Winnipeg Health Sciences Centre Research Articles

Dreams interrupted: characteristics of REM sleep-associated seizures and status epilepticus.

Seizures are rare in rapid eye movement sleep (REM). However; seizures sometimes occur in REM, and a small number of focal epilepsy patients display their maximum rate of interictal epileptiform discharges in REM. We sought to systematically identify and characterize seizures in REM. We reviewed all admissions to the Epilepsy Monitoring Unit (EMU) at the Winnipeg Health Sciences Centre over 12-months in 2014-2015. American Academy of Sleep Medicine sleep-stage scoring was initially applied in the standard 30-second epochs. Then, to capture sudden changes in sleep-wake state on shorter timescales that are associated with seizure formation and propagation, we re-scored ictal and peri-ictal EEG epochs every 1 second. Patients found to have seizures in REM were subject to chart review spanning three years pre- and post-admission. REM seizures occurred in 3/63 EMU patients. Notably, one patient exhibited continuous epileptiform activity, consistent with focal nonconvulsive electrographic status epilepticus, throughout REM cycles for each night of her admission. Otherwise, discrete REM seizures constituted a small fraction of the other patients' total seizures (range 5.0-8.3%), occurred shortly after REM onset from non-REM 2, and were manifest as minor epileptic arousals. Our results confirm that REM seizures are rare, while highlighting outliers who widen the known spectrum of heterogeneous sleep effects on seizures/epilepsy. We also report the first case of paradoxical status epilepticus in REM.

P.019 A machine learning approach to asymmetric burst suppression and refractory status epilepticus outcome

Background: Treatment of refractory status epilepticus (RSE) is often titrated to achieve EEG burst suppression. However, optimal burst suppression characteristics are largely unknown. We used an unsupervised machine learning algorithm to predict RSE outcome based on the quantitative burst suppression ratio (QBSR). Methods: We conducted principal component analysis (PCA) as a linear combination of 22 QBSR features from non-anoxic adult RSE patients at the Winnipeg Health Sciences Centre. We also determined the most predictive components that significantly differed between survivors and non-survivors. Results: Using 135,765 QBSRs from 7 survivors and 10 non-survivors, PCA identified a predominantly non-survivor cluster of 8 patients (75% non-survivors). The first 2 PCA components comprised 75% data variance. The most important first component feature was skewness of QBSR distribution in the right or left hemisphere (0.52 each). The most important second component feature was third QBSR quantile of the left hemisphere (0.49). Only right hemispheric QBSR features significantly differed between groups: QBSR skewness for the first component (Benjamini-Hochberg adjusted p=0.038) and average QBSR for the second component (0.32, Benjamini-Hochberg adjusted p=0.046). Conclusions: Our pilot study shows that RSE patient survival may be impacted by QBSR, with differential hemispheric EEG burst suppression characteristics predicting poor RSE outcome.

Utility of fecal immunochemical test vs guaiac fecal occult blood test for assessment of gastrointestinal bleed in hospitalized patients

BackgroundGuaiac fecal occult blood testing (gFOBT) is often used “off-label” for gastrointestinal (GI) bleeding. Fecal Immunochemical Test (FIT) is increasingly replacing gFOBT in colorectal cancer screening and may play a role in assessment for significant bowel disease. We examined the concordance of FIT with gFOBT (Hemoccult Sensa II) among inpatients and between day 1 and day 3 gFOBT results. MethodsFIT was performed alongside gFOBT on all inpatient stool sent for occult blood to the Winnipeg Health Sciences Centre laboratory over 1 y. gFOBT was performed on days 1 and 3 post stool collection, while FIT was performed on day 1 only. ResultsPositivity rates were highest for Day 1 gFOBT (27.7%), and lowest for FIT (18.3%). Concordance between FIT and Days 1 and 3 gFOBT for negative test results (96.4% and 94.1%) was significantly higher than that expected by chance alone (58.7% and 61.3%, P < .001). Similarly, concordance for positive test results (55.8% and 55.6%) was significantly higher as well as for days 1 and 3 gFOBT results. ConclusionsWe found no benefit in delayed testing for 3 days post collection. FIT provides equivalent results to gFOBT in hospitalized patients.

Effective Post-EVAR Surveillance and Management of Graft Complications Among Rural Inhabitants in Manitoba

All aortic surgery in Manitoba occurs in Winnipeg at two university hospitals. Given the large geographic catchment area, we hypothesized that patients living rurally would have inferior surveillance after endovascular aortic aneurysm repair (EVAR). We sought to determine if post-EVAR surveillance and endoleak management differed between urban and rural inhabitants. Our project was approved by the ethics board at the University of Manitoba. A retrospective chart review was performed for all patients who underwent EVAR at Winnipeg Health Sciences Centre between 2012 and 2014. Charts were analyzed from the day of surgery until December 31, 2018. Patients living outside of Winnipeg city limits were considered rural. Adequate follow-up was defined as a computed tomography angiogram within 1 year of surgery and then an annual computed tomography scan or ultrasound examination thereafter. The primary outcome measure was adequate follow-up. Secondary outcomes included the frequency of endoleaks, reinterventions, and death. Univariate statistics were performed. Eight-six patients underwent EVAR between 2012 and 2014, accounting for 45% of all EVARs performed in Manitoba during this time period. Forty-nine percent of patients lived rurally. There was no difference in surveillance between patients living in Winnipeg or in a rural location (81% vs 77%; P = .64). There was a similar number of endoleaks (20% vs 23%; P = .83), and reinterventions for endoleaks (11 vs 7 interventions; P = .56) and limb stenosis/occlusion (4 vs 2 interventions; P = .5). There was a nonsignificant trend toward increased mortality among urban patients (41% vs 35%; P = .05). Among patients who died, surveillance was similar between groups (P = .16). The surveillance of patients after EVAR and the management of graft complications is similar in patients living in Winnipeg and in rural Manitoba. This supports the ongoing centralization of vascular care within Manitoba. The incidence of graft-related complications is consistent with outcomes from other jurisdictions. Future work will characterize the entire provincial caseload during this time period.

Clinical Characterization of a Novel Mutation in SLC25A38 Resulting in Congenital Sideroblastic Anemia in a Canadian First Nations Population

Introduction: Congenital sideroblastic anemia (CSA) is an uncommon cause of inherited anemia characterized by pathologic iron accumulation. Severity of anemia and blood transfusion requirements are variable. Aberrations in iron-heme metabolism that underpin CSA result in iron overload, often preceding transfusion. The only curative therapy for CSA is hematopoietic stem cell transplantation (HSCT), offered to select patients with severe transfusion dependent anemia. Mutations in several genes have been identified to be responsible for CSA. Mutations in SLC25A38, encoding a mitochondrial glycine transporter required for heme biosynthesis, are a rare cause of CSA. Homozygosity for a novel founder missense mutation in SLC25A38 (c.560G>A) has been detected in a Canadian First Nations Northern Cree population. The associated phenotype is a severe anemia presenting in infancy and characterized by ineffective erythropoiesis and iron loading. The natural history and treatment outcomes of CSA caused by the c.560G>A mutation have not been described.Objectives: (1) To characterize the clinical features in patients homozygous for this founder mutation, including propensity to iron loading and (2) to describe the treatment course and outcomes for red cell transfusion, iron chelation, pyridoxine supplementation and HSCT.Methods: A retrospective chart review was conducted at the Winnipeg Health Sciences Centre and CancerCare Manitoba of all affected individuals homozygous for the c.560G>A mutation in SLC25A38.Results: Seven affected individuals (three females and four males) were identified. Comorbidities including dextrocardia, hypertrophic cardiomyopathy, rheumatoid arthritis and global developmental delay were noted in three members of the kindred, but there was no evidence of a syndromic form of CSA. The median age of presentation with anemia was 6 months (24 days - 4.4 years). The median age of CSA diagnosis was 1.5 years (6 months - 22 years). Alternative causes of anemia were initially suspected in five of the seven patients: iron deficiency, resulting in oral iron supplementation, and alpha thalassemia. Uniformly, individuals presented with a microcytic, hypochromic anemia, with elevated ferritin prior to first red cell transfusion. All affected individuals required red cell transfusion support, with six of seven patients requiring chronic transfusions at a median frequency of every four weeks. One individual, though chronically anemic, did not require regular transfusion support until the age of 20 years. One patient carried a successful pregnancy with transfusion support, but delivered prematurely. For all individuals, iron chelation was recommended, with six individuals starting chelation within three years of initiation of transfusions. Hepatic, cardiac, pituitary and pancreatic iron overload, and resultant organ dysfunction were noted in two subjects who did not adhere to chelation; one died of neutropenic sepsis after starting deferiprone for cardiac iron overload. Six individuals were given trials of pyridoxine supplementation, with two demonstrating a transient partial response with a rise in reticulocyte count and decrease in transfusion frequency. Three individuals underwent allogeneic HSCT (two from matched sibling donors, and one from a matched unrelated donor), at 5.5 years, 7.2 years, and 28 years. The oldest and most iron-loaded of the three died in the post-transplant period due to complications of sepsis. The other two individuals remain transfusion free, at 9 months and 15.6 years post-HSCT.Conclusions: A novel founder mutation in SLC25A38 causing CSA among individuals of Canadian First Nations Northern Cree descent results in a severe transfusion-dependent anemia. Despite a common genetic etiology, phenotypic variability was noted, with one individual having marked tolerance to anemia. A partial transient response to pyridoxine was noted in two individuals, raising the question of an alternative role for SLC25A38 in heme biosynthesis. HSCT, when performed before significant iron overloading, was beneficial. Characterization of this phenotype and evidence of successful HSCT may assist clinicians in identifying affected individuals with CSA and initiating timely and effective treatment. DisclosuresNo relevant conflicts of interest to declare.

The making of a lipid biochemist.

Patrick obtained his undergraduate degree at McGill University, and received his graduate training in Medicine and Biochemistry at the University of North Dakota. His postdoctoral work was conducted at the University of British Columbia. He joined the Faculty of Medicine, University of Manitoba as an Assistant Professor of Biochemistry in 1979. He was the recipient of a New Investigator Award (1979-85) from the Heart and Stroke Foundation of Canada, followed by a Scientist Award (1985-90) from the MRC/CIHR. These career awards allowed him to devote the majority of his time to research. He was promoted to Associate Professor in 1983 and Full Professor in 1986. He was cross-appointed as Professor of Pathology and participated in the teaching of General Pathology to residents. He was the founding Director of the Centre for Re-search and Treatment of Atherosclerosis at the University of Manitoba and the Winni-peg Health Sciences Centre. Administratively, he was appointed as the Professor and Head of Biochemistry and Medical Genetics (1992-1999), and an Associate Dean in the Faculty of Medicine in 1999 until his retirement in 2010.Professionally, Patrick served as President of the Canadian Biochemical Society, Chair of the Medical Research Council/Canadian Institute of Health Research New Investigator Awards Committee, Chair of the Alberta Heritage Foundation Senior Investigator Awards Committee, Vice-President of the Heart and Stroke Foundation of Manitoba, and Secretary/Treasurer of the Canadian Society for Clinical Investigation. He continues to serve on Editorial Boards of scientific journals, including the Journal of Clinical and Investigative Medicine. He was invested into the Order of Manitoba in 2011.

Effect of high dose vitamin D3 therapy on serum vitamin D3 levels in vitamin D insufficient adults with cystic fibrosis

The effect of a high dose oral cholecalciferol repletion strategy in Vitamin D insufficient adults with CF is still unknown. Therefore, we assessed the effectiveness of our current approach, giving oral vitamin D3 supplementation at a dose of 10,000IU from Monday to Friday for a total of 50,000IU D3 weekly in vitamin D insufficient adult with CF. We performed a retrospective chart review of all 59 adult CF patients between the ages of 17 and 64 years routinely followed at the CF Adult Program of Winnipeg Health Sciences Centre. Through consultation with the endocrinologist, our clinic vitamin D repletion protocol for treating CF adult patients who have serum 25-hydroxyvitamin D (25-OHD)<30ng/ml (<75nmol/L) was to prescribe vitamin D3 10,000IU orally from Monday to Friday (or the weekly equivalent of 50,000IU) for 12 weeks in addition to their regular CF vitamin that supplied from 800 to 2000IU vitamin D3 daily. Cholecalciferol was conveniently administered orally as either one capsule (oil-based) 10,000IU or one tablet (powder-based) 10,000IU. All patients were instructed to obtain follow-up serum 25-OHD levels post completion of treatment. Of the 59 adult patients at our CF Clinic, 35 patients (59%) had below optimal serum 25-OHD levels. Of the 35 patients identified, 10 patients with insufficient serum 25-OHD levels between 10 and 30ng/ml (25-75nmol/L) fulfilled the inclusion criteria. A significant increase in serum 25-OHD levels was observed (P<0.01) from mean value of 21.6±5.9ng/ml (54.1±14.8nmol/L) at baseline to 31.7±9.1ng/ml (79.3±22.8nmol/L)≥2 months post intervention. The current treatment approach was successful in treating Vitamin D insufficiency in 70% of the patients with low 25-OHD levels. The results of this study demonstrate that a large number of adults attending Winnipeg Health Sciences Centre CF Clinic have serum 25-OHD levels below 30ng/ml (75nmol/L). This supports the need for dedicated and individualized approach to manage this condition. High dose therapy of vitamin D3, although a more aggressive treatment approach, may result in achieving optimal levels of serum 25-OHD in adults with CF.

Cerebrospinal Fluid Pleocytosis in Critical Care Patients With Seizures.

To assess the etiology of cerebrospinal fluid (CSF) pleocytosis in critical care patients with seizure(s) or status epilepticus (SE). Many previous studies, some performed decades ago, concluded that CSF pleocytosis may be entirely attributable to seizure activity. We undertook a retrospective chart review of adult patients with an admitting or acquired diagnosis of seizure(s) or SE in critical care units at the Winnipeg Health Sciences Centre between 2009 and 2012. Patients were identified through a critical care information database at a tertiary care center. We limited our study to patients who had lumbar punctures at our center within 5 days of seizure(s) or SE. Of 426 patients with seizures in critical care units, 51 met the inclusion criteria. Seizure subtypes included focal seizures (5 or 10%), generalized seizures (14 or 27%), and SE (32 or 63%). Twelve (seven with SE) of the 51 (24%) were found to have CSF pleocytosis. A probable etiological cause for the CSF pleocytosis was identified in all 12 cases. We conclude that seizures do not directly induce a CSF pleocytosis. Instead, the CSF pleocytosis more likely reflects the underlying acute or chronic brain process responsible for the seizure(s). This was not readily apparent in early studies without magnetic resonance imaging (MRI) of the brain and currently available laboratory investigations. An etiological cause of CSF pleocytosis must always be sought when patients present with seizures and it should never be assumed that seizures are the cause.

Traumatic and other non-natural childhood deaths in Manitoba, Canada: a retrospective autopsy analysis (1989-2010).

The goals of analyzing all non-natural childhood deaths in Manitoba for the 22-year period (1989-2010) are to highlight preventable causes of death and to document temporal trends that might be influenced by changes in society. The 1989 to 2010 pediatric autopsy database at the Winnipeg Health Sciences Centre and records from the Office of the Chief Medical Examiner were searched for all non-natural deaths ≤ 18 years age. All files were reviewed in detail. Data collected included demographic characteristics, manner of death, details of cause and circumstances leading to death, and survival time after the event. For the 22-year period, the total number of non-natural childhood deaths after which autopsy was performed in Manitoba was 581 for males and 409 for females in a population of approximately 1.23 million (2010 estimate). This represents 22.1% of the total childhood deaths in Manitoba during the study period. A higher proportion of children living in rural and northern communities died from non-natural causes. Of all accidents, which peaked in 1999, road traffic incidents accounted for the majority. Of suicides, which peaked in 2005, hanging in the 15-18 year group accounted for almost all cases. Of homicides, child abuse deaths at <3 years age was the most frequent cause. For all causes, most individuals were dead at the scene or died shortly thereafter. Most non-natural childhood deaths in Manitoba might be avoidable through education about prevention strategies and by correction of social inequities. Improved transportation to hospital from remote locations would likely have little impact on survival.

Prohibitin interacts with phosphatidylinositol 3,4,5‐triphosphate (PIP3) and modulates insulin signaling

Mitochondrial protein prohibitin (PHB) is known to associate with the plasma membrane of various cell types. However, biological function of plasma membrane associated PHB is not known. Recently we have shown that PHB undergoes tyrosine phosphorylation in response to insulin and here we report that PHB interacts with phosphatidylinositol 3,4,5‐triphosphate (PIP3). Furthermore, we demonstrate that over expression of PHB attenuates insulin signaling downstream of phosphatidylinositol 3 (PI3) kinase. This effect was not observed with over expression of tyrosine phosphorylation site mutant‐PHB suggesting a role for tyrosine phosphorylation of PHB in this process. Interestingly phosphorylation of PHB by Akt attenuates its interaction with PIP3 and enhances insulin signaling. Thus, phosphorylation of PHB and its interaction with PIP3 may be a part of the regulatory mechanisms that is involved in the modulation of insulin signaling. We speculate that phosphorylation of PHB may serve as a general mechanism in the regulation of PI3 kinase signaling including growth factors and immune receptor signaling. This work was made possible by financial support from Manitoba Health Research Council (MHRC) and Winnipeg Health Sciences Centre Foundation to SM and MHRC postdoctoral fellowship to SRA.

Iatrogenic Severe Depression of High‐Density Lipoprotein Cholesterol

The authors present 5 cases of paradoxical depression of high-density lipoprotein (HDL) cholesterol induced by fibrate drugs. In a 24-month review of all cases seen in one physician's practice at the Winnipeg Health Sciences Centre Lipid Clinic, 492 patients made a total of 1187 visits. Sixty-eight of them were given a fibrate drug (14%). Ten patients had HDL cholesterol levels that were less than 0.5 mmol/L (2%), and of these, 5 cases were due to exposure to fenofibrate (1%). These 5 cases comprised 7.4% of the 68 patients who were given any fibrate drug during that period. Mean levels were as follows: HDL cholesterol on fenofibrate 0.27, off fenofibrate 1.0 mmol/L and apo A1 on fenofibrate 0.41, off fenofibrate 1.17 g/L. A literature review revealed documented cases in 37 patients involving fibrates alone or in combination with other drugs known to cause decreased HDL cholesterol levels. In 13 patients, exposure was to fibrate therapy alone; in those exposed to combinations, the effect was clearly attributable to fibrates in 9; in 14, the nonfibrates (mostly rosiglitazone) were the attributable drugs; and in 1, it was impossible to tell. Thus, fibrate therapy should always be suspected as a cause of profoundly depressed HDL cholesterol.

The Perfect Storm: Nursing In Twenty-First-Century America

The Perfect Storm: Nursing In Twenty-First-Century America

Coagulation Abnormalities in Patients with Noonan Syndrome - a Single Centre Case Series.

Noonan syndrome (NS) is an autosomal dominant disorder that includes short stature, characteristic facies, congenital heart defect, webbed neck, and developmental delay. A mutation in the PTPN11 gene can be identified in 50% of patients. A bleeding tendency is included in the phenotypic spectrum, with factor XI deficiency and platelet abnormalities described most frequently. At Winnipeg's Health Sciences Centre, 24 patients with features typical of NS have been studied by the Special Haemostasis Laboratory. Four patients in whom the diagnosis was suspected but not considered definite are also included in this analysis. Clinical complaints included easy bruising (9), epistaxis (2), menorrhagia (1), and a family history of bleeding problems (3). Sixteen patients were referred for investigation following the diagnosis of NS. All 28 patients had coagulation screening tests: 16 patients had an abnormal PT and 12 had an abnormal aPTT. Thrombin time was slightly prolonged in 6 of 23 patients. Reptilase time was normal in 8 patients, and fibrinogen concentration was normal in 20 patients.Factor XI levels were measured in 14 patients, with a mean value of 62% (range 32–99%). Only 2 patients had levels below the normal range. One of 13 patients evaluated for FXII levels was deficient (FXII 25%), and 2 of 19 patients evaluated for FIX levels had mild FIX deficiency (FIX 40 and 49%) without symptomatic bleeding. No other factor deficiencies were identified. Twenty-four patients had determinations of von Willebrand Factor antigen and activity; 2 had results consistent with mild Type 1 von Willebrand Disease.Platelet aggregation studies were done in 22 patients. A variety of abnormalities were noted, with the most frequent being abnormal aggregation with epinephrine (7/22). Dense granule number was decreased in 2 of 7 samples studied by electron microscopy. Lupus anticoagulants were detected in 3 of 13 patients screened. Thrombophilia investigations in 4 patients detected decreased protein S in one patient who had been diagnosed previously with protein S deficiency.This unselected case series, the largest reported to date in the literature, illustrates the heterogeneity of coagulation abnormalities that may occur in NS. Symptoms, when present, were mild, and often did not correlate with laboratory abnormalities. Non-specific platelet aggregation defects were the most commonly identified abnormalities. In contrast to the literature, factor XI deficiency was not prevalent. A specific etiology for the variable bleeding tendency has not yet been identified in NS.

Gender, power, nursing: a case analysis

This paper is concerned with events that were the subject of an inquest into the deaths of 12 children who died while undergoing or shortly after having undergone cardiac surgery at the Winnipeg Health Sciences Centre, Manitoba, Canada, during 1994. A notable finding of the Sinclair Inquest was that nurses involved with the pediatric cardiac surgery program were concerned about the competence of the surgeon and made sustained efforts throughout 1994 to have these concerns addressed. That the nurses' concerns were not taken seriously is the central problem of this paper. Essentially, the position articulated is that gendered and gendering discourses constituted a form of power that structured the field of nurses' possible actions. These discourses constituted a resource to make nurses knowable, to produce them as certain forms of the person, and were therefore part of what governed nurses everyday conduct. Though neither simply good nor bad in themselves, in this case, these discourses had constraining effects on how nurses were able to conduct themselves.

Nursing, knowledge and power: A case analysis

This paper is concerned with events that were the subject of an inquest (The report of the Manitoba pediatric cardiac surgery inquest: an inquiry into twelve deaths at the Winnipeg Health Sciences Centre in 1994, Provincial Court of Manitoba, Winnipeg) into the deaths of 12 children who died while undergoing or shortly after having undergone cardiac surgery at the Winnipeg Health Sciences Centre, Man., Canada, during 1994. A notable finding of this inquest was that nurses involved with the pediatric cardiac surgery program were concerned about the competence of the surgeon and made sustained efforts throughout 1994 to have these concerns addressed. That the nurses’ concerns were not taken seriously is the central problem of this paper. The work of Foucault is used to set out a ground for thinking about this problem. In this case, knowledge practices, specifically those concerning who can claim status as a credible knower, produced limits for nurses. Such limits are neither good nor bad in themselves, but rather have effects with which we must be concerned. In this case, the limits produced by certain knowledge practices had the effect of rendering the nurses’ concerns irrelevant and this is significant in itself and also because it was an important part of how patient care was allowed to be compromised.

Solvent Abuse in Pregnancy: A Perinatal Perspective

Objective: To review the scope and sequelae of solvent abuse in women presenting to a Manitoba teaching hospital.Methods: Fifty-six patient charts with a diagnosis of solvent abuse in pregnancy were identified through computer search in the medical records of Winnipeg Health Sciences Centre, General Hospital. These charts were reviewed and data obtained from birthing records and associated pediatric charts.Results: Renal tubular acidosis was diagnosed in three patients (5.3%). Two patients (3.6%) had adverse neurological sequelae. One patient was diagnosed with brain damage, including expressive aphasia. Twelve patients (21.4%) delivered preterm infants.Nine infants (16.1%) had major anomalies. Seven infants (12.5%) had fetal alcohol syndrome (FAS)-like facial features. Six neonates (10.7%) had hearing loss.Conclusion: Substance abuse in pregnancy is associated with severe maternal and neonatal sequelae. Physicians must be aware of this increasing problem in the obstetrical population and assistance should be offered to each woman, ideally before a woman becomes pregnant, but at least at the first contact a pregnant woman makes with the health care community.

A heartbreaking story that misses the point

A heartbreaking story that misses the point

Pharmacist Shortage: a Wake-Up Call for the Profession

As many pharmacy directors know, it has become very difficult to fill pharmacist positions. In some hospitals, 25% of positions are vacant, and some Ontario hospitals are offering signing bonuses to new pharmacists. However, the shortage is not confined to hospitals. In March of this year, the Canadian Association of Chain Drug Stores (CACDS) issued a press release drawing attention to an acute shortage of pharmacists, estimated at 1000 for its member chains. The CACDS called for an immediate increase in enrollment in pharmacy schools and fast-tracking of the licensing of foreign-trained pharmacists. The shortage is worldwide. In Canada the total shortage is currently estimated at 1500, and in the United States it was estimated at 3500 in 1999. The US Congress has commissioned a study of the problem, with the final report to be submitted in early December 2000. The American situation may be exacerbating the shortage in Canada. US chains are running strong recruiting campaigns for Canadian pharmacy graduates, offering very attractive salaries and signing bonuses. Several questions arise. First, what is the extent of the shortage — which regions in Canada and what type of positions are most affected? Second, why was the profession caught unawares? Just 5 years ago the Pew Health Profession Commission warned American educators of an impending oversupply of pharmacists because of the extent to which advances in information, communication, and dispensing technologies would increase pharmacy efficiency. It recommended that 20% to 25% of pharmacy schools in the United States close. Fortunately, none did. Indeed, several new private schools have opened since. Third, what is driving the shortage? Is it an issue of growing demand or reduced supply? The CACDS cited demand-side factors such as expansion in the role of the pharmacist, continued increase in prescription volume fuelled by the aging of the population, increased numbers of chain pharmacies, and increased operating hours. Equally plausible supplyside factors include feminization of the profession, which may be contributing to more pharmacists working on a part-time basis or taking temporary leave from the workforce, and migration of pharmacists to the United States or into pharmaceutical companies or managed care organizations, where salaries and working conditions may be better. Hospital pharmacy has its own set of issues: noncompetitive salaries (remember the threatened walkout in Quebec last summer and the walkout at the Winnipeg Health Sciences Centre a few months ago), a limited career ladder, lengthy maternity leaves, and early retirements, to name a few. The situation may be particularly acute in teaching hospitals in urban centres, where the stresses of juggling clinical teaching, service responsibilities, and urban living induce pharmacists to seek other living and working environments. What’s being done to respond to the shortage? Some faculties of pharmacy are increasing their enrollment. In 1999, the University of Toronto (U of T) increased its first-year enrollment from 120 to 140 students to begin to rectify a longstanding situation in which U of T graduates have constituted only one-third of the pharmacists licensed each year in Ontario (at present, Ontario pharmacies must recruit pharmacists from other provinces and other countries). The overall plan is to double enrollment (to 240) by 2003. The Universite de Montreal will increase its enrollment from 145 to 165 in the fall of 2000. Other schools are also considering increases. However, increases in enrollment lead to the need for additional instructional resources and funding from the province and thus take time to be approved and implemented. Moreover, it takes 4 years for an

Utilizing Data Systems to Develop and Monitor Occupational Health Programs in a Large Canadian Hospital

With rapid change in health care requiring greater emphasis on productivity and quality management, occupational health hazards in hospitals have been receiving increasing recognition, now not only focusing on controlling infection, but also on chemical, physical, mechanical as well as psychosocial hazards. Reducing costly time loss from musculoskeletal injuries is a particular imperative. The Department of Occupational and Environmental Medicine at Winnipeg's Health Sciences Centre, developed databases to help priorize, monitor and improve occupational health programs for its 6,000 employees. Risk assessment/risk management models were adopted to identify hazards, quantify risks and priorize intervention. Using the databases permitted the targeting of groups requiring immunization, resulting in increased coverage. New safety products were introduced and found to be cost-beneficial. A return-to-work post-injury program was particularly cost-beneficial. Over the five years following the implementation of occupational health programs, workers' compensation assessment reductions resulted in savings of more than half-a-million dollars annually. The databases were invaluable in affecting these changes.

Primary sclerosing cholangitis in patients &lt;20 years old: Diversity of clinical and laboratory features differing from adult disease patterns , , , , , , . Divisions of Gastroenterology, The Hospital for Sick Children, The Toronto Hospital, Winnipeg Health Sciences Centre, and Ottawa Civic Hospital, and Department of Medicine, University of Toronto, Toronto, Canada

Primary sclerosing cholangitis in patients &lt;20 years old: Diversity of clinical and laboratory features differing from adult disease patterns , , , , , , . Divisions of Gastroenterology, The Hospital for Sick Children, The Toronto Hospital, Winnipeg Health Sciences Centre, and Ottawa Civic Hospital, and Department of Medicine, University of Toronto, Toronto, Canada