Capital District Health Authority

Introduction: Diuretics are an essential component of decompensated heart failure management. Yet, some patients develop diuretic resistance. Defined as inadequate response to escalating dosage of diuretics. Management includes increasing diuretic dosage, combination diuretic therapy and ultrafiltration. A less recognized approach is Hyperdiuresis, where loop diuretics are combined with hypertonic saline to enhance natriuresis and overcome diuretic resistance. We present a case of diuretic resistant heart failure responding to Hyperdiuresis. Description: A 76-year-old male with a history of congestive heart failure presented with respiratory failure secondary to pneumonia and pulmonary congestion requiring intubation. Chest Xray showed pulmonary infiltrates and congestion. Despite completing antibiotics and receiving Bumex 2mg IV twice daily for congestion, patient failed weaning trials due to tachypnea and continued need for pressure support. Chest X-ray and CT showed persistent pulmonary congestion, BNP was 30,000 and urine output was ~1L with an intake of 2.7L. Bumex dose was increased to 2 mg three times daily, and metolazone 5 mg was added. Urine output improved to 2L. However, pulmonary congestion persisted. Considering serum sodium of 148 and Creatinine Clearance of 60 mL/min2, decision was made to pursue Hyperdiuresis. Patient received 40 mg IV Lasix and 150 ml of 3% saline. Urine output increased to 5L over 24 hours. Patient was then resumed on Bumex 2 mg IV twice daily with an output of 3 liters. Patient was liberated from mechanical ventilation 2 days after Hyperdiuresis. Discussion: Diuretic resistance poses a challenge in heart failure management. When increasing dosages of diuretics or combination therapy fail, interventions as ultrafiltration are often considered. Proposed pathophysiology of diuretic resistance includes renal hypoperfusion, neurohormonal activation and decreased sodium delivery to the distal nephron. The mechanism of Hyperdiuresis includes complementary effects on sodium reabsorption and renal blood flow, with hypertonic saline causing intravascular volume expansion, increasing sodium and chloride delivery to macula dense, inhibiting RAAS system and Lasix increasing renal blood flow, sodium and chloride delivery to macula dense, achieving both diuresis and natriuresis.

It's no surprise to anyone to have us say that we are living in challenging times. Though some may have thought that a postpandemic world would see the recovery and stabilization of economies, healthcare systems and workforces, at times it feels somewhat similar to a never-ending era of calamity. We continue to live in a time of polycrisis - from economic instability exacerbated by ongoing global trade wars, struggling health workforces impacting the accessibility and availability of healthcare services, to worsening planetary health exacerbating food and water insecurity, physical and mental health issues, health inequities and forced migration and displacement. We are severely off track to meet the United Nations' Sustainable Development Goals (SDGs) by 2030 (UN 2015). Nurses and nurse practitioners are leaving the profession at record numbers, with many leaving just within the first few years of being licensed (Faubert 2025). Working conditions remain a challenge across provincial and territorial health systems (CFNU 2025). Yet, while the future may look bleak, these wicked problems are not impossible to fix. Indeed, this is our new normal - a constantly changing world that, now more than ever, needs our resolve to create a healthier future for all.

On behalf of Cell Therapy Transplant Canada (CTTC), we are pleased to present the Abstracts of the CTTC 2024 Annual Conference. The conference was held on 1-3 May 2024 in beautiful Victoria, British Columbia, at the Victoria Conference Centre, and attracted 293 in-person delegates and five virtual attendees. Several plenary sessions were held on topics such as gene therapy for hemoglobin disorders, optimizing donor selection, graft-versus-host disease (GvHD) strategies, collaborative care, survivorship, graft failure, and CAR-T therapy. Poster authors presented their work during a lively and engaging networking reception on Thursday, 2 May, and oral abstract authors were featured during the oral abstract session in the afternoon of Friday, 3 May 2024. Forty-nine (49) abstracts were selected for presentation as posters and six (6) as oral presentations. Abstracts were submitted within four categories: (1) Basic/Translational Sciences, (2) Clinical Trials/Observations, (3) Laboratory/Quality, and (4) Pharmacy/Nursing/Other Transplant Support. The top six (6) abstract authors were invited to give an oral presentation, and the top four (4) poster abstracts were selected to receive an award. All of these were marked as "Award Recipient" within the relevant category. Three abstracts were determined by the peer review panel to be inappropriate for this conference and were not invited to present at the conference, and two authors withdrew their abstract; therefore, five abstract numbers are missing from the list. We congratulate all the 2024 abstract presenters on their research and contributions to the field.

Trigeminal neuralgia (TN) is a chronic, often debilitating neuropathic facial pain condition. First-line treatment is medical therapy, with carbamazepine (CBZ) being the gold standard. Surgery, including stereotactic radiosurgery in particular with Gamma Knife (GK-SRS), is usually considered when medical management fails, which occurs in >50% ofpatients. While surgery can provide long-term relief, prolonged disease duration before intervention is linked to a reduced response rate. A highly precise type of radiation therapy, GK-SRS is a non-invasive management option in TN, with a low risk of serious complications and fewer bothersome side effects compared to medical therapy. Evidence supports the safety and efficacy of GK-SRS in medically refractory TN, with published data suggesting that earlier intervention (within 3years of pain onset) leads to improved long-term outcomes. However, the safety and efficacy of ultra-early GK-SRS-administered soon after TN diagnosis and before medical refractoriness-have not been examined. We hypothesize that ultra-early GK-SRS will yield superior long-term pain relief compared to ongoing medical management while also having a lower incidence of treatment-related adverse events (AEs). We will perform a single-center, two-arm, randomized, controlled, parallel group design, pragmatic, noninferiority, phase II trial of ultra-early GK-SRS for TN in participants who will be treated before they have developed a medically refractory state and within 2years of diagnosed TN per study neurologist. Eighty participants will be randomized 1:1 to either GK-SRS (intervention arm) or ongoing medical management (non-intervention/control arm). Crossover from the non-intervention/control arm to the intervention arm will be permitted. An intention-to-treat analysis will be conducted. The primary outcome will be the proportion of participants with satisfactory pain control at 2years by the Barrow Neurological Institute Facial Pain Scale. This trial aims to test ultra-early GK-SRS as a first-line option in TN, based on a sound rationale for offering GK-SRS prior to failure of medical therapy. If validated, ultra-early GK-SRS will represent a paradigm shift in TN management leading to improved long-term pain control free from adverse medication-related side effects. ClinicalTrials.gov NCT06949436. Registered on April 28, 2025.

The safety, yield, and prognosis of a type 1 procainamide-induced Brugada pattern are incompletely understood and may differ from those of other sodium channel blockers with greater potencies. The safety of procainamide infusion and yield of a type 1 Brugada pattern were assessed according to indication in consecutive patients from the Canadian Hearts in Rhythm Organization registry. Outcomes were evaluated in patients with a standard or high-lead procainamide-induced Brugada pattern (without previous cardiac arrest) and compared with those with a spontaneous type 1 pattern. In 947 consecutive patients undergoing procainamide infusion for the diagnosis or exclusion of Brugada syndrome, 2 patients (0.2%) experienced asymptomatic ventricular arrhythmias related to procainamide, which resolved upon discontinuation of the infusion. The yield of a type 1 pattern was 7.2% in 390 patients with unexplained cardiac arrest, 22.2% in 135 patients with a family history of Brugada syndrome, and 6.9% in 116 patients with a family history of unexplained cardiac arrest or sudden death. Test yield was 46.6% in 189 patients with a non-specific type 2 or 3 Brugada pattern and 92% in those with an intermittent spontaneous type 1 pattern (ie, implied sensitivity of 92%). Estimated specificity was very high. In 137 patients with a procainamide-induced type 1 Brugada pattern (with no previous cardiac arrest) followed for a mean of 5.9±4.5 years, no patients met the primary composite arrhythmic end point (0%). In 105 spontaneous type 1 patients, one patient (1%) met the primary end point after receiving appropriate shocks for ventricular fibrillation. Thirteen percent had a primary prevention implantable cardioverter defibrillator implanted at baseline (one appropriate shock), with an additional 7% undergoing implantable cardioverter defibrillator implantation during follow-up, predominantly for syncope with a suspected arrhythmic mechanism. No patient who underwent implantable cardioverter defibrillator implantation during follow-up subsequently received appropriate therapy. Procainamide infusion is extremely safe for the diagnosis and exclusion of Brugada syndrome, with yield dependent on pretest probability and indication for testing. Estimated sensitivity and specificity appear to be high. Patients with an asymptomatic procainamide-induced type 1 Brugada pattern are at very low risk of malignant ventricular arrhythmias.

Urolithiasis is a common complication of primary hyperparathyroidism (PHPT). Parathyroidectomy has been shown to decrease the rate of stone formation. The purpose of this study was to evaluate healthcare resource utilization before and after parathyroidectomy and identify predictors of increased healthcare utilization. A retrospective analysis of patients who had a parathyroidectomy for PHPT in Nova Scotia from 2013-2018 was performed. Data from five years before parathyroidectomy to three years after were included. Outcomes included emergency department (ED) visits and the number of urologic interventions. Random-effects Poisson regression models were used to calculate the primary outcomes, ED visits, and the number of urologic interventions while adjusting for prespecified characteristics. Fifty patients (62% female) with a mean age of 60±11 years were identified. ED visits were 0.42 per year before parathyroidectomy and 0.20 per year after in a multivariate analysis (incidence rate ratio [IRR] 0.48, confidence interval [CI] 0.25-0.91, p=0.024). There was no statistical difference between male and female ED visits (p=0.6719). There was no difference in the rate of ED visits for non-urologic reasons after parathyroidectomy (p=0.0749). The incidence of urologic intervention for stones was 1.24 per year before parathyroidectomy and 0.53 per year after (IRR 0.42, CI 0.26-0.68, p=0.0005). Healthcare resource utilization, in terms of ED visits and urologic intervention, significantly decreased after parathyroidectomy. Sex showed no statistical difference in predicting healthcare utilization, while non-urologic ED visits remained the same after surgery. Expedited parathyroidectomy for PHPT patients may decrease urologic interventions and ED visits, resulting in less healthcare utilization.

Diffuse hemispheric glioma H3 G34-mutant is primarily diagnosed in adolescents/young adults. While molecular diagnostics have improved, cellular mechanisms that drive tumor progression and therapy resistance are poorly understood. Combining previous published studies with findings from the 2024 NIH G34-mutant symposium aid in summarizing translational and clinical updates on disease development, cellular repair processes, and the immune microenvironment. This collective work is meant to outline opportunities for treatment and prolonged survival.

Polyarteritis nodosa (PAN) is a rare autoimmune vasculitis characterized by the inflammation of medium-sized arteries throughout the body. This case report presents the clinical course of a 48-year-old female patient who experienced a complex diagnostic journey and complications during the management of PAN. The patient initially presented with dry skin, rash, and pruritus, which led to an extensive evaluation. Despite multiple visits and investigations, the definitive diagnosis of PAN was delayed. Eventually, the patient was diagnosed with PAN based on skin biopsy findings demonstrating vasculitis and inflammation of blood vessel walls. The treatment course was further complicated by the development of steroid-induced diabetes and recurrent vasculitis symptoms. Recurrence of symptoms, including rashes and neuropathy, necessitated adjustments in therapeutic interventions. This case highlights the challenges encountered in managing both PAN and its associated complications and emphasizes the importance of a multidisciplinary approach and improved patient compliance to optimize treatment outcomes.