Brenden Dufault

Brain magnetic resonance imaging CO2 stress testing in adolescent postconcussion syndrome

OBJECT A neuroimaging assessment tool to visualize global and regional impairments in cerebral blood flow (CBF) and cerebrovascular responsiveness in individual patients with concussion remains elusive. Here the authors summarize the safety, feasibility, and results of brain CO2 stress testing in adolescents with postconcussion syndrome (PCS) and healthy controls. METHODS This study was approved by the Biomedical Research Ethics Board at the University of Manitoba. Fifteen adolescents with PCS and 17 healthy control subjects underwent anatomical MRI, pseudo-continuous arterial spin labeling MRI, and brain stress testing using controlled CO2 challenge and blood oxygen level-dependent (BOLD) MRI. Post hoc processing was performed using statistical parametric mapping to determine voxel-by-voxel regional resting CBF and cerebrovascular responsiveness of the brain to the CO2 stimulus (increase in BOLD signal) or the inverse (decrease in BOLD signal). Receiver operating characteristic (ROC) curves were generated to compare voxel counts categorized by control (0) or PCS (1). RESULTS Studies were well tolerated without any serious adverse events. Anatomical MRI was normal in all study participants. No differences in CO2 stimuli were seen between the 2 participant groups. No group differences in global mean CBF were detected between PCS patients and healthy controls. Patient-specific differences in mean regional CBF and CO2 BOLD responsiveness were observed in all PCS patients. The ROC curve analysis for brain regions manifesting a voxel response greater than and less than the control atlas (that is, abnormal voxel counts) produced an area under the curve of 0.87 (p < 0.0001) and 0.80 (p = 0.0003), respectively, consistent with a clinically useful predictive model. CONCLUSIONS Adolescent PCS is associated with patient-specific abnormalities in regional mean CBF and BOLD cerebrovascular responsiveness that occur in the setting of normal global resting CBF. Future prospective studies are warranted to examine the utility of brain MRI CO2 stress testing in the longitudinal assessment of acute sports-related concussion and PCS.

Dignity and Distress towards the End of Life across Four Non-Cancer Populations

Objective The purpose of this study was to identify four non-cancer populations that might benefit from a palliative approach; and describe and compare the prevalence and patterns of dignity related distress across these diverse clinical populations. Design A prospective, multi-site approach was used. Setting Outpatient clinics, inpatient facilities or personal care homes, located in Winnipeg, Manitoba and Edmonton, Alberta, Canada. Participants Patients with advanced Amyotrophic Lateral Sclerosis (ALS), Chronic Obstructive Pulmonary Disease (COPD), End Stage Renal Disease (ESRD); and the institutionalized alert frail elderly. Main Outcome Measure In addition to standardized measures of physical, psychological and spiritual aspects of patient experience, the Patient Dignity Inventory (PDI). Results Between February 2009 and December 2012, 404 participants were recruited (ALS, 101; COPD, 100; ESRD, 101; and frail elderly, 102). Depending on group designation, 35% to 58% died within one year of taking part in the study. While moderate to severe loss of sense of dignity did not differ significantly across the four study populations (4–11%), the number of PDI items reported as problematic was significantly different i.e. ALS 6.2 (5.2), COPD 5.6 (5.9), frail elderly 3.0 (4.4) and ESRD 2.3 (3.9) [p < .0001]. Each of the study populations also revealed unique and distinct patterns of physical, psychological and existential distress. Conclusion People with ALS, COPD, ESRD and the frail elderly face unique challenges as they move towards the end of life. Knowing the intricacies of distress and how they differ across these groups broadens our understanding of end-of-life experience within non-cancer populations and how best to meet their palliative care needs.

Longitudinal Brain Magnetic Resonance Imaging CO2 Stress Testing in Individual Adolescent Sports-Related Concussion Patients: A Pilot Study

Background Advanced neuroimaging studies in concussion have been limited to detecting group differences between concussion patients and healthy controls. In this small pilot study, we used brain magnetic resonance imaging (MRI) CO2 stress testing to longitudinally assess cerebrovascular responsiveness (CVR) in individual sports-related concussion (SRC) patients. Methods Six SRC patients (three males and three females; mean age = 15.7, range = 15–17 years) underwent longitudinal brain MRI CO2 stress testing using blood oxygen level-dependent (BOLD) MRI and model-based prospective end-tidal CO2 targeting under isoxic conditions. First-level and second-level comparisons were undertaken using statistical parametric mapping (SPM) to score the scans and compare them to an atlas of 24 healthy control subjects. Results All tests were well tolerated and without any serious adverse events. Anatomical MRI was normal in all study participants. The CO2 stimulus was consistent between the SRC patients and control subjects and within SRC patients across the longitudinal study. Individual SRC patients demonstrated both quantitative and qualitative patient-specific alterations in CVR (p < 0.005) that correlated strongly with clinical findings, and that persisted beyond clinical recovery. Conclusion Standardized brain MRI CO2 stress testing is capable of providing a longitudinal assessment of CVR in individual SRC patients. Consequently, larger prospective studies are needed to examine the utility of brain MRI CO2 stress testing as a clinical tool to help guide the evaluation, classification, and longitudinal management of SRC patients.

Prevalence of Peripheral Eosinophilia at Diagnosis in Children With Inflammatory Bowel Disease.

Background and Objective: Inflammatory bowel disease (IBD) encompasses 2 disorders of unknown etiology: Crohn disease (CD) and ulcerative colitis (UC). There has been a continuous search for markers for disease activity. Eosinophils are granulocytic leukocytes that are implicated in the pathogenesis of IBD. The aim of this study was to examine the prevalence and significance of peripheral eosinophilia (PE) at diagnosis in children with IBD. Methods: A comprehensive chart review of all children with diagnosed as having IBD between January 2006 and August 2014 was performed. Patients with PE at diagnosis were compared with those without in relation to disease clinical activity and disease course. Results: A total of 109 children (mean age 14.6 ± 2.77, range 4.5–17.9 years, 55 boys) with IBD (68 with CD and 41 with UC) who were studied for a mean duration of 2.82 ± 1.89 (range 0.1–9.2 years) were identified. At diagnosis, 44 (40.4%) children had PE, which was more prevalent in patients with UC compared with those with CD (61.3% vs 36.3%, P < 0.05). At diagnosis, PE was more common in patients with high eosinophilic count in colonic biopsy samples (P < 0.01) and was significantly associated with disease activity as indicated by Pediatric CD Activity Index for children with CD (P < 0.05), Pediatric UC Activity Index for children with UC (P < 0.01). Conclusions: PE is a common finding at diagnosis in children with IBD especially in those with UC. Patients with PE at diagnosis are more likely to present with higher clinical activity indices. PE is associated with more eosinophils in colonic biopsy samples.

Data quality of electronic medical records in Manitoba: do problem lists accurately reflect chronic disease billing diagnoses?

OBJECTIVE To determine problem list completeness related to chronic diseases in electronic medical records (EMRs) and explore clinic and physician factors influencing completeness. METHODS A retrospective analysis of primary care EMR data quality related to seven chronic diseases (hypertension, diabetes, asthma, congestive heart failure, coronary artery disease, hypothyroidism, and chronic obstructive pulmonary disorder) in Manitoba, Canada. We included 119 practices in 18 primary care clinics across urban and rural Manitoba. The main outcome measure was EMR problem list completeness. Completeness was measured by comparing the number of EMR-documented diagnoses to the number of billings associated with each disease. We calculated odds ratios for the effect of clinic patient load and salary type on EMR problem list completeness of the 7 chronic diseases. RESULTS Completeness of EMR problem list for each disease varied widely among clinics. Factors that significantly affected EMR problem list completeness included the primary care provider, the patient load, and the clinics funding and organization model (ie, salaried, fee-for-service, or residency training clinics). Average rates of completeness were: hypertension, 72%; diabetes, 80%; hypothyroidism, 63%; asthma, 56%; chronic obstructive pulmonary disorder, 43%; congestive heart failure, 54%; and coronary artery disease, 64%. CONCLUSION This study demonstrates the high variability but generally low quality of problem lists (health condition records) related to 7 common chronic diseases in EMRs. There are systematic physician- and clinic-level factors associated with low data quality completeness. This information may be useful to support improvement in EMR data quality in primary care.

Health-Related Quality of Life in an Inception Cohort of Children With Juvenile Idiopathic Arthritis: A Longitudinal Analysis.

To describe changes in health‐related quality of life (HRQoL) over time in children with juvenile idiopathic arthritis (JIA), relative to other outcomes, and to identify predictors of unfavorable HRQoL trajectories.

Clonal Clusters and Virulence Factors of Group C and G Streptococcus Causing Severe Infections, Manitoba, Canada, 2012–2014

These strains are more likely to cause invasive infection, which is an emerging public health concern as incidence and disease severity are on the rise.

Education, Employment, Income, and Marital Status Among Adults Diagnosed With Inflammatory Bowel Diseases During Childhood or Adolescence

BACKGROUND & AIMS We aimed to assess levels of education attained, employment, and marital status of adults diagnosed with inflammatory bowel diseases (IBD) during childhood or adolescence, compared with healthy individuals in Canada. METHODS We performed a cross‐sectional study of adults diagnosed with IBD in childhood or adolescence at Children’s Hospital in Winnipeg, Manitoba from January 1978 through December 2007. Participants (n = 112) answered a semi‐structured questionnaire on educational achievements, employment, and marital status. Patients were matched for age and sex with random healthy individuals from the 2012 Canadian Community Health Survey (controls, 5 per patient). Conditional binary logistic regression and random‐effects ordinal logistic regression models were used for analysis. RESULTS Patients were followed for a mean duration of 14.3 years (range, 3.1–34.5 years). Persons with IBD were more likely to earn more money per annum and attain a post‐secondary school degree or receive a diploma than controls (odds ratio, 1.72; 95% confidence interval, 1.13–2.60; P < .01 and odds ratio, 2.73; 95% confidence interval, 1.48–5.04; P < .01, respectively). There was no significant difference between patients and controls in employment or marital status. CONCLUSIONS Adults diagnosed with IBD during childhood seem to achieve higher education levels than individuals without IBD. This observation should provide reassurance to children with IBD and their parents. ClinicalTrials.gov number: NCT02152241.

Quality improvement in paediatric inflammatory bowel disease: the Manitoba experience

Inflammatory bowel diseases (IBD), Crohn’s disease (CD) and ulcerative colitis (UC), have a considerable impact on patients’ health, social functioning and quality of life with significant effect on healthcare resources. In 2012, the burden-of-illness report from the Crohn’s and Colitis Canada estimated that the direct medical costs of IBD in Canada were over one billion dollars, primarily funded through the Canadian public healthcare system (1). The report also highlighted the presence of a considerable gap between the perceived ideal and actual IBD care. Quality improvement (QI) in medicine is defined as the efforts to change care using an evidence-based approach in order to make meaningful positive changes to the health care (2,3). Clinical quality indicators are quantitative endpoints used to guide, monitor and improve the quality of patient care (2). The use of QI in IBD is fast growing, and it is becoming increasingly recognised that such measures are important (3). The Crohn’s and Colitis Foundation of America developed a set of process and outcome of QI for IBD based on reviews of guidelines, position papers and input from experts in the field. It is important to understand that these QI measures are not meant to reflect ideal care, but rather a minimum acceptable standard of care that should be expected based on the best available evidence (4). Efforts to improve quality of care delivered to children with chronic disease including IBD may result in better outcomes. In January 2012, several QI initiatives were implemented in the Paediatric IBD Programme of Manitoba, Canada. The aim of this study was to examine the effect of implementing certain healthcare measures for children with IBD on health outcomes. A comprehensive chart review of all children <17 years of age who were diagnosed with IBD, based on clinical, laboratory, endoscopic, histopathologic and radiological evidence, prior to January 2012, and continued to be followed after QI initiatives (Table 1) were implemented, was performed. Quality indicators were measured and compared before and after January 2012. Indicators for QI were as follows:

Single-injection interscalene bupivacaine and dexamethasone for same-day discharge total shoulder arthroplasty: a case series

To the Editor, Continuous interscalene block (CISB) has been the typical analgesic modality reported after ambulatory total shoulder arthroplasty (TSA) because single-injection interscalene block (SISB) is perceived to have an inadequate analgesic duration. Ambulatory infusion pumps, however, require additional resources, and nerve plexus catheters are associated with complications. In October 2011, our health region launched a same-day discharge TSA program at a freestanding, publicly funded surgical centre. For postoperative analgesia, the program employed ultrasound-guided SISB with 8 mg perineural preservative-free dexamethasone sodium phosphate (Dexamethasone Omega Unidose 10 mg mL, Omega Laboratories Limited, Montreal, QC, Canada) and 0.5% bupivacaine with 1:200,000 epinephrine (0.4 mL kg maximum 40 mL). The program selected patients from the practices of orthopedic surgeons with lengthy TSA wait lists who were American Society of Anesthesiologists classification I or II with a body mass index of less than 35 kg m, age less than 70 yr, on neither chronic opioids nor corticosteroids, and who had a potential caregiver at home for the first postoperative 48 hr. With the approval of the University of Manitoba Health Research Ethics Board (H2011:407) on January 5, 2012, we prospectively studied pain and satisfaction outcomes among consenting patients until November 2013, when the frequency of cases diminished due to shortening wait lists. The TSA was performed according to the surgeon’s preference, under general anesthesia, after SISB. Upon discharge home from the recovery room, patients received an oral opioid prescription, with or without acetaminophen. They were instructed to take oral analgesics at 18:00 hr on the day of surgery, continue them regularly as the block wore off, and taper their use as the pain diminished. Patients with inadequate analgesia were instructed to return to the surgical centre for repeat SISB during daytime hours on postoperative day 1 or attend an inpatient hospital emergency room at all other times. The study staff contacted patients daily by phone for five days to inquire about emergency room visits or the need for a repeat block. Four of 23 eligible patients could not be recruited due to a lack of study staff. The mean (standard deviation) age, operating theatre time, and recovery room time were 60.4 (70.1) yr, 1.3 (0.4) hr, and 3.0 (0.7) hr, respectively. All 19 participants completed daily phone interviews, but four did not return their study diary despite repeated requests. In these diaries, 14 of 15 diaries recorded the onset of shoulder pain at a median of 28 hr (range 17.0-44.5 hr) following surgery. Visual analogue pain scores at rest and at peak along with daily opioid consumption are shown in Figures A, B, and C respectively. Median visual analogue satisfaction score on day 5 (n = 15) was 9.5 cm (range 7.19.9 cm). One patient returned for a second SISB on postoperative day 1, and no patients visited an emergency room. Our results suggest that same-day discharge after TSA using SISB with bupivacaine and perineural M. Banghu, MD, FRCPC T. Mutter, MD, FRCPC, MSc R. Amadeo, MD, FRCPC (&) Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada e-mail: ramadeo@me.com