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Herrmann N.,University of Toronto | Herrmann N.,Sunnybrook Health science Center | Cappell J.,Sunnybrook Health science Center | Eryavec G.M.,North York General Hospital | And 2 more authors.
CNS Drugs | Year: 2011

Background: Agitation and aggression are common neuropsychiatric symptoms of Alzheimer's disease (AD) with a negative impact on caregivers. Objective: The aim of the study was to determine whether changes in agitation and aggression would follow memantine treatment and, if so, be associated with changes in nursing burden in institutionalized patients with moderate to severe AD. Study Design: This was a 3-month open-label trial of memantine. Setting: The setting was two long-term care facilities. Patients: Thirty-one institutionalized patients with moderate to severe AD and significant behavioural and psychiatric symptoms were included in the study. Intervention: Memantine was titrated to a target dose of 10mg twice daily. Main Outcome Measure: Effectiveness was assessed by the change in the Neuropsychiatric Inventory-Nursing Home (NPI-NH) agitation/aggression subscale and Clinical Global Impression of Change (CGI-C) scale using the intent-to-treat population. To establish caregiver impact, the effect on nursing burden was measured by the Modified Nursing Care Assessment Scale (primary outcome). As a secondary analysis, the caregiver distress subscale of the NPI-NH was examined, as well as changes in as required (pro re nata [prn]) psychotropic medication use. Results: Twenty-four patients completed the study. A significant decrease in agitation and aggression (F-test with 3 and 90 degrees of freedom [F3,90] = 3.721, p = 0.014) was demonstrated following memantine, with 48% of patients improving (either much improved or minimally improved) on the CGI-C scale. In addition, nursing burden (t-test with 30 degrees of freedom [t30] = 3.02, p = 0.005), caregiver distress (F3,90 = 4.125, p = 0.009) and the use of prn psychotropics decreased following memantine treatment (Z=-1.99, p = 0.046). Fourteen patients experienced at least one adverse event during memantine treatment. The most common adverse event associated with treatment was somnolence (n = 5). Conclusion: The results of this study suggest that the decreased agitated and aggressive behaviour in institutionalized patients with moderate to severeAD following treatment with memantine was accompanied by improvements in nursing burden and decreased psychotropic use. These findings should be confirmed in a larger, controlled trial. © 2011 Adis Data Information BV. All rights reserved.

Richards R.N.,North York General Hospital
Journal of Cutaneous Medicine and Surgery | Year: 2010

Background: Intralesional steroid (ILS; usually triamcinolone acetonide) is commonly used, and the literature contains much information about its use in keloids, hemangiomas, and alopecia areata. Little has been written about its use in inflammatory dermatoses such as psoriasis and localized dermatitis since the 1960s, the conditions for which it was originally most studied and used. Objective: To clarify the use of ILS and to encourage its use in psoriasis and localized dermatitis. Methods: Medline peer-reviewed literature in English (1956-2008) was searched for the use of ILS in all skin diseases. Six standard textbooks of dermatology were reviewed. Information as to how they used ILS was obtained from a questionnaire completed by 33 dermatologists and from personal discussions with 15 other dermatologists. Additional information was obtained from 40 years of personal ILS use and from observation of 42 dermatologists working intermittently in our office over the past 25 years. ILS product package inserts and company drug monographs were reviewed. Results: ILS is used by most dermatologists, but there are considerable divergences in technique and dosing. Current textbooks contain little on its use in psoriasis and localized dermatitis. There have been no clinical studies since the 1960s, and their end points and descriptions were somewhat vague by today's standards. Product package inserts are dated and not helpful. Nevertheless, the use of ILS is safe and economical, and the original authors and our office have found it consistently to be virtually 100% effective at 2.5 mg/mL in small plaques of psoriasis on the trunk and limbs and highly effective in localized dermatitis (such as lichen simplex chronicus, prurigo nodularis, and nonspecific eczema). Clinical studies indicate that we can safely increase our ILS from the usual 3 cc (7.5 mg) to 6 cc (15 mg) or even to 8 cc (20 mg) for patients over 50 kg every 3 to 4 weeks. Serum cortisol can be performed if there are concerns about adrenal suppression, with use in periorbital hemangiomas and with intranasal ILS. Blindness (from central artery occlusion) was reported with injections of ILS around the eyes wih older products during the early development stages; and more recently with the use of ILS for periorbital hemangiomas and with ILS used intranasally. It has never been reported with low pressure injections of ILS using triamcinalone acetonide at 2.5 mg around the eyes. Limitations: No formal clinical studies since the 1960s. Poor statistical end points. Conclusions: ILS at 2.5 mg/cc is safe, economical, and effective and its greater use should be encouraged in inflammatory dermatoses such as psoriasis and localized dermatitis. Further well-designed research would be helpful. © 2010 Canadian Dermatology Association.

Strauss M.H.,North York General Hospital | Hall A.S.,Leeds Medical Bioinformatics Center
Progress in Cardiovascular Diseases | Year: 2016

The renin angiotensin aldosterone system (RAAS) plays a central role in the pathophysiology of hypertension and vascular disease. Angiotensin converting enzyme inhibitors (ACEis) suppress angiotensin II (ANG II) concentrations, whereas angiotensin receptor blockers (ARBs) block the binding of ANG II to AT1 receptors. ACEis and ARBs are both effective anti-hypertensive agents and have similar risk reductions in stroke - a blood pressure dependent phenomenon. ACEis also reduce the risk of myocardial infarction (MI) and mortality in high risk hypertensive patients, as well as in diabetics, the elderly, those with vascular disease, and in congestive heart failure. ARBs, in contrast, do not reduce the risk of MI or death in clinical trials where the comparator has been another active therapy or even a placebo. Systematic reviews of ARBs that include meta-analyses or meta-regression analyses confirm that ARBs lack the cardiovascular protective effects of ACEis, which in part are "independent" of blood pressure lowering. Practice guidelines, especially those in high risk hypertensive patients, should reflect the evidence that ACEis and ARBs have divergent cardiovascular effects - ACEis reduce mortality, whereas ARBs do not. ACEis should be the preferred RAAS inhibitor in high risk patients. © 2015 Elsevier Inc.

Speevak M.D.,Credit Valley Hospital | Mcgowan-Jordan J.,Childrens Hospital of Eastern Ontario | Chun K.,North York General Hospital
Prenatal Diagnosis | Year: 2011

Objective: To determine the detection rate of clinically significant chromosome abnormalities using quantitative fluorescent polymerase chain reaction (QF-PCR) of fetal DNA in comparison with G-banded analysis of cultured amniotic fluid cells and determine the residual risk if QF-PCR were performed alone for low-risk cases. Methods: Amniotic fluid samples were prospectively categorized based on the likelihood of the fetus having a chromosome anomaly. QF-PCR results were compared with the G-banded findings. The distribution of patients and the rates of clinically significant anomalies in each risk category were determined. Results: A total of 4176 amniotic fluid samples were studied. Among these, 331 cases with abnormalities were detected by both methods and an additional 19 abnormal cases were detected by G-banding only. Five of those undetected by QF-PCR were considered clinically significant, four of which were referred due to an elevated a priori risk (>4%). If QF-PCR is performed in all cases and G-banding performed only in higher risk cases, the residual risk for a clinically significant chromosome abnormality will be as low as 0.083%. Conclusions: This study suggests that QF-PCR alone is appropriate for patients with uncomplicated pregnancies, who are referred solely for an increased risk of a common trisomy. © 2011 John Wiley & Sons, Ltd.

Adamson B.J.,North York General Hospital
Healthcare Papers | Year: 2010

Although I find Graham Lowe and Ben Chan's logic model and work environment metrics thought provoking, a healthy work environment framework must be more comprehensive and consider the addition of recommended diagnostic tools, vehicles to deliver the necessary change and a sustainability strategy that allows for the tweaking and refinement of ideas. Basic structure is required to frame and initiate an effective process, while allowing creativity and enhancements to be made by organizations as they learn. I support the construction of a suggested Canadian health sector framework for measuring the health of an organization, but I feel that organizations need to have some freedom in that design and the ability to incorporate their own indicators within the established proven drivers. Reflecting on my organization's experience with large-scale transformation efforts, Ifind that emotional intelligence along with formal leadership development and front-line engagement in Lean process improvement activities are essential for creating healthy work environments that produce the balanced set of outcomes listed in my hospital's Balanced Scorecard.

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