St Michael's Hospital Research Articles

Group a Streptococcal Carriage among Residents of an Urban Homeless Shelter

Group a Streptococcal Carriage among Residents of an Urban Homeless Shelter

The salvage of aneurysmal fistulae utilizing a modified buttonhole cannulation technique and multiple cannulators

We describe the St Michael's Hospital (SMH) modified buttonhole (BH) cannulation technique as a method that offers a solution for fistulae with aneurysmal dilatation due to repetitive cannulation in a restricted area. This is a prospective cohort study of 14 chronic hemodialysis (HD) patients with problematic fistulae (marked aneurysmal formation and thinning of the overlying skin, bleeding during treatment, and prolonged hemostasis post-HD) because of repetitive, localized cannulation. Each patient was followed for 12 months. The protocol was as follows: creation of tunnel tracks by 1 to 3 experienced cannulators per patient, using sharp needles. After the tunnel tracks were established and cannulation was easily achieved with dull needles, additional cannulators were incorporated with the guidance of a mentor. Bleeding from cannulation sites during dialysis ceased within 2 weeks and skin damage resolved within 6 months in all patients. Hemostasis time postdialysis decreased from 24 to 15 min. Cannulation pain scores decreased significantly. Access flows and dynamic venous pressure measurements remained unchanged. No interventions were required to maintain access patency. In 2 cases, the aneurysms became much less evident. Complications included one episode of septic arthritis and one contact dermatitis. A third patient developed acute bacterial endocarditis 9 months following completion of her follow-up. The SMH modified BH cannulation technique can salvage problematic fistulae, prevent further damage, and induce healing of the skin in the areas of repetitive cannulation. This technique can be successfully achieved by multiple cannulators in a busy full-care HD unit.

Granular cell tumours of the gastrointestinal tract: expression of nestin and clinicopathological evaluation of 11 patients

Granular cell tumours (GCTs) in the gastrointestinal (GI) tract are rare, with few series reported in the literature. Nestin is a recently identified intermediate filament protein that is expressed in neuroectodermal stem cells and skeletal muscle progenitor cells and has been shown to be expressed in gastrointestinal stromal tumours (GISTs) and GI schwannomas. Herein, we describe the clinicopathological and immunohistochemical features of 11 GI GCTs, introducing nestin as an additional marker that identifies these tumours. The archives of the departments of pathology at London Health Sciences Centre (London, Ontario) and St Michael's Hospital (Toronto, Ontario) were searched for GCTs occurring in the GI tract, yielding 11 cases. Histological features were assessed and immunohistochemistry was performed with S100 protein, nestin, glial fibrillary acidic protein (GFAP), CD34, desmin, CD117, and inhibin-alpha. Charts were reviewed for clinical information. Ages at diagnosis ranged from 31 to 73 years; there were six males and four females. All GCTs were solitary, six in the oesophagus, three in the caecum, one in the rectum and one perianal. Most lesions were discovered incidentally. The size of the GCTs ranged from 4 mm to 30 mm. All were submucosal, typically firm, with a white-yellow appearance. Histologically, the GCTs showed moderate cellularity, predominantly solid growth with areas of nesting. While lesional cells were mainly plump and polygonal, areas of spindling were present in several tumours, more frequently in the colorectum. Margins were circumscribed. Nuclei were round to oval, with even chromatin and small nucleoli. Mitoses were rare to absent and necrosis was absent in all cases. Staining with periodic acid-Schiff, with diastase predigestion, showed globular and diffuse positivity within the cytoplasm. Moderate to strong expression of S100 protein and nestin was observed in 11 of 11 and seven of seven tumours, respectively. GFAP, CD34, desmin, CD117 and inhibin-alpha were negative. While patients were variably managed with resection or observation, all remain clinically well, without disease progression. Although rare, GI GCTs have characteristic clinicopathological features. Nestin may be a useful immunohistochemical marker for identifying these tumours; the presence of this persistent stem cell cytoskeletal filament within GI GCTs suggests that these lesions may arise from a multipotential stem cell in the GI tract.

Mosaic trisomy 8 and Townes–Brocks syndrome due to a novel SALL1 mutation in the same patient

American Journal of Medical Genetics Part AVolume 140A, Issue 6 p. 649-651 Research Letter Mosaic trisomy 8 and Townes–Brocks syndrome due to a novel SALL1 mutation in the same patient Kerstin N. Walter, Kerstin N. Walter Institut für Humangenetik und Anthropologie, Universität Freiburg, Freiburg, GermanySearch for more papers by this authorK. Lynn Greenhalgh, K. Lynn Greenhalgh Department of Clinical Genetics, St Michael's Hospital, Level B, Bristol, United KingdomSearch for more papers by this authorRuth A. Newbury-Ecob, Ruth A. Newbury-Ecob Department of Clinical Genetics, St Michael's Hospital, Level B, Bristol, United KingdomSearch for more papers by this authorJürgen Kohlhase, Corresponding Author Jürgen Kohlhase [email protected] Institut für Humangenetik und Anthropologie, Universität Freiburg, Freiburg, GermanyInstitut für Humangenetik und Anthropologie, Universität Freiburg, Breisacher Str. 33, 79106 Freiburg, Germany.Search for more papers by this author Kerstin N. Walter, Kerstin N. Walter Institut für Humangenetik und Anthropologie, Universität Freiburg, Freiburg, GermanySearch for more papers by this authorK. Lynn Greenhalgh, K. Lynn Greenhalgh Department of Clinical Genetics, St Michael's Hospital, Level B, Bristol, United KingdomSearch for more papers by this authorRuth A. Newbury-Ecob, Ruth A. Newbury-Ecob Department of Clinical Genetics, St Michael's Hospital, Level B, Bristol, United KingdomSearch for more papers by this authorJürgen Kohlhase, Corresponding Author Jürgen Kohlhase [email protected] Institut für Humangenetik und Anthropologie, Universität Freiburg, Freiburg, GermanyInstitut für Humangenetik und Anthropologie, Universität Freiburg, Breisacher Str. 33, 79106 Freiburg, Germany.Search for more papers by this author First published: 14 February 2006 https://doi.org/10.1002/ajmg.a.31136Citations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume140A, Issue615 March 2006Pages 649-651 RelatedInformation

Is zygosity or chorionicity the main determinant of fetal outcome in twin pregnancies?

The purpose of this study was to examine whether fetal outcome in twin pregnancies is dependent on zygosity or chorionicity. This was a prospective observational study comprised of women with twin pregnancies who attended the fetal medicine unit at St Michael's Hospital, Bristol, Ireland, during the years 1998 to 2000 and who were delivered in hospitals in south west England. After delivery, zygosity was determined with umbilical cord blood with the use of microsatellite markers that were amplified by polymerase chain reaction. Placentae were examined histologically for chorionic type. The perinatal outcomes of 3 groups of monozygotic monochorionic, monozygotic dichorionic, and dizygotic pregnancies were compared with the use of the Mann-Whitney U test and the Fisher's exact test. All 92 dizygotic and 15 monozygotic dichorionic pregnancies resulted in live births. In 7 of the 39 cases in the monozygotic monochorionic group, either both twins were not live born or delivery occurred <24 weeks of gestation. The gestational age at delivery and birth weight were significantly lower, and there were a greater number of cases with birth weight discordancy of >25% in the monochorionic pregnancies compared with the other 2 groups (P < .05). There were no significant differences in any of the study parameters between the monozygotic dichorionic and dizygotic groups. Fetal outcome in twin pregnancies is related to chorionicity rather than zygosity.

Red blood cell survival in chronic renal failure

A decrease in the lifespan of erythrocytes has been accepted universally as one of the contributory factors to anemia in patients with chronic renal failure. This observation was made in the 1950s and 1960s when continuous renal replacement therapy was at its infancy. Based on the premise that a reduced red blood cell (RBC) lifespan in renal disease is primarily caused by the toxic uremic milieu, the purpose of this study is 2-fold: to compare the RBC survival in today's renal patients with that in the existing literature and to explore if there are differential RBC survival benefits with various dialysis dosages. This is an observational study. Patients with end-stage renal disease were recruited from the dialysis program at the University Health Network and St Michael's Hospital in Toronto. The patients were stratified into 3 groups including conventional thrice-weekly, nocturnal, and short-daily hemodialysis. Healthy subjects were recruited to validate the normal range for RBC lifespan. Red cell survival was assessed using radiolabeled sodium chromate (Na2 51CrO4). Twenty-two patients and 2 healthy control subjects were recruited. The average red cell half-lives in thrice-weekly, nocturnal, short-daily, and healthy subjects were 14.5 +/- 1.6, 17.1 +/- 4.7, 15.9 +/- 2.2, and 23.5 days, respectively. All 3 patient groups exhibited reduced RBC lifespan (P < 0.05). Further, the overall RBC lifespan was not different from that reported half a century ago. Despite better urea clearances among the nocturnal and short-daily dialysis groups, no RBC survival benefit was observed. A reduced RBC lifespan continues to contribute to renal anemia despite technologic advancements and improved uremic environment.

52 Describing Characteristics Typical to Adolescents with Fetal Alcohol Spectrum Disorder (FASD): A Pilot Study

Caused by prenatal exposure to alcohol, Fetal Alcohol Spectrum Disorder (FASD) is a serious physical and neuro-developmental disorder. Fetal Alcohol Spectrum Disorder includes the full Fetal Alcohol Syndrome (FAS), Partial FAS (PFAS), Alcohol Related Neurodevelopmental Disorder (ARND) and Alcohol Related Birth Defects (ARBD). The terms PFAS and ARND are used to describe cases of lesser severity in terms of cognitive function and organ anomalies, but often with very serious evidence of neurotoxicity. While past research describes the typical profile of the child with FASD, there is a paucity of literature that describes characteristics specific to adolescents. To describe the typical characteristics of FASD that present in adolescents. Research Design: A prospective cohort research design was used. Sample and Setting: Participants 13 to 18 years old, referred to St. Michael's Hospital (SMH), Toronto, FASD diagnostic clinic since November 2002 (n=12). Data Collection: A 13 page intake and diagnostic form, and a detailed physical examination and history were used to collect data on prenatal alcohol history, school and/or work history, behavioral problems, neuro-psychological profile, FAS facial features, physical health, and growth of each of the participants. Data Analysis: Content analysis of the data obtained in the intake form and the written physical examination was conducted. Twelve adolescents ages 13 to 18 years old (mean=15.2 years) participated in the pilot study. All of the participants had a significant history of prenatal alcohol exposure although none had been diagnosed with FAS or other alcohol related disorders prior to entering the SMH diagnostic clinic. One adolescent (8.3%) had full Fetal Alcohol Syndrome, and 11 (91.7%) had alcohol-related neuro-developmental disorder. Five (42%) of the participants had some facial features, and one (8.3%) had growth –height, weight, and head circumference – below the 3rd percentile. Six (50%) of the adolescents had IQs less than 80. Of those in school (67%), keeping up with age appropriate peers was an ongoing challenge because of problems in memory and attention, and motivation. All of the participants had significant behavioral problems including aggressiveness, lying, stealing, alcohol and drug abuse, or risk taking behaviours. This study highlights the importance of taking a perinatal alcohol history in adolescents with major developmental, behavioral or mental health problems. The results of this pilot study also support implementation of a Canadian-wide study of adolescents referred to FASD diagnostic clinics.

Evolution of naturally acquired hepatitis B immunity in the long-term hemodialysis population

Background: Although the natural history of vaccination-induced hepatitis B virus (HBV) antibodies (Abs) is becoming clearer, little is known about naturally acquired immunity. Some assume that these patients never lose their Abs. Methods: To document the natural history of HBV immunity, we prospectively followed up all naturally immune patients initiating hemodialysis (HD) therapy at St Michael's Hospital (Toronto, Canada). Patients presenting with Ab to hepatitis B surface antigen (HBsAb) who had no history of vaccination had a core Ab level measured to confirm natural immunity. When HBsAb titer decreased to less than 10 IU/L, patients were administered a single dose of 40 μg of Engerix B vaccine (Smith Kline Beecham Pharma Inc, Oakville, Ontario, Canada) intramuscularly as a booster dose. Results: We identified 29 patients beginning HD therapy with natural immunity. Nine patients (30%) subsequently lost immunity (defined as Ab titer decreasing to < 10 IU/L) during follow-up. They were older and had a lower Ab titer at initiation of HD therapy. Four of 5 patients with a low response to the booster dose were 75 years or older. Two patients with a low peak Ab titer after the booster dose again had their Ab titer decrease to less than 10 IU/L after 6 and 10 months. Both patients were switched to intradermal vaccination. All other patients were still immune after a median of 26 months. Conclusion: Individuals who are naturally immune against HBV may experience a decrease in Ab titer. Their responses to booster vaccinations varied widely. It is possible that elderly patients with natural immunity require closer surveillance. We provide recommendations for surveillance in these patients.

Leukoreduction just doesn't "take away" immunogenic leukcocytes, it creates an immunosuppressive leukocyte dose.

Vox SanguinisVolume 83, Issue s1 p. 425-428 Leukoreduction Just Doesn't “Take Away” Immunogenic Leukcocytes, It Creates an Immunosuppressive Leukocyte Dose. John W. Semple, Corresponding Author John W. Semple Department of Laboratory Medicine and Pathobiology, St. Michael's Hospital, The University of Toronto and The Toronto Platelet Immunobiology Group, Toronto, Ontario, CanadaJohn W. Semple and John Freedman Department of Laboratory Medicine and Pathobiology, St Michael's Hospital. The University of Toronto and Toronoto Platelet Immunobiology Group, Toronto, Ontano, Canada. E-mail: [email protected]Search for more papers by this authorJohn Freedman, Corresponding Author John Freedman Department of Laboratory Medicine and Pathobiology, St. Michael's Hospital, The University of Toronto and The Toronto Platelet Immunobiology Group, Toronto, Ontario, CanadaJohn W. Semple and John Freedman Department of Laboratory Medicine and Pathobiology, St Michael's Hospital. The University of Toronto and Toronoto Platelet Immunobiology Group, Toronto, Ontano, Canada. E-mail: [email protected]Search for more papers by this author John W. Semple, Corresponding Author John W. Semple Department of Laboratory Medicine and Pathobiology, St. Michael's Hospital, The University of Toronto and The Toronto Platelet Immunobiology Group, Toronto, Ontario, CanadaJohn W. Semple and John Freedman Department of Laboratory Medicine and Pathobiology, St Michael's Hospital. The University of Toronto and Toronoto Platelet Immunobiology Group, Toronto, Ontano, Canada. E-mail: [email protected]Search for more papers by this authorJohn Freedman, Corresponding Author John Freedman Department of Laboratory Medicine and Pathobiology, St. Michael's Hospital, The University of Toronto and The Toronto Platelet Immunobiology Group, Toronto, Ontario, CanadaJohn W. Semple and John Freedman Department of Laboratory Medicine and Pathobiology, St Michael's Hospital. The University of Toronto and Toronoto Platelet Immunobiology Group, Toronto, Ontano, Canada. E-mail: [email protected]Search for more papers by this author First published: 11 February 2011 https://doi.org/10.1111/j.1423-0410.2002.tb05346.xCitations: 4Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume83, Issues1August 2002Pages 425-428 RelatedInformation

Impact of a tornado on a community hospital.

A significant tornado passed through the Oklahoma City metropolitan area on May 3,1999. This study was undertaken at St Michael Hospital (Oklahoma City, Okla) to describe the impact on a community hospital's emergency department close to the tornado strike zone. Cases were defined as patients receiving diagnostic procedures, care, and interventions at the study hospital's emergency department for injuries related to the tornado. Medical records were abstracted and entered into a custom database; descriptive analysis was done using Microsoft Excel 97. A total of 147 patients met the study criteria, with an admission rate of 31 (21%) [corrected] of 147 patients (6 [19.4%] of 31 to the operating room, 4 [12.9%] of 31 to the intensive care unit, and 21 [67.7%] [corrected] of 31 to ward beds). In addition, 4 (2.7%) of the 147 patients were transferred to tertiary-care facilities (3 pediatric patients with head injuries and 1 adult patient with spinal cord injury). Complex soft tissue wounds, head injuries, and fractures were the most common diagnoses. The number of head-injured patients arriving alive to the emergency department was higher than expected. Most soft tissue wounds were closed primarily in the emergency department. The authors recommend that preexisting referral patterns for trauma and specialty care should be a part of the overall disaster plans for community hospitals.

Pancreatic Islets and Type II Diabetes; St Michael's Hospital, Bristol: 19 October 2001

Diabetes mellitus affects almost 1 in 25 of the populations of Western Europe and North America, and the treatment of its complications presently consumes as much as 15% of the healthcare budgets of many countries. Both forms of the disease (Type I and Type II) are on the increase, with an incidence predicted to double by the year 2020. Against this backdrop, research into the biochemical mechanisms by which pancreatic islet -cells synthesize and secrete insulin has gathered significant momentum in recent years.

This month in J Lab Clin Med: Issue highlights for December 2001

This month in J Lab Clin Med: Issue highlights for December 2001

Elevated cardiac tissue aldehyde levels in heart failure: Marker of increased oxidative stress and amelioration by neurohormonal blockade Gordon W. Moe, Mehrdad Yazdanpanah, Andrea Konig, Marina Romanova, Peter Liu. St Michael's Hospital, Univ of Toronto, Toronto, ON, Canada

Elevated cardiac tissue aldehyde levels in heart failure: Marker of increased oxidative stress and amelioration by neurohormonal blockade Gordon W. Moe, Mehrdad Yazdanpanah, Andrea Konig, Marina Romanova, Peter Liu. St Michael's Hospital, Univ of Toronto, Toronto, ON, Canada

Regional variation and dynamic turnover of cardiac collagen matrix in canine experimental heart failure Gordon W. Moe, Nafiseh Nill, Effat Rezaei, Andrea Konig, Marina Romanova, Bradley H. Strauss. St Michael's Hospital, Univ of Toronto, Toronto, ON, Canada

Regional variation and dynamic turnover of cardiac collagen matrix in canine experimental heart failure Gordon W. Moe, Nafiseh Nill, Effat Rezaei, Andrea Konig, Marina Romanova, Bradley H. Strauss. St Michael's Hospital, Univ of Toronto, Toronto, ON, Canada

Hybrid gene therapy in patients turned down for coronary bypass surgery: An option for no option patients? S Kassam, M Kutryk, A Campbell, N Camack, D Latter, L Erret, R Chisholm, D Fitchett, D J. Stewart. St Michael's Hospital, Toronto, Canada

Hybrid gene therapy in patients turned down for coronary bypass surgery: An option for no option patients? S Kassam, M Kutryk, A Campbell, N Camack, D Latter, L Erret, R Chisholm, D Fitchett, D J. Stewart. St Michael's Hospital, Toronto, Canada

Missed injuries in patients with multiple trauma.

Understanding the etiology of missed injuries is essential in minimizing its occurrence. A retrospective review was conducted to identify the incidence, contributing factors, and clinical outcomes of missed injuries. All trauma patients assessed by St Michael's Hospital trauma service from April 1, 1995, to July 31, 1997, were included in the study. Demographic and medical data were compared and statistically analyzed in two patient groups to identify factors associated with missed injuries. Forty six of 567 patients (8.1%) had missed injuries. Patients with missed injuries had higher mean Injury Severity Scores and longer stays in the hospital and intensive care unit compared with patients without missed injuries (p < 0.05). Patients with missed injuries were more likely to have lower Glasgow Coma Scale scores and to have required pharmacologic paralysis (p < 0.05). Of the factors contributing to missed injuries, 56.3% were potentially avoidable and 43.8% were unavoidable. Seven patients with missed injuries had clinically significant outcomes, including one patient death. Of the seven clinically significant missed injuries, five were attributable to potentially avoidable factors. Patients with missed injuries tend to be more severely injured with initial neurologic compromise. The majority of missed injuries are potentially avoidable with repeat clinical assessments and a high index of suspicion.

Is ovarian hyperstimulation syndrome associated with a poor obstetric outcome?

BJOG: An International Journal of Obstetrics & GynaecologyVolume 107, Issue 8 p. 943-946 Is ovarian hyperstimulation syndrome associated with a poor obstetric outcome? R. S. Mathur, R. S. Mathur Clinical Research Fellow Division of Reproductive Medicine, St Michael's Hospital, University of BristolSearch for more papers by this authorJ. M. Jenkins, J. M. Jenkins Consultant Senior Lecturer Division of Reproductive Medicine, St Michael's Hospital, University of BristolSearch for more papers by this author R. S. Mathur, R. S. Mathur Clinical Research Fellow Division of Reproductive Medicine, St Michael's Hospital, University of BristolSearch for more papers by this authorJ. M. Jenkins, J. M. Jenkins Consultant Senior Lecturer Division of Reproductive Medicine, St Michael's Hospital, University of BristolSearch for more papers by this author First published: 12 August 2005 https://doi.org/10.1111/j.1471-0528.2000.tb10393.xCitations: 27Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume107, Issue8August 2000Pages 943-946 RelatedInformation

Hospitalization due to adverse drug reactions and drug interactions before and after HAART.

To characterize and compare the rates of adverse drug reactions (ADRs) and interactions on admission in two, one-year periods: pre-highly active antiretroviral therapy (HAART) (phase 1) and post-HAART (phase 2). Retrospective chart review. University-affiliated tertiary care centre. HIV-positive patients admitted to hospital. In phase 1, 436 of 517 admissions, and, in phase 2, 323 of 350 admissions were analyzed. Over 92% of patients were male, with a mean age of 38 years. Significant differences (P<0.05) in the mean length of stay (12.08 versus 10.02 days), the CD4 counts (99.25 versus 129.45) and the number of concurrent diseases (4.20 versus 3.63) were found between phase 1 and 2, respectively. The mean number of medications taken (5.52 versus 5.94) and the rates of hospitalization with ADRs (20.4% versus 21.4%) or interactions (2.5% versus 2.16%) were similar between the two phases. Antiretrovirals were more common in ADR admissions post-HAART (21.3% versus 36.2%), while antiparasitics, psychotherapeutics and antineoplastics were more common pre-HAART. Other classes of drugs involved in both phases were sulphonamides, narcotics, ganciclovir, foscarnet, antimycobacterials and antifungals. ADR causality was possible or probable in more than 80% of cases. Over 60% of ADRs were grades 3 to 4, and about 85% were either the main or contributing reason for admission. About 65% of patients had at least partial recovery at the time of discharge. In phases 1 and 2, 8.9% and 2.9% of admissions,respectively, with ADRs were fatal. Although hospitalizations with ADRs and interactions were similar in both phases, HAART therapy has had a significant impact on the incidence and nature of ADRs at St Michael's Hospital, Wellesley Central Site, Toronto, Ontario.

QUALITY OF LIFE OUTCOMES IN A PATCH TEST CLINIC POPULATION

St Michael's Hospital, University of Toronto & Ontario Workplace Safety and Insurance Board, Toronto, Canada.

Quality of life outcomes in a patch test clinic population: D Linn Holness, St Michael's Hospital, university of Toronto & Ontario workplace safety and insurance board, Toronto, Canada

Quality of life outcomes in a patch test clinic population: D Linn Holness, St Michael's Hospital, university of Toronto & Ontario workplace safety and insurance board, Toronto, Canada