Centre Hospitalier De l'Université De Montréal Research Articles

QOL-06. OPTIMIZING NEUROFIBROMATOSIS CARE: A COMPREHENSIVE ECONOMIC EVALUATION OF A SPECIALIZED EXPERTISE CENTER’S IMPACT ON PATIENT OUTCOMES

Abstract Neurofibromatosis type 1 (NF1), NF2-related schwannomatosis (NF2) and other schwannomatoses represent a spectrum of genetic disorders characterized by the development of tumors on nerve tissues, profoundly impacting patients’ quality of life and posing complex challenges. Recognizing the imperative for comprehensive care delivery, we undertook to implement a Neurofibromatosis Expertise Center (CE) at the Centre hospitalier de l’Université de Montréal (CHUM), Quebec, Canada. Employing a robust analysis framework, we aimed to assess the economic viability of the CE by quantifying the Quality-Adjusted Life Years (QALYs) gained through centralized multidisciplinary neurofibromatosis care (cost-utility ratio = CAD/QALY gained). Leveraging data from validated questionnaires including the SF-6D, our preliminary analysis revealed significant enhancements in patients’ quality of life across diverse domains, including physical pain, visible cutaneous lesions, cognitive dysfunction, hearing loss, malignancies, psychiatric comorbidities, unemployment, physical disability, and social isolation. Notably, among the respondents (N = 115), patients receiving CE services reported a 12% increase in general health compared to a 25% decline among those without CE services. Moreover, 28% of CE patients reported improved overall health compared to 12% of those without CE services. Using the Work Productivity and Activity Impairment questionnaire (WPAI-GH), we found that cohorts followed in CE for ≥ 1 year (N = 45) experienced less work productivity losses compared to the most recent cohort (N = 32), which presented scores exceeding 6 on a 1-to-10 scale. We hypothesize that the establishment of the CE will yield profound improvements in patient health outcomes and alleviate financial strains on the Ministère de la Santé et des Services Sociaux du Québec (MSSS). Therefore, our next steps include discussing a strategy for funding application to the MSSS to ensure the accessibility of necessary care for patients. Continuing data collection and analysis will also provide a more comprehensive overview of patient characteristics and needs.

7694 Characterizing NF1 Germline Pathogenic Variants In A Cohort Of Patients With Pheochromocytomas And Neurofibromatosis Type 1

Abstract Disclosure: T. Hristova: None. S. Parisien-La Salle: None. S. Lapointe: None. D. Tremblay: None. N. Dumas: None. M. Labidi: None. Z. El Haffaf: None. I. Bourdeau: None. Introduction: Pheochromocytomas and paragangliomas (PPGLs) are the tumors with the highest heritability in adult patients, with identification of a germline mutation in more than 30% of cases. Up to 20 susceptibility genes for PPGLs are known, including NF1. Neurofibromatosis type 1 (NF1) is an inherited disease affecting approximately 1 in 3000 people that predisposes to the development of tumors, such as pheochromocytomas (PHEO). Up to recently, the diagnosis of NF1 was mainly based on clinical manifestations and NF1 genetic characterization was not systematically performed. Objectives: To characterize germline pathogenic variants in the NF1 gene in patients with NF1 developing and PHEO. Methods: We reviewed the charts of patients with a pathology-proven diagnosis of PHEOs that were investigated at Centre hospitalier de l’Université de Montréal (CHUM) between 2000 and May 2023. Genetic analysis included gene sequencing by Sanger method or multigene sequencing by NGS with a panel (Invitae, CA) Results: In our cohort of 220 PHEOs, 15 patients (6.8%) (Males: 6, Females: 9) had a diagnosis of NF1. Mean age at diagnosis of PHEO in NF1 patients was 48 ± 13.6 years, contrasting to the mean age of 38,7 ± 15.2 years in patients carrying germline mutations in non-NF1 genes, most likely reflecting lack of systematic biochemically screening of PHEO in NF1. Urinary metanephrines were elevated in 9/15 patients. 2/15 (15.4%) NF1 patients had bilateral PHEO and 1/15 (7,7%) metastatic disease. Mean tumour diameter was 4.64cm (min-max 1.5 – 12.5 cm). Eight out of 15 NF1 patients underwent NF1 genetic analysis. Heterozygous NF1 germline pathogenic variants were found in all of them: 3 deletions (c.7379delG, c.5844_5845delAA and one encompassing the entire gene), 3 premature stop codons leading to truncated proteins or loss of function (c.7549C>T, c.3916C>T, c.1246C>T), and 2 splicing defects (c.4269+1 G>A, c.1885G>A). Conclusions: We report a large cohort of patients with NF1 and PHEO. The older age at diagnosis of PHEO in NF1 is expected based on lack of systematic biochemical screening for PHEO in NF1 clinical guidelines. We report 8 germline NF1 mutations associated with PHEOs. Further studies are required to fully understand the impact of genetic pathogenic variants in this population and to unravel a possible genotype-phenotype correlation. Presentation: 6/2/2024

Implementation of Artificial Intelligence-Based Diabetic Retinopathy Screening in a Tertiary Care Hospital in Quebec: Prospective Validation Study.

Diabetic retinopathy (DR) affects about 25% of people with diabetes in Canada. Early detection of DR is essential for preventing vision loss. We evaluated the real-world performance of an artificial intelligence (AI) system that analyzes fundus images for DR screening in a Quebec tertiary care center. We prospectively recruited adult patients with diabetes at the Centre hospitalier de l'Université de Montréal (CHUM) in Montreal, Quebec, Canada. Patients underwent dual-pathway screening: first by the Computer Assisted Retinal Analysis (CARA) AI system (index test), then by standard ophthalmological examination (reference standard). We measured the AI system's sensitivity and specificity for detecting referable disease at the patient level, along with its performance for detecting any retinopathy and diabetic macular edema (DME) at the eye level, and potential cost savings. This study included 115 patients. CARA demonstrated a sensitivity of 87.5% (95% CI 71.9-95.0) and specificity of 66.2% (95% CI 54.3-76.3) for detecting referable disease at the patient level. For any retinopathy detection at the eye level, CARA showed 88.2% sensitivity (95% CI 76.6-94.5) and 71.4% specificity (95% CI 63.7-78.1). For DME detection, CARA had 100% sensitivity (95% CI 64.6-100) and 81.9% specificity (95% CI 75.6-86.8). Potential yearly savings from implementing CARA at the CHUM were estimated at CAD $245,635 (US $177,643.23, as of July 26, 2024) considering 5000 patients with diabetes. Our study indicates that integrating a semiautomated AI system for DR screening demonstrates high sensitivity for detecting referable disease in a real-world setting. This system has the potential to improve screening efficiency and reduce costs at the CHUM, but more work is needed to validate it.

Quality of hydroxychloroquine retinopathy screening at a Canadian teaching hospital.

To assess the quality of hydroxychloroquine (HCQ)-induced retinopathy screening at a Canadian tertiary center, we concentrate on risk factor documentation within the electronic health record, in accordance with the 2016 AAO guidelines. We performed a retrospective quality assessment study based on chart review of patients who underwent screening for HCQ-induced retinopathy at the Centre Hospitalier de l'Université de Montréal (CHUM) from 2016 to 2019. We evaluated four key risk factors for HCQ-induced retinopathy: daily dose, duration of use, renal disease, and tamoxifen use, using a three-tier grading system (ideal, adequate, inadequate) for documentation assessment. Pareto and root cause analyses were conducted to identify potential improvement solutions. Documentation quality varied in our study: daily dosage was 33% ideal, 31% appropriate, and 36% inappropriate. Duration of use documentation was 75% ideal, 2% adequate, and 24% inadequate. Renal disease documentation was only 6% ideal, with 62% adequate and 32% of charts lacking any past medical history. Among women's charts, tamoxifen use wasn't documented at all, with 65% adequately documenting medication lists. Pareto analysis indicated that improving renal disease and tamoxifen documentation could reduce 64% of non-ideal records, and enhancing daily dose documentation could decrease this by up to 90%. Accurate documentation of key risk factors is critical for HCQ-induced retinopathy screening, impacting both exam initiation and frequency. Our study identifies potential improvements in the screening process at the hospital, referring physician, and ophthalmologist levels. Implementing integrated pathways could enhance patient experience and screening effectiveness.

Telehealth-Delivered Program and Accompanying Patients to Enhance the Clinical Condition of Patients Throughout a Liver Transplant: Protocol for a Mixed Methods Study.

Liver transplantation (LT) is indicated in patients with severe acute or chronic liver failure for which no other therapy is available. With the increasing number of LTs in recent years, liver centers worldwide must manage their patients according to their clinical situation and the expected waiting time for transplantation. The LT clinic at the Centre hospitalier de l'Université de Montréal (CHUM) is developing a new health care model across the entire continuum of pre-, peri-, and posttransplant care that features patient monitoring by an interdisciplinary team, including an accompanying patient; a digital platform to host a clinical plan; a learning program; and data collection from connected objects. This study aims to (1) evaluate the outcomes following the implementation of a patient platform with connected devices and an accompanying patient, (2) identify implementation barriers and facilitators, (3) describe service outcomes in terms of health outcomes and the rates and nature of contact with the accompanying patient, (4) describe patient outcomes, and (5) assess the intervention's cost-effectiveness. Six types of participants will be included in the study: (1) patients who received transplants and reached 1 year after transplantation before September 2023 (historical cohort or control group), (2) patients who will receive an LT between December 2023 and November 2024 (prospective cohort/intervention group), (3) relatives of those patients, (4) accompanying patients who have received an LT and are interested in supporting patients who will receive an LT, (5) health care professionals, and (6) decision makers. To describe the study sample and collect data to achieve all the objectives, a series of validated questionnaires, accompanying patient logbooks, transcripts of interviews and focus groups, and clinical indicators will be collected throughout the study. In total, 5 (steering, education, clinical-technological, nurse prescription, and accompanying patient) working committees have been established for the study. Recruitment of patients is expected to start in November 2023. All questionnaires and technological platforms have been prepared, and the clinicians, stakeholders, and accompanying patient personnel have been recruited. The implementation of this model in the trajectory of LT recipients at the CHUM may allow for better monitoring and health of patients undergoing transplantation, ultimately reducing the average length of hospital stay and promoting better use of medical resources. In the event of positive results, this model could be transposed to all transplant units at the CHUM and across Quebec (potentially affecting 888 patients per year) but could also be applied more widely to the monitoring of patients with other chronic diseases. The lessons learned from this project will be shared with decision makers and will serve as a model for other initiatives involving accompanying patients, connected objects, or digital platforms. PRR1-10.2196/54440.

The paradoxes of telehealth platforms: what did we learn from the use of telehealth platforms?

This article is an overview and reflection of the findings of an evaluative study conducted on a program called "Techno-Covid Partnership" (TCP) implemented in April 2020 at the Centre Hospitalier de l'Université de Montréal (CHUM) in Montreal, Canada. In the context of the COVID-19 pandemic, the CHUM decided in April 2020 to implement telehealth, virtual care, and telemonitoring platforms and technologies to maintain access to care and reduce the risks of contamination and spread of COVID-19 as well as to protect users of health services and health professionals. Three technological platforms for telehealth and remote care and monitoring have been developed, implemented, and evaluated in real-time within the framework of the TCP program. A cross-sectional study was carried out in which a questionnaire was used and administered to users of telehealth platforms including patients and healthcare professionals. The methods and results of the study have been published previously published. In the completion of the two articles published in this context, in this paper, we briefly recall the context of the study and the method performed. The main focus of the paper is on presenting a critical overview and reflection on the major findings of our evaluation of the use of telehealth platforms from the point of view of patients and health professionals and discuss certain paradoxes i.e., the advantages, challenges, recommendations, and other perspectives that emerged in this study.

Formation de membrane rétroprosthétique suite à la kératoprothèse de Boston de type 1 : incidence, facteurs prédisposants, complications et traitements

Evaluate the incidence and risk factors for retroprosthetic membrane (RPM) formation after Boston keratoprosthesis type 1 (BKpro), identify the associated complications and describe the treatments offered. Retrospective cohort study. In total, 133eyes of 115patients who underwent BKpro at Centre Hospitalier de l'Université de Montréal (CHUM) from 2008to 2017, with a minimum follow-up of 1year, were included in the study. Records were examined, and data was collected, including RPM incidence, preoperative and intraoperative risk factors, postoperative complications and treatments offered. Mean follow-up was 5.5years. Thirty-nine percent (n=52) eyes developed RPM. No particular etiology was significatively associated with RPM formation. Simultaneous lensectomy or IOL extraction were respectively positively and negatively correlated with RPM formation. As for postoperative complications, the strongest correlation was found between RPM formation and retinal detachment. RPM formation was also positively associated with hypotony and corneal melt. Nd:YAG membranotomy was the most frequently used treatment, in 83% of eyes with RPM (n=24), with resolution in 58%. Over one third of BKpro patients will develop a RPM, thus requiring monitoring for associated retinal detachment. IOL extraction appears to be protective, whereas lensectomy appears to increase RPM formation. Nd:YAG membranectomy is used as an initial, non-invasive approach.

Editorial Comment.

No AccessJournal of UrologyAdult Urology19 May 2023Editorial CommentThis article comments on the following:Characterization of Gender Differences in H-index Within Urological Subspecialties Anna-Lisa V. Nguyen, David-Dan Nguyen, Ashley Cox, and Naeem Bhojani Anna-Lisa V. NguyenAnna-Lisa V. Nguyen Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada More articles by this author , David-Dan NguyenDavid-Dan Nguyen Division of Urology, University of Toronto, Toronto, Ontario, Canada More articles by this author , Ashley CoxAshley Cox Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada More articles by this author , and Naeem BhojaniNaeem Bhojani Division of Urology, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003537.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, Publish Ahead of Print, pp. REFERENCES 1. Gender differences in promotions and scholarly productivity in academic urology. Can J Urol. 2017; 24(5):9011-9016. Medline, Google Scholar 2. Characterization of gender differences in h-index within urological subspecialties. J Urol. 2023; 210(2):000. Google Scholar 3. . The h-index in medicine and science: does it favor h-im or h-er? Successes and hurdles for women faculty. Dig Dis Sci.2022; 67:388-389. Crossref, Medline, Google Scholar 4. . Women are underrepresented and receive differential outcomes at ASM journals: a six-year retrospective analysis. mBio. 2020; 11(6):e01680-e01620. Crossref, Medline, Google Scholar Submitted December 28, 2022; accepted May 1, 2023; published 000. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of Urology8 May 2023Characterization of Gender Differences in H-index Within Urological Subspecialties Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anna-Lisa V. Nguyen Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada More articles by this author David-Dan Nguyen Division of Urology, University of Toronto, Toronto, Ontario, Canada More articles by this author Ashley Cox Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada More articles by this author Naeem Bhojani Division of Urology, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada More articles by this author Expand All Submitted December 28, 2022; accepted May 1, 2023; published 000. Advertisement PDF downloadLoading ...

Adherence to Cardiovascular Prevention Guidelines in an Academic Centre

BackgroundAdherence to guidelines is associated with better patient outcomes. Although studies show suboptimal adherence to cardiovascular prevention guidelines among general practitioners, adherence among specialist physicians is understudied. The aim of this analysis was to identify practice gaps among cardiologists in a tertiary academic centre. MethodsWe retrospectively audited cardiology outpatient clinic notes taken at the Cardiology Clinic at the Centre hospitalier de l’Université de Montréal (CHUM), from the period January 1, 2019 to February 28, 2019. Data were abstracted from hospital medical records. The primary outcome of interest was the rate of adherence to cardiovascular prevention guidelines. We compared the chart-documented practice at our centre to the Canadian hypertension, lipid, diabetes, antiplatelet, and heart failure guidelines in effect at the time of the audit. We also collected information regarding discussions of smoking, alcohol consumption, physical activity, and diet. ResultsA total of 2503 patients were included, with a mean age of 65.6 ± 14.5 years. Dyslipidemia occurred in 63% of patients, hypertension in 55%, and coronary artery disease in 41%. Optimal low-density lipoprotein control was documented as having been achieved in just 39% of cases. Blood pressure control was adequate for 65% of patients, and glycemic control was achieved in 47% of patients with diabetes. Heart failure treatment was optimal in 34% of patients. Nearly all patients with coronary artery disease (95%) had appropriate antithrombotic therapy. The incidence of discussion of nonpharmacologic interventions varied, ranging from 91% (smoking) to 16% (diet). ConclusionsPrimary and secondary prevention of cardiovascular events was found to be suboptimal in an academic tertiary-care outpatient cardiology clinic and may be representative of similar shortcomings nationwide. Strategies to ensure guideline adherence are needed.

The Debate about Assisted Dying for Persons with Mental Disorders: An Essential Role for Philosophy

The Debate about Assisted Dying for Persons with Mental DisordersAn Essential Role for Philosophy Mona Gupta, MD, CM, FRCPC, PhD (bio) In 20141 and 2016,2 respectively, Québec and Canada adopted legislation permitting medical assistance in dying (MAID). In this context, the question of whether persons with mental disorders should be able to access MAID has received considerable scrutiny. Over the last 5 years, I have been involved in the academic and policy debates about assisted dying for persons with mental disorders. Policymakers and clinicians alike demand that public policy be based on 'evidence' by which they tend to mean empirical, usually quantitative, data. There is little acknowledgement that some questions are not empirical and that facts require interpretation. The debate about whether a request for assistance in dying by a person with a mental disorder is a form of suicidality illustrates this problem. Because suicidality (including thoughts, plans, gestures, and attempts) is strongly associated with certain mental disorders, there are some who argue that a request for assisted dying by a person with a mental disorder is an expression of suicidality, while others argue that suicidality and requests for assisted dying are different phenomena.3 The approach to resolving this debate is to frame the problem as an empirical one. Because it is generally agreed that we should prevent suicide, we should not allow assistance in dying if it is the same thing as suicide. Researchers set about to identify characteristics of persons with mental disorders who are suicidal and those who request assistance in dying. If these two groups share characteristics, it is assumed that those who request assisted dying and those who complete suicide are the same people. If they have different characteristics, the opposite is true. Thus far, there are no characteristics that are specific to all or most members of one group nor are there a sufficient number of common characteristics that apply to all or most members of both groups. With insufficient 'evidence' one way or the other, the debate continues about whether requests for assisted dying by persons with mental disorders are an expression of suicidality. Looking at the concepts at play can clarify the matter. People engage in a variety of different actions that they know may bring about their deaths. These include refusal or non-adherence [End Page 9] to life-sustaining treatment, engaging in highrisk behaviors, or consuming potentially lethal substances to name but a few. Society's responses to these decisions vary. Sometimes society intervenes to prevent these deaths, sometimes it permits death, and sometimes society is neutral. If we think carefully about these different responses and the circumstances to which they apply, we see that suicidality is the term we use precisely to describe those deaths society wishes to prevent. Debating whether suicide differs from MAID is simply restating the issue at stake: is assisted dying for persons with mental disorders something we should accept or prevent? Questioning the meaning and use of concepts lies at the heart of philosophy. Examining how we use the seemingly descriptive term suicide shows it is preceded by a normative judgment. The fact that a person has a mental disorder and expresses an intention to end her life does not tell us what to do. We prevent this person from acting because we have already decided that this is the kind of death we should prevent. Philosophy has a crucial role to play in the debate about assisted dying by circumscribing which issues involve empirical questions, and which ones require normative reasoning. Mona Gupta Mona Gupta is a psychiatrist and clinician-scientist at the Université de Montréal and the Centre Hospitalier de l'Université de Montréal (CHUM). Her academic focus concerns the interface of ethical and epistemological issues in psychiatric practice. She is currently working on the epistemology of clinical reasoning in psychiatry. Notes 1. https://www.legisquebec.gouv.qc.ca/en/document/cs/s-32.0001. 2. https://laws-lois.justice.gc.ca/eng/annualstatutes/2016_3/fulltext.html. 3. https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advisory-bodies/expert-panel-maid-mental-illness/final-report-expert-panel...

RF21 | PSUN07 Germline Genetic Testing in a Cohort of Adults with Adrenocortical Carcinoma : Insights From a Clinical Care Setting

Abstract Context About 5-10% of adrenocortical cancer (ACC) arise in patients with genetic predisposition syndromes, including Li-Fraumeni, Lynch, MEN1, or Familial Adenomatous Polyposis (APC). Recent European (2018) and American guidelines (2020) recommend that all adults with ACC should be offered clinical genetic counseling. There is a paucity of data regarding systematic germline testing in adults with ACC and the extent of the genetic evaluation is unclear. Objective To describe the germline genetic characteristics in a cohort of adult patients with ACC evaluated in a tertiary clinical care center. Methods Data including demographics, personal and family history of neoplasia, pathology reports, clinical features and genetic testing were retrospectively collected from charts of patients treated at Centre hospitalier de l'Université de Montréal (CHUM). After genetic counseling, genetic testing was proposed to patients with a pathologic diagnosis of ACC. From 2005 to 2015, TP53 gene analysis was performed using direct sequencing and MLPA. Since 2016, multigene testing was performed for a progressively increasing number of oncogenic genes using a custom next-generation panel for germline leucocyte DNA including at least the TP53, MSH2, MSH6, MLH1,PMS2, EPCAM, MEN1, BRCA1 and BRCA2 genes (Invitae, CA). An extended panel, based on past medical and familial history, was performed at the discretion of the geneticist. Patient data was retrospectively investigated. Results We analyzed data from 44 patients with available germline genetic results. Median age of the patients was 46 years (ranging from 22 to 79 years), including 11 males (25.0%) and 33 females (75.0%). Ten patients (22.7%) underwent only TP53 gene analysis and 32 patients (72.7%) were studied using the larger oncogenic genetic panel. Germline pathogenic or likely pathogenic variants were identified in 5 of the 44 patients (11.4%) while genetic variants of unknown significance (VUS) were found in 7 of the 44 patients (15.9%). Among patients with pathogenic variants, one had a family history and known germline mutation in the BRCA2 gene (8765delAG, p.Glu2846GlyfsX23). One patient had a personal and familial medical history suggesting a MEN1 syndrome that was confirmed with the finding of a germline MEN1 mutation (c.1556delC, p.Pro519Leu fs40). Unsuspected germline pathogenic variants were found in three patients: 1) TP53 (c.425delC, p.Pro142fs), 2) MUTYH (c.536A>G, p.Tyr179Cys) and 3) MSH6 (c.3649-3655, p.Arg1217Leu fs9) genes. Variants of unknown significance (VUS) were found in the following genes: POT1, MSH3, PALB2, RAD51d, APC, ATM and BRCA2. Conclusions Germline pathogenic variants were found in 11.4% of our cohort of patients with ACC. VUS were found in 15.9% of patients but their significance remains to be determined. Genetic counseling and germline genetic testing should be offered to all patients with ACC; however the optimal use and extent of oncogenic gene panels need to be better defined. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m., Sunday, June 12, 2022 12:48 p.m. - 12:53 p.m.

On integrating patient appointment grids and technologist schedules in a radiology center.

Optimal patient appointment grid scheduling improves medical center performance and reduces pressure from excess demand. Appointment scheduling efficiency depends on resource management, and staff are a key resource. Personnel scheduling takes into account union rules, skills, contract types, training, leave, illness, etc. When combined with appointment scheduling constraints, the complexity of the problem increases. In this paper, we study the combination of the patient appointment grid and technologist scheduling. We present a well-detailed framework outlining our approach. We develop two versions of a mixed-integer programming model: integrated and sequential. In the first version, we elaborate the appointment grid and the technologist schedules simultaneously, while in the second version we generate them sequentially. We evaluate the proposed approach using real data from the MRI department of the Centre hospitalier de l'Université de Montréal (CHUM) radiology center. We study different scenarios by testing several technologist rules and planning construction methods. Obtained solutions are compared to the current CHUM scheduling approach.

A Canadian single-centre experience with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for abdominal malignancies.

Background:Cytoreductive surgery in combination with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has recently shown promise for the treatment of patients with various types of peritoneal carcinomatosis (PC). However, it is an extensive procedure that is associated with a variety of morbidities. We evaluated the safety and clinical outcomes of CRS-HIPEC performed at our centre.Methods:Patients with abdominal malignancies who underwent CRS-HIPEC between February 2005 and December 2018 at the Centre hospitalier de l’Université de Montréal (CHUM) were retrospectively reviewed.Results:A total of 141 patients were identified (66 with appendiceal cancer, 62 with colorectal cancer, 10 with mesothelioma and 3 with small intestinal tumours). The median age was 55 years. Median overall survival (OS) was not reached for patients with appendiceal tumours; it was 38.3 months for colorectal cancers. Among patients with colorectal cancer, survival was significantly better for those who received intraperitoneal HIPEC with oxaliplatin (74.9 mo) compared with mitomycin C (29.1 mo) (p = 0.006). Complete cytoreductive surgery and low peritoneal carcinomatosis index were associated with the highest overall survival in patients with appendiceal tumours and those with colorectal tumours.Conclusion:CRS-HIPEC can be performed with acceptable morbidity in patients with PC. These results validate the outcomes of previously reported trials, but further prospective trials are warranted to determine which patients will most benefit from the addition of HIPEC to CRS.

COVID-19 Impact on Diagnosis and Staging of Colorectal Cancer: A Single Tertiary Canadian Oncology Center Experience.

Background: Public health measures have imposed drastic reductions in cancer screening programs at the beginning of the COVID-19 pandemic, with an unknown impact on the diagnosis and staging of colorectal cancer (CRC). Methods: Newly diagnosed CRC cases at the Centre Hospitalier de l’Université de Montréal (CHUM) were divided into two groups according to the timeline: pre-pandemic (1 January 2018–12 March 2020), and pandemic (13 March 2020–30 June 2021) periods. Colonoscopy, surgery, and staging at diagnosis during the pandemic period were compared to the pre-pandemic period. Results: 254 CRC diagnoses were made during the pre-pandemic period in comparison to 125 during the pandemic period. Mean diagnosis rates were lower in the pandemic period (7.8 vs. 9.8 diagnoses/month, p = 0.048). Colonoscopy deadlines were less respected in the pandemic period (51.7% vs. 38.3%, p = 0.049). The rate of elective surgery did not differ (2.9 vs. 3.5 surgeries/month, p = 0.39) and mean delays were similar (58.6 vs. 60.4 days, p = 0.77). Stages at diagnosis did not differ (p = 0.17). Most of the delayed colonoscopies led to a stage 0 or I CRC (p = 0.2). Conclusion: In our center, the COVID-19 pandemic resulted in a decreased rate of CRC diagnosis and increased endoscopic delays without affecting the rate of advanced stage disease. Delays to surgery were quite similar once the CRC diagnosis was established.

Bullous Pemphigoid-Associated Mortality Rate in a Canadian Tertiary Referral Centre.

Bullous pemphigoid (BP) is the most common autoimmune blistering disorder in adults. Most individuals with BP are over the age of 60. Its worldwide incidence has been increasing owing to population aging. Observational studies published over the last 2 decades highlight the non-negligible, albeit variable overall mortality of BP patients, with reported 12-month mortality rates of 10.8% to 40.8%, and 24-month mortality rates of 20.1% to 51.0%. Data in the Canadian population are lacking. We aimed to estimate the 12- and 24-month overall mortality rate of Canadian patients diagnosed with BP, and to identify independent risk factors adversely impacting overall survival. A retrospective cohort study of 166 patients with a diagnosis of BP between 2010 and 2020 was carried out at Centre hospitalier de l'Université de Montréal (CHUM), a tertiary referral center in Montréal, Québec, Canada. Cumulative mortality was calculated using the Kaplan-Meier estimator, and independent prognostic factors were identified using a Cox proportional hazards regression model. Eighty-five patients (51.2%) in our study were female. The median age was 79.1 years old, and 80 patients (48.2%) were 80 years old or older. Mortality at 12 and 24 months in our study cohort was 16.2% (CI95% = 10.5 - 21.8) and 27.6% (CI95% = 20.5 - 34.7), respectively. In a multivariate analysis, patients who were male, 80 years old or older, and/or had a diagnosis of a major neurocognitive disorder had a poorer overall survival. The all-cause mortality of patients with BP in our study population compared favorably with international data reported in the literature.

Efficacy of ab-interno gelatin microstent implantation in primary and refractory glaucoma

ObjectifÉvaluer les résultats de l'implantation ab interno d'une micro-endoprothèse en gélatine seule ou en association avec la phacoémulsification, en vue de réduire la pression intraoculaire (PIO). NatureÉtude de cohorte rétrospective. ParticipantsOnt été inclus 141 yeux de 141 patients (peu importe le type de glaucome, y compris le glaucome réfractaire) qui ont fait l'objet d'une chirurgie au Centre hospitalier de l'Université de Montréal (CHUM) entre 2015 et 2018. Les patients ont été admis à l’étude s'ils avaient plus de 40 ans et si leur PIO préopératoire était > 18 mm Hg sous l'effet du traitement médicamenteux maximal toléré. MéthodesTous les patients ont fait l'objet de l'implantation ab interno d'une micro-endoprothèse (XEN-45, Allergan, Madison, NJ) sous couvert de mitomycine C avec ou sans phacoémulsification. Le paramètre principal était la réussite chirurgicale complète (PIO : 6-18 mm Hg et baisse < 20 % par rapport aux valeurs de départ, sans prise de médicament permettant d'abaisser la PIO ni nouvelle intervention ou cyclophotocoagulation); au nombre des paramètres secondaires, mentionnons les suivants : succès mitigé s'accompagnant de la prise de médicaments, réduction en pourcentage de la PIO moyenne et du nombre de médicaments administrés, et baisse du nombre de complications, d'interventions et de nouvelles chirurgies. RésultatsLa durée moyenne du suivi a été de 30,5 ± 10,2 mois (± é.-t.). La PIO moyenne se chiffrait à 23,3 ± 7,0 mm Hg malgré la prise de 3,4 ± 0,8 médicaments au départ et à 13,3 ± 4,7 mm Hg malgré la prise de 1,9 ± 1,5 médicament lors du suivi à 24 mois (p < 0,001). Selon l'analyse de survie à 24 mois, on estime que 34,1 % des yeux qui ont reçu une micro-endoprothèse ont bénéficié d'une réussite complète, comparativement à 20,7 % pour le groupe avec phacoémulsification (p = 0,02); le succès a été mitigé dans 79,1 % des yeux qui ont reçu une micro-endoprothèse, comparativement à 75,1 % dans le groupe avec phacoémulsification (p = 0,86). Le taux d’échec a été plus élevé dans le groupe avec phacoémulsification (rapport de risque [RR] = 1,6; intervalle de confiance [IC] à 95 %: 1,1–2,3; p = 0,02). On a dû recourir à un aiguilletage de mitomycine C ou de 5-fluorouracil en période postopératoire dans 54 yeux (38,3 %). L'hypotonie transitoire (10,6 %), l'hyphéma transitoire (6,4 %), l’œdème maculaire (4,3 %) et l'extrusion de la micro-endoprothèse (2,8 %) comptaient au nombre des complications. On a dû opérer à nouveau 33 yeux (23,4 %), et 14 yeux (9,9 %) ont dû par la suite faire l'objet d'une cyclophotocoagulation au laser. ConclusionsDans la plupart des cas, l'implantation d'une micro-endoprothèse a dû être complétée d'un traitement topique dans les 24 mois suivant la chirurgie visant le traitement d'un glaucome primaire et réfractaire. Qui plus est, l'ajout d'une phacoémulsification s'accompagnait d'un risque plus élevé d’échec.

COVID-19 impact on diagnosis and staging of colorectal cancer: A single tertiary Canadian oncology center experience.

33 Background: COVID-19 pandemic urged public health to imposed drastic reduction on endoscopic activities and surgery, leading to delays that still not have been caught up today. The Ministry of Health and Social Services (MSSS) of Quebec conducted a study of the impact of those measures and reported a 66% reduction of colonoscopy and a 30% reduction of colorectal cancer (CRC) surgery activities during the first wave (March to May 2020). Whether those reduction had an impact on diagnosis and staging of CRC remains unknown. Methods: Demographic information of CRC diagnosed at Centre Hospitalier de l’Université de Montréal (CHUM) between January 1 2018 and March 12 2020 (pre-pandemic period), and March 13 2020 and June 30 2021 (pandemic period) were obtained from the SARDO registry and data regarding colonoscopy, surgery and staging at diagnosis (clinical or pathological as appropriate) were collected. Priority of elective colonoscopy was defined using the MSSS grading system ranging from P1 to P5. We compared delays to colonoscopy, delays to surgery and CRC staging of the pandemic period to the pre-pandemic period using one-way ANOVA, t tests and Chi-square tests as appropriate. Only delays in elective surgeries intended as first and curative treatment were analyzed. Results: 280 CRC diagnosis were made at the pre-pandemic period compared to 127 CRC diagnosis during the pandemic period. Mean diagnosis rates of the pandemic period tend to be lower (8.3 vs. 10.5 diagnosis/month, p=0.03) compared to the pre-pandemic period. 37.6% of patient in the pandemic period had a diagnosis of CRC during a hospitalization compared to 25.9% at the pre-pandemic period (p=0.048). 51.7% of elective colonoscopy leading to a diagnostic of CRC during the pandemic period did not meet required delays according to priority compared to 38.3% (p=0.049) during the pre-pandemic period. P3 colonoscopies (mostly indicated for a positive FIT and iron deficiency anemia) were the most affected (58.9 vs. 106.5 days, p˂0.001). P2 colonoscopy (indicated for suspected colorectal cancer) did not experienced an augmentation in delays (20.9 vs. 25.2 days, p=0.39). A mean of 3.5 elective curative surgeries per month were performed during the pandemic period compared to 3.4 at the pre-pandemic period (p=0.96), and mean delays for surgery were not affected (60.4 vs. 57 days, p=0.59). Stages at diagnosis did not differ (p=0.2). Most of the delayed colonoscopies led to a stage 0 or I CRC and did not lead to a higher stage at diagnosis (p=0.2). Conclusions: In our center, the COVID-19 pandemic led to overall less CRC diagnosis and increased diagnostic endoscopic delays without a higher rate of advanced stage disease. Delays for elective surgeries were quite similar once the CRC diagnostic established.

Predictive Factors of Detectable Viral Load in HIV-Infected Patients.

Despite availability of effective antiretroviral therapy (ART), many HIV patients still have a detectable viral load (VL). Predictive factors of detectable VL are not well documented. This study was done at two large multidisciplinary HIV outpatient clinics at the Centre hospitalier de l'Université de Montréal (CHUM) and the McGill University Health Centre (MUHC). This is a retrospective case-control study of patients treated between 2016 and 2018. Cases had a VL ≥50 copies/mL in 2018. Controls had an undetectable VL from 2016 to 2018. Matching was based on gender and year of HIV diagnosis. Primary objective was to identify predictive factors of detectable VL. Secondary objectives included to identify predictive factors of virologic failure, low persistent viremia, and viral blip. A forward stepwise model selection by the Akaike Information Criterion of the conditional logistic regression was used to identify predictive factors. Two hundred cases were identified and matched with 200 controls. The cohort was mostly male (68.0%) with a median age of 54 years (21-83 years). Among cases, viral blip was the most common type of detectable VL (43.0%). The strong predictive factors for a detectable VL were adherence to ART and seeking health care services. Asylum seekers were less at risk of detectable VL. Adherence to ART was the only strong predictive factor for virologic failure. Three main predictive factors of detectable VL were identified in two ambulatory clinic hospitals in Montreal. Ascertaining these factors will allow for identification of patients more at risk of detectable VL.

The Clinical Significance of Bone Mineral Density Changes Following Long-Term Androgen Deprivation Therapy in Localized Prostate Cancer Patients.

Long-term androgen deprivation therapy has been associated with decreased bone mineral density in men with prostate cancer. Some evidence suggests that there is no impact on fracture risk despite this bone mineral density loss. Our study aimed to quantify changes in bone mineral density in men with high risk prostate cancer on long-term androgen deprivation therapy and calcium and vitamin D supplementation. Bone mineral density analysis was conducted for localized high risk prostate cancer patients enrolled in the phase III randomized trial PCS-V (Prostate Cancer Study 5), comparing conventional and hypofractionated radiation therapy. Patients received 28 months of luteinizing hormone-releasing hormone agonist and calcium and vitamin D supplementation (500 mg calcium BID+400 IU vitamin D3 BID). The areal density and T-scores (spine, femoral neck and total femur) at baseline and 30 months of followup were extracted, and the absolute change was calculated. Clinical bone density status (normal, osteopenia, osteoporosis) was monitored. The lumbar spine, femoral neck and total femoral bone mineral density were measured for 226, 231, and 173 patients, respectively. The mean percent change in bone mineral density was -2.65%, -2.76% and -4.27% for these respective sites (p <0.001 for all). The average decrease in bone mineral density across all sites was -3.2%, with no decline in bone mineral density category in most patients (83%). Eight patients (4%) became osteoporotic. Despite a mild decline in bone mineral density, the change in clinical bone mineral density category remained low with long-term androgen deprivation therapy. Consequently, calcium and vitamin D supplementation alone may suffice for most localized prostate cancer patients on long-term androgen deprivation therapy.

Survival Impact of Aggressive Treatment and PD-L1 Expression in Oligometastatic NSCLC

Background: Studies have shown that aggressive treatment of non-small cell lung cancer (NSCLC) with oligometastatic disease improves the overall survival (OS) compared to a palliative approach and some immunotherapy checkpoint inhibitors, such as anti-programmed cell death ligand 1 (PD-L1), anti-programmed cell death protein 1 (PD-1), and T-Lymphocyte-associated antigen 4 (CTLA-4) inhibitors are now part of the standard of care for advanced NSCLC. However, the prognostic impact of PD-L1 expression in the oligometastatic setting remains unknown. Methods: Patients with oligometastatic NSCLC were identified from the patient database of the Centre hospitalier de l’Université de Montréal (CHUM). “Oligometastatic disease” definition chosen is one synchronous metastasis based on the M1b staging of the eight IASLC (The International Association for the Study of Lung Cancer) Classification (within sixth months of diagnosis) or up to three cerebral metastasis based on the methodology of the previous major phase II randomized study of Gomez et al. We compared the OS between patients receiving aggressive treatment at both metastatic and primary sites (Group A) and patients receiving non-aggressive treatment (Group B). Subgroup analysis was performed using tumor PD-L1 expression. Results: Among 643 metastatic NSCLC patients, we identified 67 patients with oligometastasis (10%). Median follow-up was 13.3 months. Twenty-nine patients (43%) received radical treatment at metastatic and primary sites (Group A), and 38 patients (57%) received non-aggressive treatment (Group B). The median OS (mOS) of Group A was significantly longer than for Group B (26 months vs. 5 months, p = 0.0001). Median progression-free survival (mPFS) of Group A was superior than Group B (17.5 months vs. 3.4 months, p = 0.0001). This difference was still significant when controlled for primary tumor staging: stage I (p = 0.316), stage II (p = 0.024), and stage III (p = 0.001). In the cohort of patients who were not treated with PD-L1 inhibitors, PD-L1 expression negatively correlated with mOS. Conclusions: Aggressive treatments of oligometastatic NSCLC significantly improve mOS and mPFS compared to a more palliative approach. PD-L1 expression is a negative prognostic factor which suggests a possible role for immunotherapy in this setting.