Impact of surgical lung biopsy on lung function and survival in patients with idiopathic pulmonary fibrosis in a multi-centre registry cohort.

BACKGROUND AND OBJECTIVE: Establishing an accurate and timely diagnosis of idiopathic pulmonary fibrosis (IPF) is essential for appropriate management and prognostication. In some cases, surgical lung biopsy (SLB) is performed but carries non-negligible risk. The objective of this retrospective study was to determine if SLB is associated with accelerated lung function decline in patients with IPF using the Canadian Registry for Pulmonary Fibrosis. METHODS: Linear mixed models and Cox proportional hazards regression models were used to compare decline in forced vital capacity (FVC)%, diffusion capacity of the lung (DLCO%) and risk of death or lung transplantation between SLB and non-SLB patients. Adjustments were made for baseline age, sex, smoking history, antifibrotic use, and lung function. A similar analysis compared lung function changes 12 months pre- and post-SLB. RESULTS: A total of 81 SLB patients and 468 non-SLB patients were included. In the SLB group, the post-biopsy annual FVC% decline was 2.0% (±0.8) in unadjusted, and 2.1% (±0.8) in adjusted models. There was no difference in FVC% decline, DLCO% decline, or time to death or lung transplantation between the two groups, in adjusted or unadjusted models (all p-values >0.07). In the pre-post SLB group, no differences were identified in FVC% decline in unadjusted or adjusted models (p = 0.07 for both). CONCLUSION: No association between SLB and lung function decline or risk of death or lung transplantation was identified in this multi-centre study of patients with IPF.

Task-oriented exercise effects on walking and corticospinal excitability in multiple sclerosis: protocol for a randomized controlled trial.

BACKGROUND: Multiple sclerosis (MS) is a degenerative disease of the central nervous system (CNS) that disrupts walking function and results in other debilitating symptoms. This study compares the effects of 'task-oriented exercise' against 'generalized resistance and aerobic exercise' and a 'stretching control' on walking and CNS function in people with MS (PwMS). We hypothesize that task-oriented exercise will enhance walking speed and related neural changes to a greater extent than other exercise approaches. METHODS: This study is a single-blinded, three-arm randomized controlled trial conducted in Saskatchewan, Canada. Eligible participants are those older than 18 years of age with a diagnosis of MS and an expanded Patient-Determined Disease Steps (PDDS) score between 3 ('gait disability') and 6 ('bilateral support'). Exercise interventions are delivered for 12 weeks (3 × 60-min per week) in-person under the supervision of a qualified exercise professional. Interventions differ in exercise approach, such that task-oriented exercise involves weight-bearing, walking-specific activities, while generalized resistance and aerobic exercise uses seated machine-based resistance training of major upper and lower body muscle groups and recumbent cycling, and the stretching control exercise involves seated flexibility and relaxation activities. Participants are allocated to interventions using blocked randomization that stratifies by PDDS (mild: 3-4; moderate: 5-6). Assessments are conducted at baseline, post-intervention, and at a six-week retention time point. The primary and secondary outcome measures are the Timed 25-Foot Walk Test and corticospinal excitability for the tibialis anterior muscles determined using transcranial magnetic stimulation (TMS), respectively. Tertiary outcomes include assessments of balance, additional TMS measures, blood biomarkers of neural health and inflammation, and measures of cardiorespiratory and musculoskeletal fitness. DISCUSSION: A paradigm shift in MS healthcare towards the use of "exercise as medicine" was recently proposed to improve outcomes and alleviate the economic burden of MS. Findings will support this shift by informing the development of specialized exercise programming that targets walking and changes in corticospinal excitability in PwMS. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05496881, Registered August 11, 2022. https://classic. CLINICALTRIALS: gov/ct2/show/NCT05496881 . Protocol amendment number: 01; Issue date: August 1, 2023; Primary reason for amendment: Expand eligibility to include people with all forms of MS rather than progressive forms of MS only.

Treatment of rheumatoid arthritis-associated interstitial lung disease in a multi-center registry cohort.

Background: Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is challenging to manage, with a paucity of robust data to guide treatment. Our aim was to characterize the pharmacologic treatment of RA-ILD utilizing a retrospective design in a national multi-center prospective cohort, and to identify associations between treatment and change in lung function and survival. Methods: Patients with RA-ILD and a radiological pattern of non-specific interstitial pneumonia (NSIP) or usual interstitial pneumonia (UIP) were included. Unadjusted and adjusted linear mixed models and Cox proportional hazards models were used to compare lung function change and risk of death or lung transplant by radiologic patterns and treatment. Results: Of 161 patients with RA-ILD, UIP pattern was more common than NSIP (55.9% vs. 44.1%). Only 44/161 (27%) patients were treated over median follow-up of 4 years with medication choice appearing unrelated to patient-specific variables. Decline in forced vital capacity (FVC) was not associated with treatment. Patients with NSIP had lower risk of death or transplant, compared to UIP (P=0.0042). In patients with NSIP, there was no difference in time to death or transplant comparing treated to untreated in adjusted models [hazard ratio (HR) =0.73; 95% confidence interval (CI): 0.15-3.62; P=0.70]. Similarly, in patients with UIP, there was no difference in time to death or lung transplant between treated and untreated in adjusted models (HR =1.06; 95% CI: 0.49-2.28; P=0.89). Conclusions: Treatment of RA-ILD is heterogeneous, with most patients in this cohort not receiving treatment. Patients with UIP had worse outcomes compared to NSIP, similar to other cohorts. Randomized clinical trials are needed to inform pharmacologic therapy in this patient population.

A comparison of isometric and isokinetic normalization methods for electromyographic data from sub-regions of supraspinatus and infraspinatus during dynamic tasks.

This study explored effects of using isometric versus isokinetic maximal voluntary contractions (MVCs) to normalize EMG data from supraspinatus and infraspinatus subregions during isokinetic tasks. Participants performed submaximal isokinetic external rotation (ER) and scaption tasks at two speeds. Three isometric MVCs were used: seated ER; side-lying scaption; side-lying abduction. Isokinetic MVCs were performed in the same position and speeds as the experimental tasks. Data were normalized using peak EMG from reference tasks: MVC which produced the greatest amplitude overall (MEA), isometric MVC with greatest amplitude (isometric best), isokinetic MVC with greatest amplitude (isokinetic best), and the greatest amplitude from the isokinetic MVC that matched the experimental task (isokinetic matched). Mean %MVC from each experimental task/ sub-region were compared by normalization method. The isokinetic matched method versus the MEA method was significantly different in all comparisons with isokinetic matched resulting in relative normalized task values up to 162% greater. The isometric best method resulted in significantly greater %MVC 37% of the time compared to the MEA method, whereas there were no differences when using isokinetic best compared to MEA. Isokinetic MVCs are less likely to overestimate %MVC than isometric and their use should be considered when normalizing data from dynamic tasks.

Prognostic effect of HIV on visual acuity in ocular syphilis: a systematic review.

BACKGROUND/OBJECTIVES: Ocular syphilis is a vision-threatening disease that can lead to permanent blindness if left untreated. The global re-emergence of syphilis warrants greater investigations into the visual prognosis of eyes affected by this potentially devastating disease. This systematic review investigates the impact of HIV on visual acuity (VA) outcomes in ocular syphilis. METHODS: A literature search of Medline, PubMed, Embase, Clinicaltrials.gov and Cochrane Reviews was conducted for studies published between 01 January 2011 and 19 March 2022, reporting non-aggregate initial and post-treatment VA data of eyes with ocular syphilis and corresponding HIV status in patients ≥ 18 years. RESULTS: A total of 95 studies, including 364 patients and 568 eyes, were evaluated. Among people living with HIV with a diagnosis of ocular syphilis, affected eyes were more likely to have optic nerve involvement and panuveitis. However, HIV status, CD4 cell count, and HIV viral load were not predictive of VA outcomes of treated ocular syphilis. Prognostic factors of final VA worse than 1.00 logMAR were female sex, the presence of macular edema, and VA ≥ 1.00 at presentation. The strongest predictor of a worse final VA was VA ≥ 1.00 at presentation. CONCLUSIONS: This systematic review demonstrates that HIV status, CD4 cell count, and HIV viral load are not significant factors impacting VA outcomes of eyes with ocular syphilis. While visual prognosis is generally good, poor visual outcome is most strongly predicted by poor VA at presentation. This underscores the importance of early recognition and treatment prior to permanent vision loss.

The influence of a Learning to Forgive Program on institutional offending and recidivism among offenders with mental disorder.

Previous researchers have demonstrated that learning to forgive may reduce the likelihood of offending/reoffending. Forgiveness therapy may be useful for rehabilitation by assisting traumatized individuals to release revengeful emotions. The current study is a follow up to a previous study that examined the effects of a 6-week forgiveness psychoeducational intervention for offenders with mental disorders. The aim of the current study was to determine any differences for participants who received a forgiveness intervention versus a control group for rates of recidivism (likelihood of reoffending and length of time to reoffend) and type of institutional offense. Recidivism data was collected through the Canadian Police Information Center. Both the control and treatment group in this study were selected from offenders with mental disorder at the Regional Psychiatric Centre, a multilevel forensic psychiatry hospital in Saskatoon, Canada. Results indicated that participants who received the forgiveness intervention took significantly longer than the control group to both commit non-violent offenses, and to be convicted of any offense. Results suggest that forgiveness therapy for offender populations may improve behavior and reduce recidivism.

Bringing Radiology Education to a New Reality: A Pilot Study of Using Virtual Reality as a Remote Educational Tool.

Purpose: We investigated virtual reality (VR) during a 2-week, undergraduate, radiology elective to determine if it improved learning outcomes and user satisfaction. Methods: Eighteen students enrolled between August 2021 and February 2022. Each student had a collaborative Zoom teaching session with a preceptor using a Picture Archive and Communications System (PACS)-like viewing system Online DICOM Image Navigator (ODIN), followed by a teaching session using a VR, Digital Imaging and Communications in Medicine (DICOM) viewer (SieVRt). After each teaching session, the students independently reviewed 8 imaging cases and completed case related questions. The students completed a survey, rating their subjective experiences using ODIN and SieVRt. Results: There was no difference in total test scores between the two learning strategies. However, students did perform statistically better on two of five questions designed to test the detection/measurement capabilities of SieVRt vs ODIN. Students stated that they preferred using SieVRt over ODIN and agreed that they were able to view subtle imaging findings and abnormalities better using SieVRt. However, students found that some of the functions of SieVRt (measuring angles/lengths, and multitasking) were difficult. There were technical challenges with VR and minor undesirable physical effects (dizziness, nausea, etc.). Conclusions: Virtual reality has the potential to enhance radiology education by providing an immersive and engaging experience. Objectively, students were able to perform two tasks better with SieVRt. Subjectively, the VR platform received favourable reviews from students for a variety of features. There were reported technical and physical challenges related to using VR. Future developments in VR systems should focus on improving the user experience.

Can ED chest pain patients with intermediate HEART scores be managed as outpatients?

PURPOSE: Current guidelines recommend hospital admission for patients who present to the emergency department (ED) with chest pain and are scored as intermediate risk for adverse outcomes based on the HEART score. While hospital admission for these patients allows for timely investigation and treatment, it is a resource-intensive process. This study examines whether intermediate HEART score patients can be safely managed on an outpatient basis through rapid access chest pain clinics. METHODS: This retrospective observational study included all ED chest pain patients referred to rapid access clinics from January 2018 to April 2020 in Regina and Saskatoon, Saskatchewan. ED physician HEART scores were used in lieu of reviewer HEART scores when available. The primary outcome was the rate of major adverse coronary events (MACE), a composite measure of death, acute coronary syndrome, stroke, coronary angiography, and revascularization at 6 weeks in intermediate-risk patients. Secondary outcomes were the type of MACE, rate of MACE before rapid access clinic appointment and the most predictive component of the HEART score. RESULTS: There were 1989 ED referrals, of which 817 were for intermediate-risk patients. 9.3% of intermediate-risk patients had a MACE at 6 weeks. MACE occurred before rapid access clinic follow-up in 1.1% of intermediate-risk patients, with coronary angiography being the most common MACE. Excluding coronary angiography, the risk of MACE before rapid access clinic follow-up was 0.7% in intermediate-risk patients. Components of the HEART score most predictive of MACE were troponin (OR 11.0, 95% CI: 3.7-32.3) and history (5.3, 95% CI: 2.4-11.8). CONCLUSION: This study demonstrates that rapid access clinics are likely a safe alternative to admission for intermediate-risk chest pain patients and could reduce costly inpatient admissions for chest pain. With angiography excluded, MACE rates were well below the American College of Emergency Physicians cited 2% threshold.

RéSUMé: OBJECTIF: Les directives actuelles recommandent l'admission à l'hôpital des patients qui se présentent aux urgences avec une douleur thoracique et qui sont classés comme présentant un risque intermédiaire d'effets indésirables selon le score HEART. Bien que l'hospitalisation de ces patients permette une investigation et un traitement en temps opportun, il s'agit d'un processus exigeant en ressources. Cette étude examine si les patients ayant un score HEART intermédiaire peuvent être pris en charge en toute sécurité en ambulatoire par des cliniques d'accès rapide aux douleurs thoraciques. MéTHODES: Cette étude observationnelle rétrospective a inclus tous les patients souffrant de douleurs thoraciques aux urgences orientés vers des cliniques d'accès rapide de janvier 2018 à avril 2020 à Regina et Saskatoon, en Saskatchewan. Les scores HEART des médecins des urgences ont été utilisés à la place des scores HEART des examinateurs lorsqu'ils étaient disponibles. Le principal résultat était le taux d'événements coronariens indésirables majeurs (MACE), une mesure composite du décès, du syndrome coronarien aigu, de l'accident vasculaire cérébral, de l'angiographie coronaire et de la revascularisation à 6 semaines chez les patients à risque intermédiaire. Les résultats secondaires étaient le type de MACE, le taux de MACE avant un rendez-vous à la clinique d'accès rapide et la composante la plus prédictive du score HEART. RéSULTATS: Il y a eu 1989 orientations vers les urgences, dont 817 pour des patients à risque intermédiaire. 9,3 % des patients à risque intermédiaire ont subi un MACE à 6 semaines. Un MACE est survenu avant le suivi clinique d'accès rapide chez 1,1 % des patients à risque intermédiaire, la coronarographie étant le MACE le plus fréquent. À l'exclusion de l'angiographie coronarienne, le risque de MACE avant le suivi clinique d'accès rapide était de 0,7 % chez les patients à risque intermédiaire. Les composants du score HEART les plus prédictifs de MACE étaient la troponine (OR 11,0, IC 95 % : 3,7-32,3) et les antécédents (5,3, IC 95 % : 2,4-11,8). CONCLUSION: Cette étude démontre que les cliniques d'accès rapide sont probablement une alternative sûre à l'admission pour les patients souffrant de douleurs thoraciques à risque intermédiaire et pourraient réduire les admissions coûteuses de patients hospitalisés pour des douleurs thoraciques. En excluant l'angiographie, les taux de MACE étaient bien inférieurs au seuil de 2 % cité par l'American College of Emergency Physicians.

Interest In and Uptake of HIV Pre-Exposure Prophylaxis (PrEP): A Cross-Sectional Study of High-Risk Patients in Western Canada.

Rationale Pre-exposure prophylaxis (PrEP) is a highly effective, evidence-based HIV prevention strategy. However, its use in the city of Saskatoon, Saskatchewan province of western Canada, is relatively new. Therefore, this study aimed to examine the interest and uptake of PrEP and investigate factors associated with HIV PrEP by high-risk patients. Methods  A cross-sectional, self-administered survey of patients attending Saskatoon's Public Health Services Sexual Health Clinic was conducted from October until December 2018. The primary outcome was the interest in taking PrEP to reduce the risk of HIV infection. This outcome was evaluated for its association with potential correlates, which included: sociodemographic characteristics, HIV risk perception, prior PrEP awareness, and sexual behaviors/lifestyles. Descriptive, univariate, and multivariate analyses were used to pursue our research objectives. Results One hundred forty-one participants were recruited from a sexual health clinic in Saskatoon. The median age (interquartile range) was 26 (22-31) years. The median number of partners (interquartile range) was 3 (2-4) partners. A total of 66.0% of participants were unaware of PrEP, and almost half ( 49.6%) indicated an interest in taking PrEP. Among those disinterested in PrEP, 49.3% perceived minimal HIV risk, 35.2% expressed concern regarding side effects, 28.1% cited the added need for condom use, 23.9% indicated incomplete effectiveness, and 22.5% did not wish to undergo regular bloodwork. Multivariate analysis showed that interested patients were more likely to have been previously aware of PrEP (OR: 2.6, p-value = 0.03), perceived themselves to be vulnerable to HIV (OR: 15.7, p = <0.0001), or were unsure about their risk (OR: 3.9, p = 0.001). Conclusion This study suggests that a lack of knowledge regarding personal HIV risk and PrEP as a preventive option may influence PrEP interest. There lies a need for more health promotion campaigns around the health benefits of PrEP, including literacy efforts on HIV risk, concerns around side effects, and associated blood work with PrEP use.

MRI quantification of femoral neck version using the posterior lesser trochanteric line: a comparison of three measurements.

OBJECTIVE: To validate MRI for the quantification of the femoral neck version (FNV) using posterior lesser trochanteric Line (PLTL) and to compare reliability of the PLTL to the epicondylar and retrocondylar measurements. MATERIALS AND METHODS: A retrospective review of 3 T MRI scans performed for femoroacetabular impingement (FAI). Two musculoskeletal radiologists performed the measurements. MRI measurements of the PLTL were compared to CT using Bland Altman, Lin's concordance, and Lin's correlation coefficients. Interobserver reliability was determined using Bland Altman, Lin's concordance, and Lin's correlation coefficients. Intraobserver reliability was determined using Lin's concordance and Lin's correlation coefficients. RESULTS: Forty-five patients (90 lower extremities) met the inclusion criteria. Ages ranged from 20 to 41 years, with a mean of 31.5 years. There were 22 females and 23 males. Lin's concordance correlation coefficient for MRI and CT measurements of PLTL was substantial: 0.96 (95% CI: 0.94-0.98). PLTL Lin's correlation coefficient was 0.825 (95% CI 0.732-0.918) and indicated good interobserver reliability. Epicondylar and retrocondylar methods Lin's correlation coefficients demonstrated moderate interobserver reliability at 0.601 (0.415-0.786) and 0.632 (0.456-0.807), respectively. There was moderate 95% confidence interval overlap between the PLTL and the other measurements. Bland-Altman plots for each measurement were similar and demonstrated no bias. There was excellent intraobserver reliability (> 0.900) with significant 95% confidence interval overlap. CONCLUSION: MRI measurements of the PLTL are comparable to CT. The PLTL has good reliability between readers for the quantification of FNV using MRI, which could help avoid unnecessary radiation exposure using CT and reduce MRI scan time.

Coracoclavicular bursal changes on MRI: a diagnostic consideration in patients with shoulder pain and reduced coracoclavicular distance.

OBJECTIVE: To describe MRI changes of the coracoclavicular bursa in patients presenting with shoulder pain and examine whether there is an association with coracoclavicular distance measurements. METHODS: Retrospective analysis of 198 shoulder 3T MRI scans for patients with shoulder pain was performed. Two musculoskeletal trained radiologists read all MRI scans. Inter-reader and intra-reader agreements for the bursal changes were assessed using the Kappa coefficient. The coracoclavicular distance was stratified into three intervals: < 5 mm, 5-10 mm, and > 10 mm. Statistical analysis for the coracoclavicular bursal changes and coracoclavicular distance was conducted using Fisher's exact test. RESULTS: Coracoclavicular bursal changes were detected in 9% (n = 18/198) of patients. There was a statistically significant association between coracoclavicular distance (< 5 mm) and the presence of coracoclavicular bursal changes (p-value = 0.011). All patients (100%, n = 18/18) with coracoclavicular bursal fluid presented with shoulder pain with 44.5% of the patients (n = 8/18) describing anterior shoulder pain. A statistically significant association was detected between coracoclavicular bursal changes and anterior shoulder pain (p-value = 0.0011). Kappa coefficient for the bursal changes inter-reader agreement was moderate (0.67) and the intra-reader agreement was almost perfect (0.91). CONCLUSION: Coracoclavicular bursal changes were detected in 9% of shoulder MRI scans and were associated with reduced coracoclavicular distance (< 5 mm) suggesting an underlying mechanical disorder such as a friction or an impingement process. Documenting coracoclavicular bursal changes in the MRI report could help address patients' concerns and guide further management particularly in the context of shoulder pain and coracoclavicular distance of less than 5 mm.

Integrated Prenatal Care for Women Living With HIV: Primary Care Outcomes in Saskatoon, Saskatchewan.

Saskatchewan has the highest rate of new human immunodeficiency virus (HIV) infections in Canada. Of those newly diagnosed, 56% identify as female, 76% identify as Indigenous, and 71% report a history of intravenous drug use. These statistics are strikingly different compared with Canadian data. This brief communication describes prenatal care provided to women living with HIV at an interdisciplinary primary care clinic in Saskatchewan, demonstrating that, despite facing great barriers such as housing insecurity, substance use, and institutionalized racism, women living with HIV can have positive outcomes, including engagement in care and the prevention of perinatal HIV infection.

Efficacy of adjuvant trastuzumab in women with HER2-positive T1a or bN0M0 breast cancer: a population-based cohort study.

Adjuvant trastuzumab has been associated with superior survival in women with ≥ T1c or node-positive HER2-positive early-stage breast cancer; however, there is a lack of phase III trials in women with T1a/bN0 disease. Our study aimed to assess the outcomes of women with HER2-positive T1a/bN0 breast cancer who received adjuvant trastuzumab in Saskatchewan, Canada. We evaluated all women diagnosed with HER2-positive T1a/bN0 breast cancer in Saskatchewan between 2008 and 2017. We performed Cox proportional multivariable analysis to determine factors correlated with survival. In addition, inverse probability treatment weighting (IPTW) using propensity score was performed to assess benefit of adjuvant trastuzumab. Ninety-one eligible women with a median age of 61 years (range 30-89) were identified. Thirty-nine (43%) women received adjuvant trastuzumab. Women who received trastuzumab were younger and had a higher rate of T1b disease. Overall, 3% of women who received trastuzumab compared to 12% of women who did not receive trastuzumab developed breast cancer recurrence (p = 0.23). Five-year disease-free survival (DFS) of women who received adjuvant trastuzumab was 94.8% compared to 82.7% of women who did not receive trastuzumab (p = 0.22). Five-year overall survival was 100% of women who received trastuzumab compared to 90.4% of women who did not receive adjuvant trastuzumab (p = 0.038). In the multivariable analysis, grade III tumors were correlated with inferior DFS (hazard ratio [HR] 5.5, 95% CI [1.7-17.7]). The propensity score using the inverse probability of treatment weighting showed that lack of adjuvant trastuzumab was correlated inferior DFS, with an HR of 4 (95% CI 1.05-15.5). Women with HER2-positive T1a/bN0 breast cancer had overall low recurrence of breast cancer. However, the results of this exploratory analysis indicate that women who received adjuvant trastuzumab had better survival.

Regional activation of supraspinatus and infraspinatus sub-regions during dynamic tasks performed with free weights.

Growing evidence supports the existence of distinct anatomical sub-regions within supraspinatus and infraspinatus, but only recently has attention turned to exploring their potential functional differences. Using indwelling fine-wire electromyography, muscle activity was investigated from these sub-regions in 15 participants (mean 34 yr, 170 cm, 71.9 kg) during dynamic external rotation (ER), abduction, flexion, and scaption tasks with and without free weights corresponding to 50% and 75% of the participant's five repetition maximum. Electromyography data were normalized to isometric and isokinetic maximal voluntary contractions and activation ratios for each sub-region compared. Differences in mean regional activation ratios for supraspinatus and infraspinatus varied by arm posture, but were not influenced by load. Relative activation of posterior supraspinatus was greater during an ER task performed in side lying compared to an ER task performed with 90° of humeral elevation in seated and prone postures. Relative activation of superior infraspinatus was greater during an ER task in prone and side lying postures compared to flexion and scaption. Similar results were found when comparing regional muscle activation ratios for infraspinatus between tasks regardless of normalization method employed. These findings may impact exercise selection in the non-operative management of rotator cuff tears.

Sociodemographic and Geographic Factors Associated With Non-Obstetrical Ultrasound Imaging Utilization: A Population-Based Study.

OBJECTIVE: Ultrasound is one of the most commonly used imaging modalities, though some populations face barriers in accessing ultrasound services, potentially resulting in disparities in utilization. The objective of this study was to assess the association between sociodemographic and geographic factors and non-obstetrical ultrasound utilization in the province of Saskatchewan, Canada. METHODS: All non-obstetrical ultrasound exams performed from 2014 to 2018 in Saskatchewan, Canada were retrospectively identified from province-wide databases. Univariate and multivariate Poisson regression analyses were performed to assess the association between ultrasound utilization and sex, age, First Nations status, Charlson Comorbidity Index, urban vs. rural residence, geographic remoteness, and neighborhood income. RESULTS: A total of 1,324,846 individuals (5,857,044 person-years) were included in the analysis. Female sex (adjusted incidence rate ratio [aIRR], 2.20; 95% confidence interval [CI], 2.19-2.22), age (aIRR, 4.97; 95% CI, 4.90-5.05 for ≥57 years vs. <11 years), comorbidities (aIRR, 4.36 for Charlson Comorbidity Index >10 vs. 0; 95% CI, 3.78-5.03), and higher neighborhood income (aIRR, 1.04; 95% CI, 1.02-1.05 for highest vs. lowest quintile) were associated with higher rates of ultrasound utilization. Individuals who were status First Nations (aIRR, 0.91; 95% CI, 0.90-0.92) or resided in geographically remote areas (aIRR, 0.87 for most vs. least remote; 95% CI, 0.83-0.91) had lower rates of ultrasound utilization. Individuals who lived in a rural area also had lower rates of ultrasound utilization (aIRR, 0.93; 95% CI, 0.92-0.94). CONCLUSION: Substantial disparities exist in non-obstetrical ultrasound utilization among individuals in low-income neighborhoods, status First Nations individuals, and individuals in rural and remote communities.

Sociodemographic and Geographic Disparities in Obstetrical Ultrasound Imaging Utilization: A Population-based Study.

RATIONALE AND OBJECTIVES: Obstetrical ultrasound imaging is an important part of prenatal care, though not all patients have readily available access to ultrasound services. This study aimed to assess the association between sociodemographic and geographic factors and (1) having a second trimester complete obstetrical ultrasound and (2) overall obstetrical ultrasound utilization. METHODS: All pregnancies and obstetrical ultrasound exams billed from 2014-2018 in Saskatchewan, Canada were identified from province-wide databases. Generalized estimating equation (GEE) models with binomial and Poisson distributions were used to identify factors associated with having a second trimester ultrasound and overall obstetrical ultrasound utilization, respectively. RESULTS: 80,536 pregnancies from 57,881 individuals were included. Of 57,186 pregnancies carried to ≥23 weeks, a second trimester ultrasound was performed in 50,180 (87.7%). Patients living in rural areas (adjusted odds ratio [aOR], 0.70; 95% confidence interval [CI], 0.63-0.77; p <0.0001), remote areas (aOR, 0.35 for greatest vs. least remoteness level; 95% CI, 0.32-0.39; p <0.0001), and status First Nations individuals (aOR, 0.50; 95% CI, 0.46-0.53; p <0.0001) were less likely to have a second trimester ultrasound. Patients living in higher income neighbourhoods (aOR, 1.86 for highest vs. lowest quintile; 95% CI, 1.62-2.13; p <0.0001) were more likely to have a second trimester ultrasound. GEE Poisson regression analysis demonstrated these same factors, except rural residence, were associated with overall obstetrical ultrasound utilization. CONCLUSION: Substantial disparities in obstetrical ultrasound utilization exist among patients in remote geographic areas, Indigenous peoples, and patients in low income neighbourhoods. Addressing barriers which these demographic groups face in accessing ultrasound imaging is critical to ensure health equity.

Incidence Rates of Surgery After Knee MRI: Association According to Referring Physician Type and Patient's Age and Sex.

BACKGROUND: The utility of magnetic resonance imaging (MRI) in the primary care setting is uncertain, with a perception that there is less likelihood for surgery after MRI ordered by general practitioners (GPs) when compared with orthopaedic surgeons and sports medicine physicians. Additionally, the influence of patient age and sex on subsequent surgical intervention is currently unknown. PURPOSE/HYPOTHESIS: The purpose of this study was to compare surgical incidence after MRI referrals by orthopaedic surgeons, GPs, and sports medicine physicians, including a subset analysis for GP patients based on type of approval given by the radiologist. The authors also wanted to explore the association of age and sex on subsequent surgical intervention. They hypothesized that surgical incidence after MRI ordered by orthopaedic surgeons and sports medicine physicians would be higher than after MRI ordered by GPs. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Knee MRI referrals by the 3 physician cohorts during May to December 2017 were assessed. For GP patients, the types of approval or recommendation from a radiologist were categorized. Subsequent surgical intervention status was then compared among referral groups up to 2 years after MRI. Associations of age and sex with surgical occurrence were also assessed. Chi-square test, analysis of variance, and univariate/multivariable logistic regression were used for statistical analysis. RESULTS: Overall, 407 referrals were evaluated (GP, n = 173; orthopaedic, n = 176; sports medicine, n = 58). Surgical incidence was not significantly higher for orthopaedic and sports medicine than GP referrals at 3 months (10%, 3%, and 6%, respectively; P = .23), 6 months (20%, 17%, and 15%; P = .49), and 2 years (30%, 35%, and 24%; P = .25). Surgical incidence for GP patients was higher after discussion with a radiologist or when evaluating specific pathology on prior imaging versus less defined reasons (30.4% vs 15.7%, respectively; P = .03). Surgical incidence was lower for older patients (11% vs 31% for >60 years vs all other age groups combined; P = .002), and women were less likely to undergo surgery than men (22% vs 35%, respectively; P = .008). CONCLUSION: Surgical incidence after MRI was likely appropriately lower for older patients. Lower incidence for female patients is of uncertain cause and warrants further study.

An Inconsistent Canadian Provincial and Territorial Response During the Early COVID-19 Pandemic.

Objectives: According to the World Health Organization (WHO), an early and consistent international and national response is needed to control a pandemic's spread. In this analysis, we evaluate the coordination of Canada's early response to the coronavirus (COVID-19) pandemic in terms of public health interventions and policies implemented in each province and territory. Methods: Retrospective data was obtained from publicly accessible websites maintained by federal, provincial and territorial governmental agencies. Consistent with WHO's spreading of the disease pandemic action, individual and community-based public health interventions and policies were the focus. Time of intervention or policy, and COVID-19 cases per million at time of intervention was recorded for each province and territory. Results: Most public health interventions and policies demonstrated wide time ranges of implementation across individual provinces and territories. At time of implementation, there were also wide variations in the number of positive COVID-19 cases in these jurisdictions. Cases per million per implemented day were also not similar across interventions or policy, suggesting that other factors may have been preferentially considered. Conclusions: Whether an earlier and more structured national approach would have lessened the pandemic's burden is uncertain, calls for greater federal coordination and leadership should to examined.

The Association of Matrix Metalloproteinases With Acute Kidney Injury Following CPB-Supported Cardiac Surgery.

BACKGROUND: Cardiac surgery-associated acute kidney injury (AKI) is an adverse outcome that increases morbidity and mortality in patients undergoing cardiac surgical procedures. To date, the use of serum creatinine levels as an early indicator of AKI has limitations because of its slow rise and poor predictive accuracy for renal injury. This delay in diagnosis may lead to prolonged initiation in treatment and increased risk for adverse outcomes. OBJECTIVE: This pilot study explores serum and urine matrix metalloproteinases (MMPs)-2 and MMP-9 and their association, and potentially earlier detection of AKI in patients following cardiopulmonary bypass (CPB)-supported cardiac surgery. We hypothesize that increased activity of serum and urine levels MMP-2 and/ or MMP-9 are associated with AKI. Furthermore, MMP-2 and/ or MMP-9 may provide earlier identification of AKI as compared with serum levels of creatinine. METHODS: During the study period, there were 150 CPB-supported surgeries, 21 of which developed AKI according to the Kidney Disease Improving Global Outcomes criteria. We then selected a sample of 21 matched cases from those patients who went through the surgery without developing AKI. Primary outcomes were the measurement via gel zymography of the serum and urine activity of MMP-2 and MMP-9 drawn at the following intervals: pre-CPB; 10-minute post-CPB; and 4-hour post-CPB time points. Secondary variables were the measurement of serum creatinine, intensive care unit (ICU) fluid balance, and length of ICU stay. RESULTS: At the 10-minute and 4-hour post-CPB time points, the serum MMP-2 activity of AKI patients were significantly higher as compared with non-AKI patients (P < .001 and P = .004), respectively. Similarly, at the 10-minute and 4-hour post-CPB time points, the serum MMP-9 activity of AKI patients was significantly higher as compared with non-AKI patients (P = .001 and P = .014), respectively. The activity of urine MMP-2 and MMP-9 of AKI patients was significantly higher as compared with non-AKI patients at all 3 time points (P = .004, P < .001, P < .001), respectively. CONCLUSION: Although the pilot study may have limitations, it has demonstrated that the serum and urine levels of activity of MMP-2 and MMP-9 are associated with the clinical endpoint of AKI and appear to have earlier rising levels as compared with those of serum creatinine. Furthermore, in depth, exploration is underway with a larger sample size to attempt validation of the analytical performance and reproducibility of the assay for MMP-2 and MMP-9 to aid in earlier diagnosis of AKI following CPB-supported cardiac surgery.

CONTEXTE: L'insuffisance rénale aiguë (IRA) associée à la chirurgie cardiaque est un effet indésirable qui augmente la morbidité et la mortalité des patients qui subissent ce type d'intervention. La mesure de la créatinine sérique comme indicateur précoce de l'IRA continue à ce jour de présenter des limites en raison de sa lente augmentation et de l'imprécision de son pouvoir prédictif. Ce délai dans le diagnostic peut retarder l'initiation du traitement et accroître le risque d'effets indésirables. OBJECTIFS: Cette étude pilote explore les métalloprotéinases matricielles (MPM) -2 et -9 sériques et urinaires, leur association avec l'IRA et leur potentiel pour la détection plus précoce de la maladie chez les patients qui subissent une chirurgie cardiaque assistée par circulation extracorporelle. Nous émettons l'hypothèse qu'une hausse de l'activité des MMP-2 et/ou -9 et de leurs taux sériques et urinaires serait associée à l'IRA. Les MMP-2 et/ou -9 pourraient en outre permettre d'identifier la maladie plus précocement que le taux de créatinine sérique. MÉTHODOLOGIE: Au cours de la période de l'étude, 150 chirurgies cardiaques assistées par circulation extracorporelle ont été effectuées et 21 ont été associées à une IRA telle que définie par les critères du KDIGO (Kidney Disease Improving Global Outcomes). Nous avons sélectionné 21 cas appariés parmi les patients ayant subi l'intervention sans développer d'IRA. Le principal critère d'évaluation était une mesure de l'activité des MMP-2 et -9 obtenue par une zymographie sur gel d'échantillons de sérum et d'urine prélevés aux intervalles suivants: pré-circulation extracorporelle, 10 minutes après la circulation extracorporelle et 4 heures après la circulation extracorporelle. Les variables secondaires étaient la mesure de la créatinine sérique, la mesure de la balance liquidienne durant le séjour à l'unité de soins intensifs (USI) et de la durée du séjour à l'USI. RÉSULTATS: L'activité des MMP-2 sériques des patients atteints d'IRA était significativement plus élevée que celle des patients non atteints d'IRA 10 minutes et 4 heures post-circulation extracorporelle (p < 0,001 et p = 0,004 respectivement). Aux mêmes repères temporels, l'activité des MMP-9 sériques était elle aussi significativement plus élevée chez les patients atteints d'IRA (p = 0,001 [IRA]; p = 0,014 (non IRA). L'activité des MMP-2 et -9 urinaires, elle était elle aussi significativement plus élevée pour les patients atteints d'IRA, et ce, pour les trois points temporels (p = 0,004 [IRA); p < 0,001 [non IRA]). CONCLUSION: Bien que cette étude pilote comporte des limites, elle a tout de même démontré que l'activité des MMP-2 et -9 sériques et urinaires est associée aux paramètres cliniques de l'IRA, et que leurs taux augmentent plus rapidement que les taux de créatinine sérique. Des recherches plus approfondies sur un plus grand échantillon de patients sont en cours afin de valider la performance analytique et la reproductibilité du dosage des MMP-2 et -9 pour diagnostiquer plus rapidement l'IRA après une chirurgie cardiaque assistée par circulation extracorporelle.

Real World Clinical Experience of Biosimilar G-CSF (Grastofil) for Autologous Peripheral Blood Stem Cell Mobilization: Single Center Experience in Canada Following Early Adoption.

Introduction: Granulocyte colony-stimulating factor (G-CSF) is the first line treatment for mobilization, most commonly using a regimen of daily filgrastim. The use of biosimilars can provide substantial cost savings to the health care system while delivering comparable efficacy outcomes. In 2016, the Saskatchewan Cancer Agency was a leader in Canada, instituting formulary changed from a G-CSF originator product to a cost savings alternative biosimilar for stem cell mobilization prior to autologous stem cell transplant (ASCT) and for engraftment. The purpose of this study was to investigate the clinical comparability of biosimilar G-CSF to its reference product in a real-world clinical setting and to validate use of the biosimilar in mobilization and engraftment-an indication which had been granted by extrapolation. METHODS: A retrospective chart review was completed including all patients diagnosed with a hematological malignancy between 2012 and 2018 who underwent ASCT. To assess real-world outcomes across a diverse population, successful CD34+ stem cell collection was compared between patients mobilized with originator filgrastim, Neupogen, and biosimilar filgrastim, Grastofil. Additional comparisons included the number of apheresis required, time to absolute neutrophil count (ANC) engraftment, platelet engraftment, length of hospital stay, and Plerixafor use. RESULTS: 217 patients were mobilized and transplanted during the study period. There was no statistically significant difference in success rate between patients mobilized with biosimilar filgrastim and those who had received originator G-CSF (100% vs. 92.4%, p = 0.075). Neither disease type, nor concurrent chemomobilization regimen resulted in a detectable difference between the two G-CSF products in successful stem cell harvest. Engraftment was highly similar between groups, as demonstrated by ANC recovery (11.6 days Neupogen vs. 11.6 days Grastofil), platelet recovery (14.0 days Neupogen vs. 14.2 days Grastofil), and total length of hospital stay (22.4 days Neupogen vs. 22.3 days Grastofil). No statistically significant difference in adjunctive use of Plerixafor® was observed between Neupogen and Grastofil patients (25.9% vs. 23.4%, p = 0.72). CONCLUSION: Extrapolation of indications for biosimilars is justified. This real-world evidence builds upon registrational studies to confirm that no clinically meaningful differences were detected between originator Neupogen and biosimilar Grastofil in the setting of PBSC mobilization and engraftment post ASCT. Biosimilars are as safe and effective as originator products. Implementation across all approved indications without hesitation maximizes cost savings to the provincial system, allowing for more optimal allocation of health care resources.