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Hemmelgarn B.R.,University of Calgary | Zhang J.,University of Calgary | Manns B.J.,University of Calgary | James M.T.,University of Calgary | And 8 more authors.
JAMA - Journal of the American Medical Association | Year: 2010

Context: Laboratory reporting of estimated glomerular filtration rate (GFR) has been widely implemented, with limited evaluation. Objective: To examine trends in nephrologist visits and health care resource use before and after estimated GFR reporting. Design, Setting, and Patients: Community-based cohort study (N=1 135 968) with time-series analysis. Participants were identified from a laboratory registry in Alberta, Canada, and followed up from May 15, 2003, to March 14, 2007 (with estimated GFR reporting implemented October 15, 2004). Main Outcome Measure: Nephrologist visits and patient management. Results: Following estimated GFR reporting, the rate of first outpatient visits to a nephrologist for patients with chronic kidney disease (CKD; estimated GFR <60 mL/ min/1.73 m2) increased by 17.5 (95% confidence interval [CI], 16.5-18.6) visits per 10 000 CKD patients per month, corresponding to a relative increase from baseline of 68.4% (95% CI, 65.7%-71.2%). There was no association between estimated GFR reporting and rate of first nephrologist visit among patients without CKD. Among patients with an estimated GFR of less than 30 mL/min/1.73 m2, the rate of first nephrologist visits increased by 134.4 (95% CI, 60.0-208.7) visits per 10 000 patients per month. This increase was predominantly seen in women, patients aged 46 to 65 years as well as those aged 86 years or older, and those with hypertension, diabetes, and comorbidity. Reporting of estimated GFR was not associated with increased rates of internal medicine or general practitioner visits or increased use of angiotensinconverting enzyme inhibitors/angiotensin II receptor blockers among patients with CKD and proteinuria or the subgroup limited to patients with diabetes. Conclusions: Reporting of estimated GFR was associated with an increase in first nephrologist visits, particularly among patients with more severe kidney dysfunction, women, middle-aged and very elderly patients, and those with comorbidities. Any effect on outcomes remains to be shown. ©2010 American Medical Association. All rights reserved.


Lagace-Wiens P.R.S.,University of Manitoba | Baudry P.J.,University of Manitoba | Pang P.,Diagnostic Services of Manitoba | Hammond G.,University of Manitoba
Journal of Clinical Microbiology | Year: 2010

Extended-spectrum-β-lactamase (ESBL)-producing organisms have captured the attention of clinicians and laboratorians and are agents of nosocomial and community onset infections (J. D. Pitout and K. B. Laupland,. Lancet Infect. Dis. 8:159-166, 2008). ESBLs in many enterobacteriaceae and in nonfermenting Gram-negative organisms have been described (K. Bush and G. A. Jacoby, Antimicrob. Agents Chemother. 54:969-976, 2010). We present the first case of a clinical isolate of multidrug-resistant Escherichia fergusonii expressing an extended-spectrum-β-lactamase (ESBL). Copyright © 2010, American Society for Microbiology. All Rights Reserved.


Alfa M.J.,Diagnostic Services of Manitoba | Alfa M.J.,University of Manitoba | Alfa M.J.,St Boniface Research Center | Olson N.,St Boniface Research Center | Murray B.-L.,St Boniface Research Center
American Journal of Infection Control | Year: 2014

Background The objectives of this study were to recommend sample collection method(s) based on relative soiling in patient-used gastrointestinal (GI) endoscopes and determine whether the published benchmarks for protein, bioburden, and adenosine triphosphate (ATP) remain relevant for pump-assisted manual cleaning. Methods Patient-used gastroscopes, duodenoscopes, and colonoscopes were sampled before and after manual cleaning and assessed for protein, bioburden, and ATP levels. The biopsy port (BP) to distal end (D) sample was collected using 20 mL of sterile reverse-osmosis water. After a 200-mL flush, the umbilical (UM) to BP portion was sampled by flushing 40 mL from the UM to the D. Results The BP to D portion of the suction biopsy channel contained 83% of ATP residuals. Despite cleaning with brushing and a flushing pump, 25% of gastroscopes exceeded the ATP benchmark of 200 relative light units (RLU), whereas all duodenoscopes and colonoscopes had <200 RLU after cleaning. The protein and bioburden residuals after pump-assisted cleaning were consistently lower than existing benchmarks. Conclusion Sampling the suction biopsy channel from BP to D detected the most residuals from patient-used GI endoscopes. The protein and bioburden benchmarks for pump-assisted cleaning can be lowered, but 200 RLU is still adequate for ATP. © 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc.


Wiebe C.,University of Manitoba | Gibson I.W.,University of Manitoba | Blydt-Hansen T.D.,University of British Columbia | Pochinco D.,Diagnostic Services of Manitoba | And 7 more authors.
American Journal of Transplantation | Year: 2015

Understanding rates and determinants of clinical pathologic progression for recipients with de novo donor-specific antibody (dnDSA), especially subclinical dnDSA, may identify surrogate endpoints and inform clinical trial design. A consecutive cohort of 508 renal transplant recipients (n-=-64 with dnDSA) was studied. Recipients (n-=-388) without dnDSA or dysfunction had an eGFR decline of -0.65-mL/min/1.73-m2/year. In recipients with dnDSA, the rate eGFR decline was significantly increased prior to dnDSA onset (-2.89 vs. -0.65-mL/min/1.73-m2/year, p-<-0.0001) and accelerated post-dnDSA (-3.63 vs. -2.89-mL/min/1.73-m2/year, p-<-0.0001), suggesting that dnDSA is both a marker and contributor to ongoing alloimmunity. Time to 50% post-dnDSA graft loss was longer in recipients with subclinical versus a clinical dnDSA phenotype (8.3 vs. 3.3 years, p-<-0.0001). Analysis of 1091 allograft biopsies found that dnDSA and time independently predicted chronic glomerulopathy (cg), but not interstitial fibrosis and tubular atrophy (IFTA). Early T cell-mediated rejection, nonadherence, and time were multivariate predictors of IFTA. Independent risk factors for post-dnDSA graft survival available prior to, or at the time of, dnDSA detection were delayed graft function, nonadherence, dnDSA mean fluorescence intensity sum score, tubulitis, and cg. Ultimately, dnDSA is part of a continuum of mixed alloimmune-mediated injury, which requires solutions targeting T and B cells. In this study, the authors analyze clinical and histologic risk factors available at the time of de novo donor-specific antibody detection to determine clinical and histologic predictors of subsequent allograft failure, and their importance for clinical trial design. © Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons.


Alfa M.J.,Diagnostic Services of Manitoba | Alfa M.J.,University of Manitoba | Alfa M.J.,St Boniface Research Center | Olson N.,St Boniface Research Center
American Journal of Infection Control | Year: 2014

Background Because automated instrument washer-disinfectors (WD) are widely used in health care to reprocess a variety of medical instruments, we developed a study to compare 3 cleaning indicators to determine whether they detected suboptimal temperature, time, enzymatic detergent, and fluid action in a washer-disinfector. Methods The Miele WD was used for this comparison. One optimal cycle and 14 cycles with suboptimal enzymatic detergent, cleaning time, temperature, or inactive spray arms were evaluated. The cleaning indicators evaluated included the following: Pinnacle Monitor for Automated Enzymatic Cleaning Process (PNCL), Wash-Checks (WC), and TOSI. The scoring system for all 3 indicators was harmonized to a common scale. Soiled tweezers were included in each cycle evaluated. Results The PNCL, TOSI, and WC cleaning indicators showed significantly more failures at 40 C compared with 60 C (100% vs 0% for PNCL, 17% vs 0% for TOSI, and 60% vs 22% for WC, respectively). There were significantly more failures at suboptimal temperatures with a 2- versus 4-minute cycle (100% vs 0% for PNCL, 17% vs 0% for TOSI, and 17% vs 0% for WC, respectively, for 40 C cycles). Despite suboptimal cleaning cycles, all soiled tweezers looked clean. Conclusion All 3 cleaning indicators responded to suboptimal WD conditions; however, the PNCL was the most affected by alterations in the cycle conditions evaluated. In simulated use testing, cleaning indicators provided a more sensitive audit tool compared with visual inspection of soiled instruments after automated cleaning.

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