Royal Columbian Hospital

Background: Greater burdens of comorbidity and exposure to unique environmental factors predispose incarcerated individuals to polypharmacy and inappropriate prescribing. There is limited literature investigating polypharmacy within the correctional health setting. Objectives: To determine the median number of medications prescribed per client at facilities in British Columbia, to determine the proportion of clients meeting the definition for polypharmacy, to identify the top medication categories prescribed, and to screen for potential drug therapy problems among those with polypharmacy. Methods: An observational point prevalence study of adult clients with one or more active medications on the census date at 5 correctional health facilities in British Columbia was conducted. Clients were excluded if they had one-time or no medication orders on the census date. Results: Of the 500 clients screened, 420 were included in the final analysis. Across the centres, the median number of medications ranged from 3 to 5 per client, and the rate of polypharmacy ranged from 23% to 41%. Of the scheduled medications, opioid agonist therapy and psychotropics were the leading categories prescribed across all facilities. Non-opioid analgesics were the top “as needed” medications prescribed at 4 of the 5 facilities. The leading potential drug therapy problem identified was drug interactions resulting in additive sedation. Conclusions: Polypharmacy was present within all facilities in this study, with more than 25% of clients affected at 3 of the sites. The top medications prescribed aligned with those identified in the literature; however, there remain opportunities for therapy optimization. Keywords: polypharmacy, correctional health, incarceration RÉSUMÉ Contexte : Le fardeau plus important associé aux comorbidités et à l’exposition à des facteurs environnementaux uniques prédispose les personnes incarcérées à la polypharmacie et à des prescriptions inappropriées. La littérature sur la polypharmacie dans le cadre des services de santé dans le milieu correctionnel est limitée. Objectifs : Déterminer le nombre médian de médicaments prescrits par client dans des établissements en Colombie-Britannique; déterminer la part de clients répondant à la définition de la polypharmacie; recenser les principales catégories de médicaments prescrits; et procéder au dépistage des problèmes potentiels de thérapie médicamenteuse chez les clients présentant de la polypharmacie. Méthodologie : Une étude observationnelle de prévalence ponctuelle des adultes prenant un ou plusieurs médicaments actifs à la date du recensement a été menée dans 5 établissements de santé correctionnelle en Colombie-Britannique. Les clients étaient exclus s’ils n’avaient qu’une prescription unique ou aucune ordonnance médicamenteuse à la date du recensement. Résultats : Sur les 500 clients testés, 420 ont été inclus dans l’analyse finale. Dans les différents centres, le nombre médian de médicaments variait de 3 à 5 par client, et le taux de polypharmacie variait de 23 % à 41 %. Parmi les médicaments programmés, la thérapie agoniste des opioïdes et les psychotropes étaient les principales catégories prescrites dans tous les établissements. Les analgésiques non opioïdes étaient les médicaments les plus prescrits « au besoin » dans 4 des 5 établissements. Les interactions médicamenteuses entraînant une sédation additive constituaient le principal problème potentiel de la thérapie médicamenteuse recensé. Conclusions : La polypharmacie était présente dans tous les établissements de cette étude, avec plus de 25 % des clients touchés dans 3 des sites. Les principaux médicaments prescrits étaient en accord avec ceux indiqués dans la littérature; cependant, il reste des occasions d’optimiser la thérapie. Mots-clés : polypharmacie, santé correctionnelle, incarcération

OBJECTIVE The primary objective of this study was to evaluate the safety and efficacy of using an intraosseous (IO) needle for decompressive management of subacute and chronic subdural hematomas (SDHs). METHODS This is a single-center retrospective review of subacute and chronic SDHs treated with IO needle decompression from May 2022 to November 2023. Technical success, recurrence, procedure-related complications, major adverse events, patient demographics, and procedural details were analyzed using standard statistical analysis. RESULTS Fifty-one patients (mean age 75.4 [SD 11.4] years) met the inclusion criteria. Technical success was achieved in all patients, with only 1 case of recurrence. Rates of procedure-related complications (3/51, 5.9%) and major adverse events (2/51, 4%) were low. There were no statistically significant differences between those with subacute SDHs compared with those with chronic SDHs. CONCLUSIONS IO needle decompression is a feasible, safe, and effective option for management of subacute and chronic SDHs, with minimal recurrence.

This study aimed to explore the association of cytomegalovirus (CMV) infection in preterm infants of ≤32 weeks' gestation and neonatal morbidities. This was a matched cohort study of preterm infants born between 22 and 32 weeks gestation age and <1,500 g in birth weight who were admitted to participating tertiary NICUs within the Canadian Neonatal Network between April 2009 and December 2018. Infants were randomly matched in a 1:4 ratio (73 CMV-positive to 292 CMV-nonpositive infants) based on gestational age (in weeks), sex, birth weight (± 50 g), and number of days of oxygen exposure within the first 28 days after birth (± 2 days). Neonatal morbidities were compared between the two groups using conditional logistic regression after adjustment of unmatched confounders. The CMV-positive infants were of lower median birth weight compared to CMV-nonpositive infants (722 vs. 743 g; p < 0.05). The duration of noninvasive respiratory support (59 vs. 43 days; p < 0.05), invasive respiratory support (35 vs. 24 days; p < 0.05), oxygen therapy (115 vs. 67 days; p < 0.05), and odds of bronchopulmonary dysplasia (BPD; 90% vs. 71%; adjusted odds ratio: 3.52 [1.54, 8.07]) were higher for CMV-positive infants compared to CMV-nonpositive infants. Other morbidities were not statistically significantly different. CMV infection in very preterm infants was associated with increased duration of oxygen and respiratory support and increased odds of BPD.

Background: Guidelines recommend nimodipine as the standard of care for patients with aneurysmal subarachnoid hemorrhage (aSAH). Compared with placebo, this agent has been shown to reduce death and dependency on others for activities of daily living. However, retrospective data suggest that patients may not receive full treatment with nimodipine. Objectives: The primary objective was to determine the proportion of patients with aSAH admitted to an intensive care unit (ICU) or high-acuity unit (HAU) at a tertiary referral hospital who received the guideline-recommended dose and duration of nimodipine. A secondary objective was to describe barriers to receiving full treatment. Methods: This retrospective chart review involved a convenience sample of 100 patients with aSAH who were admitted to the ICU or HAU of a tertiary referral hospital between January 1, 2012, and August 31, 2022. The analysis was based on descriptive statistics. Results: Of the 100 patients with aSAH admitted to the ICU or HAU, 1 (1%) received the guideline-recommended dose and duration of nimodipine. Ninety-five (95%) of the patients experienced a delay to initiation, mainly due to transfer from another hospital (n = 45, 47%) and/or lack of a safe enteral route (n = 62, 65%). Sixty-six (66%) of the patients received alternative dosing, most because their blood pressure was below target (n = 16, 24%) or because of vasospasm requiring a higher blood pressure target (n = 22, 33%). A total of 99 patients (99%) had early discontinuation and/or treatment interruption of nimodipine; reasons included vasospasm requiring a higher blood pressure target (n = 12, 12%) and nimodipine not being continued on transfer or discharge (n = 14, 14%). Conclusions: Most of the patients in this study did not receive the full course of nimodipine therapy due to multiple barriers. Pharmacists can play a role in optimizing treatment by educating staff at transferring sites about timely initiation of therapy, reconciling medications on transfer or discharge, and mitigating interactions with concomitant medications. Keywords: aneurysmal subarachnoid hemorrhage, cerebral vasospasm, nimodipine, calcium channel blocker RÉSUMÉ Contexte : Les lignes directrices recommandent la nimodipine comme la norme de soins pour les patients atteints d’une hémorragie sous-arachnoïdienne anévrismale (HSA). Il a été démontré que ce médicament réduisait la mortalité et la dépendance à l’égard d’autrui pour les activités de la vie quotidienne, par rapport au placebo. Cependant, des données rétrospectives indiquent que les patients pourraient ne pas recevoir le traitement complet à base de nimodipine, tel que prescrit. Objectifs : L’objectif principal consistait à déterminer la part de patients atteints d’une HSA admis en unité de soins intensifs (USI) ou en unité de soins de haute acuité (USHA) dans un hôpital de référence tertiaire ayant reçu la dose de nimodipine recommandée par les lignes directrices pendant la durée du traitement également recommandée. L’objectif secondaire consistait quant à lui à décrire les obstacles empêchant le patient de recevoir le traitement complet, tel que prescrit. Méthodologie : Cette étude rétrospective des dossiers portait sur un échantillon de commodité de 100 patients atteints d’une HSA, admis en USI ou en USHA d’un hôpital de référence tertiaire entre le 1er janvier 2012 et le 31 août 2022. L’analyse se basait sur des statistiques descriptives. Résultats : Sur les 100 patients atteints d’une HSA admis en USI ou en USHA, un seul (1 %) a reçu la dose de nimodipine recommandée par les lignes directrices pendant la durée de traitement recommandée. L’initiation du traitement était retardée chez 95 patients (95 %), les raisons principales étant le transfert depuis un autre hôpital (n = 45, 47 %) et l’absence d’une voie entérale sécuritaire (n = 62, 65 %). Soixante-six patients (66 %) ont reçu un autre dosage, soit parce que la valeur de leur tension artérielle était inférieure à la cible (n = 16, 24 %), soit en raison d’un vasospasme nécessitant une valeur cible de tension artérielle plus élevée (n = 22, 33 %). Au total, 99 patients (99 %) ont vu l’arrêt précoce ou l’interruption de leur traitement par nimodipine; les raisons comprenaient un vasospasme nécessitant une valeur cible de tension plus élevée (n = 12, 12 %) et la non-continuité de la nimodipine lors du transfert ou du congé de l’hôpital (n = 14, 14 %). Conclusions : La plupart des patients de cette étude n’ont pas reçu le traitement complet à base de nimodipine en raison de multiples obstacles. Les pharmaciens peuvent jouer un rôle pour optimiser le traitement en sensibilisant le personnel des établissements de transfert à l’initiation rapide de la thérapie, en conciliant les médicaments lors du transfert ou du congé et en atténuant les interactions avec les médicaments concomitants. Mots-clés : hémorragie sous-arachnoïdienne anévrismale, vasospasme cérébral, nimodipine, bloqueur des canaux calciques

Importance Excessive bleeding is a common and prognostically important complication of cardiac surgery. For bleeding related to coagulation factor deficiency, frozen plasma is the most used therapy. Preliminary trials indicate that 4-factor prothrombin complex concentrate (PCC) may be a suitable alternative. Objective To compare the efficacy and safety of PCC with frozen plasma in patients undergoing cardiac surgery with coagulopathic bleeding. Design, Setting, and Participants Unblinded randomized noninferiority controlled clinical trial at 12 hospitals in Canada and the US involving adults (≥18 years) who had developed bleeding related to coagulation factor deficiency after termination of cardiopulmonary bypass during surgery (November 30, 2022, to May 28, 2024). Final 30-day follow-up visit was completed on June 28, 2024. Intervention A total of 265 patients were randomized to receive PCC (1500 IU ≤60 kg; 2000 IU >60 kg) and 263, frozen plasma (3 U ≤60 kg; 4 U >60 kg) in the operating room. A second dose was allowed over the next 24 hours if indicated; thereafter, only frozen plasma could be used. Main Outcomes and Measures The primary outcome was hemostatic response (effective if no hemostatic interventions occurred from 60 minutes to 24 hours after treatment initiation). The noninferiority of PCC vs frozen plasma was assessed using a 10% margin and a 1-sided α of .025, with subsequent testing for superiority if noninferiority was demonstrated. Secondary outcomes included allogeneic blood transfusions and adverse events. Patients were followed up until postoperative day 30. Results Of 538 enrolled patients, 420 patients (median age, 66 years [IQR, 57-73 years]; 74%, male; 10%, Asian; 1%, Black; and 65%, White) were included in the primary analysis; of those, 296 (70%) underwent complex surgeries. Compared with the 207 patients in the frozen plasma group, the 213 patients in the PCC group had higher hemostatic effectiveness (166 [77.9%] vs 125 [60.4%]; difference, 17.6%; 95% CI, 8.7%-26.4%; P < .001 for noninferiority and superiority) and had received fewer transfusions including red blood cells, platelets, and noninvestigational frozen plasma units (mean, 6.6 units; 95% CI, 5.7-7.7 vs 9.3 units; 95% CI, 8.0-10.8; difference, 2.7; 95% CI, 1.0-4.4; P = .002). Seventy-seven patients (36.2%) in the PCC group vs 98 (47.3%) in the frozen plasma group experienced serious adverse events (relative risk [RR], 0.76; 95% CI, 0.61-0.96; P = .02). Twenty-two patients (10.3%) in the PCC group and 39 (18.8%) in the frozen plasma group had acute kidney injury (RR, 0.55; 95% CI, 0.34-0.89; P = .02). Conclusions and Relevance In this unblinded randomized clinical trial, PCC had superior hemostatic efficacy and safety advantages to frozen plasma among patients requiring coagulation factor replacement for bleeding during cardiac surgery. Trial Registration ClinicalTrials.gov Identifier: NCT05523297

Rationale: Diaphragm inactivity during invasive mechanical ventilation may predispose the lung and diaphragm to injury, and is associated with adverse clinical outcomes. Objectives: Assess the feasibility of continuous on-demand diaphragm neurostimulation-assisted mechanical ventilation to maintain diaphragm activity in the absence of respiratory drive for at least 24 hours of mechanical ventilation. Methods: In a single center phase 1 clinical trial, patients receiving invasive mechanical ventilation for acute hypoxemic respiratory failure or after thoracic surgery underwent transvenous diaphragm neurostimulation delivered in synchrony with mechanical ventilation. Diaphragm neurostimulation was delivered when breaths were initiated by the ventilator and not by the patient until a successful spontaneous breathing trial was performed or for up to seven days. The co-primary outcomes were safety and feasibility of maintaining diaphragm activity over the first 24 hours of intervention. Measurements and main results: Twenty participants were enrolled and 19 underwent study procedures. Diaphragm neurostimulation was successfully initiated in all 19 patients (100%) and on-target diaphragm activity was maintained for ≥50% of hours of passive mechanical ventilation over the initial 24-hour period in 18/19 (95%) patients. Diaphragm neurostimulation was well-tolerated; one pneumothorax unrelated to device occurred following subclavian catheter placement prior to surgery. Over the 7-day study period, diaphragm activity was maintained during a median of 100% (IQR 95-100%) hours with absent respiratory drive. Conclusions: Continuous on-demand diaphragm neurostimulation-assisted mechanical ventilation is feasible and can prevent diaphragm inactivity during mechanical ventilation. Clinical trial registration available at www. Clinicaltrials: gov, ID: NCT05465083.

Objective We describe the implementation, outcomes, and challenges of a complex outpatient oral antimicrobial therapy program (COpAT) in Canada to provide a framework for those interested in establishing such a program. Setting Outpatient ambulatory clinic led by infectious diseases physicians, serving patients from a tertiary hospital and a small community hospital. Design Retrospective observational study that evaluated the efficacy, safety, and cost savings of patients enrolled in the program from August 2023 to June 2024. Results One hundred three patients were included, of which 84.4% achieved successful clinical outcomes. Mean age of the patients was 62 years and 30% had diabetes. The top three sources of infections were bone and joint, intra-abdominal, and skin-and-soft tissue. Mean duration of COpAT was 37 days. Seventy-five percent of patients required only a single agent, and amoxicillin/clavulanic acid was most commonly used. Twenty-two patients developed an adverse reaction, of which three required a change in therapy and one resolved with antibiotic dose reduction. No C. difficile infections or mortality were reported 30-days post COpAT discharge. Twelve patients were re-admitted to the hospital; 50% of the cases were unrelated to infections. Compared to outpatient intravenous therapy, the total cost savings from COpAT were estimated to be $255,000 Canadian dollars (CAD), which translated to an average cost savings of$2500 CAD per patient per year. Conclusion We demonstrated favorable clinical and safety outcomes with our COpAT program and substantial cost savings using existing infrastructure. COpAT allows efficient use of healthcare resources including decongestion of hospitals.

Background: Cryptogenic strokes account for approximately 30-40% of all stroke cases, underscoring the critical need for effective identification of right-to-left shunt (RLS) and PFO. The recently published BUBL Study (NCT04604015), a multicenter, prospective trial, demonstrated a 3-fold increase in the detection of RLS/PFO using raTCD compared TTE. Wechsler recognized the study's important findings in an accompanying editorial, while also highlighting the need for further validation through additional studies. This study aims to provide robust real-world data to further substantiate the findings of the BUBL Study. Methods: This study involved a multicenter retrospective analysis of prospectively collected real-world clinical data across 5 centers in the US and Canada. The inclusion criterion was any patient who underwent raTCD for RLS detection as part of their stroke evaluation. A standardized TCD, TTE, and TEE bubble study protocol was consistently applied. Key outcomes include overall and large (Spencer Grade ≥3) RLS detection rates for raTCD, detection rates comparison between matched raTCD, TTE, and TEE. Results: A total of 1,372 patients underwent raTCD, with 455 and 114 had matched TTE and TEE respectively. The overall cohort had a mean age of 55.5 ± 13.3 yrs, with 44% female. Using raTCD, RLS was detected in 54% (735/1,372) and large RLS in 28% (383/1,372) of the overall population. When compared with TTE (n=455), raTCD identified 1.7 times more cases of RLS/PFO (56.7% vs. 33.2%, p<0.001 – Table 1). For all and large RLS detected by raTCD, 27.4% (125/455) and 12.3% (56/455), respectively were negative on TTE. Comparing TEE and raTCD, 14.9% (17/114) were negative on TEE but positive on raTCD compared to 5.3% (6/114) which were positive on TEE and negative on raTCD. Overall, using TEE as the “gold standard” raTCD reported a SEN of 92.1%. For the overall population (n=1,372) TTE and TEE status was unknown for 917 patients and will subsequently be investigated. Conclusions: This study represents the largest real-world study to date, validating raTCD against traditional diagnostic modalities. The study showed that raTCD detected 1.7 times the number of positive RLS/PFO compared to TTE, revealing the limitations of TTE as a screening modality for PFO in cryptogenic stroke. These results build upon the prospective multicenter BUBL Study reinforcing the imperative to incorporate raTCD into a new diagnostic algorithm for cryptogenic stroke workup.

Importance Delirium is common after cardiac surgery and associated with adverse outcomes. Intraoperative benzodiazepines may increase postoperative delirium but restricting intraoperative benzodiazepines has not yet been evaluated in a randomized trial. Objective To determine whether an institutional policy of restricted intraoperative benzodiazepine administration reduced the incidence of postoperative delirium. Design, Setting, and Participants This pragmatic, multiperiod, patient- and assessor-blinded, cluster randomized crossover trial took place at 20 North American cardiac surgical centers. All adults undergoing open cardiac surgery at participating centers during the trial period were included through a waiver of individual patient consent between November 2019 and December 2022. Intervention Institutional policies of restrictive vs liberal intraoperative benzodiazepine administration were compared. Hospitals (clusters) were randomized to cross between the restricted and liberal benzodiazepine policies 12 to 18 times over 4-week periods. Main Outcomes and Measures The primary outcome was the incidence of delirium within 72 hours of surgery as detected in routine clinical care, using either the Confusion Assessment Method–Intensive Care Unit or the Intensive Care Delirium Screening Checklist. Intraoperative awareness by patient report was assessed as an adverse event. Results During the trial, 19 768 patients (mean [SD] age, 65 [12] years; 14 528 [73.5%] male) underwent cardiac surgery, 9827 during restricted benzodiazepine periods and 9941 during liberal benzodiazepine periods. During restricted periods, clinicians adhered to assigned policy in 8928 patients (90.9%), compared to 9268 patients (93.2%) during liberal periods. Delirium occurred in 1373 patients (14.0%) during restricted periods and 1485 (14.9%) during liberal periods (adjusted odds ratio [aOR], 0.92; 95% CI, 0.84-1.01; P = .07). No patient spontaneously reported intraoperative awareness. Conclusions and Relevance In intention-to-treat analyses, restricting benzodiazepines during cardiac surgery did not reduce delirium incidence but was also not associated with an increase in the incidence of patient-reported intraoperative awareness. Given that smaller effect sizes cannot be ruled out, restriction of benzodiazepines during cardiac surgery may be considered. Research is required to determine whether restricting intraoperative benzodiazepines at the patient level can reduce the incidence of postoperative delirium. Trial Registration ClinicalTrials.gov Identifier: NCT03928236

Introduction Neuroendocrine neoplasm (NENs) make up approximately 2–3 % of gallbladder malignancies, while only 0.5 % of all NENs develop in the gallbladder. Most Gallbladder neuroendocrine neoplasms (GB-NENs) are discovered incidentally during pathological examinations post-cholecystectomy. Case presentation 70-year-old male presents with an incidentally discovered 2.2 cm enhancing intraluminal soft tissue mass on abdominal CT scan. The mass demonstrates restricted diffusion on MR imaging, concerning for gallbladder malignancy. Radical cholecystectomy, confirms primary gallbladder neuroendocrine tumor (GB-NET). No adjuvant therapy was recommended at multidisciplinary cancer conference review. The patient is currently disease free at 18 months follow up. Discussion The management of GB-NEN remains challenging, due to the lack of specific clinical manifestations and typical imaging features preoperatively. GB-NENs are usually asymptomatic, and the paucity of reported imaging characteristics makes prospective diagnosis of GB-NENs challenging. GB-NEN tend to be larger in size, demonstrating well defined, intact mucosa, with a thick rim of hyperintensity on diffusion weighted images (DWI). Distinguishing between gallbladder neuroendocrine carcinoma (GB-NEC) and gallbladder neuroendocrine tumor (GB-NET) on pathologic evaluation is essential in developing a treatment plan. GB-NETs have superior survival compared to GB-NECs. GB-NETs can be managed utilizing a cholecystectomy with portal lymphadenectomy +/− segment 4b/5 liver resection. Conclusion GB-NETs may achieve curative resection, if identified at an early disease stage.

This paper examines the development of a nurse-led clinical pathway at the Royal Columbian Hospital in New Westminster, BC, to enhance care for cardiac surgery patients. The systematic quality improvement project aimed to standardize care and improve outcomes by addressing issues such as prolonged hospital stays, delayed extubation and limited post-operative mobility. By comparing clinical outcomes with benchmarks, the project identified opportunities for improvement, including early ambulation, timely extubation, reduced mortality, readmission rates and length of stay. The development process involved collaboration with nursing leaders, stakeholder consultations and thorough evidence review and highlighted the crucial role of strategic leadership in large-scale change initiatives.

INTRODUCTION Assessing treatments for Alzheimer's disease (AD) relies on reliable tools for measuring AD progression. In this analysis, we evaluate the sensitivity of clinical progression measures in AD within randomized controlled trials (RCTs) with confirmed positive amyloid (Aβ+) status prior to trial enrollment. METHODS Excluding trials targeting non‐cognitive symptoms, we conducted meta‐analyses on progression measures from 25 selected RCTs using R version 4.2.0, along with the metafor and emmeans libraries. RESULTS The Functional Activities Questionnaire (FAQ) demonstrated the greatest sensitivity over 12 weeks. Other cognitive measures demonstrated lower sensitivity. The integrated Alzheimer's Disease Rating Scale (iADRS) and Clinical Dementia Rating‐Sum of Boxes (CDR‐SB) seemed more effective than their individual cognitive components. Neuropsychiatric measures were the least sensitive in measuring progression. DISCUSSION Functional measures generally outperformed other measure categories. Purely cognitive domain‐based measures were suboptimal for tracking early AD progression. Ideally, future measures should incorporate both cognitive and functional components to enhance sensitivity. Highlights Concerns remain regarding the limitations of current outcome measures used in AD clinical trials, particularly their sensitivity in the early and preclinical stages of the disease, which hampers their reliability as indicators of AD progression. The Functional Activities Questionnaire (FAQ) demonstrated the most substantial weighted mean change over 12 weeks, followed by the Mini‐Mental State Examination (MMSE). Functional measures outperformed other measure categories. Composite scores of integrated Alzheimer's Disease Rating Scale and Clinical Dementia Rating‐Sum of Boxes are more sensitive to change than their individual cognitive components, possibly driven by the functional components of the score. Neuropsychiatric measures analyzed in this study appeared to be the least sensitive in measuring progression.

Background During the COVID-19 pandemic, treatment strategies evolved rapidly. The RECOVERY trial established corticosteroids as the standard care for reducing mortality in COVID-19 patients. However, some critical care clinicians began using doses higher than those recommended in RECOVERY. Objective To characterize the use of high-dose corticosteroids and IL-6 inhibitors in critically ill COVID-19 patients and examine their association with adverse drug events (ADEs). Methods A retrospective cohort study of 320 electronic health records (January 1, 2020 - June 30, 2022) was conducted on COVID-19 patients requiring high-flow oxygen or mechanical ventilation. Patients were categorized based on corticosteroid dose: “high dose dexamethasone” (daily dose greater than 12 mg and/or for longer than 10 days), “low dose dexamethasone” (daily dose 12 mg or less for 10 days or less), and “no dexamethasone” (no corticosteroid therapy). Subgroups were created based on IL-6 inhibitor use. Results High-dose dexamethasone was associated with increased odds of ADEs compared to low dose (OR 2.55, 95% CI 1.45 to 4.49) and no dexamethasone (OR 6.29, 95% CI 2.08 to 19.03). No additional efficacy benefit was observed in patients receiving high dose corticosteroids when compared to low dose corticosteroids. Patients receiving both an IL-6 inhibitor and high-dose dexamethasone had further increased odds of ADEs. High-dose dexamethasone was also associated with increased mortality compared to low dose (OR 3.78, 95% CI 1.97-7.25) and no dexamethasone (OR 15.22, 95% CI 3.27-70.74). Conclusions Acknowledging the risk for residual confounding, higher doses of dexamethasone were associated with increased ADEs and mortality. These findings highlight the need for careful consideration of the use of high-dose dexamethasone.

Syphilis is a sexually transmitted infection that is undergoing a resurgence in Canada and around the world. If not diagnosed correctly, syphilis can progress to its secondary and tertiary stages, affecting numerous organ systems. We present a case of a 41-year-old female who developed a papulosquamous rash, initially diagnosed as varicella with progression to a widespread and painful rash over 3 months. Based on clinical, histological, and serological findings, she was later diagnosed with secondary syphilis and successfully treated with intramuscular penicillin. This case underscores the importance of accurate diagnosis and treatment of syphilis to prevent systemic complications. We advocate for increased awareness among frontline providers with a proactive approach to diagnosis and management, including thorough history and physical examination, low threshold for performing serological testing, biopsy for lesions that do not resolve as expected with management, and multidisciplinary involvement for complex presentations of syphilis.

Background: Patients with acute basilar artery occlusion (BAO) and low-to-moderate symptoms (National Institutes of Health Stroke Scale [NIHSS] < 10) are poorly represented in thrombectomy trials. Our objective is to compare thrombectomy and best medical management (BMT) in this population. Methods: We compared data of all consecutive patients presenting with an initial NIHSS < 10 and acute symptomatic BAO included in two registries. The main outcome was the proportion of patients achieving a 3-months favorable outcome (mRS 0-2 or equal to the pre-stroke value). Secondary outcomes included the proportion of patients with an excellent outcome (mRS 0-1 or equal to pre-stroke value), overall mRs distribution (shift analysis) and mortality. Effect sizes for thrombectomy versus BMT alone were calculated using binary or ordinal logistic regression model before after considering confounders using the inverse probability of treatment weighting (IPTW) propensity score method. Results: One hundred twenty-seven patients were included: sixty-four patients treated with thrombectomy (mean ± SD age: 63.4 ± 16.1) and sixty-three with BMT (mean ± SD age: 69.0 ± 14.3). There was no significant difference between groups for the rate of 3 month-favorable outcome or mortality. After propensity-score adjustment, thrombectomy was associated with a significantly higher chance of excellent outcome at 3 months (mRS 0-1 or equal to pre-stroke value; adjusted OR, 2.68; 95%CI, 1.04-6.90; p = 0.041). Conclusion: Our study suggests that thrombectomy in patients with low-to-moderate symptoms (NIHSS < 10) due to BAO does not improve the rate of favorable outcome but could lead to a higher chance of excellent outcome at 3 months.Trial Registration: ETIS Registry. http://www.clinicaltrials.govNCT03776877.