Canadian Consensus Conference Research Articles

Latest Canadian Consensus Conference on the Diagnosis and Treatment of Dementia: What's in It for Primary Care?

In 2020, the fifth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD5) published up-to-date recommendations for the clinical management of persons living with dementia (PLWD) and their caregivers. During the CCCDTD5 meetings, a list of recommendations for dementia care was compiled. With the aid of family physicians and the Canadian Consortium on Neurodegeneration in Aging, we selected the most relevant CCCDTD5 recommendations for primary care and tailored and summarized them in the present manuscript to facilitate their reference and use. These recommendations focus on (a) risk reduction, (b) screening and diagnosis, (c) deprescription of dementia medications, and (d) non-pharmacological interventions. The development of recommendations for the ongoing management of dementia is an iterative process as new evidence on interventions for dementia is published. These recommendations are important in the primary care setting as the entry point for PLWD into the health system.

The impact of revised definitions for transfusion-associated circulatory overload and transfusion-related acute lung injury on haemovigilance reporting.

Transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI) are serious adverse transfusion reactions. Standardized surveillance definitions are important to ensure consistent reporting of cases. Recently, revised definitions have been developed for TACO and TRALI, the latter of which has not yet been widely implemented. This study aimed to assess the impact of the new TACO and TRALI definitions on haemovigilance reporting. The Australian Red Cross Lifeblood Adverse Transfusion Reaction database was accessed to identify all cases of suspected or confirmed TACO and TRALI referred from 1 July 2015 to 30 June 2019. Cases were assessed against both the former and new definitions and the results were compared. A total of 73 cases were assessed. There were 48 TACO cases identified. Only 26 of 48 cases strictly met the former 2011 International Society of Blood Transfusion (ISBT) definition of TACO; 6 cases did not meet the definition and 16 cases lacked sufficient clinical details. In comparison, 46 cases met the revised 2018 ISBT definition, with only 2 cases having insufficient details. There were 24 cases of TRALI according to the existing 2004 Canadian Consensus Conference (CCC) definition compared with 25 cases according to the proposed 2019 revised definition. The revised TACO definition captured more cases than the former definition. No significant differences were observed in the number of TRALI cases under the proposed new definition. This is the first study to provide validation data for the revised TRALI definition.

Latest Canadian consensus conference on the diagnosis and treatment of dementia for primary care clinicians.

Context: Dementia, characterized by a progressive decline in cognition, affects more than 50 million people globally. In 2020, the 5th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD5) published up-to-date recommendations to guide the clinical management of persons living with dementia (PLWD) and their caregivers. However, primary care clinicians are not always up-to-date with current evidence as the information might be fragmented. Objective: To provide selected new and updated clinical guidance on the management of patients with dementia that are simple to use in a routine primary care practice. Study design: Recommendations were approved and graded based on the Appraisal of Guidelines for Research and Evaluation (AGREE II collaboration), GRADE, and a Delphi process. Setting: Working groups included experts from different backgrounds (primary care physicians, nurse practitioners and other primary care clinicians, neurologists, psychiatrists and geriatricians, researchers, knowledge translation experts, decisions makers, and PLWD and caregivers' representatives). The experts carried out systematic reviews, which guided the development of new recommendations for dementia care. Recommendations included: We summarize the most relevant CCCDTD5 recommendations for primary care clinicians Results: The relevant recommendations for primary care were focused on: a) risk reduction for the general population (nutrition, exercise, social engagement, education, and medication management), as well as for persons at risk of dementia (evaluation of hearing status and sleep, and cognitive training stimulation); b) screening and diagnosis of dementia, including the role of the informant, screening for patients at risk or with symptoms, use of cognitive tests and neuro-imaging, management of subjective cognitive decline); c) de-prescribing medications for dementia, including aspirin and cognitive enhancers; and d) non-pharmacological interventions for persons with dementia (exercise, cognitive stimulation therapy, psychoeducational interventions for caregivers, case management and dementia-friendly community/organizations). Conclusions: The development of recommendations for ongoing management of dementia is an iterative process as new evidence on interventions for dementia are published. The present recommendations are of importance for dementia care in a primary care setting as the entry point for PLWD into the health system.

Informant-based tools for assessment and monitoring of cognition, behavior, and function in neurocognitive disorders: Systematic review and report from a CCCDTD5 Working Group.

As part of the fifth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia, we assessed the literature on informant-based tools for assessment and monitoring of cognition, behavior, and function in neurocognitive disorders (NCDs) to provide evidence-based recommendations for clinicians and researchers. A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards guidelines. Publications that validated the informant-based tools or described their key properties were reviewed. Quality of the studies was assessed using the modified Quality Assessment tool for Diagnostic Accuracy Studies. Out of 386 publications identified through systematic search, 34 that described 19 informant-based tools were included in the final review. Most of these tools are backed by good-quality studies and are appropriate to use in clinical care or research. The tools vary in their psychometric properties, domains covered, comprehensiveness, completion time, and ability to detect longitudinal change. Based on these properties, we identify different tools that may be appropriate for primary care, specialized memory clinic, or research settings. We also identify barriers to use of these tools in routine clinical practice. There are several good-quality tools available to collect informant-report for assessment and monitoring of cognition, behavior, or function in patients with NCDs. Clinicians and researchers may choose a particular tool based on their specific needs such as domains of interest, desired psychometric properties, and feasibility. Further work is needed to make the tools more user-friendly and to adopt them into routine clinical care.

CCCDTD5 recommendations on the deprescribing of cognitive enhancers in dementia.

IntroductionCognitive enhancers (ie, cholinesterase inhibitors and memantine) can provide symptomatic benefit for some individuals with dementia; however, there are circumstances in which the risks of continuing treatment may potentially outweigh benefits. The decision to deprescribe cognitive enhancers must consider each patient's preferences, treatment indications, current clinical status and symptoms, prognosis, and dementia type.MethodsThe 5th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD5) established a subcommittee of experts to review current evidence on the deprescribing of cognitive enhancers. The questions answered by this group included: When should cognitive enhancers be deprescribed in persons with dementia and mild cognitive impairment? How should cognitive enhancers be deprescribed? And, what clinical factors should be considered when deprescribing cognitive enhancers?ResultsPatient and care‐partner preferences should be incorporated into all decisions to deprescribe cognitive enhancers. Cognitive enhancers should be discontinued in individuals without ongoing evidence of benefit or when the indication for cognitive enhancer use was inappropriate (eg, mild cognitive impairment). Deprescribing should occur gradually and cognitive enhancers should be reinitiated if patients’ cognition or function deteriorates. Cognitive enhancers should be continued in individuals whose neuropsychiatric symptoms improve in response to treatment. Clinicians should not deprescribe cognitive enhancers in individuals with significant neuropsychiatric symptoms until symptoms have stabilized.ConclusionCCCDTD5 deprescribing recommendations provide evidence‐informed recommendations related to cognitive enhancer deprescribing that will facilitate shared decision making among patients, care partners, and clinicians.

The Impact of Revised Definitions for TACO and TRALI on Hemovigilance Reporting

IntroductionTransfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI) are serious adverse transfusion reactions. Standardized surveillance definitions are important to ensure consistent and accurate reporting of cases. Recently, revised definitions have been developed for both TACO and TRALI, the latter which have not yet been widely implemented. The primary aim of this study is to assess the impact of the new TACO and TRALI definitions on hemovigilance reporting. The secondary aim is to collate a TRALI case series to describe the epidemiological and laboratory features of this uncommon condition.MethodsThe Australian Red Cross Lifeblood Adverse Transfusion Reaction database, a passive reporting system, was accessed to identify all cases of suspected or confirmed TACO and TRALI referred from 1 July 2015 to 30 June 2019. Cases were assessed against both the former and new definitions of TACO and TRALI and results compared. For confirmed cases of TRALI the following information was collected: patient demographics, antibody investigation results, type and age of products implicated, donor gender and donor outcomes. Statistical analysis was performed using Fisher's exact test.ResultsIn total 99 cases were identified, of which 12 cases were excluded from analysis due to insufficient clinical details. A further 14 cases were excluded as they were deemed not to be transfusion related. The final number of cases assessed was 73.There were 48 TACO cases identified. Only 26 cases strictly met the former 2011 International Society of Blood Transfusion (ISBT) definition of TACO; 6 cases did not meet the definition and 16 cases lacked sufficient clinical details due to the passive nature of the reporting system. In comparison, 46 cases met the revised 2018 ISBT definition, with only 2 cases having insufficient details.There were 24 cases of TRALI according to the 2004 Canadian Consensus Conference (CCC) definition compared with 25 cases according to the proposed 2019 revised definition. Of the 24 cases of TRALI, 15 were classified as TRALI and 9 as possible TRALI. One case was excluded from having TRALI or possible TRALI under the 2004 CCC definition as the patient had pre-existing acute respiratory distress syndrome from influenza A pneumonia, but could be diagnosed as a TRALI Type II under the revised definition as their respiratory status had been stable for more than 12 hours. A total of 62 components from 81 donors were associated with the 24 TRALI cases. Forty-nine (60%) of these donors were male, 31 (38%) female and 1 (1%) unknown (cadaveric liver). Thirty-three (41%) of these donors were deferred due to the presence of HLA antibodies or being the only donor associated with a case. Sixteen cases (67%) were associated with donor antibodies, most commonly HLA class I and HLA class II antibodies that were non-recipient specific. HNA antibodies were present in 3 cases. There were 8 cases in which an HLA or HNA antibody was not implicated. There was no difference in antibody detection rates between low plasma volume components (red cells, pooled platelets and cryoprecipitate) and high plasma volume components (fresh frozen plasma and apheresis platelets) (45% versus 34%, p=0.44). There was a trend towards higher antibody detection rates in female donors (46%) compared with male donors (29%), however this was not statistically significant (p=0.10).ConclusionsThe revised TACO definition appears to capture more cases than the former definition. There appears to be no significant difference in the number of TRALI cases under the proposed new definition compared to the definition currently in use. This is the first study to provide validation data for the revised TRALI definition. TRALI is a rare condition and further studies such as these are required to improve our understanding of its pathophysiology and laboratory findings. DisclosuresNo relevant conflicts of interest to declare.

Canadian Consensus Conference on Psychological and Non-Pharmacological Interventions for Dementia

Psychological and non-pharmacological interventions that could have a positive effect on outcomes important to persons living with dementia are essential to identify given the the limited efficacy of dementia medications and the diverse needs of persons living. In 2019, for the first time the Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD) created a working group to develop recommendations related to a broad range of psychosocial and non-pharmacological interventions exist, typically aimed at improving cognition, symptoms, or well-being, as well as improving caregiver well-being and coping. The recommendations, primarily intended for primary care physicians, may also allow clinicians, organizations, and communities and help to better meet the needs of people living with dementia and their caregivers. A group of 11 experts, including persons living with dementia and informal caregivers, as well as clinicians and researchers from various organizations both nationally and internationally were invited to participate. A rapid review of meta-analyses and literature reviews on psychological and non-pharmacological interventions was conducted. The synthesized results were submitted for a consensus building approach using a Delphi method, involving a panel of more than 50 Canadian participants. Recommendations with a positive vote of 80% or more were considered to have reached consensus. All proposed recommendations reached consensus using the Delphi process. Details of the recommendations are presented. Five recommendations are made: group or individual physical exercise, group cognitive stimulation therapy, psychoeducational interventions for caregivers, dementia friendly organizations/communities, and case management.

CCCDTD5: Reducing the risk of later-life dementia. Evidence informing the Fifth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD-5).

The Fifth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD‐5) was a year‐long process to synthesize the best available evidence on several topics. Our group undertook evaluation of risk reduction, in eight domains: nutrition; physical activity; hearing; sleep; cognitive training and stimulation; social engagement and education; frailty; and medications. Here we describe the rationale for the undertaking and summarize the background evidence—this is also tabulated in the Appendix. We further comment specifically on the relationship between age and dementia, and offer some suggestions for how reducing the risk of dementia in the seventh decade and beyond might be considered if we are to improve prospects for prevention in the near term. We draw to attention that a well‐specified model of success in dementia prevention need not equate to the elimination of cognitive impairment in late life.

Canadian Consensus Conference on Diagnosis and Treatment of Dementia (CCCDTD)5: Guidelines for management of vascular cognitive impairment.

IntroductionVascular disease is a common cause of dementia, and often coexists with other brain pathologies such as Alzheimer's disease to cause mixed dementia. Many of the risk factors for vascular disease are treatable. Our objective was to review evidence for diagnosis and treatment of vascular cognitive impairment (VCI) to issue recommendations to clinicians.MethodsA subcommittee of the Canadian Consensus Conference on Diagnosis and Treatment of Dementia (CCCDTD) reviewed areas of emerging evidence. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to assign the quality of the evidence and strength of the recommendations.ResultsUsing standardized diagnostic criteria, managing hypertension to conventional blood pressure targets, and reducing risk for stroke are strongly recommended. Intensive blood pressure lowering in middle‐aged adults with vascular risk factors, using acetylsalicylic acid in persons with VCI and covert brain infarctions but not if only white matter lesions are present, and using cholinesterase inhibitors are weakly recommended.ConclusionsThe CCCDTD has provided evidence‐based recommendations for diagnosis and management of VCI for use nationally in Canada, that may also be of use worldwide.

CCCDTD5: Individual and community-based psychosocial and other non-pharmacological interventions to support persons living with dementia and their caregivers.

IntroductionCurrent pharmacological therapies for dementia have limited efficacy. Thus it is important to provide recommendations on individual and community‐based psychosocial and non‐pharmacological interventions for persons living with dementia (PLWDs) and their caregivers.MethodsPhase 1: A systematic review for developing recommendations on psychosocial and non‐pharmacological interventions at the individual and community level for PLWDs and their caregivers. Phase 2: Rating of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Phase 3: Delphi process (>50 dementia experts) for approving recommendations by the 5th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD5).ResultsThe CCCDTD5 approved the following recommendations: Exercise (1B) and group cognitive stimulation for PLWDs (2B), psychosocial and psychoeducational interventions for caregivers (2C), development of dementia friendly organization and communities (2C), and case management for PLWDs (2B).DiscussionThe CCCDTD5 provides for the first time, evidence‐based recommendations on psychosocial and non‐pharmacological interventions for PLWDs and their caregivers that can inform evidence‐based policies for PLWDs in Canada.

CCCDTD5 recommendations on early and timely assessment of neurocognitive disorders using cognitive, behavioral, and functional scales.

IntroductionEarlier diagnosis of neurocognitive disorders and neurodegenerative disease is needed to implement preventative interventions, minimize harm, and reduce risk of exploitation in the context of undetected disease. Along the spectrum from subjective cognitive decline (SCD) to dementia, evidence continues to emerge with respect to detection, staging, and monitoring. Updates to previous guidelines are required for clinical practice.MethodsA subcommittee of the 5th Canadian Consensus Conference on Diagnosis and Treatment of Dementia (CCCDTD) reviewed emerging evidence to address the following: (1) Is there a role for screening at‐risk patients without clinical concerns? In what context is assessment for dementia appropriate? (2) What tools can be used to evaluate patients in whom cognitive decline is suspected? (3) What important information can be gained from an informant, using which measures? (4) What instruments can be used to get more in‐depth information to diagnose mild cognitive impairment (MCI) or dementia? (5) What is the approach to those with cognitive concerns but without objective changes (ie, SCD)? (6) How do we track response to treatment and change over time? The Grading of Recommendations Assessment, Development, and Evaluation system was used to rate quality of the evidence and strength of the recommendations.ResultsWe recommend instruments to assess and monitor cognition, behavior, and function across the cognitive spectrum, including reports from patient and informant. We recommend against screening asymptomatic older adults but recommend investigation for self‐ or informant reports of changes in cognition, emergence of behavioral or psychiatric symptoms, or decline in function or self‐care. Standardized assessments should be used for cognitive and behavioral change that have sufficient validity for use in clinical practice.DiscussionThe CCCDTD5 provides evidence‐based recommendations for detection, assessment, and monitoring of neurocognitive disorders. Although these guidelines were developed for use in Canada, they may also be useful in other jurisdictions.

CCCDTD5 recommendations on early non cognitive markers of dementia: A Canadian consensus.

IntroductionCognitive impairment is the hallmark of Alzheimer's disease (AD) and related dementias. However, motor decline has been recently described as a prodromal state that can help to detect at‐risk individuals. Similarly, sensory changes, sleep and behavior disturbances, and frailty have been associated with higher risk of developing dementia. These clinical findings, together with the recognition that AD pathology precedes the diagnosis by many years, raises the possibility that non‐cognitive changes may be early and non‐invasive markers for AD or, even more provocatively, that treating non‐cognitive aspects may help to prevent or treat AD and related dementias.MethodsA subcommittee of the Canadian Consensus Conference on Diagnosis and Treatment of Dementia reviewed areas of emerging evidence for non‐cognitive markers of dementia. We examined the literature for five non‐cognitive domains associated with future dementia: motor, sensory (hearing, vision, olfaction), neuro‐behavioral, frailty, and sleep. The Grading of Recommendations Assessment, Development, and Evaluation system was used to assign the strength of the evidence and quality of the recommendations. We provide recommendations to primary care clinics and to specialized memory clinics, answering the following main questions: (1) What are the non‐cognitive and functional changes associated with risk of developing dementia? and (2) What is the evidence that sensory, motor, behavioral, sleep, and frailty markers can serve as potential predictors of dementia?ResultsEvidence supported that gait speed, dual‐task gait speed, grip strength, frailty, neuropsychiatric symptoms, sleep measures, and hearing loss are predictors of dementia. There was insufficient evidence for recommending assessing olfactory and vision impairments as a predictor of dementia.ConclusionsNon‐cognitive markers can assist in identifying people at risk for cognitive decline or dementia. These non‐cognitive markers may represent prodromal symptoms and several of them are potentially amenable to treatment that might delay the onset of cognitive decline.

Potential organ donor identification and system accountability: expert guidance from a Canadian consensus conference

PurposeDeceased donation rates in Canada remain below the predicted potential and lag behind leading countries. Missing a potential donor leads to preventable death and disability of transplant candidates and increased healthcare costs.MethodsStakeholders were invited to a national consensus conference on improving deceased organ donor identification and referral (ID&R) and healthcare system accountability. In advance, participants received evidence-based, background documents addressing death audits, clinical triggers, required referral legislation, ethics, clinical pathways, and donation standards. At the conference, expert presentations and summaries of background information prepared by the Steering Committee informed group discussions of the preset questions. The conference’s themes were: 1) expectations of potential donors, recipients and their families; 2) donor ID&R: clinical and legal perspectives; 3) enhancing accountability: gaps and solutions; and 4) enhancing accountability: quality/safety organizations.ResultsThirty-seven consensus statements were generated. At the healthcare professional (HCP) level, key statements include: 1) donation be consistently addressed as part of end-of-life care but only after a decision to withdraw life-sustaining treatment; 2) HCP know how and when to identify and refer potential donors; and 3) transplant candidates be informed of local allocation guidelines and performance. At the healthcare system level, key statements include: 1) national adoption of clinical criteria to trigger ID&R; 2) dedicated resources to match donation activities, including transfer of a potential donor; 3) performance measurement through death audits; 4) reporting and investigation of missed donation opportunities (MDO); 5) recognition of top performers; and 6) missed donor ID&R be considered a preventable and critical safety incident.ConclusionOur consensus statements establish HCP and healthcare system responsibilities regarding potential organ donor ID&R and include the tracking, reviewing and elimination of MDO through system-wide death audits. Once implemented, these consensus statements will help honour patients’ wishes to donate, improve service to potential transplant recipients, and support HCPs in fulfilling their ethical and legal responsibilitites. Next steps include implementation, assessment of their impact on donation rates, and investigation of new evidence-based targets for system improvement.

Poster Number: NR 18 - Effectiveness of A Review and Reduction Strategy for Patients Receiving Atypical Neuroleptic Treatment for Behavioral and Psychological Symptoms of Dementia on Hospital Inpatient Geriatric Units

Introduction: Behavioural and psychological symptoms of dementia (BPSD) have a high prevalence in dementia. There are many suggested management strategies for BPSD. Neuroleptics have a role in the management of these symptoms, but the potential benefits must be weighed against the significant risks such as cerebrovascular adverse events and mortality. The 3rd Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD, 2007) recommends careful review and documentation of BPSD, with efforts at modifying behaviours through non pharmacological methods first. Neuroleptic medications may be necessary for symptoms of severe agitation, aggression and psychosis where there is risk of harm to the patient and/or others. The CCCDTD3 recommends that if used, these medications should be reviewed for potential taper or withdrawal after 3 months of stability.

Knowledge Mobilization and Mental Health Policy: Lessons from the Canadian Consensus Conference on the Mental Health of Emerging Adults

This case study explores how the Consensus Conference on the Mental Health of Emerging Adults, hosted by the Mental Health Commission of Canada in 2015, can impact mental health policy and practice in Canada. The study draws on interviews from 14 delegates who attended the conference. Participants praised innovations such as the inclusion of an emerging adult panel that provided feedback on all discussions, and efforts to make the consensus-building process meaningful in the Canadian policy context. Findings suggest that consensus conferences are a promising way to operationalize the Mental Health Strategy for Canada through policy and practice changes.

Analysis of Transfusion-Related Acute Lung Injury and Possible Transfusion-Related Acute Lung Injury Reported to the French Hemovigilance Network From 2007 to 2013.

Using the French Hemovigilance Network database from 2007 to 2013, we provide information on demographics, incidence, and risk factors of reported transfusion-related acute lung injury (TRALI) and possible TRALI, analyze TRALI mitigation efforts for fresh frozen plasma and platelet concentrates, and consider the impact of platelet additive solutions on TRALI incidence. We applied the Toronto consensus conference definitions for TRALI and possible TRALI. Two TRALI subgroups were considered: "antibody positive" when a donor has human leukocyte antigen (class I or II) and/or human neutrophil antigen antibodies and the recipient has cognate antigen, and "antibody negative" when immunological investigation is negative or not done. The analysis targeted 378 cases, divided into antibody-positive TRALI (n=75), antibody-negative TRALI (n=100), and possible TRALI (n=203). TRALI patients were younger and received more blood components than the general population of transfused patients. Moreover, we identified the following clinical conditions where patients seemed to be at higher risk to develop TRALI: postpartum hemorrhage, acute myeloid leukemia, liver transplantation, allogeneic and autologous hematopoietic stem cells transplantation, polytrauma, and thrombotic microangiopathy. Policy measures intended to reduce antibody-positive TRALI were found effective for apheresis platelet concentrates and fresh frozen plasma but not for whole blood-derived platelet concentrates. The use of platelet additive solutions was associated with a significant reduction in the incidence of TRALI following transfusion of buffy coat-derived platelet concentrates but not following transfusion of apheresis platelets. Our data reinforce the concept that possible TRALI and TRALI, as defined in the Canadian consensus conference, share many characteristics. No specific policy measures are currently directed at mitigation of possible TRALI despite its impact on transfusion safety. Despite TRALI mitigation measures, the overall incidence of TRALI cases reported to the French Hemovigilance system was not significantly reduced. Therefore, additional research is needed to reduce, if not eradicate, all TRALI categories.

The New Criteria for Alzheimer's Disease - Implications for Geriatricians.

Two new sets of criteria for Alzheimer’s disease (AD) are now in play, including one set released in 2014, and a proposal for a “new lexicon” for how to describe the disease spectrum. A 2012 Canadian consensus conference said that to then, none of the new criteria or terminology would change primary care practice; that is still likely to be so. For dementia consultants, however, the new criteria pose challenges and offer opportunities.In general, the new criteria see an expanded role for bio-markers. Even so, the evidence base for this remains incomplete. Our understanding of the neuropathological criteria for dementia changed as the evidence base included more community cases. This is likely to inform the experience with biomarkers. At present, each of the criteria specifies an exclusive research role. Still, wider uptake is likely, especially in the United States.Geriatricians should be aware of the fundamental change in the terminology now being employed: AD diagnosis no longer obliges a diagnosis of dementia. Until more data emerge—something to which geriatricians can contribute—there is reason to be cautious in the adoption of the new criteria, as they are likely to be least applicable to older adults.

An update on the management of chronic hepatitis C: 2015 Consensus guidelines from the Canadian Association for the Study of the Liver.

Chronic hepatitis C remains a significant medical and economic burden in Canada, affecting nearly 1% of the population. Since the last Canadian consensus conference on the management of chronic hepatitis C, major advances have occurred that warrant a review of recommended management approaches for these patients. Specifically, direct-acting antiviral agents with dramatically improved rates of virological clearance compared with standard therapy have been developed and interferon-free, all-oral antiviral regimens have been approved. In light of this new evidence, an update to the 2012 Canadian Association for the Study of the Liver consensus guidelines on the management of hepatitis C was produced. The present document reviews the epidemiology of hepatitis C in Canada, preferred diagnostic testing approaches and recommendations for the treatment of chronically infected patients with the newly approved antiviral agents, including those who have previously failed peginterferon and ribavirin-based therapy. In addition, recommendations are made regarding approaches to reducing the burden of hepatitis C in Canada.

Perioperative transfusion-related acute lung injury: the Canadian Blood Services experience.

Transfusion-related acute lung injury (TRALI) is a devastating transfusion-associated adverse event. There is a paucity of data on the incidence and characteristics of TRALI cases that occur perioperatively. We classified suspected perioperative TRALI cases reported to Canadian Blood Services between 2001 and 2012, and compared them to non-perioperative cases to elucidate factors that may be associated with an increased risk of developing TRALI in the perioperative setting. All suspected TRALI cases reported to Canadian Blood Services (CBS) since 2001 were reviewed by two experts or, from 2006 to 2012, the CBS TRALI Medical Review Group (TMRG). These cases were classified based on the Canadian Consensus Conference (CCC) definitions and detailed in a database. Two additional reviewers further categorized them as occurring within 72 h from the onset of surgery (perioperative) or not in that period (non-perioperative). Various demographic and characteristic variables of each case were collected and compared between groups. Between 2001 and 2012, a total of 469 suspected TRALI cases were reported to Canadian Blood Services; 303 were determined to be within the TRALI diagnosis spectrum. Of those, 112 (38%) were identified as occurring during the perioperative period. Patients who underwent cardiac surgery requiring cardiopulmonary bypass (25.0%), general surgery (18.0%) and orthopedics patients (12.5%) represented the three largest surgical groups. Perioperative TRALI cases comprised more men (53.6% vs. 41.4%, p=0.04) than non-perioperative patients. Perioperative TRALI patients more often required supplemental O2 (14.3% vs. 3.1%, p=0.0003), mechanical ventilation (18.8% vs. 3.1%), or were in the ICU (14.3% vs. 3.7%, p=0.0043) prior to the onset of TRALI compared to non-perioperative TRALI patients. The surgical patients were transfused on average more components than non-perioperative patients (6.0 [SD=8.3] vs. 3.6 [5.2] products per patient, p=0.0002). Perioperative TRALI patients were transfused more plasma (152 vs. 105, p=0.013) and cryoprecipitate (51 vs. 23, p<0.01) than non-perioperative TRALI patients. There was no difference between donor antibody test results between the groups. CBS data has provided insight into the nature of TRALI cases that occur perioperatively; this group represents a large proportion of TRALI cases.

Emerging Concepts in Geriatric Psychiatry: an Update on the Canadian Academy of Geriatric Psychiatry Annual Scientific Meeting

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