133 results on '"Zarnke A"'
Search Results
2. Sarcoidosis in Northern Ontario hard‐rock miners: A case series
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L. Christine Oliver, Paul Sampara, Donna Pearson, Janice Martell, and Andrew M. Zarnke
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Public Health, Environmental and Occupational Health - Published
- 2022
3. Barriers to Implementing Internist Recommendations for Perioperative Anticoagulation Management by Surgical Teams
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Kristin Flemons, Michael Bosch, Gabriel Marcil, Rahim Kachra, Kelly Zarnke, Leslie Skeith, and Shannon Marie Ruzycki
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General Medicine - Abstract
Introduction: In our center, half of all recommendations made by an internist about perioperative anticoagulation management are not followed by surgical team members. We aimed to understand the barriers to implementing perioperative anticoagulation recommendations.Methods: This was a prespecified analysis of interviews with surgical team members about individual- and systems-level drivers of missed perioperative anticoagulation recommendations. Interviews and analysis were guided by the Theoretical Domains Framework and the Consolidation Framework for Implementation Research.Results: We interviewed 16 surgical team members and 2 internists. Surgical team members intentionally did not follow recommendations about perioperative anticoagulation management when they felt that the bleeding risk outweighed the risk of thrombosis. This assessment of risk was driven by emotion and previous experience, even among participants who were familiar with perioperative literature.Conclusions: Development of study outcomes and guideline recommendations for perioperative anticoagulation management should include surgical team members in order to address the acceptability of these recom-mendations and increase adoption. RésuméIntroduction : Dans notre centre, la moitié des recommandations formulées par un interniste concernant la prise en charge de l’anticoagulation périopératoire ne sont pas suivies par les membres de l’équipe chirurgicale. Nous avons cherché à comprendre les obstacles à l’application des recommandations relatives à l’antico-agulation périopératoire. Méthodologie : Il s’agit d’une analyse prédéterminée d’entrevues menées auprès des membres de l’équipe chirurgicale au sujet des facteurs individuels et systémiques de l’insuccès des recommandations relatives à l’anticoagulation périopératoire. Les entrevues et l’analyse ont été guidées par le Theoretical Domains Framework et le Consolidation Framework for Implementation Research.Résultats : Nous avons interrogé 16 membres de l’équipe chirurgicale et 2 internistes. Intentionnellement, les membres de l’équipe chirurgicale ne suivent pas les recommandations concernant la prise en charge de l’anti-coagulation périopératoire lorsqu’ils estiment que le risque d’hémorragie l’emporte sur le risque de thrombose. Cette évaluation du risque est dictée par l’émotion et l’expérience antérieure, même parmi les participants qui connaissent bien la documentation du domaine périopératoire.Conclusions : La mise en application des résultats des études et des recommandations formulées par les lignes directrices pour la prise en charge de l’anticoagulation périopératoire devrait comprendre des membres de l’équipe chirurgicale pour aborder l’acceptabilité de ces recommandations et augmenter l’adoption.
- Published
- 2022
4. Additional file 1 of Prediction of major postoperative events after non-cardiac surgery for people with kidney failure: derivation and internal validation of risk models
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Harrison, Tyrone G., Hemmelgarn, Brenda R., James, Matthew T., Sawhney, Simon, Manns, Braden J., Tonelli, Marcello, Ruzycki, Shannon M, Zarnke, Kelly B., Wilson, Todd A., McCaughey, Deirdre, and Ronksley, Paul E.
- Abstract
Additional file 1: Supplementary Table 1. Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) Checklist for Prediction model development. Supplementary Table 2. Algorithms of ICD-9 and 10 codes used to define components of our composite outcome. Supplementary Table 3. Candidate Predictor definition along with source of data and ICD-9/10 algorithms if applicable. Supplementary Table 4. Surgical Categories by Canadian Classification of Health Intervention (CCI) codes. Supplementary Table 5. Estimated Sample Size Calculations using ‘pmsampsize’ in Stata software v17.0 and as suggested by Riley et al (2020). Supplementary Table 6. Top causes of death for those that died within 30 days of surgery, with associated ICD-10 codes. Supplementary Table 7. Performance of models evaluated in cohort with only first surgery per participant. Supplementary Table 8. Event and non-eventReclassification Tables between models, stratified by clinically important probability categories. Supplementary Figure 1. Decision Curve Analysis to estimate the net benefit of use of perioperative risk prediction models in ambulatory or inpatient elective surgery (sensitivity analysis).
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- 2023
- Full Text
- View/download PDF
5. Sequential measurement of the neurosensory retina in hypertensive disorders of pregnancy: a model of microvascular injury in hypertensive emergency
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R. Geoff Williams, Kelly B. Zarnke, Fiona Costello, Anshula Ambasta, Mingkai Peng, T. Lee-Ann Hawkins, and Robert J. Herman
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Retina ,Pregnancy ,Mean arterial pressure ,medicine.medical_specialty ,genetic structures ,business.industry ,Blood flow ,medicine.disease ,Microvascular injury ,eye diseases ,medicine.anatomical_structure ,Blood pressure ,Ophthalmology ,Internal Medicine ,Medicine ,Gestation ,Hypertensive emergency ,sense organs ,business - Abstract
Optical coherence tomography of the eye suggests the retina thins in normal pregnancy. Our objectives were to confirm and extend these observations to women with hypertensive disorders of pregnancy (HDP). Maternal demographics, clinical/laboratory findings and measurements of macular thickness were repeatedly collected at gestational ages P P = 0.983 HDP versus controls). This thinning response continued to delivery in all controls and in 7 women with HDP superimposed on chronic hypertension. Macular thinning was lost after 20 weeks gestation in the other 20 women with HDP. MAP at loss of macular thinning in women without prior hypertension (n = 12) was identical to MAP at enrollment. However, mean MAP subsequently rose 19 mmHg (15, 22) leading to de novo HDP in all 12 women. Loss of thinning leading to a rise in MAP was also observed in 8 of 15 women with HDP superimposed on chronic hypertension. We conclude the macula thins in most women in early pregnancy. Those who lose this early macular thinning response often develop blood pressure elevations leading to HDP.
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- 2021
6. Sarcoidosis
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L. Christine Oliver and Andrew M. Zarnke
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Pulmonary and Respiratory Medicine ,business.industry ,Job-exposure matrix ,Occupational disease ,Lymphocyte proliferation ,Human leukocyte antigen ,Disease ,Critical Care and Intensive Care Medicine ,medicine.disease ,Pathogenesis ,medicine.anatomical_structure ,Immunology ,medicine ,Sarcoidosis ,Cardiology and Cardiovascular Medicine ,business ,Sensitization - Abstract
Sarcoidosis is an important member of the family of granulomatous lung diseases. Since its recognition in the late 19th century, sarcoidosis has been thought of as a disease of unknown cause. Over the past 20 years, this paradigm has been shifting, more rapidly in the past 10 years. Epidemiologic studies, bolstered by case reports, have provided evidence of causal associations between occupational exposure to specific agents and sarcoidosis. Pathogenesis has been more clearly defined, including the role of gene-exposure interactions. The use of in vitro lymphocyte proliferation testing to detect sensitization to inorganic antigens is being examined in patients with sarcoidosis. These antigens include silica and certain metals. Results of studies to date show differences in immunoreactivity of occupationally exposed sarcoidosis cases compared with control cases, suggesting that lymphocyte proliferation testing may prove useful in diagnosing work-related disease. This review discusses recently published findings regarding associations between occupational exposure to silica and silicates, World Trade Center dust, and metals and risk for sarcoidosis, as well as advances in the development of diagnostic tools. Not all cases of sarcoidosis have an identified cause, but some do. Where the cause is occupational, its recognition is critical to enable effective treatment through removal of the affected worker from exposure and to inform intervention aimed at primary prevention.
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- 2021
7. Description of a Multi-faceted COVID-19 Pandemic Physician Workforce Plan at a Multi-site Academic Health System
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Jane Lemaire, Adam Papini, Shannon M. Ruzycki, Kelly B. Zarnke, Parabhdeep Lail, Stephanie Smith, Paul MacMullan, Kim Cheema, Kerri A. Johannson, Paul S. Gibson, Wendy Desjardins-Kallar, Irene W. Y. Ma, Meghan E O Vlasschaert, Angela Hunter, Meghan J. Elliott, Jeffrey P Schaefer, Gabriel Fabreau, Brendan Kerr, Nimira Alimohamed, Rahim Kachra, Evan P. Minty, Sachin R. Pendharkar, Caley B. Shukalek, Aleem Bharwani, and Thomas Allen
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Canada ,medicine.medical_specialty ,Plan (drawing) ,030501 epidemiology ,health workforce ,03 medical and health sciences ,0302 clinical medicine ,Academic department ,Physicians ,Acute care ,Pandemic ,Health care ,Internal Medicine ,Humans ,Medicine ,030212 general & internal medicine ,Pandemics ,Personal protective equipment ,Original Research ,SARS-CoV-2 ,business.industry ,Public health ,COVID-19 ,medicine.disease ,General partnership ,disease outbreaks ,Workforce ,delivery of healthcare ,Medical emergency ,0305 other medical science ,business - Abstract
Background The evolving COVID-19 pandemic has and continues to present a threat to health system capacity. Rapidly expanding an existing acute care physician workforce is critical to pandemic response planning in large urban academic health systems. Intervention The Medical Emergency-Pandemic Operations Command (MEOC)—a multi-specialty team of physicians, operational leaders, and support staff within an academic Department of Medicine in Calgary, Canada—partnered with its provincial health system to rapidly develop a comprehensive, scalable pandemic physician workforce plan for non-ventilated inpatients with COVID-19 across multiple hospitals. The MEOC Pandemic Plan comprised seven components, each with unique structure and processes. Methods In this manuscript, we describe MEOC’s Pandemic Plan that was designed and implemented from March to May 2020 and re-escalated in October 2020. We report on the plan’s structure and process, early implementation outcomes, and unforeseen challenges. Data sources included MEOC documents, health system, public health, and physician engagement implementation data. Key Results From March 5 to October 26, 2020, 427 patients were admitted to COVID-19 units in Calgary hospitals. In the initial implementation period (March–May 2020), MEOC communications reached over 2500 physicians, leading to 1446 physicians volunteering to provide care on COVID-19 units. Of these, 234 physicians signed up for hospital shifts, and 227 physicians received in-person personal protective equipment simulation training. Ninety-three physicians were deployed on COVID-19 units at four large acute care hospitals. The resurgence of cases in September 2020 has prompted re-escalation including re-activation of COVID-19 units. Conclusions MEOC leveraged an academic health system partnership to rapidly design, implement, and refine a comprehensive, scalable COVID-19 acute care physician workforce plan whose components are readily applicable across jurisdictions or healthcare crises. This description may guide other institutions responding to COVID-19 and future health emergencies.
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- 2021
8. Perioperative management for people with kidney failure receiving dialysis: A scoping review
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Tyrone G. Harrison, Brenda R. Hemmelgarn, Janine F. Farragher, Connor O'Rielly, Maoliosa Donald, Matthew T. James, Deirdre McCaughey, Shannon M. Ruzycki, Kelly B. Zarnke, and Paul E. Ronksley
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Nephrology - Abstract
People with kidney failure receiving dialysis (CKD-G5D) are more likely to undergo surgery and experience poorer postoperative outcomes than those without kidney failure. In this scoping review, we aimed to systematically identify and summarize perioperative strategies, protocols, pathways, and interventions that have been studied or implemented for people with CKD-G5D.We searched MEDLINE, EMBASE, CINAHL Plus, Cochrane Database of Systematic Reviews, and Cochrane Controlled Trials registry (inception to February 2020), in addition to an extensive grey literature search, for sources that reported on a perioperative strategy to guide management for people with CKD-G5D. We summarized the overall study characteristics and perioperative management strategies and identified evidence gaps based on surgery type and perioperative domain. Publication trends over time were assessed, stratified by surgery type and study design.We included 183 studies; the most common study design was a randomized controlled trial (27%), with 67% of publications focused on either kidney transplantation or dialysis vascular access. Transplant-related studies often focused on fluid and volume management strategies and risk stratification, whereas dialysis vascular access studies focused most often on imaging. The number of publications increased over time, across all surgery types, though driven by non-randomized study designs.Despite many current gaps in perioperative research for patients with CKD-G5D, evidence generation supporting perioperative management is increasing, with recent growth driven primarily by non-randomized studies. Our review may inform organization of evidence-based strategies into perioperative care pathways where evidence is available while also highlighting gaps that future perioperative research can address.
- Published
- 2022
9. Hypertension Canada’s 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children
- Author
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Robert A. Hegele, Peter Bolli, Milan Gupta, Steven A. Grover, Swapnil Hiremath, Andrew C. Don-Wauchope, Tabassum Firoz, Evelyne Rey, Simon W. Rabkin, Mike Sharma, Jonathan Y. Gabor, Fady Hannah-Shmouni, Charlotte Jones, Richard E. Gilbert, Janusz Kaczorowski, Vincent Woo, Janis M. Dionne, Alexander A. Leung, Sonia Butalia, Peter Selby, Tavis S. Campbell, Praveena Sivapalan, Ernesto L. Schiffrin, Andrew L. Pipe, André Michaud, Kevin C. Harris, Ruth Sapir-Pichhadze, Michael Roerecke, S. Brian Penner, Donna McLean, Luc Trudeau, Stella S. Daskalopoulou, Alexander G. Logan, Patrice Lindsay, Kim L. Lavoie, Meranda Nakhla, Anne Fournier, Alain Milot, Ellen Burgess, Gordon W. Moe, Jeffrey E. Alfonsi, Birinder K. Mangat, Alan Bell, Kelly B. Zarnke, Simon L. Bacon, Steven E. Gryn, Maxime Lamarre-Cliche, Ally P.H. Prebtani, Philip A. McFarlane, JoAnne Arcand, Nadia A. Khan, Ross T. Tsuyuki, Karen Tran, Michael D. Hill, Marcel Ruzicka, Jean Grégoire, François Audibert, George Honos, Michel Vallée, Kerry McBrien, Jesse Bittman, Laura A. Magee, Sheldon W. Tobe, Sandra M. Dumanski, Jonathan G. Howlett, Anne-Marie Côté, Ross D. Feldman, Geneviève Benoit, Doreen M. Rabi, Richard Lewanczuk, Kara Nerenberg, Laura M. Kuyper, Cedric Edwards, Lyne Cloutier, Raymond R. Townsend, Lawrence A. Leiter, George K. Dresser, Sofia B. Ahmed, Robert J. Herman, Alexandre Y Poppe, Ashkan Shoamanesh, and Gregory L. Hundemer
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Adult ,Canada ,medicine.medical_specialty ,Telemedicine ,Pregnancy Complications, Cardiovascular ,Drug Resistance ,Pharmacy ,Health Promotion ,030204 cardiovascular system & hematology ,Risk Assessment ,Preconception Care ,Medication Adherence ,Diabetes Complications ,03 medical and health sciences ,0302 clinical medicine ,Pregnancy ,Health care ,medicine ,Humans ,030212 general & internal medicine ,Renal Insufficiency, Chronic ,Child ,Antihypertensive Agents ,Heart Failure ,business.industry ,Guideline ,Blood Pressure Monitoring, Ambulatory ,Stroke ,Masked Hypertension ,Health promotion ,Cardiovascular Diseases ,Family medicine ,Hypertension ,Female ,Hypertrophy, Left Ventricular ,Cardiology and Cardiovascular Medicine ,business ,Risk assessment ,Algorithms - Abstract
Hypertension Canada's 2020 guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children provide comprehensive, evidence-based guidance for health care professionals and patients. Hypertension Canada develops the guidelines using rigourous methodology, carefully mitigating the risk of bias in our process. All draft recommendations undergo critical review by expert methodologists without conflict to ensure quality. Our guideline panel is diverse, including multiple health professional groups (nurses, pharmacy, academics, and physicians), and worked in concert with experts in primary care and implementation to ensure optimal usability. The 2020 guidelines include new guidance on the management of resistant hypertension and the management of hypertension in women planning pregnancy.
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- 2020
10. Bone aluminum measured in miners exposed to McIntyre powder
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Bickley, L. M., Martell, J., Cowan, D., Wilken, D., Yan, W., McNeill, F. E., Zarnke, A., Hedges, K., and Chettle, D. R.
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Cross-Sectional Studies ,Occupational Exposure ,Public Health, Environmental and Occupational Health ,Humans ,Pilot Projects ,Miners ,Middle Aged ,Powders ,Aged ,Aluminum - Abstract
A small pilot study was conducted to test whether the technique of in vivo neutron activation analysis could measure bone aluminum levels in 15 miners who had been exposed to McIntyre Powder over 40 years prior. All miners were over 60 years of age, had worked in mines that used McIntyre Powder, and were sufficiently healthy to travel from northern to southern Ontario for the measurements. Individual aluminum levels were found to be significantly greater than zero with 95% confidence (p < 0.05) in 7 out of the 15 miners. The inverse variance weighted mean of the 15 participants was 21.77 ± 2.27µgAl/gCa. This was significantly higher (p < 0.001) than in a group of 15 non-occupationally exposed subjects of a comparable age from Southern Ontario who had been measured in a previous study. The inverse variance weighted mean bone aluminum content in the non-occupationally exposed group was 3.51 ± 0.85µgAl/gCa. Since the use of McIntyre Powder ceased in 1979, these subjects had not been exposed for more than 40 years. Calculations of potential levels at the cessation of exposure in the 1970s, using a biological half-life of aluminum in bone of 10 to 20 years predicted levels of bone aluminum comparable with studies performed in dialysis patients in the 1970s and 1980s. This pilot study has shown that the neutron activation analysis technique can determine differences in bone aluminum between McIntyre Powder exposed and non-exposed populations even though 40 years have passed since exposure ceased. The technique has potential application as a biomarker of exposure in cross-sectional studies of the health consequences of exposure to McIntyre Powder.
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- 2022
- Full Text
- View/download PDF
11. The Feasibility of a Transitional Care Unit for Patients Newly Started on In-Center Hemodialysis: A Research Letter
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Shabnam Hamidi, Sasha Zarnke, Kim Turcotte, and Samuel A. Silver
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Nephrology - Abstract
Background: Patients with end-stage kidney disease face high mortality and morbidity after dialysis initiation. Transitional care units (TCUs) are typically 4- to 8-week structured multidisciplinary programs targeted toward patients starting hemodialysis during this high-risk time in their care. The goals of such programs are to provide psychosocial support, provide dialysis modality education, and reduce risks of complications. Despite apparent benefits, the TCU model may be challenging to implement, and the effect on patient outcomes is unclear. Objective: To assess a newly created multidisciplinary TCUs’ feasibility for patients newly started on hemodialysis. Design: Before-and-after study. Setting: Kingston Health Sciences Centre hemodialysis unit in Ontario, Canada. Patients: We considered all adult patients (age 18+) who initiated in-center maintenance hemodialysis eligible for the TCU program, although patients on infection control precautions and evening shifts were not able to receive TCU care due to staffing limitations. Measurements: We defined feasibility as eligible patients completing the TCU program in a timely fashion without additional need for space, no signal of harm, and without explicit concerns from TCU staff or patients at weekly meetings. Key outcomes at 6 months included mortality, proportion hospitalized, dialysis modality, vascular access, initiation of transplant workup, and code status. Methods: The TCU care consisted of 1:1 nursing and education until predefined clinical stability and dialysis decisions were satisfied. We compared outcomes among the pre-TCU cohort who initiated hemodialysis between June 2017 and May 2018, and TCU patients who initiated dialysis between June 2018 and March 2019. We summarized outcomes descriptively, along with unadjusted odds ratios (ORs) and 95% confidence intervals (CIs). Results: We included 115 pre-TCU patients and 109 post-TCU patients, of whom 49/109 (45%) entered and completed the TCU. The most common reasons for not participating in the TCU included evening hemodialysis shifts (18/60, 30%) or contact precautions (18/60, 30%). The TCU patients completed the program in a median of 35 (25-47) days. We observed no differences in mortality (9% vs 8%; OR = 0.93, 95% CI = 0.28-3.13) or proportion hospitalized (38% vs 39%; OR = 1.02, 95% CI = 0.51-2.03) between the pre-TCU cohort and TCU patients. There was also no difference in use of home dialysis (16% vs 10%; OR = 1.67, 95% CI = 0.64-4.39), non-catheter access (32% vs 25%; OR = 1.44, 95% CI = 0.69-2.98), initiation of transplant workup (14% vs 12%; OR 1.67; 95% CI = 0.64-4.39), and choosing “do not resuscitate” (DNR) orders (22% vs 19%; OR = 1.22, 95% CI = 0.54-2.77). There was no negative patient or staff feedback on the program. Limitations: Small sample size and potential for selection bias given inability to provide TCU care for patients on infection control precautions or evening shifts. Conclusions: The TCU accommodated a large number of patients, who completed the program in a timely fashion. The TCU model was determined to be feasible at our center. There was no difference in outcomes due to the small sample size. Future work at our center is required to expand the number of TCU dialysis chairs to evening shifts and evaluate the TCU model in prospective, controlled studies.
- Published
- 2023
12. Association of Kidney Function With Major Postoperative Events After Non-Cardiac Ambulatory Surgeries: A Population-Based Cohort Study
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Brenda R. Hemmelgarn, Matthew T. James, Marcello Tonelli, Mary Brindle, Deirdre McCaughey, Tyrone G Harrison, Paul E. Ronksley, Shannon M. Ruzycki, James Wick, Braden J. Manns, and Kelly B. Zarnke
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education.field_of_study ,medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,Population ,Emergency department ,Odds ratio ,Perioperative ,medicine.disease ,Internal medicine ,Ambulatory ,medicine ,Surgery ,education ,business ,Dialysis ,Cohort study ,Kidney disease - Abstract
OBJECTIVE To estimate the association between estimated glomerular filtration rate (eGFR) and acute myocardial infarction (AMI) or death after ambulatory non-cardiac surgery. SUMMARY BACKGROUND DATA People with chronic kidney disease (CKD) commonly undergo surgical procedures. While most are performed in an ambulatory setting, the risk of major perioperative outcomes after ambulatory surgery for people with CKD is unknown. METHODS In this retrospective population-based cohort study using administrative health data from Alberta, Canada, we included adults with measured preoperative kidney function undergoing ambulatory non-cardiac surgery between April 1 2005 and February 28 2017. Participants were categorized into six eGFR categories (in mL/min/1.73m2) of ≥ 60 (G1-2), 45-59 (G3a), 30-44 (G3b), 15-29 (G4), < 15 not receiving dialysis (G5ND), and those receiving chronic dialysis (G5D). The odds of AMI or death within 30 days of surgery were estimated using multivariable generalized estimating equation models. RESULTS We identified 543,160 procedures in 323,521 people with a median age of 66 years (IQR 56-76); 52% were female. Overall, 2,338 people (0.7%) died or had an AMI within 30 days of surgery. Compared with the G1-2 category, the adjusted odds ratio of death or AMI increased from 1.1 (95% Confidence interval [CI]: 1.0, 1.3) for G3a to 3.1 (2.6, 3.6) for G5D. Emergency Department and Urgent Care Center visits within 30 days were frequent (17%), though similar across eGFR categories. CONCLUSIONS Ambulatory surgery was associated with a low risk of major postoperative events. This risk was higher for people with CKD, which may inform their perioperative shared decision-making and management.
- Published
- 2021
13. Sequential measurement of the neurosensory retina in hypertensive disorders of pregnancy: a model of microvascular injury in hypertensive emergency
- Author
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Robert J, Herman, Anshula, Ambasta, R Geoff, Williams, Kelly B, Zarnke, Fiona E, Costello, Mingkai, Peng, and T Lee-Ann, Hawkins
- Abstract
Optical coherence tomography of the eye suggests the retina thins in normal pregnancy. Our objectives were to confirm and extend these observations to women with hypertensive disorders of pregnancy (HDP). Maternal demographics, clinical/laboratory findings and measurements of macular thickness were repeatedly collected at gestational ages20 weeks, 20-weeks to delivery, at delivery and postpartum. The primary outcome was the change in macular thickness from non-pregnant dimensions in women with incident HDP compared to non-hypertensive pregnant controls. Secondary outcomes were the relationship(s) between mean arterial pressure (MAP) and macular response. Data show macular thicknesses diminished at20 weeks gestation in each of 27 pregnancies ending in HDP (mean 3.94 µm; 95% CI 4.66, 3.21) and 11 controls (mean 3.92 µm; 5.05, 2.79; P 0.001 versus non-pregnant dimensions in both; P = 0.983 HDP versus controls). This thinning response continued to delivery in all controls and in 7 women with HDP superimposed on chronic hypertension. Macular thinning was lost after 20 weeks gestation in the other 20 women with HDP. MAP at loss of macular thinning in women without prior hypertension (n = 12) was identical to MAP at enrollment. However, mean MAP subsequently rose 19 mmHg (15, 22) leading to de novo HDP in all 12 women. Loss of thinning leading to a rise in MAP was also observed in 8 of 15 women with HDP superimposed on chronic hypertension. We conclude the macula thins in most women in early pregnancy. Those who lose this early macular thinning response often develop blood pressure elevations leading to HDP.
- Published
- 2021
14. Physical and chemical characterization of McIntyre Powder: An aluminum dust inhaled by miners to combat silicosis
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Jake Pirkkanen, Andrew M. Zarnke, Christopher Thome, Kevin Hedges, Pat E. Rasmussen, Konnor J Kennedy, Todd Irick, Marie-Odile David, Douglas R. Boreham, and Housam Eidi
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Ontario ,Materials science ,Inhalation ,Silicosis ,Metallurgy ,Public Health, Environmental and Occupational Health ,Aluminum dust ,Dust ,010501 environmental sciences ,medicine.disease ,030210 environmental & occupational health ,01 natural sciences ,03 medical and health sciences ,0302 clinical medicine ,Lung disease ,Occupational Exposure ,medicine ,Humans ,Nanoparticles ,Powders ,Lung ,Aluminum ,0105 earth and related environmental sciences - Abstract
McIntyre Powder (MP) is a finely ground aluminum powder that was used between 1943 and 1979 as a prophylaxis for silicosis. Silicosis is a chronic lung disease caused by the inhalation of crystalline silica dust and was prevalent in the Canadian mining industry during this time period. The McIntyre Research Foundation developed, patented, and produced the MP and distributed it to licensees in Canada, the United States, Mexico, Chile, Belgian Congo, and Western Australia. In the province of Ontario, Canada it is estimated that at least 27,500 miners between 1943 and 1979 were exposed to MP. The present study was undertaken to examine the chemical and physical characteristics of two variations of MP (light grey and black). Chemical analyses (using X-ray Fluorescence and Inductively Coupled Plasma approaches) indicate that the black MP contains significantly higher concentrations of aluminum and metal impurities than the light grey MP (p
- Published
- 2019
15. Recovery From Dialysis-Treated Acute Kidney Injury in Patients With Cirrhosis: A Population-Based Study
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Maya Djerboua, Sasha Zarnke, Samuel A. Silver, Jennifer A. Flemming, Susan Thanabalasingam, and Peter L Wang
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Adult ,Liver Cirrhosis ,Male ,medicine.medical_specialty ,Cirrhosis ,medicine.medical_treatment ,Population ,Liver transplantation ,Severity of Illness Index ,End Stage Liver Disease ,Liver disease ,Renal Dialysis ,Internal medicine ,Humans ,Medicine ,education ,Dialysis ,Retrospective Studies ,Ontario ,education.field_of_study ,business.industry ,Fatty liver ,Acute kidney injury ,Retrospective cohort study ,Acute Kidney Injury ,Middle Aged ,medicine.disease ,Nephrology ,Female ,business - Abstract
Rationale & Objective The decision to initiate kidney replacement therapy (KRT) for acute kidney injury (AKI) in cirrhosis remains controversial as it is unclear which patients will benefit. We sought to characterize factors associated with recovery from AKI requiring KRT in patients with cirrhosis to inform shared clinical decision-making. Study Design Population-based retrospective cohort study. Setting & Participants Adult patients from Ontario, Canada identified, using administrative data, to have cirrhosis at the time of admission to hospital with AKI (based on serum creatinine) requiring KRT (01/01/2009–12/31/2016) and followed until 12/31/2017. Exposures Demographics and comorbidities prior to admission. Outcomes Kidney recovery defined as the absence of KRT for at least 30 days. Analytical Approach The cumulative incidences of kidney recovery, death, and liver transplantation were calculated at 1, 3, 6, and 12 months and independent predictors of kidney recovery were evaluated using Fine and Gray competing risk regression models that generated subdistribution hazards ratios (sHR). Results Overall, 722 patients were included (median age 61 years [IQR 54-68]; MELD-Na 26 [IQR 22-34]; 66% male; 52% had viral hepatitis, 25% non-alcoholic fatty liver disease, 18% alcohol-associated liver disease). The cumulative incidences of kidney recovery at 1, 3, 6, and 12 months were 3%, 22%, 25%, and 26%, respectively. Higher MELD-Na score (sHR 0.72 per 5 units, 95%CI 0.65-0.80), acute-on-chronic liver failure (sHR 0.61, 95%CI 0.43-0.86), and sepsis (sHR 0.57, 95%CI 0.41-0.81) were associated with a lower hazard of kidney recovery while those on a liver transplant waitlist (sHR 3.10, 95% CI 1.96-4.88) and who were admitted to a teaching hospital (sHR 1.48, 95%CI 1.05-2.08) were more likely to experience kidney recovery. Limitations Observational design, AKI etiology not identified. Conclusions Kidney recovery from KRT occurred in only one-quarter of patients and was very unlikely after 3-months. These findings provide information regarding prognosis that may guide decisions regarding KRT initiation and continuation.
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- 2022
16. Rib Fracture Mortality: Are There Clues in the Core?
- Author
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Gaby A. Iskander, Alistair J. Chapman, Anna M. Levine, Luke T. Durling, Charles J. Gibson, Steffen Pounders, Elizabeth Steensma, Laura Krech, Matthew Lypka, Kathrine A. Kelly-Schuette, Anthony Prentice, Adam Orr, Allison Zarnke, and Emily Pardington
- Subjects
Male ,medicine.medical_specialty ,Core (anatomy) ,Sarcopenia ,Trauma patient ,Rib Fractures ,Adverse outcomes ,business.industry ,Trauma center ,Middle Aged ,Logistic regression ,medicine.disease ,Quartile ,Trauma Centers ,Internal medicine ,medicine ,Humans ,Surgery ,In patient ,Female ,business ,Psoas Muscles ,Retrospective Studies - Abstract
Background Sarcopenia is associated with increased morbidity and mortality in the trauma patient. The primary objective of this study was to determine the relationship of psoas cross sectional area with hospital mortality in patients with rib fractures over the age of 55 years. Materials and Methods We retrospectively reviewed 1223 patients presenting to a Level 1 Trauma Center between 1/1/2002 and 1/31/2019. Psoas cross sectional area was measured using a polygonal tracing tool. Patients were stratified into four quartiles based on sex-specific values. Results There was increased in-hospital mortality for patients with a lower psoas cross sectional area (10 %, 8%, 6%, and 4%, Q1-Q4 respectively; P=0.021). The logistic regression model determined for every increase in psoas cross sectional area by 1 cm2 the odds of in-hospital mortality decreased by 4%. Conclusions In-hospital mortality is multifactorial; however, psoas cross sectional area may provide a clue in predicting adverse outcomes after traumatic rib fractures.
- Published
- 2021
17. Sarcoidosis: An Occupational Disease?
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L Christine, Oliver and Andrew M, Zarnke
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Sarcoidosis ,Immunologic Tests ,ATS, American Thoracic Society ,Lymphocyte Activation ,PM, particulate matter ,Calcium Sulfate ,CBD, chronic beryllium disease ,RCS, respirable crystalline silica ,Ti, titanium ,Calcium Carbonate ,MELISA, Memory Lymphocyte ImmunoStimulation Assay ,JEM, job-exposure matrix ,Sarcoidosis, Pulmonary ,Occupational Exposure ,World Trade Center dust ,Humans ,genetics ,Diffuse Lung Disease: CHEST Reviews ,LPT, lymphocyte proliferation test ,WTC, World Trade Center ,HLA, human leukocyte antigen ,Silicates ,Emergency Responders ,lymphocyte proliferation test ,Al, aluminum ,SLGPD, sarcoidosis-like granulomatous pulmonary disease ,Silicon Dioxide ,Occupational Diseases ,Metals ,silica ,New York City ,September 11 Terrorist Attacks ,NYC, New York City - Abstract
Sarcoidosis is an important member of the family of granulomatous lung diseases. Since its recognition in the late 19th century, sarcoidosis has been thought of as a disease of unknown cause. Over the past 20 years, this paradigm has been shifting, more rapidly in the past 10 years. Epidemiologic studies, bolstered by case reports, have provided evidence of causal associations between occupational exposure to specific agents and sarcoidosis. Pathogenesis has been more clearly defined, including the role of gene-exposure interactions. The use of in vitro lymphocyte proliferation testing to detect sensitization to inorganic antigens is being examined in patients with sarcoidosis. These antigens include silica and certain metals. Results of studies to date show differences in immunoreactivity of occupationally exposed sarcoidosis cases compared with control cases, suggesting that lymphocyte proliferation testing may prove useful in diagnosing work-related disease. This review discusses recently published findings regarding associations between occupational exposure to silica and silicates, World Trade Center dust, and metals and risk for sarcoidosis, as well as advances in the development of diagnostic tools. Not all cases of sarcoidosis have an identified cause, but some do. Where the cause is occupational, its recognition is critical to enable effective treatment through removal of the affected worker from exposure and to inform intervention aimed at primary prevention.
- Published
- 2021
18. Additional file 1 of Mortality and cardiovascular events in adults with kidney failure after major non-cardiac surgery: a population-based cohort study
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Harrison, Tyrone G., Ronksley, Paul E., James, Matthew T., Ruzycki, Shannon M., Tonelli, Marcello, Manns, Braden J., Zarnke, Kelly B., McCaughey, Deirdre, Schneider, Prism, Wick, James, and Hemmelgarn, Brenda R.
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Data_FILES - Abstract
Additional file 1:.
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- 2021
- Full Text
- View/download PDF
19. Perioperative management for people with chronic kidney disease receiving dialysis undergoing major surgery: a protocol for a scoping review
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Connor M. O'Rielly, Paul E. Ronksley, Tyrone G. Harrison, Matthew T. James, Janine F. Farragher, Shannon M. Ruzycki, Kelly B. Zarnke, Brenda R. Hemmelgarn, Deirdre McCaughey, and Maoliosa Donald
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Adult ,medicine.medical_specialty ,medicine.medical_treatment ,Population ,MEDLINE ,Psychological intervention ,CINAHL ,end stage renal failure ,Renal Dialysis ,medicine ,Humans ,adult surgery ,Renal Insufficiency, Chronic ,education ,Dialysis ,education.field_of_study ,business.industry ,General Medicine ,Perioperative ,adult nephrology ,medicine.disease ,Kidney Transplantation ,Surgery ,Review Literature as Topic ,Systematic review ,Research Design ,dialysis ,Medicine ,Health Services Research ,business ,Kidney disease ,Systematic Reviews as Topic - Abstract
IntroductionPeople with chronic kidney disease receiving dialysis (CKD G5D) have an increased risk of poor postoperative outcomes and a high incidence of major surgery. Despite the high burden of these combined risks, there is a paucity of evidence to support tailored perioperative strategies to manage this population. A comprehensive evidence synthesis would inform the management of these patients in the perioperative period and identify knowledge gaps. We describe a protocol for a scoping review of the literature to identify existing perioperative strategies, protocols, pathways and interventions for people with CKD G5D undergoing major surgery.Methods and analysisWe will conduct a scoping review in accordance with the Joanna Briggs Institute methodology and report per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. In February 2020, we will complete our search of MEDLINE, EMBASE, CINAHL Plus, Cochrane Database of Systematic Reviews, and Cochrane Controlled Trials Registry for published literature from inception to present. All study types are eligible for inclusion, without language restriction. Studies reporting a perioperative intervention in adult patients with CKD G5D are eligible for inclusion. Studies in prevalent kidney transplant patients or patients with acute kidney injury, and studies that report on surgical approaches without consideration of perioperative management strategies, will be excluded. Reviewers will independently assess abstracts for all identified studies in duplicate, and again at the full-text stage. Following published literature searches, a search of the grey literature will be developed. We will extract and narratively report study, participant and intervention details. This will include a summary table outlining the strategies employed, organised into post hoc developed perioperative domains.Ethics and disseminationEthical considerations do not apply to this scoping review. Findings will be disseminated through relevant conference presentations and publications.
- Published
- 2020
20. Estimated GFR and Incidence of Major Surgery: A Population-Based Cohort Study
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Brenda R. Hemmelgarn, Matthew T. James, Deirdre McCaughey, Victoria S. Owen, Braden J. Manns, Shannon M. Ruzycki, Tyrone G. Harrison, Marcello Tonelli, Kelly B. Zarnke, Elijah Dixon, Zhihai Ma, Prism S. Schneider, Rebecca L Hartley, and Paul E. Ronksley
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Adult ,Male ,medicine.medical_specialty ,medicine.medical_treatment ,Population ,030232 urology & nephrology ,Alberta ,Cohort Studies ,03 medical and health sciences ,0302 clinical medicine ,Renal Dialysis ,medicine ,Humans ,030212 general & internal medicine ,Renal Insufficiency, Chronic ,10. No inequality ,education ,Dialysis ,Aged ,Retrospective Studies ,Aged, 80 and over ,education.field_of_study ,business.industry ,Incidence (epidemiology) ,Incidence ,Retrospective cohort study ,Vascular surgery ,Middle Aged ,medicine.disease ,3. Good health ,Surgery ,Hospitalization ,Nephrology ,Creatinine ,Surgical Procedures, Operative ,Cohort ,Kidney Failure, Chronic ,Female ,business ,Kidney disease ,Cohort study ,Glomerular Filtration Rate - Abstract
Rationale & Objective Kidney disease is associated with an increased risk for postoperative morbidity and mortality. However, the incidence of major surgery on a population level is unknown. We aimed to determine the incidence of major surgery by level of kidney function. Study Design Retrospective cohort study with entry from January 1, 2008, through December 31, 2009, and outcome surveillance from January 1, 2010, through December 31, 2016. Setting & Participants Population-based study using administrative health data from Alberta, Canada; adults with an outpatient serum creatinine measurement or receiving maintenance dialysis formed the study cohort. Exposure Participants were categorized into 6 estimated glomerular filtration rate (eGFR) categories: ≥60 (G1-G2), 45 to 59 (G3a), 30 to 44 (G3b), 15 to 29 (G4), and Outcome Major surgery defined as surgery requiring admission to the hospital for at least 24 hours. Analytical Approach Incidence rates (IRs) for overall major surgery were estimated using quasi-Poisson regression and adjusted for age, sex, income, location of residence, albuminuria, and Charlson comorbid conditions. Age- and sex-stratified IRs of 13 surgery subtypes were also estimated. Results 1,455,512 cohort participants were followed up for a median of 7.0 (IQR, 5.3) years, during which time 241,989 (16.6%) underwent a major surgery. Age and sex modified the relationship between eGFR and incidence of surgery. Men younger than 65 years receiving maintenance dialysis experienced the highest rates of major surgery, with an adjusted IR of 243.8 (95% CI, 179.8-330.6) per 1,000 person-years. There was a consistent trend of increasing surgery rates at lower eGFRs for most subtypes of surgery. Limitations Outpatient preoperative serum creatinine measurement was necessary for inclusion and outpatient surgical procedures were not included. Conclusions People with reduced eGFR have a significantly higher incidence of major surgery compared with those with normal eGFR, and age and sex modify this increased risk. This study informs our understanding of how surgical burden changes with differing levels of kidney function.
- Published
- 2020
21. DNA barcoding vs. morphological identification of larval fish and embryos in Lake Huron: Advantages to a molecular approach
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Andrew M. Zarnke, Natalie D.J. Taylor, Joanna Y. Wilson, Christopher M. Somers, Emily N. Hulley, Richard G. Manzon, and Douglas R. Boreham
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0106 biological sciences ,0301 basic medicine ,Catostomus ,Ecology ,biology ,Zoology ,Morphology (biology) ,Aquatic Science ,Ichthyoplankton ,biology.organism_classification ,010603 evolutionary biology ,01 natural sciences ,DNA barcoding ,03 medical and health sciences ,030104 developmental biology ,Habitat ,Genus ,Freshwater fish ,Identification (biology) ,14. Life underwater ,Ecology, Evolution, Behavior and Systematics - Abstract
The Great Lakes provide habitat to over 160 species of freshwater fish, many of which are ecologically and economically important. Concern for management and conservation of declining fish populations makes it important that accurate identification techniques are used for environmental monitoring programs. DNA barcoding may be an effective alternative to morphological identification for industrial monitoring programs of larval and embryonic fish, but comparisons of the two approaches with species from the Great Lakes are limited. It may be particularly important to examine this issue in the Great Lakes because a relatively young group of post-glacial fish species are present which may be difficult to resolve using morphology or genetics. Six hundred and fifty seven larval fish were identified from Lake Huron (Ontario, Canada), using morphology and DNA barcoding. DNA barcoding was used to identify 103 embryos that morphology could not identify. Morphological identification and DNA barcoding had a percent similarity of 76.9%, 96.6% and 96.6% at the species, genus, and family levels, respectively. Thirty-seven specimens were damaged and unidentifiable using morphology; 35 of these were successfully identified using DNA barcoding. However, 23 other specimens produced no PCR product for barcoding using 2 different primer sets. Discrepancies between morphology and DNA barcoding were driven by two major factors: inability of cytochrome oxidase I to resolve members of the genus Coregonus and limited resolution of morphological features for Catostomus. Both methods have pros and cons; however, DNA barcoding is more cost-effective and efficient for industrial monitoring programs.
- Published
- 2018
22. Hypertension Canada’s 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children
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Lyne Cloutier, G. V. Ramesh Prasad, George K. Dresser, Steven E. Gryn, Kara Nerenberg, Sonia Butalia, Alexander A. Leung, Andrew C. Don-Wauchope, Vincent Woo, Karen C. Tran, Simon L. Bacon, Laura M. Kuyper, Andrew L. Pipe, Marcel Ruzicka, George Honos, Milan Gupta, Janusz Feber, Richard Lewanczuk, Pavel Hamet, Gordon W. Moe, Kerry McBrien, Kevin C. Harris, Evelyne Rey, Theodore Wein, Mike Sharma, Donna McLean, Tavis S. Campbell, Ally P.H. Prebtani, Michael Roerecke, Robert A. Hegele, Peter Bolli, Janis M. Dionne, Swapnil Hiremath, Raj Padwal, Geneviève Benoit, Michel Vallée, Simon W. Rabkin, Guy Tremblay, Stella S. Daskalopoulou, S. Brian Penner, Sheldon W. Tobe, Thalia S. Field, Janusz Kaczorowski, Laura A. Magee, Ernesto L. Schiffrin, Meranda Nakhla, Charlotte Jones, Kaberi Dasgupta, Richard E. Gilbert, Anne-Marie Côté, JoAnne Arcand, Ross D. Feldman, Jean Grégoire, Tabassum Firoz, Alexander G. Logan, Michael D. Hill, Steven A. Grover, Alain Milot, Jonathan Y. Gabor, Peter Selby, Luc Trudeau, Philip A. McFarlane, Ellen Burgess, Patrice Lindsay, Maxime Lamarre-Cliche, Ross T. Tsuyuki, Praveena Sivapalan, Norman R.C. Campbell, Jonathan G. Howlett, Kim L. Lavoie, Anne Fournier, Doreen M. Rabi, Kelly B. Zarnke, Lawrence A. Leiter, Paul Oh, Cedric Edwards, Robert J. Herman, Raymond R. Townsend, Mark Gelfer, Gregory A. Kline, Ashkan Shoamanesh, and Luc Poirier
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lifestyle ,medicine.medical_specialty ,hypertension ,Ambulatory blood pressure ,pediatrics ,blood pressure measurement ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,Renal artery stenosis ,tobacco ,pharmacotherapy ,03 medical and health sciences ,0302 clinical medicine ,adults ,medicine ,guidelines ,030212 general & internal medicine ,global cardiovascular risk ,automated blood pressure ,renal artery stenosis ,primary aldosteronism ,Ejection fraction ,business.industry ,Guideline ,Thrombolysis ,medicine.disease ,diagnostic algorithm ,pheochromocytoma ,smoking cessation ,home blood pressure monitoring ,ambulatory blood pressure monitoring ,lipid profile ,Blood pressure ,Heart failure ,recommendations ,Emergency medicine ,renovascular disease ,Cardiology and Cardiovascular Medicine ,business ,Risk assessment ,high blood pressure - Abstract
Hypertension Canada provides annually-updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension in adults and children. This year, the adult and pediatric guidelines are combined in one document. The new 2018 pregnancy-specific hypertension guidelines are published separately. For 2018, 5 new guidelines were introduced, and one existing guideline on the blood pressure thresholds and targets in the setting of thrombolysis for acute ischemic stroke was revised. The use of validated wrist devices for the estimation of blood pressure in individuals with large arm circumference is now included. Guidance is provided for the follow-up measurements of blood pressure, with the use of standardized methods and electronic (oscillometric) upper arm devices in individuals with hypertension, and either ambulatory blood pressure monitoring or home blood pressure monitoring in individuals with white coat effect. We specify that all individuals with hypertension should have an assessment of global cardiovascular risk to promote health behaviours that lower blood pressure. Finally, an angiotensin receptor-neprilysin inhibitor combination should be used in place of either an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in individuals with heart failure (with ejection fraction < 40%) who are symptomatic despite appropriate doses of guideline-directed heart failure therapies. The specific evidence and rationale underlying each of these guidelines are discussed.
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- 2018
23. Engineering Approaches to Assessing Hydration Status
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Jared R. Fletcher, David C. Garrett, Elise C. Fear, Nyssa Rae, Sasha Zarnke, Sarah Thorson, and David B. Hogan
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0301 basic medicine ,medicine.medical_specialty ,030109 nutrition & dietetics ,Dehydration ,biology ,Athletes ,Body water ,Biomedical Engineering ,Routine laboratory ,Organism Hydration Status ,030229 sport sciences ,Environmental exposure ,medicine.disease ,biology.organism_classification ,03 medical and health sciences ,0302 clinical medicine ,Body Water ,Mild dehydration ,medicine ,Humans ,Cognitive impairment ,Intensive care medicine ,Stroke ,Monitoring, Physiologic ,Hydration status - Abstract
Dehydration is a common condition characterized by a decrease in total body water. Acute dehydration can cause physical and cognitive impairment, heat stroke and exhaustion, and, if severe and uncorrected, even death. The health effects of chronic mild dehydration are less well studied with urolithiasis (kidney stones) the only condition consistently associated with it. Aside from infants and those with particular medical conditions, athletes, military personnel, manual workers, and older adults are at particular risk of dehydration due to their physical activity, environmental exposure, and/or challenges in maintaining fluid homeostasis. This review describes the different approaches that have been explored for hydration assessment in adults. These include clinical indicators perceived by the patient or detected by a practitioner and routine laboratory analyses of blood and urine. These techniques have variable accuracy and practicality outside of controlled environments, creating a need for simple, portable, and rapid hydration monitoring devices. We review the wide array of devices proposed for hydration assessment based on optical, electromagnetic, chemical, and acoustical properties of tissue and bodily fluids. However, none of these approaches has yet emerged as a reliable indicator in diverse populations across various settings, motivating efforts to develop new methods of hydration assessment.
- Published
- 2018
24. Predictors, Prognosis, and Management of New Clinically Important Atrial Fibrillation After Noncardiac Surgery: A Prospective Cohort Study
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Pablo Alonso-Coello, Homer Yang, Soori Sivakumaran, Alben Sigamani, Philip J. Devereaux, Pedro Ibarra, Luz X Martínez, Poise Trial Investigators, Otavio Berwanger, Deborah J. Cook, Denis Xavier, Purnima Rao-Melacini, Jack Ostrander, Salim Yusuf, J Pogue, Kelly Zarnke, Shou Chun Xu, and Pilar Paniagua
- Subjects
Male ,medicine.medical_specialty ,Time Factors ,MEDLINE ,030204 cardiovascular system & hematology ,Electrocardiography ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,Internal medicine ,Abdomen ,Atrial Fibrillation ,Humans ,Medicine ,Prospective Studies ,cardiovascular diseases ,030212 general & internal medicine ,Prospective cohort study ,Stroke ,Aged ,Randomized Controlled Trials as Topic ,Aged, 80 and over ,Laparotomy ,medicine.diagnostic_test ,business.industry ,Incidence ,Incidence (epidemiology) ,Age Factors ,Anticoagulants ,Atrial fibrillation ,Length of Stay ,Middle Aged ,Thoracic Surgical Procedures ,medicine.disease ,Treatment Outcome ,Anesthesiology and Pain Medicine ,Surgical Procedures, Operative ,cardiovascular system ,Cardiology ,Female ,Observational study ,business ,Vascular Surgical Procedures ,Noncardiac surgery - Abstract
Despite the frequency of new clinically important atrial fibrillation (AF) after noncardiac surgery and its increased association with the risk of stroke at 30 days, there are limited data informing their prediction, association with outcomes, and management.We used the data from the PeriOperative ISchemic Evaluation trial to determine, in patients undergoing noncardiac surgery, the association of new clinically important AF with 30-day outcomes, and to assess management of these patients. We also aimed to derive a clinical prediction rule for new clinically important AF in this population. We defined new clinically important AF as new AF that resulted in symptoms or required treatment. We recorded an electrocardiogram 6 to 12 hours postoperatively and on the 1st, 2nd, and 30th days after surgery.A total of 211 (2.5% [8351 patients]; 95% confidence interval, 2.2%-2.9%) patients developed new clinically important AF within 30 days of randomization (8140 did not develop new AF). AF was independently associated with an increased length of hospital stay by 6.0 days (95% confidence interval, 3.5-8.5 days) and vascular complications (eg, stroke or congestive heart failure). The usage of an oral anticoagulant at the time of hospital discharge among patients with new AF and a CHADS2 score of 0, 1, 2, 3, and ≥4 was 6.9%, 10.2%, 23.0%, 9.4%, and 33.3%, respectively. Two independent predictors of patients developing new clinically important AF were identified (ie, age and surgery). The prediction rule included the following factors and assigned weights: age ≥85 years (4 points), age 75 to 84 years (3 points), age 65 to 74 years (2 points), intrathoracic surgery (3 points), major vascular surgery (2 points), and intra-abdominal surgery (1 point). The incidence of new AF based on scores of 0 to 1, 2, 3 to 4, and 5 to 6 was 0.5%, 1.0%, 3.1%, and 5.3%, respectively.Age and surgery are independent predictors of new clinically important AF in the perioperative setting. A minority of patients developing new clinically important AF with high CHADS2 scores are discharged on an oral anticoagulant. There is a need to develop effective and safe interventions to prevent this outcome and to optimize the management of this event when it occurs.
- Published
- 2017
25. Association of NT-proBNP and BNP With Future Clinical Outcomes in Patients With ESKD: A Systematic Review and Meta-analysis
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Brenda R. Hemmelgarn, Caley B. Shukalek, Nicolas Iragorri, Matthew T. James, Tyrone G. Harrison, Paul E. Ronksley, Michelle M. Graham, and Kelly B. Zarnke
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medicine.medical_specialty ,medicine.drug_class ,medicine.medical_treatment ,030232 urology & nephrology ,Risk Assessment ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,Cause of Death ,Natriuretic Peptide, Brain ,medicine ,Natriuretic peptide ,Humans ,cardiovascular diseases ,030212 general & internal medicine ,Mortality ,Dialysis ,Proportional Hazards Models ,business.industry ,Hazard ratio ,Brain natriuretic peptide ,medicine.disease ,Peptide Fragments ,3. Good health ,Nephrology ,Cardiovascular Diseases ,Meta-analysis ,Cohort ,Kidney Failure, Chronic ,Risk assessment ,business ,hormones, hormone substitutes, and hormone antagonists ,Kidney disease - Abstract
Rationale & Objective Use of brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) for cardiovascular (CV) risk assessment in patients with end-stage kidney disease (ESKD) remains unclear. We examined the associations between different threshold elevations of these peptide levels and clinical outcomes in patients with ESKD. Study Design Systematic review and meta-analysis. Setting & Study Populations We searched MEDLINE and EMBASE (through September 2019) for observational studies of adults with ESKD (estimated glomerular filtration rate≤15mL/min/1.73m2 or receiving maintenance dialysis). Selection Criteria for Studies Studies that reported NT-proBNP or BNP levels and future CV events, CV mortality, or all-cause mortality. Data Extraction Cohort characteristics and measures of risk associated with study-specified peptide thresholds. Analytical Approach Hazard ratios (HRs) for clinical outcomes associated with different NT-proBNP and BNP ranges were categorized into common thresholds and pooled using random-effects meta-analysis. Results We identified 61 studies for inclusion in our review (19,688 people). 49 provided sufficient detail for inclusion in meta-analysis. Pooled unadjusted HRs for CV mortality were progressively greater for greater thresholds of NT-proBNP, from 1.45 (95% CI, 0.91-2.32) for levels>2,000pg/mL to 5.95 (95% CI, 4.23-8.37) for levels>15,000pg/mL. Risk for all-cause mortality was significantly higher at all NT-proBNP thresholds ranging from> 1,000 to> 20,000pg/mL (HR range, 1.53-4.00). BNP levels>550pg/mL were associated with increased risk for CV mortality (HR, 2.54; 95% CI, 1.49-4.33), while the risks for all-cause mortality were 2.04 (95% CI, 0.82-5.12) at BNP levels>100pg/mL and 2.97 (95% CI, 2.21-3.98) at BNP levels>550pg/mL. Adjusted analyses demonstrated similarly greater risks for CV and all-cause mortality with greater NT-proBNP concentrations. Limitations Incomplete outcome reporting and risk for outcome reporting bias. Estimation of risk for CV events for specific thresholds of both peptides were limited by poor precision. Conclusions ESKD-specific NT-proBNP and BNP level thresholds of elevation are associated with increased risk for CV and all-cause mortality. This information may help guide interpretation of NT-proBNP and BNP levels in patients with ESKD.
- Published
- 2019
26. POS-522 MORTALITY AND CARDIOVASCULAR EVENTS IN ADULTS WITH KIDNEY FAILURE AFTER MAJOR NON-CARDIAC SURGERY: A POPULATION-BASED COHORT STUDY
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Deirdre McCaughey, Brenda R. Hemmelgarn, Matthew T. James, James Wick, Paul E. Ronksley, Kelly B. Zarnke, Tyrone G. Harrison, and Shannon M. Ruzycki
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medicine.medical_specialty ,Kidney ,Population based cohort ,medicine.anatomical_structure ,Nephrology ,business.industry ,Non cardiac surgery ,Internal medicine ,medicine ,RC870-923 ,business ,Diseases of the genitourinary system. Urology - Published
- 2021
27. A novel specialized tissue culture incubator designed and engineered for radiobiology experiments in a sub-natural background radiation research environment
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Tom Sonley, Mike Hood, T. C. Tai, Simon J. Lees, Douglas R. Boreham, Taylor Laframboise, Mehwish Obaid, Stephen Stankiewicz, Christopher Thome, Jake Pirkkanen, Peter Liimatainen, and Andrew Zarnke
- Subjects
Radiobiology ,010504 meteorology & atmospheric sciences ,Health, Toxicology and Mutagenesis ,Nuclear engineering ,chemistry.chemical_element ,Radon ,010501 environmental sciences ,01 natural sciences ,Incubators ,Radiation Monitoring ,Research environment ,Background Radiation ,Environmental Chemistry ,Waste Management and Disposal ,0105 earth and related environmental sciences ,Background radiation ,Ontario ,Incubator ,Radon gas ,General Medicine ,Pollution ,Overburden ,chemistry ,13. Climate action ,Underground laboratory ,Environmental science - Abstract
Extensive research has been conducted investigating the effects of ionizing radiation on biological systems, including specific focus at low doses. However, at the surface of the planet, there is the ubiquitous presence of ionizing natural background radiation (NBR) from sources both terrestrial and cosmic. We are currently conducting radiobiological experiments examining the impacts of sub-NBR exposure within SNOLAB. SNOLAB is a deep underground research laboratory in Sudbury, Ontario, Canada located 2 km beneath the surface of the planet. At this depth, significant shielding of NBR components is provided by the rock overburden. Here, we describe a Specialized Tissue Culture Incubator (STCI) that was engineered to significantly reduce background ionizing radiation levels. The STCI was installed 2 km deep underground within SNOLAB. It was designed to allow precise control of experimental variables such as temperature, atmospheric gas composition and humidity. More importantly, the STCI was designed to reduce radiological contaminants present within the underground laboratory. Quantitative measurements validated the STCI is capable of maintaining an appropriate experimental environment for sub-NBR experiments. This included reduction of sub-surface radiological contaminants, most notably radon gas. The STCI presents a truly novel piece of infrastructure enabling future research into the effects of sub-NBR exposure in a highly unique laboratory setting.
- Published
- 2021
28. BEIR VI radon: The rest of the story
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Antone L. Brooks, Andrew M. Zarnke, Sujeenthar Tharmalingam, and Douglas R. Boreham
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0301 basic medicine ,medicine.medical_specialty ,chemistry.chemical_element ,Radon ,Toxicology ,Individual risk ,Risk Assessment ,03 medical and health sciences ,0302 clinical medicine ,Cigarette smoking ,Environmental health ,Rest (finance) ,medicine ,Cigarette smoke ,Humans ,Lung cancer ,business.industry ,Public health ,Radiobiology ,General Medicine ,Radiation Exposure ,medicine.disease ,respiratory tract diseases ,030104 developmental biology ,chemistry ,030220 oncology & carcinogenesis ,Attributable risk ,business - Abstract
The National Academy of Sciences (USA) conducted an extensive review on the health effects of radon (BEIR VI). This was a well written and researched report which had impact on regulations, laws and remediation of radon in homes. There were a number of problems with the interpretation of the report and three are focused on here. First, most of the radiation dose used to estimate risk was from homes with radon levels below the US Environmental Protection Agency's action level so that remediation had minor impact on total calculated attributable risk. Remediation of the high level homes (i.e., above the action level) would therefore have a minor impact on the calculated "population attributable risk". In individual homes with very high levels of radon, remediation may minimally reduce individual risk. Second, the conclusion communicated to the public, regulators and law makers was "Next to cigarette smoking radon is the second leading cause of lung cancer." This is not an accurate evaluation of the report. The correct conclusion would be: Next to cigarette smoking, high levels of radon combined with cigarette smoking is the second leading cause of lung cancer. In the never-smokers, few cancers could be attributable to radon. Thirdly, there is little question that high levels of radon exposure in mines combined with cigarette smoke and other significant insults in the mine environment produces excess lung cancer. However, the biological responses to low doses of radiation are different from those produced by high levels and low doses may result in unique protective responses (e.g. against smoking-related lung cancer). These three points will be discussed in detail. This paper shows that in contrary to the BEIR VI report, risk of lung cancer from residential radon is not increased and radon in homes appears to be helping to prevent smoking-related lung cancer. Thus, laws requiring remediation of homes for radon are providing little if any public health benefits.
- Published
- 2018
29. The REPAIR Project: Examining the Biological Impacts of Sub-Background Radiation Exposure within SNOLAB, a Deep Underground Laboratory
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Douglas R. Boreham, Taylor Laframboise, Andrew M. Zarnke, Christopher Thome, Sujeenthar Tharmalingam, and Jake Pirkkanen
- Subjects
Astroparticle physics ,Radiation ,Radiochemistry ,Biophysics ,Radiobiology ,Cosmic ray ,Radiation Exposure ,030218 nuclear medicine & medical imaging ,Ionizing radiation ,03 medical and health sciences ,Overburden ,0302 clinical medicine ,Mining engineering ,030220 oncology & carcinogenesis ,Electromagnetic shielding ,Underground laboratory ,Environmental science ,Animals ,Background Radiation ,Radiology, Nuclear Medicine and imaging ,Laboratories ,Cosmic Radiation ,Salmonidae ,Background radiation - Abstract
Considerable attention has been given to understanding the biological effects of low-dose ionizing radiation exposure at levels slightly above background. However, relatively few studies have been performed to examine the inverse, where natural background radiation is removed. The limited available data suggest that organisms exposed to sub-background radiation environments undergo reduced growth and an impaired capacity to repair genetic damage. Shielding from background radiation is inherently difficult due to high-energy cosmic radiation. SNOLAB, located in Sudbury, Ontario, Canada, is a unique facility for examining the effects of sub-background radiation exposure. Originally constructed for astroparticle physics research, the laboratory is located within an active nickel mine at a depth of over 2,000 m. The rock overburden provides shielding equivalent to 6,000 m of water, thereby almost completely eliminating cosmic radiation. Additional features of the facility help to reduce radiological contamination from the surrounding rock. We are currently establishing a biological research program within SNOLAB: Researching the Effects of the Presence and Absence of Ionizing Radiation (REPAIR project). We hypothesize that natural background radiation is essential for life and maintains genomic stability, and that prolonged exposure to sub-background radiation environments will be detrimental to biological systems. Using a combination of whole organism and cell culture model systems, the effects of exposure to a sub-background environment will be examined on growth and development, as well as markers of genomic damage, DNA repair capacity and oxidative stress. The results of this research will provide further insight into the biological effects of low-dose radiation exposure as well as elucidate some of the processes that may drive evolution and selection in living systems. This Radiation Research focus issue contains reviews and original articles, which relate to the presence or absence of low-dose ionizing radiation exposure.
- Published
- 2017
30. How Attending Physician Preceptors Negotiate Their Complex Work Environment: A Collective Ethnography
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William A. Ghali, Maria Bacchus, Peter Sargious, David R Ward, Jane B Lemaire, Kelly B. Zarnke, and Jean E. Wallace
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Clinical clerkship ,Adult ,Male ,Canada ,020205 medical informatics ,media_common.quotation_subject ,02 engineering and technology ,Education ,03 medical and health sciences ,0302 clinical medicine ,Nursing ,Ethnography ,0202 electrical engineering, electronic engineering, information engineering ,Internal Medicine ,Medicine ,Humans ,030212 general & internal medicine ,Physician's Role ,Workplace ,Anthropology, Cultural ,media_common ,business.industry ,Clinical Clerkship ,Preceptor ,General Medicine ,Middle Aged ,Medical teaching ,Work environment ,Negotiation ,Female ,business - Abstract
To generate an empiric, detailed, and updated view of the attending physician preceptor role and its interface with the complex work environment.In 2013, the authors conducted a modified collective ethnography with observations of internal medicine medical teaching unit preceptors from two university hospitals in Canada. Eleven observers conducted 32 observations (99.5 hours) of 26 preceptors (30 observations [93.5 hours] of 24 preceptors were included in the analysis). An inductive thematic approach was used to analyze the data with further axial coding to identify connections between themes. Four individuals coded the main data set; differences were addressed through discussion to achieve consensus.Three elements or major themes of the preceptor role were identified: (1) competence or the execution of traditional physician competencies, (2) context or the extended medical teaching unit environment, and (3) conduct or the manner of acting or behaviors and attitudes in the role. Multiple connections between the elements emerged. The preceptor role appeared to depend on the execution of professional skills (competence) but also was vulnerable to contextual factors (context) independent of these skills, many of which were unpredictable. This vulnerability appeared to be tempered by preceptors' use of adaptive behaviors and attitudes (conduct), such as creativity, interpersonal skills, and wellness behaviors.Preceptors not only possess traditional competencies but also enlist additional behaviors and attitudes to deal with context-driven tensions and to negotiate their complex work environment. These skills could be incorporated into role training, orientation, and mentorship.
- Published
- 2017
31. Bulk permittivity variations in the human breast over the menstrual cycle
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Elise C. Fear, Jacob R. Budzis, David C. Garrett, Sasha Zarnke, Daphne Mew, and Jeremie Bourqui
- Subjects
Permittivity ,endocrine system ,medicine.diagnostic_test ,business.industry ,media_common.quotation_subject ,020206 networking & telecommunications ,02 engineering and technology ,Luteal phase ,03 medical and health sciences ,0302 clinical medicine ,030220 oncology & carcinogenesis ,Follicular phase ,0202 electrical engineering, electronic engineering, information engineering ,medicine ,Electronic engineering ,Mammography ,Breast density ,business ,Volunteer ,Human breast ,reproductive and urinary physiology ,Menstrual cycle ,Biomedical engineering ,media_common - Abstract
A female volunteer is scanned daily using a system to measure bulk permittivity of the breast. The measured data are then compared to the volunteer's menstrual cycle. A permittivity increase of about 10% is found during the luteal phase compared to the follicular phase of the cycle. This correlates with breast density increase reported with X-ray mammography during the luteal phase.
- Published
- 2017
32. Genomic agonism and phenotypic antagonism between estrogen and progesterone receptors in breast cancer
- Author
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Allison L. Zarnke, Ganesh V. Raj, Wayne D. Tilley, Geoffrey L. Greene, Anna G. Dembo, Ryan J. Bourgo, Ya Fang Chang, Marianne E. Greene, Gerard A. Tarulli, Hari Singhal, Shihong Ma, Theresa E. Hickey, and Muriel Laine
- Subjects
0301 basic medicine ,Genes, BRCA1 ,Estrogen receptor ,Pharmacology ,0302 clinical medicine ,agonism ,Antineoplastic Combined Chemotherapy Protocols ,Cluster Analysis ,Molecular Targeted Therapy ,skin and connective tissue diseases ,Research Articles ,Multidisciplinary ,Chromatin binding ,SciAdv r-articles ,Genomics ,Prognosis ,Chromatin ,Nucleosomes ,3. Good health ,Enhancer Elements, Genetic ,Phenotype ,Treatment Outcome ,Receptors, Estrogen ,Oncology ,030220 oncology & carcinogenesis ,Receptors, Progesterone ,hormones, hormone substitutes, and hormone antagonists ,Protein Binding ,Signal Transduction ,Research Article ,medicine.drug ,Selective Estrogen Receptor Modulators ,Agonist ,Antineoplastic Agents, Hormonal ,medicine.drug_class ,therapies ,Breast Neoplasms ,progesterone ,Biology ,03 medical and health sciences ,breast cancer ,Progesterone receptor ,medicine ,Humans ,Nucleotide Motifs ,Estrogen receptor beta ,Binding Sites ,Gene Expression Profiling ,reprogramming ,BRCA1 ,Estrogen ,antagonism ,Tamoxifen ,030104 developmental biology ,Progestins ,Estrogen receptor alpha ,Genome-Wide Association Study - Abstract
Individual and concerted actions of ER and PR highlight the prognostic and therapeutic value of PR in ER+/PR+ breast cancers., The functional role of progesterone receptor (PR) and its impact on estrogen signaling in breast cancer remain controversial. In primary ER+ (estrogen receptor–positive)/PR+ human tumors, we report that PR reprograms estrogen signaling as a genomic agonist and a phenotypic antagonist. In isolation, estrogen and progestin act as genomic agonists by regulating the expression of common target genes in similar directions, but at different levels. Similarly, in isolation, progestin is also a weak phenotypic agonist of estrogen action. However, in the presence of both hormones, progestin behaves as a phenotypic estrogen antagonist. PR remodels nucleosomes to noncompetitively redirect ER genomic binding to distal enhancers enriched for BRCA1 binding motifs and sites that link PR and ER/PR complexes. When both hormones are present, progestin modulates estrogen action, such that responsive transcriptomes, cellular processes, and ER/PR recruitment to genomic sites correlate with those observed with PR alone, but not ER alone. Despite this overall correlation, the transcriptome patterns modulated by dual treatment are sufficiently different from individual treatments, such that antagonism of oncogenic processes is both predicted and observed. Combination therapies using the selective PR modulator/antagonist (SPRM) CDB4124 in combination with tamoxifen elicited 70% cytotoxic tumor regression of T47D tumor xenografts, whereas individual therapies inhibited tumor growth without net regression. Our findings demonstrate that PR redirects ER chromatin binding to antagonize estrogen signaling and that SPRMs can potentiate responses to antiestrogens, suggesting that cotargeting of ER and PR in ER+/PR+ breast cancers should be explored.
- Published
- 2016
33. Hypertension Canada's 2016 Canadian Hypertension Education Program Guidelines for Blood Pressure Measurement, Diagnosis, and Assessment of Risk of Pediatric Hypertension
- Author
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Doreen M. Rabi, Janis M. Dionne, Lyne Cloutier, Anne Fournier, Kelly B. Zarnke, Janusz Feber, Raj Padwal, Geneviève Benoit, and Kevin C. Harris
- Subjects
medicine.medical_specialty ,Canada ,Pediatric Obesity ,MEDLINE ,030204 cardiovascular system & hematology ,Pediatrics ,Risk Assessment ,Childhood obesity ,Body Mass Index ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,030225 pediatrics ,medicine ,Humans ,Intensive care medicine ,Child ,Health Education ,Antihypertensive Agents ,Pediatric hypertension ,business.industry ,Blood Pressure Determination ,Guideline ,medicine.disease ,Blood pressure ,Cardiovascular Diseases ,Hypertension ,Health education ,Cardiology and Cardiovascular Medicine ,business ,Risk assessment ,Body mass index - Abstract
We present the inaugural evidence-based Canadian recommendations for the measurement of blood pressure in children and the diagnosis and evaluation of pediatric hypertension. Rates of pediatric hypertension are increasing concomitant with increased rates of childhood obesity. With this, there is growing awareness of the need to measure blood pressure in children. Consequently, the present recommendations have been developed to address an important gap and improve the clinical care of children. For 2016, a total of 15 recommendations are presented. These are categorized in a fashion similar to that of the existing adult recommendations. Specifically, we present recommendations on (1) accurate measurement of blood pressure in children, (2) criteria for diagnosis of hypertension in children, (3) assessment of overall cardiovascular risk in hypertensive children, (4) routine laboratory tests for the investigation of children with hypertension, (5) ambulatory blood pressure measurement in children, and (6) the role of echocardiography. We discuss the rationale for the recommendations and present additional supporting material for the clinician, including tables with standardized techniques for blood pressure measurement and determination of normative blood pressure values for children. Hypertension Canada's Canadian Hypertension Education Program Guidelines Task Force will update the recommendations annually and develop future evidence-based recommendations to guide prevention and treatment of pediatric hypertension.
- Published
- 2016
34. Hypertension Canada's 2016 Canadian Hypertension Education Program Guidelines for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension
- Author
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Janis M. Dionne, Shelagh B. Coutts, Donna McLean, Mark Gelfer, Michel Vallée, Sheldon W. Tobe, Kara Nerenberg, Debra Reid, Milan Khara, Raj Padwal, Kaberi Dasgupta, Pierre Larochelle, Robert A. Hegele, Marcel Lebel, Vincent Woo, Peter Bolli, Patrice Lindsay, Gregory Moullec, Luc Trudeau, Gord Gubitz, Michael D. Hill, Robert J. Herman, Alexander G. Logan, Lyne Cloutier, Maxime Lamarre-Cliche, Philip A. McFarlane, Kim L. Lavoie, Charlotte Jones, Richard E. Gilbert, Janusz Kaczorowski, Steven A. Grover, Geneviève Benoit, Alain Milot, Ally P.H. Prebtani, Lawrence A. Leiter, G. V. Ramesh Prasad, George K. Dresser, Andrew L. Pipe, Milan Gupta, Swapnil Hiremath, George Fodor, Tavis S. Campbell, Kevin D. Burns, Simon W. Rabkin, Peter Selby, Stella S. Daskalopoulou, Alexander A. Leung, Norman R.C. Campbell, Simon L. Bacon, Richard I. Ogilvie, Thomas W. Wilson, Marcel Ruzicka, Ellen Burgess, Robert J. Petrella, Gordon W. Moe, Anne Fournier, Kevin C. Harris, George Honos, Kelly B. Zarnke, Paul Oh, Janusz Feber, Kerry McBrien, Laura A. Magee, Jean Grégoire, S. Brian Penner, Luc Poirier, Ernesto L. Schiffrin, Mukul Sharma, Jonathan G. Howlett, Doreen M. Rabi, Ross D. Feldman, Jean-Martin Boulanger, Pavel Hamet, Richard Lewanczuk, Denis Drouin, Guy Tremblay, and Scott A. Lear
- Subjects
medicine.medical_specialty ,Canada ,Hyperkalemia ,medicine.drug_class ,Secondary hypertension ,Calcium channel blocker ,030204 cardiovascular system & hematology ,Risk Assessment ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,Hyperaldosteronism ,medicine ,Humans ,030212 general & internal medicine ,Intensive care medicine ,Health Education ,Antihypertensive Agents ,Evidence-Based Medicine ,business.industry ,Blood Pressure Determination ,Guideline ,Evidence-based medicine ,medicine.disease ,Blood pressure ,Hypertension ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,Risk assessment ,business - Abstract
Hypertension Canada's Canadian Hypertension Education Program Guidelines Task Force provides annually updated, evidence-based recommendations to guide the diagnosis, assessment, prevention, and treatment of hypertension. This year, we present 4 new recommendations, as well as revisions to 2 previous recommendations. In the diagnosis and assessment of hypertension, automated office blood pressure, taken without patient-health provider interaction, is now recommended as the preferred method of measuring in-office blood pressure. Also, although a serum lipid panel remains part of the routine laboratory testing for patients with hypertension, fasting and nonfasting collections are now considered acceptable. For individuals with secondary hypertension arising from primary hyperaldosteronism, adrenal vein sampling is recommended for those who are candidates for potential adrenalectomy. With respect to the treatment of hypertension, a new recommendation that has been added is for increasing dietary potassium to reduce blood pressure in those who are not at high risk for hyperkalemia. Furthermore, in selected high-risk patients, intensive blood pressure reduction to a target systolic blood pressure ≤ 120 mm Hg should be considered to decrease the risk of cardiovascular events. Finally, in hypertensive individuals with uncomplicated, stable angina pectoris, either a β-blocker or calcium channel blocker may be considered for initial therapy. The specific evidence and rationale underlying each of these recommendations are discussed. Hypertension Canada's Canadian Hypertension Education Program Guidelines Task Force will continue to provide annual updates.
- Published
- 2016
35. The independent association of provider and information continuity on outcomes after hospital discharge: Implications for hospitalists
- Author
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Alan J. Forster, Carl van Walraven, Chaim M. Bell, Ian G. Stiell, Edward Etchells, Kelly B. Zarnke, and Monica Taljaard
- Subjects
Male ,medicine.medical_specialty ,Time Factors ,Leadership and Management ,Coronary Artery Disease ,Assessment and Diagnosis ,Patient Readmission ,Alberta ,Confidence Intervals ,Hospital discharge ,Health Status Indicators ,Humans ,Medicine ,Prospective Studies ,Registries ,Prospective cohort study ,Care Planning ,Aged ,Ontario ,business.industry ,Health Policy ,Mortality rate ,Hazard ratio ,General Medicine ,Continuity of Patient Care ,Middle Aged ,After discharge ,Readmission rate ,Patient Discharge ,Confidence interval ,Hospital medicine ,Treatment Outcome ,Hospitalists ,Multivariate Analysis ,Emergency medicine ,Female ,Fundamentals and skills ,business - Abstract
BACKGROUND: Since hospitalist physicians do not frequently see patients in follow-up after discharge from the hospital, patient continuity of care will decrease. To determine how this influenced patient outcomes, we examined the independent association of several physician continuity and information continuity measures on death or urgent readmission after discharge from hospital. DESIGN: Multicenter, prospective cohort study of patients discharged to the community after elective or emergency hospitalization. We measured three physician continuity scores (preadmission; hospital; and postdischarge) and two information continuity scores (discharge summary; postdischarge visit information) as time-dependent covariates. Continuity scores ranged from 0 (perfect discontinuity) to 1 (perfect continuity). The primary outcomes were time to all-cause death or urgent readmission. RESULTS: A total of 3876 people were followed for a median of 175 days. Death rate was 2.6 events per 100 patient-years observation (pys) (95% confidence interval [CI], 2.0-3.4) and urgent readmission rate was 19.6 events per 100 pys (95% CI, 15.9-24.3). After adjusting for important covariates and other continuity scores, increased preadmission physician continuity was independently associated with a decreased risk of urgent readmission (adjusted hazard ratio 0.94 [95% CI, 0.91-0.98] for each absolute increase in continuity of 0.1). Other continuity measures—including hospital physician continuity—were not associated with either outcome. CONCLUSIONS: After discharge from the hospital, increased continuity with physicians who routinely treated the patient prior to the admission was significantly and independently associated with a decreased risk of urgent readmission. These data suggest that continuity with the hospital physician after discharge did not independently influence the risk of patient death or urgent readmission. Journal of Hospital Medicine 2010;5:398–405. © 2010 Society of Hospital Medicine.
- Published
- 2010
36. Identification of factors driving differences in cost effectiveness of first-line pharmacological therapy for uncomplicated hypertension
- Author
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Karen Tu, Finlay A. McAlister, Scott Klarenbach, Helen Johansen, Robin L. Walker, Maureen Hazel, Norman R.C. Campbell, and Kelly B. Zarnke
- Subjects
Male ,Canada ,medicine.medical_specialty ,Cost effectiveness ,Cost-Benefit Analysis ,Alternative medicine ,MEDLINE ,Risk Assessment ,Drug Costs ,Pharmacotherapy ,Cost of Illness ,Health care ,medicine ,Humans ,Practice Patterns, Physicians' ,Intensive care medicine ,Antihypertensive Agents ,health care economics and organizations ,Cost–benefit analysis ,business.industry ,Health technology ,Hypertension ,Practice Guidelines as Topic ,Physical therapy ,Female ,Guideline Adherence ,Cardiology and Cardiovascular Medicine ,Risk assessment ,business - Abstract
Background Published practice guidelines and economic evaluations have come to different conclusions regarding optimal pharmacotherapy for the treatment of uncomplicated hypertension. The drivers of these disparities are not clear. Greater understanding is needed for clinicians, researchers and policy makers to determine the most effective and sustainable strategies. Objectives To identify how cost and cost-effectiveness considerations are used to generate recommendations by major hypertension guidelines, and determine key drivers of cost-effectiveness conclusions in available economic evaluations. Methods A systematic search and narrative review of major hypertension guidelines and health technology assessments of first-line antihypertensive therapy were performed. Results Of the eight guidelines identified, formal cost-effectiveness analysis was rarely integrated in the formulation of recommendations. When guidelines considered costs, recommendations remained incongruent. Two economic evaluations were identified (United Kingdom and Canada); however, these differed in their conclusion of the most cost-effective agent and attractiveness of calcium channel blockers. Review of these economic evaluations suggests that cost-effectiveness conclusions are strongly influenced by relative costs of drug classes; when relative differences in drug costs are lower, the impact on associated conditions such as heart failure and diabetes influences cost-effectiveness conclusions. Conclusion In the setting of finite health care resources and significant budget impact due to high population prevalence, cost effectiveness is an important consideration in the treatment of uncomplicated hypertension. Identification of key drivers of cost effectiveness will assist interpretation and conduct of current and future economic evaluations.
- Published
- 2010
37. Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community
- Author
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Carl van Walraven, Kelly B. Zarnke, Alan J. Forster, Chaim M. Bell, Ian G. Stiell, Irfan A. Dhalla, Edward Etchells, and Peter C. Austin
- Subjects
medicine.medical_specialty ,Index (economics) ,business.industry ,General Medicine ,Emergency department ,After discharge ,medicine.disease ,Comorbidity ,Emergency medicine ,Unplanned readmission ,Medicine ,Derivation ,business ,Intensive care medicine ,Prospective cohort study ,Statistic - Abstract
Background: Readmissions to hospital are common, costly and often preventable. An easy-to-use index to quantify the risk of readmission or death after discharge from hospital would help clinicians identify patients who might benefit from more intensive post-discharge care. We sought to derive and validate an index to predict the risk of death or unplanned readmission within 30 days after discharge from hospital to the community. Methods: In a prospective cohort study, 48 patient-level and admission-level variables were collected for 4812 medical and surgical patients who were discharged to the community from 11 hospitals in Ontario. We used a split-sample design to derive and validate an index to predict the risk of death or nonelective readmission within 30 days after discharge. This index was externally validated using administrative data in a random selection of 1 000 000 Ontarians discharged from hospital between 2004 and 2008. Results: Of the 4812 participating patients, 385 (8.0%) died or were readmitted on an unplanned basis within 30 days after discharge. Variables independently associated with this outcome (from which we derived the nmemonic “LACE”) included length of stay (“L”); acuity of the admission (“A”); comorbidity of the patient (measured with the Charlson comorbidity index score) (“C”); and emergency department use (measured as the number of visits in the six months before admission) (“E”). Scores using the LACE index ranged from 0 (2.0% expected risk of death or urgent readmission within 30 days) to 19 (43.7% expected risk). The LACE index was discriminative (C statistic 0.684) and very accurate (Hosmer–Lemeshow goodness-of-fit statistic 14.1, p = 0.59) at predicting outcome risk. Interpretation: The LACE index can be used to quantify risk of death or unplanned readmission within 30 days after discharge from hospital. This index can be used with both primary and administrative data. Further research is required to determine whether such quantification changes patient care or outcomes.
- Published
- 2010
38. Information exchange among physicians caring for the same patient in the community
- Author
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Edward Etchells, Chaim M. Bell, Ian G. Stiell, Carl van Walraven, Kelly B. Zarnke, Monica Taljaard, and Alan J. Forster
- Subjects
Male ,medicine.medical_specialty ,Office Visits ,Hospitals, Community ,Physician visit ,Access to Information ,Hospitals, University ,Primary outcome ,Physicians ,Health care ,Humans ,Medicine ,Prospective Studies ,Letters ,Cooperative Behavior ,Prospective cohort study ,Information exchange ,Ontario ,business.industry ,Research ,Communication ,General Medicine ,Odds ratio ,Continuity of Patient Care ,Middle Aged ,After discharge ,Confidence interval ,Family medicine ,Emergency medicine ,Female ,Medical Record Linkage ,business ,Follow-Up Studies - Abstract
Background: The exchange of information is an integral component of continuity of health care and may limit or prevent costly duplication of tests and treatments. This study determined the probability that patient information from previous visits with other physicians was available for a current physician visit. Methods: We conducted a multicentre prospective cohort study including patients discharged from the medical or surgical services of 11 community and academic hospitals in Ontario. Patients included in the study saw at least 2 different physicians during the 6 months after discharge. The primary outcome was whether information from a previous visit with another physician was available at the current visit. We determined the availability of previous information using surveys of or interviews with the physicians seen during current visits. Results: A total of 3250 patients, with a total of 39 469 previous–current visit combinations, met the inclusion criteria. Overall, information about the previous visit was available 22.0% of the time. Information was more likely to be available if the current doctor was a family physician (odds ratio [OR] 1.75, 95% confidence interval [CI] 1.54–1.98) or a physician who had treated the patient before the hospital admission (OR 1.33, 95% CI 1.21–1.46). Conversely, information was less likely to be available if the previous doctor was a family physician (OR 0.38, 95% CI 0.32–0.44) or a physician who had treated the patient before the admission (OR 0.72, 95% CI 0.60–0.86). The strongest predictor of information exchange was the current physician having previously received information about the patient from the previous physician (OR 7.72, 95% CI 6.92–8.63). Interpretation: Health care information is often not shared among multiple physicians treating the same patient. This situation would be improved if information from family physicians and patients9 regular physicians was more systematically available to other physicians.
- Published
- 2008
39. Patient-directed intelligent and interactive computer medical history-gathering systems: A utility and feasibility study in the emergency department
- Author
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Roman Elinson, Mark Benaroia, and Kelly B. Zarnke
- Subjects
Adult ,Male ,Canada ,Medical Records Systems, Computerized ,Point-of-Care Systems ,Health Informatics ,computer.software_genre ,Patient response ,User-Computer Interface ,Documentation ,Mode (computer interface) ,Complaint ,medicine ,Humans ,Medical history ,Medical History Taking ,Attitude to Computers ,business.industry ,Data Collection ,Emergency department ,Middle Aged ,medicine.disease ,Triage ,Expert system ,Female ,Medical emergency ,Patient Participation ,Emergency Service, Hospital ,business ,computer - Abstract
Introduction Patients can be used as a resource to enter their own pertinent medical information. This study will evaluate the feasibility of an intelligent computer medical history-taking device directed at patients in the emergency department (ED). Methods Two of the authors (MB, RE) developed an expert system that can take patient-directed medical histories. Patients interacted with the computer in the ED waiting room while it gathered a medical history based on chief complaint (CC). A survey was completed post history. A sub-study assessed the computer's ability to take an adequate history for an index CC. We compared the computer and emergency physician histories for the presence or absence of important historical elements. Results Sixty-seven patients used the interactive computer system. The mean time to complete the history was 5 min and 32 s ± 1 min and 21 s. The patient response rate was 97%. Over 83% felt that the computer was very easy to use and over 92% would very much use the computer again. A total of 15 patients with abdominal pain (index CC) were evaluated for the sub-study. The computer history asked 90 ± 7%, and the emergency physician asked 55 ± 18%, of the important historical elements. These groups were statistically different with a p-value of Conclusion This feasibility study has shown that the computer history-taking device is well accepted by patients and that such a system can be integrated into the normal process of patient triage without delaying patient care. Such a system can serve as an initial mode for documentation and data acquisition directly from the patient.
- Published
- 2007
40. Risk prediction models for acute kidney injury following major noncardiac surgery: systematic review
- Author
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Rob R. Quinn, Matthew T. James, Kim Cheema, Samuel Quan, Elijah Dixon, Kelly B. Zarnke, Lawrence de Koning, Todd Wilson, and Neesh Pannu
- Subjects
medicine.medical_specialty ,medicine.medical_treatment ,MEDLINE ,Renal function ,Liver transplantation ,urologic and male genital diseases ,Global Health ,Risk Assessment ,Postoperative Complications ,Risk Factors ,Medicine ,Humans ,Rifle ,cardiovascular diseases ,Renal replacement therapy ,Intensive care medicine ,Transplantation ,business.industry ,Incidence ,Acute kidney injury ,Acute Kidney Injury ,Models, Theoretical ,medicine.disease ,Prognosis ,female genital diseases and pregnancy complications ,Nephrology ,Surgical Procedures, Operative ,business ,Risk assessment ,Kidney disease - Abstract
Background Acute kidney injury (AKI) is a serious complication of major noncardiac surgery. Risk prediction models for AKI following noncardiac surgery may be useful for identifying high-risk patients to target with prevention strategies. Methods We conducted a systematic review of risk prediction models for AKI following major noncardiac surgery. MEDLINE, EMBASE, BIOSIS Previews and Web of Science were searched for articles that (i) developed or validated a prediction model for AKI following major noncardiac surgery or (ii) assessed the impact of a model for predicting AKI following major noncardiac surgery that has been implemented in a clinical setting. Results We identified seven models from six articles that described a risk prediction model for AKI following major noncardiac surgeries. Three studies developed prediction models for AKI requiring renal replacement therapy following liver transplantation, three derived prediction models for AKI based on the Risk, Injury, Failure, Loss of kidney function, End-stage kidney disease (RIFLE) criteria following liver resection and one study developed a prediction model for AKI following major noncardiac surgical procedures. The final models included between 4 and 11 independent variables, and c-statistics ranged from 0.79 to 0.90. None of the models were externally validated. Conclusions Risk prediction models for AKI after major noncardiac surgery are available; however, these models lack validation, studies of clinical implementation and impact analyses. Further research is needed to develop, validate and study the clinical impact of such models before broad clinical uptake.
- Published
- 2015
41. Diagnosing technical competence in six bedside procedures: comparing checklists and a global rating scale in the assessment of resident performance
- Author
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Irene W. Y. Ma, Alison Walzak, Charlene Brass, Kevin McLaughlin, Jeffrey P. Schaefer, Kelly B. Zarnke, Jennifer Glow, and Maria Bacchus
- Subjects
Adult ,Male ,medicine.medical_specialty ,Point-of-Care Systems ,MEDLINE ,Education ,Alberta ,medicine ,Internal Medicine ,Humans ,Psychiatry ,Competence (human resources) ,Global rating scale ,Medical education ,Medical Errors ,Videotape Recording ,business.industry ,Internship and Residency ,Reproducibility of Results ,General Medicine ,Checklist ,Education, Medical, Graduate ,Employee Performance Appraisal ,Female ,Clinical Competence ,Educational Measurement ,Clinical competence ,business - Abstract
To compare procedure-specific checklists and a global rating scale in assessing technical competence.Two trained raters used procedure-specific checklists and a global rating scale to independently evaluate 218 video-recorded performances of six bedside procedures of varying complexity for technical competence. The procedures were completed by 47 residents participating in a formative simulation-based objective structured clinical examination at the University of Calgary in 2011. Pass/fail (competent/not competent) decisions were based on an overall global assessment item on the global rating scale. Raters provided written comments on performances they deemed not competent. Checklist minimum passing levels were set using traditional standard-setting methods.For each procedure, the global rating scale demonstrated higher internal reliability and lower interrater reliability than the checklist. However, interrater reliability was almost perfect for decisions on competence using the overall global assessment (Kappa range: 0.84-1.00). Clinically significant procedural errors were most often cited as reasons for ratings of not competent. Using checklist scores to diagnose competence demonstrated acceptable discrimination: The area under the curve ranged from 0.84 (95% CI 0.72-0.97) to 0.93 (95% CI 0.82-1.00). Checklist minimum passing levels demonstrated high sensitivity but low specificity for diagnosing competence.Assessment using a global rating scale may be superior to assessment using a checklist for evaluation of technical competence. Traditional standard-setting methods may establish checklist cut scores with too-low specificity: High checklist scores did not rule out incompetence. The role of clinically significant errors in determining procedural competence should be further evaluated.
- Published
- 2015
42. The attributes of an effective teacher differ between the classroom and the clinical setting
- Author
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Pietro Ravani, Jeffrey P. Schaefer, Jolene T. Haws, Luke Rannelli, Kevin McLaughlin, Kelly B. Zarnke, and Sylvain Coderre
- Subjects
Male ,Faculty, Medical ,Students, Medical ,020205 medical informatics ,media_common.quotation_subject ,education ,Impression formation ,050109 social psychology ,Context (language use) ,Stereotype ,02 engineering and technology ,behavioral disciplines and activities ,Interpersonal attraction ,Education ,Developmental psychology ,Alberta ,Beauty ,Professional Competence ,0202 electrical engineering, electronic engineering, information engineering ,Internal Medicine ,Humans ,0501 psychology and cognitive sciences ,Association (psychology) ,media_common ,Context effect ,Teaching ,05 social sciences ,Physical attractiveness ,Regression analysis ,General Medicine ,Education, Medical, Graduate ,Female ,Psychology ,Social psychology ,Personality - Abstract
Most training programs use learners’ subjective ratings of their teachers as the primary measure of teaching effectiveness. In a recent study we found that preclinical medical students’ ratings of classroom teachers were associated with perceived charisma and physical attractiveness of the teacher, but not intellect. Here we explored whether the relationship between these variables and teaching effectiveness ratings holds in the clinical setting. We asked 27 Internal Medicine residents to rate teaching effectiveness of ten teachers with whom they had worked on a clinical rotation, in addition to rating each teacher’s clinical skills, physical attractiveness, and charisma. We used linear regression to study the association between these explanatory variables and teaching effectiveness ratings. We found no association between rating of physical attractiveness and teaching effectiveness. Clinical skill and charisma were independently associated with rating of teaching effectiveness (regression coefficients [95 % confidence interval] 0.73 [0.60, 0.85], p
- Published
- 2015
43. The 2015 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension
- Author
-
Stella S. Daskalopoulou, Doreen M. Rabi, Kelly B. Zarnke, Kaberi Dasgupta, Kara Nerenberg, Lyne Cloutier, Mark Gelfer, Maxime Lamarre-Cliche, Alain Milot, Peter Bolli, Donald W. McKay, Guy Tremblay, Donna McLean, Sheldon W. Tobe, Marcel Ruzicka, Kevin D. Burns, Michel Vallée, G.V. Ramesh Prasad, Marcel Lebel, Ross D. Feldman, Peter Selby, Andrew Pipe, Ernesto L. Schiffrin, Philip A. McFarlane, Paul Oh, Robert A. Hegele, Milan Khara, Thomas W. Wilson, S. Brian Penner, Ellen Burgess, Robert J. Herman, Simon L. Bacon, Simon W. Rabkin, Richard E. Gilbert, Tavis S. Campbell, Steven Grover, George Honos, Patrice Lindsay, Michael D. Hill, Shelagh B. Coutts, Gord Gubitz, Norman R.C. Campbell, Gordon W. Moe, Jonathan G. Howlett, Jean-Martin Boulanger, Ally Prebtani, Pierre Larochelle, Lawrence A. Leiter, Charlotte Jones, Richard I. Ogilvie, Vincent Woo, Janusz Kaczorowski, Luc Trudeau, Robert J. Petrella, Swapnil Hiremath, James A. Stone, Denis Drouin, Kim L. Lavoie, Pavel Hamet, George Fodor, Jean C. Grégoire, Anne Fournier, Richard Lewanczuk, George K. Dresser, Mukul Sharma, Debra Reid, Geneviève Benoit, Janusz Feber, Kevin C. Harris, Luc Poirier, and Raj S. Padwal
- Subjects
Male ,medicine.medical_specialty ,Canada ,Ambulatory blood pressure ,medicine.medical_treatment ,White coat hypertension ,Renal artery stenosis ,Risk Assessment ,medicine ,Humans ,Antihypertensive Agents ,medicine.diagnostic_test ,business.industry ,Blood Pressure Determination ,Auscultation ,Blood Pressure Monitoring, Ambulatory ,medicine.disease ,Surgery ,Primary Prevention ,Mean blood pressure ,Blood pressure ,Emergency medicine ,Hypertension ,Practice Guidelines as Topic ,Smoking cessation ,Education, Medical, Continuing ,Female ,Cardiology and Cardiovascular Medicine ,business ,Risk assessment - Abstract
The Canadian Hypertension Education Program reviews the hypertension literature annually and provides detailed recommendations regarding hypertension diagnosis, assessment, prevention, and treatment. This report provides the updated evidence-based recommendations for 2015. This year, 4 new recommendations were added and 2 existing recommendations were modified. A revised algorithm for the diagnosis of hypertension is presented. Two major changes are proposed: (1) measurement using validated electronic (oscillometric) upper arm devices is preferred over auscultation for accurate office blood pressure measurement; (2) if the visit 1 mean blood pressure is increased but < 180/110 mm Hg, out-of-office blood pressure measurements using ambulatory blood pressure monitoring (preferably) or home blood pressure monitoring should be performed before visit 2 to rule out white coat hypertension, for which pharmacologic treatment is not recommended. A standardized ambulatory blood pressure monitoring protocol and an update on automated office blood pressure are also presented. Several other recommendations on accurate measurement of blood pressure and criteria for diagnosis of hypertension have been reorganized. Two other new recommendations refer to smoking cessation: (1) tobacco use status should be updated regularly and advice to quit smoking should be provided; and (2) advice in combination with pharmacotherapy for smoking cessation should be offered to all smokers. The following recommendations were modified: (1) renal artery stenosis should be primarily managed medically; and (2) renal artery angioplasty and stenting could be considered for patients with renal artery stenosis and complicated, uncontrolled hypertension. The rationale for these recommendation changes is discussed.
- Published
- 2015
44. GEOGRAPHIC PATTERN OF SERUM ANTIBODY PREVALENCE FOR BRUCELLA SPP. IN CARIBOU, GRIZZLY BEARS, AND WOLVES FROM ALASKA, 1975–1998
- Author
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Robert A. Delong, Jay M. Ver Hoef, and Randall L. Zarnke
- Subjects
Wolves ,Ecology ,biology ,Grizzly Bears ,Zoology ,Animals, Wild ,Brucella ,biology.organism_classification ,organization ,Antibodies, Bacterial ,Brucellosis ,organization.mascot ,Serum antibody ,Canis ,Seroepidemiologic Studies ,Animals ,Ursus ,Antibody prevalence ,Alaska ,Ursidae ,Ecology, Evolution, Behavior and Systematics ,Reindeer - Abstract
Blood samples were collected from 2,635 caribou (Rangifer tarandus), 1,238 grizzly bears (Ursus arctos), and 930 wolves (Canis lupus) from throughout mainland Alaska during 1975-98. Sera were tested for evidence of exposure to Brucella spp. Serum antibody prevalences were highest in the northwestern region of the state. In any specific area, antibody prevalences for caribou and wolves were of a similar magnitude, whereas antibody prevalence for bears in these same areas were two to three times higher.
- Published
- 2006
45. Public health evaluation of cadmium concentrations in liver and kidney of moose (Alces alces) from four areas of Alaska
- Author
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Tracey V. Lynn, Scott M. Arnold, Marc-Andre R. Chimonas, Adrian Frank, and Randall L. Zarnke
- Subjects
Male ,medicine.medical_specialty ,Environmental Engineering ,chemistry.chemical_element ,Food Contamination ,Biology ,Kidney ,Risk Assessment ,World health ,Animal science ,Environmental protection ,Biomonitoring ,medicine ,Animals ,Humans ,Environmental Chemistry ,Waste Management and Disposal ,Atomic emission spectrometry ,Cadmium ,Deer ,Public health ,Liver and kidney ,Pollution ,medicine.anatomical_structure ,Liver ,chemistry ,Environmental Pollutants ,Female ,Alaska ,Environmental Monitoring ,Food contaminant - Abstract
Liver and/or kidney samples were collected from 139 hunter-killed moose from four areas of Alaska during 1986. The concentration of cadmium in organ tissue was determined by direct-current plasma atomic emission spectrometry. All results are reported as mug/g wet weight. Concentrations of cadmium in liver ranged from 0.06 microg/g to 9.0 microg/g; in the kidney cortex they ranged from 0.10 microg/g to 65.7 microg/g. Cadmium levels were significantly associated with location and age. The highest geometric mean liver (2.11 microg/g) and kidney cortex (20.2 microg/g) cadmium concentrations were detected in moose harvested near Galena, Alaska. Limited dietary information from Alaska and Canada indicates that the intake of moose liver or kidney does not exceed, in most individuals, the World Health Organization recommendations for weekly cadmium consumption of 400 microg to 500 microg. Additionally, human biomonitoring data from Canada and Alaska indicate exposure to cadmium is low except for individuals who smoke cigarettes. Given the nutritional and cultural value of subsistence foods, the Alaska Division of Public Health continues to support the consumption of moose liver and kidney as part of a well-balanced diet. Human biomonitoring studies are needed in Alaska to determine actual cadmium exposure in populations with a lifelong history of moose liver and kidney consumption.
- Published
- 2006
46. Diabetes During Diarrhea-Associated Hemolytic Uremic Syndrome
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Jeffrey L. Mahon, William F. Clark, Kelly B. Zarnke, Nick Barrowman, M. Patricia Rosas-Arellano, Jocelyn S. Garland, Amit X. Garg, Rita S. Suri, and Heather Thiessen-Philbrook
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Advanced and Specialized Nursing ,medicine.medical_specialty ,business.industry ,Endocrinology, Diabetes and Metabolism ,Insulin ,medicine.medical_treatment ,Incidence (epidemiology) ,medicine.disease ,Diarrhea-associated Hemolytic Uremic Syndrome ,Surgery ,Diarrhea ,Meta-analysis ,Diabetes mellitus ,Internal medicine ,Internal Medicine ,medicine ,medicine.symptom ,business ,Dialysis ,Kidney disease - Abstract
OBJECTIVE—To quantify the incidence of diabetes during the acute phase of diarrhea-associated hemolytic uremic syndrome (D+HUS) and to identify features associated with its development. RESEARCH DESIGN AND METHODS—A systematic review and meta-analysis of articles assessing diabetes during D+HUS was conducted. Relevant citations were identified from Medline, Embase, and Institute for Scientific Information Citation Index databases. Bibliographies of relevant articles were hand searched. All articles were independently reviewed for inclusion and data abstraction by two authors. RESULTS—Twenty-one studies from six countries were included. Only 2 studies reported a standard definition of diabetes; 14 defined diabetes as hyperglycemia requiring insulin. The incidence of diabetes during the acute phase of D+HUS could be quantified in a subset of 1,139 children from 13 studies (1966–1998, age 0.2–16 years) and ranged from 0 to 15%, with a pooled incidence of 3.2% (95% CI 1.3–5.1, random-effects model, significant heterogeneity among studies, P = 0.007). Children who developed diabetes were more likely to have severe disease (e.g., presence of coma or seizures, need for dialysis) and had higher mortality than those without diabetes. Twenty-three percent of those who developed diabetes acutely died, and 38% of survivors required long-term insulin (median follow-up 12 months). Recurrence of diabetes was possible up to 60 months after initial recovery. CONCLUSIONS—Children with D+HUS should be observed for diabetes during their acute illness. Consideration should be given to long-term screening of D+HUS survivors for diabetes.
- Published
- 2005
47. Toxoplasma gondii, Neospora caninum, Sarcocystis neurona, and Sarcocystis canis-like infections in marine mammals
- Author
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R. Zarnke, Jitender P. Dubey, Stéphane Romand, Oliver C.H. Kwok, Nancy J. Thomas, M. Briggs, S. K. Wong, R. Ewing, M. Mense, Philippe Thulliez, W. Van Bonn, and J.W. Davis
- Subjects
Male ,Sarcocystosis ,Zalophus californianus ,Seals, Earless ,Antibodies, Protozoan ,Phoca ,Microbiology ,Seroepidemiologic Studies ,Agglutination Tests ,Direct agglutination test ,biology.animal ,parasitic diseases ,medicine ,Animals ,General Veterinary ,Enhydra lutris ,biology ,Coccidiosis ,fungi ,Neospora ,Sarcocystis ,Toxoplasma gondii ,General Medicine ,Anatomy ,biology.organism_classification ,medicine.disease ,Neospora caninum ,Toxoplasmosis ,Toxoplasmosis, Animal ,Canis ,Female ,Parasitology ,Cetacea ,Toxoplasma ,Otters - Abstract
Toxoplasma gondii, Neospora caninum, Sarcocystis neurona, and S. canis are related protozoans that can cause mortality in many species of domestic and wild animals. Recently, T. gondii and S. neurona were recognized to cause encephalitis in marine mammals. As yet, there is no report of natural exposure of N. caninum in marine mammals. In the present study, antibodies to T. gondii and N. caninum were assayed in sera of several species of marine mammals. For T. gondii, sera were diluted 1:25, 1:50, and 1:500 and assayed in the T. gondii modified agglutination test (MAT). Antibodies (MATor =1:25) to T. gondii were found in 89 of 115 (77%) dead, and 18 of 30 (60%) apparently healthy sea otters (Enhydra lutris), 51 of 311 (16%) Pacific harbor seals (Phoca vitulina), 19 of 45 (42%) sea lions (Eumetopias jubatus) [corrected] 5 of 32 (16%) ringed seals (Phoca hispida), 4 of 8 (50%) bearded seals (Erignathus barbatus), 1 of 9 (11.1%) spotted seals (Phoca largha), 138 of 141 (98%) Atlantic bottlenose dolphins (Tursiops truncatus), and 3 of 53 (6%) walruses (Odobenus rosmarus). For N. caninum, sera were diluted 1:40, 1:80, 1:160, and 1:320 and examined with the Neospora agglutination test (NAT) using mouse-derived tachyzoites. NAT antibodies were found in 3 of 53 (6%) walruses, 28 of 145 (19%) sea otters, 11 of 311 (3.5%) harbor seals, 1 of 27 (3.7%) sea lions, 4 of 32 (12.5%) ringed seals, 1 of 8 (12.5%) bearded seals, and 43 of 47 (91%) bottlenose dolphins. To our knowledge, this is the first report of N. caninum antibodies in any marine mammal, and the first report of T. gondii antibodies in walruses and in ringed, bearded, spotted, and ribbon seals. Current information on T. gondii-like and Sarcocystis-like infections in marine mammals is reviewed. New cases of clinical S. canis and T. gondii infections are also reported in sea lions, and T. gondii infection in an Antillean manatee (Trichechus manatus manatus).
- Published
- 2003
48. Temporal trends in antihypertensive drug prescriptions in Canada before and after introduction of the Canadian Hypertension Education Program
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Mitch Levine, Denis Drouin, Rollin Brant, Robert J. Herman, Finlay A. McAlister, Norman R.C. Campbell, Kelly B. Zarnke, and Ross D. Feldman
- Subjects
Canada ,medicine.medical_specialty ,Digoxin ,Physiology ,medicine.drug_class ,Pharmacology ,Internal medicine ,Internal Medicine ,Humans ,Medicine ,Longitudinal Studies ,Practice Patterns, Physicians' ,Medical prescription ,Antihypertensive drug ,Antihypertensive Agents ,business.industry ,Incidence (epidemiology) ,Guideline ,Loop diuretic ,medicine.disease ,Confidence interval ,Heart failure ,Drug Information Services ,Hypertension ,Education, Medical, Continuing ,Cardiology and Cardiovascular Medicine ,business ,medicine.drug - Abstract
Objective Poor control of hypertension is a world-wide health issue. In 1999, the Canadian Hypertension Education Program (CHEP) was launched to annually develop and implement evidence-based hypertension guidelines in an effort to improve hypertension control rates. This study was designed to examine temporal trends in antihypertensive drug prescribing and to explore whether drug prescriptions changed after initiation of the new CHEP guideline process. Design and methods We used longitudinal Canadian dispensing data (from the IMS CompuScript database; IMS Health, Pointe-Claire, Quebec) to examine antihypertensive prescriptions in the 3 years prior to and the 3 years following introduction of the new CHEP process. To control for temporal changes in the incidence of other cardiovascular conditions for which antihypertensive agents may be prescribed for their non-blood pressure-lowering effects (for example, angiotensin-converting enzyme (ACE) inhibitors for heart failure or coronary artery disease), prescription rates for digoxin, loop diuretics, and nitrates were also examined. Results Prescriptions for all antihypertensive agents increased significantly between 1996 and 2001 [11% for thiazides, 45% for beta-blockers, 68% for ACE inhibitors, 19% for calcium channel blockers, and 4332% for angiotensin receptor blockers (ARBs)]. Loop diuretic prescriptions increased 27%, but prescriptions for digoxin (-19%) and nitrates (-8%) declined over this time frame. Time series analyses demonstrated increases in the prescription growth rate for all four antihypertensive drug classes recommended in CHEP for the period 1999-2001 compared with 1996-1998, which were statistically significantly and of substantial magnitude (absolute annual increase in prescription growth rate of 4.6% (95% confidence interval 3.5-5.9%) for thiazides, 3.0% (1.8-4.2%) for beta-blockers, 8.2% (6.7-9.7%) for ACE inhibitors, and 6.1% (4.4-7.8%) for calcium channel blockers). The growth rate in nitrate prescriptions did not significantly change [1.1% (-0.6 to +3.0%)] and, although the changes in growth rate for loop diuretics [4.7% (3.2-6.3%)] and digoxin [2.1% (0.6-3.5%)] were statistically significant, they were of smaller magnitude than the changes in the four recommended antihypertensive agents. Similar results were observed when analysis was restricted to new prescriptions only. Conclusions Prescriptions for all antihypertensive drugs increased substantially in Canada between 1996 and 2001; the rate of increase was significantly greater after 1999 for all four drugs recommended as first-line therapy in the annual CHEP guidelines. This preliminary data is encouraging, but a national survey of blood pressure control is needed to fully evaluate the impact of the new Canadian guideline process.
- Published
- 2003
49. Molecular identification of natural hybrids between Trichinella nativa and Trichinella T6 provides evidence of gene flow and ongoing genetic divergence
- Author
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Dante S. Zarlenga, R.L. Zarnke, G. La Rosa, Edoardo Pozio, Adriano Casulli, and Gianluca Marucci
- Subjects
Genetic Markers ,Male ,Sympatry ,Genotype ,Trichinella ,Molecular Sequence Data ,Population Dynamics ,Trichinella spiralis ,Allopatric speciation ,Population genetics ,Zoology ,Gene flow ,parasitic diseases ,Animals ,Amino Acid Sequence ,Genes, Helminth ,Genetics ,Wolves ,Base Sequence ,biology ,Arctic Regions ,Reproduction ,fungi ,biology.organism_classification ,Genetic divergence ,Infectious Diseases ,Hybridization, Genetic ,Female ,Parasitology ,Sequence Alignment ,Trichinella nativa ,Alaska - Abstract
To date, there are no data available on the population genetics of Trichinella due to the lack of genetic markers and the difficulty of working with such small parasites. In the Arctic region of North America and along the Rocky Mountains, there exist two genotypes of Trichinella , Trichinella nativa and Trichinella T6, respectively, which are well differentiated by biochemical and molecular characters. However, both are resistant to freezing, show other common biological characters (e.g. low or no infectivity to rodents and swine) and produce fertile F1 offspring upon interbreeding. To data, these two genotypes have been considered allopatric. In this study, we detected both genotypes in wolves of the same wolf packs in Alaska, suggesting sympatry. A single GTT trinucleotide present in the ITS-2 sequence of T. nativa but not in Trichinella T6 was used as a genetic marker to study gene flow for this character in both a murine infection model and in larvae from naturally-infected Alaskan wolves. Only F1 larvae originating from a cross between T. nativa male and Trichinella T6 female were able to produce F2 offspring. Larvae (F1) originating from a cross between Trichinella T6 male and T. nativa female were not reproductively viable. As expected, all F1 larvae showed a heterozygote pattern for the GTT character upon heteroduplex analysis; however, within the F2 population, the number of observed heterozygotes ( n =52) was substantially higher than expected ( n =39.08), as supported by the F is index, and was not in the Hardy–Weinberg equilibrium. Larvae from two of the 16 Trichinella positive Alaskan wolves, showed the Trichinella T6 pattern or the T. nativa / Trichinella T6 hybrid pattern. Our data demonstrate that T. nativa and Trichinella T6 live in sympatry at least in Alaskan wolves, where T. nativa occurs more frequently (69%) than Trichinella T6 (31%). One explanation for this phenomenon is that glacial periods may have caused a geographical relocation, colonisation and independent evolution of T. nativa within the Rocky Mountains, resulting in a bifurcation of the freeze-resistant genotype. Additional studies will be required to test this hypothesis.
- Published
- 2003
50. [Untitled]
- Author
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Raymond Yee, Christopher S. Simpson, George J. Klein, Andrew D. Krahn, John K. Lee, Kelly B. Zarnke, and Allan C. Skanes
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medicine.medical_specialty ,business.industry ,Atrial fibrillation ,Retrospective cohort study ,medicine.disease ,law.invention ,Cardiac surgery ,Coronary artery bypass surgery ,Randomized controlled trial ,law ,Internal medicine ,Cardiology ,medicine ,Clinical endpoint ,Sinus rhythm ,Cardiology and Cardiovascular Medicine ,business ,Prospective cohort study - Abstract
Atrial fibrillation (AF) remains a frequent complication of cardiac surgery. The optimal treatment strategy has not been established. Retrospective studies have suggested that a primary rate-control strategy may be equivalent to a strategy that restores sinus rhythm. Fifty patients with postoperative atrial fibrillation were randomly assigned to a strategy of antiarrhythmic therapy +/- electrical cardioversion or ventricular rate control. Anticoagulation with heparin overlapped with coumadin was administered to both arms. The primary endpoint of the study was time to conversion to sinus rhythm analyzed by the Kaplan-Meier method. The effects of strategy on hospital length of stay was examined as well as the incidence of recurrent AF. This study demonstrated no significant difference between an antiarrhythmic conversion strategy (n = 27) and a rate-control strategy (n = 23) in time to conversion to sinus rhythm (11.2 +/- 3.2 vs. 11.8 +/- 3.9 hours; p = 0.8). With Cox multivariate analysis to control for the effects of age, sex, beta-blocker usage, and type of surgery, the conversion strategy showed a trend toward reducing the time from treatment to restoration of sinus rhythm (p = 0.08). The length of hospital stay was reduced in the antiarrhythmic arm compared with the rate-control strategy (9.0 +/- 0.7 vs. 13.2 +/- 2.0 days; p = 0.05). In hospital relapse rates in the antiarrhythmic arm were 30% compared with 57% in the rate-control strategy (p = 0.24). At the termination of the study, 91% of the patients in the rate-control arm were in sinus rhythm compared with 96% in the antiarrhythmic arm. In conclusion, this pilot study shows little difference between a rate-control strategy and a strategy to restore/maintain sinus rhythm. Regardless of the strategy, majority of patients will be in sinus rhythm after two months. A larger randomized, controlled study is needed to assess the impact of restoration of sinus rhythm on length of stay.
- Published
- 2003
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