Vernon Jubilee Hospital

BACKGROUND: Defects in the small intestinal epithelial barrier have been associated with inflammatory bowel disease but their role in the causation of disease is still a matter of debate. In some models of disease increased permeability appears to be a very early event. The interleukin 10 (IL10) gene-deficient mouse spontaneously develops colitis after 12 weeks of age. These mice have been shown to have increased small intestinal permeability that appears early in life. Furthermore, the development of colitis is dependent upon luminal agents, as animals do not develop disease if raised under germ-free conditions. AIMS: To determine if the elevated small bowel permeability can be prevented, and if by doing so colonic disease is prevented or attenuated. METHODS: IL10 gene-deficient (IL10(-)/(-)) mice) were treated with AT-1001 (a zonulin peptide inhibitor), a small peptide previously demonstrated to reduce small intestinal permeability. Small intestinal permeability was measured, in vivo, weekly from 4 to 17 weeks of age. Colonic disease was assessed at 8 weeks in Ussing chambers, and at 17 weeks of age inflammatory cytokines and myeloperoxidase were measured in the colon. Colonic permeability and histology were also endpoints. RESULTS: Treated animals showed a marked reduction in small intestinal permeability. Average area under the lactulose/mannitol time curve: 5.36 (SE 0.08) in controls vs 3.97 (SE 0.07) in the high-dose AT-1001 group, p<0.05. At 8 weeks of age there was a significant reduction of colonic mucosal permeability and increased electrical resistance. By 17 weeks of age, secretion of tumour necrosis factor alpha (TNFalpha) from a colonic explant was significantly lower in the treated group (25.33 (SE 4.30) pg/mg vs 106.93 (SE 17.51) pg/ml in controls, p<0.01). All other markers also demonstrated a clear reduction of colitis in the treated animals. Additional experiments were performed which demonstrated that AT-1001 was functionally active only in the small intestine. CONCLUSIONS: This work suggests that increased intestinal permeability may be an important aetiological event in the development of colitis in IL10(-)/(-) mice.

Hepatitis C virus (HCV) is a blood-borne pathogen and a major cause of liver disease worldwide. Gene expression profiling was used to characterize the transcriptional response to HCV H77c infection. Evidence is presented for activation of innate antiviral signaling pathways as well as induction of lipid metabolism genes, which may contribute to oxidative stress. We also found that infection of chimeric SCID/Alb-uPA mice by HCV led to signs of hepatocyte damage and apoptosis, which in patients plays a role in activation of stellate cells, recruitment of macrophages, and the subsequent development of fibrosis. Infection of chimeric mice with HCV H77c also led an inflammatory response characterized by infiltration of monocytes and macrophages. There was increased apoptosis in HCV-infected human hepatocytes in H77c-infected mice but not in mice inoculated with a replication incompetent H77c mutant. Moreover, TUNEL reactivity was restricted to HCV-infected hepatocytes, but an increase in FAS expression was not. To gain insight into the factors contributing specific apoptosis of HCV infected cells, immunohistological and confocal microscopy using antibodies for key apoptotic mediators was done. We found that the ER chaperone BiP/GRP78 was increased in HCV-infected cells as was activated BAX, but the activator of ER stress-mediated apoptosis CHOP was not. We found that overall levels of NF-kappaB and BCL-xL were increased by infection; however, within an infected liver, comparison of infected cells to uninfected cells indicated both NF-kappaB and BCL-xL were decreased in HCV-infected cells. We conclude that HCV contributes to hepatocyte damage and apoptosis by inducing stress and pro-apoptotic BAX while preventing the induction of anti-apoptotic NF-kappaB and BCL-xL, thus sensitizing hepatocytes to apoptosis.

BACKGROUND: The EXtracorporeal TReatments In Poisoning (EXTRIP) workgroup presents its systematic review and clinical recommendations on the use of extracorporeal treatment (ECTR) in valproic acid (VPA) poisoning. METHODS: The lead authors reviewed all of the articles from a systematic literature search, extracted the data, summarized the key findings, and proposed structured voting statements following a predetermined format. A two-round modified Delphi method was chosen to reach a consensus on voting statements and the RAND/UCLA Appropriateness Method was used to quantify disagreement. Anonymous votes were compiled, returned, and discussed in person. A second vote was conducted to determine the final workgroup recommendations. RESULTS: The latest literature search conducted in November 2014 retrieved a total of 79 articles for final qualitative analysis, including one observational study, one uncontrolled cohort study with aggregate analysis, 70 case reports and case series, and 7 pharmacokinetic studies, yielding a very low quality of evidence for all recommendations. Clinical data were reported for 82 overdose patients while pharmaco/toxicokinetic grading was performed in 55 patients. The workgroup concluded that VPA is moderately dialyzable (level of evidence = B) and made the following recommendations: ECTR is recommended in severe VPA poisoning (1D); recommendations for ECTR include a VPA concentration > 1300 mg/L (9000 μmol/L)(1D), the presence of cerebral edema (1D) or shock (1D); suggestions for ECTR include a VPA concentration > 900 mg/L (6250 μmol/L)(2D), coma or respiratory depression requiring mechanical ventilation (2D), acute hyperammonemia (2D), or pH ≤ 7.10 (2D). Cessation of ECTR is indicated when clinical improvement is apparent (1D) or the serum VPA concentration is between 50 and 100 mg/L (350-700 μmol/L)(2D). Intermittent hemodialysis is the preferred ECTR in VPA poisoning (1D). If hemodialysis is not available, then intermittent hemoperfusion (1D) or continuous renal replacement therapy (2D) is an acceptable alternative. CONCLUSIONS: VPA is moderately dialyzable in the setting of overdose. ECTR is indicated for VPA poisoning if at least one of the above criteria is present. Intermittent hemodialysis is the preferred ECTR modality in VPA poisoning.

No consensus strategies exist for prognosticating metastatic castration-resistant prostate cancer (mCRPC). Circulating tumor DNA fraction (ctDNA%) is increasingly reported by commercial and laboratory tests but its utility for risk stratification is unclear. Here, we intersect ctDNA%, treatment outcomes, and clinical characteristics across 738 plasma samples from 491 male mCRPC patients from two randomized multicentre phase II trials and a prospective province-wide blood biobanking program. ctDNA% correlates with serum and radiographic metrics of disease burden and is highest in patients with liver metastases. ctDNA% strongly predicts overall survival, progression-free survival, and treatment response independent of therapeutic context and outperformed established prognostic clinical factors. Recognizing that ctDNA-based biomarker genotyping is limited by low ctDNA% in some patients, we leverage the relationship between clinical prognostic factors and ctDNA% to develop a clinically-interpretable machine-learning tool that predicts whether a patient has sufficient ctDNA% for informative ctDNA genotyping (available online: https://www.ctDNA.org ). Our results affirm ctDNA% as an actionable tool for patient risk stratification and provide a practical framework for optimized biomarker testing.

The prevention of depression in individuals who are at risk is important for affected individuals, their family members, and for society at large. This study presents the results of a randomized clinical trial aimed at the prevention of depression in nursing home residents. Residents were screened with the Geriatric Depression Scale (GDS) and a diagnostic interview. Those with elevated GDS scores who did not meet diagnostic criteria for depression were randomly assigned to a treatment or control (treatment as usual, TAU) condition. The treatment was an adaptation of the Coping with Stress program developed by Clarke et al. (1995 Clarke, GN, Hawkins, W, Murphy, M, Sheeber, L, Lewinsohn, PM and Seeley, JR. 1995. Targeted prevention of unipolar depressive disorder in an at-risk sample of high school adolescents: A randomized trial of group cognitive intervention. Journal of the American Academy of Child and Adolescent Psychiatry, 34: 312–321. [Crossref], [PubMed], [Web of Science ®] , [Google Scholar]; Journal of the American Academy of Child and Adolescent Psychiatry, 34, 312–321), and focused on various components typical of cognitive–behavioral treatment (CBT) programs (e.g. increasing pleasant events, reducing negative cognitions). Both groups were assessed on measures of depression before treatment, after treatment, and at 3- and 6-month follow-up points. Compared with the TAU group, residents receiving the intervention showed considerable improvement over the 6-month follow-up on the GDS. Average scores on the GDS, for example, went from 14.0 to 9.4 in the CBT group over the course of treatment and follow-up, vs. scores from 13.4 to 12.3 for the TAU group over the same time. However, results on the Center for Epidemiological Studies Depression Scale at 3 months were nonsignificant. Overall, the results of this study suggest that a brief, group-based CBT program can have significant benefit in nursing home residents at risk for depression.

BACKGROUND: Acute cholecystitis is one of the most common diseases requiring emergency surgery. Ultrasonography is an accurate test for cholelithiasis but has a high false-negative rate for acute cholecystitis. The Murphy sign and laboratory tests performed independently are also not particularly accurate. This study was designed to review the accuracy of ultrasonography for diagnosing acute cholecystitis in a regional hospital. METHODS: We studied all emergency cholecystectomies performed over a 1-year period. All imaging studies were reviewed by a single radiologist, and all pathology was reviewed by a single pathologist. The reviewers were blinded to each other's results. RESULTS: A total of 107 patients required an emergency cholecystectomy in the study period; 83 of them underwent ultrasonography. Interradiologist agreement was 92% for ultrasonography. For cholelithiasis, ultrasonography had 100% sensitivity, 18% specificity, 81% positive predictive value (PPV) and 100% negative predictive value (NPV). For acute cholecystitis, it had 54% sensitivity, 81% specificity, 85% PPV and 47% NPV. All patients had chronic cholecystitis and 67% had acute cholecystitis on histology. When combined with positive Murphy sign and elevated neutrophil count, an ultrasound showing cholelithiasis or acute cholecystitis yielded a sensitivity of 74%, specificity of 62%, PPV of 80% and NPV of 53% for the diagnosis of acute cholecystitis. CONCLUSION: Ultrasonography alone has a high rate of false-negative studies for acute cholecystitis. However, a higher rate of accurate diagnosis can be achieved using a triad of positive Murphy sign, elevated neutrophil count and an ultrasound showing cholelithiasis or cholecystitis.

OBJECTIVE: To evaluate the Canadian Diet History Questionnaire I (C-DHQ I) food list and to adapt the US DHQ II for Canada using Canadian dietary survey data. DESIGN: Twenty-four-hour dietary recalls reported by adults in a national Canadian survey were analysed to create a food list corresponding to C-DHQ I food questions. The percentage contribution of the food list to the total survey intake of seventeen nutrients was used as the criterion to evaluate the suitability of the C-DHQ I to capture food intake in Canadian populations. The data were also analysed to identify foods and to modify portion sizes for the C-DHQ II. SETTING: The Canadian Community Health Survey (CCHS) - Cycle 2.2 Nutrition (2004). SUBJECTS: Adults (n 20 159) who completed 24 h dietary recalls during in-person interviews. RESULTS: Four thousand five hundred and thirty-three foods and recipes were grouped into 268 Food Groups, of which 212 corresponded to questions on the C-DHQ I. Nutrient intakes captured by the C-DHQ I ranged from 79 % for fat to 100 % for alcohol. For the new C-DHQ II, some food questions were retained from the original US DHQ II while others were added based on foods reported in CCHS and foods available on the Canadian market since 2004. Of 153 questions, 143 were associated with portion sizes of which fifty-three were modified from US values. Sex-specific nutrient profiles for the C-DHQ II nutrient database were derived using CCHS data. CONCLUSIONS: The C-DHQ I and II are designed to optimize the capture of foods consumed by Canadian populations.

OBJECTIVES: Adverse drug events (ADEs) are unintended and harmful consequences of medication use. They are associated with high health resource use and cost. Yet, high levels of inaccuracy exist in their identification in clinical practice, with over one-third remaining unidentified in the emergency department (ED). The study objective was to derive clinical decision rules (CDRs) that are sensitive for the detection of ADEs, allowing their systematic identification early in a patient's hospital course. METHODS: This was a prospective observational cohort study carried out in two Canadian tertiary care hospitals. Participants were adults presenting to the ED having ingested at least one prescription or over-the-counter medication within 2 weeks. Nurses and physicians evaluated patients for standardized clinical findings. A second evaluator performed interobserver assessments of predictor variables in a subset of patients. Pharmacists, who were blinded to the predictor variables, evaluated all patients for ADEs. An independent committee reviewed and adjudicated cases where the ADE assessment was uncertain or the pharmacist's diagnosis differed from the physician's working diagnosis. The primary outcome was an ADE that required a change in medical therapy, diagnostic testing, consultation, or hospital admission. CDRs were derived using kappa coefficients, chi-square statistics, and recursive partitioning. RESULTS: Among 1,591 patients, 131 (8.2%, 95% confidence interval [CI] = 7.0% to 9.7%) were diagnosed with the primary outcome. The following variables were associated with ADEs and were used to derive two CDRs: 1) presence of comorbid conditions, 2) antibiotic use within 7 days, 3) medication changes within 28 days, 4) age ≥ 80 years, 5) arrival by ambulance, 6) triage acuity, 7) recent hospital admission, 8) renal failure, and 9) use of three or more prescription medications. The more sensitive rule had a sensitivity of 96.7% (95% CI = 91.8% to 98.6%) and required 40.8% (95% CI = 37.7% to 42.9%) of patients to have medication review. The more specific rule had a sensitivity 90.8% (95% CI = 81.4% to 95.7%) and required 28.3% of patients to proceed to medication review. CONCLUSIONS: The authors derived CDRs that identified patients with ADEs with high sensitivity. These rules may improve the identification of ADEs early in a patient's hospital course while limiting the number of patients requiring a detailed medication review.

BACKGROUND: In the IL-10 gene-deficient mouse model, development of intestinal inflammation is associated with a defect in epithelial barrier integrity that is thought to allow sufficient passage of bacteria or bacterial antigens to initiate a mucosal immune response. Microbial monoassociation experiments into axenic animals have shown that some, but not all, endogenous bacteria will initiate an intestinal inflammatory response. For instance, Bacteroides vulgatus does not initiate intestinal inflammation in axenic IL-10 gene-deficient mice. We investigated whether B. vulgatus requires concomitant disruption of the intestinal epithelial barrier integrity in order to initiate an inflammatory response. METHODS: We first identified a dose of the indomethacin that would cause a primary disruption of the epithelial barrier without causing intestinal inflammation. IL-10 axenic mice were then administered this dose of indomethacin in their drinking water for 7 days and concomitantly monoassociated, by oral gavage, with B. vulgatus. RESULTS: Indomethacin treatment (2 microg/g/d) for 7 days resulted in disruption of epithelial barrier integrity, but it caused neither a systemic inflammatory response nor a mucosal inflammatory response in the colon or cecum. Monoassociation with B. vulgatus alone did not lead to a mucosal inflammatory response, despite a measurable systemic response. In contrast, administration of indomethacin plus B. vulgatus-monoassociation resulted in a marked intestinal inflammatory response in colon and cecum. CONCLUSIONS: Our data show that, in a genetically predisposed animal model, the nondisease-causing endogenous bacteria, B. vulgatus, is able to cause an intestinal inflammatory response provided that disruption of the intestinal epithelial barrier has occurred.

Summary Since the introduction prior to 1915 of white pine blister rust ( Cronartium ribicola ) into the forests of western North America, many populations of native white pine species have seriously declined. Because western white pine ( Pinus monticola ) and sugar pine ( P. lambertiana ) are highly valued timber species, their silviculture under intensive management is well‐documented. The silviculture of other white pine species has received less attention but is no less important. For all western species, silvicultural management is a key component for sustaining and restoring viable white pine populations. This review examines approaches for assessing and reducing blister rust hazard, regenerating white pine stands, and tending established stands to reduce damage and impact from blister rust. Hazard and risk ratings provide means for assessing the potential severity of blister rust infestation and its probable impacts on management. An epidemiological simulation model is available for describing complex pathosystem interactions, their consequences on white pine growth and survival, and likely outcomes of silvicultural activities. Until the 1960s, Ribes eradication was the principal method for blister rust control; it is now rarely used except for high‐value trees. The choices of harvest and site preparation methods are critical for successful white pine regeneration. As host responses to blister rust infection are inherited, regeneration is an opportunity to increase seedling survival and disease resistance. For artificial regeneration, the western genetics programmes provide improved planting stock. For natural regeneration, the selection and retention of well‐adapted white pines as seed sources can enhance stand genetics. Thinning and pruning are common silvicultural activities for tending stands and are readily modified for blister rust‐infested stands. Although biological and chemical agents have been used, their performance has been less than satisfactory. Likewise, genetics and other silvicultural practices have also demonstrated limited success in blister rust control. An alternative, adaptive approach could use both silvicultural and genetic techniques to mitigate impacts and maintain white pines.

The effects of positive reframing and restraining in the context of time-limited brief couples therapy were investigated. Forty couples were randomly assigned to either an immediate treatment group or to a waiting-list control group that received delayed treatment. The interventions had a positive impact on dyadic adjustment, target complaints, and conflict resolution of treated couples compared to couples in the waiting-list control group. There were no significant differences observed in the relationship beliefs and spousal attributions between the treated and untreated couples. Thirty-nine percent of couples met L. Christensen and J. Mendoza's (1986) definition of clinically meaningful improvement. Treatment gains observed at the termination of the 3-session treatments appear to have been maintained at 6-weeks follow-up. A positive relation was observed between couples' improvement and compliance with treatment directives. Implications for time-limited brief therapy are discussed.

This article focuses on acquaintance rape, which under Canadian law constitutes a form of sexual assault. Frequency of acquaintance rape often is underestimated due to under-reporting, resulting in a local perception that acquaintance rape rarely occurs in a small Canadian community. A survey was conducted to determine whether acquaintance rape does occur in this community. One hundred sixty-four male and female students from grades 8-12 completed a questionnaire. Twenty-six percent of respondents reported being forced into some type of sexual activity. Based on the survey, this article explores the type of force used, the relationship between acquaintance rape and use of alcohol and drugs, and the relationship between acquaintance rape and the ability to indicate to a partner to stop a behavior. Results confirmed a need to develop programs to prevent rather than merely respond to issues of sexual assault on a date.

The Nicola horst exposes plutonic and amphibolite-grade metamorphic rocks and is surrounded by low-grade arc rocks of the Late Triassic Nicola Group. We present new geological mapping and U–Pb, Nd, and metamorphic data for the Nicola horst near Bob Lake, ~40 km south of Kamloops, British Columbia. The Bob Lake assemblage includes felsic to intermediate metavolcaniclastic rocks, metaconglomerate, schist, phyllite, and other rock types. From U–Pb zircon analysis, a felsic metaporphyry clast in metaconglomerate is 1.04 Ga old. The oldest detrital zircons in metaconglomerate and schist are also near 1 Ga. The Bob Lake assemblage was intruded by 230 Ma tonalite, 219 Ma diorite, and 64 Ma leucogranite and includes 161 Ma felsic porphyry and 157 Ma rhyodacite. Amphibolite-grade metamorphism and ductile flattening and stretching affected all rocks except crosscutting Paleocene granite and granodiorite. The high-grade rocks may be exposed as a result of latest Cretaceous – Eocene extensional ductile flow beneath a thin brittle upper crust. A thickness of ~20 km of juvenile crust beneath the proposed Quesnel terrane is inconsistent with the evidence of Proterozoic source rocks at surface. We infer that most of the crustal lithosphere in this part of the Intermontane Belt is continental, which does not preclude possibly thick arc rocks in other parts. The local thinness of the Nicola Group, however, is inconsistent with emplacement as a regional allochthon and thus with their inclusion in a Quesnel "terrane." The Nicola arc succession appears to have been built on the ancient continental margin.

Metabolomic profiling can be used to study disease-induced changes in inflammatory bowel diseases (IBD). The aim of this study was to investigate the difference in the metabolomic profile of males and females as they developed IBD. Using the IL-10 gene-deficient mouse model of IBD and wild-type mice, urine at age 4, 6, 8, 12, 16, and 20 weeks was collected and analyzed by nuclear magnetic resonance (NMR) spectroscopy. Multivariate data analysis was employed to assess differences in metabolomic profiles that occurred as a consequence of IBD development and severity (at week 20). These changes were contrasted to those that occurred as a consequence of gender. Our results demonstrate that both IL-10 gene-deficient and wild-type mice exhibit gender-related changes in urinary metabolomic profile over time. Some male-female separating metabolites are common to both IL-10 gene-deficient and control wild-type mice and, therefore, appear to be related predominantly to gender maturation. In addition, we were able to identify gender-separating metabolites that are unique for IL-10 gene-deficient and wild-type mice and, therefore, may be indicative of a gender-specific involvement in the development and severity of the intestinal inflammation. The comparison of the gender-separating metabolomic profile from IL-10 gene-deficient mice and wild-type mice during the development of IBD allowed us to identify changes in profile patterns that appear to be imperative in the development of intestinal inflammation, but yet central to gender-related differences in IBD development. The knowledge of metabolomic profile differences by gender and by disease severity has potential clinical implications in the design of both biomarkers of disease as well as the development of optimal therapies.

A multiproxy paleoecological investigation of Lac la Biche, a large boreal lake in northeastern Alberta, Canada, revealed that the lake was eutrophic before European settlement but has undergone additional cultural eutrophication in the past 30 to 50 years. Annual fluxes to sediments of phosphorus, nitrogen, carbon, and inorganic sediments have increased with time. A declining N–P ratio has increasingly favored nitrogen-fixing cyanobacteria. Increased deposition of microbial pigments and diatom frustules and a recent shift in diatom species also indicate increasing eutrophication. Biogenic silica increased with time, but there is no evidence of a near-surface decline that would indicate silica limitation. Stable isotopes suggest that an increasing proportion of carbon deposited in sediments is of in-lake origin, indicating increased productivity. In the basin nearest the town of Lac La Biche, an increase in δ 15 N followed the construction of the sewage treatment plant, but more recently, decreased δ 15 N in both basins suggests that nitrogen fixation has become a more important source of nitrogen. Despite documented damage to the fishery of the lake, zooplankton fossils do not show evidence of a strong trophic cascade. The study illustrates the power of a multiproxy approach in obtaining reliable paleolimnological conclusions.

The Spa Creek assemblage is a distinctive thin pericratonic succession that crosses the Okanagan Valley in the hinterland of the southern Cordilleran Orogen in Canada. The succession was ductilely deformed and metamorphosed before deposition of overlying Triassic dark metaclastic strata. A metaconglomerate within the succession, locally composed of more than 90% biotite granite clasts, yielded five fractions of euhedral zircon that define a precise U–Pb upper intercept of 555.6 ± 2.5 Ma, inferred to be the age of a nearby pluton. Other clasts in the metaconglomerate are generally more abundant, consisting of quartzite, amphibole schist, chlorite schist, sericite schist, biotite schist, and quartz–feldspar porphyry. They are likely host rocks of the pluton and, if so, are Late Proterozoic or older. The granite is interpreted as a terminal product of the Eocambrian rifting that preceded Paleozoic miogeoclinal sedimentation farther inboard. The continuity of pericratonic rocks west of the miogeocline and the occurrence of Proterozoic cratonic rocks at the surface west of the Okanagan Valley show that the ancient continental margin extends into a region where most of the crustal lithosphere was until now thought to consist of accreted Phanerozoic arc and accretionary complexes.

PURPOSE: Summarize available information regarding clinical impact of citalopram on the QTc interval. METHODS: A literature search was conducted in Pubmed, EMBASE, and Cochrane databases using the MeSH term "long QT syndrome" and key word "citalopram" on July 11, 2014. RESULTS: Thirty-one studies were evaluated with 4 included in this review. Studies were excluded if they reported acute overdoses of citalopram or did not report on patient-specific risk factors for long QT syndrome (eg, hypokalemia, bradycardia, and increased age). The majority of the available data is derived from case reports. A number of confounders complicate the determination of a causal link between QTc prolongation and citalopram. Of the 4 studies included for review, none identified significant QTc prolongation in patients taking citalopram 20 to 60 mg daily without the patients having one or more patient-specific risk factors for prolonged QTc. CONCLUSION: There is insufficient evidence to establish a causal link between citalopram 20 to 60 mg orally daily and increased risk of TdP. Further research is required to determine the clinical impact and association between citalopram 20 to 60 mg daily and QTc prolongation.

Objective: To characterize the literature describing the therapeutic use of opioids in the elderly. Data Sources: Two electronic databases, EMBASE and MEDLINE, were searched from years 1990 to September 5, 2018. Relevant reference lists were reviewed. Searches were restricted to English language. Study Selection and Data Extraction: Two reviewers independently screened 827 citations to identify observational studies, population-based cohort studies, retrospective analyses, and control trials looking at the management of persistent pain in patients aged ≥65 years and/or frail patients. Data Synthesis: Thirty-nine articles were included in the systematic review. More specifically, 17 observational studies, 7 population-based cohort studies, 10 retrospective analyses, and 4 controlled trials. The most common etiology of persistent pain was musculoskeletal (50%), and the most often adverse effects reported were central nervous system related (41%) and falls/fractures (39%). Relevance to Patient Care and Clinical Practice: As there is a lack of strong evidence-based recommendations for opioid use in the elderly, this review aims to evaluate opioid use in the elderly and compare their efficacy and safety among this population. Conclusions: Overall, central nervous system adverse effects were most commonly seen in the elderly. However, higher quality evidence is required to further appreciate the dose-related effects on efficacy and safety of opioids in the elderly.

Abstract Background: The use of inclusive terminology in health records continues to be a challenge for transgender, gender-diverse, and nonbinary peoples. When patients access electronic health records, laboratory results, including pathology reports, are among the most frequently viewed items. There has been limited discussion of transgender care within laboratory medicine, despite its role in providing written pathology reports after gender-affirming surgery. Proposal: This group proposes inclusive diagnostic terminology for pathology reporting and puts forward recommendations for procedural descriptions in the pathology report. Finally, we highlight pathological information that should be included in a report that has future cancer screening or diagnostic consequences.

We report a young woman who presented with a reproductive history of three recurrent spontaneous abortions (RSA) and two neonatal deaths. Comparative genomic hybridization (CGH) was used to determine the chromosomal composition of the patient's last miscarriage. It showed the presence of monosomy for the distal end of chromosome 2 long arm (segment 2q37.2 to qter) and trisomy for the distal end of chromosome 17 long arm (segment 17q25 to qter). The mother was found to be a carrier for a cryptic translocation between chromosomes 2 and 17 long arms by fluorescence in situ hybridization using a subtelomeric probe for 17q. Retrospective CGH analysis on one baby who died neonatally showed that he had inherited the maternal translocation in the same unbalanced state as the last pregnancy loss. His detailed postmortem examination is reported.