Lakeshore General Hospital

Recently, "Technical standards for respiratory oscillometry" was published, which reviewed the physiological basis of oscillometric measures and detailed the technical factors related to equipment and test performance, quality assurance and reporting of results. Here we present a review of the clinical significance and applications of oscillometry. We briefly review the physiological principles of oscillometry and the basics of oscillometry interpretation, and then describe what is currently known about oscillometry in its role as a sensitive measure of airway resistance, bronchodilator responsiveness and bronchial challenge testing, and response to medical therapy, particularly in asthma and COPD. The technique may have unique advantages in situations where spirometry and other lung function tests are not suitable, such as in infants, neuromuscular disease, sleep apnoea and critical care. Other potential applications include detection of bronchiolitis obliterans, vocal cord dysfunction and the effects of environmental exposures. However, despite great promise as a useful clinical tool, we identify a number of areas in which more evidence of clinical utility is needed before oscillometry becomes routinely used for diagnosing or monitoring respiratory disease.

The availability, accessibility and acceptability of services are critical factors in rural health service delivery. In Canada, the aging population and the consequent increase in prevalence of dementia challenge the ability of many rural communities to provide specialized dementia care. This paper describes the development, operation and evaluation of an interdisciplinary memory clinic designed to improve access to diagnosis and management of early stage dementia for older persons living in rural and remote areas in the Canadian province of Saskatchewan. We describe the clinic structure, processes and clinical assessment, as well as the evaluation research design and instruments. Finally, we report the demographic characteristics and geographic distribution of individuals referred during the first three years.

The role of report (recall) bias in case-control studies of possible reproductive hazards was investigated in a study of women who gave birth at the Royal Victoria Hospital, Montreal from September 1983 to May 1985. Women were questioned twice (early in pregnancy; after delivery) about exposures that might influence pregnancy outcome. The two sets of responses of case mothers, control mothers, and mothers of infants of intermediate health status were then compared. Similar inconsistencies in the reporting of 39 exposure variables were common in all three groups, with postdelivery deletion of previous reports more frequent than addition of new information. Changes in reporting were not associated with pregnancy outcome, maternal concern about the baby or maternal sociodemographic characteristics. Odds ratios of exposure estimated from the two sets of data did not differ importantly. Moreover, there was no postdelivery trend to increases, or decreases, in the estimates of the odds ratios. The data do not provide evidence of biased reporting of exposures.

Many migratory animals are experiencing rapid population declines, but migration data with the geographic scope and resolution to quantify the complex network of movements between breeding and nonbreeding regions are often lacking. Determining the most frequently used migration routes and nonbreeding regions for a species is critical for understanding population dynamics and making effective conservation decisions. We tracked the migration of individual Wood Thrushes (Hylocichla mustelina) (n = 102) from across their range with light-level geolocators and, for the first time, quantified migration routes and wintering regions for distinct breeding populations. We identified regional and species-level migratory connectivity networks for this declining songbird by combining our tracking results with range-wide breeding abundance estimates and forest cover data. More than 50% of the species occupied the eastern wintering range (Honduras to Costa Rica), a region that includes only one-third of all wintering habitat and that is undergoing intensive deforestation. We estimated that half of all Wood Thrushes in North America migrate south through Florida in fall, whereas in spring approximately 73% funnel northward through a narrow span along the central U.S. Gulf Coast (88-93°W). Identifying migratory networks is a critical step for conservation of songbirds and we demonstrated with Wood Thrushes how it can highlight conservation hotspots for regional populations and species as a whole.

BACKGROUND: Review of the literature reveals a need to develop a questionnaire that measures patient perceptions of factors impacting continuity of care following discharge from hospital. Such a measure has the potential to guide quality improvement initiatives related to continuity of care. OBJECTIVE: Our objective was to develop and examine the psychometric properties of a measure that would meet this need, the Patient Continuity of Care Questionnaire (PCCQ). METHOD: The PCCQ was administered to 204 inpatients 4 weeks after discharge. The questionnaire was assessed by item and principal components analysis. Factors derived from principal components analysis were assessed for internal consistency and construct validity. RESULTS: A principal components analysis resulted in six subscales including perceptions of: (1) relationships with providers in hospital, (2) information transfer to patients, (3) relationships with providers in community, (4) management of written forms, (5) management of follow-up and (6) management of communication among providers. These subscales were internally consistent in our sample and demonstrated construct validity through correlations with other related constructs. CONCLUSION: This initial study supports the reliability and validity of the PCCQ for measuring patient perceptions of factors central to continuity of care. The questionnaire subscales correspond to the theoretical components of continuity of care that have been proposed in the literature, namely informational, relational and management continuity. The subscales may be of value for identifying problems in continuity of care and for evaluating interventions aimed at improving continuity of care for patients after hospital discharge.

Abstract The stratigraphic succession in eastern Central Otago consists of Eocene quartzose fluvial sediments and middle Tertiary marine strata (Onekakara Group), early‐middle Miocene quartzose fluvial sediments and lake deposits (Manuherikia Group), late Miocene‐Pliocene immature sandstones and conglomerates, and Quaternary terrace and fan gravels. Published literature contains at least 20 different approaches for subdivision of this succession. The late Miocene‐Pliocene conglomerates were formed during the rise of fault‐bounded greywacke and semischist mountain ranges. Conspicuous conglomerates in the upper part of this succession are widely referred to as Maori Bottom Formation, but that name was originally applied by miners to a locally auriferous erosion surface beneath Quaternary terrace and fan gravels in Otago. In addition, the term is culturally offensive. We propose the name Hawkdun Group for the late Miocene‐Pliocene succession of tectonically generated sediments in the Maniototo, Ida, and Manuherikia Basins, and propose the name Maniototo Conglomerate to replace Maori Bottom. The Hawkdun Group in Central Otago can be subdivided into two mappable units. The basal Wedderburn Formation consists predominantly of late Miocene quartzose fluvial strata recycled largely from cover strata of the St Bathans, Kakanui, and Hawkdun Ranges. Wedderburn Formation contains an upwardly increasing component of first‐cycle lithic detritus derived from these ranges, and grades up into late Miocene‐Pliocene Maniototo Conglomerate, consisting of thick beds of greywacke‐dominated conglomerate and interbedded loess horizons. In previous usage, Wedderburn Formation included some strata which more appropriately belong with the underlying Manuherikia Group. Quartzose fluvial strata and intervening marine and lacustrine strata have been aggregated by previous workers for regional mapping purposes. Correlation problems leading to aggregation have arisen largely from stacking of up to three lithologically similar quartzose conglomerate and quartzose sandstone units, but also from the difficulty in differentiating between these units where distinctive, intervening marine or lacustrine strata are absent, and where unconformities are not exposed. The redefined units as proposed above are individually mappable and eliminate the necessity for mapping of grouped units. Usage of Stranraer Group, Maori Bottom Group, Maori Bottom Formation, and Blue Gravel Member (of the latter) is discontinued. Contemporaneous, lithologic and stratigraphic correlatives of the Hawkdun Group were deposited in the Nevis, lower Manuherikia, Cromwell, and upper Clutha Basins in Central Otago, and in many other basins on both sides of the plate boundary throughout the South Island.

Thirty S s were allowed to inspect a set of slides varying in content for an unlimited time. Looking time was found to be dependent upon stimulus variables: content of the slides, position in the series, level of complexity, and affect level of the figures. Tests of personality traits and factors failed to account for individual differences in inspection time.

Abstract Environmental toxicologists rarely investigate multigeneration effects of aquatic contaminants. In this study we investigated the survivorship of fathead minnow larvae two generations removed from an exposure to the potent mutagen benzo[a]pyrene. The F2 broods with a grandparental exposure history showed a marked decrease in survival. In the highest-exposure group, reproductive capacity and larval survivorship were significantly lower than the solvent control.

The efficacy and tolerability of reboxetine, a unique selective noradrenaline reuptake inhibitor, were compared with those of placebo in a 6-week, randomized, double-blind study of hospitalized patients with a DSM-III-R diagnosis of major depressive disorder. Fifty-two patients (25 in the placebo group, 27 in the reboxetine group) were included in the efficacy analysis. Sixteen (64%) of those in the placebo group and four (15%) in the reboxetine group were withdrawn during the study because of lack of efficacy. Improvement in the mean Hamilton Rating Scale for Depression (HAM-D) total score at last assessment was significantly greater in the reboxetine group than in the placebo group (p < 0.001). Similarly, the response rate to treatment, defined as > or =50% reduction in HAM-D total score, was 74% for patients who received reboxetine compared with 20% for those who received placebo (p < 0.001). A significantly greater response with reboxetine than with placebo was seen as early as day 10 of treatment (p = 0.006). The therapeutic efficacy of reboxetine was substantiated by improvement in mean scores on the Zung Self-Rating Scale and on the Clinical Global Impression Severity of Illness and Global Improvement scales. Reboxetine was well tolerated, and only one patient in each group withdrew because of adverse events. Dry mouth, insomnia, blurred vision, sweating, and constipation were recorded more frequently in the reboxetine group than in the placebo group. There was a tendency toward orthostatic changes in the systolic blood pressure, but this was not clinically significant. This study demonstrated that reboxetine is significantly more effective than placebo in the treatment of hospitalized patients with severe major depressive disorder and is well tolerated.

BACKGROUND: Various lines of research point to the overrepresentation of individuals with intellectual disability (ID) in the criminal justice system. Studies have also shown that individuals with ID are vulnerable to mental health problems. To date there have been no Canadian studies of individuals with an ID in the criminal justice system. METHOD: The present study reports on the sociodemographic, mental health and criminological characteristics of 281 individuals with an ID from a Canadian study of men in a pre-trial holding centre. RESULTS: Almost 19% of the men had a probable ID, and nearly one-third (29.9%) were in the borderline IQ range. As was the case for their non-ID counterparts, the mean age of the probable ID group was in the early 30s, few were employed, and most had low incomes. Individuals in the probable and borderline ID groups had lower rates of high school completion than those in the average intellectual ability range. Over 60% of individuals with an ID had a substance use disorder, and 1 in 5 was intoxicated at the time of assessment. These rates were similar across groups, and to those found in the literature. A large majority of individuals with ID had a previous conviction, and most had previously committed a violent offence. CONCLUSIONS: Among other limitations, the sample may not have been entirely representative of the total population of men in the pre-trial detention centre, given the relatively high refusal rate (39.5%). Results are discussed in terms of orienting criminological and mental health services as a function of the level of intellectual and adaptive functioning of individuals with ID.

From our experience with 45 children with urinary tract infection and constipation, the improvement or cure of 80% by correcting abnormal bowel habits suggests that constipation may be an etiological factor in urinary tract infections. While successful regulation of bowel habits was accompanied by termination of the infection, failure to correct constipation was associated with recurrence.

BACKGROUND: Opioids and benzodiazepines are frequently used in the intensive care unit (ICU). Regular use and prolonged exposure to opioids in ICU patients followed by abrupt tapering or cessation may lead to iatrogenic withdrawal syndrome (IWS). IWS is well described in pediatrics, but no prospective study has evaluated this syndrome in adult ICU patients. The objective of this study was to determine the incidence of IWS caused by opioids in a critically ill adult population. This multicenter prospective cohort study was conducted at two level-1 trauma ICUs between February 2015 and September 2015 and included 54 critically ill patients. Participants were eligible if they were 18 years and older, mechanically ventilated and had received more than 72 h of regular intermittent or continuous intravenous infusion of opioids. For each enrolled patient and per each opioid weaning episode, presence of IWS was assessed by a qualified ICU physician or senior resident according to the 5th edition of Diagnostic and Statistical Manual of Mental Disorders criteria for opioid withdrawal. RESULTS: The population consisted mostly of males (74.1%) with a median age of 50 years (25th-75th percentile 38.2-64.5). The median ICU admission APACHE II score was 22 (25th-75th percentile 12.0-28.2). The overall incidence of IWS was 16.7% (95% CI 6-27). The median cumulative opioid dose prior to weaning was higher in patients with IWS (245.7 vs. 169.4 mcg/kg, fentanyl equivalent). Patients with IWS were also exposed to opioids for a longer period of time as compared to patients without IWS (median 151 vs. 125 h). However, these results were not statistically significant. CONCLUSIONS: IWS was occasionally observed in this very specific population of mechanically ventilated, critically ill ICU patients. Further studies are needed to confirm these preliminary results and identify risk factors.

The incest taboo is a moral imperative; its force reflects a cross-cultural preoccupation with the incest theme. The importance of this subject in psychiatric theory and practice justifies a concerted effort to synthesize the available data into a coherent overview, drawing on the findings of a variety of relevant disciplines. Epidemiologists have shown that almost all civilizations recognize incest, but that it is universally uncommon. The influence of sociocultural and socioeconomic variables upon the occurrence of incest is disputed, partly because of the contamination of data due to unfortunate study designs. A glance at the classical literature shows that incest is an ever-recurring theme of mythologies of many civilizations. Anthropologists have pointed out cross-cultural variations in the nature of the incest taboo but have generally substantiated its universal presence in some form. The incest theme is an appealing area for theorists. The incest taboo is multi-determined. Freud spoke of the need to prevent the destruction of society by a band of brothers who would murder the tyrannical father, then mutilate the social order through a chain of ‘fraternal’ wars. However a variety of biological, psychological and social theories have been carefully and thoughtfully articulated to explain the incest taboo and man's pervasive preoccupation with this theme. The occurrence of overt incest is usually in the setting of a dysfunctional family and is accompanied by drastic role shifts so far-reaching as to constitute a virtual re-programming of the familial unit. Sociocultural, socioeconomic and purely psychiatric factors may play a further part in the breakdown of the incest barrier in these situations. The psychodynamics of incest can best be conceptualized within the framework of a three-generational schema, with desertion anxiety being a recurrent theme. For example, in father-daughter incest the mother deals with desertion anxiety stemming from the maternal grandmother by casting an older daughter in the role of homemaker and sexual partner to her husband. Overt incest is but the top of the proverbial ‘ice-berg’. Incestuous behaviour appears deeply rooted in the pre-œdipal period. Incestuous fathers have usually been rejected recently by their usual sexual partners, and they deal with the guilt arising from incestuous behaviour with flagrant and sometimes naive rationalizations. Their backgrounds are usually marginal. The wives of incestuous men collude with the incestuous liaison by rejecting their husbands sexually and by subtly encouraging their daughters to become the ‘woman of the home’. Incestuous daughters are generally felt to encourage their fathers' sexual advances or at least to refrain from resisting them. Incestuous behaviour in daughters is at least in part a function of hostile impulses toward the mother and a penis envy hypertrophied by the wish for revenge against the pre-œdipal mother. In father-daughter incest, youth in the daughter and a relative absence of anxiety and guilt in the incestuous father or colluding mother are factors leading to a favourable prognosis, and the converse is also true. Prevention of overt incest rests on measures to enhance the definitions of the social role and generational boundaries within the family and upon devices which serve to buttress the incest taboo. Insight psychotherapy may play a part in the treatment of discovered cases and family therapy with the aim of promoting a healthier role allocation in the dysfunctional family has proven helpful.

175 years have elapsed since John Hutchinson introduced the world to his version of an apparatus that had been in development for nearly two centuries, the spirometer. Though he was not the first to build a device that sought to measure breathing and quantify the impact of disease and occupation on lung function, Hutchison coined the terms spirometer and vital capacity that are still in use today, securing his place in medical history. As Hutchinson envisioned, spirometry would become crucial to our growing knowledge of respiratory pathophysiology, from Tiffeneau and Pinelli's work on forced expiratory volumes, to Fry and Hyatt's description of the flow–volume curve. In the 20th century, standardization of spirometry further broadened its reach and prognostic potential. Today, spirometry is recognized as essential to respiratory disease diagnosis, management and research. However, controversy exists in some of its applications, uptake in primary care remains sub-optimal and there are concerns related to the way in which race is factored into interpretation. Moving forward, these failings must be addressed, and innovations like Internet-enabled portable spirometers may present novel opportunities. We must also consider the physiologic and practical limitations inherent to spirometry and further investigate complementary technologies such as respiratory oscillometry and other emerging technologies that assess lung function. Through an exploration of the storied history of spirometry, we can better contextualize its current landscape and appreciate the trends that have repeatedly arisen over time. This may help to improve our current use of spirometry and may allow us to anticipate the obstacles confronting emerging pulmonary function technologies.

OBJECTIVE: To investigate the efficacy, safety, and clinical benefit of a once-daily formulation of trazodone (Trazodone Contramid((c)) OAD) in the treatment of major depressive disorder. DESIGN/PARTICIPANTS: In this double-blind study, 412 patients with major depressive disorder (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria) were randomized 1:1 to receive either Trazodone Contramid OAD (150 to 375mg) or placebo. Treatment was titrated over two weeks to each individual optimal dose. Patients then continued six weeks of treatment; further dose adjustments were allowed based on efficacy and tolerability. MEASUREMENTS: The primary end point was change in the 17-item Hamilton Depression Rating Scale total score from baseline to last study visit. Secondary end points included Hamilton Depression Rating Scale responders/remitters, change in Montgomery-Asberg Depression Rating Scale, Clinician and Patient Global Improvement Scales, and quality of sleep. RESULTS: From the end of titration to the end of the six-week treatment period, the mean maximum daily dose of the intent-to-treat population was 310mg for the active group and 355mg for the placebo group. There was a statistically significant difference between trazodone and placebo on the mean HAMD-17 score (-11.4 vs. -9.3, P=0.012). A significant difference was present as early as Week 1 and was maintained at all subsequent study visits. Many secondary end points supported these findings, including improvements in quality of sleep. The most frequent adverse events were the same for both the treatment and placebo groups: headache and somnolence. There were no serious adverse events that were considered related to treatment. There were no clinically significant electrocardiogram or laboratory abnormalities. CONCLUSIONS: The trazodone Contramid formulation was more effective than placebo in major depressive disorder and was well tolerated.

The Cretaceous Mont Saint-Hilaire complex (Quebec, Canada) comprises three major rock units that were emplaced in the following sequence: (I) gabbros; (II) diorites; (III) diverse partly agpaitic foid syenites. The major element compositions of the rock-forming minerals, age-corrected Nd and oxygen isotope data for mineral separates and trace element data of Fe-Mg silicates from the various lithologies imply a common source for all units. The distribution of the rare earth elements in clinopyroxene from the gabbros indicates an ocean island basalt type composition for the parental magma. Gabbros record temperatures of 1200 to 800°C, variable silica activities between 0·7 and 0·3, and fO2 values between −0·5 and +0·7 (log ΔFMQ, where FMQ is fayalite-magnetite-quartz). The diorites crystallized under uniform aSiO2 (aSiO2 = 0·4-0·5) and more reduced fO2 conditions (log ΔFMQ ~ −1) between ~1100 and ~800°C. Phase equilibria in various foid syenites indicate that silica activities decrease from 0·6-0·3 at ~1000°C to &lt;0·3 at ~550°C. Release of an aqueous fluid during the transition to the hydrothermal stage caused aSiO2 to drop to very low values, which results from reduced SiO2 solubilities in aqueous fluids compared with silicate melts. During the hydrothermal stage, high water activities stabilized zeolite-group minerals. Fluid inclusions record a complex post-magmatic history, which includes trapping of an aqueous fluid that unmixed from the restitic foid syenitic magma. Cogenetic aqueous and carbonic fluid inclusions reflect heterogeneous trapping of coexisting immiscible external fluids in the latest evolutionary stage. The O and C isotope characteristics of fluid-inclusion hosted CO2 and late-stage carbonates imply that the surrounding limestones were the source of the external fluids. The mineral-rich syenitic rocks at Mont Saint-Hilaire evolved as follows: first, alkalis, high field strength and large ion lithophile elements were pre-enriched in the (late) magmatic and subsequent hydrothermal stages; second, percolation of external fluids in equilibrium with the carbonate host-rocks and mixing processes with internal fluids as well as fluid-rock interaction governed dissolution of pre-existing minerals, element transport and precipitation of mineral assemblages determined by locally variable parameters. It is this hydrothermal interplay between internal and external fluids that is responsible for the mineral wealth found at Mont Saint-Hilaire

Fluvoxamine and imipramine were compared to placebo in an 8-week doubleblind randomized multicentre trial comprising of 148 outpatients between 19 and 57 years of age (mean: 35) with a DSM-III-R diagnosis of Panic Disorder. mean daily dose at endpoint was: fluvoxamine, 171.4 mg; imipramine 164.7 mg. The mean number of panic attacks per week at baseline were 10.9, 14.4 and 6.5 for fluvoxamine, imipramine and placebo, respectively. The intent-to-treat analysis of the change from baseline (difference score) of the number of panic attacks at endpoint revealed: a difference of 3.3 attacks (95% CI: -0.3, 6.8) between fluvoxamine and placebo and a difference of 6.0 attacks (95% CI: 1.5, 10.5) between imipramine and placebo. Treatment was stopped prematurely in 31 (62%) on fluvoxamine, 16 (33%) on imipramine and 29 (58%) on placebo. The number of patients withdrawing due to intolerance was 13 (26%) for fluvoxamine, 10 (21%) for imipramine and 4 (8%) for placebo. The number of patients withdrawing due to lack of efficacy was 10 (20%) for fluvoxamine, 4 (8%) for imipramine and 12 (24%) for placebo. Overall, this study demonstrated that fluvoxamine was not effective in the treatment of panic disorder but did show a strong effect for imipramine. A chance occurrence of significantly fewer number of panic attacks in the placebo group at baseline may limit the conclusions of this study.

Purpose: The purpose of this article is to update the previously published consensus recommendations from March 2017 discussing the optimal management of adult patients with autosomal dominant polycystic kidney disease (ADPKD). This document focuses on recent developments in genetic testing, renal imaging, assessment of risk regarding disease progression, and pharmacological treatment options for ADPKD. Sources of information: Published literature was searched in PubMed, the Cochrane Library, and Google Scholar to identify the latest evidence related to the treatment and management of ADPKD. Methods: All pertinent articles were reviewed by the authors to determine if a new recommendation was required, or if the previous recommendation needed updating. The consensus recommendations were developed by the authors based on discussion and review of the evidence. Key findings: The genetics of ADPKD are becoming more complex with the identification of new and rarer genetic variants such as GANAB. Magnetic resonance imaging (MRI) and computed tomography (CT) continue to be the main imaging modalities used to evaluate ADPKD. Total kidney volume (TKV) continues to be the most validated and most used measure to assess disease progression. Since the publication of the previous consensus recommendations, the use of the Mayo Clinic Classification for prognostication purposes has been validated in patients with class 1 ADPKD. Recent evidence supports the benefits of a low-osmolar diet and dietary sodium restriction in patients with ADPKD. Evidence from the Replicating Evidence of Preserved Renal Function: an Investigation of Tolvaptan Safety and Efficacy in ADPKD (REPRISE) trial supports the use of ADH (antidiuretic hormone) receptor antagonism in patients with ADPKD 18 to 55 years of age with eGFR (estimated glomerular filtration rate) of 25 to 65 mL/min/1.73 m 2 or 56 to 65 years of age with eGFR of 25 to 44 mL/min/1.73 m 2 with historical evidence of a decline in eGFR &gt;2.0 mL/min/1.73 m 2 /year. Limitations: Available literature was limited to English language publications and to publications indexed in PubMed, the Cochrane Library, and Google Scholar. Implications: Advances in the assessment of the risk of disease progression include the validation of the Mayo Clinic Classification for patients with class 1 ADPKD. Advances in the pharmacological management of ADPKD include the expansion of the use of ADH receptor antagonism in patients 18 to 55 years of age with eGFR of 25 to 65 mL/min/1.73 m 2 or 56 to 65 years of age with eGFR of 25 to 44 mL/min/1.73 m 2 with historical evidence of a decline in eGFR &gt;2.0 mL/min/1.73 m 2 /year, as per the results of the REPRISE study.

Methotrexate is used in the treatment of many malignancies, rheumatological diseases, and inflammatory bowel disease. Toxicity from use is associated with severe morbidity and mortality. Rescue treatments include intravenous hydration, folinic acid, and, in some centers, glucarpidase. We conducted systematic reviews of the literature following published EXtracorporeal TReatments In Poisoning (EXTRIP) methods to determine the utility of extracorporeal treatments in the management of methotrexate toxicity. The quality of the evidence and the strength of recommendations (either “strong” or “weak/conditional”) were graded according to the GRADE approach. A formal voting process using a modified Delphi method assessed the level of agreement between panelists on the final recommendations. A total of 92 articles met inclusion criteria. Toxicokinetic data were available on 90 patients (89 with impaired kidney function). Methotrexate was considered to be moderately dialyzable by intermittent hemodialysis. Data were available for clinical analysis on 109 patients (high-dose methotrexate [&gt;0.5 g/m 2 ]: 91 patients; low-dose [≤0.5 g/m 2 ]: 18). Overall mortality in these publications was 19.5% and 26.7% in those with high-dose and low-dose methotrexate–related toxicity, respectively. Although one observational study reported lower mortality in patients treated with glucarpidase compared with those treated with hemodialysis, there were important limitations in the study. For patients with severe methotrexate toxicity receiving standard care, the EXTRIP workgroup: ( 1 ) suggested against extracorporeal treatments when glucarpidase is not administered; ( 2 ) recommended against extracorporeal treatments when glucarpidase is administered; and ( 3 ) recommended against extracorporeal treatments instead of administering glucarpidase. The quality of evidence for these recommendations was very low. Rationales for these recommendations included: ( 1 ) extracorporeal treatments mainly remove drugs in the intravascular compartment, whereas methotrexate rapidly distributes into cells; ( 2 ) extracorporeal treatments remove folinic acid; ( 3 ) in rare cases where fast removal of methotrexate is required, glucarpidase will outperform any extracorporeal treatment; and ( 4 ) extracorporeal treatments do not appear to reduce the incidence and magnitude of methotrexate toxicity.

Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited renal disorder worldwide. The disease is characterized by renal cysts and progressive renal failure due to progressive enlargement of cysts and renal fibrosis. An estimated 45% to 70% of patients with ADPKD progress to end-stage renal disease by age 65 years. Although both targeted and nontargeted therapies have been tested in patients with ADPKD, tolvaptan is currently the only pharmacological therapy approved in Canada for the treatment of ADPKD. The purpose of this consensus recommendation is to develop an evidence-informed recommendation for the optimal management of adult patients with ADPKD. This document focuses on the role of genetic testing, the role of renal imaging, predicting the risk of disease progression, and pharmacological treatment options for ADPKD. These areas of focus were derived from 2 national surveys that were disseminated to nephrologists and patients with ADPKD with the aim of identifying unmet needs in the management of ADPKD in Canada. Specific recommendations are provided for the treatment of ADPKD with tolvaptan.