Dobson S.R.M.,University of British Columbia |
Dobson S.R.M.,Vaccine Evaluation Center |
McNeil S.,Dalhousie University |
Dionne M.,University of Québec |
And 24 more authors.
JAMA - Journal of the American Medical Association | Year: 2013
Importance: Global use of human papillomavirus (HPV) vaccines to prevent cervical cancer is impeded by cost. A 2-dose schedule for girls may be possible. Objective: To determine whether mean antibody levels to HPV-16 and HPV-18 among girls receiving 2 doses was noninferior to women receiving 3 doses. Design, Setting, and Patients: Randomized, phase 3, postlicensure, multicenter, age-stratified, noninferiority immunogenicity study of 830 Canadian females from August 2007 through February 2011. Follow-up blood samples were provided by 675 participants (81%). Intervention: Girls (9-13 years) were randomized 1:1 to receive 3 doses of quadrivalent HPV vaccine at 0, 2, and 6 months (n = 261) or 2 doses at 0 and 6 months (n = 259). Young women (16-26 years) received 3 doses at 0, 2, and 6 months (n = 310). Antibody levels were measured at 0, 7, 18, 24, and 36 months. Main Outcomes and Measures: Primary outcome was noninferiority (95% CI, lower bound >0.5) of geometric mean titer (GMT) ratios for HPV-16 and HPV-18 for girls (2 doses) compared with young women (3 doses) 1 month after last dose. Secondary outcomes were noninferiority of GMT ratios of girls receiving 2 vs 3 doses of vaccine; and durability of noninferiority to 36 months. Results: The GMT ratios were noninferior for girls (2 doses) to women (3 doses): 2.07 (95% CI, 1.62-2.65) for HPV-16 and 1.76 (95% CI, 1.41-2.19) for HPV-18. Girls (3 doses) had GMT responses 1 month after last vaccination for HPV-16 of 7736 milli-Merck units per mL (mMU/mL) (95% CI, 6651-8999) and HPV-18 of 1730 mMU/mL (95% CI, 1512-1980). The GMT ratios were noninferior for girls (2 doses) to girls (3 doses): 0.95 (95% CI, 0.73-1.23) for HPV-16 and 0.68 (95% CI, 0.54-0.85) for HPV-18. The GMT ratios for girls (2 doses) to women (3 doses) remained noninferior for all genotypes to 36 months. Antibody responses in girls were noninferior after 2 doses vs 3 doses for all 4 vaccine genotypes at month 7, but not for HPV-18 by month 24 or HPV-6 by month 36. Conclusions and Relevance: Among girls who received 2 doses of HPV vaccine 6 months apart, responses to HPV-16 and HPV-18 one month after the last dose were noninferior to those among young women who received 3 doses of the vaccine within 6 months. Because of the loss of noninferiority to some genotypes at 24 to 36 months in girls given 2 doses vs 3 doses, more data on the duration of protection are needed before reduced-dose schedules can be recommended. Trial Registration: clinicaltrials.gov Identifier: NCT00501137. ©2013 American Medical Association. All rights reserved.
Montaner J.S.,British Columbia Center for Excellence in |
Montaner J.S.,University of British Columbia |
Montaner J.S.,University of California at San Diego |
Lima V.D.,British Columbia Center for Excellence in |
And 15 more authors.
The Lancet | Year: 2010
Results of cohort studies and mathematical models have suggested that increased coverage with highly active antiretroviral therapy (HAART) could reduce HIV transmission. We aimed to estimate the association between plasma HIV-1 viral load, HAART coverage, and number of new cases of HIV in the population of a Canadian province. We undertook a population-based study of HAART coverage and HIV transmission in British Columbia, Canada. Data for number of HIV tests done and new HIV diagnoses were obtained from the British Columbia Centre for Disease Control. Data for viral load, CD4 cell count, and HAART use were extracted from the British Columbia Centre for Excellence in HIV/AIDS population-based registries. We modelled trends of new HIV-positive tests and number of individuals on HAART using generalised additive models. Poisson log-linear regression models were used to estimate the association between new HIV diagnoses and viral load, year, and number of individuals on HAART. Between 1996 and 2009, the number of individuals actively receiving HAART increased from 837 to 5413 (547 increase; p=0·002), and the number of new HIV diagnoses fell from 702 to 338 per year (52 decrease; p=0·001). The overall correlation between number of individuals on HAART and number of individuals newly testing positive for HIV per year was -0·89 (p<0·0001). For every 100 additional individuals on HAART, the number of new HIV cases decreased by a factor of 0·97 (95 CI 0·96-0·98), and per 1 log10 decrease in viral load, the number of new HIV cases decreased by a factor of 0·86 (0·75-0·98). We have shown a strong population-level association between increasing HAART coverage, decreased viral load, and decreased number of new HIV diagnoses per year. Our results support the proposed secondary benefit of HAART used within existing medical guidelines to reduce HIV transmission. Ministry of Health Services and Ministry of Healthy Living and Sport, Province of British Columbia; US National Institute on Drug Abuse; US National Institutes of Health; Canadian Institutes of Health Research. © 2010 Elsevier Ltd.
Okoli C.T.C.,University of Kentucky |
Khara M.,Vancouver Coastal Health Authority
Journal of Dual Diagnosis | Year: 2014
Individuals with substance use and psychiatric disorders have a high prevalence of tobacco use disorders and are disproportionately affected by tobacco-related morbidity and mortality. However, it is unclear how having co-occurring disorders affects tobacco cessation. Our aim was to examine smoking cessation outcomes and relevant predictors of smoking cessation among smokers with substance use and/or psychiatric disorders. Methods: Data from medical records of 674 participants in a tobacco treatment program within mental health and addictions services in Vancouver, Canada, were analyzed. The 26-week treatment program included an 8-week structured behavioral counseling group, an 18-week support group, and 26 weeks of no-cost pharmacotherapy. Information on demographics, tobacco use and history, type of pharmacotherapy received, nicotine dependence, importance of and confidence in quitting smoking, expired carbon monoxide level, substance use and psychiatric disorder history, and total program visits were gathered. Results: Approximately 67% (n = 449) of participants had co-occurring substance use and psychiatric disorders, while 20% (n = 136) had substance use disorder only, 10% (n = 67) had psychiatric disorder only, and 3% (n = 22) had tobacco dependence only. Rates of tobacco cessation (i.e., 7-day point prevalence of abstinence verified by expired carbon monoxide of .8 ppm) by group in the 522 people who completed treatment were as follows: 38.2% for those with co-occurring disorders, 47.1% for those with tobacco dependence only, 47.1% for those with substance use disorder only, and 41.8% for those with psychiatric disorder only. Length of treatment was a significant predictor of smoking cessation for those with co-occurring disorders and substance use disorder only. In the final stratified multivariate analysis, for individuals with co-occurring disorders, having an opiate use disorder (as compared to an alcohol use disorder) and higher nicotine dependence scores at baseline were predictive of poor cessation outcomes, while greater length of treatment was predictive of successful smoking cessation. Conclusions: Tobacco cessation treatment for individuals with co-occurring substance use and psychiatric disorders is likely to be as effective as for smokers with either disorder alone. Treatment duration predicts success among these smokers so strategies to enhance engagement and retention are needed. © Taylor & Francis Group, LLC.
Dunne T.J.,Vancouver Coastal Health Authority |
Gaboury I.,Université de Sherbrooke |
Ashe M.C.,Center for Hip Health and Mobility |
Ashe M.C.,University of British Columbia
Journal of Evaluation in Clinical Practice | Year: 2014
Rationale, aims and objectives Acute inpatient falls are common and serious adverse events that lead to injury, prolonged hospitalization and increased cost of care. To determine the difference in total acute hospital care length of stay (LOS) for patients with and without an in-hospital fall (IHF), regardless of degree of harm. Methods This was a retrospective observational study at a 728-bed acute care teaching hospital. We used propensity scores to match 292 patients with 330 controls by case mix group, sex, Resource Intensity Weights and week of admission. We used two administrative databases: hospital fall incident reporting system and Discharge Abstract Database. We reviewed all IHF incidents for patients 18 years and older, admitted to inpatient acute care hospital units/programs between 1 November 2009 and 31 August 2011. Results The average LOS for IHF cases was 37.2 days [median 26.5 days; interquartile range (IQR) 14, 54] and 25.7 days (median 13 days; IQR 5, 33) for matched control patients. Survival analysis results indicated that patients who did not have an IHF were 2.4 times (95% CI 2.1, 2.7; P < 0.001) more likely to be discharged earlier from acute care than patients who had an IHF. Conclusions Experiencing either an injurious or a non-injurious fall during an acute care hospitalization was associated with prolonged LOS. © 2014 John Wiley & Sons, Ltd.
Sahota I.S.,Simon Fraser University |
Sahota I.S.,University of British Columbia |
Ravensbergen H.J.C.,Simon Fraser University |
Ravensbergen H.J.C.,University of British Columbia |
And 4 more authors.
Journal of Neurotrauma | Year: 2012
Orthostatic hypotension (OH) is a debilitating condition affecting individuals with spinal cord injury (SCI) that may be associated with cerebral hypoperfusion. We studied orthostatic cerebral control in individuals with SCI with different levels and severities of injury to spinal cardiovascular autonomic pathways. We measured beat-to-beat cardiovascular and cerebrovascular responses to passive orthostatic stress in 16 controls and 26 subjects with chronic SCI. Cerebrovascular control was assessed from diastolic cerebral blood flow velocity (CBFVD), and indices of static and dynamic cerebral autoregulation. Severity of autonomic injury was inferred from spectral analyses of systolic arterial pressure, and supine plasma noradrenaline concentrations. Symptoms of OH were evaluated using questionnaires. CBFVD decreased during orthostasis only in individuals with autonomically complete injuries above T6. Orthostatic CBFVD was significantly correlated (p<0.05) with the severity of autonomic injury. Individuals with injuries above T6 had impaired dynamic autoregulation (p<0.05) compared to controls, and this was correlated (p<0.05) with the severity of autonomic injury. Individuals with autonomically complete SCI reported increased severity of symptoms relative to controls (p<0.05). Symptom severity was correlated with the efficacy of dynamic autoregulation. During orthostatic stress, SCI individuals have impaired cerebrovascular control that is related to the level and severity of autonomic injury. © Copyright 2012, Mary Ann Liebert, Inc.
Townsend A.,University of British Columbia |
Adam P.,Vancouver Coastal Health Authority |
Cox S.M.,University of British Columbia |
Li L.C.,University of British Columbia
Chronic Illness | Year: 2010
Background: Sociological understandings of chronic illness have revealed tensions and complexities around help-seeking. Although ethics underpins healthcare, its application in the area of chronic illness is limited. Here we apply an ethical framework to interview accounts and identify ethical challenges in the early rheumatoid arthritis (RA) experience. Methods: In-depth interviews were conducted with eight participants who had been diagnosed with RA in the 12 months prior to recruitment. Applying the concepts of autonomous decision-making and procedural justice highlighted ethical concerns which arose throughout the help-seeking process. Analysis was based on the constant-comparison approach. Results: Individuals described decision-making, illness actions and the medical encounter. The process was complicated by inadequate knowledge about symptoms, common-sense understandings about the GP appointment, difficulties concerning access to specialists, and patient-practitioner interactions. Autonomous decision-making and procedural justice were compromised. The accounts revealed contradictions between the policy ideals of active self-management, patient-centred care and shared decision-making, and the everyday experiences of individuals. Conclusions: For ethical healthcare there is a need for: public knowledge about early RA symptoms; more effective patient-practitioner communication; and increased support during the wait between primary and secondary care. Healthcare facilities and the government may consider different models to deliver services to people requiring rheumatology consults. © The Author(s), 2010.
Wu C.,University of Alberta |
Lee A.Y.Y.,University of British Columbia |
Lee A.Y.Y.,Vancouver Coastal Health Authority
Seminars in Thrombosis and Hemostasis | Year: 2015
Cancer-associated thrombosis remains a common and challenging clinical presentation. Despite advances in therapy using low-molecular-weight heparins, both venous thromboembolic recurrence and clinically relevant bleeding while on therapeutic anticoagulation occur at high rates. Multiple novel (or non-vitamin K antagonist) oral anticoagulants have recently been developed for the treatment and prevention of venous thromboembolism. There are many attractive features of these agents including convenience and simplicity of administration. Unfortunately, there are also several limitations such as dependency on gastrointestinal absorption, renal clearance, and some significant drug-drug interactions. The use of these newer oral agents in cancer patients is not recommended, as their safety and efficacy are not yet established and the complexity of these patients warrants further cancer-specific clinical trials. © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York.
Mayo J.,University of British Columbia |
Mayo J.,Vancouver Coastal Health Authority |
Thakur Y.,University of British Columbia |
Thakur Y.,Vancouver Coastal Health Authority
Seminars in Respiratory and Critical Care Medicine | Year: 2014
This article reviews the current diagnostic strategies for patients with suspected pulmonary embolism (PE) focusing on the current first choice imaging modality, computed tomographic pulmonary angiography (CTPA). Diagnostic strengths and weaknesses and associated cost-effectiveness of the diagnostic pathways will be discussed. The radiation dose risk of these pathways will be described and techniques to minimize dose will be reviewed. Finally the impact of new dual energy applications which have the potential to provide additional functional information will be briefly reviewed. Imaging plays a vital role in the diagnostic pathway for clinically suspected PE. CT has been established as the most robust morphologic imaging tool for the evaluation of patients with suspected PE. This conclusion is based on the high diagnostic utility of CT for the detection of PE and its unique capacity for accurate diagnosis of conditions that can mimic the clinical presentation of PE. Although current cost-effectiveness evaluations have established CT as integral in the PE diagnostic pathway, failure to acknowledge the impact of alternate diagnosis represents a current knowledge gap. The emerging dual energy capacity of current CT scanners offers the potential to evaluate both pulmonary vascular morphology and ventilation perfusion relationships within the lung parenchyma at high spatial resolution. This dual assessment of lung morphology and lung function at low (< 5 millisievert) radiation dose represents a substantial advance in PE imaging. Copyright © 2014 by Thieme Medical Publishers, Inc.
Raschka S.,Vancouver Coastal Health Authority |
Dempster L.,Vancouver Coastal Health Authority |
Bryce E.,Vancouver Coastal Health Authority
American Journal of Infection Control | Year: 2013
Background: The effect of regional consolidation of an infection prevention and control (IPC) program on reduction of selected health care-acquired infections (HAIs), the economic burden of these illnesses, and where the potential for greatest financial benefit in reducing infection rates lies was assessed. Methods: Cost-benefit analysis (in Canadian $) was used to evaluate the effectiveness of a regional IPC program in preventing incident cases of HAIs. The costs of managing these infections, as well as the operational costs of the IPC program were compared against reductions in HAI rates over a 4-year period. Benefits were calculated as cost avoided by reducing HAI cases year over year. Results: The Health Authority spent more than $66.3 million managing 24,937 HAI cases over the 4-year evaluation period. Urinary tract infections, methicillin-resistant Staphylococcus aureus, and bacteremias incurred the greatest costs. A reduction of 4,739 HAI cases led to avoided costs of $9.1 million in 4 years; the IPC program budget was $6.7 million during this period. Conclusion: Regionalization of the IPC program with standardized policies, procedures, and initiatives led to a 19% reduction in selected HAIs over 4 years and a cost avoidance of at least $9 million. This was particularly evident in years 3 and 4 of the program when $7.2 million (79% of the total) savings were realized.
McIntyre L.,Center for Disease Control |
Vallaster L.,Vancouver Coastal Health Authority |
Wilcott L.,Center for Disease Control |
Henderson S.B.,Center for Disease Control |
Kosatsky T.,Center for Disease Control
Food Control | Year: 2013
The purpose of this study was to examine food safety knowledge of trained food handlers certified under the FOODSAFE training program in British Columbia, Canada and to evaluate food safety knowledge, attitudes and self-reported hand washing practices in trained and untrained food handler groups. Data gathered in a telephone survey demonstrated knowledge scores significantly decreased in FOODSAFE trained workers over a 15 year period post-certification. Knowledge scores were significantly higher in trained compared with untrained food handlers. No differences were noted between groups based on sex. Supervisory status and years of experience resulted in improved knowledge scores in both trained and untrained groups, but increasing age was important for improved knowledge in only the untrained group. Food handlers' place of employment and level of education were also associated with significantly improved knowledge scores. FOODSAFE trained food handlers' reported significantly better hand washing practices and attitudes compared with the untrained food handler group. These results support a requirement for recertification of trained food handlers and demonstrate a need for education of untrained food handlers with a food safety training program such as FOODSAFE. © 2012 Elsevier Ltd.