Canadian Tertiary Care Centre Research Articles

QOL-25. IMPACTS OF IMPLEMENTING A PROSPECTIVE TREATMENT AND SURVEILLANCE PROTOCOL FOR THE MANAGEMENT OF NF2-ASSOCIATED VESTIBULAR SCHWANNOMAS ON TUMOR GROWTH, HEARING OUTCOMES, AND QUALITY OF LIFE

Abstract Neurofibromatosis type 2 (NF2) is an autosomal dominant neurocutaneous syndrome associated with the development of nervous system tumors, including vestibular schwannomas (VS), meningiomas, and ependymomas. Although considered a rare illness, it is a source of significant morbidity, mainly due to early hearing loss leading to decreased autonomy and productivity among young adults. Bevacizumab, a monoclonal antibody against VEGF, has been shown to improve audition and tumor size in observational studies on NF2-associated VS. The most common limitations in the literature include the lack of reliable control groups, the paucity of data on quality of life, and the lack of detailed audiology testing guidelines. Moreover, the cost of bevacizumab is a limiting factor in access to care. In our Canadian tertiary care center, bevacizumab has been offered to NF2 patients with VS complications without specific indications on optimal treatment initiation time or duration. We present a hybrid cohort study protocol with retrospective and prospective arms aimed at measuring the impacts of introducing a standardized treatment and surveillance protocol on tumor growth, hearing outcomes, and quality of life. Patients from the multidisciplinary neurofibromatosis clinic at the University of Montreal Health Center, Canada, will be evaluated for inclusion in the prospective arm through regular audiological evaluations and imaging. Eligible individuals will receive bevacizumab at an initial dose of 5 mg/kg every 2 weeks for a year while participating in serial audiological, radiological, and quality of life assessments. The results will be compared to those of our historical cohort. Our primary outcomes will be tumor growth rate (% per year) for vestibular schwannomas, meningiomas and ependymomas, audiological test results, and quality of life and subjective hearing estimated through standardized questionnaires (SF-36, SSQ). We hypothesize that patients enrolled in the prospective arm will show improved clinical response compared to our historical cohort.

Review of the utility of routine mortality reviews among deaths on General Internal Medicine wards in a Canadian tertiary care hospital

BackgroundHospital morbidity and mortality reviews are common quality assurance activities, intended to uncover latent or unrecognised systemic issues that contribute to preventable adverse events and patient harm. Mortality reviews may...

Virtual Mindfulness Therapy for the Management of Endometriosis Chronic Pelvic Pain: A Novel Delivery Platform to Increase Access to Care.

<h3>Study Objective</h3> The objective of this study was to assess the effectiveness of virtual mindfulness-based stress reduction (MBSR) program to improve quality of life and pain in people with endometriosis. <h3>Design</h3> Mixed-methods before and after study design. <h3>Setting</h3> Urban Canadian tertiary-care centre. <h3>Patients or Participants</h3> Fifteen adult patients with a clinical or surgical diagnosis of endometriosis were recruited to participate through an outpatient academic gynecology clinic. Sample size was limited to fifteen to facilitate participation in the MBSR program. <h3>Interventions</h3> Patients participated in a virtual eight-week MBSR program run by an experienced social worker. Participants completed the Endometriosis Health Profile (EHP), a validated survey tool, and a pain medication use questionnaire before and after the program. A focus group was held upon completion of the program to assess participants experiences using mindfulness for the management of endometriosis-related chronic pelvic pain. <h3>Measurements and Main Results</h3> 67% of people enrolled completed the MBSR course (10/15). Following the MBSR program participants had a statistically significant decrease in four components of the EHP: control and powerlessness (p = 0.12), emotional well-being (p = 0.048), social support (p = 0.030), and self-image (p = 0.014). There was no change in pain scores or pain medication use. Based on the thematic analysis the participants felt the program's benefits came from a sense of community, education about their condition, and application of mindfulness tools when approaching pain. Participants felt more comfortable with the virtual format over in-person sessions. <h3>Conclusion</h3> A virtual MBSR course can improve quality of life domains in people with endometriosis but does not impact pain. Participants felt more comfortable in a virtual format, which has the potential to decrease some geographic barriers to care. Further research should focus on assessing this MBSR program in a randomized control trial.

Anticoagulation stewardship: Descriptive analysis of a novel approach to appropriate anticoagulant prescription

BackgroundAnticoagulants are a leading cause of morbidity among hospitalized patients, with prescription errors commonly reported. Literature surrounding anticoagulation stewardship is scarce despite its documented effectiveness in the antimicrobial realm. ObjectiveTo determine the proportion of accepted recommendations on inappropriate anticoagulant prescriptions suggested by a multidisciplinary anticoagulation stewardship program (ASP). MethodsWe conducted a descriptive cohort study of hospitalized patients using therapeutic anticoagulation at a large Canadian tertiary care center between September 1, 2019, and February 28, 2020. A multidisciplinary ASP, composed of physicians and pharmacists, was implemented on June 1, 2019. Patient‐, anticoagulant‐, and admission‐related characteristics were collected. The primary outcome was the proportion of accepted ASP team recommendations by the prescribing team. ResultsA total of 381 patients were enrolled during the study period, resulting in 553 anticoagulant reviews (1.56 reviews/patient) by the ASP. The most common indications for anticoagulation were atrial fibrillation (n = 276, 72%) and venous thromboembolism (n = 84, 22%). Direct oral anticoagulants were most frequently prescribed (n = 253, 67%), followed by vitamin K antagonists (n = 88, 23%). Among the reviewed prescriptions, 355 of 553 (64%) generated a recommendation; 299 of 355 (84%) recommendations were accepted by the treating team. Dose adjustments were the leading category of recommendations (31%), followed by alerts regarding drug interactions (19%). ConclusionInpatient anticoagulant prescriptions were optimized following recommendations by the ASP team. The most frequent types of prescription changes concerned dose adjustments and drug interactions. Further research is required to assess the effect of an ASP on clinical outcomes.

COVID-19 infection in liver transplant recipients: Clinical features and outcomes from a Canadian multicentre cohort.

BACKGROUND: Prior studies have assessed risk factors and clinical outcomes in liver transplant (LT) recipients infected with COVID-19 globally; however, there is a paucity of Canadian data. Our multicentre study aims to examine the characteristics and clinical outcomes of LT patients with COVID-19 infection in Canada. METHODS: Adult LT recipients with reverse transcription-polymerase chain reaction (RT-PCR) confirmed COVID-19, from Canadian tertiary care centres between March 2020 and June 2021 were included. RESULTS: A total of 49 patients with a history of LT and COVID-19 infection were identified. Twenty-nine patients (59%) were male, median time from LT was 66 months (IQR 1-128), and median age was 59 years (IQR 52-65). At COVID-19 diagnosis, the median alanine transaminase (ALT) was 37 U/L (IQR 21-41), aspartate aminotransferase (AST) U/L was 34 (IQR 20-37), alkaline phosphatase (ALP) U/L was 156 (IQR 88-156), total bilirubin was 11 μmol/L (IQR 7-14), and international normalized ratio (INR) was 1.1 (IQR 1.0-1.1). The majority of patients (86%) were on tacrolimus (monotherapy or combined with mycophenolate mofetil); median tacrolimus level at COVID-19 diagnosis was 5.3 μg/L (IQR 4.0-8.1). Immunosuppression was modified in eight (16%) patients post-infection. Eighteen patients (37%) required hospitalization, and three (6%) required intensive care unit (ICU) admission and mechanical ventilation. Four patients (8%) died from complications related to COVID-19 infection. On univariate analysis, neither age, sex, comorbidities, nor duration post-transplant were associated with risk of hospitalization or ICU admission. CONCLUSIONS: LT recipients with COVID-19 have high rates of hospitalization but fortunately have low rates of ICU admission and mortality in this national registry.

High-impedance alerts with pulse generator-Lead mismatch.

BackgroundCardiac Implantable Electronic Devices (CIED) include pulse generators and leads. In some implanting centers, it is a common practice to combine devices with leads from different companies. Case series have reported episodic high‐impedance changes in Boston Scientific CIEDs with competitor leads. We investigated the incidence of high‐impedance abnormalities in matched versus mismatched Boston Scientific Accolade pacemakers.MethodsA retrospective chart review identified all consecutive Boston Scientific Accolade pacemakers implanted between January 2017 and June 2019 at a Canadian tertiary care center. The primary outcome was the occurrence of transient, high‐impedance changes which resulted in a switch to unipolar pacing/sensing in the absence of any other identifiable lead issue. Fisher exact tests (two‐tailed, α = .05) were used to compare the incidence of outcomes in matched versus mismatched systems.Results514 Boston Scientific Accolade pacemakers were associated with 882 individual leads. The primary outcome occurred with 21 leads (20 Medtronic and 1 Abbott), associated with occasional pacing inhibition, presyncope, and/or early surgical revision. Mismatched lead‐device pairs were significantly associated with CIED malfunction compared to matched lead‐device pairs (3.3% vs. 0%, p = .0019). The median time from implant to unipolar safety switch was 12.4 months. The median follow‐up time was 21.6 months.ConclusionUse of mismatched leads with a Boston Scientific Accolade device was associated with an increased risk of undesirable changes in sensing polarity with occasional inappropriate pacing inhibition. Awareness of this interaction can allow for the institution of appropriate programming remedies and may increase scrutiny of the use of mismatched CIED systems.

GP.4 The epilepsy surgery experience in children with infantile spasms at a tertiary care centre in Canada

Background: Infantile spasms (IS) is an epileptic encephalopathy, characterized by spasms, hypsarrhythmia, and developmental regression. This is a retrospective case series of children with IS who underwent epilepsy surgery at The Hospital for Sick Children (HSC) in Toronto, Canada. Methods: The records of 223 patients seen in the IS clinic were reviewed. Results: Nineteen patients met inclusion criteria. The etiology of IS was encephalomalacia in six patients (32%), malformations of cortical development in 11 patients (58%), atypical hypoglycaemic injury in one patient (5%), and partial hemimegalencephaly in one patient (5%). Nine patients (47%) underwent hemispherectomy and 10 patients (53%) underwent lobectomy/lesionectomy. Three patients (16%) underwent a second epilepsy surgery. Fifteen patients (79%) were considered ILAE Seizure Outcome Class 1 (completely seizure free; no auras). The percentage of patients who were ILAE Class 1 at most recent follow-up decreased with increasing duration of epilepsy prior to surgery. Developmental outcome was improved in 14/19 (74%) and stable in 5/19 (26%) patients. Conclusions: Our study found excellent seizure freedom rates and improved developmental outcomes following epilepsy surgery in patients with a history of IS with a structural lesion detected on MRI brain.

Using Smartphone Wireless ECG Monitoring to Provide Symptom-Rhythm Correlation in the Paediatric Population.

Children frequently present with symptoms of palpitations. These symptoms can occur in isolation or in association with other presentations such as chest pain, presyncope, or syncope. Usually, their symptoms are episodic in occurrence; therefore, establishment of symptom-rhythm correlation is challenging but critical for accurate diagnosis and management. We reviewed the use of smartphone-based wireless electrocardiogram monitoring with AliveCor Kardia, to establish symptom-rhythm correlation in a paediatric case series at a single Canadian tertiary care centre.

Standard Versus Extended Neoadjuvant Chemotherapy: A Canadian Tertiary Centre Cohort Study of Ovarian Cancer Care Amidst the COVID-19 Pandemic

To compare treatment response in patients with ovarian cancers treated with extended neoadjuvant chemotherapy compared to standard chemotherapy, a strategy adopted during the COVID-19 operating room closures. This retrospective cohort study included patients with ovarian cancers treated with neoadjuvant chemotherapy before interval debulking surgery at a Canadian tertiary care centre during the COVID-19 pandemic. Patients with extended neoadjuvant chemotherapy consisting of 6 cycles of chemotherapy prior to surgery were compared to patients receiving the standard 3 cycles of neoadjuvant chemotherapy followed by 3 cycles after surgery. The primary outcome was disease response to treatment measured by percent change in the biomarker CA-125. Secondary outcomes were disease extent at time of surgery, chemotherapy response scores, perioperative morbidity, and chemotherapy adverse events. Binary outcomes were ascertained by chi-square or Fischer exact tests and continuous outcomes were obtained by the Wilcoxon-rank sum test. A total of 9 patients received extended neoadjuvant chemotherapy and 18 patients received standard chemotherapy. Percent change in CA-125 levels between cycles 0–3 were similar between the extended neoadjuvant cohort (median 88.0%, IQR 52.4, 92.1) and the standard chemotherapy cohort (median 91.7%, IQR 79.8, 96.2), P = 0.38. The 6-cycle group had statistically significant less change in CA-125 between cycles 3–6 (median 31.9%, IQR 25.0, 46.7) compared to the standard group (median 90.7, IQR 76.9, 95.3), P = 0.001. The extent of disease at the time of surgery, chemotherapy response scores, perioperative outcomes and chemotherapy adverse events were similar between groups. Biochemical disease response to neoadjuvant chemotherapy slows after 3 cycles of chemotherapy.

Usage of Genetic Panels in an Adult Epilepsy Clinic.

There is limited data on the utility, yield, and cost efficiency of genetic testing in adults with epilepsy. We aimed to describe the yield and utility of genetic panels in our adult epilepsy clinic. We performed a retrospective, cross-sectional study of all patients followed by an epileptologist at a Canadian tertiary care centre's epilepsy clinic between January 2016 and August 2021 for whom a genetic panel was ordered. A panel was generally ordered when the etiology was unknown or in the presence of a malformation of cortical development. We determined the yield of panel positivity and of confirmed genetic diagnoses. We also estimated the proportion of these diagnoses that were clinically actionable. In total, 164 panels were ordered in 164 patients. Most had refractory epilepsy (80%), and few had comorbid intellectual disability (10%) or a positive family history of epilepsy (11%). The yield of panel positivity was 11%. Panel results were uncertain 49% of the time and negative 40% of the time. Genetic diagnoses were confirmed in 7 (4.3%) patients. These genetic conditions involved the following genes: SCARB2, DEPDC5, PCDH19, LGI1, SCN1A, MT-TL1, and CHRNA7. Of the seven genetic diagnoses, 5 (71%) were evaluated to be clinically actionable. We report a lower diagnostic yield for genetic panels in adults with epilepsy than what has so far been reported. Although the field of the genetics of epilepsy is a fast-moving one and more data is required, our findings suggest that guidelines for genetic testing in adults are warranted.

Central retinal artery occlusion: a retrospective study of disease presentation, treatment, and outcomes

ObjectifL'occlusion de l'artère centrale de la rétine (OACR) constitue en fait une forme d'accident vasculaire cérébral (AVC) oculaire au pronostic visuel médiocre. Si la physiopathologie de l'OACR est semblable à celle de l'AVC ischémique, l'OACR s'accompagne de défis uniques en matière de diagnostic et de prise en charge, ce qui donne lieu à une grande variabilité en pratique clinique. Notre étude a pour objectif d’évaluer les résultats de l'examen initial, le traitement et le bilan de l'OACR dans un centre de soins tertiaires du Canada sur une période de 2 ans, et de proposer des axes d'amélioration potentielle de la prise en charge de ces patients. MéthodesRevue rétrospective réalisée dans un établissement unique qui regroupait 27 patients chez lesquels on a établi un diagnostic d'OACR entre mars 2018 et mars 2020 à Edmonton, en Alberta. RésultatsLa plupart des patients qui ont subi une OACR ont d'abord consulté un spécialiste des soins oculaires (14 sur 27); d'autres se sont rendus au service des urgences (10 sur 27) ou ont consulté leur médecin de famille (2 sur 27). Trois patients (11,1 %) ont consulté dans les 4,5 heures suivant l'apparition des symptômes. Lors de l'examen initial, l'acuité visuelle de 81 % des patients était de 20/400 ou pire dans l’œil atteint. Aucun patient n'a fait l'objet d'une thrombolyse. La majorité des cas d'OACR était d'origine non artéritique (92,6 %). Tous les patients présentaient déjà au moins un facteur de risque vasculaire, et 48 % des patients ont fait l'objet d'une intensification du traitement médicamenteux. Une sténose de la carotide homolatérale a été diagnostiquée chez 5 patients (18,5 %); d'ailleurs, 3 patients ont dû subir une endartériectomie de la carotide. On a noté la présence d'une fibrillation auriculaire chez 2 patients. Enfin, il s'est produit une ischémie cérébrale symptomatique chez 2 patients dans les 6 semaines suivant l'OACR. ConclusionsLa majorité des patients qui ont subi une OACR ont consulté un spécialiste des soins oculaires, mais très peu l'ont fait à l'intérieur de la fenêtre pendant laquelle une thrombolyse peut être réalisée, soit dans les 4,5 heures suivant l’épisode. Voilà qui met en lumière l'importance des stratégies de sensibilisation du public. Notre étude fait également ressortir le taux significatif de comorbidité générale présente chez ce type de patients.

The impact of robotic surgery on a tertiary care colorectal surgery program, an assessment of costs and short term outcomes: A Canadian perspective.

Robotic surgery for colorectal pathology has gained interest as it can overcome technical challenges and limitations of traditional laparoscopic surgery. A lack of training and costs have been cited as reasons for limiting its use in Canada. The objective of this paper was to assess the impact of robotic surgery on outcomes and costs in a Canadian setting. This is a retrospective study of consecutive patients undergoing left sided colorectal surgery ("Pre-Robotic Phase" n = 145 vs. "Post Robotic Phase" n = 150) and a single tertiary care centre in Ontario, Canada. Utilization and success of minimally invasive surgery (MIS), length of stay, complications and hospital costs were compared. Univariate and Multivariate analysis was used for these comparisons. Characteristics, diagnosis and type of resection were similar between groups. Robotic Implementation resulted in higher rates of successful MIS (i.e. attempt at MIS without conversion) (85% vs. 47%, P < 0.001), shorter mean length of stay (4.7days vs. 8.4days, P < 0.001), and similar mean operative times (3.9h vs. 3.9h, P = 0.93). Emergency Department visits were fewer in the Robotic Phase (24% vs. 34%, P = 0.04), with no difference in readmission, anastomotic leak or unplanned reoperation. After robotic implementation, the mean total hospital costs decreased, but this was not statistically significant (-$1453, 95% CI -$3974 to +$1068, P = 0.25). Regression analysis, adjusting for age, gender, obesity, ASA and procedure showed similar findings (Robotic Phase -$657, 95% CI -$3038 to +$1724, vs Pre Robotic Phase [Reference], P = 0.59). Implementation of a robotic colorectal surgery program in a Canadian tertiary care centre showed improved clinical outcomes, without a significant increase in the cost of care. Although this study is from a single institution, we have demonstrated that robotic colorectal surgery is feasible and can be cost effective in the right setting.

A224 COVID-19 INFECTION IN LIVER TRANSPLANT RECIPIENTS: CLINICAL FEATURES, HOSPITALIZATION, AND MORTALITY FROM A CANADIAN MULTICENTRE COHORT

BackgroundThe COVID-19 pandemic has brought significant challenges to clinicians caring for liver transplant (LT) recipients. Researchers have sought to better understand the risk and clinical outcomes of LT recipients infected with COVID-19 globally, however, there is a paucity of data from within Canada.AimsOur multi-center study aims to examine the characteristics and clinical outcomes of LT patients with COVID-19 in Canada.MethodsWe identified a retrospective cohort of adult LT recipients with RT-PCR confirmed COVID-19 from 7 Canadian tertiary care centers between March 2020 and June 2021. Demographic and clinical data were compiled by clinicians within those centers. We identified liver enzyme profile at the time of COVID-19 infection, immunosuppression type and post-infection adjustments, rate of hospitalization, ICU admission, mechanical ventilation, and death.ResultsA total of 49 patients with a history of LT and COVID-19 infection were identified. Twenty nine patients (59%) were male, the median time from LT was 66 months (1, 128) and the median age at COVID-19 infection was 59 years (52, 65). At COVID-19 diagnosis, the median ALT was 37 U/L (21, 41), AST U/L was 34 (20, 37), ALP U/L was 156 (88, 156), Total Bilirubin was 11 umol/L (7, 14), and INR was 1.1 (1.0, 1.1). The majority of patients (92%) were on tacrolimus monotherapy or a combination of tacrolimus and mycophenolate mofetil (MMF); median tacrolimus level at COVID-19 diagnosis was 5.3 ug/L (4.0, 8.1). Immunosuppression was modified in 8 (16%) patients post-infection; either the tacrolimus dose was reduced or MMF was held. One patient developed acute cellular rejection which recovered after re-initiation of the prior regimen. Eighteen patients (37%) required hospitalization, 6 (12%) were treated with dexamethasone, and 3 (6%) required ICU admission and mechanical ventilation. Four patients (8%) died due to complications of COVID-19. On univariate analysis, neither age, sex, co-morbidities nor duration post-transplant were associated with risk of hospitalization.ConclusionsIn our national retrospective study, approximately 40% of patients required hospitalization with a mortality rate of < 10%. Previous studies have shown proximity to LT as an independent factor for mortality with COVID-19; the median time from LT for our patients was 5 years, which may explain the lower mortality rate. Of note, the median tacrolimus levels were much lower in comparison to the target of 8–10 ug/L used in the first year post-transplant. As the landscape of COVID-19 changes with vaccination, evolving treatments, and increasing rates of variant transmission, additional studies are required to continue identifying trends in clinical outcomes.Funding AgenciesNone

A220 THE IMPACT OF DIABETES AND AGE ON PERFORMANCE OF NON-INVASIVE SERUM-BASED TESTS FOR PREDICTION OF ADVANCED FIBROSIS IN BIOPSY-PROVEN NAFLD

Abstract Background Non-alcoholic fatty liver disease (NAFLD) is now a leading cause of end-stage liver disease. Advanced stage F3-4 fibrosis predicts liver-related mortality in NAFLD patients. Simple non-invasive serum-based tests (NIT) for F3-4 are limited by indeterminate scores, necessitating secondary tests or liver biopsy. Diagnostic NIT cut-offs may vary in NAFLD patients with diabetes mellitus (DM) and the elderly. Identifying appropriate thresholds in populations in which these tests can be applied will reduce indeterminates and facilitate their broader use. Aims The aim of this study was to assess the impact of DM status and age on the performance of NIT for prediction of advanced fibrosis in patients with biopsy-proven NAFLD. Methods Patients presenting to two Canadian tertiary care centers between 2010–2018 for liver biopsy to diagnose NAFLD were included in this study. NIT including NFS, FIB4, BARD, AST-to-platelet ratio index (APRI), and AST to ALT ratio (AST/ALT) were calculated for each patient using validated cut-offs. Results 457 patients were included in this study. Mean age was 48.8±12.9 years, 56% male, mean BMI 32.3 ± 6.7kg/m2, 69% with DM, and F3-4 prevalence 48%. Indeterminate rates for NIT were generally higher for older patients, with or without DM (27–49% and 37–52%, vs. 33–42% and 20–37%, respectively). FIB-4 and NFS both had high specificity &amp;gt;0.9 in DM patients &amp;lt;60 years (Table 1). There were no differences in AUROC for individual NITs between patients with and without DM, and those &amp;lt; 60 vs. ≥ 60, nor between individual NIT within these groups. Conclusions DM status and age, ≥ 60 vs. &amp;lt; 60, do not appear to have a significant impact on diagnostic performance of serum-based NIT in our cohort. Older patients had higher indeterminate results and reduced specificity, but T2DM status and age did not appear to have an impact on rate of misclassified patients. Serum-based NIT thresholds need to be optimized for older patients to reduce indeterminates and improve specificity. Funding Agencies None

Evaluation of the characteristics of primary iridociliary cysts using ultrasound biomicroscopy at a tertiary care centre

ObjectifPrésenter les caractéristiques des kystes irido-ciliaires primaires à l’échographie biomicroscopique dans un centre de soins tertiaires du Canada. NatureÉtude rétrospective. ParticipantsAu total, 189 patients (212 yeux) ont été adressés au Sinai Health System (Toronto) en raison d'une suspicion d'anomalies de l'iris. MéthodesOn a examiné les dossiers médicaux des patients qui nous ont été adressés entre mars 2016 et octobre 2019. Tous les patients ont été évalués par échographie biomicroscopique et ont reçu un diagnostic de kyste irido-ciliaire. Les données sur l’âge, le sexe, l'atteinte (iris vs corps ciliaire), la latéralité du kyste, sa taille et sa localisation ont été notées lors de l'examen initial et du suivi. RésultatsParmi les 189 patients (212 yeux) qui présentaient un kyste irido-ciliaire, les femmes (65,1 %) étaient plus nombreuses que les hommes (34,9 %). L'incidence la plus élevée a été enregistrée chez les femmes de 21 à 30 ans (13,2 %). L’épithélium pigmentaire de l'iris était touché dans 84,4 % des cas, et seul le corps ciliaire était atteint dans 3,8 % des cas. Le kyste touchait à la fois l’épithélium pigmentaire de l'iris et le corps ciliaire dans 10,8 % des cas. Le diamètre des kystes s’échelonnait de 0,5 à 4,41 mm et dépassait 1 mm dans 78,7 % des cas; 86,8 % des kystes étaient unilatéraux. On comptait 12 % de polykystose, tandis que 8,5 % des kystes étaient multiloculaires; 1 % des kystes présentaient ces deux caractéristiques. Vingt-trois (23) yeux (12,2 %) ont fait l'objet d'une échographie biomicroscopique 1 an plus tard. La taille des kystes irido-ciliaires était demeurée stable, et ces derniers n'avaient pour ainsi dire pas pris de volume dans 73,9 % des cas (n = 17). Cependant, on a observé une augmentation de la taille du kyste irido-ciliaire chez 1 patient après 4 mois. ConclusionOn trouve peu de données sur les kystes irido-ciliaires dans la littérature médicale. L’échographie biomicroscopique est un outil clinique utile pour évaluer les anomalies de l'iris. Les kystes irido-ciliaires ont tendance à demeurer stables au fil du temps et à entraîner peu de complications.

Mifepristone-Misoprostol Use for Second- and Third-Trimester Medical Termination of Pregnancy in a Canadian Tertiary Care Centre

ObjectiveThis study aims to evaluate the impact of the implementation a mifepristone-misoprostol protocol (MIFE/MISO) on the induction-to-expulsion interval in the context of second- and third-trimester pregnancy termination or intrauterine fetal death (IUFD) compared with misoprostol alone (MISO), and to share the experience of a Canadian tertiary hospital concerning the feasibility and safety of such a protocol. MethodsThis is a single-centre retrospective pre–post cohort study carried out at the Centre Hospitalier Universitaire (CHU) Sainte-Justine between 2017 and 2019. Women in the MIFE/MISO group were instructed to take mifepristone 24-48 hours before induction. Induction in the MIFE/MISO group was performed with misoprostol dosages adjusted to gestational age and the presence of previous uterine scars, while, in the MISO group, all patients received 400 μg of misoprostol vaginally every 4 hours. ResultsNinety-four patients were included in the MIFE/MISO group and 103 patients, in the MISO group. Median time to expulsion was significantly lower in the MIFE/MISO group than the MISO group (13.5 and 19.5 h respectively; P < 0.001). The total dose of misoprostol administered was significantly lower in the MIFE/MISO group than the MISO group, and adverse effects were reported in 60% and 82% of patient records, respectively (P < 0.001). Complication rates were similar between the 2 groups. ConclusionThe MIFE/MISO protocol is highly effective for second- and third-trimester induction for pregnancy termination or IUFD, without increasing complication rates and with fewer reported adverse effects. Its implementation is safe and feasible in a tertiary medical centre.

Insular Involvement in Cases of Epilepsy Surgery Failure.

Background: Epilepsy surgery failure is not uncommon, with several explanations having been proposed. In this series, we detail cases of epilepsy surgery failure subsequently attributed to insular involvement. Methods: We retrospectively identified patients investigated at the epilepsy monitoring units of two Canadian tertiary care centers (2004–2020). Included patients were adults who had undergone epilepsy surgeries with recurrence of seizures post-operatively and who were subsequently determined to have an insular epileptogenic focus. Clinical, electrophysiological, neuroimaging, and surgical data were synthesized. Results: We present 14 patients who demonstrated insular epileptic activity post-surgery-failure as detected by intracranial EEG, MEG, or seizure improvement after insular resection. Seven patients had manifestations evoking possible insular involvement prior to their first surgery. Most patients (8/14) had initial surgeries targeting the temporal lobe. Seizure recurrence ranged from the immediate post-operative period to one year. The main modality used to determine insular involvement was MEG (8/14). Nine patients underwent re-operations that included insular resection; seven achieved a favorable post-operative outcome (Engel I or II). Conclusions: Our series suggests that lowering the threshold for suspecting insular epilepsy may be necessary to improve epilepsy surgery outcomes. Detecting insular epilepsy post-surgery-failure may allow for re-operations which may lead to good outcomes.

Human Amniotic Membrane Plug for Chronic or Persistent Macular Holes

To report on the use of human amniotic membrane for macular holes at 2 Canadian tertiary care centers. Retrospective cohort study. Twenty-two patients with persistent or chronic macular holes. Macular hole surgery was performed by 3 vitreoretinal surgeons. Macular hole closure with complete plugging by human amniotic membrane on spectral-domain OCT. The closure rate was 91% (20 of 22; median follow-up, 7 months), with no statistically significant visual acuity change overall. Complications included subretinal silicone oil (5%), choroidal neovascularization (5%), atrophy (5%), and cystoid macular edema (9%). Anatomical success with limited visual recovery was observed.

Mutations in CLDN2 Are Not a Common Cause of Pediatric Idiopathic Hypercalciuria in Canada.

Background:Hypercalciuria is the most common risk factor for kidney stone formation, including in pediatric patients. However, the etiology is often unknown and children are frequently diagnosed with idiopathic hypercalciuria. Nearly 50% of children with hypercalciuria have a first-degree relative with kidney stones, suggesting a strong genetic basis for this disease. A failure of calcium reabsorption from the proximal nephron is implicated in the pathogenesis of hypercalciuria. Claudin-2 is a tight junction protein abundantly expressed in the proximal tubule. It confers paracellular permeability to calcium that is essential for transport across the proximal tubule where the majority of filtered calcium is reabsorbed.Objective:Our objective was to examine the frequency of coding variations in CLDN2 in a cohort of children with idiopathic hypercalciuria.Design:Mixed method including retrospective chart review and patient interview, followed by genetic sequencing.Setting:Three tertiary care centers in Canada.Patients:Children (age 1-18 years) with idiopathic hypercalciuria. Patients with other causes of hypercalciuria were excluded.Methods:Data were collected from 40 patients with idiopathic hypercalciuria. Informed consent to collect DNA was obtained from 13 patients, and the final and only coding exon of CLDN2 was sequenced.Results:The majority of patients were male, white, and had a positive family history of kidney stones. Parathyroid hormone levels were significantly lower than the reference range (P < .001). The levels of 1,25-dihydroxyvitamin D were also significantly higher in our patient cohort, relative to the reference range (P < .001). Sequence analysis of CLDN2 did not identify any coding variations.Limitations:Sequencing analysis was limited to the final coding exon and small sample size.Conclusions:CLDN2 coding variations are not a common cause of idiopathic hypercalciuria in Canadian children. Further study is needed to determine the causes of hypercalciuria in pediatric patients and develop targeted therapies.

The Canadian Glomerulonephritis Registry (CGNR) and Translational Research Initiative: Rationale and Clinical Research Protocol.

Background:Glomerulonephritis (GN) is a leading cause of kidney failure and accounts for 20% of incident cases of end-stage kidney disease (ESKD) in Canada annually. Reversal of kidney injury and prevention of progression to kidney failure is possible; however, limited knowledge of underlying disease mechanisms and lack of noninvasive biomarkers and therapeutic targets are major barriers to successful therapeutic intervention. Multicenter approaches that link longitudinal clinical and outcomes data with serial biologic specimen collection would help bridge this gap.Objective:To establish a national, patient-centered, multidimensional web-based clinical database and federated virtual biobank to conduct human-based molecular and clinical research in GN in Canada.Design:Multicenter, prospective observational registry, starting in 2019.Setting:Nine participating Canadian tertiary care centers.Patients:Adult patients with a histopathologic pattern of injury consistent with IgA nephropathy, focal and segmental glomerulosclerosis, minimal change disease, membranous nephropathy, C3 glomerulopathy, and membranoproliferative GN recruited within 24 months of biopsy.Measurements:Initial visits include detailed clinical, histopathological, and laboratory data collection, blood, urine, and tonsil swab biospecimen collection, and a self-administered quality of life questionnaire. Follow-up clinical and laboratory data collection, biospecimen collection, and questionnaires are obtained every 6 months thereafter.Methods:Patients receive care as defined by their physician, with study visits scheduled every 6 months. Patients are followed until death, dialysis, transplantation, or withdrawal from the study. Key outcomes include a composite of ESKD or a 40% decline in estimated glomerular filtration rate (eGFR) at 2 years, rate of kidney function decline, and remission of proteinuria. Clinical and molecular phenotypical data will be analyzed by GN subtype to identify disease predictors and discover therapeutic targets.Limitations:Given the relative rarity of individual glomerular diseases, one of the major challenges is patient recruitment. Initial registry studies may be underpowered to detect small differences in clinically meaningful outcomes such as ESKD or death due to small sample sizes and short duration of follow-up in the initial 2-year phase of the study.Conclusions:The Canadian Glomerulonephritis Registry (CGNR) supports national collaborative efforts to study glomerular disease patients and their outcomes.Trial registration:NCT03460054.