Patient-oriented research: An essential driver of learning health system capacity development

Canada's health system faces a lag in implementing high-quality evidence and research-driven innovation into service delivery, while demonstrating accountability and benefit to the public. To address these challenges, Patient-Oriented Research (POR) builds teams that engage researchers, healthcare providers, decision-makers, and most importantly, patients (people with lived and living experience) in the process of generating and applying evidence to inform health services and decision-making. A Learning Health System (LHS) systematically integrates external evidence with internal data and experience and puts that knowledge into practice in a continuous cycle. Using a POR/LHS example from a BC health authority, we describe nine enablers required to support LHS capacity development. The LHS case study, Walk With Me, addresses a health system high-priority topic: the toxic drug crisis. Understanding the value of LHSs, along with the enablers required to support and implement them, will empower health leaders to champion and orchestrate positive change.

Choosing Wisely: The Canadian Rheumatology Association Pediatric Committee's List of Items Physicians and Patients Should Question

OBJECTIVE

To develop a list of tests or treatments frequently used in pediatric rheumatology practice that may be unnecessary based on existing evidence.

METHODS

A Choosing Wisely (CW) working group composed of 16 pediatric rheumatologists, 1 allied health professional, 1 parent, and 1 patient used the Delphi method to generate, rank, and refine a list of tests and treatments that may be unnecessary or harmful. The items with the highest content agreement and perceived impact were presented in a survey to all Canadian Rheumatology Association (CRA) physicians who practice pediatric rheumatology. Respondents were asked to rate their agreement and impact, and to rank the items. Five items with the highest composite scores and 2 additional items selected by the CW working group were put forward for literature review.

RESULTS

The initial Delphi procedure generated 80 items. After 3 rounds, the list was narrowed to 13 items. The survey was completed by 41/81 (51%) CRA pediatric members across Canada. Respondent characteristics were similar to those of the CRA pediatric membership for self-reported gender, geographical location, and career stage. The highest composite score items were antinuclear antibody testing, drug toxicity monitoring, HLA-B27 testing, rheumatoid factor/anticyclic citrullinated peptide testing, and Lyme serology testing. Two additional items (numerous or repeated intraarticular corticosteroid injections, and autoinflammatory diseases genetic testing) were also selected. Literature review was performed for these 7 highest priority items.

CONCLUSION

We have identified areas for quality improvement in the evaluation and treatment of rheumatic diseases in Canadian children.

Real-world experience managing unresectable or metastatic small cell carcinoma of the prostate

INTRODUCTION

Unresectable and metastatic small cell carcinoma of the prostate (SCPC) is a rare and aggressive disease that is under-represented in clinical trials. We carried out a retrospective chart review of metastatic or unresectable SCPC patients at British Columbia (BC) Cancer centers, studying diagnosis and treatment patterns.

METHODS

Drug dispensing records from the six BC Cancer centers were obtained from 2002- 2017. For each patient, information was collected on baseline information prior to therapy, and for each line of treatment. Treatments at each line were compared regarding time to progression and overall survival by Kaplan-Meier curves.

RESULTS

Forty-one patients received treatment; 65.6% had metastatic disease and 61% had pure small cell carcinoma. Median time from treatment to death was 10 months (95% confidence interval [CI] 6-16). Patients with initially prostate-confined disease had a better median overall survival (mOS) of 21 months (95% CI 13-34) compared to those with initially locally advanced (mOS 19 months, 95% CI 5-37) and metastatic disease (mOS 8 months, 95% CI 6-10) (log-rank p=0.0364). All patients received either cisplatin- or carboplatin-based combination chemotherapy as the first-line treatment and 36.7% received second-line therapy. Time to second-line therapy was eight months for those who presented with metastatic SCPC, compared to 13 months for those with initial non-metastatic SCPC.

CONCLUSIONS

This single-province, multi-institution cohort reports data on unresectable and metastatic SCPC and highlights the poor prognosis of this rare disease entity.

Hydroxychloroquine-induced hyperpigmentation in a 14-year-old female with systemic lupus erythematosus

Hydroxychloroquine (HCQ)-induced hyperpigmentation is uncommon but is increasingly recognized. To our knowledge, HCQ-induced hyperpigmentation has not been reported in the pediatric age group. Herein, we present the case of a 14-year-old girl with systemic lupus erythematosus, who developed hyperpigmentation on her shins and dorsum of the left foot, approximately 3 years after initiating treatment with HCQ. Physicians who treat children with HCQ for reasons such as rheumatologic disorders, dermatologic disorders and, more recently, coronavirus disease-19 should be aware of this less-known side effect of HCQ.

Photodynamic therapy and the alimentary tract

Photodynamic therapy offers the possibility of relatively selective tumour necrosis and normal tissue healing. It has many potential applications but as yet no clear role. Articles, editorials and case reports published primarily in English and listed in Medline/ISI up to April 2000 or identified by a manual search have been reviewed in an attempt to provide a comprehensive overview of the use of photodynamic therapy in the alimentary tract. It is concluded that photodynamic therapy can be an effective treatment for superficial pre-malignant mucosal lesions and early cancers, especially in diffuse disease. Suitable patients include those wishing to avoid surgery, high risk subjects or those in whom other forms of treatment have failed. Superiority over other methods of ablation has not so far been demonstrated. Cheaper and more effective photosensitizers and improved techniques of light delivery are likely to increase the application of photodynamic therapy.

Neuropsychological change and S-100 protein release in 130 unselected patients undergoing cardiac surgery

BACKGROUND AND PURPOSE

S-100 protein promises to be a valuable surrogate end point for cerebral injury. This is of particular interest within the context of cardiac surgery. We sought to explore the relationship between change in neurospychological performance attributable to cardiopulmonary bypass and the release of brain-specific S-100 protein.

METHODS

In an observational comparative study in a University Hospital Cardiac Surgical Unit, S-100 protein release during and 5 hours after the onset of cardiopulmonary bypass was compared with change (from preoperative to 6 to 8 weeks postoperative) in neuropsychological tests in 130 patients undergoing the full range of cardiac surgical procedures.

RESULTS

Neuropsychological performance usually improved, being significantly so in 10 of 25 parameters. S-100 area under the curve (AUC) protein release correlated with age (r=0.24, P<0.008) and bypass time (r=0.17, P<0.02). S-100 Cmax correlated with bypass times (r=0.29, P<0.0001). Bypass times correlated with memory performance (Rey R5; r=-0.21, P<0.03). Less S-100 protein release was associated with better neuropsychological performance, as indexed by significant correlations with the Rey Auditory Verbal Learning memory test, descending Critical Flicker Fusion thresholds, and the Hospital Anxiety and Depression rating scales, typically around r=0.2. Multiple regression models showed that neuropsychological tests accounted for 23% of the variance associated with S-100 AUC release, after partialing out the effects of age and bypass time.

CONCLUSIONS

The correlation between S-100 protein release and neuropsychological function supports the belief that it is a measure of brain injury, which may be useful in future studies of mechanisms and prevention.

Growth factor regulation of the amylase promoter in a differentiating salivary acinar cell line

Salivary glands contain two major epithelial cell types: acinar cells which produce the primary salivary secretion, including amylase, and ductal cells which reabsorb electrolytes but also secrete kallikrein. Here we investigated salivary acinar cell differentiation in vitro using the activity of the salivary amylase and tissue kallikrein promoters as markers of acinar cell and ductal cell differentiation, respectively. Each of the promoter sequences was cloned into a replication-deficient adenoviral vector containing the luciferase reporter gene. Previous studies showed that a human submandibular gland cell line (HSG) differentiated into acinar cells when cultured on a reconstituted basement membrane matrix (Matrigel). The luciferase activity of the amylase promoter vector (AdAMY-luc) was low in HSG cells cultured on plastic, where they grow as an epithelial monolayer. The promoter activity increased approximately tenfold when HSG cells were cultured on Matrigel and developed an acinar phenotype. Under the same conditions, the luciferase activity of the kallikrein promoter (AdKALL-luc) was not induced. Because HSG cells demonstrate acinar cell morphology, but not amylase gene expression, when cultured on laminin-1, certain soluble components of Matrigel were tested for their ability to induce the amylase promoter during in vitro differentiation of acinar cells. We find that epidermal growth factor (EGF) and transforming growth factor-alpha (TGF-alpha), which are present in the basement membrane, and hepatocyte growth factor (HGF) increase activity of the amylase promoter. Other basement membrane-derived growth factors such as TGF-beta, basic fibroblast growth factor (bFGF), and platelet-derived growth factor (PGDF), as well as tumor necrosis factor (TNF-alpha), keratinocyte growth factor (KGH), nerve growth factor (NGF) and interferon gamma (IFN-gamma) were inactive. This system will be further exploited to study the mechanisms by which extracellular matrix molecules and growth factors regulate salivary acinar cell differentiation.

Efficacy and safety of enzymatic posterior vitreous detachment by intravitreal injection of hyaluronidase

PURPOSE

To investigate the efficacy and safety of intravitreal injection of hyaluronidase in producing liquefaction resulting in a posterior vitreous detachment.

METHODS

Fifteen young pigmented rabbits were randomized into 3 groups that received 5 (group 1), 10 (group 2), or 20 (group 3) IU of hyaluronidase. The fellow eyes were injected with a volumetric equivalent dose of balanced salt solution as control. The rabbits were followed for 9 weeks and examined for signs of ocular and retinal toxicity. The animals were then euthanized and their eyes were examined histologically.

RESULTS

Biomicroscopic evaluation in all but one rabbit revealed no evidence of ocular toxicity. One rabbit showed evidence of vitreous traction on the retina with transient retinal elevation. Biomicroscopically and histologically, all rabbits in group 3 and four of five rabbits in group 2 had evidence of a posterior vitreous detachment.

CONCLUSION

Intravitreal injection of hyaluronidase in doses of 10 IU or higher induces posterior vitreous detachment in rabbits over a period of 5 weeks. Intravitreal doses of 20 IU or less do not appear to affect the biomicroscopic morphology or function of ocular structures adversely. Injections of hyaluronidase, therefore, could be considered as an alternative or adjunct to conventional mechanical vitrectomy.

A YAC contig encompassing the XRCC5 (Ku80) DNA repair gene and complementation of defective cells by YAC protoplast fusion

The Chinese hamster ovary xrs mutants are sensitive to ionizing radiation, defective in DNA double-strand break rejoining, and unable to carry out V(D)J recombination effectively. Recently, the gene defective in these mutants, XRCC5, has been shown to encode Ku80, a component of the Ku protein and DNA-dependent protein kinase. We present here a YAC contig involving 25 YACs mapping to the region 2q33-q34, which encompasses the XRCC5 gene. Eight new markers for this region of chromosome 2 are identified. YACs encoding the Ku80 gene were transferred to xrs cells by protoplast fusion, and complementation of all the defective phenotypes has been obtained with two YACs. We discuss the advantages and disadvantages of this approach as a strategy for cloning human genes complementing defective rodent cell lines.

Pathology of silicone intraocular lenses in human eyes obtained postmortem

The increased use of phacoemulsification and small incision surgery has led to interest in a soft intraocular lens (IOL) for implantation after cataract extraction. We present the pathologic findings of seven eyes obtained postmortem from five patients with silicone IOLs. Length of implantation ranged from 6 weeks to 13 months. There was symmetric bag-bag fixation in all cases. Two IOLs had distorted and compressed polypropylene loops, resulting in decentration. The silicone IOL appeared to be well tolerated in all cases.

Contemporaneous shunting with repair of myelomeningocele

The combination of overt hydrocephalus and an open myelomeningocele in a newborn has prompted some authors to advocate the repair of the myelomeningocele and the performance of a shunt procedure during the same anesthetic procedure. Advocates of this approach stress the merits of administering only one anesthetic, diminution in incidence of cerebrospinal fluid leaks from the repair, and shortened hospital stay and the resultant cost-effectiveness. This study was performed to assess the complication rate of shunts inserted at the time of myelomeningocele repair as well as of those inserted at a later date as a separate procedure. It would later appear that the insertion of a ventriculoperitoneal shunt, contemporaneous with the repair of the myelomeningocele, does not increase the risks of shunt infection or shunt malfunction within the 1st year of life.

Ataxia telangiectasia: an investigation of the repair defect in the cell line AT5BIVA by plasmid reconstitution

The ataxia telangiectasia cell line, AT5BIVA, exhibited low repair fidelity measured by the reconstitution of transfected linear plasmid. This assay involves transfecting a linear plasmid containing two selectable marker genes: one gene (neo) is undamaged and marks transfection and the other gene (gpt) is cleaved to test functional repair. The proportion of transfected cells which have a functionally intact gpt gene gives a measure of repair fidelity. Southern analysis of individual transfected clones showed that integrated plasmids in AT5BIVA had a high frequency of sequence rearrangement. Blunt or staggered-ended termini of a linear plasmid did not determine the type of misrepair. A variety of sizes of deletions and sequence insertions were found at and around the cleavage site. Loss of intact sequence occurred similarly following transfection by linear or circular plasmid (misrepair or rearrangement error). This suggests that the action of excess exonuclease activity upon, or lack of protection of, exposed DNA termini is not the sole mechanism of misrepair. Erroneous rearrangement of circular plasmid could involve any location along the plasmid. Rearrangement of transfected circular plasmid occurred in multiple copies of the same abnormal size, suggesting that error-prone recombination rather than degradation of presumed nicked circular plasmid was the underlying mechanism. It is hypothesized that misrepair in ataxia-telangiectasia arises by error-prone recombination.

Management of adipsia by a behavioural modification technique

Adipsia combined with diabetes insipidus after hypothalamic damage may produce major difficulties in clinical management. If there is an associated memory impairment it may be impossible to teach self-regulation of fluid balance, necessitating long-term hospital supervision. The successful use of a behaviour modification technique to achieve independent drinking and allow discharge from hospital into the community is described in a patient with adipsia, diabetes insipidus and memory impairment resulting from the removal of a craniopharyngioma.

The effect of hyperbaric oxygen therapy of oral mucosal carcinoma

Hyperbaric oxygen is sometimes used in the course of treatment in head and neck cancer patient. This study was undertaken to investigate the effect of hyperbaric oxygen on oral cavity carcinogenesis in an animal model. Dimethylbenzanthracene was applied three times weekly to induce oral squamous cell cancers. The group that received simultaneous hyperbaric oxygen had fewer tumors, but the tumors were larger than the dimethylbenzanthracene-only group. We concluded that hyperbaric oxygen has a tumor-suppressive effect during the induction phase of oral carcinoma and appears to have a stimulatory effect during the proliferative phase of carcinoma in this animal model.

The new Maudsley series of temporal lobectomy. I: Short-term cognitive effects

Cognitive effects of temporal lobectomy for the relief of focal seizures were examined in 59 adult cases (29 left and 30 right). Verbal and non-verbal intelligence and memory were tested pre-operatively and four weeks post-operatively. Slight, non-significant differences between left and right cases pre-operatively were added to by slight, non-significant differences in change across the operation, to produce some significant post-operative differences--right cases being significantly higher on verbal IQ and lower on non-verbal IQ, for example. Variation in cognitive outcome was related to certain subject variables. Those who showed no deterioration or more improvement across the operation tended to be younger, less intellectually able pre-operatively, had an earlier first seizure and an earlier onset of regular seizures. The implications of these results for a model of the effects of temporal lobectomy are discussed.

Alpha-adrenoceptor number and function in rat cortex after ethanol and immobilization stress

Alpha-Adrenoceptor number and function were assessed in rat cortex after ethanol and immobilization stress. Rats subjected to immobilization stress for 2 h/day/7 days showed a significant reduction in alpha 2-adrenoceptors in cortex ( [3H]clonidine binding) but no change in alpha 1-adrenoceptors ( [3H]prazosin binding). The inhibitory effect of clonidine (500 nM) on 3H efflux from cortical slices preincubated with [3H]norepinephrine was reversed in the stressed animals. These effects on alpha 2-adrenoceptor number and function were reduced when stress was accompanied by chronic administration of ethanol (35% of calories in a liquid diet) although when given alone ethanol produced small changes in the same direction as those produced by stress. It is suggested that, in its effects on cortical alpha-adrenoceptors, chronic ethanol administration attenuates the effects of severe stress though itself perhaps acting as a mild stressor when given as part of a liquid diet regimen.