostol (MTX/miso) and surgical abortion, as well as cost-effectiveness ratios. RESULTS: The proportion of medical abortions increased from 15.4% in 2016/2017 to 28.7% in 2017/2018 (χ21 = 54.629; P < 0.001). Calculated costs for mife/miso, with and without complications were CAD $1173.70 and CAD $1708.90, respectively, versus CAD $871.10 and CAD $1204.10, respectively, for MTX/miso, and CAD $1445.95 and CAD $2261.95, respectively, for hospital-based vacuum aspiration. At a willingness-to-pay threshold of CAD $318 (the cost of mife/miso), statistical modelling showed a 61.3% chance that mife/miso was more cost-effective than surgical abortion and a 90.8% chance that it was more cost-effective than MTX/miso. Patients from Regina were significantly more likely (χ21 = 29.406; P < 0.001) to receive a medical abortion (34.9% of abortions) than those living outside of Regina (19.6% of abortions). CONCLUSION: The proportion of abortions completed medically increased significantly over the period studied. Patients from Regina were more likely to receive medical abortion during both time periods. Mife/miso had a >50% probability of cost-effectiveness over both surgical and MTX/miso options.

Use of synthetic adrenocorticotropic hormone in patients with IgA nephropathy.

BACKGROUND: Synthetic adrenocorticotropic hormone (ACTH) has been demonstrated to be effective in patients with membranous nephropathy, minimal change disease and some histological subtypes of focal segmental glomerulosclerosis. Its clinical impact in patients with IgA nephropathy is currently unclear. CASE PRESENTATION: In this report, we describe the clinical use of ACTH in patients with IgA nephropathy. Three female patients (24-44 years) with overt proteinuria received intramuscular (IM) ACTH for varying time periods (8-14 months). Pre-treatment urine protein varied from 2.9 g/d to 4.3 g/d. CONCLUSIONS: There was complete remission in one patient on ACTH monotherapy and in the other two when prescribed as a steroid-sparing agent in combination with cyclophosphamide. All three had resolution in proteinuria to less than 1 g/d and maintained their GFR to baseline values. There were no reported side effects at a once a week dose. This study illustrates that ACTH is an effective agent that is well tolerated with minimal side effects and can be used as an alternative to prednisone in patients with IgA nephropathy.

Identifying Barriers to Healthcare Access for New Immigrants: A Qualitative Study in Regina, Saskatchewan, Canada.

Despite universal healthcare, immigrants often face unique challenges accessing healthcare. Employing an interpretative phenomenological analysis approach, four focus groups were conducted with 29 women and eight men from 15 different countries attending English language classes hosted at a non-governmental organization in Regina, Saskatchewan, Canada in 2016 and 2017. Personal factors such as language barrier, lack of transportation, childcare and others interacted with systemic factors such as lack of appointment, long wait times, etc. delaying access at each point of contact with the healthcare system. Participants expressed dissatisfaction with the potency of medications, time spent in appointments and the way healthcare professionals communicated health information. The referral process and wait times were viewed as barriers to accessing specialist, diagnostic and acute care services. Participants were concerned that appropriate healthcare will be unavailable when needed. Strategies addressing systemic and person-specific barriers are needed to provide equitable client-centered care.

Assessment of Knowledge, Comfort, and Skills Working with Transgender Clients of Saskatchewan Family Physicians, Family Medicine Residents, and Nurse Practitioners.

People who are transgender and gender diverse (TGD) report suboptimal care from health care providers. A cross-sectional survey was codesigned with community partners to assess the knowledge, comfort, and skills of family physicians, family medicine residents, and nurse practitioners working with TGD patients in Saskatchewan. It was administered from August to October 2019. Of 188 participants, 30% and 96% were comfortable providing transition-related and non-transition-related medical care to patients who are TGD, respectively. Interest in further training in providing transition-related medical care and cultural safety was high. No significant differences between provider groups were observed. Based on our results, provincial training initiatives will be undertaken.

The Royal Canadian Mounted Police (RCMP) Study: protocol for a prospective investigation of mental health risk and resilience factors. / Étude de la Gendarmerie royale du Canada : protocole d'enquête prospective sur les facteurs de risque et de résilience en matière de santé mentale.

The Royal Canadian Mounted Police (RCMP), like all public safety personnel (PSP), are frequently exposed to potentially psychologically traumatic events that contribute to posttraumatic stress injuries (PTSI). Addressing PTSI is impeded by the limited available research. In this protocol paper, we describe the RCMP Study, part of the concerted efforts by the RCMP to reduce PTSI by improving access to evidence-based assessments, treatments and training as well as participant recruitment and RCMP Study developments to date. The RCMP Study has been designed to (1) develop, deploy and assess the impact of a system for ongoing annual, monthly and daily evidence-based assessments; (2) evaluate associations between demographic variables and PTSI; (3) longitudinally assess individual differences associated with PTSI; (4) augment the RCMP Cadet Training Program with skills to proactively mitigate PTSI; and (5) assess the impact of the augmented training condition (ATC) versus the standard training condition (STC). Participants in the STC (n = 480) and ATC (n = 480) are assessed before and after training and annually for 5 years on their deployment date; they also complete brief monthly and daily surveys. The RCMP Study results are expected to benefit the mental health of all participants, RCMP and PSP by reducing PTSI among all who serve.

Research is limited on how to mitigate posttraumatic stress injuries (PTSIs) among Royal Canadian Mounted Police (RCMP) who are exposed to potentially psychologically traumatic events. The RCMP Study has been designed to develop, deploy and assess the impact of skills taught to proactively mitigate PTSI. RCMP cadets recruited into the study to receive the augmented training are assessed before and after training and annually for 5 years on their deployment date. The RCMP Study results are expected to benefit the mental health of study participants, RCMP and other public safety personnel by mitigating PTSI among all who serve.

On dispose de peu de recherches sur les moyens d'atténuer les blessures de stress post­traumatique chez les membres de la Gendarmerie royale du Canada (GRC) qui sont exposés à des événements potentiellement traumatiques sur le plan psychologique. L'étude de la GRC a été conçue pour mettre au point des compétences permettant d'atténuer de façon proactive les blessures de stress post­traumatique, pour intégrer ces compétences à la formation offerte aux cadets et pour en évaluer les effets. Les cadets de la GRC recrutés dans le cadre de l'étude en vue de suivre une formation renforcée sont évalués avant et après la formation ainsi que chaque année pendant cinq ans à compter de la date de leur déploiement. Les résultats de l'étude de la GRC devraient être bénéfiques pour la santé mentale des participants de l'étude, pour la GRC et pour les autres membres du personnel de la sécurité publique, en contribuant à atténuer les blessures de stress post­traumatique de tous ceux qui sont au service de la population.

Assessing the impact of the Royal Canadian Mounted Police (RCMP) protocol and Emotional Resilience Skills Training (ERST) among diverse public safety personnel.

BACKGROUND: Public safety personnel (PSP; e.g., border services personnel, correctional workers, firefighters, paramedics, police, public safety communicators) are frequently exposed to potentially psychologically traumatic events. Such events contribute to substantial and growing challenges from posttraumatic stress injuries (PTSIs), including but not limited to posttraumatic stress disorder. METHODS: The current protocol paper describes the PSP PTSI Study (i.e., design, measures, materials, hypotheses, planned analyses, expected implications, and limitations), which was originally designed to evaluate an evidence-informed, proactive system of mental health assessment and training among Royal Canadian Mounted Police for delivery among diverse PSP (i.e., firefighters, municipal police, paramedics, public safety communicators). Specifically, the PSP PTSI Study will: (1) adapt, implement, and assess the impact of a system for ongoing (i.e., annual, monthly, daily) evidence-based assessments; (2) evaluate associations between demographic variables and PTSI; (3) longitudinally assess individual differences associated with PTSI; and, (4) assess the impact of providing diverse PSP with a tailored version of the Emotional Resilience Skills Training originally developed for the Royal Canadian Mounted Police in mitigating PTSIs based on the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders. Participants are assessed pre- and post-training, and then at a follow-up 1-year after training. The assessments include clinical interviews, self-report surveys including brief daily and monthly assessments, and daily biometric data. The current protocol paper also describes participant recruitment and developments to date. DISCUSSION: The PSP PTSI Study is an opportunity to implement, test, and improve a set of evidence-based tools and training as part of an evidence-informed solution to protect PSP mental health. The current protocol paper provides details to inform and support translation of the PSP PTSI Study results as well as informing and supporting replication efforts by other researchers. TRIAL REGISTRATION: Hypotheses Registration: aspredicted.org, #90136. Registered 7 March 2022-Prospectively registered. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05530642. Registered 1 September 2022-Retrospectively registered. The subsequent PSP PTSI Study results are expected to benefit the mental health of all participants and, ultimately, all PSP.

Opportunity costs of attending surgical clinic appointments and experiences with telemedicine for follow-up care.

OBJECTIVES: Telemedicine has been rapidly implemented in orthopedics during the coronavirus (COVID-19) pandemic. The purpose of this study was to quantify opportunity costs for patients attending typical in-person appointments and understand their perceptions of telemedicine for follow-up care. METHODS: A cross-sectional study was performed by surveying patients who had elective orthopedic surgery and attended at least one in-person and one phone call appointment. The survey assessed opportunity costs associated with in-person appointments, experience with telemedicine, and preferred type of future appointment. RESULTS: Of the 49 eligible patients, 41 (83.7%) completed the survey. The median travel distance to the clinic was 108 km, and the time spent in the clinic was 60 min. Participants responded "yes" to various forms of opportunity costs associated with attending in-person appointments, including missed work (46.3%), lost income (34.1%), recreational activities (26.8%), home or yard care (14.6%), socializing with friends or family (12.2%), school (2.4%), and childcare (2.4%). In addition, elements of the telemedicine appointment were rated from 1 (least favorable) to 10 (most favorable), and averages were calculated for ease of use (9.2), convenience (8.4), confidence in the doctor's diagnostic ability (8.2), likelihood of using the service again (6.4), and overall satisfaction (8.2). Preferred future appointment types included having the first visit in-person and subsequent visits via telephone (61.0%), in-person only (36.6%), and unsure (2.4%). CONCLUSION: This study identifies various opportunity costs associated with in-person orthopedic appointments and a favorable view toward telemedicine for follow-up care.

Interpretation and management of genetic test results by Canadian family physicians: a multiple choice survey of performance.

Family physicians (FPs) will encounter genetic concerns within community practice. To determine how FPs compare to genetic counselors (GCs), a cross-sectional survey was distributed to Canadian FPs and GCs in 2019. The survey assessed risk analysis, counseling, and management of genetic information. FPs performed less well than GCs on each survey question and scenario (p < 0.05). Average overall survey scores for FPs were lower than GCs (62% vs. 93%, p < 0.001). Additional genetic training for FPs may help avoid potential harm.

Community-Based Dialysis in Saskatchewan First Nations: A Grassroots Approach to Gaining Insight and Perspective From First Nations Patients With Chronic Kidney Disease.

BACKGROUND: Renal replacement options or dialysis can be delivered in the home setting or hospital setting. Home dialysis offers a number of benefits over hospital-delivered dialysis. These advantages include improved quality of life, less travel, and fewer dietary restrictions. Despite the benefits, home-based dialysis therapies are significantly underutilized by First Nations with only 16.2% uptake versus 25.7% uptake in non-First Nations people in Saskatchewan. It is important to recognize that First Nations have a greater burden of end-stage renal disease including higher prevalence, younger age at diagnosis, increased severity of disease, mortality at an earlier age, and increased travel distance to access kidney services. OBJECTIVE: The goal of this study is to identify the existing barriers to home peritoneal dialysis and provide insight for future programs in Saskatchewan First Nations communities in a culturally meaningful framework. DESIGN: Through qualitative research utilizing sharing circles and individual interviews, barriers to utilizing home-based dialysis were identified. SETTING: Four sharing circles were held and interviews were conducted with four First Nations dialysis patients. PARTICIPANTS: Total number of participants in sharing circles were 67. Sharing circles were composed of patients with chronic kidney disease, patients on hospital-based dialysis, patients on home-based peritoneal dialysis, family members, health care providers (nurses, physicians, dietitians, primary care director, and coordinators). Face-to-face interviews were conducted with four First Nations dialysis patients. MEASUREMENTS: The data from the sharing circles and interviews were transcribed and analyzed by a PhD researcher using constructivist grounded theory, with elements of narrative inquiry to ascertain participants' experiences of care. Data were coded and then grouped into categories using qualitative research software NVivo. Saturation of data was achieved. METHODS: Documenting and recounting patient and community experience with chronic kidney disease through sharing circles involving patients, family members, and health care providers has been the central information base for this project. Qualitative interviews were conducted with patients who currently use home dialysis and those who travel to hospital for dialysis. Written consent was obtained from all participants. Information was gathered via audio recording of all sharing circles and interviews. Transcription of the interviews was completed with confidentiality maintained during transcription. RESULTS: The main theme of our results was addressing the underutilization of home-based peritoneal dialysis in First Nations Communities. Five subthemes emerged from the main theme and included logistics, education and information, training and support, community support, and culture and leadership. Through sharing circles, a secondary theme of observations about living with chronic kidney disease and experiences of being on dialysis was explored. LIMITATIONS: A small number of First Nations communities were involved in this project, and although the data reached saturation, we cannot presume that the information is representative of all First Nations in Saskatchewan. There were a limited number of patients currently on home-based peritoneal dialysis, and therefore their perceptions may not be adequately captured. Participant characteristics (patient, caregiver, nurse, etc) were not captured when speaking in the sharing circles, and therefore participants are not classified when quoted. CONCLUSIONS: Strategies to help improve home-based dialysis included improved education, local support, integrated traditional medicine, cultural sensitivity, and leadership prioritization.

CONTEXTE: La dialyse et les autres modalités de remplacement rénal sont offertes en centre ou au domicile du patient. La dialyse à domicile offre de nombreux avantages comparativement à la dialyse en centre, notamment une meilleure qualité de vie, et requiert moins de déplacements et de restrictions alimentaires. Néanmoins, cette modalité continue d'être sous-utilisée par les patients autochtones en Saskatchewan (16,2 % contre 25,7 % dans la population allochtone). Il convient de souligner que le fardeau de l'insuffisance rénale terminale est plus important chez les patients autochtones: prévalence plus élevée, diagnostic et mortalité plus précoces, sévérité accrue de la maladie et distances plus grandes à parcourir pour accéder aux services néphrologiques. OBJECTIFS: L'étude vise à recenser les facteurs limitant l'adoption de la dialyse péritonéale à domicile comme modalité, et à fournir un aperçu des programmes à venir dans les communautés des Premières Nations de la Saskatchewan dans un cadre culturellement significatif. TYPE D'ÉTUDE: Nous avons recensé les obstacles au choix de la dialyse à domicile comme modalité de traitement par l'entremise d'une recherche qualitative fondée sur des cercles de partage et des entretiens individuels. CADRE: Quatre cercles de partage ont été tenus et des entretiens ont été conduits auprès de quatre patients autochtones dialysés. PARTICIPANTS: Au total, 67 personnes ont participé aux cercles de partage composés de patients atteints d'insuffisance rénale chronique, de patients dialysés en centre, de patients dialysés à domicile, de membres de leurs familles et de fournisseurs de soins (infirmières, médecins, diététistes, coordinateurs, administrateurs de centres de soins de santé primaires). Quatre patients autochtones traités en dialyse ont été questionnés individuellement. MESURES: Pour catégoriser les expériences de soins, les données recueillies au cours des entretiens et des cercles de partage ont été transcrites et analysées par un chercheur doctorant à l'aide d'une théorie constructiviste fondée sur des éléments d'enquête narrative. Les données ont été codées et groupées en catégories grâce au logiciel d'analyse qualitative NVivo. La saturation des données a été atteinte. MÉTHODOLOGIE: La base d'information centrale de ce projet a été de documenter et de relater l'expérience des communautés autochtones et des patients atteints de néphropathie par l'entremise de cercles de partages impliquant leurs familles et des fournisseurs de soins. Les entretiens qualitatifs ont été menés auprès de patients pratiquant la dialyse à domicile et de patients recevant leurs traitements en centre hospitalier. Le consentement écrit a été obtenu de tous les participants. L'information a été recueillie à partir de l'enregistrement audio des entretiens et des cercles de partage. La transcription des entretiens a été complétée dans le respect de la confidentialité. RÉSULTATS: Le thème principal de notre recherche était d'aborder la sous-utilisation de la dialyse péritonéale à domicile comme modalité dans les communautés autochtones. Cinq sous-thèmes ont découlé du thème principal, soit: a) la logistique, b) l'éducation et l'information, c) la formation et le soutien, d) le soutien de la communauté, et e) la culture et le leadership. Un thème secondaire a été exploré par l'entremise des cercles de partages, soit la collecte d'observations concernant la vie avec l'insuffisance rénale chronique et l'expérience d'être traité en dialyse. LIMITES: Peu de communautés autochtones ont été impliquées dans ce projet et bien que les données aient atteint la saturation, nous ne pouvons présumer que l'information recueillie est représentative de tous les membres des Premières Nations de la Saskatchewan. Un faible nombre de patients était traité par dialyse à domicile; dès lors, leurs perceptions pourraient ne pas être saisies adéquatement. Les caractéristiques des participants (patients, fournisseurs de soins, infirmières, etc.) n'ont pas été colligées lors des cercles de partage et ainsi, les participants ne sont pas classés lorsque cités. CONCLUSION: Les stratégies visant à favoriser la dialyse à domicile incluaient l'amélioration de l'éducation, le soutien local, l'intégration des pratiques de la médecine traditionnelle, une approche tenant compte des différences culturelles et la priorisation de la part des intervenants.

A Case Report of Nephrotic Syndrome While Undergoing Quinine Therapy.

We summarize the case of an 81-year-old Caucasian female who presented to her family physician with signs and symptoms of nephrotic syndrome following a brief exposure to quinine. Prior to that visit, she was clinically well with no chronic medical ailments and met with her family physician for annual physical assessments. She had taken 11 tablets of quinine for nocturnal leg cramps over the course of 28 days before starting to notice mild peripheral edema, which subsequently progressed, leading to a family physician review. Her initial serum albumin level was 12 g/L, and a 24-hour urine protein output was quantified at 8.14 g/day; she was diagnosed as having nephrotic syndrome. A kidney biopsy confirmed the diagnosis of minimal change disease (MCD). Quinine therapy was stopped, and she was initiated on a tapering regime of prednisone with concurrent cyclosporine therapy. Within a fortnight of starting therapy, she went into remission and her immunosuppressive medications were rapidly tapered and discontinued. This paper reports an association between the use of quinine and subsequent MCD. This case report proposes that the use of quinine has an association with, and may be causal for, the development of minimal change disease. As this is yet an unreported adverse effect, this paper seeks to increase the knowledge of the varied and numerous effects of quinine.

A Retrospective Study of Chronic Kidney Disease Burden in Saskatchewan's First Nations People.

BACKGROUND: Chronic kidney disease is more prevalent among First Nations people than in non-First Nations people. Emerging research suggests that First Nations people are subject to greater disease burden than non-First Nations people. OBJECTIVE: We aimed to identify the severity of chronic kidney disease and quantify the geographical challenges of obtaining kidney care by Saskatchewan's First Nations people. DESIGN: This study is a retrospective analysis of the provincial electronic medical record clinical database from January 2012 to December 2013. SETTING: The setting involved patients followed by the Saskatchewan provincial chronic kidney care program, run out of two clinics, one in Regina, SK, and one in Saskatoon, SK. PATIENTS: The patients included 2478 individuals (379 First Nations and 2099 non-First Nations) who were older than 18 years old, resident in Saskatchewan, and followed by the provincial chronic kidney care program. First Nations individuals were identified by their Indigenous and Northern Affairs Canada (INAC) Number. MEASUREMENTS: The demographics, prevalence, cause of end-stage renal disease, severity of chronic kidney disease, use of home-based therapies, and distance traveled for care among patients are reported. METHODS: Data were extracted from the clinical database used for direct patient care (the provincial electronic medical record database for the chronic kidney care program), which is prospectively managed by the health care staff. Actual distance traveled by road for each patient was estimated by a Geographic Information System Analyst in the First Nations and Inuit Health Branch of Health Canada. RESULTS: Compared with non-First Nations, First Nations demonstrate a higher proportion of end-stage renal disease (First Nations = 33.0% vs non-First Nations = 21.4%, P < .001), earlier onset of chronic kidney disease (MFN = 56.4 years, SD = 15.1; MNFN = 70.6 years, SD = 14.7, P < .001), and higher rates of end-stage renal disease secondary to type 2 diabetes (First Nations = 66.1% vs non-First Nations = 39.0%, P < .001). First Nations people are also more likely to be on dialysis (First Nations = 69.7% vs non-First Nations = 40.2%, P < .001), use home-based therapies less frequently (First Nations = 16.2% vs non-First Nations = 25.7%; P = 003), and must travel farther for treatment (P < .001), with First Nations being more likely than non-First Nations to have to travel greater than 200 km. LIMITATIONS: Patients who are followed by their primary care provider or solely through their nephrologist's office for their chronic kidney disease would not be included in this study. Patients who self-identify as Aboriginal or Indigenous without an INAC number would not be captured in the First Nations cohort. CONCLUSIONS: In Saskatchewan, First Nations' burden of chronic kidney disease reveals higher severity, utilization of fewer home-based therapies, and longer travel distances than their non-First Nations counterparts. More research is required to identify innovative solutions within First Nations partnering communities.

CONTEXTE: La prévalence de l'insuffisance rénale chronique (IRC) est plus élevée chez les autochtones (AUT) que chez les allochtones (ALL); de nouvelles études indiquent que les Premières Nations seraient davantage affligés que les allochtones par le fardeau de la maladie. OBJECTIFS: Notre objectif était bipartite : i) mesurer la gravité de l'IRC chez les autochtones et; ii) quantifier le défi géographique posé par la distance que les Saskatchewanais autochtones ont à parcourir pour obtenir des soins de santé rénale. TYPE D'ÉTUDE: L'étude est une analyse rétrospective de la base de données provinciale des dossiers médicaux informatisés pour la période s'échelonnant de janvier 2012 à décembre 2013. CADRE: L'étude concerne les patients suivis dans deux cliniques saskatchewanaises (une à Régina et une autre à Saskatoon) participant au programme provincial de soins des maladies rénales chroniques. SUJETS: L'étude porte sur 2 478 patients adultes (379 autochtones et 2 099 allochtones) résidents de la Saskatchewan et suivis par le programme provincial de soins des maladies rénales chroniques. Les membres des Premières Nations ont été identifiés par leur numéro de Certificat de statut Indien (CSI) émis par le ministère des Affaires Autochtones et du Nord Canada (AADNC*). MESURES: Ont été colligées les données démographiques des patients, la prévalence de la maladie, les causes de l'insuffisance rénale terminale (IRT), la gravité de l'atteinte, le recours ou non à des traitements à domicile, et la distance à parcourir pour obtenir des soins. MÉTHODOLOGIE: Les données ont été extraites de la base de données cliniques utilisée pour les soins directs aux patients (dossiers médicaux informatisés du programme de soin des maladies rénales chroniques), gérée prospectivement par le personnel soignant. La distance parcourue par le patient pour obtenir des soins a été estimée par un analyste du système d'informations géographiques de la Direction générale de la santé des Premières Nations et des Inuits, de Santé Canada. RÉSULTATS: Comparativement aux patients allochtones, les patients autochtones : présentaient une plus grande prévalence d'IRT (33,0 % vs 21,4 %; p < 0,001); présentaient un déclenchement plus précoce de la maladie (âge moyenAUT : 56,4 ans [SD=15,1]; âge moyenALL : 70,6 ans [SD=14,7]; p < 0,001) et un taux plus élevé d'IRT consécutive à un diabète de type 2 (66,1 % vs 39,0 %; p < 0,001); étaient plus susceptibles d'être dialysés (69,7 % vs 40,2 %; p < 0,001); recouraient moins à des traitements à domicile (AUT : 16,2 %; ALL : 25,7 %; p = 0,003); et étaient contraints de se déplacer davantage pour suivre leurs traitements (p < 0,001) ­ notamment, les autochtones étaient plus susceptibles de devoir parcourir au-delà de 200 km pour obtenir des soins. LIMITES: Les patients qui recevaient leurs traitements chez leur fournisseur de soins primaires ou uniquement via le cabinet de leur néphrologue n'étaient pas inclus dans l'étude. Les patients s'identifiant comme autochtones, mais ne possédant pas de numéros de CSI, n'ont pu être répertoriés aux fins de l'étude. CONCLUSION: En Saskatchewan, le fardeau différentiel que représente l'IRC chez les gens issus des Premières Nations se traduit par une atteinte plus sévère, par un moindre recours aux traitements à domicile et par de plus grandes distances à parcourir pour obtenir des soins. Des recherches supplémentaires sont requises pour proposer des solutions innovantes aux communautés partenaires des Premières Nations.

Cyclooxygenase-2 inhibitor-induced acute interstitial nephritis.

A 64-year-old female patient presented to the emergency department with a 3-week history of persistent nausea and vomiting. Her serum creatine prior to admission was 118 µmol/L and on presentation was elevated to 420 µmol/L. On clinical history, she indicated that 3 weeks prior, she had been initiated on a cyclooygenase-2 (COX-2) inhibitor, celecoxib, for her osteoarthritis of her knees. Renal biopsy confirmed the diagnosis of acute interstitial nephritis (AIN). Celecoxib was discontinued and the patient's renal function improved to a discharge creatine of 205-220 µmol/L. Nine months later, her creatine had decreased to 195 µmol/L and she was initiated on tapering doses of prednisone therapy for 4 months, after which time her creatine had improved further to 143 µmol/L. She was later transitioned to mycophenolatemofetil for 9 months and her creatine improved to 110 µmol/L. This report provides further evidence that COX-2 inhibitors are associated with AIN.

The Impact on Central Blood Pressure and Arterial Stiffness Post Renal Denervation in Patients With Stage 3 and 4 Chronic Kidney Disease: The Prairie Renal Denervation Study.

BACKGROUND: Central aortic blood pressures and arterial stiffness are better indicators of cardiovascular outcomes than brachial blood pressures. However, their response to renal denervation (RDN) in patients with stage 3 and stage 4 chronic kidney disease (CKD) has not yet been examined. OBJECTIVE: To evaluate the impact of RDN on central blood pressures, brachial (office and ambulatory) blood pressures, arterial stiffness, glomerular filtration rate (GFR), 24-hour urine protein, and selective cardiac parameters observed on echocardiograms. DESIGN: Single-center, single-arm with pre-RDN/post-RDN follow-up. SETTING: Patients are being recruited from the multidisciplinary CKD clinic. PATIENTS: Fifty consecutive patients with stage 3 or stage 4 CKD and resistant hypertension, with no radiological or laboratory evidence of secondary causes of hypertension. MEASUREMENTS: The key measurements are central blood pressures, pulse wave velocity, ambulatory 24-hour blood pressure, office blood pressures on BP Tru, GFR, 24-hour urine protein and sodium, blood pressure medication, and doses. METHODS: For our primary outcome, we will compare changes in central blood pressures from baseline to 6 months post RDN using a paired t test or Mann-Whitney U test. Secondary outcomes will examine changes in central blood pressures from baseline to 3, 12, 18, and 24 months post RDN as well as changes in office pressures, GFR, 24-hour urine protein and sodium, and medications at all time points using mixed-model analyses of variance or Friedman test. Multiple regression may be used to control for potential covariates. LIMITATIONS: Single-center study, with no sham arm. CONCLUSIONS: Aortic blood pressure, rather than brachial blood pressure, optimally reflects the load placed on the left ventricle. Aortic blood pressure is also better associated with cardiovascular outcomes. If our study shows a preferential decrease in central blood pressures and improvements in cardiac parameters on echocardiograms post RDN, this may influence the way in which blood pressures are managed in clinics and offices. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01832233).

CONTEXTE: La mesure de la pression centrale et de la rigidité artérielle sont de meilleurs indicateurs de troubles cardiovasculaires que la mesure de la pression sanguine par l'artère brachiale. Cependant, leur réponse à une dénervation rénale chez les patients atteints d'insuffisance rénale chronique (IRC) de stade 3 et 4 n'a pas encore été étudiée. OBJECTIF DE L'ÉTUDE: Évaluer l'effet d'une dénervation rénale sur les mesures de la pression artérielle centrale et brachiale (par le médecin ou ambulatoire), sur la rigidité artérielle, le débit de filtration glomérulaire (DFG), le taux de protéines dans les urines sur une période de 24 heures, de même que sur les paramètres cardiaques sélectifs observés sur les échocardiogrammes. TYPE D'ÉTUDE: Une étude à une seule branche avec un suivi des patients avant et après la dénervation rénale. CADRE DE L'ÉTUDE: Les patients sont recrutés au sein d'une clinique multidisciplinaire spécialisée dans les soins offerts aux personnes atteintes d'IRC. PATIENTS: Cinquante patients atteints à la fois d'IRC de stade 3 ou de stade 4 et d'hypertension résistante, et pour qui il n'existe aucun signe radiologique ou biochimique de causes secondaires de l'hypertension. MESURES: Les principaux paramètres qui seront analysés sont la pression centrale, la vélocité de l'onde de pouls, la pression artérielle mesurée par le patient lui-même (ambulatoire) sur une période de 24 heures, la pression sanguine mesurée par BP Tru dans le bureau du médecin, le DFG, le taux de protéines et de sodium dans les urines sur 24 heures, de même que la liste des médicaments prescrits pour traiter l'hypertension et les doses correspondantes. MÉTHODOLOGIE: Pour atteindre notre objectif principal, nous allons comparer les variations de la valeur de la pression centrale mesurée six mois après la dénervation rénale par rapport à la valeur initiale. Cette comparaison sera effectuée à l'aide d'un test T jumelé ou d'un test U de Mann-Whitney. Les résultats secondaires examineront les variations observées dans la mesure de la pression centrale initiale par rapport aux mesures faites à 3, 12, 18 et 24 mois après la dénervation rénale. On analysera également les variations dans les valeurs de la pression artérielle mesurées au bureau du médecin, dans les valeurs de DFG et dans les taux de protéines et de sodium mesurés dans les urines sur 24 heures. Tout au long de l'étude, les changements dans la médication seront analysés en utilisant le modèle mixte d'ANOVA ou le Test de Friedman. Un modèle de régression multiple pourrait aussi être utilisé pour tenir compte des possibles covariables. LIMITE DE L'ÉTUDE: Les résultats seront limités par le fait qu'il s'agit d'une étude à une seule branche et qu'elle se tiendra dans un seul établissement. CONCLUSIONS: La mesure de la pression centrale reflète, mieux que la mesure de la pression de l'artère brachiale, la charge imposée au ventricule gauche. La pression sanguine à la sortie de l'aorte est également associée de façon plus spécifique aux troubles cardiovasculaires. Si notre étude montre une diminution préférentielle de la pression centrale et une amélioration des paramètres cardiaques observés sur les échocardiogrammes pratiqués, ces résultats seraient susceptibles d'influencer la façon dont la pression artérielle est prise en charge dans les cliniques et les bureaux de médecins.

Assessment and Treatment for Persons with Coexisting Ability and Substance Use Issues: A Review and Analysis of the Literature.

Persons with ability issues are at considerably higher risk to develop substance use problems when compared to the general population. Yet, little is known about the current status of substance use treatment for this population. A comprehensive search of the literature revealed a need for (a) population-specific instruments for screening and assessment of the use of alcohol and drugs, including the misuse of prescription medication; (b) tailored treatment methods and individualized treatment plans that meet diverse literacy or cognitive needs;

Stability and change in children's division strategies.

Age-related changes in children's performance on simple division problems (e.g., 6/2, 72/9) were investigated by asking children in Grades 4 through 7 to solve 32 simple division problems. Differences in performance were found across grade, with younger children performing more slowly and less accurately than older children. Problem size effects were also found in that children were faster and more accurate on small problems than on large problems. Two strategies changed across age, with children in Grade 4 relying heavily on the strategy of "addition" (adding the divisor until the dividend was reached) to solve the problems and children in Grades 5 through 7 relying primarily on the strategy of "multiplication" (recasting the division problem as a multiplication problem) to solve the problems. Surprisingly, the frequency of direct retrieval (retrieving the answer directly from memory) did not increase across grade and never became the dominant strategy of choice. Reasons for why retrieval use remains infrequent and age invariant are discussed. Overall, the results suggest that division is a unique operation and that the continued study of division may have implications for further understanding of how procedural and conceptual knowledge of arithmetic develops.