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ElMaraghy A.,University of Toronto | ElMaraghy A.,St Josephs Health Center | Devereaux M.,Fluid Motion Physiotherapy 2012 Ltd
Journal of Shoulder and Elbow Surgery | Year: 2013

Background: One mitigating factor in the accurate diagnosis of complete distal biceps tendon ruptures (DBTR) is the integrity of the bicipital aponeurosis (BA). Current orthopedic literature lacks a descriptive means of evaluating the integrity of the BA in the presence of distal biceps injury. Methods: A consecutive cohort of 17 patients with suspected DBTR was examined. The hook test, passive forearm pronation test, and the biceps crease interval (BCI) test were performed as part of the overall clinical examination to assess the integrity of the distal tendon. The biceps crease ratio (BCR), a component of the BCI test, was used as an objective measure of distal tendon retraction. Integrity of the BA was assessed using the "BA flex test." The status of the distal tendon and BA were confirmed intraoperatively. Results: Sixteen patients had complete rupture of the distal biceps tendon. One had a high-grade partial thickness tear. The BA remained intact in 59%. Application of the BA flex test resulted in 100% sensitivity and 90% specificity, with overall diagnostic accuracy of 94%. Despite complete DBTR, there was a significant difference in the amount of distal tendon retraction (P = .012) between those with the BA intact (median BCR, 1.5, interquartile range, 1.3-1.9) and those where the BA was absent (median BCR, 2.2, interquartile range, 1.7-2.6). Conclusion: Evaluating the integrity of the BA can help to inform evaluation and treatment of DBTR, especially when visible or palpable alterations in biceps contour and proximal tendon migration are absent or equivocal. © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.


Devereaux M.W.,Fluid Motion Physiotherapy 2012 Ltd | Elmaraghy A.W.,University of Toronto | Elmaraghy A.W.,St Josephs Health Center
American Journal of Sports Medicine | Year: 2013

Background: Diagnosis of complete distal biceps tendon rupture (DBTR) is frequently missed or delayed on clinical examination. No single clinical test, including MRI, has demonstrated 100% efficacy in assessing the integrity of the distal biceps tendon. Hypothesis: Combining 3 validated clinical tests for identifying complete rupture can maximize a true-positive diagnosis for complete DBTR without the need for confirmatory soft tissue imaging when performed in concert with other important factors from the history and clinical examination. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The hook test, the passive forearm pronation (PFP) test, and the biceps crease interval (BCI) test were applied in sequence in conjunction with a standard patient history and physical examination on 48 patients with suspected distal biceps tendon injuries. If results on all 3 special tests were positive for complete rupture, the patient was referred for surgical repair; diagnosis was confirmed intraoperatively. If results on all 3 special tests were negative, diagnosis was confirmed with soft tissue imaging and patients were managed nonoperatively. If results of the 3 tests were not in agreement, soft tissue imaging was used to clarify the disagreement and to confirm the diagnosis. Results: Thirty-five patients had unequivocal results based on history, physical examination, and special tests. Thirty-two tested in agreement positive for complete rupture, which were confirmed intraoperatively. Three tested in agreement negative, with subsequent imaging confirming partial rupture. Thirteen patients had equivocal special test results; soft tissue imaging suggested complete rupture in 10 and partial rupture in 3. Conclusion: Application in sequence of the hook test, the PFP test, and the BCI test results in 100% sensitivity and specificity when the outcomes on all 3 special tests are in agreement. © 2013 The Author(s).


Saleh H.E.,Consultant Orthopaedic Surgeon | Pennings A.L.,St Josephs Health Center | ElMaraghy A.W.,St Josephs Health Center | ElMaraghy A.W.,University of Toronto
Journal of Shoulder and Elbow Surgery | Year: 2013

Background: Shoulder arthroplasty (SA) is a common orthopaedic procedure that is being performed on a more and more frequent basis. Venous thromboembolism (VTE) as a complication has received little attention when it occurs after SA. The literature lacks a comprehensive summary of the incidence, risk factors, and prophylaxis of VTE in this population of patients. Methods: Literature on VTE after SA has been identified from 5 scientific databases: EMBASE, MEDLINE, Web of Science, CINAHL, and Cochrane. All primary full-text articles reporting at least 1 case of deep vein thrombosis or pulmonary embolism after SA were included. Articles were critically appraised and systematically analyzed to determine the incidence, risk factors, thromboprophylaxis, diagnosis, and management of VTE after SA. Results: This study included 14 articles. The reported incidence of VTE after SA was 0.2% to 16.0%. The most serious risk factors for development of VTE included history of VTE, thrombophilia, major surgery, advanced age, current malignant disease, immobility, and bed confinement. Diagnosis was typically determined by duplex scan and chest computed tomography scan. VTE prophylaxis was used in 6 (43%) of the included studies, with the ideal method of prophylaxis unknown. Conclusions: Although variability exists in the reported incidence of VTE, surgeons should still be aware of the potential for this serious complication after SA. We recommend assessing the risk factors and estimating the VTE risk status for all patients undergoing SA. The ideal method of prophylaxis for this population of patients remains unknown and should be investigated in future high-quality clinical studies. © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.


ElMaraghy A.W.,St Josephs Health Center | ElMaraghy A.W.,University of Toronto | Devereaux M.W.,University of Toronto
Journal of Shoulder and Elbow Surgery | Year: 2012

Background: Reported descriptions of pectoralis major (PM) injury are often inconsistent with the actual musculotendinous morphology. The literature lacks an injury classification system that is consistently applied and accurately reflects surgically relevant anatomic injury patterns, making meaningful comparison of treatment techniques and outcomes difficult. Materials and methods: Published cases of PM injury between 1822 and 2010 were analyzed to identify incidence and injury patterns and the extent to which these injuries fit into a classification category. Recent work outlining the 3-dimensional anatomy of the PM muscle and tendon, as well as biomechanical studies of PM muscle segments, were reviewed to identify the aspects of musculotendinous anatomy that are clinically and surgically relevant to injury classification. Results: We identified 365 cases of PM injury, with 75% occurring in the last 20 years; of these, 83% were a result of indirect trauma, with 48% occurring during weight-training activities. Injury patterns were not classified in any consistent way in timing, location, or tear extent, particularly with regard to affected muscle segments contributing to the PM's bilaminar tendon. Conclusions: A contemporary injury classification system is proposed that includes (1) injury timing (acute vs chronic), (2) injury location (at the muscle origin or muscle belly, at or between the musculotendinous junction and the tendinous insertion, or bony avulsion), and (3) standardized terminology addressing tear extent (anterior-to-posterior thickness and complete vs incomplete width) to more accurately reflect the musculotendinous morphology of PM injuries and better inform surgical management, rehabilitation, and research. © 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.


Pasic M.D.,University of Toronto | Pasic M.D.,St Josephs Health Center | Samaan S.,St Michaels Hospital | Samaan S.,Li Ka Shing Knowledge Institute | And 3 more authors.
Clinical Chemistry | Year: 2013

BACKGROUND: The practice of personalized medicine has made large strides since the introduction of high-throughput technologies and the vast improvements in computational biotechnology. The personalized-medicine approach to cancer management holds promise for earlier disease detection, accurate prediction of prognosis, and better treatment options; however, the early experience with personalized medicine has revealed important concerns that need to be addressed before research findings can be translated to the bedside. CONTENT: We discuss several emerging "practical" or "focused" applications of personalized medicine. Molecular testing can have an important positive impact on health and disease management in a number of ways, and the list of specific applications is evolving. This list includes improvements in risk assessment, disease prevention, identification of new disease-related mutations, accurate disease classification based on molecular signatures, selection of patients for enrollment in clinical trials, and development of new targeted therapies, especially for metastatic tumors that are refractory to treatment. Several challenges remain to be addressed before genomics information can be applied successfully in the routine clinical management of cancers. Further improvements and investigations are needed in data interpretation, extraction of actionable items, cost-effectiveness, how to account for patient heterogeneity and ethnic variation, and how to handle the risk of "incidental findings" in genetic testing. SUMMARY: It is now clear that personalized medicine will not immediately provide a permanent solution for patient management and that further refinement in the applications of personalized medicine will be needed to address and focus on specific issues. © 2012 American Association for Clinical Chemistry.


Binnie A.,St Josephs Health Center | Tsang J.L.Y.,McMaster University | Dos Santos C.C.,Li Ka Shing Knowledge Institute | Dos Santos C.C.,University of Toronto
Current Opinion in Critical Care | Year: 2014

PURPOSE OF REVIEW: The article provides an overview of efforts to identify and validate biomarkers in acute respiratory distress syndrome (ARDS) and a discussion of the challenges confronting researchers in this area. RECENT FINDINGS: Although various putative biomarkers have been investigated in ARDS, the data have been largely disappointing and the 'troponin' of ARDS remains elusive. Establishing a relationship between measurable biological processes and clinical outcomes is vital to advancing clinical trials in ARDS and expanding our arsenal of treatments for this complex syndrome. SUMMARY: This article summarizes the current status of ARDS biomarker research and provides a framework for future investigation. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Vimr M.,St Josephs Health Center | Dickens P.,Iris Group
Healthcare Management Forum | Year: 2013

In 2001, St. Joseph's Health Centre reported on its efforts to design and deliver a physician leadership program. The program was launched in Fall 2010 and has just completed its second cohort with a total of 29 physicians participating. The results and associated learning have been very encouraging. © 2013 Canadian College of Health Leaders. Published by Elsevier Inc. All rights reserved.


Coghlan J.G.,Royal Free Hospital | Pope J.,St Josephs Health Center | Denton C.P.,Royal Free Hospital
Current Opinion in Pulmonary Medicine | Year: 2010

Connective tissue disease-associated pulmonary arterial hypertension (PAH) is mostly related to systemic sclerosis, overlap syndromes with features of systemic sclerosis, mixed connective tissue disease, and systemic lupus erythematosus. It is an important cause of mortality in these conditions and represents up to one third of patients seen in most specialist pulmonary hypertension centers. Patients with PAH associated with connective tissue disease may have a worse outcome than those with other forms of PAH. Most randomized clinical trials of PAH therapies have included patients with connective tissue disease as part of a mixed population. Overall, analyses suggest that treatment responses parallel those seen in idiopathic PAH, though subgroup analyses must be interpreted with caution. There may also be significant comorbidity from other pulmonary complications such as interstitial fibrosis, aspiration, or chest wall restriction. In addition, the majority of clinical trials have used 6-minute walk distance as the primary endpoint; the clinical relevance of this is questionable in connective tissue disease patients, who often have multiple comorbidities, other than PAH, which adversely affect exercise tolerance. © 2010 Wolters Kluwer Health. Lippincott Williams & Wilkins.


Vimr M.A.,St Josephs Health Center | Thompson G.G.,Independent Consultant
Healthcare Management Forum | Year: 2011

Hospital physicians often have little formal preparation for leadership roles. The St. Joseph's Health Centre program for physician leaders includes a competency profile, personal development plans, self-directed reflective learning, and action learning groups to work on current challenges. The program, developed with the participation of physicians, is intended to promote a culture that recognizes and supports physicians' contribution to hospital leadership and in which medical staff and hospital administrators work collaboratively and share accountability. © 2011 Canadian College of Health Leaders.


Haggarty J.M.,St Josephs Health Center
Rural and remote health | Year: 2010

For those residing in rural and isolated parts of Canada, obtaining quality mental health services is often an unfulfilled wish. Rural and isolated communities share the problems of health status and access to care. Health deteriorates the greater the distance from urban areas in the following dimensions: lower life expectancy than the national average; higher rates of disability, violence, poisoning, suicide and accidental death; and more mental and physical health issues than those who live in urban areas. The Canadian Collaborative Mental Health Initiative (CCMHI) was formed to provide, in part, a practical means to encouraging collaborations between primary care and mental health providers. This article provides a synopsis of the Rural and Isolated (R&I) toolkit developed through the CCMHI, which was intended to develop primary care and mental health collaboration in such areas. This toolkit was developed using focus group discussions with mental health providers, and surveys completed by providers and consumers. Key messages from the consultative process included: access to services; interprofessional education; consumer involvement; research and evaluation; models of collaboration; ethics; funding; and policy and legislation. A flow diagram was devised to detail the synthesis and practical application of the toolkit, as well as the challenges, key questions and principles of implementation associated with collaborative care initiatives in rural and isolated regions.

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