Health Canada advisory impacts on the prevalence of oral codeine use in the Pediatric Canadian population: comparative study across provinces

Health Canada (HC) has, since 2013, issued safety alerts restricting the use of codeine-containing drugs among breastfeeding women and children/adolescents under 18 years of age. These products are linked to breathing problems among ultra-rapid CYP2D6 metabolizers and early use of opioid can lead to future opioid misuse. Using a multi-province population-based cohort study, we estimate the impact of federal safety alerts on annual rates of codeine use in the Canadian pediatric population. We analyzed data from 8,156,948 children/adolescents in five Canadian provinces between 1996 and 2021, using a common protocol. Children/adolescents were categorized as: ≤ 12 years (children) or > 12 years (adolescents). We defined codeine exposure by ≥ 1 prescription filled for codeine alone or combined with other medications. For both age categories, we obtained province-specific codeine prescription filling rates per calendar year by dividing the number of children/adolescents with ≥ 1 codeine prescription filled by the number of person-time. Annual rates of codeine use per 1000 persons vary by province from 3.0 (Quebec) to 10.1 (Manitoba) in children, and from 5.5 to 51.3 in adolescents. After the 2013 HC advisory, exposure decreased in all provinces (adjusted level change from - 0.6 to - 18.4%) in children and from - 2.1 to - 17.9% in adolescents after the 2016 advisory. Annual rates declined over time in all provinces, following HC safety alerts specific to each of the two age categories.

Time trends in preeclampsia and gestational diabetes in Denmark and Alberta, Canada, 2005-2018-A population-based cohort study

INTRODUCTION

Preeclampsia and gestational diabetes mellitus share risk factors such as obesity and increased maternal age, which have become more prevalent in recent decades. We examined changes in the prevalence of preeclampsia and gestational diabetes between 2005 and 2018 in Denmark and Alberta, Canada, and investigated whether the observed trends can be explained by changes in maternal age, parity, multiple pregnancy, comorbidity, and body mass index (BMI) over time.

MATERIAL AND METHODS

This study was a register-based cohort study conducted using data from the Danish National Health Registers and the provincial health registers of Alberta, Canada. We included in the study cohort all pregnancies in 2005-2018 resulting in live-born infants and used binomial regression to estimate mean annual increases in the prevalence of preeclampsia and gestational diabetes in the two populations across the study period, adjusted for maternal characteristics.

RESULTS

The study cohorts included 846 127 (Denmark) and 706 728 (Alberta) pregnancies. The prevalence of preeclampsia increased over the study period in Denmark (2.5% to 2.9%) and Alberta (1.7% to 2.5%), with mean annual increases of 0.03 (95% confidence interval [CI] 0.02-0.04) and 0.06 (95% CI 0.05-0.07) percentage points, respectively. The prevalence of gestational diabetes also increased in Denmark (1.9% to 4.6%) and Alberta (3.9% to 9.2%), with average annual increases of 0.20 (95% CI 0.19-0.21) and 0.44 (95% CI 0.42-0.45) percentage points. Changes in the distributions of maternal age and BMI contributed to increases in the prevalence of both conditions but could not explain them entirely.

CONCLUSIONS

The prevalence of both preeclampsia and gestational diabetes increased significantly from 2005 to 2018, which portends future increases in chronic disease rates among affected women. Increasing demand for long-term follow up and care will amplify the existing pressure on healthcare systems.

Impact of a modified screening approach during the COVID-19 pandemic on the diagnosis and outcomes of gestational diabetes mellitus: A population-level analysis of 90,518 pregnant women

AIMS

To provide real-world evidence on the uptake of and outcomes associated with the modified gestational diabetes mellitus (GDM) screening approach offered during the COVID-19 pandemic compared with the standard screening approach.

METHODS

All pregnancies between 01 January 2020 and 31 December 2021, in Alberta, Canada, were included in the study. We examined GDM screening and diagnosis rates, and large-for-gestational-age (LGA) outcomes.

RESULTS

Annual GDM screening rates were > 95% during the study time period. Overall, 84.7%, and 11.6% of the 92,505 pregnancies underwent standard and modified screening for GDM, respectively. The use of modified screening was the highest among deliveries in August 2020 (49.8%) which corresponded to the early first wave of the pandemic. GDM diagnosis rate was lower in the modified screening (7.4%) than in the standard screening (12.3%, p < 0.001) group. The LGA rates in the modified screening with GDM and the standard screening with GDM groups were 24.8% and 12.6%, respectively (p < 0.001). Women in the modified screening with GDM group were at a higher risk of having an LGA infant (adjusted odds ratio: 3.46; 95% confidence interval: 2.93, 4.08) compared to the standard screening with no GDM group.

CONCLUSIONS

The COVID-19 epidemic had no impact on screening for GDM. Women who underwent modified screening, based on HbA1c/random plasma glucose, had lower rates of GDM cases.

Administrative Databases: Friend or Foe in Paediatric Cardiomyopathy

Background

Cardiomyopathy (CM) is a rare childhood disease associated with morbidity and mortality. Limited data exist on paediatric CM in Canada. Given the rare nature, single-centre studies are not sufficiently powered to address important questions. Therefore, administrative health data may serve as a resource for the study of childhood CM. The goal of this study was to validate the accuracy of International Classification of Diseases (ICD)-based algorithms to identify paediatric CM in health databases using a clinical registry as the gold standard.

Methods

The clinical registry was compiled from outpatient and inpatient records at the Stollery Children's Hospital (January 1, 2013, to December 31, 2021). Patients were categorized as having CM or screened without CM. Data were linked to administrative health databases using the patient's Unique Lifetime Identifier. Algorithms based on the presence of ICD, 10th Revision, codes for CM were then evaluated, and cross-tabulations against the clinical registry were generated. Accuracy, positive predictive value, negative predictive value, sensitivity, and specificity were calculated.

Results

The clinical registry had 90 patients with CM and 249 screened without CM. The algorithms ruled out CM (high negative predictive value) but had variability in the ability to diagnose CM positive predictive value. The algorithm that performed the best was based on a diagnosis of CM in a hospitalization or 2 ambulatory visits.

Conclusions

A combination of inpatient and outpatient databases can be used, with acceptable accuracy, to identify paediatric patients with CM. This finding allows for the use of the identified algorithm for the comprehensive study of paediatric CM in Canada.

Health care impact of implementing a clinical pathway for acute care of pediatric concussion: a stepped wedge, cluster randomised trial

OBJECTIVES

To test the effects of actively implementing a clinical pathway for acute care of pediatric concussion on health care utilization and costs.

METHODS

Stepped wedge, cluster randomized trial of a clinical pathway, conducted in 5 emergency departments (ED) in Alberta, Canada from February 1 to November 30, 2019. The clinical pathway emphasized standardized assessment of risk for persistent symptoms, provision of consistent information to patients and families, and referral for outpatient follow-up. De-identified administrative data measured 6 outcomes: ED return visits; outpatient follow-up visits; length of ED stay, including total time, time from triage to physician initial assessment, and time from physician initial assessment to disposition; and total physician claims in an episode of care.

RESULTS

A total of 2878 unique patients (1164 female, 1713 male) aged 5-17 years (median 11.00, IQR 8, 14) met case criteria. They completed 3009 visits to the 5 sites and 781 follow-up visits to outpatient care, constituting 2910 episodes of care. Implementation did not alter the likelihood of an ED return visit (OR 0.77, 95% CI 0.39, 1.52), but increased the likelihood of outpatient follow-up visits (OR 1.84, 95% CI 1.19, 2.85). Total length of ED stay was unchanged, but time from physician initial assessment to disposition decreased significantly (mean change - 23.76 min, 95% CI - 37.99, - 9.52). Total physician claims increased significantly at only 1 of 5 sites.

CONCLUSIONS

Implementation of a clinical pathway in the ED increased outpatient follow-up and reduced the time from physician initial assessment to disposition, without increasing physician costs. Implementation of a clinical pathway can align acute care of pediatric concussion more closely with existing clinical practice guidelines while making care more efficient.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05095012.

Longitudinal trends in incidence and health care use for pediatric concussion in Alberta, Canada

BACKGROUND

We described longitudinal trends in the incidence of episodes of care (EOC) and follow-up care for pediatric concussion in relation to age, sex, rurality of patient residence, point of care, and area-based socioeconomic status (SES) in Alberta, Canada.

METHODS

A retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age who received a diagnosis of concussion, other specified injuries of head, unspecified injury of head, or post-concussion syndrome between April 1, 2004 and March 31, 2018. Data were geospatially mapped.

RESULTS

Concussion EOCs increased 2.2-fold over the study period, follow-up visits 5.1-fold. Care was increasingly received in physician office (PO) settings. Concussion diagnoses in rural and remote areas occurred in emergency department (ED) settings more often than in metro centres or urban areas (76%/75% vs. 52%/60%). Proportion of concussion diagnoses was positively related to SES and age. Diagnosis and point of care varied geographically.

CONCLUSIONS

The shift in care to PO settings, increased incidence of all diagnoses, and the higher use of the ED by some segments of the population all have important implications for appropriate clinical management and the efficient provision of health care for pediatric concussion.

IMPACT

This is the first study to use EOC to describe longitudinal trends in incidence and follow-up care for pediatric concussion in relation to age, sex, rurality, point of care, and area-based SES. We report increased incidence of concussion in both emergency and outpatient settings and the proportion of diagnoses was positively related to SES and age. Patients increasingly received care for concussion in PO over time. Geospatial mapping indicated that the incidence of concussion and unspecified injury of head varied geographically and temporally. Results have important implications for appropriate clinical management and efficient provision of health care following pediatric concussion.

Primary care service use during adolescence and young adulthood: Tertiary care cohort affected by chronic health conditions

OBJECTIVE

To understand use of family physician services and emergency department visits by adolescents and young adults with chronic health conditions.

DESIGN

Longitudinal retrospective observational cohort study using administrative health data.

SETTING

Chronic care clinics at a tertiary care pediatric hospital in Calgary, Alta.

PARTICIPANTS

In total, 1326 adolescents who were between 12 and 15 years old in 2008, who were observed until 2016, and who received medical services for chronic conditions were enrolled in the study. Eligible participants had at least 4 visits to the same chronic disease clinic in any 2-year window before age 18.

MAIN OUTCOMES MEASURES

Group-based trajectory modeling was used to identify groups of adolescents with distinct patterns of health care use (for visits to emergency departments and to primary care practices), while ² tests explored trajectory group differences (eg, sex, location of residence).

RESULTS

Median age was 14 years (range 12 to 17 years) at study entry, and 22 years (range 14 to 24 years) at study exit. Half were female and most (85.4%) lived in an urban area. Median observation period was 8.7 person-years (range 1.3 to 9.1 years). Group-based trajectory modeling identified 5 distinct trajectory groups of primary care use and 4 groups of emergency services use. Groups differed by sex and location of residence in each trajectory model.

CONCLUSION

Many adolescents increased their use of emergency services between the ages of 12 and 24 years, with distinct patterns of primary care use being observed. Association of additional patient- and system-level factors (eg, disease severity, distance to nearest family physician office) should be explored.

Factors associated with follow-up care after pediatric concussion: A longitudinal population-based study in Alberta, Canada

BACKGROUND

Concussion is a common injury in children and adolescents. Current best practice guidelines indicate that recovery should be supervised through recurrent follow-up visits. A more detailed understanding of the system-level and individual factors that are associated with follow-up care is a critical step towards increasing evidence-based practice. The objective of this study was to identify predisposing, enabling, and need-based factors associated with follow-up care after pediatric concussion.

MATERIALS AND METHODS

A retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age with a diagnosis of concussion, other specified injuries of the head, unspecified injury of head, or post-concussion syndrome (PCS) between April 1, 2004 and March 31, 2018 in Alberta, Canada. The association between predisposing, enabling, and need-based factors and the receipt of follow-up care within a defined episode of care (EOC) was analyzed using logistic regression models for the entire cohort and for EOC that began with a concussion diagnosis. Predisposing factors included age and sex. Enabling factors included the community type of patient residence, area-based socioeconomic status (SES), and visit year. Need-based factors included where the EOC began (outpatient vs. emergency settings) and history of previous concussion-related EOC.

RESULTS

194,081 EOCs occurred during the study period but only 13% involved follow-up care (n = 25,461). Males and adolescents were more likely to receive follow-up care. Follow-up was less likely among patients who lived in remote communities or in areas of lower SES, while EOCs beginning in 2011 or later were more likely to involve follow-up care. Patients whose EOC began in outpatient settings, had more than one EOC, or a diagnosis of concussion were more likely to receive follow-up care.

CONCLUSION

Follow-up care for pediatric concussion has increased over time and is associated with patient age and sex, history of concussion-related EOC, where a patient lives (community type and area-based SES), and when and where the index visit occurs. A better understanding of which children are more likely to receive follow-up care, as well as how and when they do, is an important step in aligning practice with follow-up guidelines.

Long-term outcome of patients with myocardial infraction with nonobstructive coronary arteries

Background

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a condition of growing interest and research. We aimed to evaluate the long-term prognosis of MINOCA patients and identify possible risk factors associated with long term mortality in this patient's population.

Methods

We performed a retrospective observational cohort study including all patients aged ≥18 years hospitalized to a large tertiary center between 2005–2018 with a primary diagnosis of acute myocardial infarction (AMI) and non-obstructive lesions with less than &lt;50% stenosis in all coronary arteries. The aim of the study was to assess the long-term mortality and to evaluate factors associated with increased mortality in this population.

Results

MINOCA was diagnosed in 1544 patients during the study period. Mean age of patients was 61±12.3 and 46% were female. Common comorbidities were dyslipidemia (32.6%) and hypertension (21.2%) and 17% had prior PCI. More than third of the patients were treated with statins (37.2%), micropirin (32.7%) and angiotensin converting enzyme (ACE)-inhibitors (30.4%). While short-term prognosis was favorable with only 1.2% mortality at 30-days, 1-year mortality was 3.9% and 19.9% mortality at mean follow-up time of 8.5 years. While many factors were associated with unfavorable long-term outcome in the univariate analysis, only advanced age (HR =1.05, 95% confidence interval (CI) 1.02–1.07; p&lt;0.001) and congestive heart failure (HR=3.53, 95% CI 1.74–7.18; P&lt;0.001) were independently associated with increased mortality risk in the adjusted model.

Conclusions

MINOCA is not an infrequent condition that carries a good short-term outcome, but long-term outcome may be comparable to patients with obstructive coronary disease. Further research should be performed to elucidate the various mechanisms of MINOCA.

Funding Acknowledgement

Type of funding sources: None.

Comparison of coronary bifurcation lesions stenting techniques- a network meta-analysis

Background

Coronary bifurcations lesions (CBL) are account for 15–20% of all percutaneous coronary interventions (PCI) and constitute a major challenge for interventionists in terms of procedural success rate and long-term cardiac events. Based on data from multiple randomized trials and registries, current guidelines advocate the use of provisional side branch (SB) stenting strategy for the majority of CBL's. However, for true or complex CBL's (long side branches lesions, difficult side branches access or high risk of side branches compromise), which account for up to 25% of CBL's, this strategy may by unsafe and ineffective due to a potential risk of intraprocedural or long-term occlusion of a significant side branch and a two-stenting technique may be needed in order to achieve optimal results. Up to date, the optimal two- stenting technic for CBL remains in debate. Accordingly, our aim was to compare different stenting techniques in coronary bifurcation lesions.

Methods

We performed a MEDLINE search for randomized controlled trials (RCT) and observational studies comparing stenting techniques in CBL's with reported clinical outcomes. Mixed treatment comparison model generation was performed to directly and indirectly compare culotte, T and protrusion (TAP), crush and provisional techniques

Results

A total of 13 RCT and 12 observational studies were identified including 6806 patients, among whom 1,201 were treated with cullotte, 2,731 with crush, 797 with TAP and 2077 with provisional stenting. The Bayesian hierarchical random-effects model demonstrated a significant reduction in target lesion revascularization (TLR) rate with crush techniques compared with provisional technique (OR 0.64 95% CI 0.42–0.97) along with a trend for reduction in major adverse cardiovascular (MACE) events (OR 0.75, 95% CI 0.55–1.02). TAP and culotte techniques did not show similar results. Equality of other endpoints, including mortality, myocardial infarction and re-stenosis was found between all CBL's techniques (Figure 1).

Discussion

Our findings suggest improved outcomes with crush technique compared to other double stenting techniques in terms of TLR with a trend towards MACE reduction. Further research is required to determine the optimal stenting technique for coronary bifurcations lesions along with the utility of imaging and physiology in this complex subset.

Figure 1. Comparison of double stentin techniques

Funding Acknowledgement

Type of funding source: None

307Clinical outcomes of pacing induced cardiomyopathy in patients with preserved left ventricular systolic function and atrioventricular block

Funding Acknowledgements

None

Background

Patients with preserved LVEF and atrioventricular block (AVB) who are anticipated for high-burden of right ventricular (RV) pacing possess a risk to develop pacing induced cardiomyopathy (PICM).

Aims

To evaluate the incidence and outcomes of RV-PICM in this patient"s population.

Methods

1013 patients with AVB underwent first time pacemaker (PM) implantation between 2002 and 2016. A total of 203 patients with normal LVEF were included. Follow-up echocardiography was examined for a decrease in LVEF &gt; 10%. Alternative causes for cardiomyopathy were excluded. Patient"s characteristics, mortality and hospitalizations for heart failure (HF) were compared between the PICM and non-PICM groups. 

Results

51 patients (25%) developed PICM, with 22 patients (11%) showing LVEF &lt; 40%. During mean follow-up of 49.2 months, the risk of HF hospitalization or all-cause mortality was significantly higher in the PICM group (35.3% vs. 19.1%, p = 0.009). LVEDD was independently associated with PICM (HR = 1.10, 95% CI: 1.03-1.17, p = 0.01) and CAD was nearly associated with PICM (HR = 2.19, 95% CI: 0.98-4.90, p = 0.06). 

Conclusions

The incidence of PICM in patients with normal LVEF and AVB is alarmingly high. PICM in patients with a previously normal LVEF is associated with unfavorable outcomes.

Table 1 Characteristics Cohort without PICM (152) n (%) Cohort with PICM (51) n(%) p Age mean ± SD 74.6 ± 10.5 71 ± 13 0.04 Gender (male) 80 (52.6) 29 (56.9) 0.6 Pacing modeDDDVDDVVI 108 (71.1) 38 (25) 6 (3.9) 34 (66.7) 15 (29.4) 2(3.9) 0.83 Hypertension 112 (73.7) 36 (70.6) 0.67 PVD 16 (10.5) 5 (8.9) 0.88 CAD 36 (23.7) 19 (37.3) 0.01 CVA / TIA 17 (11.2) 7 (13.7) 0.63 Atrial fibrillation / flutter 18 (11.8) 9 (17.6) 0.29 COPD 15 (9.9) 2 (3.9) 0.25 Diabetes Mellitus 56 (36.8) 27 (52.9) 0.04 Chronic Kidney Disease 27 (17.9) 14 (27.5) 0.14 Statins 65 (43) 30(60) 0.04 ACE inhibitors / ARBs 52 (34.4) 18 (36) 0.84 Beta Blockers 42 (28) 10 (20) 0.26 LVEDD mm 45.13 ± 5.53 48.46 ± 5.97 &lt;0.001 LVESD mm 25.68 ± 5.28 27.72 ± 4.67 0.02 Baseline characteristics

Abstract Figure. HF and Mortality outcomes

P391Estimated glomerular filtration rate levels and risk of stroke in individuals with diabetes mellitus and atrial fibrillation

Funding Acknowledgements

pfizer

Background

Diabetes mellitus (DM) is associated with increased risk of embolic complications in non-valvular atrial fibrillation (NVAF). Chronic kidney disease (CKD) has been shown in some studies to increase the risk of stroke. This finding is not consistent among all studies. Therefore the relationship between kidney function, diabetes and stroke risk is complex and warrants further investigation.

Purpose

To assess the incidence rates and risk of ischemic stroke and mortality by baseline Estimated Glomerular Filtration Rate (eGFR) levels among individuals with AF and DM.

Methods

A prospective, historical cohort study using our electronic medical records database. The study population included all members 21 years old, with a first diagnosis of NVAF between January 1, 2010 to December 31, 2016 and a minimal follow-up period of 1 year. Among those patients identified as diabetics, we compared three groups of patients according to eGFR levels at the time of AF diagnosis: eGFR ≥ 60, between 30-60 and ≤ 30 or chronic dialysis or kidney transplant.

Results

A total of  17,567 cases were included in the final analysis, of them, 11013 (62.7%) had eGFR ≥ 60, 4930 (28%) with eGFR between 30-60 and 1624 (9.24%) with eGFR ≤30 . The median age was 75 years (IQR 65-83) with a majority of females in all groups, 52.5%, 51.2% and 55.5% respectively. The incidence of stroke per 100 person-years in the three study groups was: 1.88 in patients with eGFR ≥ 60, 2.69 in patients with eGFR between 30-60 and 3.34 in those with eGFR ≤ 30 . Impaired renal function was associated with increased risk of stroke in univariate analysis, but not found in the adjusted model  (Adjusted Hazard Ratio (AHR) = 1.04 {95% 0.89-1.23} for eGFR 30-60  and 1.16 {95% CI 0.88-1.51} for eGFR ≤ 30 compared to GFR ≥ 60). incidence of mortality per 100 person-years was 10.78 in patients with  eGFR ≥ 60, 21.49 in patients with eGFR 30-60 and 41.55 in those with eGFR ≤ 30. In both univariate and multivariate analyses, decreased levels of eGFR were associated with increased mortality risk compared to subjects with normal renal function (AHR 1.22 {95%CI 1.14-1.27} and AHR 2.09 {95%CI 1.95-2.24} for eGFR between 30-60 and for eGFR ≤ 30, respectively).

Conclusion

In this observational prospective cohort of patients with newly diagnosed NVAF, impaired renal function was not found to be associated with increased risk of stroke. Lower eGFR levels were associated with an increased mortality risk.

P997Risk of stroke and mortality in patients with atrial fibrillation and insulin dependent versus non-insulin dependent diabetes mellitus

Funding Acknowledgements

Pfizer pharmaceutical corporation

Background

Diabetes is a known risk factor for thromboembolic events in patients with non-valvular atrial fibrillation (NVAF). Whether patients on insulin therapy are at an increased risk for stroke compered to patients treated solely by oral antidiabetic medications is not yet established.

Aim

To assess the risk of ischemic stroke and mortality in patients with NVAF and diabetes mellitus (DM) treated by insulin vs. oral antidiabetic treatment.

Methods

A prospective, historical cohort study based on the Clalit Health Services (CHS) electronic medical records database, including all individuals age ≥ 21 years with a first diagnosis of NVAF between January 2010 to December 2016 and a minimal follow-up period of 1 year. Patients were divided into two groups based on their diabetes therapy regiment (insulin vs. oral antidiabetic medications).

Results

Overall study population included 12,231 patients with AF and DM, of them 3510 (28.7%) had an insulin-requiring diabetes. The median age was 72.4 years (IQR 65-80) in the insulin- treated group and 75.2 (IQR 68-83) in the orally treated group, with a slight majority of women in both groups, 51.6% and 53.5% respectively. Patients in the insulin group had significantly higher co-morbidity rates including hypertension (HTN) (93.6% vs. 91.2%; p &lt; 0.001), congestive heart failure (CHF) (38% vs. 22.2%%; p &lt; 0.001), previous cerebrovascular accident/ transient ischemic attack (CVA/TIA) (23.1% vs.14.5%;  p &lt; 0.001) and vascular diseases (62.1% vs. 46.5%; p &lt; 0.001). Moreover, patient on insulin therapy were significantly less treated with anticoagulation medications at baseline compered to patients not treated with insulin (38.9% vs. 46.6%; p &lt; 0.001). The incidence of stroke per 100 person-years was 2.62 in the insulin-treated group and 2.02 in the oral-treated group. Although, diabetes patients on insulin therapy had a significantly increased risk for stroke compared to patients not treated with insulin in the univariate analysis (HR: 1.34; 95%CI: 1.13- 1.60), this association was not found to be significant after adjusting for confounding variables (HR: 1.17; 95%CI: 0.96- 1.41). The rate of mortality per 100 person-years was 19 in the insulin-treated group and 12.6 in the oral-treated group. The risk for overall mortality was significantly higher in the insulin-treated group compared to the non-insulin group (HR: 1.38; 95%CI: 1.29- 1.48), as found in the multivariate Cox model, adjusted for age, gender, Creatinine clearance, HTN, CHF , CVA/TIA, vascular diseases, duration of diabetes and use of anticoagulation therapy.

Conclusion

In this cohort of patients with newly diagnosed NVAF and DM, patients on insulin are at increased risk of all cause mortality and a have a trend of increased risk of stroke after accounting for other recognized risk factors for stroke and mortality in this population.

Identifying a retrospective cohort of adolescents with chronic health conditions from a paediatric hospital prior to transfer to adult care: the Calgary Transition Cohort

PURPOSE

The Calgary Transition Cohort was created to examine health service utilisation by adolescents affected by chronic health conditions seen in a tertiary paediatric hospital in the province of Alberta, Canada. The cohort includes adolescents who received care before the implementation of a hospital-wide intervention to improve transitions to adult care.

PARTICIPANTS

Using hospital records, a stepwise methodology involving a series of algorithms based on adolescents' visit frequency to a hospital ambulatory chronic care clinic (CCC) was used to identify the cohort. A visit frequency of ≥4 visits in any 24-month window, during the ages of 12-17 years old, was used to identify eligible adolescents, as agreed on by key stakeholders and chronic disease clinical providers, and reflects the usual practice at the hospital for routine care of children with chronic disease.

FINDINGS TO DATE

Adolescents with ≥4 visits to the same CCC in any 2-year period (n=1344) with a median of 8.7 years of follow-up data collected (range 1.4-9.1). The median age at study entry was 14 years (range 12-17) and 22 years (range 14-24) at study exit. The cohort was linked (97% successful match proportion) to their population-level health records that allowed for examination of occurrence of chronic disease codes in health utilisation encounters (ie, physician claims, hospital admissions and emergency room visits). At least one encounter with a chronic disease code (International Classification of Diseases, 9th/10th Revisions) was observed during the entire study window in 87.9% of the cohort.

FUTURE PLANS

The Calgary Transition Cohort will be used to address existing knowledge gaps about health service utilisation by adolescents, seen at a tertiary care hospital, affected by a broad group of chronic health conditions. These adolescents will require transition to adult-oriented care. Longitudinal analysis of health service use patterns over a 9-year window (2008-2016) will be conducted.

Incidence and variables associated with short and long-term mortality in patients with systemic lupus erythematosus and sepsis admitted in intensive care units

Background Infections are common among patients with systemic lupus erythematosus (SLE), and are associated with increased morbidity and mortality. Objectives To determine whether SLE is an independent risk factor for short- and long-term mortality in patients admitted to an intensive care unit (ICU) with sepsis, and to identify the characteristics of SLE patients admitted to an ICU with sepsis. Methods A retrospective age- and sex-matched cohort study, based on data of the SEPSIS-ISR (Sepsis Israel) Registry, an ongoing study that collects data on all patients admitted with sepsis to the ICUs. The primary outcome was to determine whether SLE is an independent risk factor for 30-day and 3-year mortality. Secondary outcomes were 30-day and 3-year survival rates, and the identification of variables associated with mortality within the group of patients with SLE. Results In total, 29 SLE and 87 non-SLE patients (median age 55 years; 79.3% females) were included. The primary sites of infection as well as pathogen distributions were similar between the two groups. The most common infections among the SLE and non-SLE patients were pneumonia (48.3 vs. 31%, p = 0.09), urinary tract infection (20.7 vs. 14.9%, p = 0.56) and peritonitis (13.8 vs. 16.1%, p = 0.77). Severe sepsis and septic shock were diagnosed in 79.3 versus 80.5% ( p = 0.89) and 55.2 versus 33.3% ( p = 0.04) of the SLE and non-SLE patients, respectively. The 30-day and 3-year survival rates did not differ between SLE and non-SLE patients, and were 69 versus 67.8% ( p = 0.79) and 41.4 versus 47.1% ( p = 0.69), respectively. In multivariate Cox regression analysis, age (hazard ratio (HR) = 1.02; 95% confidence interval (CI) 1.00-1.05) and cardiovascular involvement during sepsis (HR = 3.32; 95% CI 1.4-7.86) were significant independent risk factors for 30-day mortality. Multiorgan dysfunction during sepsis admission was associated with increased 3-year mortality (HR = 1.37; 95% CI 1.07-1.75). Conclusions SLE is not an independent risk factor for 30-day or 3-year mortality following ICU admission with sepsis. Increased late mortality was associated with congestive heart failure within the SLE patients alone. None of the SLE-related variables were statistically different between the living and deceased SLE patients.

Using Administrative Health Data to Define a Cohort of Youth Affected by Chronic Health Conditions: Preparing for Cross-Sectoral Data Linkage

IntroductionIn Alberta, 2,400 youth with chronic needs transition to adulthood every year, and many are not prepared for this change. Transferring youth from pediatric to adult-oriented care is poorly managed. To improve this process, we need to know how youth patients use health services during this period. Objectives and ApproachWe used the Alberta Health Services Corporate Data Repository (CDR-9), which collects records of ambulatory visits, to define a cohort of patients with chronic disease using pediatric tertiary care; data is available from 2008 to 2016. Personal health numbers allowed for deterministic data linkage to CDR-9, registry data (e.g., death dates, moves out of province), and area deprivation indices. Eligible patients were: (a) between ages 12-15 years in 2008 (for ≥2 years observation in adulthood, after age 18), (b) involved with a Chronic Care Clinic (CCC) at Alberta Children’s Hospital, and (c) had repeated CCC visits with ≥3 months between visits. ResultsWe identified 26 Chronic Care Clinics (CCC) at Alberta Children’s Hospital (Calgary, Alberta), with stakeholder input. Using CDR-9, a total of 10,111 patients at the hospital were identified who were 12 to 15 years old at the start of the study window (in 2008), and who visited a CCC before age 18. Less than 1% (n=418) were excluded due to moving out of province or having an invalid personal heath number. Final sample sizes were captured across 3 algorithms (A1, A2, A3), based on frequency of CCC visits within a 2-year period: (i) A1: ≥2 CCC visits (N=4123); (ii) A2: ≥3 CCC visits (N=2242); (iii) A3: ≥4 CCC visits (N=1344). Conclusion/ImplicationsOur identified cohort of youth affected by chronic conditions is the first of its kind in Alberta, and can answer important questions about patterns of service utilization in other sectors of care. Our next step is to link the cohort to population-level datasets (e.g., physician claims, NACRS, CIHI-DAD).

Is the Current BST ePortfolio fulfilling its Role in the Training of Clinical Medicine SHOs?

While the objective recording of clinical competencies in an electronic portfolio (ePortfolio) has become a key aspect of basic specialist training (BST), it continues to divide opinion. We surveyed medical trainees and their supervisors in the Dublin region examining their views of the ePortfolio and workplace-based assessments (WPBAs). Responses were received from 27 of 149 (18.1%) SHOs and 24 of 307 (7.9%) consultants. Our results highlight significant dissatisfaction amongst trainees with 20 (74.1%) stating that the ePortfolio is not an effective educational tool. Consultants had more mixed views. While 16 (66.7%) reported that feedback sessions were useful for trainee development, only 4 (16.7%) found the ePortfolio to be useful in highlighting trainees' strengths and weaknesses. Although other studies have emphasised its educational potential, our results suggest that practical barriers, such as time constraints and a lack of training, lead to poor engagement and a negative view of the ePortfolio.

Electrocardiographic diagnosis of left atrial enlargement. Role of the P terminal force in lead V1

The ability of the electrocardiographic criterion, P terminal force in lead V1 (PTF-V1), to diagnosis left atrial enlargement (LAE) is evaluated in a group of 317 men. A left atrial index greater than 2.2 cm/m2, determined by echocardiography, is used as the standard for LAE. The value for this criterion of 0.04 mm-sec performs best, although there is no significant difference in percent correct diagnosis for values of PTF-V1 ranging from 0.03 to 0.09 mm-sec.

Myocardial infarction in sickle cell anemia

A review of the electrocardiograms (ECG) of 108 patients with sickle cell anemia found only 3 with patterns consistent with myocardial infarction. Two of the 3 patients with ECG infarct patterns had postmortem examination confirmation of the infarction. These two patients had no significant coronary atherosclerosis nor did the other six autopsied patients in the present series. Literature reports of postmortem examinations on patients with sickle cell anemia confirm the scarcity of coronary atherosclerosis and myocardial infarction in these patients. Forty of the 108 ECGs showed signs of left ventricular hypertrophy and 20 others had nondiagnostic ST and T wave abnormalities. Nine showed first degree AV block and four right bundle branch block.

Positive mono-spot test in histiocytic medullary reticulosis

A case of rapidly fatal histiocytic medullary reticulosis in which two positive mono-spot tests were found is presented. In addition, there was a low liter antibody to EB virus. The patient died with a bleeding diathesis terminally. Postmortem examinations confirmed the diagnosis of histiocytic medullary reticulosis.