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Zinman L.,Sunnybrook Health science Center | Cudkowicz M.,Massachusetts General Hospital
The Lancet Neurology | Year: 2011

Amyotrophic lateral sclerosis (ALS) is a progressive motor neuron disease that is currently untreatable. Many compounds have been tested in laboratory-based models and in patients with ALS, but so far only one drug, riluzole, has shown efficacy, yet it only slightly slows disease progression. Several new insights into the causes of motor neuron death have led to the identification of some important novel targets for intervention. At no time have studies involved such a wide range of innovations and such advanced technologies. Many promising studies are underway to test potential targets that will hopefully translate into meaningful therapeutics for patients with ALS. © 2011 Elsevier Ltd.


Callum J.L.,Sunnybrook Health science Center
Hematology / the Education Program of the American Society of Hematology. American Society of Hematology. Education Program | Year: 2012

This review details the current knowledge in massive hemorrhage with regard to the pathophysiology and laboratory assessment of the coagulation disturbance, the role of plasma and platelet transfusion, the role of pharmaceutical strategies, and the clinical value of having a massive transfusion protocol. The bulk of the recent medical literature on this topic stems from the study of military and civilian trauma; however, where applicable, reference to postcardiac and post-noncardiac surgery and postpartum hemorrhage will also be discussed.


Goldstein B.I.,Sunnybrook Health science Center
Archives of Pediatrics and Adolescent Medicine | Year: 2012

Bipolar disorder is one of the most severe psychiatric illnesses, particularly when onset occurs during childhood or adolescence. With recent empirical evidence, questions regarding the existence of bipolar disorder among children and adolescents have given way to questions regarding prevalence. There are substantial risks inherent in misapplying diagnoses and treatments of bipolar disorder when not warranted and in withholding these diagnoses and treatments when they are warranted. As with adults, the course of bipolar disorder among children and adolescents diagnosed using unmodified diagnostic criteria is characterized by recovery and recurrence, functional impairment, suicidality, and high rates of comorbid psychiatric and medical problems. Discrepancies between increasing billing diagnoses and a stable epidemiologic prevalence of bipolar disorder suggest the possibility that diagnostic criteria are not being systematically applied in some clinical settings. Introducing new diagnoses may exacerbate rather than mitigate concerns regarding misdiagnosis and excessive use of mood-stabilizing medications. Several medications, particularly second-generation antipsychotics, are efficacious for treating acute manic episodes of bipolar I disorder. However, less is known regarding the treatment of other mood states and subtypes of bipolar disorder. Psychosocial treatments provide a forum in which to educate children and families regarding bipolar disorder and its treatment, and may be especially beneficial for reducing depressive symptoms. Offspring of parents with bipolar disorder are at increased risk of developing the illness, as are youth with major depressive disorder and certain psychiatric comorbidities. Preliminary findings regarding biomarkers offer hope that, in the future, these biomarkers may inform diagnostic and treatment decisions. ©2012 American Medical Association. All rights reserved.


Background This report provides a comprehensive analysis of transfusion errors occurring at a large teaching hospital and aims to determine key errors that are threatening transfusion safety, despite implementation of safety measures. Study Design and Methods Errors were prospectively identified from 2005 to 2010. Error data were coded on a secure online database called the Transfusion Error Surveillance System. Errors were defined as any deviation from established standard operating procedures. Errors were identified by clinical and laboratory staff. Denominator data for volume of activity were used to calculate rates. Results A total of 15,134 errors were reported with a median number of 215 errors per month (range, 85-334). Overall, 9083 (60%) errors occurred on the transfusion service and 6051 (40%) on the clinical services. In total, 23 errors resulted in patient harm: 21 of these errors occurred on the clinical services and two in the transfusion service. Of the 23 harm events, 21 involved inappropriate use of blood. Errors with no harm were 657 times more common than events that caused harm. The most common high-severity clinical errors were sample labeling (37.5%) and inappropriate ordering of blood (28.8%). The most common high-severity error in the transfusion service was sample accepted despite not meeting acceptance criteria (18.3%). The cost of product and component loss due to errors was $593,337. Conclusion Errors occurred at every point in the transfusion process, with the greatest potential risk of patient harm resulting from inappropriate ordering of blood products and errors in sample labeling. © 2013 American Association of Blood Banks (CME).


Worthington I.,Sunnybrook Health science Center
The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques | Year: 2013

The primary objective of this guideline is to assist the practitioner in choosing an appropriate acute medication for an individual with migraine, based on current evidence in the medical literature and expert consensus. It is focused on patients with episodic migraine ( headache on ≤ 14 days a month). A detailed search strategy was used to find a relevant meta-analyses, systematic reviews and randomized double-blind controlled trials. Recommendations were graded with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, using a consensus group. In addition, a general literature review and expert consensus were used for aspects of acute therapy for which randomized controlled trials were not available. Twelve acute medications received a strong recommendation for use in acute migraine therapy (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zomitriptan, ASA, ibuprofen, naproxen sodium, diclofenac potassium, and acetaminophen). Four received a weak recommendation for use (dihydroergotamine, ergotamine, codeine-containing combination analgesics, and tramadol- containing medications). Three of these were NOT recommended for routine use (ergotamine and codeine- and tramadol- containing medications). Strong recommendations were made to avoid use of butorphanol and butalbital- containing medications. Metoclopramide and domperidone were strongly recommended for use when necessary. Our analysis also resulted in the formulation of eight general acute migraine management strategies. These were grouped into: 1) two mild-moderate attack strategies, 2) two moderate-severe attack or NSAID failure strategies, 3) three refractory migraine strategies, and 4) a vasoconstrictor unresponsive-contraindicated strategy. Additional were developed for menstrual migraine during pregnancy, and migraine during lactation. This guideline provides evidence-based advice on acute pharmacological migraine therapy, and should be helpful to both health professionals and patients, The available medications have been organized into a series of strategies based on patient clinical features. These strategies may help practitioners make appropriate acute medication choices for patients with migraine.

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