Providence Health Care

Buprenorphine (Bup) is a first-line medication for opioid use disorder (OUD) that carries risk of precipitated withdrawal (PW) with ongoing need for rapid and effective initiation strategies. We report a novel approach to low-dose initiation using transdermal Bup patches (TD-Bup) and characterize the efficacy and tolerability of 24 h and 48 h TD-Bup initiation protocols for Bup as a medication for OUD (MOUD). We conducted a retrospective chart review using data extracted from paper and electronic medical records of adult inpatients with OUD admitted to Vancouver General Hospital between January 2022 and October 2023. Eligible patients were started on low-dose transdermal buprenorphine (TD-Bup) initiation protocols. The intervention involved sequenced application of TD-Bup patches reaching a total of 12 patches (240 µg/h) over 24 to 48 hours, with continuation of full opioid agonists. Protocol variants included: 6 patches q24h for 48 hours, 6 patches q12h for 24 hours, and 4 patches q8h for 24 hours. Primary outcomes were the rate of successful initiation onto therapeutic doses of sublingual or extended-release depot Bup, and the incidence of opioid withdrawal. Seventy five patients were identified. Fifty five (73%) were successfully initiated and discharged on Bup and the most common reasons for unsuccessful initiation were preference to switch to another medication for OUD (n = 11) and withdrawal (n = 6). There was no significant difference between the protocol variants for successful initiation (p = 0.191). Adverse events (agitation, increased pain, insomnia, pruritus) were reported in 5 dropouts. Only 28 patients had sufficient Clinical Opioid Withdrawal Scale (COWS) scores to allow for objective assessment of withdrawal, with the remainder evaluated from full chart review. Nineteen patients had COWS score elevation > 6 and/or any narrative documentation of withdrawal. Three patients were felt to represent probable PW. No relationships were found between withdrawals and protocol variant (p = 0.621) or successful initiation (p = 0.082). All-cause withdrawals were associated with self-directed discharges (p = 0.042). Rapid low-dose buprenorphine initiation with TD-Bup appears feasible with relatively low risk of withdrawals and PW, although a weakness is the vulnerability to underdosing patients with full opioid agonists resulting in opioid deficit withdrawal. Further prospective evaluation of d rapid low-dose buprenorphine initiation with TD-Bup against other evidence-based contemporary Bup MOUD initiations is warranted.

Understanding is limited about how youths (ages 12-24) engage with peer support services across in-person, virtual, and hybrid formats, particularly within integrated youth services (IYS) settings. This study aimed to examine the demographic, health, and social characteristics of youths accessing peer support services; explore the types of peer support services utilized at an IYS initiative; and identify potential differences between clients who access in-person, virtual, and hybrid (i.e., in-person and virtual) services. A secondary data analysis was performed for all youths who accessed youth peer support services at an IYS initiative in British Columbia, Canada, from April 2018 to February 2023. Self-reported demographic characteristics, mental health, and distress and the services accessed were examined across three modalities (in-person, virtual, and hybrid services). During the study period, 3,586 unique youths attended 12,343 peer support visits. Youths had low self-rated mental health (poor, 35%; fair, 36%) and high distress (mean±SD Kessler Psychological Distress Scale score=30.73±9.08 out of 50) upon initial presentation. Significant differences were found among the in-person, virtual, and hybrid groups by age, race, and sexual and gender minority status. This large cohort of youth peer support clients had extremely high distress at initial presentation. Youth peer support, provided through an IYS model with multiple modalities to improve service access for diverse youths, should be considered as one option for addressing systemic inequity in health care and the current global youth mental health crisis.

Abstract Objective: To determine the value of estrogen in overall management of breast cancer. Background: Despite the prior consensus of Estrogen [E] Breast Cancer [BrCa] harm, recent 20-year follow-up data from the double-blind randomized Women’s Health Initiative Trial 2 [WHI-2], show E-alone based Hormone Replacement Therapy [E-HRT] reducing BrCa incidence by 22%, and, unexpectedly, BrCa mortality by 40%.1For comparison, the Tamoxifen randomized breast cancer prevention trial [IBIS-1] also reported a lower BrCa incidence [RR=0.71], but no mortality reduction [RR = 1.19, 95% CI].2,3 (Table 1). Comments: These prevention outcomes show both E-HRT and Tamoxifen equally effective in reducing incidence rates. The striking difference, however, is the significant mortality reduction with E-HRT, but not with Tamoxifen. Furthermore, E-HRT offers major benefits for quality-of-life [QOL] and for other rate reductions: Alzheimer dementia mortality: -26%; women age <60 at E-HRT start, both myocardial infarctions [-41%] and the all-cause mortality [-26%].3,4 In addition to these prevention benefit outcomes, estrogen emerged much more effective than Tamoxifen in stage IV BrCa [5 year overall survival: 35% vs 16%, adjusted p = 0.039].5 Conclusion: We believe the observed benefits of E-HRT* are sufficiently compelling to seek its guideline approval both in breast cancer prevention and in adjuvant settings, with or without anti-estrogens, with expectations of tens of thousands more avoided deaths per year, just in USA alone,4 while QOL is dramatically improved.*E-HRT: Estrogen alone for women with hysterectomy; Estrogen + progesterone for women with retained uterus

BackgroundHomozygous familial hypercholesterolemia (HoFH) is a rare genetic disorder characterized by extreme elevations in low-density lipoprotein cholesterol levels and premature cardiovascular disease.ObjectivesThe objective of this study was to assess the prevalence, clinical presentation, and current therapeutic approaches for aortic stenosis in Canadian patients with HoFH.MethodsDemographic data, lipid profiles, and genetic testing results for patients with HoFH were collected prospectively since 2008. Reports from echocardiography, cardiac catheterization, and surgical or transcatheter interventions involving the aortic valve and/or ascending aorta were retrieved from medical records.ResultsData were available for 63 patients with either a clinical diagnosis (n = 14, 22.2%) or genetic confirmation (n = 49, 77.8%) of HoFH. The median age at diagnosis was 14.0 years (Q1-Q3: 6.0 to 31.0), the median highest recorded low-density lipoprotein cholesterol level was 13.0 mmol/L (Q1-Q3: 10.6-16.3), and 17 patients (27.0%) developed moderate-to-severe aortic stenosis. Extensive calcification of the aortic valve and ascending aorta, combined with severe valvular and/or supravalvular stenosis and coronary ostial stenosis, necessitated complex and often consecutive surgical procedures. Six transcatheter aortic valve replacements were performed in 4 patients, 4 of which failed. Thirteen patients (20.6%) underwent at least 1 surgical aortic valve procedure. Patients developed aortic stenosis at a young age despite intensive treatment, including lipoprotein apheresis started at an early age.ConclusionsModerate-to-severe aortic stenosis was observed in 27.0% of patients in the Canadian HoFH Registry, with 20.6% requiring invasive intervention. The severe aortic phenotype associated with HoFH requires complex, multidisciplinary surgical management in specialized centers with appropriate expertise.

BackgroundPersons with Parkinson’s disease (PwPD) require ongoing rehabilitation to maintain independence, but traditional center-based and unsupervised home programs have limitations in accessibility and adherence. Home-based telerehabilitation (TR) offers a promising alternative by enabling remote delivery of exercise interventions.ObjectiveTo evaluate the effect of home-based TR on balance, functional mobility, and quality of life in PwPD.MethodsA comprehensive electronic search was conducted across PubMed, CINAHL, Embase, OvidSP, ProQuest, Scopus, Web of Science, Cochrane CENTRAL, and PEDro databases. Interventional studies on exercise-centric home-based TR for PwPD with either balance, functional mobility, or quality of life as outcomes were included.ResultsA total of 37 studies were included in this systematic review, of which 13 were eligible for meta-analysis. The meta-analysis revealed small but significant improvements in balance (SMD = 0.25; 95% CI: 0.04 to 0.45; p = 0.02). and functional mobility (SMD = −0.28; 95% CI: −0.52 to −0.05; p = 0.02). However, no significant effect was observed for quality of life (SMD = −0.08; 95% CI: −0.25 to 0.09; p = 0.35).ConclusionHome-based TR is effective for improving balance and functional mobility in PwPD, although, its effect on quality of life is unclear which warrants further research.

A serious illness conversation elicits a patient's wishes, goals and values in the setting of advancing illness. Patients living with structural vulnerabilities and substance use disorders encounter barriers to these conversations and therefore often experience less than ideal deaths. This study aims to understand the needs and preferences of these patients during serious illness conversations in the acute hospital setting and to inform best practice recommendations for serious illness conversations with this patient population. We performed a qualitative research study using interpretive description methodology at a single tertiary care inner-city hospital in Vancouver, British Columbia, Canada. Data was collected from 16 hospitalized participants living with structural vulnerability, substance use disorder and chronic illness. Semi-structured interviews were recorded, transcribed and analyzed iteratively by our research team using thematic analysis. Participants had unmet basic needs and therefore unique priorities during serious illness conversations. Participants frequently had previous negative healthcare experiences which resulted in them guarding their feelings from healthcare providers. Hope was emphasized as an important component of serious illness conversations. Participants also outlined specific preferences and recommendations for healthcare providers engaging in these conversations. Our findings offer several important considerations for engaging in serious illness conversations with patients living with structural vulnerabilities and substance use disorders that, if implemented, should improve the quality of conversations and care.

status: Published online