Saskatoon City Hospital

KIRKALDY-WILLIS, W. H. M.A., M.D., F.R.C.S. (E. AND C.); FARFAN, H. F. M.Sc, M.D., CM., F.R.C.S. (C)Editor(s): CALANDRUCCIO, ROCCO A. M.D. Author Information

A lumbar motion segment is considered to be unstable when it exhibits abnormal movement. This movement can be abnormal in quality (abnormal coupling patterns) or in quantity (abnormal increased motion). This instability can be symptomatic or asymptomatic, depending on the demands made on the motion segment. Pain is a signal of impending or actual tissue damage, and when present it indicates that a certain mechanical threshold has been reached or transgressed. Repeated transgressions will damage the stabilizing structures beyond physiologic repair, thus putting abnormal demands on secondary restraints. Radiographic study with dynamic views obtained in the frontal and lateral planes identify unstable states in the clinical environment.

Disruptive technologies are revolutionising continuing professional development in emergency medicine and critical care (EMCC). Data on EMCC blogs and podcasts were gathered prospectively from 2002 through November 2013. During this time there was a rapid expansion of EMCC websites, from two blogs and one podcast in 2002 to 141 blogs and 42 podcasts in 2013. This paper illustrates the explosive growth of EMCC websites and provides a foundation that will anchor future research in this burgeoning field.

Researchers have rarely addressed the relationship between socioeconomic status (SES) and physical activity from the perspective of youth. To illuminate the factors that youth from low and high-SES areas consider important to increase physical activity participation among their peers, 160 youth (12-18 years) participated in small focus group interviews. Guiding questions centered on the general theme, "If you were the one in charge of increasing the physical activity levels of kids your age, what would you do?" Findings show that environmental factors (i.e., proximity, cost, facilities, and safety) are very important for youth living in low-SES areas to ensure participation in physical activity. Results also show that intrapersonal (i.e., perceived skill, competence, time) and social factors (i.e., friends, adult support) must be considered to help improve participation rates among both high- and low-SES youth.

PURPOSE: To examine relationships between selected sociodemographic, health-related and environmental factors and levels of physical activity in older adults across three age groups. METHODS: Seven hundred sixty-four older adults (mean age = 77.4 +/- 8.6 yr) from a midsize Canadian city completed a self-administered questionnaire under researcher supervision. Level of physical activity was determined using the Physical Activity Scale for the Elderly (PASE). Correlates of physical activity were examined using previously validated questionnaires. The findings pertaining to personal and environmental factors are presented. RESULTS: Overall, significantly higher mean PASE scores were seen in those individuals in the following categories: male (P < 0.001), married or common-law (P < 0.001), not living alone (P < 0.001), not living in senior's housing (P < 0.001), higher levels of education (P < 0.001) and higher incomes (P < 0.001). Better physical health showed significant positive associations (P < 0.001) with PASE score. Individuals reporting at least four or more chronic health conditions had significantly lower PASE scores than those reporting no chronic conditions (P < 0.001). Significantly lower PASE scores were also reported in those using domestic services (P < 0.001). Higher PASE scores were related to the presence of hills, biking and walking trails, street lights, various recreation facilities, seeing others active and unattended dogs (P < 0.001 to P < 0.05). CONCLUSION: An understanding of the factors that influence physical activity behavior in older adults is critical to developing effective intervention strategies that will address the problem of physical inactivity in this population, and in doing so, improve the health status and quality of life of the older adult, while having a significant impact on healthcare expenditures.

Lower-extremity muscle strength is important in predicting fall risk in older adults. Handheld dynamometry (HHD) is a tool used to measure isometric muscle strength in the older adult, but few studies have evaluated the utility of HHD for muscle groups beyond knee extension. The purpose of this study was to evaluate the reliability of HHD at the hip, knee, and ankle and to compare HHD strength values to other isometric dynamometry (ID) and to balance and recovery in older adults. This was a repeated measures study design of 18 men and women, age 65 to 92 years of age, who had HHD strength testing 3 to 7 days apart by the same examiner and repeat testing on the same day using 2 independent examiners. ID strength, balance, step length, and reaction time were measured once. HHD demonstrated good intrarater and interrater reliability for isometric strength at the hip and knee but was not a reliable measure for ankle strength. The HHD was a valid measure of isometric strength at the hip and knee, demonstrating moderate to high correlation values when compared to ID strength measures (r = 0.57-0.86; p < 0.05). Hip and knee strength was positively associated to step length and reaction time but not to balance (r = 0.40-0.71; p < 0.05). In conclusion, HHD is a reliable and valid assessment tool for measuring strength at the hip and knee in older adults, and greater strength in these muscles is associated with longer step length and decreased reaction time, which are important components of balance recovery in older adults. HHD can be used as an effective strength measurement tool for the older adult population.

Although historically considered a disease primarily affecting the white matter of the central nervous system, recent pathological and imaging studies have established that cortical demyelination is common in multiple sclerosis and more extensive than previously appreciated. Subpial, intracortical and leukocortical lesions are the three cortical lesion types described in the cerebral and cerebellar cortices of patients with multiple sclerosis. Cortical demyelination may be the pathological substrate of progression, and an important pathologic correlate of irreversible disability, epilepsy and cognitive impairment. Cortical lesions of chronic progressive multiple sclerosis patients are characterized by a dominant effector cell population of microglia, by the absence of macrophagic and leukocytic inflammatory infiltrates, and may be driven in part by organized meningeal inflammatory infiltrates. Cortical demyelination is also present and common in early MS, is topographically associated with prominent meningeal inflammation and may even precede the appearance of classic white matter plaques in some MS patients. However, the pathology of early cortical lesions is different than that of chronic MS in the sense that early cortical lesions are highly inflammatory, suggesting that neurodegeneration in MS occurs on an inflammatory background and raising interesting questions regarding the role of cortical demyelination and meningeal inflammation in initiating and perpetuating the disease process in early MS.

Mesonephric carcinomas of the gynecologic tract are neoplasms that are often under-recognized due to their varied morphologic appearances. Recently, GATA3 and TTF1 have been reported to be useful immunohistochemical markers for distinguishing mesonephric carcinomas from its morphologic mimics. Herein, we compared the performance of GATA3 and TTF1 to the traditional markers used for mesonephric carcinomas, CD10 and calretinin. We studied 694 cases: 8 mesonephric carcinomas (7 cervical [includes 3 mesonephric carcinosarcomas], 1 vaginal), 5 mesonephric-like carcinomas (4 uterine corpus, 1 ovarian), 585 endometrial adenocarcinomas, and 96 cervical adenocarcinomas. Mesonephric-like carcinomas were defined as tumors exhibiting the classic morphologic features of mesonephric carcinoma, but occurring outside of the cervix and without convincing mesonephric remnants. GATA3 had the highest sensitivity and specificity (91% and 94%) compared with TTF1 (45% and 99%), CD10 (73% and 83%), and calretinin (36% and 89%). GATA3, however, also stained a substantial number of uterine carcinosarcomas (23/113, 20%). TTF1 was positive in 5/5 (100%) mesonephric-like carcinomas and only 1/8 (13%) mesonephric carcinomas. In 4/6 (67%) TTF1 positive cases, GATA3 exhibited an inverse staining pattern with TTF1. In summary, GATA3 was the best overall marker for mesonephric and mesonephric-like carcinomas, but cannot be used to distinguish mesonephric carcinosarcomas from Müllerian carcinosarcomas. The inverse staining pattern between GATA3 and TTF1, suggests that TTF1 may be useful when GATA3 is negative in small biopsies where mesonephric or mesonephric-like carcinoma is suspected. The greater TTF1 positivity in mesonephric-like carcinomas suggests they may be biologically different from prototypical mesonephric carcinomas.

Research has demonstrated that the probability of repeat victimization is greater than the probability of an independent offence. The time course of elevated risk has important implications for crime prevention. For burglaries, the current received wisdom is that the characteristics of homes which make burglary more probable persist over the medium and long term. Addressing the lime course question, previous research by the authors examined the change in risk of repeat burglary victimization for up to twelve months after the initial offence (Polvi et al. 1990). The study is here extended to the analysis of a four-year time period (1984 to 1987). It was found that the elevated risk of repeat burglary does not last over long time periods. Based on the present data, the risk becomes average once six months has passed and remains so subsequently. It is contended that the work should be replicated, given its surprising results. One implication of this research is that preventative action should be taken as soon as possible after a burglary. One of the criminological legacies of the late Richard Sparks was his recognition of the importance of the phenomenon of repeat crime victimization (see Sparks 1981). In essence, the probability of being victimized a second or subsequent time is several times the rate that would be expected if offences were independent events. This seems to be

B rence of different primary malignant tuniors in the same patient. Since then numerous papers (most of them reporting one or more cases) have been written on the subject, the definition of multiple cancer differing from author to author. Billroth formulated postulates that stated that each tumor must be histologically different, each must arise in a differen: location, and each must produce its own metastases. This last requirement would obviously exclude a very large number of genuine cases, and it has not been adhered to i n this series. However, any case in which there was even a remote possibility of the one lesion being a metastasis of the other has been excluded from this study.

Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system (CNS) in which oligodendrocytes, the CNS cells that stain most robustly for iron and myelin are the targets of injury. Metals are essential for normal CNS functioning, and metal imbalances have been linked to demyelination and neurodegeneration. Using a multidisciplinary approach involving synchrotron techniques, iron histochemistry and immunohistochemistry, we compared the distribution and quantification of iron and zinc in MS lesions to the surrounding normal appearing and periplaque white matter, and assessed the involvement of these metals in MS lesion pathogenesis. We found that the distribution of iron and zinc is heterogeneous in MS plaques, and with few remarkable exceptions they do not accumulate in chronic MS lesions. We show that brain iron tends to decrease with increasing age and disease duration of MS patients; reactive astrocytes organized in large astrogliotic areas in a subset of smoldering and inactive plaques accumulate iron and safely store it in ferritin; a subset of smoldering lesions do not contain a rim of iron-loaded macrophages/microglia; and the iron content of shadow plaques varies with the stage of remyelination. Zinc in MS lesions was generally decreased, paralleling myelin loss. Iron accumulates concentrically in a subset of chronic inactive lesions suggesting that not all iron rims around MS lesions equate with smoldering plaques. Upon degeneration of iron-loaded microglia/macrophages, astrocytes may form an additional protective barrier that may prevent iron-induced oxidative damage.

Oligodendrocytes (OGs) assemble the myelin sheath around axons in the central nervous system. Specification of cells into the OG lineage is largely the result of interplay between bone morphogenetic protein, sonic hedgehog and Notch signaling pathways, which regulate expression of transcription factors (TFs) dictating spatial and temporal aspects of oligodendrogenesis. Many of these TFs and others then direct OG development through to a mature myelinating OG. Here we describe signaling pathways and TFs that are inductive, inhibitory, and/or permissive to OG specification and maturation. We develop a basic transcriptional network and identify similarities and differences between regulation of oligodendrogenesis in the spinal cord and brain.

The purpose of this study was to measure treatment outcomes in a group of six adults with chronic dysphagia following acquired brain injury, who each completed 24 sessions of tongue-pressure resistance training, over a total of 11-12 weeks. The treatment protocol emphasized both strength and accuracy. Biofeedback was provided using the Iowa Oral Performance Instrument. Amplitude accuracy targets were set between 20-90% of the patient's maximum isometric pressure capacity. Single subject methods were used to track changes in tongue strength (maximum isometric pressures), with functional swallowing outcomes measured using blinded ratings of a standard pre- and post-treatment videofluoroscopy protocol. Improvements were seen in post-treatment measures of tongue pressure and penetration-aspiration. No improvements were seen in pharyngeal residues, indeed worsening residue was seen in some patients.

BACKGROUND: Despite evidence suggesting that coping is an important concept in the study of pain, its role in predicting the development of disabling pain has not been previously studied. To assess the relationship between coping and the development of disabling pain. METHODS: From a random sample of adults, we formed a cohort of individuals with non-disabling neck and/or low back pain (n=571). Participants were followed 6 and 12 months after the index survey. Coping was measured with the Vanderbilt Pain Management Inventory. The Chronic Pain Questionnaire was used to measure the presence of disabling neck and/or low back pain. We used Cox proportional hazards regression analyses to investigate the role of passive coping in the development of disabling pain while controlling for confounders. RESULTS: Passive coping was a strong, independent risk factor for disabling neck and/or back pain. Those using moderate to high levels of passive coping strategies were at an over five-fold increased risk of developing disabling pain (Moderate: HRR=5.19, 95% CI=1.78-15.1; High: HRR=6.80, 95% CI=2.36-19.6). Active coping was not found to be a significant risk factor for disabling neck and/or back pain. CONCLUSION: Passive coping is a strong and independent predictor of disabling neck and/or back pain. This strong relationship identifies passive coping as a marker for risk of disability and can allow for the identification of individuals at risk and in need of intervention to aid in improving their overall adjustment.

The authors carried out a prospective review of the initial and consecutive experience with laparoscopic cholecystectomy of 58 surgeons from 31 teaching and nonteaching institutions throughout Canada. The perioperative morbidity of 2201 cases is described, with special attention to iatrogenic complications. The data suggest that complications, including bile-duct injury, are not frequent. Pneumonia and wound infection rates appear lower than after open surgery. There were no deaths. Laparoscopic cholecystectomy is replacing open cholecystectomy for the management of symptomatic cholelithiasis.

The Cancer Genome Atlas recently identified a genomic-based molecular classification of endometrial carcinomas, with 4 molecular categories: (1) ultramutated (polymerase epsilon [POLE] mutated), (2) hypermutated (microsatellite instability), (3) copy number abnormalities-low, and (4) copy number abnormalities-high. Two studies have since proposed models to classify endometrial carcinomas into 4 molecular subgroups, modeled after The Cancer Genome Atlas, using simplified and more clinically applicable surrogate methodologies. In our study, 151 endometrial carcinomas were molecularly categorized using sequencing for the exonuclease domain mutations (EDM) of POLE, and immunohistochemistry for p53 and mismatch repair (MMR) proteins. This separated cases into 1 of 4 groups: (1) POLE EDM, (2) MMR-D, (3) p53 wildtype (p53 wt), or (4) p53 abnormal (p53 abn). Seven gynecologic pathologists were asked to assign each case to one of the following categories: grade 1 to 2 endometrioid carcinoma (EC), grade 3 EC, mucinous, serous carcinoma (SC), clear cell, dedifferentiated, carcinosarcoma, mixed, and other. Consensus diagnosis among all 7 pathologists was highest in the p53 wt group (37/41, 90%), lowest in the p53 abn group (14/36, 39%), and intermediate in the POLE EDM (22/34, 65%) and MMR-D groups (23/40, 58%). Although the majority of p53 wt endometrial carcinomas are grade 1 to 2 EC (sensitivity: 90%), fewer than half of grade 1 to 2 EC fell into the p53 wt category (positive predictive value: 42%). Pure SC almost always resided in the p53 abn group (positive predictive value: 96%), but it was insensitive as a marker of p53 abn (sensitivity 64%) and the reproducibility of diagnosing SC was suboptimal. The limitations in the precise histologic classification of endometrial carcinomas highlights the importance of an ancillary molecular-based classification scheme.

In the Cree Lake Zone of northern Saskatchewan, reworked Archean orthogneisses are overlain by a highly deformed supracrustal sequence, the Paleoproterozoic Wollaston Group. This package of rocks was deformed and metamorphosed during the ca. 1.8 Ga continent–continent collision of the Trans-Hudson Orogen (THO), forming the Wollaston fold–thrust belt that underlies the eastern Athabasca Basin. The Hudsonian structural, metamorphic, and magmatic evolution of the Wollaston fold-thrust belt in the eastern Athabasca area involved six major stages. (1) Early collisional stage, D P1 at 1860–1835 Ma, involved burial of Wollaston Group metasediments from surface to depths equivalent to 3–5vkbar (1 kbar = 100 MPa) by thrust-pile stacking or imbrication tectonics, prograde metamorphism with garnet growth and development of early leucosomes, and emplacement of ca. 1840 Ma grey granite suite. (2) Collisional stage, D P2a at 1835–1820 Ma, involved continued deeper burial of Wollaston Group metasediments along a prograde P–T–t (pressure–temperature–time) path at depths equivalent to peak pressures of 6–9 kbar and approaching peak temperatures (750–825 °C), mafic magma underplating in the lower crust, initiation of large-scale crustal melting, emplacement of 1835–1820 Ma tholeiitic to calc-alkaline intrusions, and initiation of strike-slip tectonics. (3) Oblique collisional stage, D P2b at 1820–1805 Ma, involved strong transpressional tectonics with NE–SW shearing and NW–SE shortening, partitioned high-strain ductile flow, kilometre-scale fold development, initiation of exhumation, attainment of peak temperatures (750–825 °C), and essentially isothermal decompression with decompressional melting and intrusion of the main pulse of leucogranites and granitic pegmatites. (4) Late oblique collisional stage, D P3 at 1805–1775 Ma, caused development of amphibolite-facies dextral strike-slip shear zones and retrograde movement of older shear zones. It included apparent rotation of the main shortening axis and development of accommodation features due to vertical uplift (i.e., extension). (5) Post-collisional stage, D P4 at 1775–1760 Ma, involved continued localized adjustments along an essentially isobaric cooling path and produced NNE-trending, sinistral, oblique-slip reverse faults with reactivation of older shear zones. (6) Late post-collisional stage, D P5, produced north- to northwest-trending sinistral faults, including the Tabbernor fault system. Extension and tectonic extrusion during D P4 and D P5 were significant and resulted in orogenic collapse and formation of the Athabasca Basin at ca. 1750–1680 Ma.

Although Sirt2 is primarily expressed in oligodendrocytes of the central nervous system, its role in oligodendroglial lineage differentiation is not fully understood. Our findings demonstrate that the transcription factor Nkx2.2 binds to the Sirt2 promoter via histone deacetylase 1 (HDAC-1), the binding site for Nkx2.2 maps close to the start codon of the Sirt2 gene, and Nkx2.2 negatively regulates Sirt2 expression in CG4 cells, an oligodendroglial precursor cell line. HDAC-1 knock-down not only significantly attenuates the binding capacity of Nkx2.2 to the Sirt2 promoter but also releases repression of Sirt2 expression by Nkx2.2. Nkx2.2 over-expression down-regulates Sirt2 expression and delays differentiation of CG4 cells; in contrast, up-regulation of Sirt2 does not impact Nkx2.2 expression level. Sirt2 knock-down via RNAi or inhibition of Sirt2 by sirtinol, a Sirt2 activity inhibitor, blocks CG4 cell differentiation. Over-expression of Sirt2 facilitates CG4 cell differentiation at both molecular and cellular levels, enhancing expression of myelin basic protein and facilitating the growth of cell processes. We have conclusively demonstrated that Sirt2 enhances CG4 oligodendroglial differentiation and report a novel mechanism through which Nkx2.2 represses CG4 oligodendroglial differentiation via Sirt2.

The patterns of use of psychiatric emergency services in Saskatoon, Saskatchewan were studied. A total of 576 patients who had received psychiatric emergency care from any of the four major health care facilities in Saskatoon during a three month period were included in the study. Visits for psychiatric emergency services during the study period represented 2.32% of the total number of visits to emergency facilities. Most patients with psychiatric emergencies went to hospitals with psychiatric units. The characteristics of patients served by the four facilities and those who visited the psychiatric emergency services on more than one occasion during the study period are reported. The implications of these findings for health care planning are discussed.

BACKGROUND: People who inject drugs (PWID) often encounter barriers when attempting to access health care and social services. In our previous study conducted to identify barriers to accessing care from the perspective of PWIDs in Saskatoon, Canada: poverty, lack of personal support, discrimination, and poor knowledge and coordination of service providers among other key barriers were identified. The purpose of the present investigation was to explore what service providers perceive to be the greatest barriers for PWIDs to receive optimal care. This study is an exploratory investigation with a purpose to enrich the literature and to guide community action. METHODS: Data were collected through focus groups with service providers in Saskatoon. Four focus groups were held with a total of 27 service providers. Data were transcribed and qualitative analysis was performed. As a result, concepts were identified and combined into major themes. RESULTS: Four barriers to care were identified by service providers: inefficient use of resources, stigma and discrimination, inadequate education and the unique and demanding nature of PWIDs. Participants also identified many successful services. CONCLUSION: The results from this investigation suggest poor utilization of resources, lack of continuing education of health care providers on addictions and coping skills with such demanding population, and social stigma and disparity. We recommend improvements in resource utilization through, for example, case management. In addition, sensitivity training and more comprehensive service centers designed to meet PWID's complex needs may improve care. However, community-wide commitment to addressing injection drug issues will also be required for lasting solutions.