Red Deer Regional Hospital

BACKGROUND: Morphoea is characterized by fibrosis, which is mediated by cytokines including transforming growth factor (TGF)-beta. OBJECTIVE: Our objective was to use imiquimod 5% cream (Aldara), an inducer of interferon-gamma, known to inhibit TGF-beta, to treat morphoea. METHODS: Patients with morphoea were treated with imiquimod and evaluated during their follow-up visits to 6 months. RESULTS: The dyspigmentation, induration and erythema of 12 patients with morphoea lesions improved. The histology of the skin also showed a decrease in dermal thickness. CONCLUSION: This is the first case series describing the successful application of imiquimod in the management of morphoea.

This study examines the utility of objective histopathological studies in the evaluation of adult patients with erythroderma. A series of 56 skin biopsies, from 40 erythrodermic patients, was reviewed sequentially by 4 Canadian dermatopathologists who were unaware of clinical details of the cases. The final diagnosis (gold standard), in each instance, had already been determined by others, based on clinicopathologic data and response to therapy. Direct comparison revealed that the mean accuracy of the histopathological diagnoses was 53% (range: 48-66%), a favorable result in view of the difficulty of the task at hand. Additional points of information which evolved from the study are as follows: (i) identification, by microscopy alone, of spongiotic dermatitis, cutaneous T-cell lymphoma and psoriasis, as underlying causes of erythroderma was more successful than that of drug eruptions and pityriasis rubra pilaris; (ii) the epidermotropism which characterizes cutaneous T-cell lymphoma may be mistaken for inflammatory interface changes seen in drug eruptions and vice versa, thus constituting a pitfall in diagnosis; (iii) finally, it appears that submission of multiple simultaneous biopsies, rather than a single specimen, from patients with erythroderma would be likely to enhance the accuracy of histopathological diagnosis.

AIM: The aim of the study was to determine whether positive psychological interventions (PPIs) in a primary health care setting would improve physical and mental health over time. BACKGROUND: Most treatments for depression focus on reducing symptoms rather than on creating positive states of mental health. Empirical studies to verify the efficacy of PPIs in primary health care are needed. METHOD: In a six-week pilot program, we invited patients in a primary health care setting with symptoms of depression to participate in groups designed to increase levels of happiness. The program involved interventions such as engaging in good deeds, writing gratitude letters, and introducing empirical research. Patients completed the SF12v2(®) at the beginning and end of the program and at three- and six-month follow-up. Measures included physical functioning, bodily pain, mental health, social functioning, and vitality. Patients also participated in focus groups to discuss their experiences. FINDINGS: Of the 124 patients who enrolled in this pilot study, 75 completed the six-week program, and 35 participated in two follow-up assessments. Among the participants who remained for all follow-up assessments, scores improved from baseline to 6-month follow-up for health, vitality, mental health, and the effects of mental and physical health on daily activities. This subset of patients reported greater energy and more daily accomplishments, along with reductions in functional limitations. Improvements in mental and physical health and functioning were shown over a six-month period. The study provides a basis for the further investigation of PPIs in creating improvements for patients with depression in primary health care.

The International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) COVID-19 dataset is one of the largest international databases of prospectively collected clinical data on people hospitalized with COVID-19. This dataset was compiled during the COVID-19 pandemic by a network of hospitals that collect data using the ISARIC-World Health Organization Clinical Characterization Protocol and data tools. The database includes data from more than 705,000 patients, collected in more than 60 countries and 1,500 centres worldwide. Patient data are available from acute hospital admissions with COVID-19 and outpatient follow-ups. The data include signs and symptoms, pre-existing comorbidities, vital signs, chronic and acute treatments, complications, dates of hospitalization and discharge, mortality, viral strains, vaccination status, and other data. Here, we present the dataset characteristics, explain its architecture and how to gain access, and provide tools to facilitate its use.

To determine the cytodiagnostic accuracy rate and pitfalls of Hashimoto's thyroiditis (HT), the files and smears prepared from the thyroid needle aspirates of 146 patients with suspected HT and/or clinically and serologically confirmed HT were reviewed. Of those patients, 105 presented with a diffuse and rubbery thyroid enlargement, and 41 with one or two prominent nodules. For the first group (105 patients), the needle aspiration biopsy (NAB) was performed on one or two thyroid lobes during their initial endocrinologic consultation, and for the second group (41 patients), the NAB was performed on and around the predominant nodules that were found either at initial physical examination or during the patients' routine follow-ups. In 134 cases, a cytodiagnosis of HT was made on the first NAB. Among the 41 patients with a prominent thyroid nodule, a thyroid neoplasm was suspected clinically in four because their thyroid nodules increased in size. In the other 12 patients, a cytodiagnosis of follicular neoplasm (FN) was made in five cases, and a Hürthle cell tumor (HCT) was diagnosed or suspected in seven patients. All 16 patients had thyroid surgery, and a HT was histologically confirmed in all cases. In the first four patients, no tumor was found. Among five patients with a cytodiagnosis of FN, one had a hyperplastic follicular cell nodule (HFCN), two had follicular adenomas, and two had papillary carcinomas of follicular variant. For the seven patients with a cytodiagnosis of HCT, HCT was confirmed in three, three were found to have hyperplastic Hürthle cell nodules (HHCN), and one showed a benign colloid nodule with Hürthle cell changes and remote hemorrhagic necrosis. It is concluded that NAB is highly sensitive in diagnosing HT, with a diagnostic accuracy rate of 92% by the first biopsy attempt. The cytologic differential diagnosis between an HFCN and a follicular neoplasm and between an HHCN and an HCT is impossible in some cases.

Key points Ascent to high altitude imposes an acid‐base challenge in which renal compensation is integral for maintaining pH homeostasis, facilitating acclimatization and helping prevent mountain sicknesses. The time‐course and extent of plasticity of this important renal response during incremental ascent to altitude is unclear. We created a novel index that accurately quantifies renal acid‐base compensation, which may have laboratory, fieldwork and clinical applications. Using this index, we found that renal compensation increased and plateaued after 5 days of incremental altitude exposure, suggesting plasticity in renal acid‐base compensation mechanisms. The time‐course and extent of plasticity in renal responsiveness may predict severity of altitude illness or acclimatization at higher or more prolonged stays at altitude. Abstract Ascent to high altitude, and the associated hypoxic ventilatory response, imposes an acid‐base challenge, namely chronic hypocapnia and respiratory alkalosis. The kidneys impart a relative compensatory metabolic acidosis through the elimination of bicarbonate (HCO 3 − ) in urine. The time‐course and extent of plasticity of the renal response during incremental ascent is unclear. We developed an index of renal reactivity (RR), indexing the relative change in arterial bicarbonate concentration ([HCO 3 − ] a ) (i.e. renal response) against the relative change in arterial pressure of CO 2 ( ) (i.e. renal stimulus) during incremental ascent to altitude ( ). We aimed to assess whether: (i) RR magnitude was inversely correlated with relative changes in arterial pH (ΔpH a ) with ascent and (ii) RR increased over time and altitude exposure (i.e. plasticity). During ascent to 5160 m over 10 days in the Nepal Himalaya, arterial blood was drawn from the radial artery for measurement of blood gas/acid‐base variables in lowlanders at 1045/1400 m and after 1 night of sleep at 3440 m (day 3), 3820 m (day 5), 4240 m (day 7) and 5160 m (day 10) during ascent. At 3820 m and higher, RR significantly increased and plateaued compared to 3440 m ( P < 0.04), suggesting plasticity in renal acid‐base compensations. At all altitudes, we observed a strong negative correlation ( r ≤ −0.71; P < 0.001) between RR and ΔpH a from baseline. Renal compensation plateaued after 5 days of altitude exposure, despite subsequent exposure to higher altitudes. The time‐course, extent of plasticity and plateau in renal responsiveness may predict severity of altitude illness or acclimatization at higher or more prolonged stays at altitude.

> Courage rather than cowardice, compassionate human concern of one for the other; and resilience in the face of overwhelming stress.1 Many of today's violent conflicts can be characterised as “complex humanitarian emergencies.” Complex humanitarian emergencies are defined by Leaning as “Crises in life support and security that threaten large civilian populations with suffering and death and impose severe constraints on those who would seek to offer help.”2 Lauttze interprets these emergencies as “complicated disaster situations that have political, military and humanitarian dimensions and are often associated with natural disasters, especially drought.”3 Kosovo, Rwanda, Sudan, and Afghanistan are recent examples. The rapid growth, in capacity and number, of humanitarian relief organisations in response to complex humanitarian emergencies has created concern about the professionalism of their relief workers. The risk to the psychological wellbeing of relief workers caused by exposure to traumatic events is a particular worry and has been studied little.4 Research on the psychological sequelae to trauma has focused on primary victims,5–7 domestic rescue workers, 8 9 military personnel,10 and psychologists.11 Complex humanitarian emergencies may generate more stress among relief workers than “natural” disasters for several reasons. Firstly, an element of physical insecurity, with the risk of violent personal assault or injury, is increasingly present.12 Secondly, work in these situations necessarily involves moral and ethical dilemmas—for example, negotiating with warlords; witnessing human rights abuses, but being constrained from responding by operational considerations; and concern that humanitarian aid may perpetuate conflicts.13–16 Finally, caring for people with serious injuries caused by violence, witnessing unnatural deaths, and handling dead bodies or body parts are highly traumatic experiences in themselves.17 #### Summary points

Background/Aims. Nonalcoholic fatty liver disease (NAFLD) is a chronic liver disease that can progress to cirrhosis and hepatocellular carcinoma. This retrospective chart review investigated the incidence of hepatic steatosis in London, Ontario, Canada. Methods. A retrospective chart review was performed on emergency room (ER) patients undergoing nonscheduled computed tomography (CT) imaging over a six-month period in London, Ontario. CT images and reports were examined to determine presence of steatosis. Analyses of the electronic chart for a period of six months following the CT and communication with the patients' family doctors were used to determine if there was follow-up. Waist circumference, subcutaneous fat depth, and abdominal fat volumes were calculated. Results. 48/450 patients meeting inclusion criteria were identified by radiology as having steatosis, with 34/40 (85%) family physicians unaware of the finding. 24.7% (100/405) of patients met standard CT criteria for steatosis, 40 of which were reported by the radiologist. Waist circumference, subcutaneous adipose tissue depth, subcutaneous adipose tissue volume, and visceral adipose tissue volume were significantly associated with steatosis. Conclusions. The hepatic steatosis prevalence we report is the first reported in a Canadian population. Early identification of steatosis will become more important as new pharmacologic therapies arise.

Importance: It is unknown whether intravenous thrombolysis using tenecteplase is noninferior or preferable compared with alteplase for patients with acute ischemic stroke. Objective: To examine the safety and efficacy of tenecteplase compared to alteplase among patients with large vessel occlusion (LVO) stroke. Design, Setting, and Participants: This was a prespecified analysis of the Intravenous Tenecteplase Compared With Alteplase for Acute Ischaemic Stroke in Canada (ACT) randomized clinical trial that enrolled patients from 22 primary and comprehensive stroke centers across Canada between December 10, 2019, and January 25, 2022. Patients 18 years and older with a disabling ischemic stroke within 4.5 hours of symptom onset were randomly assigned (1:1) to either intravenous tenecteplase or alteplase and were monitored for up to 120 days. Patients with baseline intracranial internal carotid artery (ICA), M1-middle cerebral artery (MCA), M2-MCA, and basilar occlusions were included in this analysis. A total of 1600 patients were enrolled, and 23 withdrew consent. Exposures: Intravenous tenecteplase (0.25 mg/kg) vs intravenous alteplase (0.9 mg/kg). Main Outcomes and Measures: The primary outcome was the proportion of modified Rankin scale (mRS) score 0-1 at 90 days. Secondary outcomes were an mRS score from 0 to 2, mortality, and symptomatic intracerebral hemorrhage. Angiographic outcomes were successful reperfusion (extended Thrombolysis in Cerebral Infarction scale score 2b-3) on first and final angiographic acquisitions. Multivariable analyses (adjusting for age, sex, National Institute of Health Stroke Scale score, onset-to-needle time, and occlusion location) were carried out. Results: Among 1577 patients, 520 (33.0%) had LVO (median [IQR] age, 74 [64-83] years; 283 [54.4%] women): 135 (26.0%) with ICA occlusion, 237 (45.6%) with M1-MCA, 117 (22.5%) with M2-MCA, and 31 (6.0%) with basilar occlusions. The primary outcome (mRS score 0-1) was achieved in 86 participants (32.7%) in the tenecteplase group vs 76 (29.6%) in the alteplase group. Rates of mRS 0-2 (129 [49.0%] vs 131 [51.0%]), symptomatic intracerebral hemorrhage (16 [6.1%] vs 11 [4.3%]), and mortality (19.9% vs 18.1%) were similar in the tenecteplase and alteplase groups, respectively. No difference was noted in successful reperfusion rates in the first (19 [9.2%] vs 21 [10.5%]) and final angiogram (174 [84.5%] vs 177 [88.9%]) among 405 patients who underwent thrombectomy. Conclusions and Relevance: The findings in this study indicate that intravenous tenecteplase conferred similar reperfusion, safety, and functional outcomes compared to alteplase among patients with LVO.

Researchers have typically used factor-analytic composite measures of coping, instead of individual scales, to predict rehabilitation outcome. There are, however, both advantages and disadvantages to using individual or composite scores. This study extended the findings of Jensen et al. (1992), by prospectively comparing the individual and composite scores of the Coping Strategies Questionnaire (CSQ) in the prediction of 4 types of adjustment to low back pain. Two-hundred patients completed the CSQ, the Oswestry Index, the SCL-90R, and 4 lifting tasks at admission and discharge from a multidisciplinary pain clinic. Return to work was determined at 9-month follow-up. The CSQ scales were factor-analyzed to devise composite indices, and the 3 resultant factors were compared to the individual scales in the prediction of pain and other outcomes. The results indicated that the relative predictive utility of the composite or individual scales depended on which outcome measure was used to define adjustment.

OBJECTIVE: The purpose of our study was to compare axial multiple-echo recombined gradient echo (MERGE) with axial T2-weighted fast spin-echo (FSE) imaging for the detection of multiple sclerosis (MS) lesions in the cervical spinal cord on MRI. MATERIALS AND METHODS: Twenty-nine cervical spine MRI studies of patients with MS lesions and 29 control cases were reviewed retrospectively. Two blinded neuroradiologists independently assessed randomized axial MERGE and axial T2-weighted FSE sequences from each study, documenting the location and number of cord lesions, the degree of confidence in calling each lesion, and the presence of artifacts. The reference standard was determined by an unblinded consensus review of all sequences performed for each case, with lesions considered present if detected on two or more sequences. Lesion detection rates and conspicuity, false-positive findings, and reader confidence and artifact scores were compared for the sequences, and interreader agreement was assessed. RESULTS: Eighty-three lesions were assessed. The mean true-positive lesion detection rate was 87% (95% CI, 79-93%) with MERGE and 67% (60-75%) with T2-weighted FSE, with interreader positive agreement scores of 74% and 75%, respectively. A greater number of false-positive findings were seen with MERGE for both the MS and control cases. Average confidence and artifact scores were similar for both sequences. Subjectively, lesions were more conspicuous in 21 cases with MERGE and four cases with T2-weighted FSE and were equally conspicuous in four cases. CONCLUSION: MERGE and T2-weighted FSE sequences are complementary. MERGE provided greater sensitivity for cord lesions whereas axial T2-weighted FSE provided improved lesion specificity. Further investigation is required to assess the clinical impact of MERGE in the diagnosis and management of MS.

Forty-two histologically confirmed cases of pancreatic cystic lesions with cytologic evaluation by needle aspiration biopsy (NAB) were reviewed. There were 21 inflammatory pseudocysts (IPC), nine mucinous cystic neoplasms (MCN), six microcystic serous adenomas (MSA), one macrocystic serous adenoma, and five papillary solid and cystic neoplasms (PSCN). Correct cytodiagnosis was made in all cases of IPC and MCN. The contents of IPCs were characterized by turbid or blood-tinged fluid containing cellular debris, numerous foamy macrophages, and other inflammatory cells. There were few or no epithelial lining cells. The aspirates from MCNs showed gelatinous mucoid material containing mucus-secreting cells that were present singly, in clusters, or in sheets. Depending on the individual case, benign or malignant columnar cells, or an admixture of these cells, were present in a mucinous background. The preoperative needle aspirates of five MSAs were acellular. In one case of MSA and in one example of macrocystic serous adenoma, small monolayered sheets of benign cubic epithelial cells were seen in the needle aspirates. Similar cytologic findings were noted in the materials obtained by intraoperative NAB performed under direct vision of the aforementioned five MSAs. Difficulties were encountered in typing three PSCNs that yielded in NAB cells resembling those of an islet cell tumor. They were diagnosed as low-grade neoplasms (PSCN vs. islet cell tumor). In two other patients, a cytodiagnosis of PSCN was correctly made as the NAB revealed monomorphic tumor cells wrapping around small capillary blood vessels.

Cross-sectional and longitudinal analyses were used to compare age-related changes in adaptive functioning in institutionalized adults with and without Down syndrome. Cross-sectional analysis showed significant differences related to level of functioning but not to age or etiology of disability. Longitudinal analysis showed a pattern of decline in self-help and communication skills in several individuals with Down syndrome older than 40. The case of an adult with Down syndrome with confirmed Alzheimer pathology at postmortem was presented. Results were discussed in relation to aging and the likelihood of Alzheimer-like changes in individuals with Down syndrome.

OBJECTIVE: To identify expected pharmacokinetic changes and provide practical recommendations for the medication management of chronic disease states after bariatric surgery. SOURCES OF INFORMATION: . Reference lists of original studies and reviews were also hand searched. Included studies were entered into PubMed and articles under the "Similar articles" heading were also reviewed. Only studies relevant to bariatric surgery types currently available in Canada (ie, Roux-en-Y gastric bypass, sleeve gastrectomy, or gastric banding) were included. MAIN MESSAGE: Pharmacokinetic changes anticipated after bariatric surgery vary by surgery type. There are several guiding principles that might be applied to medication management regimens after bariatric surgery. Practice tips are also presented for medication management of specific chronic disease states. CONCLUSION: Changes to long-term medication regimens after bariatric surgery should be anticipated and managed in an appropriate and timely manner. The provided clinical practice recommendations might be used in conjunction with a patient's clinical picture to adjust chronic medication regimens in an appropriate and evidence-based manner after bariatric surgery.

BACKGROUND: We examined the concordance of 13 commercial cardiac troponin (cTn) assays [point-of-care, high-sensitivity (hs), and conventional] using samples distributed across a continuum of results. METHODS: cTnI (11 assays) and cTnT (2 assays) were measured in 191 samples from 128 volunteers. cTn assays included Abbott (iSTAT, STAT, and hs), Alere (Cardio 3), Beckman (AccuTnI+3), Pathfast (cTnI-II), Ortho (Vitros), Siemens (LOCI, cTnI-Ultra, Xpand, Stratus CS), and Roche [4th Generation (Gen), hs]. Manufacturer-derived 99th percentile cutoffs were used to classify results as positive or negative. Alternative 99th percentile cutoffs were tested for some assays. Correlation was assessed using Passing-Bablok linear regression, bias was examined using Bland-Altman difference plots, and concordance/discordance of each method comparison was determined using the McNemar method. RESULTS: Regression slopes ranged from 0.63 to 1.87, y-intercepts from 0.00 to 0.03 ng/mL, and r values from 0.93 to 0.99. The cTnT methods had a slope of 0.93, y-intercept of 0.02 ng/mL, and r value of 0.99. For the cTnI assays, positive, negative, and overall concordance was 76.2%-100%, 66.0%-100%, and 82.9%-98.4%, respectively. Overall concordance between the 4th Gen cTnT and hsTnT assays was 88.9%. A total of 30 of the 78 method comparisons showed significant differences in classification of samples (P <0.001); the iSTAT showed 10, hsTnT showed 9, AccuTnI+3 showed 5, Xpand showed 5, and Stratus CS showed 1. Using alternative 99th percentile cutoffs to those listed by manufacturers lowered the method discordance by 6-fold, from 30 to 5 (all involved iSTAT). CONCLUSIONS: These data provide insight into characteristics of cTn methods and will assist the healthcare community in setting expectations for relationships among commercial cTn assays.

BACKGROUND: Interventions that promote positive mother-infant interactions may reduce the risk of poor developmental outcomes for the child. OBJECTIVE: To examine the effect of infant communication education presented prenatally to first-time mothers on the quality of interaction that occurs between the mother-infant dyad in the first 24 hours following birth. METHOD: Twenty-nine first-time mothers were randomly assigned to either an intervention or control group. The intervention group received education on infant behaviors, states, and communication cues. A specific mother-infant interaction was videotaped and scored using the Nursing Child Assessment Teaching Scale (NCATS). The scores between groups were compared to determine the effect of education on the interaction that occurred between the dyads. RESULTS: Significant intervention effect was found in the overall totals (t(27)= 1.69; p = .05) as well as the contingency scores related to sensitivity to cues (t(27)= 1.93; p = .05) and social-emotional growth-fostering behaviors (t(27)= 1.93; p = .05). CONCLUSION: A videotaped educational intervention on infant communication implemented prenatally resulted in significant differences between the intervention and control groups on NCATS scores (totals, sensitivity to cues, and social-emotional growth-fostering behaviors). The use of videotaped educational information facilitates very early mother-infant interaction.

BACKGROUND: The AcT (Alteplase Compared to Tenecteplase) randomized controlled trial showed that tenecteplase is noninferior to alteplase in treating patients with acute ischemic stroke within 4.5 hours of symptom onset. The effect of time to treatment on clinical outcomes with alteplase is well known; however, the nature of this relationship is yet to be described with tenecteplase. We assessed whether the association of time to thrombolysis treatment with clinical outcomes in patients with acute ischemic stroke differs by whether they receive intravenous tenecteplase versus alteplase. METHODS: Patients included were from AcT, a pragmatic, registry-linked, phase 3 randomized controlled trial comparing intravenous tenecteplase to alteplase in patients with acute ischemic stroke. Eligible patients were &gt;18 years old, with disabling neurological deficits, presenting within 4.5 hours of symptom onset, and eligible for thrombolysis. Primary outcome was modified Rankin Scale score 0 to 1 at 90 days. Safety outcomes included 24-hour symptomatic intracerebral hemorrhage and 90-day mortality rates. Mixed-effects logistic regression was used to assess the following: (a) the association of stroke symptom onset to needle time; (b) door (hospital arrival) to needle time with outcomes; and (c) if these associations were modified by type of thrombolytic administered (tenecteplase versus alteplase), after adjusting for age, sex, baseline stroke severity, and site of intracranial occlusion. RESULTS: Of the 1538 patients included in this analysis, 1146 (74.5%; 591 tenecteplase and 555 alteplase) presented within 3 hours versus 392 (25.5%; 196: TNK and 196 alteplase) who presented within 3 to 4.5 hours of symptom onset. Baseline patient characteristics in the 0 to 3 hours versus 3- to 4.5-hour time window were similar, except patients in the 3- to 4.5-hour window had lower median baseline National Institutes of Health Stroke Severity Scale (10 versus 7, respectively) and lower proportion of patients with large vessel occlusion on baseline CT angiography (26.9% versus 18.7%, respectively). Type of thrombolytic agent (tenecteplase versus alteplase) did not modify the association between continuous onset to needle time ( P interaction =0.161) or door-to-needle time ( P interaction =0.972) and primary clinical outcome. Irrespective of the thrombolytic agent used, each 30-minute reduction in onset to needle time was associated with a 1.8% increase while every 10 minutes reduction in door-to-needle time was associated with a 0.2% increase in the probability of achieving 90-day modified Rankin Scale score 0 to 1, respectively. CONCLUSIONS: The effect of time to tenecteplase administration on clinical outcomes is like that of alteplase, with faster administration resulting in better clinical outcomes. REGISTRATION: URL: https://classic.clinicaltrials.gov ; Unique identifier: NCT03889249.

Background and Purpose: Improving door-to-needle times (DNTs) for thrombolysis of acute ischemic stroke patients improves outcomes, but participation in DNT improvement initiatives has been mostly limited to larger, academic medical centers with an existing interest in stroke quality improvement. It is not known whether quality improvement initiatives can improve DNT at a population level, including smaller community hospitals. This study aims to determine the effect of a provincial improvement collaborative intervention on improvement of DNT and patient outcomes. Methods: A pre post cohort study was conducted over 10 years in the Canadian province of Alberta with 17 designated stroke centers. All ischemic stroke patients who received thrombolysis in the Canadian province of Alberta were included in the study. The quality improvement intervention was an improvement collaborative that involved creation of interdisciplinary teams from each stroke center, participation in 3 workshops and closing celebration, site visits, webinars, and data audit and feedback. Results: Two thousand four hundred eighty-eight ischemic stroke patients received thrombolysis in the pre- and postintervention periods (630 in the post period). The mean age was 71 years (SD, 14.6 years), and 46% were women. DNTs were reduced from a median of 70.0 minutes (interquartile range, 51–93) to 39.0 minutes (interquartile range, 27–58) for patients treated per guideline ( P &lt;0.0001). The percentage of patients discharged home from acute care increased from 45.6% to 59.5% ( P &lt;0.0001); the median 90-day home time increased from 43.3 days (interquartile range, 27.3–55.8) to 53.6 days (interquartile range, 36.8–64.6) ( P =0.0015); and the in-hospital mortality decreased from 14.5% to 10.5% ( P =0.0990). Conclusions: The improvement collaborative was likely the key contributing factor in reducing DNTs and improving outcomes for ischemic stroke patients across Alberta.

BACKGROUND: Paraproteins, immunoglobulins (Igs), which are elevated in various autoimmune disorders, are known to interfere with various laboratory immunoassays, including vancomycin (VANC). Rheumatoid factor (RF), a known immunoassay interferant, may cause falsely elevated results. OBJECTIVES: The aims of this study were to (1) evaluate the effect of 3 paraproteins (IgA, IgG, and IgM) on 4 commercial VANC immunoassays [fluorescence polarization immunoassay; enzyme multiplied immunoassay; 2 particle-enhanced turbidimetric inhibition immunoassays]; (2) determine the concentration at which the effect is obtained, and (3) examine the influence of RF on the VANC methods. METHOD: Serum and plasma pools from patients prescribed VANC and a spiked VANC pool (20 mg/L) were each mixed 1:1 with individual patient specimens containing IgA (6-63 g/L), IgG (6-54 g/L), IgM (3-30 g/L) (n = 4 for each Ig), and a patient RF pool (196 IU/L). The mixtures (n = 39) were split and distributed for VANC analysis. RESULTS: IgA and IgG in serum and plasma did not affect any of the VANC immunoassays. RF added to plasma specimens did not interfere, but in serum, elevated VAN results were observed. IgM did not affect the fluorescence polarization immunoassay and enzyme multiplied immunoassay methods but did attenuate VANC concentrations by both particle-enhanced turbidimetric inhibition immunoassays (Siemens, Beckman Coulter), with a more pronounced effect on the latter, producing concentrations >20% lower than expected in the patient serum and spiked plasma pools. The effect was progressively negative at effective IgM concentrations of 10 and 15 mg/L. CONCLUSIONS: This phenomenon is a major analytical and clinical issue that must be communicated to health care professionals caring for patients receiving VANC, so optimal therapy is achieved.

The cytologic findings in fine-needle aspiration biopsy (FNAB) of 9 histologically, immunohistochemically, and ultrastructurally confirmed malignant mesotheliomas of the pleura were reviewed. There were 4 epithelial malignant mesotheliomas (EMM), 3 sarcomatous mesotheliomas (SM), 1 mixed malignant mesothelioma (MMM), and 1 poorly differentiated malignant mesothelioma (PDMM). In FNAB, three EMMs yielded polygonal malignant cells with oval nuclei and prominent nucleoli, singly, in small sheets, and in tridimensional clusters with smooth or lobulated contours. In one EMM, only atypical mesothelial cells with prominent nucleoli were seen singly and in loose aggregates. In FNAB, two SM showed malignant spindle-shaped cells (MSC) with scant, ill-defined cytoplasm singly and in loose clusters. Cohesive clusters of elongated and polygonal cells with ill-defined, clear cytoplasm and pleomorphic nuclei containing small or prominent nucleoli were observed in one SM, with extensive clear-cell changes. In needle aspirates, the MMM showed polygonal malignant cells in clusters admixed with MSC. The PDMM displayed single and clustered large pleomorphic malignant cells, with prominent single or multiple nucleoli. Electron microscopic examination of minute tissue fragments retrieved from the FNAB in 2 cases of EMM revealed epithelial mesothelial cells with well-formed desmosomes and long slender microvilli (LSM) on the free tumor cell surfaces. In one case, LSM in direct contact with collagen fiber bundles in the tumor tissue matrix were observed, supporting the diagnosis of an invasive EMM. Diagn. Cytopathol. 1999;21:253-259.