Vancouver General Hospital

Background Most Canadians receive their care in community hospitals, yet most clinical research is conducted in academic hospitals. This study aims to compare patients with community acquired pneumonia (CAP) treated in academic and community hospitals with respect to their demographics, clinical characteristics, treatments and outcomes. Methods This nested observational cohort substudy of the Community Acquired Pneumonia: Toward InnoVAtive Treatment (CAPTIVATE) trial included 1,329 hospitalized adults with CAP recruited between March 1st, 2018 and September 31st, 2023 from 15 Canadian hospitals. Unadjusted and adjusted analyses for age, sex and co-morbidities using logistic, Cox and censored quantile regressions were conducted. Results Patients in community hospitals were older (mean [SD] 75.0 [15.7] years vs. 68.3 [16.2] years; p < 0.001), were more likely to be female (49.7% vs. 41.0%, p = 0.002), and had more comorbidities (75.9% vs. 64.8%, p < 0.001). More patients in community hospitals received corticosteroids (49.2% vs. 37.4%, p < 0.001). Community hospital patients had a higher likelihood of developing acute respiratory distress syndrome (OR 3.13, 95% CI: 1.87, 5.24, p = < 0.001), and acute cardiac injury (OR 2.53, 95% CI: 1.33, 4.83, p = 0.005). In unadjusted and adjusted analyses, 28-day mortality difference did not meet statistical significance (OR 1.43, 95% CI: 0.98, 20.7, p = 0.062 and OR 1.23, 95% CI: 0.81, 1.87, p = 0.332, respective). Conclusion Patients with CAP in Canadian community and academic hospitals differed with respect to their age, clinical characteristics, treatments and outcomes, emphasizing the importance of including more community hospitals in clinical research studies to ensure the generalizability of results.

Infections are a significant cause of morbidity and mortality in myelodysplastic syndrome (MDS). Precise estimates of infection frequency and severity with modern therapies are uncertain. We conducted a retrospective analysis of a prospective cohort enrolled in a Canadian MDS registry and characterized the frequency and severity of infectious complications. Among 1,115 patients enrolled in the registry from 2006 to 2022, 349 (31%) experienced fever/infection, 207 (19%) were hospitalized due to fever/infection, and 95 (9%) died from fever/infection. Patients with severe neutropenia (absolute neutrophil count < 0.5 × 10⁹/L) experienced more fever/infection (40% vs. 30%; p = 0.05), shorter time to fever/infection (7 vs. 25 months; p < 0.01) and more hospitalization for fever/infection (9 vs. 27 months; p < 0.01). Higher-risk MDS patients (Revised International Prognostic Scoring System > 3.5) had more fever/infection (36% vs. 29%; p = 0.05), infection-related hospitalizations (24% vs. 14%; p < 0.01), and a trend toward higher mortality due to fever/infection (11% vs. 7%; p = 0.06). Hypomethylating agent (HMA) treatment was associated with higher rates of fever/infection (40% vs. 26%; p < 0.01), as well as increased infection-related hospitalization (27% vs. 14%; p < 0.01) and death (14% vs. 6%; p < 0.01). Multivariate analysis showed that higher-risk disease and HMA treatment contributed to poorer infection-related outcomes including a shorter time from diagnosis to fever/infection (HR 1.9; p < 0.01 and HR 1.8; p < 0.01, respectively), hospitalization (HR 2.5; p < 0.01 and HR 1.9; p < 0.01, respectively), and death (HR 2.3; p = 0.01 and HR 3.3; p < 0.01, respectively). In a Canadian MDS population, infectious events were common with baseline neutropenia, higher-risk disease, and hypomethylating agents associated with increased infection risk.

Introduction Complex regional pain syndrome (CRPS) is a common complication following distal radius fractures that is difficult to diagnose and can lead to permanent disability. While various proposed prophylaxis and treatment modalities exist, high-quality evidence guiding practice is limited. This survey of Orthopaedic Trauma Association (OTA) and Canadian Orthopaedic Association (COA) members was conducted with the primary aim of assessing practice patterns in distal radius fractures complicated with CRPS. Methods An electronic survey was distributed to practicing orthopaedic surgeons in the COA and OTA. Questions assessed practice setting, preference in management of distal radius fractures and CRPS, comfort level in managing CRPS, and identification of gaps in management. Responses were anonymized and collected over 8 months. Response data was analyzed using descriptive statistics; thematic analysis was used on free text response. Results 134 survey responses were completed. 84% of respondents felt the incidence of CRPS in distal radius fractures was 1–10%, while 15% felt it was closer to 11–20%. 24% of respondents utilized the “Budapest Criteria” to diagnose CRPS. 40% offered prophylaxis in patients felt to be at high risk of developing CRPS. 66% of surgeons felt neutral, uncomfortable, or very uncomfortable managing CRPS in distal radius fractures. When asked to consider adopting a prophylactic therapy, 38% of surgeons indicated that a therapy that reduced the absolute risk of CRPS by 6–10% would change their practice. Gaps in current practice included lack of evidence-based treatment and prevention strategies and diagnostic uncertainty. Conclusion This study identified that amongst orthopaedic surgeons in the COA and OTA, diagnosis, treatment, and prophylaxis strategies for CRPS in distal radius fractures are heterogeneous. Surgeons are not confident in their treatment of CRPS. Future studies using rigorous research methods are warranted to improve management.

Background As previously published, the MMPOWER-3 clinical trial did not demonstrate a significant benefit of elamipretide treatment in a genotypically diverse population of adults with primary mitochondrial myopathy (PMM). However, the prespecified subgroup of subjects with disease-causing nuclear DNA (nDNA) pathogenic variants receiving elamipretide experienced an improvement in the six-minute walk test (6MWT), while the cohort of subjects with mitochondrial DNA (mtDNA) pathogenic variants showed no difference versus placebo. These published findings prompted additional genotype-specific post hoc analyses of the MMPOWER-3 trial. Here, we present these analyses to further investigate the findings and to seek trends and commonalities among those subjects who responded to treatment, to build a more precise Phase 3 trial design for further investigation in likely responders. Results Subjects with mtDNA pathogenic variants or single large-scale mtDNA deletions represented 74% of the MMPOWER-3 population, with 70% in the mtDNA cohort having either single large-scale mtDNA deletions or MT-TL1 pathogenic variants. Most subjects in the nDNA cohort had pathogenic variants in genes required for mtDNA maintenance (mtDNA replisome), the majority of which were in POLG and TWNK . The mtDNA replisome post-hoc cohort displayed an improvement on the 6MWT, trending towards significant, in the elamipretide group when compared with placebo (25.2 ± 8.7 m versus 2.0 ± 8.6 m for placebo group; p = 0.06). The 6MWT results at week 24 in subjects with replisome variants showed a significant change in the elamipretide group subjects who had chronic progressive external ophthalmoplegia (CPEO) (37.3 ± 9.5 m versus − 8.0 ± 10.7 m for the placebo group; p = 0.0024). Pharmacokinetic (exposure–response) analyses in the nDNA cohort showed a weak positive correlation between plasma elamipretide concentration and 6MWT improvement. Conclusions Post hoc analyses indicated that elamipretide had a beneficial effect in PMM patients with mtDNA replisome disorders, underscoring the importance of considering specific genetic subtypes in PMM clinical trials. These data serve as the foundation for a follow-up Phase 3 clinical trial (NuPOWER) which has been designed as described in this paper to determine the efficacy of elamipretide in patients with mtDNA maintenance-related disorders. Classification of evidence Class I ClinicalTrials.gov identifier NCT03323749

Myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) are severe myeloid disorders associated with significant morbidity and mortality. Because of patient and disease factors, many older adults are treated as outpatients with less-intensive therapy. Optimal supportive care strategies to minimize bleeding and infectious complications in this patient population have not been systematically evaluated. We conducted a survey of Canadian hematologists to explore current practice in the use of tranexamic acid (TXA) and prophylactic antimicrobials in patients with MDS/AML treated with less-intensive therapy, and to evaluate equipoise for future trials. Survey items were generated through a combination of literature review and discussion with content experts. The survey was disseminated to 304 potential respondents with a response rate of 52%. Prophylactic platelet transfusions were used by 95%, while prophylactic TXA was used by 57%; the most frequent reason for not using TXA was uncertainty about benefit or harm. Use of prophylactic antimicrobials varied by chemotherapy regimen. If antimicrobial prophylaxis was used, the most frequently prescribed antibacterials were fluroquinolones (90%) and trimethoprim/sulfamethoxazole (21%); the most commonly used antifungals were fluconazole (66%) and voriconazole (36%). The most common reason for not using prophylactic antimicrobials was insufficient evidence of benefit. Most respondents agreed that clinical trials are needed to define the use of TXA and prophylactic antimicrobials in this patient population. Among survey respondents, there was variation in the use of supportive care strategies to address bleeding and infection risk in older adults with MDS/AML. The results of this survey will help to inform clinical trials to assess the benefits and risks of these prophylactic strategies.

Surgical patient optimization is a proactive approach to improve postoperative outcomes. This article reviews the development of the Surgical Patient Optimization Collaborative, an initiative supporting preoperative optimization in British Columbia, Canada. The Collaborative facilitated optimization programs over two cohorts between 2019 and 2024. A “Change Package” offered screening, intervention, and measurement tools for the following 13 surgical risk factors: anemia, anxiety, body mass index (cohort 2 only), cardiac status, frailty, glycemic control, nutrition, sleep apnea, pain management, physical activity, smoking, social support, substance use, and venous thromboembolism (cohort 1 only). Monthly data submissions from participating sites included the number of patients undergoing optimization, National Surgical Quality Improvement Program-defined 30-day outcomes, length of stay, and patient-reported measures. Run charts were used to analyze the progress of optimization implementation across both cohorts. Fourteen sites participated in each cohort. In total, 9,686 patients were screened for optimization, with 7,100/7,505 (95%) patients receiving at least one optimization intervention. Improvement shifts in the number of patients screened were identified in the run charts across both cohorts. Most patients felt that their optimization improved their surgical experience and outcomes. Data for clinical outcomes were inconsistently reported from sites and precluded analyses. Barriers to implementation included project complexity and structural characteristics, and facilitators were knowledge and beliefs about the intervention, reflection, and evaluation. Preoperative optimization programs were successfully implemented across multiple sites in British Columbia. High-quality clinical outcome analyses are still needed to determine the impact of preoperative optimization on postoperative outcomes. The insight gained from the Collaborative’s implementation process may help inform future multicentre preoperative optimization efforts.

This cross-sectional study assesses changes in gender, racial, and ethnic representation among US neurology faculty from 1972 to 2021.

Introduction: Anaphylaxis is an acute life-threatening allergy, most commonly provoked by food, venom, or drugs. There is limited data regarding differences in symptomatology between anaphylaxis provoked by different triggers. This study aimed to assess sociodemographic characteristics, clinical symptoms, and management of anaphylaxis, according to triggers in adults. Methods: We conducted a cross-sectional study recruiting adult patients with anaphylactic reactions across 8 emergency departments (EDs) and 1 electronic medical service (EMS) in Canada. Univariate and multivariate regression models were used to evaluate symptoms involving all patients with the outcome of drug-induced anaphylaxis (DIA), venom-induced anaphylaxis (VIA), peanut-induced anaphylaxis (PIA), shellfish-induced anaphylaxis, tree-nut induced anaphylaxis (TIA) and nut-induced anaphylaxis (NIA). We assessed comorbidities associated with severe reactions, stratified by triggers listed above. Additionally, we evaluated the association of each trigger with treatment through regression models involving all patients with medications used as outcome and anaphylaxis triggers used as independent variables. Results: From April 2011 to November 2023, 1,135 adults presenting with anaphylaxis to EDs were recruited. The median age was 35.5 (interquartile range 25.3–51.1). Most of the patients presented with FIA (50.3%). Regarding symptomatology, hypotension was more likely associated with DIA (aOR = 1.20, 95% CI = 1.11–1.30, p < 0.01). When adjusted for age at reaction and male sex, alcohol was more likely associated (aOR = 1.51, 95% CI = 1.04–2.19, p = 0.035) with NIA. Regarding management, TIA was more likely associated with inpatient epinephrine (aOR = 2.05, 95% CI = 1.16–3.64, p = 0.014). DIA was less likely associated with outpatient antihistamine (aOR = 0.68, 95% CI = 0.48–0.89, p < 0.01) whereas TIA was more likely associated with outpatient antihistamine (aOR = 1.81, 95% CI = 1.03–3.19, p = 0.040). Conclusion: Our study underscores associations between specific triggers, clinical manifestations and managements, such as the potential link between TIA and throat tightness and hypotension and VIA. Identifying such associations can aid with the prompt diagnosis of anaphylaxis in patients presenting to the ED, leading to swifter treatment initiation and improving overall outcomes.

Background In February 2022, a novel antiviral for the treatment of COVID-19, nirmatrelvir/ritonavir (Paxlovid), was approved by Health Canada and made available to patients in British Columbia (BC). BC community pharmacists did not prescribe nirmatrelvir/ritonavir, but dispensing involved a detailed assessment with close attention to drug-drug interactions and patient monitoring. As the nirmatrelvir/ritonavir service was unique in BC, and not all pharmacists participated in the program, it is important to evaluate the perspectives of all the pharmacists who were affected so that lessons learned from the program can inform future pandemic planning and government initiatives. Methods A qualitative research study using key informant semistructured interviews was conducted. Community pharmacists with varying degrees of experience with nirmatrelvir/ritonavir were recruited using multiple methods of recruitment through e-mail and fax invitations and social media posts. Open-ended questions explored pharmacists’ experiences with the nirmatrelvir/ritonavir program, including barriers and facilitators to dispensing it, and recommendations for future pharmacy initiatives. Results Forty-three community pharmacists participated in the study. Most participants were between the ages of 30 and 39 years and had practiced for less than 10 years. Thematic analysis yielded 36 codes that were organized into 3 overarching themes related to the following: learning; in-process experiences, supports, difficulties; and perceptions about the expanded scope of practice. Discussion The following strategies may be helpful to consider including in future initiatives: preprinted forms, a hotline for peer support, slower rollouts, a single source for communicating changes, a patient portal, addressing the divisions between dispensary and clinical work, and having specialized positions to support future rollouts. Conclusion Lessons learned from the nirmatrelvir/ritonavir service included a slower approach to program initiation with additional training opportunities and more streamlined prescription options. Pharmacists also wished for better communication support and involvement in the planning of future initiatives.

Context: Calls to collect patients’ race/ethnicity (RE) data as a measure to promote equitable health care among vulnerable patient groups are increasing. The COVID-19 pandemic has highlighted how a public health crisis disproportionately affects racialized patient groups. However, less is known about the uptake of RE data collection in the context of mental health care services. Methodology: A qualitative case study used surveys with mental health patients (n = 47) and providers (n = 12), a retrospective chart review, and a focus group to explore healthcare providers’ and patients’ perspectives on collecting RE data in Canada. Results: The patient survey data and focus groups show that patients avoid providing identifying information due to perceived stigma and discrimination and a lack of trust. Providers did not feel comfortable asking patients about RE, leading to chart review data where RE information was not systematically collected. Conclusions: The uptake and implementation of RE data collection in mental health care contexts require increased training and support, systematic implementation, and further evaluation and measurement of how the collection of RE data will be used to mitigate systemic racism and improve mental health outcomes.

Background Residency training and parenthood are conflicting pursuits for many residents, as both often occur during similar years of life. Online policy about paid parental leave for residents is important for not only mitigating this dilemma, but also ensuring that the associated health benefits can be fully capitalised on. Purpose Investigate the extent of advertised paid parental leave for anaesthesiology residencies in the USA and to explore whether this had an association with the gender of the department chair for these programmes. Analysis of Canadian anaesthesiology residencies was performed to assess whether a nation with federally protected paid parental leave yielded disparate rates of advertised paid parental leave. Methods All accredited US anaesthesiology residency programme websites were reviewed to determine the gender of the department chair and the existence of advertised paid parental leave for residents. χ² analysis was used to determine if there was a statistically significant association between the gender of anaesthesiology residency department chairs and paid parental leave advertised. Rates of advertised paid parental leave were compared with those seen in Canadian anaesthesiology residencies. Results US anaesthesiology residency department chairs were 84% (137/164) men. Of the men-led programmes, 42% (58/137) advertised paid parental leave, while 70% (19/27) of women-led programmes advertised such benefits (p<0.05). Overall, 47% of (77/164) of US anaesthesiology residencies advertised paid parental leave, while 76% (13/17) of Canadian anaesthesiology residencies advertised paid parental leave (p<0.05). Conclusion In the USA, anaesthesiology residencies with department chairs held by women had a higher rate of advertised paid parental leave. Such findings call attention to the potential downstream effects of lacking diversity in leadership within medicine. When compared with the USA, Canada was found to have higher rates of advertised paid parental leave across their anaesthesiology residencies, potentially highlighting the impact of federal legislature on medical residents.

Background Chronic pain is among the leading causes of disability worldwide, of which only a small percentage of patients receive adequate treatment for. Non‐prescribed opioid analgesics are commonly sought out in effort to alleviate unrelieved pain. This study assesses the prevalence and correlates of chronic pain among primary fentanyl users. Methods A cross‐sectional and structured survey was conducted with 200 adults who reported fentanyl as their drug of choice from a Vancouver acute care hospital. Presence and levels of chronic pain were determined through self‐report. Results The majority of participants ( n = 130, 72.6%) reported having chronic pain in the past 6 months, with the mean level of pain on a typical day to be 7.6 out of a scale of 10 ( SD = 1.9). Majority ( n = 85, 65.4%) reported using street opioids to self‐medicate, while only 9 (6.9%) reported that their chronic pain was unrelated. Regression analysis indicated that increasing age and co‐use of cannabis and opioids were independent associated factors of chronic pain. Higher levels of reported pain on a typical day were further associated with age and self‐medication. Conclusions The findings of this study demonstrate a significant association between self‐medication and chronic pain among primary fentanyl users in British Columbia. For these individuals, inadequate pain relief may drive continued opioid use, which in turn may increase risks of treatment discontinuation and overdose. Appropriate pain management strategies are crucial to avoid opioid misuse and decrease the large societal burden caused by chronic pain. Significance Our work points to the high prevalence of self‐reported chronic pain among individuals who primarily use fentanyl. Among those with self‐reported fentanyl use and chronic pain, self‐medication with street opioids was found to be common and associated with higher reported pain levels on a typical day. This highlights the need for pain management strategies to be integrated into opioid dependence treatment and more research in the overlap of pain and fentanyl use.

Background: Stent misdeployment (SMD) is a feared technical challenge of EUS-guided choledochoduodenostomy using a lumen apposing stent (EUS-CDS) that has been poorly characterized. We aim to ascertain the rate of SMD in EUS-CDS for malignant distal biliary obstruction (MDBO) and describe its outcomes while identifying variables associated with its occurrence. In addition, we aim to propose a de novo SMD classification. Method: A post hoc analysis of two RCTs comparing EUS-CDS vs. endoscopic retrograde cholangiopancreatography in MDBO. The main endpoint was the rate of SMD classified as misdeployment of the distal flange (type I), proximal flange (type II), contralateral bile duct wall injury (type III), or double mucosal puncture (type IV). A multivariable analysis was performed to identify variables associated with the odds of SMD and/or technical failure and clinical failure or stent dysfunction. Results: 152 patients were included with a technical success of 93.4%. SMDs occurred in 11 (7.2%) patients (95% CI, 3.1%-11.4%): 8 type I, 1 type II, and 2 type III. Endoscopic salvage was successful in 81.8%. SMDs led to an adverse event (AE) in 4 cases (2 mild and 2 moderate) with an overall AE rate of 2.6% (95% CI, 0.7%-6.6%). On multivariable analysis, an extrahepatic bile duct diameter of ≤ 15 mm was associated with increase odds of SMD and/or technical failure. Conclusion: SMD is relatively common in EUS-CDS and is associated with an extra-hepatic bile duct diameter measuring ≤ 15 mm. The majority of SMDs can be rescued endoscopically with low risk for AE.

Background Young patients ≤ 50 years old with multiple myeloma (MM) account for about 10% of cases and are underrepresented in the literature. Methods We explored disease characteristics, treatments, and outcomes following modern therapies of young MM patients using the Canadian Myeloma Research Group (CMRG) database. We included 493 patients ≤ 50 years old diagnosed with MM or plasma cell leukemia without concurrent amyloidosis or POEMS syndrome from January 1, 2010, to July 1, 2022. Results The median age was 46 years old (range: 25.6–50). Most patients fell into the R‐ISS II category (72.7%), and 24.1% had high‐risk cytogenetics. The majority of patients (89.9%) received a proteasome inhibitor‐based first‐line treatment, 92.1% received a stem cell transplant, and 65.6% had maintenance therapy post–autologous stem cell transplant (ASCT). Median follow‐up from initial treatment to patients' last follow‐up was 48.5 (range: 0–155) months. Median progression‐free survival (PFS) was 45.0 months (95% CI: 40.2–50.0). Maintenance therapy post‐ASCT improved median PFS to 52.3 months (95% CI: 43.1–68.2), compared to 23.6 months (95% CI: 20.0–34.8) without maintenance [p < 0.001]. Conclusion Although the overall survival has not yet been reached in this young population, our reported median PFS of only 45 months highlights the urgent need to develop innovative treatments to induce more profound and durable responses.

Sustainable diets can achieve considerable reductions in greenhouse gas emissions and improvements in human health, but changing dietary behavior remains a challenge. We assessed the impacts of two behavioral insights strategies on bridging the intention-action gap related to sustainable and healthy food choices amongst hospital cafeteria patrons. In a pilot survey of hospital staff (N = 1,165), 56% identified limited awareness and availability of sustainable food as barriers to purchasing, although 46% were extremely willing to try sustainable dishes. We examined increasing salience (Study 1), varying availability (Study 2a), and decreasing availability (Study 2b) on sustainable and healthy dish purchases in three hospital cafeterias. Each study ran for seven weeks from March to April, 2023. In total, 10,616 dishes were purchased. In Study 1, increasing salience was associated with significant uptake of sustainable and healthy dishes, but the effect disappeared once the salience intervention was removed. In Study 2a, increasing availability of sustainable dishes corresponded to a significant increase in purchases of sustainable dishes, while decreasing availability in Study 2b followed a downward trend in purchases, suggesting that availability drove dietary choices. We recommend hospitals consider these choice architecture interventions to support the adoption of sustainable and healthy diets.