Health Sciences North Research Articles

Association of hospital-based substance use supports on emergency department revisits: a retrospective cohort study in Sudbury, Canada from 2018 to 2022

BackgroundThis study compares emergency department (ED) revisits for patients receiving hospital-based substance-use support compared to those who did not receive specialized addiction services at Health Sciences North in Sudbury, Ontario, Canada.MethodsThe study is a retrospective observational study using administrative data from all patients presenting with substance use disorder (SUD) at Health Sciences North from January 1, 2018, and August 31, 2022 with ICD-10 codes from the Discharge Database (DAD) and the National Ambulatory Care Database (NACRS). There were two interventions under study: addiction medicine consult services (AMCS group), and specialized addiction medicine unit (AMU group). The AMCS is a consult service offered for patients in the ED and those who are admitted to the hospital. The AMU is a specialized inpatient medical unit designed to offer addiction support to stabilize patients that operates under a harm-reduction philosophy. The primary outcome was all cause ED revisit within 30 days of the index ED or hospital visit. The secondary outcome was all observed ED revisits in the study period. Kaplan–Meier curves were used to measure the proportion of 30-day revisits by exposure group. Odds ratios and Hazard Ratios were calculated using logistic regression models with random effects and Cox-proportional hazard model respectively.ResultsA total of 5,367 patients with 10,871 ED index visits, and 2,127 revisits between 2018 and 2022 are included in the study. 45% (2,340/5,367) of patient were not admitted to hospital. 30-day revisits were less likely among the intervention group: Addiction Medicine Consult Services (AMCS) in the ED significantly reduced the odds of revisits (OR 0.53, 95% CI 0.39–0.71, p < 0.01) and first revisits (OR 0.42, 95% CI 0.33–0.53, p < 0.01). The AMU group was associated with lower revisits odds (OR 0.80, 95% CI 0.66–0.98, p = 0.03). For every additional year of age, the odds of revisits slightly decreased (OR 0.99, 95% CI 0.98–1.00, p = 0.01) and males were found to have an increased risk compared to females (OR 1.50, 95% CI 1.35–1.67, p < 0.01).InterpretationWe observe statistically significant differences in ED revisits for patients receiving hospital-based substance-use support at Health Sciences North. Hospital-based substance-use supports could be applied to other hospitals to reduce 30-day revisits.

Evaluating an addiction medicine unit in Sudbury, Ontario Canada: a mixed-methods study protocol

BackgroundIn response to the escalating global prevalence of substance use and the specific challenges faced in Northern Ontario, Canada, an Addiction Medicine Unit (AMU) was established at Health Sciences North (HSN) in Sudbury. This protocol outlines the approach for a comprehensive evaluation of the AMU, with the aim of assessing its impact on patient outcomes, healthcare utilization, and staff perspectives.MethodsWe conducted a parallel mixed-method study that encompassed the analysis of single-center-level administrative health data and primary data collection, including a longitudinal observational study (target n = 1,200), pre- and post-admission quantitative interviews (target n = 100), and qualitative interviews (target n = 25 patients and n = 15 staff). We implemented a participatory approach to this evaluation, collaborating with individuals who possess lived or living expertise in drug use, frontline staff, and decision-makers across the hospital. Data analysis methods encompass a range of statistical techniques, including logistic regression models, Cox proportional hazards models, Kaplan-Meier curves, Generalized Estimating Equations (GEE), and thematic qualitative analysis, ensuring a robust evaluation of patient outcomes and healthcare utilization.DiscussionThis protocol serves as the foundation for a comprehensive assessment designed to provide insights into the AMU’s effectiveness in addressing substance use-related challenges, reducing healthcare disparities, and improving patient outcomes. All study procedures have been meticulously designed to align with the ethical principles outlined in the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans. The findings will be disseminated progressively through committees and working groups established for this research, and subsequently published in peer-reviewed journals. Anticipated outcomes include informing evidence-based healthcare decision-making and driving improvements in addiction treatment practices within healthcare settings.

Utilization of Shock Team and Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) in the Management of Cardiogenic Shock in Northern Ontario

BackgroundDespite advancements in critical care and coronary revascularization, cardiogenic shock (CS) outcomes remain poor. Implementing a shock team and use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) have been associated with improved CS outcomes, but its feasibility in remote and rural areas remains unknown. MethodsThis retrospective study included patients with CS who required mechanical circulatory support (MCS) at Health Sciences North, Sudbury, Ontario. The analysis aimed to accomplish 2 objectives: first, to review the outcomes associated with use of Impella (Abiomed, Danvers, MA) and, second, to assess the feasibility of establishing a shock team to facilitate the local implementation of VA-ECMO. The primary endpoint was in-hospital mortality. ResultsThe outcomes of 15 patients with CS who received Impella between 2015 and 2021 were reviewed. Their average age was 65 years (standard deviation [SD]: 13), and 8 patients (53%) were female. CS was ischemic in 12 patients (80%). Transfemoral Impella CP (cardiac power) was the most frequently used (93%). Thirteen patients (87%) died during the index hospital stay post-Impella because of progressive circulatory failure. The shock team was established following consultations with several Canadian MCS centres, leading to the development of a protocol to guide use of MCS. There have been 4 cases in which percutaneous VA-ECMO using Cardiohelp (Getinge/Maquet, Wayne, NJ) has been used; 3 (75%) survived beyond the index hospitalization. ConclusionsThis analysis demonstrated the feasibility of implementing a shock team in remote Northern Ontario, enabling the use of VA-ECMO with success in a centre with a sizeable rural catchment area. This initiative helps address the gap in cardiac care outcomes between rural and urban areas in Ontario.

Intermediate-term Outcomes Following a Case Series of Reoperations for Medtronic Freestyle Stentless Aortic Valves

BackgroundData are limited on long-term outcomes in patients who have undergone a reoperation following failure of a stentless aortic valve. MethodsBetween 2006 and 2016, a retrospective analysis was performed on 24 patients who underwent open aortic valve replacement surgery for a failed stentless aortic valve prosthesis at Health Sciences North, Sudbury, Ontario, Canada. The primary outcome was a low mortality rate from cardiac-related deaths after 5 years. ResultsAll patients underwent insertion of a Medtronic Freestyle bioprosthesis (Minneapolis, MN) implanted using the modified subcoronary technique for their initial operation. The interval from the first operation to the stentless redo surgery ranged from 6 to 13 years. Aortic valve reoperation was performed for structural valve deterioration in 96% (n = 23) of the cases. Reoperations involved a removal of the stented valve leaflets and standard aortic valve replacement within the stentless casing in 20% (n = 5) of the cases, with the remaining cases requiring complete removal of the stentless prosthesis and aortic valve replacement. In those in whom a complete removal of the stentless valve was possible (n = 19), no disruption of the native aortic root occurred, with a 0% rate of conversion to a Bentall procedure. No intraoperative mortality occurred. The 30-day and 10-year operative mortality rates were 4% and 16%, respectively. ConclusionsRedo surgery for failing stentless valves can be done with relatively low risk and with acceptable long-term outcomes without resorting to root-replacement techniques.

P.111 5-ALA guided surgical resection of newly diagnosed high grade gliomas at Health Sciences North (HSN) in Sudbury, Ontario

Background: Since its approval by Health Canada in 2020, several neurosurgical centres across Canada have used 5-ALA, an oral drug that assists with surgical resection of malignant gliomas by causing tumour cells to fluoresce under the microscope. The study’s objective is to prospectively evaluate the extent of resection (EOR) and clinical outcomes in 5-ALA-guided surgery at HSN compared to historical controls. Methods: A retrospective analysis was performed of patients with malignant gliomas having undergone surgery at HSN from 2011 to December 2020, assessing the EOR (contrast-enhanced tumour on post-operative CT/MRI), progression-free survival (PFS), overall survival (OS). Results: 235 patients underwent surgery for malignant glioma including 51 newly-diagnosed patients felt to be surgically resectable and with post-operative imaging. 25/51 (49%) had no residual tumour. The median PFS and OS were 7.1 and 11.5 months respectively. To date, 3 patients have successfully undergone 5-ALA-guided surgery with complete resection of contrast-enhancing tumour and no new focal neurological deficit post-operatively. Conclusions: We continue to recruit and follow prospectively patients having undergone 5-ALA-guided resection of malignant gliomas at HSN. Patients living in Northern Ontario may derive significant benefits from the use of 5-ALA-guided surgery, particularly since other technologies, such as intraoperative MRI and ultrasound, are costly and not available.

Building an inpatient addiction medicine consult service in Sudbury, Canada: preliminary data and lessons learned in the era of COVID-19

ObjectiveThe goal of this study was to (1) Describe the patient population of a newly implemented addiction medicine consult service (AMCS); (2) Evaluate referrals to community-based addiction support services and acute health service use, over time; (3) Provide lessons learned.MethodsA retrospective observational analysis was conducted at Health Sciences North in Sudbury, Ontario, Canada, with a newly implemented AMCS from November 2018 and July 2021. Data were collected using the hospital’s electronic medical records. The outcomes measured included the number of emergency department visits, inpatient admissions, and re-visits over time. An interrupted time-series analysis was performed to measure the effect of AMCS implementation on acute health service use at Health Sciences North.ResultsA total of 833 unique patients were assessed through the AMCS. A total of 1,294 referrals were made to community-based addiction support services, with the highest proportion of referrals between August and October 2020. The post-intervention trend for ED visits, ED re-visits, ED length of stay, inpatient visits, re-visits, and inpatient length of stay did not significantly differ from the pre-intervention period.ConclusionImplementation of an AMCS provides a focused service for patients using with substance use disorders. The service resulted in a high referral rate to community-based addiction support services and limited changes in health service usage.

A112 VIDEO CAPSULE ENDOSCOPY REGISTRY OF ONTARIO (VCERO) - RETROSPECTIVE PHASE (NORTHERN ONTARIO REGION)

AimsThe primary aim of this project is to determine the feasibility of establishing and maintaining a registry of all video capsule endoscopy procedures performed at a large regional center. Secondary aims include the determination of indications for capsule endoscopy, quality measures, and procedural outcomes at a large regional center and the comparison of these metrics to other locations globally.MethodsA retrospective collection and analysis of all video capsule endoscopies performed at Health Sciences North in Sudbury Ontario between 2016 and 2020 has been performed. Information was collected with the aid of a standardized data collection tool and stored under anonymized patient profiles. Once this pilot registry was created, data was pooled for further analysis. Data regarding indications for capsule endoscopy, patient factors, previous investigations, anticoagulant usage, procedure interpretation, need for subsequent interventions, and need for blood transfusion among others was then established for this group. Findings were then compared to previously published regional and global norms where available.ResultsIn total 98 video capsule endoscopies encompassing 94 individual patients have been catalogued at the end of the study period. With available information through individual patient records, complete information for all fields of the standardized collection tool was obtained for 91 individual patients. The most common indications for VCE include gastro-intestinal bleeding (38%), anemia (38%), Crohn’s disease (13%) and abdominal pain (3%). In total, 45% of all procedures noted an acute finding in the report. Of VCE performed for gastro-intestinal bleeding, 50% reported on an acute finding while in those performed for anemia, 47% reported on an acute finding. Mortality during the study period was 12% while there was 1 documented incident of capsule retention. The rate of acute findings is greater than previously published international studies.ConclusionsThis project has established the feasibility of the creation of a regional capsule endoscopy registry. Further work to expand the patient pool as well as move to a prospective collection model are reasonable next steps to expand this project. We have also demonstrated significant differences regarding indications for VCE as well as the rate of significant findings of VCE of a our northern cohort compared to previously reported international sites. In particular the high rate of significant findings in anemia warrants further investigations.Funding AgenciesNone

The Gap in Prescribing Stroke Prevention Therapies in Postoperative Atrial Fibrillation After Isolated Coronary Artery Bypass Grafting Surgery.

Postoperative atrial fibrillation (POAF) commonly occurs after coronary artery bypass graft (CABG) surgery. Patients with POAF are at higher risk of stroke and mortality. The use of oral anticoagulation (OAC) in POAF remains inconsistent, and the care gap is unknown. We sought to evaluate rate of adherence and factors associated with OAC use in POAF patients after isolated CABG. In this study, all patients who had an isolated CABG between April 1, 2019 and March 30, 2020, at Health Sciences North, Sudbury retrospectively were evaluated. We identified all patients who developed POAF and captured the use of OAC. Multivariable logistic regression models were used to identify predictors of OAC prescription. In total, 339 CABG patients between April 1, 2019 and March 30, 2020, were identified; 86 patients developed POAF. No patients had major perioperative bleeding. All POAF patients had an indication for OAC therapies based on CHADS 65 score. However, only 17 (19.8%) patients with POAF had OAC prescription at the time of hospital discharge. Baseline characteristics were similar between those with or without OAC. In multivariable analysis, the use of dual antiplatelet therapy was associated with a decreased use of OAC therapy in POAF (OR 0.037 (95% CI 0.005, 0.29), P = .002). Moreover, in comparison to surgeon A, surgeon B was associated with a decreased use of OAC therapy, whereas surgeon C was associated with an increased use of OAC therapy in POAF (OR 0.15 (95% CI 0.03, 0.83), P = .03 and OR 6.49 (95% CI 1.21, 34.82), P = .03, respectively). None of the CHADS 65 elements, including age, hypertension, stroke, diabetes mellitus or congestive heart failure, correlated with the use of OAC. Eighty percent of patients who developed POAF after isolated CABG failed to receive stroke prevention therapies. The use of dual antiplatelet therapy and individual surgeons' preference were associated with the use of OAC therapy among POAF. This data set suggests that approximately only 1 in 5 patients with POAF after isolated CABG got prescribed OAC.

MP25: Assessing the learning impact of the Northern City of Heroes public exhibit on bystander cardiopulmonary resuscitation response

Innovation Concept: In Sudbury, ON 44% of out-of-hospital cardiac arrest (OHCA) patients receive bystander CPR (bCPR), and only 4.7% survive cardiac arrest. The Northern City of Heroes (NCH) community initiative was launched in April 2019 with a goal of improving survival from OHCA through hands-only bCPR in the municipality. One NCH initiative is an interactive exhibit at Science North, a science centre in Sudbury that hosts 250,000 visitors annually. The exhibit employs simulation trainers for CPR, accompanying signage and interactive elements. The goals of the exhibit are to activate bCPR, change and measure behaviours through exhibit interactions on how to deliver excellent CPR, and improve survival rates in OHCA patients. Methods: Data is being collected from 3000 visitors using self-reported surveying via SurveyGizmo to assess likelihood of performing bCPR, pre and post interacting with the exhibit. Visitor behaviour will be examined at the exhibit using video-recorded interactions and coding those behaviours using BORIS software. Behavioural data will be analyzed using the Visitor Engagement Framework (VEF) where initiation, transition and breakthrough learning-behaviours are coded and an exhibit Visitor Engagement Profile (VEP) is created. The VEF and VEP are tools used in informal learning settings to assess exhibit impacts on learning. Curriculum, Tool, or Material: The use of an easily-apprehendable, hands-on exhibit tool located in a public setting, such as a science centre, creates a platform for engaging large and diverse public audiences. This type of bCPR exhibitry has not been implemented in other similar environments. The informal learning setting allows the science centre staff to engage in personalized interactions that can solidify the quality of learning and confidence in employing the new skills developed. Conclusion: The NCH exhibit and new strategies for embedding informal curriculum are powerful tools to reach diverse audiences, build knowledge and skills, and have a measurable impact on bCPR and OHCA survival rates. Data is being captured and tracked by Health Sciences North around the City of Greater Sudbury's bCPR and OHCA survival rates to monitor long-term impacts of the NCH community initiatives. Limitations of the study may be found in the focused demographics as well as the nature of self-reported learning. Future research directions include broader geographical surveying to assess improvements in community response to OHCA as a direct result of an interactive bCPR exhibitry.

Collaborating with healthcare providers to understand their perspectives on a hospital-to-home warning signs intervention for rural transitional care: protocol of a multimethod descriptive study

IntroductionThis study builds on our prior research, which identified that older rural patients and families (1) view preparation for detecting and responding to worsening health conditions as their most pressing...

The impact of a new hepatopancreatobiliary surgery program on the management of pancreatic cancer at Health Sciences North

Centralization of specialist services to urban centres presents a challenge to patients living in rural communities. The hepatopancreatobiliary surgery (HPB) program at Health Sciences North (HSN) is the tenth and newest HPB centre by Cancer Care Ontario and presents a unique opportunity to evaluate the barriers to delivering HPB cancer care to patients in northern Ontario. We retrospectively reviewed the cases of patients referred to the Northeastern Ontario Cancer Centre and HSN with a pancreatic cancer diagnosis between 2009 and 2015. July 2013 marked the inception of the HPB surgical program. Our primary outcome was time to HPB surgical consultation. Secondary outcomes included distance of travel and time to curative intent operation. Our population consisted of 207 patients (98 pre-HPB v. 109 post-HPB). Median time to consultation with an HPB surgeon was decreased in the post-HPB group (43 v. 11 d, p < 0.001). An increased proportion of patients with pancreatic malignancies in the post-HPB group received HPB surgical consultations (34% v. 74%, p < 0.001), with decreased median distance travelled to surgical consultation (411 v. 79 km, p < 0.001). Time to curative intent operation or medical oncology consultation did not significantly increase. A new HPB program appears to have facilitated the proportion of patients with pancreatic malignancies at HSN receiving an HPB surgical consultation. Patients received complex surgeries, closer to their home regions. It is anticipated that these changes may affect overall outcomes and patient satisfaction and will be the focus of future investigations.

Estimation of Costs-Savings and Improved Patient Outcomes of Implementing a Consultation-Liaison Service at Health Sciences North

Objective: The study was conducted to assess the implementation of a psychiatric consultation-liaison service (C-L) from the perspective of cost-savings, staff satisfaction, patient satisfaction and to assess the general features of patients referred to the C-L service. Methodology: Cost-savings were evaluated using a large cohort of referrals to the hospital were identified using data derived from the Institute of Clinical Evaluative Sciences (N = 2246); these data were divided into pre and post periods with respect to imitation of the C-L service. To evaluate staff satisfaction, 170 nurses and physicians completed an online survey. Patient satisfaction was assessed through a survey assessing various aspects of their experiences with the C-L service that was completed by each patient (N = 40). Finally referrals to the C-L service (N = 445) were analyzed to discern indicators of the C-L service’s efficacy (i.e. reasons for referral, time to accommodate referral). Results: The data indicated: 1) a reduction in the number of re-admissions and length of stay after the initiation of the C-L service translating into significant cost-savings for the hospital, 2) that increased staff satisfaction was associated with providing confidence, support, and improved communication, and 3) that the C-L service accommodated approximately 90% of patients within 1 day. Conclusion: The results of this study support stakeholders’ decisions to implement C-L services and also indicate areas of improvement that may improve the quality of C-L services within other institutions.

Quantifying candidate volume for endovascular therapy for acute ischemic stroke: a retrospective chart review.

Endovascular therapy is the new standard of care for certain patients with acute ischemic stroke. We aimed to determine whether procedural volumes at an academic health sciences centre in northeastern Ontario exceeded the minimum of 20 procedures annually to support establishment of an endovascular therapy centre and thus improve regional access to this type of care. We conducted a retrospective chart review at Health Sciences North, a regional stroke centre for northeastern Ontario that currently does not offer endovascular therapy for patients with acute ischemic stroke. Medical records and neurovascular imaging results for patients with a discharge diagnosis of cerebral infarction who were seen by the stroke on-call team at Health Sciences North between May 1, 2016, and Apr. 30, 2017, were retrospectively examined in accordance with criteria of the ESCAPE trial to identify potential candidates for endovascular therapy. The number of candidates was extrapolated to include patients discharged with cerebral infarction from referral centres within a 2-hour transport radius from the study institution. Of 71 patients who met the inclusion criteria, 9 were identified as candidates. Of the 71 cases reviewed, 62 (87%) presented within the window for administration of recombinant tissue plasminogen activator of 4.5 hours from symptom onset, 66 (93%) within the endovascular therapy window of 6 hours and 69 (97%) within the extended endovascular therapy window of 12 hours. Expanding these estimates to include regional referral centres, we conservatively estimated that Health Sciences North has the potential to perform 22 or 23 procedures annually. The projected annual number of procedures met the minimum requirement to maintain competency. Establishing Health Sciences North as a centre for endovascular therapy could be an important step in improving equity in stroke outcomes across northeastern Ontario.

NT-proBNP is a potential mediator between reduced ejection fraction and depression in patients with heart failure

Depression and anxiety are prevalent in patients with heart failure (HF). Reduced ejection fraction (EF) and increased N-terminal-prohormone B-type natriuretic peptide (NT-proBNP) have been shown to be independently associated with depressive symptoms and may therefore increase HF disease progression and mortality. This study evaluated whether NT-proBNP mediated the impact of reduced EF on depressive and anxiety symptoms in patients with HF. Participants (n = 124) were patients with a diagnosis of chronic HF enrolled in the Heart Failure Disease Management Program at Health Sciences North. Subjects were assessed for depressive and anxiety symptoms according to the Hospital Anxiety and Depression Scale questionnaire at enrolment. Ejection fraction, measured through Multigated Acquisition Technique and NT-proBNP, measured through chemiluminescent immunoassay, were obtained at baseline. Patient outcomes were monitored for 12-months after enrollment. Associations were determined using regression and multivariate models. Indirect effects were assessed using mediation analysis. EF and NT-proBNP were highly correlated. Mediation analysis showed no significant direct effect of EF on the levels of depressive and anxiety symptoms, however, there was a significant indirect effect of EF on depression that was mediated by the levels of NT-proBNP, but not for EF and anxiety. Our results suggest that NT-proBNP is a potential mechanism linking reduced EF and depressive symptoms in patients with HF. While results are still preliminary, this study suggests that NT-proBNP may be a potential biomarker in identifying HF patients with reduced EF at high risk for depression, disease progression and mortality.

Evaluation of the impact of various definitions of rurality on the prediction of prostate cancer progression

This study evaluates whether three definitions of rural and urban residence predict prostate cancer progression. People were classified as urban or rural using three definitions: rural and small town (RST), Beale's rural-urban continuum codes, and the Rurality Index of Ontario (RIO) 2008 score. This was a chart-based cohort study of males with prostate cancer who underwent external beam radiation therapy (EBRT) in the Regional Cancer Program at Health Sciences North in Sudbury, Ontario from 1996 to 2003. Data indicative of each of the three definitions were used as predictors in Cox regression analysis for the period of 1,000 to 3,000 days after initial diagnosis and as the basis for dichotomous strata in a log rank test.&#x0D; Complete data were acquired from 629 charts. There was no significant association between any of the three definitions of rurality and prostate cancer progression. However, a Beale-based dichotomization led to survival differences using the log rank test. Beale stratification was potentially sensitive to relevant differences in populations that were not represented by the other two definitions. Given the moderate correlations between the different rurality scores, there may be merit to considering multiple rurality scores as they may lead to different cancer progression outcomes in some situations.

The Elderly Mobility Scale

Registered Physiotherapist, Medicine, Oncology and Palliative care unit, Health Sciences North Sudbury, Ontario, Canada, Email: [email protected] Health and Rehabilitation Science, Western University, London, Ontario, Canada The author has no conflict of interest and no source of funding to declare.

Access to oncology consultation in a cancer cohort in northeastern Ontario.

To enhance cancer symptom management for residents of Sudbury-Manitoulin District, an ambulatory palliative clinic (pac) was established at the Northeast Cancer Centre of Health Sciences North. The pac is accessed from a medical or radiation oncology consultation. The primary purpose of the present population-based retrospective study was to estimate the percentage of cancer patients who died without ever having a medical or radiation oncology consultation. A secondary purpose was to determine factors associated with never having received one of those specialized consultations. Administrative data was obtained through the Ontario Cancer Data Linkage Project. For each index case, we constructed a timeline, in days, of all Ontario Health Insurance Plan billing codes and associated service dates starting with the primary cancer diagnosis and ending with death. Within the 5-year study period (2004-2008), 6683 people in the area of interest with a valid record of primary cancer diagnosis died from any cause. Most (n = 5988, 89.6%) had 1 primary cancer diagnosis. For that subgroup, excluding those with a disease duration of 0 days (n = 67), about 18.4% (n = 1088) never had a consultation with a medical or radiation oncologist throughout their disease trajectory. Patients who were older or who resided in a rural area were significantly less likely to have had a consultation. Specific strategies directed toward older and rural patients might help to address this important access-to-care issue.

Antimicrobial susceptibility of Canadian isolates of Helicobacter pylori in Northeastern Ontario.

Helicobacter pylori plays a significant role in gastritis and ulcers. It is a carcinogen as defined by the WHO, and infection can result in adenocarcinomas and mucosa-associated lymphoid tissue lymphomas. In Canada, rates of antimicrobial resistance are relatively unknown, with very few studies conducted in the past 15 years. To examine rates of resistance in Sudbury, Ontario, compare antimicrobial susceptibility methods and attempt to determine the molecular basis of antibiotic resistance. Patients attending scheduled visits at Health Sciences North (Sudbury, Ontario) provided gastric biopsy samples on a volunteer basis. In total, 20 H pylori isolates were collected, and antimicrobial susceptibility testing (on amoxicillin, tetracycline, metronidazole, ciprofloxacin, levofloxacin and clarithromycin) was conducted using disk diffusion and E-test methods. Subsequently, genomic DNA from these isolates was sequenced to detect mutations associated with antimicrobial resistance. Sixty-five percent of the isolates were found to be resistant to at least one of the listed antibiotics according to E-test. Three isolates were found to be resistant to ≥3 of the above-mentioned antibiotics. Notably, 25% of the isolates were found to be resistant to both metronidazole and clarithromycin, two antibiotics that are normally prescribed as part of first-line regimens in the treatment of H pylori infections in Canada and most of the world. Among the resistant strains, the sequences of 23S ribosomal RNA and gyrA, which are linked to clarithromycin and ciprofloxacin/levofloxacin resistance, respectively, revealed the presence of known point mutations associated with antimicrobial resistance. In general, resistance to metronidazole, ciprofloxacin/levofloxacin and clarithromycin has increased since the studies in the early 2000s. These results suggest that surveillance programs of H pylori antibiotic resistance may need to be revisited or improved to prevent antimicrobial therapy failure.

Is B-mode ultrasound alone a sufficient screening tool for carotid stenosis? A pilot study

BackgroundCarotid ultrasound is performed solely in hospital ultrasound departments or outpatient labs, using both B- and Doppler modes. We hypothesize that B-mode without Doppler can be used to classify patients as having carotid stenosis (CS) above or below 50%. Our objective is to determine the frequency with which a CS >50% is found using Doppler when no such stenosis was visible using B-mode.MethodsThis was a retrospective study of 100 patients referred to the stroke clinic and 100 patients referred for carotid endarterectomy (CEA). All patients had an elective carotid ultrasound done at Health Sciences North. The ultrasound reports were mixed together and blinded. Investigators determined if there was a CS of greater or less than 50% based on the carotid diagram. These results were compared to the degree of CS found on Doppler.ResultsIn the CEA group, there were 198 ultrasounds, with 153 showing a CS of >50%. Only one case of CS >50% was missed by B-mode. In the clinic group, 32 of 192 ultrasounds showed a CS of >50%. None were missed by B-mode. B-mode had a sensitivity and negative predictive value of 100% and a specificity of 65%.ConclusionThis study supports the theory that it may be possible to use B-mode ultrasound without Doppler to reliably determine if there is CS above or below 50%. Further research is required before carotid ultrasound using B-mode alone can be recommended.

Abstract 4141: Access to medical or radiation oncology consultation in patients who died from cancer in the Sudbury-Manitoulin District of Northeastern Ontario, Canada

Abstract Sudbury-Manitoulin district is located in Northeastern Ontario, Canada, and resident cancer patients often receive care at the Northeast Cancer Centre (NECC), a Cancer Care Ontario regional cancer program located at Health Sciences North in Sudbury. In 2008, as part of enhancing services in this district, the NECC established an ambulatory Palliative Clinic. Presently, referral to this clinic occurs subsequent to a patient consultation with a medical or radiation oncology specialist. Using administrative data, the primary purpose of this population-based retrospective study was to estimate the percentage of patients who died from cancer without having had the opportunity to access this clinic through a prior documented medical or radiation oncology consultation during the interval of 2004-2008. A secondary purpose was to determine factors associated with never having received this specialized medical consult. Data was obtained through The Ontario Cancer Data Linkage Project (`cd-link') an initiative of the Ontario Institute for Cancer Research/Cancer Care Ontario Health Services Research Program. For each index case, we constructed a timeline (days) of all Ontario Health Insurance Plan (OHIP) billing codes and associated service dates, from primary cancer diagnosis through to cancer death. Our main outcome variable, consultation with a medical or radiation oncologist, was dichotomized as “ever” or “never”. A total of 6,683 individuals with a valid primary cancer diagnosis record died from any cancer cause in the Sudbury-Manitoulin District within the 5 year period from 2004-2008. Most (n=5988, 89.6%) had one primary cancer diagnoses. For this subgroup, and excluding those with a disease duration of 0 days (n=67), about 18.4% (n=1088/5921) never consulted a medical or radiation oncologist through their disease trajectory. Multivariable logistic regression identified three significant and independent predictors of having never received a consultation. Older age and rural residence were associated with increased risk of “never consultation”, with adjusted Odds Ratio (OR)s of 7.13 (95% Confidence Interval (CI) 3.68-13.81) and 1.77 (95% CI 1.51-2.06) for residents 80 years and older, or living in a rural residence, respectively. A longer duration of disease was associated with a decreased risk, with an OR of 0.99 (95% CI 0.99-0.99). While there are limitations to using administrative data, we estimate that 18.4% of the residents in this area did not benefit from a specialized consultation about their cancer care, which could also have included suitability and timing of referral to the palliative care clinic. Specific strategies directed towards older and rural patients may help to address this important access to care issue. Citation Format: Michael Conlon, Mark Hartman, Barbara Ballantyne, Mary Bewick, Margaret Meigs, Natalie Aubin, Andrew Knight. Access to medical or radiation oncology consultation in patients who died from cancer in the Sudbury-Manitoulin District of Northeastern Ontario, Canada. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4141. doi:10.1158/1538-7445.AM2014-4141