Therapy In Canada Research Articles

Life expectancy of HIV-positive individuals on combination antiretroviral therapy in Canada.

BackgroundWe sought to evaluate life expectancy and mortality of HIV-positive individuals initiating combination antiretroviral therapy (ART) across Canada, and to consider the potential error introduced by participant loss to follow-up (LTFU).MethodsOur study used data from the Canadian Observational Cohort (CANOC) collaboration, including HIV-positive individuals aged ≥18 years who initiated ART on or after January 1, 2000. The CANOC collaboration collates data from eight sites in British Columbia, Ontario, and Quebec. We computed abridged life-tables and remaining life expectancies at age 20 and compared outcomes by calendar period and patient characteristics at treatment initiation. To correct for potential underreporting of mortality due to participant LTFU, we conservatively estimated 30 % mortality among participants lost to follow-up.Results9997 individuals contributed 49,589 person-years and 830 deaths for a crude mortality rate of 16.7 [standard error (SE) 0.6] per 1000 person-years. When assigning death to 30 % of participants lost to follow-up, we estimated 1170 deaths and a mortality rate of 23.6 [SE 0.7] per 1000 person-years. The crude overall life expectancy at age 20 was 45.2 [SE 0.7] and 37.5 [SE 0.6] years after adjusting for LTFU. In the LTFU-adjusted analysis, lower life expectancy at age 20 was observed for women compared to men (32.4 [SE 1.1] vs. 39.2 [SE 0.7] years), for participants with injection drug use (IDU) history compared to those without IDU history (23.9 [SE 1.0] vs. 52.3 [SE 0.8] years), for participants reporting Aboriginal ancestry compared to those with no Aboriginal ancestry (17.7 [SE 1.5] vs. 51.2 [SE 1.0] years), and for participants with CD4 count <350 cells/μL compared to CD4 count ≥350 cells/μL at treatment initiation (36.3 [SE 0.7] vs. 43.5 [SE 1.3] years). Life expectancy at age 20 in the calendar period 2000–2003 was lower than in periods 2004–2007 and 2008–2012 in the LTFU-adjusted analyses (30.8 [SE 0.9] vs. 38.6 [SE 1.0] and 54.2 [SE 1.4]).ConclusionsLife expectancy and mortality for HIV-positive individuals receiving ART differ by calendar period and patient characteristics at treatment initiation. Failure to consider LTFU may result in underestimation of mortality rates and overestimation of life expectancy.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-015-0969-x) contains supplementary material, which is available to authorized users.

Delivery of electroconvulsive therapy in Canada: a first national survey report on usage, treatment practice, and facilities.

The aims of this study were to document electroconvulsive therapy use in Canada with respect to treatment facilities and caseloads based on a survey of practice (Canadian Electroconvulsive Therapy Survey/Enquete Canadienne Sur Les Electrochocs-CANECTS/ECANEC) and to consider these findings in the context of guideline recommendations. All 1273 registered hospitals in Canada were contacted, and 175 sites were identified as providing electroconvulsive therapy; these sites were invited to complete a comprehensive questionnaire. The survey period was calendar year 2006 or fiscal year 2006/2007. National usage rates were estimated from the responses. Sixty-one percent of the sites completed the questionnaire; a further 10% provided caseload data. Seventy were identified as general; 31, as university teaching; and 21, as provincial psychiatric/other single specialty (psychiatric) hospitals. Caseload volumes ranged from a mean of fewer than 2 to greater than 30 treatments per week. Estimated national usage during the 1-year survey period was 7340 to 8083 patients (2.32-2.56 per 10,000 population) and 66,791 to 67,424 treatments (2.11-2.13 per 1000 population). The diagnostic indications, admission status, and protocols for course end points are described. The usage rates are in keeping with earlier Canadian data and with those from other jurisdictions. The difficulty obtaining caseload data from individual hospitals is indicative of the need for standardized data collection to support both clinical research and quality assurance. The wide variation in protocols for number of treatments per course indicates a need for better informed clinical guidelines. The broad range of caseload volumes suggests the need to review the economies of scale in the field.

Severe malaria in Canada, 2001–2013

BackgroundImported malaria is the principal, preventable, life-threatening infection among Canadians travelling abroad. The Canadian Malaria Network supplies information and parenteral malaria therapy to healthcare providers treating severe and complicated malaria and gathers surveillance information on these cases.MethodsData were collected on the characteristics, risk factors, and clinical outcomes of severe malaria cases in Canada from June 2001 to December 2013.ResultsThe need for parenteral therapy in Canada has increased in the last decade. The vast majority of cases are reported from Ontario and Quebec and occur among travellers to and from Africa. Regardless of country of birth, all persons originating from endemic and non-endemic countries are at a similar risk of malaria-related complications. Overall use and appropriateness of pre-travel advice and chemoprophylaxis remains low. Most cases result from patient delays in recognizing symptoms and seeking appropriate medical attention. Although some healthcare delays occurred in a select number of cases, the majority of patients were diagnosed quickly and were appropriately treated with parenteral therapy within a few hours of diagnosis.ConclusionsData from the Canadian Malaria Network provide insight into the characteristics of imported severe and complicated malaria infections in Canada. Improved understanding of this population can help target risk reduction strategies and interventions to limit personal susceptibility and healthcare treatment delays.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-015-0638-y) contains supplementary material, which is available to authorized users.

Current and Emerging Pharmacotherapies for Obesity

Obesity is prevalent chronic condition associated with increased morbidity and mortality. Pharmacotherapy is indicated as adjuncts to health behavior modification when overweight or obese adults fail to achieve or maintain the desired weight loss to improve their health status. Orlistat, a lipase inhibitor that decreases fat absorption by 30%, is the only anti-obesity agent approved for long-term therapy in Canada. With the rapid advance in knowledge of the pathogenesis of obesity, the list of potential anti-obesity agents has increased considerably. Anti-obesity drugs lower body weight by 5-15% and fall into 3 major groups: centrally acting medications that inhibit appetite or promote satiety, or both; drugs that act peripherally to impair nutrient absorption; and drugs that increase energy expenditure. Phentermine and diethylpropion are adrenergic stimulants that inhibit appetite by increasing the release and reuptake of norepinephrine and dopamine in the brain. A low-dose combination of phentermine and extended-release topiramate, an antiepileptic drug, has recently been approved in the US. Lorcaserin decreases food consumption and promotes satiety by selectively activating 5-HT2C receptors on anorexigenic pro-opiomelanocortin (POMC) neurons located in the hypothalamus. Another FDA-approved combination pill - bupropion and naltrexone, increases dopamine activity in the brain, and increases in energy expenditure by increasing activity of POMC neurons. It regulates the dopamine reward system and control food cravings and overeating. The most recent FDA-approved drug is liraglutide, an incretin analogue that inhibits appetite and energy intake. The benefits and risks of current and emerging anti-obesity agent will be discussed in the presentation.

Late initiation of combination antiretroviral therapy in Canada: a call for a national public health strategy to improve engagement in HIV care.

IntroductionCombination antiretroviral therapy (ART) significantly decreases morbidity, mortality and HIV transmission. We aimed to characterize the timing of ART initiation based on CD4 cell count from 2000 to 2012 and identify factors associated with late initiation of treatment.MethodsParticipants from the Canadian Observational Cohort (CANOC), a multi-site cohort of HIV-positive adults initiating ART naively after 1 January 2000, in three Canadian provinces (British Columbia, Ontario and Québec) were included. Late initiation was defined as a CD4 count <200 cells/mm3 or an AIDS-defining illness before ART initiation (baseline). Temporal trends were assessed using the Cochran–Armitage test, and independent correlates of late initiation were identified using logistic regression.ResultsIn total, 8942 participants (18% female) of median age 40 years (Q1–Q3 33–47) were included. The median baseline CD4 count increased from 190 cells/mm3 (Q1–Q3 80–320) in 2000 to 360 cells/mm3 (Q1–Q3 220–490) in 2012 (p<0.001). Overall, 4274 participants (48%) initiated ART with a CD4 count <200 cells/mm3 or AIDS-defining illness. Late initiation was more common among women, non-MSM, older individuals, participants from Ontario and BC (vs. Québec), persons with injection drug use (IDU) history and individuals starting ART in earlier calendar years. In sub-analysis exploring recent (2008 to 2012) predictors using an updated CD4 criterion (<350 cells/mm3), IDU and residence in BC (vs. Québec) were no longer significant correlates of late initiation.ConclusionsThis analysis documents increasing baseline CD4 counts over time among Canadians initiating ART. However, CD4 counts at ART initiation remain below contemporary treatment guidelines, highlighting the need for strategies to improve earlier engagement in HIV care.

CellCAN: a unique enabler of regenerative medicine and cell therapy in Canada.

Regenerative Medicine and Cell Therapy (RMCT) is paving the way for the most innovative and promising medical breakthroughs of the 21st century. Indeed, its curative potential is immense and builds on the already proven benefits of stem cell transplantation. Successful and broad clinical implementation of RMCT, as well as reaping of its full social and economic benefits, is contingent on the resolution of a range of issues. The CellCAN network, a not-for-profit corporation, was created to tackle these challenges, gathering the key forces of the numerous Canadian organizations involved in basic research, assay development, manufacturing, clinical research, clinical trials, legal and ethical regulations, and policies, all working to move RMCT forward. CellCAN creates a national enterprise by bringing together a community of renowned researchers, industries, clinicians, funders and regulators, and aligning it with cell-handling facilities involved in processing cell products and other products for cell therapy clinical trials to ensure capacity and know-how for stem cell research and efficient execution of cell therapy clinical trials. CellCAN is uniquely positioned to accelerate the implementation of RMCT in Canada and disseminate novel developments and findings, thus significantly contributing to the world's knowledge in cellular therapeutics. As such, the CellCAN model could also serve as a useful benchmark to accelerate RMCT implementation in other countries.

Gender Differences in Clinical Outcomes among HIV-Positive Individuals on Antiretroviral Therapy in Canada: A Multisite Cohort Study

BackgroundCohort data examining differences by gender in clinical responses to combination antiretroviral therapy (ART) remain inconsistent and have yet to be explored in a multi-province Canadian setting. This study investigates gender differences by injection drug use (IDU) history in virologic responses to ART and mortality.MethodsData from the Canadian Observational Cohort (CANOC) collaboration, a multisite cohort study of HIV-positive individuals initiating ART after January 1, 2000, were included. This analysis was restricted to participants with a follow-up HIV-RNA plasma viral load measure and known IDU history. Weibull hazard regression evaluated time to virologic suppression (2 consecutive measures <50 copies/mL), rebound (>1000 copies/mL after suppression), and all-cause mortality. Sensitivity analyses explored the impact of presumed ART use in pregnancy on virologic outcomes.ResultsAt baseline, women (1120 of 5442 participants) were younger (median 36 vs. 41 years) and more frequently reported IDU history (43.5% vs. 28.8%) (both p<0.001). Irrespective of IDU history, in adjusted multivariable analyses women were significantly less likely to virologically suppress after ART initiation and were at increased risk of viral load rebound. In adjusted time to death analysis, no differences by gender were noted. After adjusting for presumed ART use in pregnancy, observed gender differences in time to virologic suppression for non-IDU, and time to virologic rebound for IDU, became insignificant.ConclusionsHIV-positive women in CANOC are at heightened risk for poor clinical outcomes. Further understanding of the intersections between gender and other factors augmenting risk is needed to maximize the benefits of ART.

Being our own sponsors

EnglishIncluded among six non- physicians were the president of Mount Allison University (whose university had been involved with occupational therapy in World War I), the president of the Quebec Society for Crippled Children (now the Quebec Society for Disabled Children), three prominent Canadian women with connections to occupational therapy, and the preeminent American occupational therapist Eleanor Clarke Slagle. Sponsorship from the elite medical community (and other individuals of high status) paved the way for many of the developments of early occupational therapy in Canada: the founding of provincial societies in the 1920s, the establishment of educational programs at the University of Toronto (first in 1918 and again in 1926), the formation of the CAOT in 1926, and the debut of this journal in 1933. The characteristics of the ward aides of World War I who had shown themselves to be so creative, and entrepreneurial, independent, and self-motivated, venturing into unknown territory at every turn, had somehow become masked. francaisEn 1933, lorsque cette revue a ete publiee pour la premiere fois, il ne semblait pas essentiel que les ergotherapeutes jouent un role de defenseur ou de revendication; l'ACE et la sororite externe assumaient la tache d'expliquer la profession aux medecins, aux membres des conseils d'administration des hopitaux et a la population.

Delivery of Electroconvulsive Therapy in Canada

Electroconvulsive therapy (ECT) is an effective treatment for mood and other psychiatric disorders. Despite widespread use, the specifics of ECT practice in Canada are largely unknown. A nationwide survey designed to document current delivery was therefore conducted. One hundred seventy-five Canadian ECT delivery sites were identified. A detailed questionnaire (13 pages, 76 questions grouped in 11 subheadings) was developed, translated into French, piloted, and then forwarded to all ECT centers. Return rate for the full questionnaire was 61%. Wide-ranging information pertaining to ECT was gathered. This article, which addresses the data specifically pertaining to ECT devices, electrical stimulus parameters and electrode placements, showed that many core aspects of ECT practice in Canada are in keeping with current recommendations. The use of old sine wave devices is virtually nonexistent. Electroencephalographic (EEG) monitoring of seizures is widespread. Specific concerns were identified, including the need for access to back-up devices at all centers, the lack of ECT credentialing requirements by Canadian hospitals, and a striking variation in dosing practices. An audit of Canadian practice and the development of a National Standards Document would be an essential next undertaking.

Does geography influence the treatment and outcomes of colorectal cancer? A population-based analysis

BackgroundThe Canadian province of Manitoba covers a large geographical area but only has one major urban center, Winnipeg. We sought to determine if regional differences existed in the quality of colorectal cancer care in a publicly funded health care system.MethodsThis was a population-based historical cohort analysis of the treatment and outcomes of Manitobans diagnosed with colorectal cancer between 2004 and 2006. Administrative databases were utilized to assess quality of care using published quality indicators.ResultsA total of 2,086 patients were diagnosed with stage I to IV colorectal cancer and 42.2% lived outside of Winnipeg. Patients from North Manitoba had a lower odds of undergoing major surgery after controlling for other confounders (odds ratio (OR): 0.48, 95% confidence interval (CI): 0.26 to 0.90). No geographic differences existed in the quality measures of 30-day operative mortality, consultations with oncologists, surveillance colonoscopy, and 5-year survival. However, there was a trend towards lower survival in North Manitoba.ConclusionWe found minimal differences by geography. However, overall compliance with quality measures is low and there are concerning trends in North Manitoba. This study is one of the few to evaluate population-based benchmarks for colorectal cancer therapy in Canada.

Promoting an occupational perspective in public health

Although the value of occupation for health and well-being is fundamental to the occupational therapy profession, this view is not well recognized in the field of public health. In this article, we argue that occupational therapists have a unique and valuable perspective to bring to the field of public health, particularly with respect to the importance of occupational engagement in promoting the health and well-being of Canadians. There are many compelling reasons for public health advocacy, including the need to increase awareness of the health benefits and risks of occupational engagement for individuals and communities. Challenges that lie ahead, however, include issues related to terminology, the complexity of occupation, the need to consider multidimensional outcomes, and diversity of evidence. To move forward, the profession of occupational therapy in Canada needs to position health promotion messaging in a way that clearly captures the complexity and value of occupation and resonates with Canadians of all ages and abilities.

Couple and Family Therapy Within the Current Pan-Canadian Context

Canadians take numerous approaches to couple and family therapy due in part to Canada’s diversity of people and geography, as well as the influence of the health care context, a central facet of our national identity. Tracing back to Nathan Epstein, the founder of family therapy in Canada, there continues to be a strong tradition of couple and family therapy within Canada which has international reach. Formal training in family therapy, as well as couple/marital therapy occurs largely outside of the scope of degree granting programs and university settings. The American Association for Marriage and Family Therapy has a strong presence in Canada, with six divisions across the country. Popular models of practice for Canada’s couple and family therapists include cognitive-behavioral therapy, solution-focused therapy, narrative therapy, emotionally-focused therapy, and Bowenian/intergenerational therapy. A growing number of training opportunities are becoming available across Canada, and the practice of couple and family therapy is becoming institutionalized as one of the core competencies for professions such as psychiatry. In this article, we examine the context of family therapy in Canada by examining its history, the unique accreditation standards, qualifications and organizations associated with family therapy, the relationship between couple and family therapy, and future directions for this field of practice.

Influence of Geographical Origin and Ethnicity on Mortality in Patients on Antiretroviral Therapy in Canada, Europe, and the United States

Our objective was to assess differences in all-cause mortality, as well as AIDS and non-AIDS death rates, among patients started on antiretroviral therapy (ART) according to their geographical origin and ethnicity/race in Europe, Canada, and the United States. This was a collaboration of 19 cohort studies of human immunodeficiency virus-positive subjects who have initiated ART (ART Cohort Collaboration) between 1998 and 2009. Adjusted mortality hazard ratios (AHRs) were estimated using Cox regression. A competing risk framework was used to estimate adjusted subdistribution hazard ratios for AIDS and non-AIDS mortality. Of 46 648 European patients, 16.3% were from sub-Saharan Africa (SSA), 5.1% Caribbean and Latin America, 1.6% North Africa and Middle East, and 1.7% Asia/West; of 1371 patients from Canada, 14.9% were First Nations and 22.4% migrants, and of 7742 patients from North America, 55.5% were African American and 6.6% Hispanic. Migrants from SSA (AHR, 0.79; 95% confidence interval [CI], .68-.92) and Asia/West (AHR, 0.62; 95% CI, .41-.92) had lower mortality than Europeans; these differences appeared mainly attributable to lower non-AIDS mortality. Compared with white Canadians, mortality in Canadian First Nations people (AHR, 1.48; 95% CI, .96-2.29) was higher, both for AIDS and non-AIDS mortality rates. Among US patients, when compared with whites, African Americans had higher AIDS and non-AIDS mortality, and hazard ratios for all-cause mortality increased with time on ART. The lower mortality observed in migrants suggests "healthy migrant" effects, whereas the higher mortality in First Nations people and African Americans in North America suggests social inequality gaps.

Biologic Drug Access and Juvenile Idiopathic Arthritis in Canada: Improving Collaboration Between Clinician Experts and Funders

To the Editor: We read with great interest the article by LeBlanc, et al , “ Access to Biologic Therapies in Canada for Children with Juvenile Idiopathic Arthritis”1. We congratulate the authors for highlighting the challenges for Canada’s healthcare system in delivering equitable drug access across the country when healthcare is provincially delivered and there is still no national pharmaceutical program. This is particularly important in areas such as juvenile idiopathic arthritis (JIA), where because of the rarity of the underlying condition, the development of different funding decisions across provinces and territories leads to inefficient drug policy. Provincial governments should be encouraged to review the advice of national organizations such as the Canadian Agency for Drugs and Technologies in Health (CADTH) and the pan-Canadian Oncology Drug Review (pCODR). These organizations provide evidence-based information about health technologies, including drugs, with the goal of harmonizing drug funding across the country. We would like to clarify a few misconceptions in the LeBlanc article. First, the authors stated … Address correspondence to Dr. E. Cohen, Department of Pediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; E-mail: eyal.cohen{at}sickkids.ca

Prolonged Treatment Duration is Required for SuccessfulHelicobacter pyloriEradication with Proton Pump Inhibitor Triple Therapy in Canada

Traditional seven-day proton pump inhibitor triple therapy for Helicobacter pylori eradication has recently shown disappointing results outside of Canada. Prolonging therapy may be associated with poorer compliance and, hence, may not have a better outcome in a real-world setting. To compare the outcomes of seven- and 14-day triple therapy for first-line treatment of H pylori infection in an effectiveness setting in Canada. A total of 314 consecutive treatment-naive, adult H pylori-infected patients were allocated to either a seven- or 14-day triple therapy regimen, with a subgroup of 172 consecutive patients quasi-randomized to treatment according to date of visit. Eradication was confirmed using either urea breath test or gastric biopsies. Analysis was by intention to treat. Eradication was achieved in a higher proportion of patients who underwent 14-day versus seven-day treatment regimens (overall: 85% versus 70% [P≤0.001]; subgroup: 83% versus 64% [P≤0.01]). Although successful eradication was also associated with older age and a diagnosis of ulcer disease, multivariate analysis revealed only longer treatment duration and lack of yogurt ingestion as independent predictors of successful eradication. There was a trend toward reduced success in the latter years of the study. Side effects were similar in both groups and were not prevented by yogurt ingestion. The currently recommended duration of proton pump inhibitor triple therapy in Canada should be increased from seven to 14 days, the latter having achieved an excellent result in this particular real-world setting. Yogurt added no benefit. Further study is required to compare 10-day with 14-day treatment regimens.

Book Review: Restoring the Spirit: The Beginnings of Occupational Therapy in Canada, 1890–1930 (2011)

Book Review: Restoring the Spirit: The Beginnings of Occupational Therapy in Canada, 1890–1930 (2011)

PSY19 A Cost-Consequence Analysis of Patient Self-Management Versus Physician-Managed Monitoring of Long-Term Oral Anticoagulation Therapy in Canada

PSY19 A Cost-Consequence Analysis of Patient Self-Management Versus Physician-Managed Monitoring of Long-Term Oral Anticoagulation Therapy in Canada

Barriers to accessing radiation therapy in Canada: a systematic review.

IntroductionRadiation therapy (RT) is effective treatment for curing and palliating cancer, yet concern exists that not all Canadians for whom RT is indicated receive it. Many factors may contribute to suboptimal use of RT. A review of recent Canadian literature was undertaken to identify such barriers.MethodsMEDLINE, CINAHL, and EMBase databases were used to search keywords relating to barriers to accessing or utilizing RT in Canada. Collected abstracts were reviewed independently. Barriers identified in relevant articles were categorized as relating to the health systems, patient socio-demographic, patient factors, or provider factors contexts and thematic analysis performed for each context.Results535 unique abstracts were collected. 75 met inclusion criteria. 46 (61.3%) addressed multiple themes. The most cited barriers to accessing RT when indicated were patient age (n = 26, 34.7%), distance to treatment centre (n = 23, 30.7%), wait times (n = 22, 29.3%), and lack of physician understanding about the use of RT (n = 16, 21.6%).ConclusionsBarriers to RT are reported in many areas. The role of provider factors and the lack of attention to patient fears and mistrust as potential barriers were unexpected findings demanding further attention. Solutions should be sought to overcome identified barriers facilitating more effective cancer care for Canadians.

Book Review: Restoring the Spirit: The Beginnings of Occupational Therapy in Canada, 1890–1930

Book Review: Restoring the Spirit: The Beginnings of Occupational Therapy in Canada, 1890–1930

Access to Biologic Therapies in Canada for Children with Juvenile Idiopathic Arthritis

To compare access to biologic therapies for children with juvenile idiopathic arthritis (JIA) across Canada, and to identify differences in provincial regulations and criteria for access. Between June and August 2010, we compiled the provincial guidelines for reimbursement of biologic drugs for children with JIA and conducted a multicenter Canada-wide survey of pediatric rheumatologists to determine their experience with accessing biologic therapies for their patients. There were significant difficulties accessing biologic treatments other than etanercept and abatacept for children. There were large discrepancies in the access criteria and coverage of biologic agents across provinces, notably with age restrictions for younger children. Canadian children with JIA may not receive optimal internationally recognized "standard" care because pediatric coverage for biologic drugs through provincial formularies is limited and inconsistent across the country. There is urgent need for public policy to improve access to biologic therapies for these children to ensure optimal short-term and longterm health outcomes.