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Peirano G.,Calgary Laboratory Services | Pillai D.R.,Mount Sinai Hospital | Pitondo-Silva A.,University of Sao Paulo | Richardson D.,William Osler Health Center | And 2 more authors.
Diagnostic Microbiology and Infectious Disease | Year: 2011

After recent hospitalization in India (New Delhi and Mumbai), 2 patients, on their return to Canada, presented with lower urinary tract infections due to multiresistant Klebsiella pneumoniae that produced New Delhi metallo-β-lactamase and CTX-M-15. The organisms belonged to clones ST147 and ST340, and were positive for aac(6')-Ib-cr, as well as for the ccdAB and vagCD addiction systems. The bla NDM plasmid was located on the IncFIIA and IncA/C replicon groups of plasmids. Clones ST147 and ST340 are also responsible for harbouring bla KPC, and it is possible that they played an important role in the intercontinental spread of antimicrobial resistance. © 2011 Elsevier Inc.


Sinuff T.,Sunnybrook Research Institute | Muscedere J.,Queen's University | Cook D.J.,McMaster University | Dodek P.M.,University of British Columbia | And 13 more authors.
Critical Care Medicine | Year: 2013

OBJECTIVE:: Ventilator-associated pneumonia is an important cause of morbidity and mortality in critically ill patients. Evidence-based clinical practice guidelines for the prevention, diagnosis, and treatment of ventilator-associated pneumonia may improve outcomes, but optimal methods to ensure implementation of guidelines in the intensive care unit are unclear. Hence, we determined the effect of educational sessions augmented with reminders, and led by local opinion leaders, as strategies to implement evidence-based ventilator-associated pneumonia guidelines on guideline concordance and ventilator-associated pneumonia rates. DESIGN:: Two-year prospective, multicenter, time-series study conducted between June 2007 and December 2009. SETTING:: Eleven ICUs (ten in Canada, one in the United States); five academic and six community ICUs. PATIENTS:: At each site, 30 adult patients mechanically ventilated >48 hrs were enrolled during four data collection periods (baseline, 6, 15, and 24 months). INTERVENTION:: Guideline recommendations for the prevention, diagnosis, and treatment of ventilator-associated pneumonia were implemented using a multifaceted intervention (education, reminders, local opinion leaders, and implementation teams) directed toward the entire multidisciplinary ICU team. Clinician exposure to the intervention was assessed at 6, 15, and 24 months after the introduction of this intervention. MEASUREMENTS AND MAIN RESULTS:: The main outcome measure was aggregate concordance with the 14 ventilator-associated pneumonia guideline recommendations. One thousand three hundred twenty patients were enrolled (330 in each study period). Clinician exposure to the multifaceted intervention was high and increased during the study: 86.7%, 93.3%, 95.8%, (p < .001), as did aggregate concordance (mean [SD]): 50.7% (6.1), 54.4% (7.1), 56.2% (5.9), 58.7% (6.7) (p = .007). Over the study period, ventilator-associated pneumonia rates decreased (events/330 patients): 47 (14.2%), 34 (10.3%), 38 (11.5%), 29 (8.8%) (p = .03). CONCLUSIONS:: A 2-yr multifaceted intervention to enhance ventilator-associated pneumonia guideline uptake was associated with a significant increase in guideline concordance and a reduction in ventilator-associated pneumonia rates. © 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.


PubMed | McGill University, William Osler Health Center, Institute for Clinical Evaluative science and University of Toronto
Type: | Journal: Arthritis care & research | Year: 2016

Quality measurement for rheumatoid arthritis (RA) patients has largely focused on care provided by rheumatologists. Our aim was to develop and assess quality measures related to the screening and management of comorbidity in RA patients in primary care.We used the primary care Electronic Medical Record Administrative data Linked Database in Ontario, Canada. We harmonized Canadian general population and RA clinical recommendations to develop and assess screening, process, and outcome measures. For each RA patient, 10 non-RA patients were matched on age and sex. Stratified analyses were performed, comparing patients with versus without RA, to assess the performance of quality measures.We compared 1,405 RA patients to 14,050 matched non-RA patients (72.8% female with a mean age of 62.5 years). RA patients more frequently had influenza (44.9% vs. 40.0%) and pneumococcal (40.4% vs. 34.1%) vaccinations, and bone mineral density testing (67.4% vs. 58.1%) in comparison to non-RA patients, respectively. Zoster vaccinations were less frequent among RA patients (13.8% vs. 19.5%), as well as screening for cervical cancer (58.6% vs. 64.0%). No significant differences were observed for breast (70.7% vs. 73.8%) and colorectal cancer (31.7% vs. 34.5%) screenings. Only a quarter of RA patients had a comprehensive cardiovascular risk assessment. No definite differences were detected in the management of patients who had co-occurring cardiovascular diseases or diabetes.In both RA and non-RA patients, there was low performance with Canadian recommendations for preventative medical services and screening for comorbid conditions in primary care. This suggests key targets for improvement. This article is protected by copyright. All rights reserved.


Seeley E.J.,University of California at San Francisco | McAuley D.F.,Queen's University of Belfast | Eisner M.,University of California at San Francisco | Miletin M.,William Osler Health Center | And 3 more authors.
Respiratory Research | Year: 2011

Background: Multiple studies have identified single variables or composite scores that help risk stratify patients at the time of acute lung injury (ALI) diagnosis. However, few studies have addressed the important question of how changes in pulmonary physiologic variables might predict mortality in patients during the subacute or chronic phases of ALI. We studied pulmonary physiologic variables, including respiratory system compliance, P/F ratio and oxygenation index, in a cohort of patients with ALI who survived more than 6 days of mechanical ventilation to see if changes in these variables were predictive of death and whether they are informative about the pathophysiology of subacute ALI.Methods: Ninety-three patients with ALI who were mechanically ventilated for more than 6 days were enrolled in this prospective cohort study. Patients were enrolled at two medical centers in the US, a county hospital and a large academic center. Bivariate analyses were used to identify pulmonary physiologic predictors of death during the first 6 days of mechanical ventilation. Predictors on day 1, day 6 and the changes between day 1 and day 6 were compared in a multivariate logistic regression model.Results: The overall mortality was 35%. In multivariate analysis, the PaO2/FiO2(OR 2.09, p < 0.04) and respiratory system compliance (OR 3.61, p < 0.01) were predictive of death on the 6thday of acute lung injury. In addition, a decrease in respiratory system compliance between days 1 and days 6 (OR 2.14, p < 0.01) was independently associated with mortality.Conclusions: A low respiratory system compliance on day 6 or a decrease in the respiratory system compliance between the 1stand 6thday of mechanical ventilation were associated with increased mortality in multivariate analysis of this cohort of patients with ALI. We suggest that decreased respiratory system compliance may identify a subset of patients who have persistent pulmonary edema, atelectasis or the fibroproliferative sequelae of ALI and thus are less likely to survive their hospitalization. © 2011 Seeley et al; licensee BioMed Central Ltd.


Su N.,Jilin University | Marek C.L.,University of Iowa | Ching V.,York University | Grushka M.,University of Florida | Grushka M.,William Osler Health Center
Journal of the Canadian Dental Association | Year: 2011

Patients with xerostomia, or dry mouth, resulting from various causes, are at higher risk for developing caries because of a loss of saliva and its benefits. A loss of saliva increases the acidity of the mouth, which affects many factors that contribute to the development of caries, such as proliferation of acid-producing bacteria, inability to buffer the acid produced by bacteria or from ingested foods, loss of minerals from tooth surfaces and inability to replenish the lost minerals, and loss of lubrication. Currently, a number of new products that can substitute for these functions of saliva or induce production of saliva are available in Canada. Some of these products are reviewed and a protocol for caries prevention in this high-risk population is proposed.


Lovren F.,Li Ka Shing Knowledge Institute | Pan Y.,Li Ka Shing Knowledge Institute | Quan A.,Li Ka Shing Knowledge Institute | Singh K.K.,Li Ka Shing Knowledge Institute | And 11 more authors.
Circulation | Year: 2010

Background-: Adropin is a recently identified protein that has been implicated in the maintenance of energy homeostasis and insulin resistance. Because vascular function and insulin sensitivity are closely related, we hypothesized that adropin may also exert direct effects on the endothelium. Methods and results-: In vitro cell culture models were partnered with an in vivo murine injury model to determine the potential vascular effects of adropin. Adropin was expressed in human umbilical vein and coronary artery endothelial cells (ECs). Adropin-treated endothelial cells exhibited greater proliferation, migration and capillary-like tube formation and less permeability and tumor necrosis factor-α-induced apoptosis. In keeping with a vascular protective effect, adropin stimulated Akt Ser473 and endothelial nitric oxide (NO) synthase Ser1177 phosphorylation. The former was abrogated in the presence of the phosphatidylinositol 3-kinase inhibitor LY294002, whereas the latter was attenuated by LY294002 and by mitogen-activated protein kinase kinase 1 inhibition with PD98059. Together, these findings suggest that adropin regulates NO bioavailability and events via the phosphatidylinositol 3-kinase-Akt and extracellular signal regulated kinase 1/2 signaling pathways. Adropin markedly upregulated vascular endothelial growth factor receptor-2 (VEGFR2) transcript and protein levels, and in VEGFR2-silenced endothelial cells, adropin failed to induce phosphorylation of endothelial NO synthase, Akt, and extracellular signal regulated kinase 1/2, supporting VEGFR2 as an upstream target of adropin-mediated endothelial NO synthase activation. Last, adropin improved murine limb perfusion and elevated capillary density following induction of hindlimb ischemia. Conclusions-: We report a potential endothelial protective role of adropin that is likely mediated via upregulation of endothelial NO synthase expression through the VEGFR2-phosphatidylinositol 3-kinase-Akt and VEGFR2-extracellular signal regulated kinase 1/2 pathways. Adropin represents a novel target to limit diseases characterized by endothelial dysfunction in addition to its favorable metabolic profile. © 2010 American Heart Association, Inc.


Heckmann S.M.,Friedrich - Alexander - University, Erlangen - Nuremberg | Kirchner E.,Friedrich - Alexander - University, Erlangen - Nuremberg | Grushka M.,William Osler Health Center | Wichmann M.G.,Friedrich - Alexander - University, Erlangen - Nuremberg | Hummel T.,University of Dresden Medical School
Laryngoscope | Year: 2012

Objectives/Hypothesis: In the treatment of burning mouth syndrome (BMS), various approaches have been tried with equivocal results. The aim of the present randomized clinical trial was to determine the efficacy of clonazepam, a GABA agonist designed as an antiepileptic drug that exerts the typical effects of benzodiazepines. Study Design: Randomized clinical trial. Methods: Twenty patients with idiopathic BMS were carefully selected. Clonazepam (0.5 mg/day, n = 10) or placebo (lactose, n = 10) were randomly assigned to the patients. Results: Patients on clonazepam significantly improved in pain ratings (P <.001). These changes were less pronounced in the placebo group (P <.11). No significant changes were observed in a mood scale (P =.56) or for depression scores (P =.56). Taste test and salivary flow increased over sessions, but were not different between groups (P =.83 and P =.06, respectively). Conclusions: Clonazepam appears to have a positive effect on pain in BMS patients. © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.


Peirano G.,University of Calgary | Richardson D.,William Osler Health Center | Nigrin J.,Dynacare Kasper Medical Laboratories | McGeer A.,Mount Sinai Hospital | And 6 more authors.
Antimicrobial Agents and Chemotherapy | Year: 2010

Phenotypic and genotypic methods were used to characterize extended-spectrum-β-lactamase (ESBL)-producing Escherichia coli isolated in 2007 from 11 different Canadian medical centers. Of the 209 ESBLproducing E. coli isolates tested, 148 (71%) produced CTX-M-15, 17 (8%) produced CTX-M-14, 5 (2%) produced CTX-M-3, and 1 produced CTX-M-27. Overall, 96 (46%) of the ESBL producers belonged to clonal complex ST131, with the highest prevalence in Brampton, Calgary, and Winnipeg. ST131 is an important cause of community onset urinary tract infections due to ESBL-producing E. coli across Canada. Copyright © 2010, American Society for Microbiology. All Rights Reserved.


Sibbald R.W.,London Health Sciences Center | Chidwick P.,William Osler Health Center
Journal of Critical Care | Year: 2010

Purpose: When patients are unable to communicate their own wishes, surrogates are commonly used to aid in decision making. Although each jurisdiction has its own rules or legislation governing how surrogates are to make health care decisions, many rely on the notion of "best interests" when no prior expressed wishes are known. Methods: We purposively sampled written decisions of the Ontario Consent and Capacity Board that focused on the best interests of patients at the end of life. Interpretive content analysis was performed independently by 2 reviewers, and themes that were identified by consensus as describing best interests were construed, as well as the characteristics of an end-of-life dispute that may be most appropriately handled by an application to the Consent and Capacity Board. Results: We found that many substitute decision makers rely on an appeal to religion or God in their interpretation of best interests, whereas physicians focused narrowly on the clinical condition of the patient in their interpretations. Conclusions: Several lessons are drawn for the benefit of health care teams engaged in end-of-life conflicts with substitute decision makers over the best interests of patients. © 2010 Elsevier Inc. All rights reserved.


PubMed | 974 Eginton Ave W, William Osler Health Center and Louisiana State University Health Sciences Center
Type: Journal Article | Journal: Oral and maxillofacial surgery clinics of North America | Year: 2016

Burning mouth syndrome (BMS) is an enigmatic, misunderstood, and under-recognized painful condition. Symptoms associated with BMS can be varied, thereby providing a challenge for practitioners and having a negative impact on oral health-related quality of life for patients. Management also remains a challenge for practitioners because it is currently only targeted for symptom relief without a definitive cure. There is an urgent need for further investigations to determine the efficacy of different therapies because this is the only way viable therapeutic options can be established for patients with this chronic and painful syndrome.

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