Modelling the role of enzymatic pathways in the metabolism of docosahexaenoic acid by monocytes and its association with osteoarthritic pain

Chronic pain is a major cause of disability and suffering in osteoarthritis (OA) patients. Endogenous specialised pro-resolving molecules (SPMs) curtail pro-inflammatory responses. One of the SPM intermediate oxylipins, 17-hydroxydocasahexaenoic acid (17-HDHA, a metabolite of docosahexaenoic acid (DHA)), is significantly associated with OA pain. The aim of this multidisciplinary work is to develop a mathematical model to describe the contributions of enzymatic pathways (and the genes that encode them) to the metabolism of DHA by monocytes and to the levels of the down-stream metabolites, 17-HDHA and 14-hydroxydocasahexaenoic acid (14-HDHA), motivated by novel clinical data from a study involving 30 participants with OA. The data include measurements of oxylipin levels, mRNA levels, measures of OA severity and self-reported pain scores. We propose a system of ordinary differential equations to characterise associations between the different datasets, in order to determine the homeostatic concentrations of DHA, 17-HDHA and 14-HDHA, dependent upon the gene expression of the associated metabolic enzymes. Using parameter-fitting methods, local sensitivity and uncertainty analysis, the model is shown to fit well qualitatively to experimental data. The model suggests that up-regulation of some ALOX genes may lead to the down-regulation of 17-HDHA and that dosing with 17-HDHA increases the production of resolvins, which helps to down-regulate the inflammatory response. More generally, we explore the challenges and limitations of modelling real data, in particular individual variability, and also discuss the value of gathering additional experimental data motivated by the modelling insights.

Fusion and patient-reported outcomes after navigated decortication and direct arthrodesis in minimally invasive sacroiliac joint fusion using cylindrical threaded implants: a case series and literature review

OBJECTIVE

Sacroiliac joint (SIJ) dysfunction is a significant cause of back pain. Despite recent advances in minimally invasive (MIS) SIJ fusion, the fusion rate remains controversial. This study sought to demonstrate that a navigated decortication and direct arthrodesis technique in MIS SIJ fusion would result in satisfactory fusion rates and patient-reported outcomes (PROs).

METHODS

The authors retrospectively reviewed consecutive patients who underwent MIS SIJ fusion from 2018 to 2021. SIJ fusion was performed using cylindrical threaded implants and SIJ decortication employing the O-arm surgical imaging system and StealthStation. The primary outcome was fusion, evaluated using CT at 6, 9, and 12 months postoperatively. Secondary outcomes included revision surgery, time to revision surgery, visual analog scale (VAS) score for back pain, and the Oswestry Disability Index (ODI), measured preoperatively and 6 and 12 months postoperatively. Patient demographics and perioperative data were also collected. PROs over time were analyzed using ANOVA followed by a post hoc analysis.

RESULTS

One hundred eighteen patients were included in this study. The mean (± SD) patient age was 58.56 ± 13.12 years, and most patients were female (68.6% vs 31.4% male). There were 19 smokers (16.1%) with an average BMI of 29.92 ± 6.73. One hundred twelve patients (94.9%) underwent successful fusion on CT. The ODI improved significantly from baseline to 6 months (Δ7.73, 95% CI 2.43-13.03, p = 0.002) and from baseline to 12 months (Δ7.54, 95% CI 1.65-13.43, p = 0.008). Similarly, VAS back pain scores improved significantly from baseline to 6 months (Δ2.31, 95% CI 1.07-3.56, p < 0.001) and from baseline to 12 months (Δ1.63, 95% CI 0.25-3.00, p = 0.015).

CONCLUSIONS

MIS SIJ fusion with navigated decortication and direct arthrodesis was associated with a high fusion rate and significant improvement in disability and pain scores. Further prospective studies examining this technique are warranted.

"COVID just kind of opened a can of whoop-ass": The rapid growth of safer supply prescribing during the pandemic documented through an environmental scan of addiction and harm reduction services in Canada

OBJECTIVES

In the context of the ongoing overdose crisis, a stark increase in toxic drug deaths from the unregulated street supply accompanied the onset of the COVID-19 pandemic. Injectable opioid agonist treatment (iOAT - hydromorphone or medical-grade heroin), tablet-based iOAT (TiOAT), and safer supply prescribing are emerging interventions used to address this crisis in Canada. Given rapid clinical guidance and policy change to enable their local adoption, our objectives were to describe the state of these interventions before the pandemic, and to document and explain changes in implementation during the early pandemic response (March-May 2020).

METHODS

Surveys and interviews with healthcare providers comprised this mixed methods national environmental scan of iOAT, TiOAT, and safer supply across Canada at two time points. Quantitative data were summarized using descriptive statistics; interview data were coded and analyzed thematically.

RESULTS

103 sites in 6 Canadian provinces included 19 iOAT, 3 TiOAT and 21 safer supply sites on March 1, 2020; 60 new safer supply sites by May 1 represented a 285% increase. Most common substances were opioids, available at all sites; most common settings were addiction treatment programs and primary care clinics, and onsite pharmacies models. 79% of safer supply services were unfunded. Diversity in service delivery models demonstrated broad adaptability. Qualitative data reinforced the COVID-19 pandemic as the driving force behind scale-up.

DISCUSSION

Data confirmed the capacity for rapid scale-up of flexible, community-based safer supply prescribing during dual public health emergencies. Geographical, client demographic, and funding gaps highlight the need to target barriers to implementation, service delivery and sustainability.

Service delivery models for injectable opioid agonist treatment in Canada: 2 sequential environmental scans

BACKGROUND

Injectable opioid agonist treatment (iOAT) is an emerging evidence-based option in the continuum of care for opioid use disorder in parts of Canada. Our study objective was to identify and describe iOAT programs operating during the ongoing opioid overdose crisis.

METHODS

We conducted 2 sequential environmental scans. Programs were eligible to participate if they were in operation as of Sept. 1, 2018, and Mar. 1, 2019. Information was collected over 2-3 months for each scan (September-October 2018, March-May 2019). Programs that participated in the first scan and newly established programs were invited to participate in the second scan. The scans included questions about location, service delivery model, clinical and operational characteristics, numbers and demographic characteristics of clients, and program barriers and facilitators. Descriptive analysis was performed.

RESULTS

We identified 14 unique programs across the 2 scans. Eleven programs located in urban centres in British Columbia and Ontario participated in the first scan. At the time of the second scan, 2 of these programs were on hold and 2 of 3 newly established programs were in Alberta. The total capacity of all participating programs was 420 clients at most. Four service delivery models were identified; iOAT was most commonly integrated within existing health and social services. All programs offered hydromorphone, and 1 program also offered diacetylmorphine. In the first scan, 73% of clients (133/183) were male; the mean age of clients was 47 years. Limited capacity, pharmacy operations and lack of diacetylmorphine access were among the most frequently reported barriers. The most commonly reported facilitators included client-centred care, client relationships and access to other health and social support.

INTERPRETATION

Evidence indicates that iOAT can be successfully implemented using diverse service delivery models. Future work should facilitate scale-up of this evidence-based treatment where gaps persist in high-risk communities.

Seeking shelter: homelessness and COVID-19

Those experiencing homelessness in Canada are impacted inequitably by COVID-19 due to their increased exposure, vulnerability of environment and medical comorbidities, and their lack of access to preventive care and treatment in the context of the pandemic. In shelter environments one is unable to effectively physically distance, maintain hygiene, obtain a test, or isolate. As a result, unique strategies are required for this population to protect them and those who serve them. Recommendations are provided to reduce or prevent further negative consequences from the COVID-19 pandemic for people experiencing homelessness. These recommendations were informed by a systematic review of the literature, as well as a jurisdictional scan. Where evidence did not exist, expert consensus from key providers and those experiencing homelessness throughout Canada was included. These recommendations recognize the need for short-term interventions to mitigate the immediate risk to this community, including coordination of response, appropriate precautions and protective equipment, reducing congestion, cohorting, testing, case and contact management strategies, dealing with outbreaks, isolation centres, and immunization. Longer-term recommendations are also provided with a view to ending homelessness by addressing the root causes of homelessness and by the provision of adequate subsidized and supportive housing through a Housing First strategy. It is imperative that meaningful changes take place now in how we serve those experiencing homelessness and how we mitigate specific vulnerabilities. These recommendations call for intersectoral, collaborative engagement to work for solutions targeted towards protecting the most vulnerable within our community through both immediate actions and long-term planning to eliminate homelessness.

Determination of Lead in Wine by Graphite Furnace Atomic Absorption Spectrophotometry: Interlaboratory Study

An interlaboratory study of a graphite furnace atomic absorption spectrophotometry (GFAAS) method for the determination of lead in wine was conducted. Seventeen laboratories from France, United States, and the United Kingdom, using a variety of GFAAS instruments, took part in the study. The method incorporated a novel matrix-matching procedure to minimize matrix effects between standards and samples. Six wine test materials were prepared and sent to participants as 12 blind duplicate or split level samples. There was good agreement between results obtained from participants and target values (24–279 μg/L) obtained with an inductively coupled plasma-mass spectrometry method. The precision of the GFAAS method was well within the range predicted by the Horwitz equation for the 6 test materials analyzed. Repeatability standard deviations ranged from 3 to 17%. Reproducibility standard deviations were in the range of 10 to 30%. The method is recommended for use for official purposes.

Physician performance feedback in a Canadian academic center

Purpose

This paper aims at the implementation and early evaluation of a comprehensive, formative annual physician performance feedback process in a large academic health-care organization.

Design/methodology/approach

A mixed methods approach was used to introduce a formative feedback process to provide physicians with comprehensive feedback on performance and to support professional development. This initiative responded to organization-wide engagement surveys through which physicians identified effective performance feedback as a priority. In 2013, physicians primarily affiliated with the organization participated in a performance feedback process, and physician satisfaction and participant perceptions were explored through participant survey responses and physician leader focus groups. Training was required for physician leaders prior to conducting performance feedback discussions.

Findings

This process was completed by 98 per cent of eligible physicians, and 30 per cent completed an evaluation survey. While physicians endorsed the concept of a formative feedback process, process improvement opportunities were identified. Qualitative analysis revealed the following process improvement themes: simplify the tool, ensure leaders follow process, eliminate redundancies in data collection (through academic or licensing requirements) and provide objective quality metrics. Following physician leader training on performance feedback, 98 per cent of leaders who completed an evaluation questionnaire agreed or strongly agreed that the performance feedback process was useful and that training objectives were met.

Originality/value

This paper introduces a physician performance feedback model, leadership training approach and first-year implementation outcomes. The results of this study will be useful to health administrators and physician leaders interested in implementing physician performance feedback or improving physician engagement.

Learning disability nursing: a position paper

Learning disability nurses in the UK have received unprecedented attention over the past 5 years in response to anxieties about their role. The problem has been conceptualized as being the inability of nurses to articulate their contribution to meeting the needs of people with learning disabilities and a lack of evidence of their effectiveness. This paper proposes that, although nurses are valued for their contribution individually in services, they are working within devaluing systems which have created conceptual and strategic uncertainty about learning disabilities generally. In order to move forward, nurses need to understand the ways in which these systems exert their influence. It is proposed that if three broad aims for the profession are pursued this will help improve practice whilst simultaneously helping nurses feel more secure about their contribution in the field of learning disabilities.

Quality gaps identified through mortality review

BACKGROUND

Hospital mortality rate is a common measure of healthcare quality. Morbidity and mortality meetings are common but there are few reports of hospital-wide mortality-review processes to provide understanding of quality-of-care problems associated with patient deaths.

OBJECTIVE

To describe the implementation and results from an institution-wide mortality-review process.

DESIGN

A nurse and a physician independently reviewed every death that occurred at our multisite teaching institution over a 3-month period. Deaths judged by either reviewer to be unanticipated or to have any opportunity for improvement were reviewed by a multidisciplinary committee. We report characteristics of patients with unanticipated death or opportunity for improved care and summarise the opportunities for improved care.

RESULTS

Over a 3-month period, we reviewed all 427 deaths in our hospital in detail; 33 deaths (7.7%) were deemed unanticipated and 100 (23.4%) were deemed to be associated with an opportunity for improvement. We identified 97 opportunities to improve care. The most common gap in care was: 'goals of care not discussed or the discussion was inadequate' (n=25 (25.8%)) and 'delay or failure to achieve a timely diagnosis' (n=8 (8.3%)). Patients who had opportunities for improvement had longer length of stay and a lower baseline predicted risk of death in hospital. Nurse and physician reviewers spent approximately 142 h reviewing cases outside of committee meetings.

CONCLUSIONS

Our institution-wide mortality review found many quality gaps among decedents, in particular inadequate discussion of goals of care.

Genomic comparison of virulent and non-virulent Streptococcus agalactiae in fish

Streptococcus agalactiae infections in fish are predominantly caused by beta-haemolytic strains of clonal complex (CC) 7, notably its namesake sequence type (ST) 7, or by non-haemolytic strains of CC552, including the globally distributed ST260. In contrast, CC23, including its namesake ST23, has been associated with a wide homeothermic and poikilothermic host range, but never with fish. The aim of this study was to determine whether ST23 is virulent in fish and to identify genomic markers of fish adaptation of S. agalactiae. Intraperitoneal challenge of Nile tilapia, Oreochromis niloticus (Linnaeus), showed that ST260 is lethal at doses down to 10(2) cfu per fish, whereas ST23 does not cause disease at 10(7) cfu per fish. Comparison of the genome sequence of ST260 and ST23 with those of strains derived from fish, cattle and humans revealed the presence of genomic elements that are unique to subpopulations of S. agalactiae that have the ability to infect fish (CC7 and CC552). These loci occurred in clusters exhibiting typical signatures of mobile genetic elements. PCR-based screening of a collection of isolates from multiple host species confirmed the association of selected genes with fish-derived strains. Several fish-associated genes encode proteins that potentially provide fitness in the aquatic environment.