A61 FOCUSING ON THE FUTURE: REDUCING BARRIERS AND IMPROVING ACCESS TO IBD SPECIALTY CARE ACROSS CANADA

Background

Canada has the highest global age-adjusted incidence and prevalence rates of Inflammatory Bowel Disease (IBD). Resulting from compounding prevalence and limited resources, timely access to specialty care is a challenge faced by patients and healthcare providers. Despite this issue, there has been no published research elucidating the patient perspective using qualitative approaches to compare and contrast the patient experience across Canada.

Aims

To elicit a qualitative data stream to better understand phenomena related to access to healthcare for Canadians living with IBD from a patient-centered perspective.

Methods

Patients diagnosed with IBD (≥18 years of age) were recruited from gastroenterology clinics and communities through IBD specialists and Crohn’s & Colitis Canada. To ensure geographic diversity and representation, patients were recruited from urban and rural regions. In order to acquire multiple access perspectives, patients were invited to bring a family member who was involved in their care to the focus groups. Co-facilitated by a researcher and a patient research partner, the focus groups were held in Nova Scotia, New Brunswick, Quebec, Ontario, Manitoba, Saskatchewan, and British Columbia. All focus groups were audio recorded, transcribed, and coded for themes. Themes were distilled through qualitative thematic analysis using Atlas.ti software to ascertain congruence or discordance of IBD specialty care access experiences.

Results

A total of 63 participants were recruited in fourteen focus groups across seven provinces. The majority of participants were female (41/63, 65%) and from urban/suburban regions (34/63, 54%). The mean age of participants was 48 years (SD=16 years, range=16 to 77 years). Preliminary analyses illustrated three patient-identified access barrier themes: 1) Lack of multidisciplinary care (psycho-social and nutrition support), 2) Diagnostic delay, and 3) Inability to effectively receive and provide communication with healthcare providers. In response, four solutions were proposed: 1) Integration of holistic care into the clinical practice, 2) Readily accessible psycho-social and nutritional support, 3) Increased patient advocacy, and 4) Continuity and liaison through provision of a healthcare navigator resource.

Conclusions

The complexity of specialty care access for IBD patients in Canada cannot be underestimated. It is vital to possess a robust understanding of healthcare system structures, processes, and the significant impact these factors have on patients and the care received. Through the use of patient-centered exploration of barriers and facilitators, access to IBD specialty care in Canada can be better understood and improved on both a provincial and national scale.

Funding Agencies

CIHRNova Scotia Health Authority Research Fund

A67 EVALUATING ACCESS TO IBD CARE ACROSS CANADA: PROCEEDINGS FROM THE 2017 IBD ACCESS SUBMMIT

Background

Inflammatory Bowel Disease (IBD) is a chronic, immune-mediated disease, with Canada demonstrating the highest incidence and prevalence rates in the world. Patients with IBD often require lifelong treatment and, therefore, lifelong interactions with the healthcare system. Access to care can have a direct impact on patient health-related outcomes. Although acknowledged as a problem, the complexity of accessing IBD specialty care in Canada has not been reviewed. This lack of understanding presents a barrier in evaluating and implementing changes in IBD specialty care.

Aims

To identify key barriers and facilitators for and to develop a national working strategy to address limitations in access to IBD specialty care by exploring the perceptions and experiences of key stakeholders (pediatric and adult gastroenterologists, IBD patients, researchers, and policy makers).

Methods

The IBD Summit was held in Toronto, Ontario in November 2017, sponsored by SPOR-CIHR catalyst funding and in partnership with Crohn’s & Colitis Canada. Perceptions and experiences of key stakeholders were gathered during two audio-recorded stakeholder dialogues held during the Summit. The audio recordings were transcribed and coded to compare and contrast between key stakeholders to determine potential differences in access to IBD care. Five final themes are highlighted in this report.

Results

A total of 21 key stakeholders attended, including pediatric and adult gastroenterologists, patients, researchers, and policy makers. Five key themes of importance relating to access to IBD care arose from The IBD Summit:(1) Integrated Models of Care, (2) IT Enhanced Care, (3) Health System Process, (4) Communication and Advocacy, and (5) Community Supports. The IBD Summit identified similar perceptions and experiences, highlighting common barriers and facilitators that transcend provincial borders. Shared perceptions included a need for common medical records and overall improved IT-enhanced care for managing IBD; improved centralized triage systems; increased comprehensive care support for patients and primary care physicians; and increased community supports for patients and providers.

Conclusions

Highlights from the IBD Summit present several clinically relevant and actionable suggestions for improved access to IBD speciality care across Canada. The suggestions provided by key stakeholders highlight the need for a system-level redesign in order to improve access to enhanced models of care. Improvements in access to IBD specialty care can only occur through partnerships between those working within the healthcare system and those within the community. Future research will involve pursuing deeper insight into the experience of patient and provider stakeholders as they navigate the healthcare system in order to access and provide care.

Funding Agencies

CIHRNova Scotia Health Authority Research Fund

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Internal Medicine Residents' Beliefs, Attitudes, and Experiences Relating to Palliative Care: A Qualitative Study

BACKGROUND

Internal medicine residents are frequently called upon to provide palliative care to hospitalized patients, but report feeling unprepared to do so effectively. Curricular development to enhance residents' palliative care skills and competencies requires an understanding of current beliefs, attitudes and learning priorities.

METHODS

We conducted a qualitative study consisting of semi-structured interviews with ten internal medicine residents to explore their understanding of and experiences with palliative care.

RESULTS

All of the residents interviewed had a sound theoretical understanding of palliative care, but faced many challenges in being able to provide care in practice. The challenges described by residents were system-related, patient-related and provider-related. They identified several priority areas for further learning, and discussed ways in which their current education in palliative care could be enhanced.

CONCLUSIONS

Our findings provide important insights to guide curricular development for internal medicine trainees. The top five learning priorities in palliative care that residents identified in our study were: 1) knowing how and when to initiate a palliative approach, 2) improving communication skills, 3) improving symptom management skills, 4) identifying available resources, and 5) understanding the importance of palliative care. Residents felt that their education in palliative care could be improved by having a mandatory rotation in palliative care, more frequent didactic teaching sessions, more case-based teaching from palliative care providers, opportunities to be directly observed, and increased support from palliative care providers after-hours.

Swine flu: a new emerging disease

Swine flu is an important zoonotic disease that has been recognized as an important global health problem by any one of several types of swine influenza virus or swine-origin influenza virus. Due to its increasing incidence in many countries of the world and occurrence of several large outbreaks in present year, it is a burning issue nowadays. It is thought to be a mutation--more specifically, a reassortment of four known strains of influenza A virus subtype H1N1. Swine influenza virus is common throughout pig populations worldwide. Transmission of the virus from pigs to humans is not common and does not always lead to human influenza, often resulting only in the production of antibodies in the blood. Due to variability of clinical features and limited availability of laboratory facilities, the disease remains largely under-reported. Early and specific diagnosis is important to ensure a favourable outcome. In this paper we attempted to explore history, classification, transmission, sign symptoms, diagnosis and prevention of swine flu as a critical review to provide some new upgrade regarding this devastating pandemic disease.

Prognostic factors of survival in patients with non-resectable hepatocellular carcinoma: hepatitis C versus miscellaneous etiology

OBJECTIVE

To identify prognostic determinants of survival in patients with non-resectable hepatocellular carcinoma (HCC), determine the effect of transarterial chemoembolization (TACE) on prognosis, compare hepatitis C related HCC with mixed etiologies and evaluate the prognostic value of different staging systems.

METHODS

This cohort study included 129 patients (male = 97, 75%) with non-resectable HCC. Data was collected from 2002 until August 2006. A series of demographic, clinical and biochemical and radiological data were collected. Cases were staged according to the Child's, Okuda, Cancer Liver Italian program (CLIP), Barcelona Clinic Liver Cancer (BCLC) and Chinese University Prognostic Index (CUPI) systems. Survival analysis was performed. Any effect of TACE on prognosis was recorded.

RESULTS

Median age of patients was 52 years (range 18-82). Median follow-up 11 months (range 2-36). At the time of analysis, 102 patients had died (79%). Etiology of HCC was hepatitis C virus (HCV) in 66 (51.2%), hepatitis B virus (HBV) 31 (24%), HBV + HCV 10 (7.8%), HBV + delta hepatitis 02 (1.6), and non-B non-C 20 (15.4%). Forty-one patients (31%) were offered TACE. Univariate analysis for HCV related HCC showed that age > 52 years (p<0.05), bilirubin >1.17 mg/dl (p<0.01), INR > 1.3 (p<0.01), alpha fetoprotein > 400 ng/ml (p<0.05), splenomegaly (p<0.01), ascites (p<0.001), portal vein thrombosis (p<0.01), splenic varices (p<0.01), and TACE not offered (p<0.01) were the prognostic factors while in miscellaneous etiology female sex (p<0.05), haemoglobin < 11.0 gm/dl (p<0.01), alkaline Phosphatase > 169 lU/L (p<0.05), ascites (p<0.05) and multifocality (p<0.05) were adversely effecting prognosis. Overall independent determinants were Hepatitis C etiology, female sex and multifocality of tumour (Hazard ratios 3.0, 3.0 and 1.9 respectively). Mean survival was 17.2 vs. 12.8 months for patients offered vs. not offered TACE respectively (p value = 0.015). Okuda, CLIP, BCLC, CUPI and Child's staging systems retained their performance as judged by chi square values in regression analysis. Discriminatory ability for death evaluated by receiver operating characteristic curve was better for Okuda system in the first year.

CONCLUSION

Hepatitis C as the etiology of HCC, female sex and multi-focality are associated with poor prognosis. HCV related HCC may differ in prognostic factors from non-HCV HCC. Simple staging system by Okuda predicts prognosis effectively in non-resectable.

Increased expression of aquaporin-3 in the epidermis of DHCR24 knockout mice

BACKGROUND

The DHCR24 (3beta-hydroxysterol-Delta24 reductase) gene encodes an enzyme catalysing conversion of desmosterol to cholesterol. Desmosterolosis is an autosomal recessive disease due to mutation in the DHCR24 gene, with low cholesterol and high desmosterol levels. To understand the pathophysiology of this disease, we utilized DHCR24 knockout mice and reported that DHCR24-/- mice die soon after birth. Their skin was less wrinkled, shiny, and revealed features of lethal restrictive dermopathy associated with severe defects in epidermal maturation and barrier function.

OBJECTIVES

Markedly increased transepidermal water loss in DHCR24-/- mice led us to examine the role of aquaporin-3 (AQP3), because this is the only water/glycerol transporting channel protein expressed in the epidermis.

METHODS

Expression of AQP3 was studied by Western blot analysis and immunohistochemistry in the epidermis of DHCR24-/- and wild-type newborn mice. Glycerol uptake was determined in the isolated keratinocytes and glycerol content in the epidermis was analysed by an enzymatic method.

RESULTS

In control mice, AQP3 was expressed only in cells of the stratum basale, indicating its expression in immature keratinocytes. In DHCR24-/- mice, AQP3 was expressed throughout the epidermis and colocalized with the immature keratinocytes (keratin 14-positive cells). The increased AQP3 expression in the epidermis of DHCR24-/- mice was mirrored by a significantly higher glycerol uptake and glycerol content. This was associated with an increase in epidermal water content of DHCR24-/- mice.

CONCLUSIONS

This is the first demonstration that elevated AQP3 results in the retention of epidermal water, causing the taut, wrinkle-free skin phenotype of the DHCR24-/- mice.

Progressive familial intrahepatic cholestasis

Progressive familial intrahepatic cholestasis (PFIC) is an important cause of cholestatic liver disease and biliary cirrhosis in pediatric population. Three cases of PFIC are described that were diagnosed on the basis of family history, pruritus, cirrhosis and / or paucity of interlobular bile ducts on liver biopsy and presence of extrahepatic biliary tree on imaging. These patients were initially labeled as suffering from extra-hepatic biliary atresia and neonatal hepatitis. PFIC-1 and 2 could not be differentiated on histological grounds, since these patients presented late and process of fibrosis was advanced.

Biliary atresia with situs inversus: an experience shared

Biliary Atresia (BA) is a well-known entity and can present with multiple congenital anomalies. BA is one of the most common conditions in which pediatric liver transplant is performed. Identification of Biliary atresia with situs inversus (SI) has not been documented in Pakistan. We report two such cases. First was an eighty-day-old baby boy, icteric from day of birth. On further evaluation had dextrocardia, SI, gross hydronephrosis (HN) of left kidney and stasis at pelvi ureteric junction (PUJ). Liver biopsy showed biliary cirrhosis secondary to extra hepatic biliary atresia (EHBA). The second baby presented at two months of age. Ultrasound abdomen and hepatobiliary scintigraphy confirmed liver in left hypochondrium (SI) and findings suggestive of BA. Echocardiography confirmed SI with mesocardia. In this paper we have described the association of BA with SI in two patients presenting at the pediatric Gastroenterology, hepatology and nutrition unit.

A review of the role of plastics in energy recovery

This report reviews the major scientific investigations that have been reported world wide over the last ten years on the effect of plastics on the process and emission performance of energy from waste (EFW) facilities. Concentrations of contaminants in air emissions and other process residues measured during tests with added plastics are compared with concentrations during normal operations and with the stringent emission limits stipulated in municipal waste combustor standards and guidelines in Canada, the United States and the European Union. The emission limits in these standards and guidelines are based on the use of the best technology available (Maximum Achievable Control Technology (MACT) standards in North America and Best Available Technology (BAT) standards in Europe) and are amongst the most stringent in the world.

Upper airway obstruction with hypoxaemia and sleep disruption in Down syndrome

Six of 12 children with Down syndrome (DS) tested by means of long-term tape-recordings of oxygen saturation, breathing movements and expired CO2 were found to have previously undetected and severe upper airway obstruction during sleep. In five cases the obstruction occurred in the pharynx and in the sixth it was due to bilateral choanal stenosis. When compared with age-matched controls, overnight tape-recordings showed episodes of abnormal arterial hypoxaemia and an abnormally elevated end-tidal CO2. Episodes of obstruction were most marked during sleep associated with a non-regular breathing pattern. Abnormal episodes of hypoxaemia were associated with continued breathing movements. Sometimes there was no airflow (complete obstruction); at other times airflow continued normally or was reduced in amplitude (partial obstruction). During episodes of partial or complete airway obstruction the inspiratory waveform showed a characteristic shape. These results show sleep-related upper airway obstruction to be an often undetected complication of DS and all necessary measures should be taken to overcome the obstruction when it reaches the stage of producing abnormal hypoxaemia. Choanal dilatation and tracheostomy were successful in treating two of the children. Tonsillectomy and adenoidectomy were successful for one child, but only of marginal benefit for two others.