Incremental costs of fragility fractures: a population-based matched -cohort study from Ontario, Canada

Using a matched cohort design, the 1-year excess cost of incident fragility fractures at any site was $26,341 per patient, with 43% of total excess costs attributed to hospitalization. The high economic burden of fractures in Ontario underscores the urgency of closing the secondary fracture prevention gap.

INTRODUCTION

This retrospective real-world observational study was conducted to document the incremental costs associated with fragility fractures in Ontario, Canada.

METHODS

Patients aged >65 years with an index fragility fracture occurring between January 2011 and March 2015 were identified from administrative databases and matched 1:1 to a cohort of similar patients without a fracture. Healthcare resource utilization data were extracted from healthcare records and associated costs were calculated on a per-patient level and for the province of Ontario. Costs were presented as 2017 Canadian dollars.

RESULTS

The eligible cohort included 115,776 patients with a fragility fracture. Of these, 101,773 patients were successfully matched 1:1 to a non-fracture cohort. Overall, hip fractures (n = 31,613) were the most common, whereas femur fractures (n = 3002) were the least common type. Hospitalization and continuing care/home care/long-term care accounted for more than 60% of 1-year direct costs, whereas 5% was attributed to medication costs. First-year costs per patient in the fracture cohort were approximately threefold higher versus the non-fracture cohort (mean $37,362 versus $11,020, respectively). The incremental first-year direct healthcare costs of fragility fractures for the province of Ontario were calculated at $724 million per year.

CONCLUSIONS

Fragility fractures were associated with a threefold increase in overall mean healthcare costs per patient compared to patients without fractures. With an aging population, there is an urgent need for improved prevention strategies for patients at high-risk of fracture to decrease the economic burden of fragility fractures on the Canadian healthcare system.

A scorecard for osteoporosis in Canada and seven Canadian provinces

The scorecard evaluates the burden and management of osteoporosis in Canada and how care pathways differ across Canadian provinces. The results showed there are inequities in patients' access to diagnosis, treatment, and post-fracture care programs in Canada. Interventions are needed to close the osteoporosis treatment gap and minimize these inequities.

INTRODUCTION

The purpose of this study was to develop a visual scorecard that assesses the burden of osteoporosis and its management within Canada and seven Canadian provinces.

METHODS

We adapted the Scorecard for Osteoporosis in Europe (SCOPE) to score osteoporosis indicators for Canada and seven provinces (British Columbia, Alberta, Saskatchewan, Ontario, Quebec, New Brunswick, and Newfoundland). We obtained data from a comprehensive literature review and interviews with osteoporosis experts. We scored 20 elements across four domains: burden of disease, policy framework, service provision, and service uptake. Each element was scored as red, yellow, or green, indicating high, intermediate, or low risk, respectively. Elements with insufficient data were scored black.

RESULTS

Canada performed well on several elements of osteoporosis care, including high uptake of risk assessment algorithms and minimal wait times for hip fracture surgery. However, there were no established fracture registries, and reporting on individuals with high fracture risk who remain untreated was limited. Furthermore, osteoporosis was not an official health priority in most provinces. Government-backed action plans and other osteoporosis initiatives were primarily confined to Ontario and Alberta. Several provinces (Saskatchewan, New Brunswick, Newfoundland) did not have any registered fracture liaison service (FLS) programs. Access to diagnosis and treatment was also inconsistent and reimbursement policies did not align with clinical guidelines.

CONCLUSION

Government-backed action plans are needed to address provincial inequities in patients' access to diagnosis, treatment, and FLS programs in Canada. Further characterization of the treatment gap and the establishment of fracture registries are critical next steps in providing high-quality osteoporosis care.

Sonographic markers of fetal adiposity and risk of Cesarean delivery

OBJECTIVE

Increased fetal size is associated with shoulder dystocia during labor and subsequent need for assisted delivery. We sought to investigate if increased fetal adiposity diagnosed sonographically in late pregnancy is associated with increased risk of operative delivery.

METHODS

This secondary analysis of the Genesis Study recruited 2392 nulliparous women with singleton pregnancy in cephalic presentation, in a prospective, multicenter study, to examine prenatal and intrapartum predictors of Cesarean delivery. Participants underwent ultrasound and clinical evaluation between 39 + 0 and 40 + 6 weeks' gestation. Data on fetal biometry were not revealed to patients or to their managing clinicians. A fetal adiposity composite of fetal thigh adiposity and fetal abdominal wall thickness was compiled for each infant in order to determine whether fetal adiposity > 90^th centile was associated with an increased risk of Cesarean or operative vaginal delivery.

RESULTS

After exclusions, data were available for 2330 patients. Patients with a fetal adiposity composite > 90^th centile had a higher maternal body mass index (BMI) (25 ± 5 kg/m² vs 24 ± 4 kg/m² ; P = 0.005), birth weight (3872 ± 417 g vs 3585 ± 401 g; P < 0.0001) and rate of induction of labor (47% (108/232) vs 40% (834/2098); P = 0.048) than did those with an adiposity composite ≤ 90^th centile. Fetuses with adiposity composite > 90^th centile were more likely to require Cesarean delivery than were those with adiposity composite ≤ 90^th centile (P < 0.0001). After adjusting for birth weight, maternal BMI and need for induction of labor, fetal adiposity > 90^th centile remained a risk factor for Cesarean delivery (P < 0.0001). A fetal adiposity composite > 90^th centile was more predictive of the need for unplanned Cesarean delivery than was an estimated fetal weight > 90^th centile (odds ratio, 2.20 (95% CI, 1.65-2.94; P < 0.001) vs 1.74 (95% CI, 1.29-2.35; P < 0.001). Having an adiposity composite > 90^th centile was not associated with an increased likelihood of operative vaginal delivery when compared with having an adiposity composite ≤ 90^th centile (P = 0.37).

CONCLUSIONS

Fetuses with increased adipose deposition are more likely to require Cesarean delivery than are those without increased adiposity. Consideration should, therefore, be given to adding fetal thigh adiposity and abdominal wall thickness to fetal sonographic assessment in late pregnancy. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Abstract P4-10-05: Engaging linguistically and ethnically diverse low income women in health research: A randomized controlled trial

Background: Underserved breast cancer survivors are typically offered fewer opportunities to participate in cancer research. To address this disparity, a community based navigator program, Shanti's Margot Murphy Breast Cancer Program (Shanti) initiated a collaboration with UCSF researchers and BreastCancerTrials.org (BCT), a nonprofit clinical trials matching service to explore the potential role of a trusted community-based organization as a source of culturally appropriate education and access to clinical trial information. Through formative research, we developed the Health Research Engagement Intervention (HREI), a one-on-one navigator-client education session emphasizing the range of treatment and non-treatment quality-of-life and observational studies, conducted at a time when the participant is not in the initial crisis of diagnosis. The HREI ends by providing participants with an information card listing BCT and other organizations that provide information about health research for breast cancer patients and survivors.

Methods: We tested the HREI in a randomized controlled trial, comparing the HREI to simply providing the information card. Pre and post intervention surveys one month apart measured our primary outcome of health research information-seeking behavior. Secondary outcomes include health research knowledge, attitudes towards research participation, and health empowerment. All Shanti clients who spoke English, Cantonese or Spanish and had “low care navigation needs” (either completed treatment or no longer in the crisis of initial diagnosis and/or burdened by treatment protocols) were eligible.

Results: We recruited 133 Shanti Clients, including 59 who spoke English, 48 Cantonese, and 26 Spanish; 66 were randomized to the intervention arm and 67 to the control arm, and 130 completed both pre- and post-test surveys. Almost one-third of participants in both the intervention and control arms reported having talked to someone about health research or having called a telephone number or visited a website listed on the card (30% vs. 30%, p=0.94); a smaller proportion of participants confirmed that their information-seeking was related to the content of the educational materials (17% vs. 9%, p=0.22). On average the change from pre- to post-test in a 5-item knowledge score, adjusted for pre-test knowledge, was greater in the intervention group than in the control group (p=0.028), but the proportion of participants who were very confident that they could find health research information (had health empowerment) remained essentially unchanged in both study arms (intervention: 20% post vs. 21% pre, p=0.76; control: 25% post vs. 25% pre, p=1.00). Women were more likely to seek information if they had higher pre-test knowledge scores (odds ratio [OR]=3.5 per item, 95% confidence interval [CI] 1.5-8.4) or a greater increase in knowledge from pre- to post-test (OR=2.2 per item, 95% CI 1.1-4.7); there was no association between information-seeking and health empowerment (OR=0.6, 95% CI 0.2-2.5) or study arm (OR=1.6, 95% CI 0.5-4.9).

Conclusion: The HREI had a positive impact on knowledge of health research but did not significantly affect health empowerment or health research information-seeking behavior.

Citation Format: Joseph G, Nickell A, Cohen E, Burke NJ, Colen S, Lawlor K, Guerra C, Stewart SL. Engaging linguistically and ethnically diverse low income women in health research: A randomized controlled trial [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-05.

Abstract P6-12-19: Healing art: Breast cancer survivor experiences with nipple-areola tattoo procedures during breast reconstruction

Background: Nipple-areola tattoos can provide restoration of a natural looking breast that more closely resembles its pre-surgical appearance while avoiding additional surgeries. To date, the majority of nipple-areola tattoo procedures are performed by healthcare providers with minimal training in tattoo procedures. Substandard results explain the high rates of dissatisfaction among women who receive nipple-areola tattoos. In response, professional tattoo artists have emerged as an alternative provider for women seeking reconstruction. However, few studies have examined expectations and experiences of women undergoing nipple-areola tattoo procedures provided by a professional tattoo artist outside of the traditional healthcare setting. Methods: In-depth interviews were conducted with a racially/ethnically diverse group of 30 women who had undergone nipple-areola tattooing in the past 0-2 years. Interviews were conducted in English, Spanish, Chinese, and Arabic, recorded, and translated and transcribed into English for analysis. A team of three researchers conducted iterative reviews of the data which included closely reading each transcript, coding, running queries of codes, and developing summary documents to highlight recurrent concepts and patterns which were shared and discussed in group meetings. Results: Interview narratives addressed the often unexpected impact nipple-areola tattooing had on body image, self-esteem, emotional well-being, and interpersonal relationships. Women described their decision-making processes as weighing concern about the needle, the pain, and uncertainty about the tattoo artist, setting for the procedure, and outcome with the opportunity to return to a more “normal” appearance without further surgeries. Women discussed how their initial preconceptions of tattoos and tattoo parlors were ameliorated by the spa-like setting and the tattoo artist's anticipation of such concerns which enhanced her ability to put them at ease and provide professional and compassionate care. Participants noted the integral role the tattoo artist played in their positive experiences, describing her as both an “artist” and “caregiver.” The manner in which she guided them through the decision-making process regarding the color, size, shape, and placement of their nipple-areola tattoo was noted as particularly significant and empowering. Conclusions: Nipple-areola tattooing is an acceptable and meaningful reconstruction process for medically underserved public hospital patients. Our results indicate that women should be informed of nipple-areola tattooing as an alternative to more invasive, surgical reconstruction options. Results also illustrate how the healthcare system can extend beyond the traditional healthcare setting to include and leverage non-clinical and non-traditional specialists to provide appropriate care and positive breast health outcomes for women. In order to increase access and legitimacy to these services, additional research is needed to understand how to bring tattoo artists “in-house” (i.e., into the medical setting) and how to incorporate tattoo artists into breast health teams.

Citation Format: Napoles TM, Guerra C, Orenstein F, Luce JA, Merritt S, Burke NJ. Healing art: Breast cancer survivor experiences with nipple-areola tattoo procedures during breast reconstruction [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-19.

Low-intensity pulsed ultrasound for treatment of tibial fractures: an economic evaluation of the TRUST study

AIMS

This 501-patient, multi-centre, randomised controlled trial sought to establish the effect of low-intensity, pulsed, ultrasound (LIPUS) on tibial shaft fractures managed with intramedullary nailing. We conducted an economic evaluation as part of this trial.

PATIENTS AND METHODS

Data for patients' use of post-operative healthcare resources and time taken to return to work were collected and costed using publicly available sources. Health-related quality of life, assessed using the Health Utilities Index Mark-3 (HUI-3), was used to derive quality-adjusted life years (QALYs). Costs and QALYs were compared between LIPUS and control (a placebo device) from a payer and societal perspective using non-parametric bootstrapping. All costs are reported in 2015 Canadian dollars unless otherwise stated.

RESULTS

With a cost per device of $3,995, the mean cost was significantly higher for patients treated with LIPUS versus placebo from a payer (mean increase = $3647, 95% confidence interval (CI) $3244 to $4070; p < 0.001) or a societal perspective (mean increase = $3425, 95% CI $1568 to $5283; p < 0.001). LIPUS did not provide a significant benefit in terms of QALYs gained (mean difference = 0.023 QALYs, 95% CI -0.035 to 0.069; p = 0.474). Incremental cost-effectiveness ratios of LIPUS compared with placebo were $155 433/QALY from a payer perspective and $146 006/QALY from a societal perspective.

CONCLUSION

At the current price, LIPUS is not cost-effective for fresh tibial fractures managed with intramedullary nailing. Cite this article: Bone Joint J 2017;99-B:1526-32.

The current economic burden of illness of osteoporosis in Canada

We estimate the current burden of illness of osteoporosis in Canada is double ($4.6 billion) our previous estimates ($2.3 billion) due to improved data capture of the multiple encounters and services that accompany a fracture: emergency room, admissions to acute and step-down non-acute institutions, rehabilitation, home-assisted or long-term residency support.

INTRODUCTION

We previously estimated the economic burden of illness of osteoporosis-attributable fractures in Canada for the year 2008 to be $2.3 billion in the base case and as much as $3.9 billion. The aim of this study is to update the estimate of the economic burden of illness for osteoporosis-attributable fractures for Canada based on newly available home care and long-term care (LTC) data.

METHODS

Multiple national databases were used for the fiscal-year ending March 31, 2011 (FY 2010/2011) for acute institutional care, emergency visits, day surgery, secondary admissions for rehabilitation, and complex continuing care, as well as national dispensing data for osteoporosis medications. Gaps in national data were supplemented by provincial and community survey data. Osteoporosis-attributable fractures for Canadians age 50+ were identified by ICD-10-CA codes. Costs were expressed in 2014 dollars.

RESULTS

In FY 2010/2011, the number of osteoporosis-attributable fractures was 131,443 resulting in 64,884 acute care admissions and 983,074 acute hospital days. Acute care costs were $1.5 billion, an 18 % increase since 2008. The cost of LTC was 33.4 times the previous estimate ($31 million versus $1.03 billion) because of improved data capture. The cost for rehabilitation and secondary admissions increased 3.4 fold, while drug costs decreased 19 %. The overall cost of osteoporosis was over $4.6 billion, an increase of 83 % from the 2008 estimate.

CONCLUSION

Since the 2008 estimate, new Canadian data on home care and LTC are available which provided a better estimate of the burden of osteoporosis in Canada. This suggests that our previous estimates were seriously underestimated.

Hearts deficient in both Mfn1 and Mfn2 are protected against acute myocardial infarction

Mitochondria alter their shape by undergoing cycles of fusion and fission. Changes in mitochondrial morphology impact on the cellular response to stress, and their interactions with other organelles such as the sarcoplasmic reticulum (SR). Inhibiting mitochondrial fission can protect the heart against acute ischemia/reperfusion (I/R) injury. However, the role of the mitochondrial fusion proteins, Mfn1 and Mfn2, in the response of the adult heart to acute I/R injury is not clear, and is investigated in this study. To determine the effect of combined Mfn1/Mfn2 ablation on the susceptibility to acute myocardial I/R injury, cardiac-specific ablation of both Mfn1 and Mfn2 (DKO) was initiated in mice aged 4-6 weeks, leading to knockout of both these proteins in 8-10-week-old animals. This resulted in fragmented mitochondria (electron microscopy), decreased mitochondrial respiratory function (respirometry), and impaired myocardial contractile function (echocardiography). In DKO mice subjected to in vivo regional myocardial ischemia (30 min) followed by 24 h reperfusion, myocardial infarct size (IS, expressed as a % of the area-at-risk) was reduced by 46% compared with wild-type (WT) hearts. In addition, mitochondria from DKO animals had decreased MPTP opening susceptibility (assessed by Ca(2+)-induced mitochondrial swelling), compared with WT hearts. Mfn2 is a key mediator of mitochondrial/SR tethering, and accordingly, the loss of Mfn2 in DKO hearts reduced the number of interactions measured between these organelles (quantified by proximal ligation assay), attenuated mitochondrial calcium overload (Rhod2 confocal microscopy), and decreased reactive oxygen species production (DCF confocal microscopy) in response to acute I/R injury. No differences in isolated mitochondrial ROS emissions (Amplex Red) were detected in response to Ca(2+) and Antimycin A, further implicating disruption of mitochondria/SR tethering as the protective mechanism. In summary, despite apparent mitochondrial dysfunction, hearts deficient in both Mfn1 and Mfn2 are protected against acute myocardial infarction due to impaired mitochondria/SR tethering.

Abstract P2-13-11: Assessing the impact of post-surgery areola repigmentation and 3-dimensional nipple tattoo procedures on body image and quality of life among medically underserved breast cancer survivors

Background: The benefits of 3D nipple tattooing include restoration of a natural looking breast as well as the avoidance of additional surgeries to create a breast that more closely resembles its pre-surgical appearance. 3D nipple tattooing forms part of completion of the physical reconstruction process, offers women opportunity for a greater sense of closure around the loss of their breast, and plays an important role in helping a woman feel "whole again" physically, sexually and emotionally. The project's aim was to evaluate the experience of 3D-nipple/areola tattooing for medically underserved women who have undergone breast reconstruction and remain without a nipple or areola.

Methods: In-depth interviews were conducted with 20 women who had undergone 3D-nipple/areola tattooing. Interviews were conducted in English and Spanish, recorded, translated and transcribed into English for analysis. Two research team members coded all interview transcripts and the research team met monthly to discuss emergent themes.

Results: Interview narratives addressed the often unexpected impact 3D nipple-tattooing had on body image, self-esteem, emotional well-being, intimacy, and inter-personal relationships. Women described their decision-making processes as weighing concern about the needle, the pain, and the uncertainty of the outcome with the opportunity for returning to a more 'normal' appearance. Women also discussed the impact of the experience on their survivorship and sexuality in positive ways.

Conclusions: 3-D nipple and/or areola tattooing is an acceptable and meaningful reconstruction process for medically underserved public hospital patients. The decision to undergo 3-D nipple and /or areola tattooing can be complex and is impacted by a women's surgical history and outcomes. The emotional response and positive impacts of the tattooing on body image and self-esteem illustrate the value of the procedure in the context of women's lives.

Citation Format: Burke NJ, Orenstein F, Napoles T, Chaumette S, Luce J. Assessing the impact of post-surgery areola repigmentation and 3-dimensional nipple tattoo procedures on body image and quality of life among medically underserved breast cancer survivors. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-13-11.

Does fine sediment source as well as quantity affect salmonid embryo mortality and development?

Fine sediments are known to be an important cause of increased mortality in benthic spawning fish. To date, most of the research has focussed on the relationship between embryo mortality and the quantity of fine sediment accumulated in the egg pocket. However, recent evidence suggests a) that the source of fine sediment might also be important, and b) that fitness of surviving embryos post-hatch might also be impacted by the accumulation of fine sediments. In this paper, we report an experiment designed to simulate the incubation environment of brown trout (Salmo trutta) and Atlantic salmon (Salmo salar). During the experiment, the incubating embryos were exposed to different quantities of fine (<63 μm) sediment derived from four different sources; agricultural topsoils, damaged road verges, eroding river channel banks and tertiary level treated sewage. Results showed that mass and source are independently important for determining the mortality and fitness of alevin. Differences between species were observed, such that brown trout are less sensitive to mass and source of accumulated sediment. We demonstrate for the first time that sediment source is an additional control on the impact of fine sediment, and that this is primarily controlled by the organic matter content and oxygen consumption of the catchment source material.

Mitochondrial fusion and fission proteins: novel therapeutic targets for combating cardiovascular disease

Mitochondria are no longer considered to be solely the static powerhouses of the cell. While they are undoubtedly essential to sustaining life and meeting the energy requirements of the cell through oxidative phosphorylation, they are now regarded as highly dynamic organelles with multiple functions, playing key roles in cell survival and death. In this review, we discuss the emerging role of mitochondrial fusion and fission proteins, as novel therapeutic targets for treating a wide range of cardiovascular diseases.

Platelet reactivity changes significantly throughout all trimesters of pregnancy compared with the nonpregnant state: a prospective study

OBJECTIVE

Platelets play an important role in the pathophysiology of uteroplacental disease and platelet reactivity may be an important marker of uteroplacental disease activity. However, platelet reactivity has not been evaluated comprehensively in normal pregnancy. We sought to evaluate platelet reactivity using a number of agonists at defined time points in pregnancy using a novel platelet assay and compare these with a nonpregnant cohort.

DESIGN

Prospective longitudinal study.

SETTING

Outpatient department of a large tertiary referral centre.

SAMPLE

Eighty participants with 30 nonpregnant women and 50 pregnant women assessed longitudinally.

METHODS

This was a prospective cohort study performed longitudinally throughout uncomplicated singleton pregnancies with participants recruited before 15 weeks of gestation. They were controlled for a number of factors known to affect platelet reactivity. Blood samples were obtained in each trimester. Thirty nonpregnant healthy female volunteers also had a platelet assay performed. A modification of standard light transmission aggregometry was used to assess platelet function, with light absorbance measured following the addition of five different agonists at submaximal concentrations. Dose-response curves were plotted for each agonist for the nonpregnant cohort and in each trimester for the pregnant cohort.

MAIN OUTCOME MEASURES

Dose-response curves and median effective concentration.

RESULTS

When compared with the nonpregnant controls a significant reduction was demonstrated in platelet reactivity to collagen during the first trimester of pregnancy (P < 0.0001). Platelet aggregation increased significantly from the first to third trimesters in response to collagen and arachidonic acid.

CONCLUSION

Platelet reactivity varies according to pregnancy state, gestational age and agonist. The finding that platelet reactivity is reduced in the first trimester of pregnancy may be useful for the interpretation of further studies examining the role of platelet reactivity in the first trimester of pregnancies that develop uteroplacental disease.

The economic burden of schizophrenia in Canada in 2004

OBJECTIVE

To estimate the financial burden of schizophrenia in Canada in 2004.

METHODS

A prevalence-based cost-of-illness (COI) approach was used. The primary sources of information for the study included a review of the published literature, a review of published reports and documents, secondary analysis of administrative datasets, and information collected directly from various federal and provincial government programs and services. The literature review included publications up to April 2005 reported in MedLine, EMBASE and PsychINFO. Where specific information from a province was not available, the method of mean substitution from other provinces was used. Costs incurred by various levels/departments of government were separated into healthcare and non-healthcare costs. Also included in the analysis was the value of lost productivity for premature mortality and morbidity associated with schizophrenia. Sensitivity analysis was used to test major cost assumptions used in the analysis. Where possible, all resource utilization estimates for the financial burden of schizophrenia were obtained for 2004 and are expressed in 2004 Canadian dollars (CAN dollars).

RESULTS

The estimated number of persons with schizophrenia in Canada in 2004 was 234 305 (95% CI, 136 201-333 402). The direct healthcare and non-healthcare costs were estimated to be 2.02 billion CAN dollars in 2004. There were 374 deaths attributed to schizophrenia. This combined with the high unemployment rate due to schizophrenia resulted in an additional productivity morbidity and mortality loss estimate of 4.83 billion CAN dollars, for a total cost estimate in 2004 of 6.85 billion CAN dollars. By far the largest component of the total cost estimate was for productivity losses associated with morbidity in schizophrenia (70% of total costs) and the results showed that total cost estimates were most sensitive to alternative assumptions regarding the additional unemployment due to schizophrenia in Canada.

CONCLUSIONS

Despite significant improvements in the past decade in pharmacotherapy, programs and services available for patients with schizophrenia, the economic burden of schizophrenia in Canada remains high. The most significant factor affecting the cost of schizophrenia in Canada is lost productivity due to morbidity. Programs targeted at improving patient symptoms and functioning to increase workforce participation has the potential to make a significant contribution in reducing the cost of this severe mental illness in Canada.

Comparison of outcomes of untreated carpal tunnel syndrome and asymptomatic controls in meat packers

Our objectives were to determine the reporting of symptoms, the medical outcome and the work status of meat plant workers diagnosed with clinical carpal tunnel syndrome (CTS). Forty-seven cases of CTS were identified from a previously reported study, and were matched by age, gender and hand use. Cases and controls were followed up for 24 months. The Provincial Workers' Compensation Board and company health records were used to determine the reporting of symptoms, interventions and work status. Thirty-one study cases and all control cases were followed for the full 24 months (16 study cases were lost to follow-up). In total, 12 cases reported symptoms of CTS during the 24 months (eight study cases and four controls). Of the eight study cases, one required surgical release of the carpal tunnel. After a period of work modification, five of the eight study cases returned to regular duty and the remainder were placed on permanent job restrictions. Of the four controls, one subject had a surgical release and returned to regular work, two subjects' jobs were permanently modified, and the fourth returned to regular duty. Occupation-related CTS in meat packers appears to be transient and responsive to conservative measures, with a surgical rate comparable to other occupations.

Persistent activation of ERK contributes to glutamate-induced oxidative toxicity in a neuronal cell line and primary cortical neuron cultures

Oxidative stress can trigger neuronal cell death and has been implicated in several chronic neurological diseases and in acute neurological injury. Oxidative toxicity can be induced by glutamate treatment in cells that lack ionotrophic glutamate receptors, such as the immortalized HT22 hippocampal cell line and immature primary cortical neurons. Previously, we found that neuroprotective effects of geldanamycin, a benzoquinone ansamycin, in HT22 cells were associated with a down-regulation of c-Raf-1, an upstream activator of the extracellular signal-regulated protein kinases (ERKs). ERK activation, although often attributed strictly to neuronal cell survival and proliferation, can also be associated with neuronal cell death that occurs in response to specific insults. In this report we show that delayed and persistent activation of ERKs is associated with glutamate-induced oxidative toxicity in HT22 cells and immature primary cortical neuron cultures. Furthermore, we find that U0126, a specific inhibitor of the ERK-activating kinase, MEK-1/2, protects both HT22 cells and immature primary cortical neuron cultures from glutamate toxicity. Glutamate-induced ERK activation requires the production of specific arachidonic acid metabolites and appears to be downstream of a burst of reactive oxygen species (ROS) accumulation characteristic of oxidative stress in HT22 cells. However, inhibition of ERK activation reduces glutamate-induced intracellular Ca(2+) accumulation. We hypothesize that the precise kinetics and duration of ERK activation may determine whether downstream targets are mobilized to enhance neuronal cell survival or ensure cellular demise.

Alternative methods for newborn urine sample collection

PURPOSE

To investigate the accuracy of laboratory results of urine samples collected from cotton balls as compared with paired samples collected from catheterization, Preemie Pampers, and Newborn Pampers.

METHOD

Urine samples were collected from 30 infants by aspirating urine from a cotton ball placed over the meatus. An additional urine sample was obtained from the same infants by aspiration from the diaper. The samples were tested by labstik analysis and results were compared by t-test. An additional sample of 20 infants had urine collected by cotton ball and catheterization for detection of Group B strep antigen and the results were correlated.

FINDINGS

Samples obtained from cotton balls and Preemie Pampers yielded equivalent results. Significant differences were found in the pH and specific gravity of Newborn Pampers and Preemie Pampers. No redness nor skin breakdown was observed with the cotton ball application. Three positive Group B strep results were detected by both methods of urine collection. The remainder of the samples were negative by both methods.

CONCLUSIONS

Urine samples collected by the cotton ball method were accurate for pH and specific gravity and were atraumatic to the skin of newborns. The sample size of positive Group B strep antigen was small (n = 3) and results should be replicated with further research.

Surgical correction of the Wolff-Parkinson-White syndrome

The results of corrective surgery in 75 consecutive patients with Wolff-Parkinson-White (WPW) syndrome are reported. There were 47 male and 28 female patients with a median age of 27 years. Intraoperative mapping disclosed 88 accessory pathways, of which 83 were successfully divided at the primary operation without mortality. Two patients underwent successful reoperation at three days and two years respectively. Patient success rates were 93% and 96% for first and total operations. Complications, usually minor, occurred in 20 patients, including permanent pacemaker implantation in two. Surgical correction of WPW syndrome is recommended as a safe alternative to lifelong medical treatment.

Operations for Wolff-Parkinson-White syndrome

Forty-six patients with symptomatic tachycardia underwent operations to divide 55 atrioventricular accessory pathways. Mean age was 29 years (range 11 to 63). Ten patients (22%) had associated cardiac disease, including two with a congenital diverticulum of the coronary sinus and six (13%) who had concomitant surgical procedures. A bipolar hand-held electrode was used in 22 operations, and simultaneous multisite mapping in the last 24 operations. Ten patients (22%) had multiple accessory pathways. A modified endocardial approach was used. The overall patient success rate was 93% with 91% to 93% of accessory pathways successfully divided. The perioperative morbidity was 17%. There were two reoperations. There were no early or late deaths. Patients have been followed up for a mean of 16 months. There were five recurrences of preexcitation (two early, three late). Two of these patients (both with a congenital diverticulum of the coronary sinus) had reoperation. One patient had late recurrence of atrial fibrillation. Operation for the Wolff-Parkinson-White syndrome has a high probability of success with a low operative risk.

Design of a measurement system for electrophysiological cardiac surgery

The treatment of cardiac arrhythmias by surgical removal of abnormal electrical pathways across the atrio-ventricular ring or re-entrant circuits within the myocardium is dependent on the ability to accurately locate the abnormality by measuring and displaying the activation front of muscle depolarisation as it spreads across the surface of the heart. The localisation of the aberration requires induction of the arrhythmia, simultaneous measurement of activity from many (100-200) sites over the surface of the heart, attachment of fiducial markers to this data, and display of the activation sequence in the form of an isochronous map. An instrument has been built at Green Lane Hospital to provide the necessary measurement, control, and analysis facilities required by this procedure. The purpose built measurement system is a multiprocessor unit which incorporates up to 512 programmable intracardiac amplifiers, two multifunction cardiac pacing stimulators, a versatile real time data display, a patient safety isolation system, and digital storage for eight seconds of electrocardiographic data. Signals are acquired from a mesh of bipolar electrodes attached to either a 'sock' or a 'band' which is placed on the heart during open heart surgery. The analysis of data is carried out on a personal computer, connected to the measurement system via a serial command link and a high speed parallel data link. Corrective surgery is now being carried out on a routine basis for some types of arrhythmias.

Cotinine validation of self-reported smoking in commercially run community surveys

A validation study was carried out on self-reported smoking for 1177 people in Sydney and Melbourne in 1983. Because of its long half life and the fact that smoking is its only source in body fluids, saliva cotinine was chosen as the validation measure. Cotinine levels above 250 nmol/l were used to classify people as smokers. The sensitivity of self-reported smoking was 92.6% and the specificity was 93.4%. There was some evidence that people in the process of changing their smoking status might be slow in updating their self-classification. The smoking prevalence estimate based on cotinine levels was found to be 1.7% lower than that for self-reported smoking status. The small proportion of false negatives and false positives suggests that commercially collected data banks can be valid sources of prevalence data. Correlation between cotinine level and reported cigarette consumption was not affected by sample volume, and was similar to that achieved for carbon monoxide and thiocyanate at a low 0.34. Regression analysis using self-reported cigarette consumption filter/non-filter cigarettes, and time since last cigarette as predictors, explained 13.6% of the variance in cotinine level.

Evaluation of the Sydney "Quit. For Life" anti-smoking campaign. Part 2. Changes in smoking prevalence

Between June and November 1983, the "Quit. For Life" media campaign was conducted in Sydney to reduce the prevalence of smoking. Surveys on a cross-sectional sample of the Sydney population were conducted before and after the campaign, and similar measures were undertaken in the rest of Australia for comparison. The sample sizes for both the Sydney and control areas comprised more than 4000 subjects. In addition, a cohort of 949 residents of Sydney and Melbourne were followed for changes in the prevalence of smoking during the year of the campaign. The cross-sectional survey results for 1984 and 1983 demonstrated decreases in the prevalence of smoking of approximately 1% for both men and women in Sydney compared with the rest of Australia. In the cohort study there was a 3.4% decrease in smoking prevalence in Sydney compared with a 0.8% increase in Melbourne. The pooled estimate of the difference in smoking prevalence attributable to the campaign was 2.8% (95% confidence interval, 0.5%-5.1%).

Evaluation of the Sydney "Quit. For Life" anti-smoking campaign. Part 1. Achievement of intermediate goals

The "Quit. For Life" campaign was a media-based programme that was aimed at reducing the prevalence of smoking in Sydney. The programme committee set four intermediate goals which it felt had to be met for such a change in prevalence to occur. From households selected at random in Sydney and Melbourne, 5713 people were interviewed to assess whether the campaign attained these goals. The television commercials that were designed for the campaign, their frequency and the timing of their screening produced a higher recall of the commercial's message and the use of campaign back-up services than were specified originally in the goals. During the campaign there was a progressive increase in the number of smokers in Sydney who reported that they were likely to quit; this was significantly different from Melbourne data by the end of the campaign and thus fulfilled another campaign goal. However, shortly after the campaign ended, the proportion of smokers who intended to quit smoking was the same in the two cities. A cohort study of 949 people from the baseline study showed that, during the 12-month period of follow-up, 66% of Sydney smokers tried to stop or to reduce their smoking. In the control city, Melbourne, 60% of smokers reported making such attempts. Of the original smokers, 23% in Sydney and 9% in Melbourne quit during the follow-up period--a statistically significant difference. As well, 10% of the original ex-smokers in Sydney and 11% in Melbourne relapsed, while 4% of nonsmokers in both cities began smoking by the end of the second survey.