Centre Hospitalier Universitaire De Sherbrooke Research Articles

Interdisciplinary quality improvement in oculoplastic surgery: transforming biopsy follow-up through PDSA cycles

ObjectiveTo evaluate and improve the quality of periocular biopsy follow-up by determining the absolute compliance rate, examining delays between stages, identifying obstacles to high-quality follow-up, and offering recommendations for improvement. MethodsPhase 1: A retrospective, observational, and descriptive study was conducted using chart reviews of adult patients who underwent periocular biopsies at the Centre Hospitalier Universitaire de Sherbrooke (CHUS) from January 2019 to October 2022. Phase 2: Three simultaneous Plan-Do-Study-Act (PDSA) cycles were implemented, focusing on enhancing communication channels between clinicians and pathologists, introducing a priority system for urgent cases, and establishing an automatic reminder system for pathologists. ResultsPhase 1: Among the 103 patients analyzed, 29 had malignant lesions, while 74 had nonmalignant lesions. The absolute compliance rate was 37.9% for malignant lesions. All of these noncompliances were due to excessive turnaround time (TT) to issue the pathology report. The percentage of cases that had adequate pathology TT (≤ 7 days) were 37.9% for malignant lesions, much lower than the Quebec Ministry of Health's target (80% at ≤7 days). Phase 2: The implemented PDSA cycles led to significant increases in absolute compliance rates and pathology TT compliance rates for malignant lesions. Primary outcomes showed that the absolute compliance rate increased to 93.3%. Secondary outcomes indicated that the pathology TT compliance rate also reached 93.3%. ConclusionsDelayed pathology reporting was identified as the primary cause of suboptimal follow-up. The successful implementation of targeted PDSA cycles improved communication, prioritization, and reminder systems, resulting in considerable improvements in primary and secondary outcomes.

THU591 HyperAldosteronism In Pregnancy Predicted Impacts (H.A.P.P.I.): A Retrospective Cohort Study

Abstract Disclosure: D. Oprea: None. F. Lefrançois: None. A.C. Côté: None. M. Roy-Lacroix: None. M. St-Jean: None. N. Sauvé: None. Introduction: Hypertensive disorders of pregnancy (HDP) are increasing worldwide and are associated with a high rate of maternal and fetal morbidity and mortality. Primary aldosteronism (PA) is a frequent and reversible cause of secondary hypertension in young non-pregnant women (18%) (1). Until now, no studies have detailed the prevalence, nor the outcomes associated with PA during pregnancy. Research Question: In HDP, are cases of PA associated with different impacts on maternal-fetal health compared to pregnant women without PA? Methods: This retrospective cohort study compared 252 pregnancies according to their PA status. We included pregnancies that were followed at the Centre Hospitalier Universitaire de Sherbrooke (CHUS) between 2011 and 2022, and who had had an aldosterone/renin ratio (ARR) screening for PA, in a five-year period before or after the analyzed pregnancy. Monofetal and twin pregnancies were included. Concomitant diagnoses of pheochromocytoma, hyperthyroidism or Cushing syndrome were excluded. The primary objective of this study was to describe the occurrence of HDP in women with PA. Secondary objectives were to describe maternal, fetal and neonatal outcomes and compare them according to PA status. Results: Among 252 pregnancies, 15 were diagnosed with a PA (concerning 12 women). Our preliminary analysis showed a greater prevalence of advanced maternal age (53.3% vs 24.5, p = 0.028) and Afro-American ethnicity (60.0 % vs 10.1%, p < 0.001) in the PA group, in addition to a tendency towards class I obesity (40.0% vs 13.1%, p = 0.166) in this group. There were no differences in terms of prevalence of chronic hypertension (26.7% vs 25.7 %, p = 0.936), delivery mode and overall fetal morbidity and mortality. Although not statistically significant, preeclamspia tended to be more frequent (40.0% vs 27.0%, p = 0.276) and gestational hypertension less frequent (0.0 % vs 16.0%, p = 0.092) during pregnancy in the PA group. 40.1% (vs 19.0%, p = 0.052) of PA-associated HDP were diagnosed in post-partum (including 33.4 % of preeclampsia in this group) and required intravenous hypertensive treatment (40.0% vs 23.2%, p = 0.209). Also, 13.3% of pregnancies in the PA group (vs. 3.0 %, p = 0.093) required hospitalization at the intensive care unit (ICU). All cases of PA were diagnosed within 5 years pre-conception or post-partum. Conclusion: Pregnancies with PA diagnosis within a five-year period tended to present more frequently with HDP as preeclampsia, especially in the post-partum period, and often required more intensive antihypertensive treatment and ICU hospitalization. The upcoming second prospective phase of this study will better assess the prevalence of PA in pregnant women experiencing HDP. Reference: (1) Alam S. et al., Clin Endocrinol, June 2021;94(6):895903. Presentation: Thursday, June 15, 2023

Decisional needs assessment for patient-centred pain care in Canada: the DECIDE-PAIN study protocol

IntroductionThe 2021 Action Plan for Pain from the Canadian Pain Task Force advocates for patient-centred pain care at all levels of healthcare across provinces. Shared decision-making is the crux of...

Evolution of Bosniak IIF Renal Cysts and Impact of the 2019 Bosniak Classification. Reply.

No AccessJournal of UrologyReply to Letters to the Editor14 Feb 2023Clinical Outcomes of Bosniak IIF Renal Cysts and Impact of the 2019 Bosniak Classification. Reply.is a reply to letterEvolution of Bosniak IIF Renal Cysts and Impact of the 2019 Bosniak Classification. Letter. Patrick O. Richard and Felix Couture Patrick O. RichardPatrick O. Richard * E-mail Address: [email protected] Department of Urology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada More articles by this author and Felix CoutureFelix Couture Department of Urology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003366AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookLinked InTwitterEmail "Clinical Outcomes of Bosniak IIF Renal Cysts and Impact of the 2019 Bosniak Classification. Reply.." The Journal of Urology, Publish Ahead of Print, pp. – REFERENCES 1. . Evolution of Bosniak IIF renal cysts and impact of the 2019 Bosniak classification. J Urol.2023; 209(5):000-000. Link, Google Scholar 2. . Bosniak classification for complex renal cysts reevaluated: a systematic review. J Urol.2017; 198(1):12-21. Link, Google Scholar 3. . Proportion of malignancy in Bosniak classification of cystic renal masses version 2019 (v2019) classes: systematic review and meta-analysis. Eur Radiol.2022; 33(2):1307-1317. Crossref, Medline, Google Scholar 4. . Outcomes of Bosniak classification version 2019 class IIF cystic renal masses at imaging surveillance. AJR Am J Roentgenol.2022. Crossref, Google Scholar Submitted February 2, 2023; accepted February 3, 2023; published 000. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of Urology14 Feb 2023Evolution of Bosniak IIF Renal Cysts and Impact of the 2019 Bosniak Classification. Letter. Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Patrick O. Richard Department of Urology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada * E-mail Address: [email protected] More articles by this author Felix Couture Department of Urology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada More articles by this author Expand All Submitted February 2, 2023; accepted February 3, 2023; published 000. Advertisement PDF downloadLoading ...

ODP038 Efficacy of Medical Treatment Compared to Unilateral Adrenalectomy in a Cohort of Patients with Primary Aldosteronism Treated at the Centre Hospitalier Universitaire de Sherbrooke – CHUS

Abstract Background Primary aldosteronism (PA) is associated with a high burden of cardiometabolic complications such as coronary heart disease, atrial fibrillation, left ventricular hypertrophy, stroke and chronic kidney disease. It is therefore essential to screen, confirm the diagnosis and then implement a targeted treatment, to lower the rate of these complications. According to the latest Endocrine Society guidelines for the management of PA, unilateral adrenalectomy is recommended when the secretion of aldosterone is mostly coming from one adrenal. If the secretion is bilateral or if the patient refuse surgery, medical treatment with mineralocorticoid receptor antagonist is indicated. Nevertheless, there are limited data comparing these two treatments on their impact on the number and dosage of anti-hypertensive drugs needed to control the disease. Objective The objective was to compare the impact of medical or surgical treatment on the antihypertensive defined daily dose (DDD) after 6 months of treatment in our cohort of PA patients followed at the CHUS. We've also evaluated the kalemia, blood pressure and renin after 6 and 12 months of treatment. Long term blood pressure control has also been evaluated. Methodology To answer this question, we conducted a single-center retrospective cohort study. Adults followed at CHUS between 2000 and 2021, with a confirmed diagnosis of PA and a follow-up of at least 6 months were included. Pregnancy was the only exclusion criteria. The primary outcome was the variation in the antihypertensiveDDD in patients medically treated compared to those surgically treated after 6 months. Results A total of 46 patients were included in our cohort, from which 28 were medically treated. Patients in the surgical group were younger, had a higher diastolic blood pressure and aldosterone/renin ratio. Among the 18 patients who underwent unilateral adrenalectomy, only 6 of them had a clearly lateralized secretion confirmed by adrenal veins sampling. At 6 months, the antihypertensive DDD variation was statistically significantly higher in the surgical group, with a decrease of 1.7 compared to a decrease of 0.6 in the medical group. Even after age, diastolic blood pressure and aldosterone/renin ratio adjustments, the difference between the 2 groups remains statistically significant, with a p value of 0. 033. Conclusion These results indicate that the surgical treatment of patient with primary aldosteronism leads to a greater DDD decrease at 6 months, even after adjusting for disease severity and despite the fact that the surgical group is not exclusively unilateral. However, the impact of disease control on long-term outcomes could not be assessed due to missing data. Presentation: No date and time listed

Gastrointestinal Symptomatology as a Predictor of Esophagogastroduodenoscopy Findings in the Bariatric Population: a Retrospective Cohort Study with Review of the Literature.

Esophagogastroduodenoscopy (EGD) is a useful test to diagnose significant pathologies before bariatric surgery. Controversy remains about its role in the preoperative workup of asymptomatic patients. This study aims to describe findings and changes in the management related to EGD. A secondary objective was to review the existing literature on the subject to analyze the role of patients' gastrointestinal symptomatology as an indication to undergo a preoperative EGD. A retrospective chart review of patients operated at the Centre hospitalier universitaire de Sherbrooke (CHUS) since the opening of the Clinique médico-chirurgicale du traitement de l'obésité (CMCTO) was conducted, alongside a review of the literature. Pathologic findings on EGD were classified into 4 groups (groups 0 to 3). Results of this study were combined with literature to calculate weighted averages of global sensitivity, specificity, positive/negative predictive values, and likelihood ratios of gastrointestinal symptomatology as a predictor of pathologic endoscopy findings. A total of 737 patients were included in the study. Of those, 236 (35,7%) were considered symptomatic. Significant pathologic findings on EGD (group 2 and 3) were present for 270 patients (36.6%). Changes in medical management occurred in 22.8% of cases and in surgical management in 3.5% of cases. When combining past studies with the present one, the presence of symptoms had a sensitivity of 57.4% and a specificity of 82.4% for findings on EGD. Considering that this exam is relatively safe, that it allows uncovering a great number of pathologies altering management, and that symptoms are not a good screening test to decide of its indication, the authors recommend that all bariatric surgery patients undergo an EGD in their preoperative workup.

A197 ACUTE ILEITIS IN ADULT PATIENT: A RETROSPECTIVE STUDY OF PATIENT OUTCOMES

BackgroundRising availability of medical imaging exams in the emergency room potentially leads to an increase of ileitis findings by imaging in a context of gastrointestinal symptoms. However, it can be difficult to determine the clinical significance of this radiological finding in an acute consultation setting and to establish the relevant investigations.AimsThe aim of this study is to describe the current management and the long-term outcome of patients with diagnostic of acute ileitis on imaging during an emergency consultation in our center, Centre Hospitalier Universitaire de Sherbrooke(CHUS).MethodsWe performed a retrospective study of all patients diagnosed with ileitis by abdominal ultrasound or computed tomography (CT scan) during a visit in our emergency department over the years 2010 and 2017. Patients with previous diagnosis of Crohn disease were excluded. Data collected were clinical, radiological and endoscopic at diagnostic and over at least 3 years following the initial visit.ResultsA total of 118 files were reviewed. The initial imaging modality was 43% ultrasound and 57% CT scan. 36% of patients had an ileocolonoscopy within one month of the initial visit. Of these, 60% demonstrated macroscopic endoscopic abnormalities. 51% of patients had follow-up imaging within 3 months of the initial consultation. 64% of these images demonstrated persistence of pathological changes in the ileal region. Only 48% had a stool culture at diagnosis. 72% of patients met a gastroenterologist and 45% saw a general surgeon. The most common cause of ileitis was an infectious origin at 44% predominantly with Yersinia enterocolitica and Campylobacter jejuni. 13% received a diagnostic of Crohn disease. 20% of ileitis remained undetermined. Among these, there was a case of Crohn’s disease which was eventually diagnosed 2 years later. The initial factors associated with a diagnosis of Crohn’s disease were family history of inflammatory bowel disease (OR 6.17 95% CI 1.67 to 22.781 p = 0.006), extra-digestive manifestations (OR 23.31 95% CI 2.255 to 240.92 p = 0.008), discontinuous impairment at initial imaging (OR 19.8 95% CI 4.284 to 91.52 p = 0.000), presence of stenosis at initial imaging (OR 14.429 95% CI 1.227 to 169.68 p = 0.034), the presence of abscess or collection on imaging (OR 11.54 95% CI 1.76 to 75.63 p = 0.011) and wall thickness in mm (1.22 95% CI 1.06 to 1.40 p = 0.005).ConclusionsOur study shows that the majority of acute ileitis found on imaging are of infectious origin. A portion of acute ileitis corresponded to the initial presentation of Crohn’s disease. Thus, we believe that it is preferable to offer at least clinical follow-up to patients with acute ileitis on imaging and to consider additional investigation by imaging and / or colonoscopy when symptoms persist and this particularly in presence of factors associated with Crohn’s disease.Funding AgenciesNone

The acceptability of two remote monitoring modalities for patients waiting for services in a physiotherapy outpatient clinic.

Access to public rehabilitation services for patients with non-urgent conditions - which suffer mainly from musculoskeletal disorders - is problematic around the world. Remote rehabilitation services are recognized as effective means to increase accessibility. Patient acceptability is an important element in the successful implementation of such clinical innovations and has not yet been studied thoroughly in this context. Thus, the aim of this study was to evaluate and compare the acceptability of two remote consultation modalities - phone and teleconsultation - for patients waiting for public outpatient non-urgent rehabilitation services. We conducted a qualitative descriptive study nested within a randomized clinical trial in which participants received either phone or teleconsultation follow-ups with a physiotherapist after a first systematic face-to-face evaluation. Semi-structured interviews were conducted with participants of both groups selected with purposive sampling. Sekhon's acceptability metaframework was used and interviews were transcribed and coded with thematic analysis. The research protocol was approved by the Research Ethics Board of the Centre intégré universitaire de santé et de services sociaux - Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie - CHUS) (#2019-2919). Twenty participants were recruited. Results show both follow-up modalities have a good level of acceptability for participants; however, teleconsultation stands out because its visual dimension offers higher quality human contact and satisfactorily meets greater needs for support. Systematic in-person assessment and advice combined with telephone or teleconsultation follow-up can contribute to diversifying the services offered in physiotherapy outpatient clinics. Offering a range of service modalities with different resource requirements may shorten wait times. Such an approach seems to be well accepted by patients, especially with teleconsultation. gov ID: NCT03991858.

Safety of COVID-19 vaccination in patients with polyethylene glycol allergy: A case series

Safety of COVID-19 vaccination in patients with polyethylene glycol allergy: A case series

Factors Associated with Discontinuation of Active Surveillance among Men with Low-Risk Prostate Cancer: A Population-Based Study.

The purpose of this study was to describe the uptake, discontinuation and variation of active surveillance (AS) by provider and patient level characteristics. This observational, population-based study used linked administrative databases and pathology reports to identify all men diagnosed with Gleason score ≤6 prostate cancer (PC) between January 1, 2008 and December 31, 2014 in Ontario, Canada. The Cochran-Armitage test was used for AS trend over time. Treatment-free survival was estimated using cumulative incidence function. Factors associated with discontinuation of AS were evaluated using Cox proportional hazard models. Active surveillance was the initial management strategy for 8,541 cases (51%). Use of AS significantly increased from 38% in 2008 to 69% in 2014 (p=0.001). Men on AS were significantly older (64 years, SD 8.0) than those on initial treatment (62 years, SD 7.7; p=0.001). After a median followup of 48 months, 4,337 (51%) patients had discontinued AS. Treatment-free survival for AS patients at 1, 3, and 5 years were 85%, 58% and 52%, respectively. Median time to definitive treatment after initial AS was 16 months (IQR 11-25 months). Factors associated with AS discontinuation were younger age at diagnosis, year of diagnosis, higher comorbidities, treatment at academic center, treatment by physician and institution in the highest volume tertile, and adverse cancer-specific characteristics (higher prostate specific antigen [PSA], higher number of positive cores and higher percentage of core involvement at diagnosis). Although the uptake of AS significantly increased over time, there has been a relatively high rate of discontinuation over 5 years. Factors associated with transition to definitive treatment were younger age, care provided by higher volume physicians and institutions, higher PSA and greater PC volume at diagnosis. These results may help guide policy making, developing quality indicators, and developing targeted continued education for physician and patients embarking on AS to establish realistic expectations.

Validation of algorithms using International Classification of Diseases for the identification of herpes zoster episodes requiring hospitalization in Quebec, Canada

ObjectiveWe determined secular changes in the incidence of hospitalizations due to herpes zoster (HZh) and assessed the validity of HZ International Classification of Diseases (ICD) code algorithms for identifying HZh in a region of Quebec, Canada. MethodsWe performed a validation study as part of a retrospective cohort study of adult HZ patients hospitalized at Centre Hospitalier Universitaire de Sherbrooke during 2000–2017. Cases were identified using ICD codes from an inpatient administrative database. HZ cases identified by ICD-9 (053.xx) and ICD-10 (B02.x) codes were chart-confirmed, and performance characteristics of ICD code algorithms were calculated (positive predictive value [PPV] and sensitivity). ResultsOverall, 1314 hospitalizations with HZ diagnosis (HZh) with or without complications were identified during 2000–2017. Among the hospitalizations, 526 (44.4%) were due to active HZ disease or a complication related to a recent or previous HZ episode. These hospitalizations were due to active disease at the time of admission (340/526, 64.6%), HZ that developed during hospitalization (120/526, 22.8%), or a complication directly related to a recent or previous HZ episode (66/526, 12.6%). PPV was significantly higher when HZ was the primary diagnosis (276/310, 89%, 95% confidence interval [CI]: 85–92%) than when HZ was a secondary diagnosis (254/928, 27%, 95% CI: 25–30%) (p < 0.0001), and the PPV of a first secondary diagnosis (84/140, 60.0%, 95% CI: 51.3–68.2%) was higher than that of other secondary diagnoses (203/794, 25.6%, 95% CI: 22.6–28.8%) (p < 0.0001). An algorithm combining ICD codes and antiviral usage demonstrated the best sensitivity (86.3%, 95% CI: 83.1–89.1%) and PPV to identify HZh (100%, 95% CI: 99.2–100%). Poisson regression revealed no significant changes in HZh over time (incidence rate ratio: 0.98, 95% CI: 0.92–1.04%; p = 0.5). ConclusionHZh incidence was stable over time. Prescription of antivirals might be a useful addition to ICD codes to identify HZh cases from administrative databases.

Cost-Effectiveness Analysis of an Interdisciplinary Lifestyle Intervention Targeting Women With Obesity and Infertility in Comparison to Usual Care

Although lifestyle modification is considered as the first-line treatment for women with obesity and infertility, these women generally do not have access to a program supporting them in adopting healthy habits that is integrated to fertility care. Implementing such a program requires to demonstrate its efficiency. The purpose of this study was to conduct a cost-effectiveness analysis (CEA) of an interdisciplinary lifestyle intervention (Fit-for-Fertility (FFF) program) for women with obesity and infertility, in comparison with the usual care protocol, i.e. fertility treatments. Methods: A CEA was conducted alongside a randomized controlled trial, recruiting women at the fertility clinic of the Centre hospitalier universitaire de Sherbrooke. Women were randomized to: i) the intervention group (IG): FFF program alone for 6 months (individual follow-ups every 6 weeks and 12 group sessions), and in combination with usual care for infertility after 6 months if not pregnant; or ii) control group (CG): usual care from the outset. Data were collected in both groups, during 18 months or until the end of the pregnancy for those who became pregnant. Costs related to the management of infertility, obesity, pregnancy and childbirth, and the FFF program were considered and collected by self-reported questionnaires, review of medical records and administrative databases. Live birth (LB) rate was used to assess effectiveness. The CEA’s parameter of interest was the incremental cost-effectiveness ratio (ICER), calculated by non-parametric bootstrap with 5,000 iterations. All costs are in Canadian dollars, 2019. Results: A total of 130 women were randomized (65 CG, 65 IG). We present results for the 108 women (57 CG, 51 IG) who completed at least 6 months in the study. We observed an absolute difference of 14.2% (p=0.328) in LB rate between groups (IG: 51.0%; CG: 36.8%). Total mean costs per patient were significantly higher in the IG vs the CG for healthcare system’s ($5,660 ± $3,200 vs $3,631 ± $3,389; p=0.002) and society’s ($9,745 ± $5,899 vs $6,898 ± 7,021; p=0.026) perspectives. We observed an ICER of $12,633 per additional LB [$5,319-$19,947] from the healthcare system’s perspective, and $5,980 [$3,086-$8 874] from the patients’ perspective. Overall, the ICER for the society’s perspective, which includes both previous perspectives, was estimated at $24,393 per additional LB [$15,509-$33,276]. Conclusion: According to our results, a lifestyle intervention may be clinically more effective than the usual protocol of care for women with obesity and infertility, but generates higher costs as well, resulting in a positive ICER (of $12,600 per additional life birth for the healthcare system). Such an intervention could be considered efficient compared to the usual standard of care, but studies are needed to assess the willingness to pay of stakeholders for this type of intervention.

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.

The Potential Impact of Recreational Cannabis Legalization on the Prevalence of Cannabis Use Disorder and Psychotic Disorders: A Retrospective Observational Study

The principal objective of our study was to document the short-term impact of the legalization of recreational cannabis on active cannabis use, cannabis use disorder, and various psychotic disorders. We carried out a retrospective observational study of patients who were at least 12 years old and who had visited a psychiatrist in the emergency unit of the Centre hospitalier universitaire de Sherbrooke (CHUS). We included all the consultations of this type over a 5-month period, immediately following the legalization of recreational cannabis in Canada. We then divided our population into an adult (over 18) and teenager group (12 to 17) compared the data to the data from consultations made 2 years earlier, using a generalized linear mixed model. We examined consultations in patients over 18 years old in prelegalization (n = 1,247) and postlegalization (n = 1,368) groups. We observed a statistically significant increase in the use of cannabis (28.0% to 37.1%; odds ratio [OR] = 1.81 [1.34 to 2.44], P = 0.00011) as well as an increase in diagnoses of active cannabis use disorder (17.7% to 24.3%; OR = 1.53 [1.13 to 2.08], P = 0.0064). The increase in cannabis use disorder was more prominent among patients between 18 and 24 years old (17.3% to 25.9%; OR = 2.27 [1.17 to 4.40], P = 0.015). We observed no statistically significant difference in terms of psychotic disorder diagnoses (27.4% to 29.2%; OR = 1.17 [0.84 to 1.63], P = 0.35)]. Conversely, we identified a greater proportion of patients who had a personality disorder diagnosis in the postlegalization period (39.6% to 44.9%; OR = 1.35 [1.02 to 1.80], P = 0.038). Examination of pediatric (under 18 years old) consultations revealed no statistically significant differences. Although an affirmative conclusion is tentative, the current findings suggest a first link between the legalization of cannabis in Canada and increased diagnoses of cannabis use disorder, as well as cannabis use in general among patients in a university hospital psychiatric emergency department.

Methylparaben in Meconium and Risk of Maternal Thyroid Dysfunction, Adverse Birth Outcomes, and Attention-Deficit Hyperactivity Disorder

Background Parabens are detected ubiquitously in human urine samples, but the effects of prenatal exposure are unclear, partially due to inadequate exposure assessment in maternal urine, which may fail to capture fetal exposure. We examined the association of meconium methylparaben detection with preterm birth, gestational age, birthweight, maternal thyroid hormones, and child attention-deficit hyperactivity disorder (ADHD) at 6-7 years. Methods Methylparaben was measured in meconium with ultraperformance liquid chromatography mass spectrometry and dichotomized (detect/non-detect) for 345 children in the Gestation and the Environment cohort in Sherbrooke, Quebec, Canada, Birth outcomes and maternal thyroid hormones (T3, T4, and thyroid stimulating hormone [TSH]) at &lt;20 weeks gestation were measured at the Centre Hospitalier Universitaire de Sherbrooke. ADHD diagnosis at age 6-7 was determined at follow-up or from medical records. Associations were estimated with logistic and linear regressions, and the potential for mediation by birthweight and preterm birth of the effect of methylparaben on ADHD was modeled with causal mediation analysis. Results Meconium methylparaben detection was associated with increased odds of preterm birth (odds ratio [OR]=4.81; 95% CI [2.29, 10.10]), decreased gestational age (beta [β]=-0.61 weeks; 95% CI [-0.93, -0.29]) and decreased birthweight (β=-0.12 kilograms; 95% CI [-0.21, -0.03]). Associations were also found with decreased maternal TSH (relative concentration [RC]=0.76; 95% CI [0.58, 0.99]) and total T3 (RC=0.84; 95% CI [0.75, 0.96]), but increased total T4 (RC=1.10; 95% CI [1.01, 1.19]). Mothers of infants with detectable meconium methylparaben had increased odds of hypothyroxinemia (OR=2.50, 95% CI [1.01, 6.22]), and children were more likely to be diagnosed with ADHD at age 6-7 (OR=2.33, 95% CI [1.45, 3.76]). Preterm birth and birthweight mediated 20% and 13% of the effect of methylparaben on ADHD respectively. Conclusions This adverse association between methylparaben and ADHD, partially mediated by birth outcomes, warrants further research into fetal methylparaben exposure.

P057: Impact of a clinical pathway for the treatment of acute asthma in the emergency department

Introduction: In Canada, acute asthma is a common cause of emergency department (ED) attendance and its treatment is affected by ED overcrowding and increasing wait times. Literature suggests that a clinical pathway (CP) for the treatment of acute asthma can increase the use of medical therapy, reduce hospital admission rates and decrease associated costs. However, only few have looked at the effect on ED length of stay (ED LOS) when such a CP is initiated by triage nurse/respiratory therapist among adults. In this optic, an asthma CP was launched on Feb. 2016 at Centre Hospitalier Universitaire de Sherbrooke (QC) and included medical directives allowing triage nurse and respiratory therapist initiation of treatment. Methods: The objectives are to determine the effect of an ED nurse/respiratory therapist-initiated asthma CP on (1) ED LOS, (2) time-to-treatment (beta-agonist, corticosteroids), time-to-MD and other secondary outcomes. This was a retrospective before-after study. Adults presenting to the ED before and after CP implementation with a final diagnosis of asthma or asthma exacerbation were eligible. The groups A (before implementation) and B (after implementation) were compared for ED LOS. Three subgroups of 50 patients were generated and compared for outcomes: A1 (before implementation), B1 (after implementation without CP) and B2 (after implementation with CP). All five groups were controlled for triage level and sex. Results: In total, 1086 patients were included; 543 before implementation (Mar. 2011 – Feb. 2016) and 543 after (Feb. 2016 – Jun. 2019), of whom 14% (N = 77) were treated by CP. The average ED LOS was similar (10.36h vs 10.65h; (p = 0,31)) in group A and in group B. In groups A1, B1 and B2, the median ED LOS were respectively 6.00, 6.84, 4.80; these differences were not statistically significant. The average time-to-treatment for beta-agonist in A1, B1 and B2 was respectively 148, 180 and 50 mins; the differences between B2 and A1 and between B2 and B1 were both statistically significant (p &lt; 0,05). Conclusion: Although this study indicates a low compliance to the CP, it shows that time-to-treatment can be reduced. It didn't demonstrate any statistically significant decrease in ED LOS, most likely due to low number of patients and non-normal distribution, but the 1.2h shorter could be a major advantage if it proves true. Further studies are essential to understand facilitators and alleviate the barriers in anticipation of a multi-centric implementation.

Highlights From the Circulation Family of Journals.

Highlights From the Circulation Family of Journals.

Methylparaben in meconium and risk of maternal thyroid dysfunction, adverse birth outcomes, and Attention-Deficit Hyperactivity Disorder (ADHD)

BackgroundParabens, which are used as a preservative in foods and personal care products, are detected in nearly 100% of human urine samples. Exposure to parabens is associated with DNA damage, male infertility, and endocrine disruption in adults, but the effects of prenatal exposure are unclear. In part, this is due to inadequate assessment of exposure in maternal urine, which may only reflect maternal rather than fetal exposure. To address this gap, we examined the association of prenatal methylparaben measured in meconium with preterm birth, gestational age, birthweight, maternal thyroid hormones, and child Attention-Deficit Hyperactivity Disorder (ADHD) at 6–7 years. DesignData come from the GESTation and the Environment (GESTE) prospective observational pregnancy cohort in Sherbrooke, Quebec, Canada. Participants were 345 children with data on ADHD among 394 eligible pregnancies in women age ≥18 years with no known thyroid disease before pregnancy and meconium collected at delivery. Methylparaben was measured in meconium. Birthweight, gestational age, and maternal thyroid hormones at <20 weeks gestation were measured at the Centre Hospitalier Universitaire de Sherbrooke. Preterm birth was defined as vaginal birth before the 37th week of gestation. Physician diagnosis of ADHD was determined at a scheduled cohort follow-up when children were 6–7 years old or from medical records. Associations between meconium methylparaben and outcomes were estimated with logistic and linear regressions weighted on the inverse probability of exposure to account for potential confounders, including child sex, familial income, maternal education, pre-pregnancy body mass index, age, and smoking and alcohol consumption during pregnancy. ResultsMethylparaben was detected in 65 meconium samples (19%), 33 children were diagnosed with ADHD (10%), and 13 children were born preterm (4%). Meconium methylparaben was associated with preterm birth (odds ratio [OR] = 4.81; 95% CI [2.29, 10.10]), decreased gestational age (beta [β] = −0.61 weeks; 95% CI [−0.93, −0.29]) and birthweight (β = −0.12 kg; 95% CI [−0.21, −0.03]), altered maternal TSH (relative concentration [RC] = 0.76; 95% CI [0.58, 0.99]), total T3 (RC = 0.84; 95% CI [0.75, 0.96]) and total T4 (RC = 1.10; 95% CI [1.01, 1.19]), maternal hypothyroxinemia (OR = 2.50, 95% CI [1.01, 6.22]), and child ADHD at age of 6–7 (OR = 2.33, 95% CI [1.45, 3.76]). The effect of meconium methylparaben on ADHD was partially mediated by preterm birth (20% mediation) and birthweight (13% mediation). ConclusionsMeconium methylparaben was associated with preterm birth, decreased gestational age and birthweight, maternal thyroid hormone dysfunction, and child ADHD. Parabens are a substantial health concern if causally related to these adverse outcomes.

P14.84 Intraarterial chemotherapy and osmotic blood-brain barrier modification in the treatment of primary CNS lymphoma

Abstract BACKGROUND Primary central nervous system lymphomas (PCNSL) are considered a rare and aggressive form of central nervous system (CNS) tumors. High-dose methotrexate has become the backbone of PCNSL treatment, and is recommended by the EANO guidelines. In most recent protocols, investigators tend to postpone or even avoid the use of radiotherapy; indeed, its use has become controversial with findings of associated severe neuro-toxicity, especially in elderly patients. To maximize delivery across the BBB, we use cerebral intra-arterial chemotherapy (CIAC) coupled with osmotic blood-brain barrier disruption (OBBBD). We hereby report our single-center experience over 18 years with the CIAC + BBBD technique using 2 different HD-MTX protocols. MATERIAL AND METHODS This phase II study was conducted at the Centre hospitalier Universitaire de Sherbrooke (CHUS) from November 1999 to May 2018. The protocol was approved by the institutional review board, and informed consent was obtained in accordance to institutional regulation in every patient After enrollment and initial evaluation, patients were treated every four weeks (1 cycle) for 12 cycles, unless progression. After general anesthesia, a transfemoral approach was used to catheterize either the right or left internal carotid artery or the dominant vertebral artery, depending on tumor(s) location. OBBBD was performed by infusing 20% mannitol in the selected vascular distribution for 30 seconds at a rate that fills the vascular distribution so as to maximize the contact of the mannitol with the endothelial cells.Two different chemotherapy regimens were sequentially used in this study. High-dose MTX (5 g IV) was the cornerstone of both regimens: the first regimen (1999 to 2007) also included etoposide phosphate IV (400 mg/m²) and cyclophosphamide IV (660 mg/m²), whereas the 2nd regimen (1998 to 2018) also included carboplatin IA (400 mg/m²). RESULTS The present analysis therefore concerns a cohort of 44 naive patients recruited over 18 years in a single center. Median follow-up was 38 months. Overall, a CR was induced in 34 patients (79%). Themedian time to CR was 7.3 months (IQR: 7.8). Of these 34 patients, 11 (25.6%) are still alive, and 9 of these are disease-free after treatment discontinuation. The actuarial median survival (MS) was 46.5 months (95% CI: 30.9–62.2) for the cohort. Survival was 88%, 64%, 54%, 39% and 18% at 1, 2, 3,5 and 10 years (Figure 1 and Table 2).The progression-free survival was 43.4 months (95% CI: 17.9–68.9). Five occurrences of vascular complications related to the treatment were observed (11.6%). Conclusion: CIAC HD-MTX-based protocols with OBBBD is a safe and well-tolerated procedure for the management of primary CNS lymphoma. Our single center data suggests better PFS and survival outcomes compared to IV protocols with less hematologic toxicity and good tolerability, especially in the elderly.

Comparison of two dose calculation methods of intra-arterial carboplatin in the treatment of recurrent glioblastoma multiforme.

e13503 Background: Glioblastoma is a deadly brain cancer, and as part of the natural evolution, its relapses will mostly occur 32 to 36 weeks after the initial diagnosis. The standard of care for recurrent glioblastomas is not well defined and multiple options exist. Intra-arterial chemotherapy as one option is currently practiced at the Centre hospitalier universitaire de Sherbrooke, the only center doing this procedure in Canada. The aim of this study is to evaluate the impact of using the area under the curve (AUC) or body surface area (BSA) dosing formula to guide intra-arterial carboplatin administration. It was designed to explore the relation of two dose calculation methods on efficacy and toxicity, determined by progression-free survival (PFS) and hematologic toxicity, respectively. Methods: A retrospective observational study was conducted, which includes adult in-patients who received intra-arterial carboplatin for recurrent glioblastoma from June 1st, 2000 to December 31st, 2017. It examined the associations of the method used to calculate the doses, in mg or mg/mL x min-1, with clinical outcomes. Results: One hundred ninety patients were included in the analysis. For the primary endpoint, an exposure greater than 6 of AUC was found potentially harmful in terms of efficacy compared to AUC under 6 (HR 0.529, p = 0.0044). In terms of toxicity, a higher AUC is highlighted to correlate with a slightly higher incidence of thrombocytopenia and neutropenia (OR 1.051 p = 0.0271; OR 1.072 p = 0.049). No significant association between toxicity and dose calculated with BSA could be established. Conclusions: AUC greater than 6 is detrimental in terms of effectiveness according to progression free survival. Moreover, AUC could be used to predict neutropenia and thrombocytopenia. However no significant predictions were found using BSA method. We recommend the use of AUC method in intra-arterial carboplatin instead of BSA method since the latter was not statistically related to toxicity. A prospective trial comparing the two dosage methods would be needed.