Using family physician Electronic Medical Record data to measure the pathways of cancer care

  Introduction Gaps in care have been identified along the disease pathway for specific cancers. However, no real-world data exists to identify wait times along these cancer pathways. Secondary use of family physician (FP) electronic medical record data (EMR) can augment existing health administrative data in measuring steps in the care pathways. Objectives and Approach We used FP EMR data to identify care pathways for lung cancer and breast cancer patients from the description of symptoms, to the initiation of investigations, referrals to specialty care and the receipt of specific treatments (surgery, chemotherapy, radiation treatment). Data from the Electronic Medical Record Administrative data Linked Database (EMRALD) held at the Institute for Clinical Evaluative Sciences (ICES) was used to identify a cohort of lung cancer and breast cancer patients. Data abstractors examined the FP EMR notes to identify pre-diagnostic symptoms, pre-diagnostic radiological test, biopsy results, oncology and surgical specialist referrals and post-diagnostic surgical and oncological consultations. Results To date, abstractors have reviewed the FP EMR notes for 300 lung cancer patient and 1200 breast cancer patients. Abstractors identified an index date where there was documentation of the first abnormal test result and/or a FP progress note documenting a “suspicious” or “concerning” sign or symptom. For both lung cancer and breast cancer patients, a pre-diagnostic index date was identified in 88.5% of FP EMR notes. For lung cancer patients 66.7% based were based on abnormal chest x-rays and for breast cancer patients 81.1% were based on abnormal mammograms. Pre-diagnostic symptoms were identified in 62.1% of FP EMR notes and 81.6% had post-diagnostic consultation notes. Wait times from the index date to seeing an oncological specialist were less than four weeks for all patients. Conclusion/Implications We are able to use information from FP EMRs linked to health administrative data to identify pre-diagnostic care received by patients prior to their cancer diagnosis. This information can be used to identify care gaps and measure wait times in receiving cancer care from a patient’s perspective

Over-use of thyroid testing in Canadian and UK primary care in frequent attenders : a cross-sectional study

Dr Greiver is supported through the Gordon F. Cheesbrough Research Chair in Family and Community Medicine from North York General Hospital.Background Thyroid stimulating hormone (TSH) is a common test used to detect and monitor clinically significant hypo- and hyperthyroidism. Population based screening of asymptomatic adults for thyroid disorders is not recommended. Objective The research objectives were to determine patterns of TSH testing in Canadian and English primary care practices, as well as patient and physician practice characteristics associated with testing TSH for primary care patients with no identifiable indication. Methods In this two-year cross-sectional observational study, Canadian and English electronic medical record databases were used to identify patients and physician practices. Cohorts of patients aged 18 years or older, without identifiable indications for TSH testing, were generated from these databases. Analyses were performed using a random-effects logistic regression to determine patient and physician practice characteristics associated with increased testing. We determined the proportion of TSH tests done concurrently with at least one common screening blood test (lipid profile or hemoglobin A1c). Standardized proportions of TSH test per family practice were used to examine the heterogeneity in the populations. Results At least one TSH test was done in 35.97 % (N=489,663) of Canadian patients and 29.36% (N=1,030,489) of English patients. Almost all TSH tests in Canada and England (95.69% and 99.23% respectively) were within the normal range (0.40-5.00 mU/L). A greater number of patient-physician encounters was the strongest predictor of TSH testing. 51.40% of TSH tests in Canada and 76.55% in England were done on the same day as at least one other screening blood test. There was no association between practice size and proportion of asymptomatic patients tested. Conclusions This comparative binational study found TSH patterns suggestive of over-testing and potentially thyroid disorder screening in both countries. There may be significant opportunities to improve appropriateness of TSH ordering in Canada and England and therefore improve allocation of limited system resources.PostprintPeer reviewe

Teaching Electronic Medical Record (EMR) Data Discipline to Clinical Trainees: A Canadian Pilot Study

Evidence suggests that patients whose electronic medical records (EMR) are documented with high quality data obtain higher quality care. However, most clinicians do not routinely document with this data discipline, and to date how to instruct this has not been clear. In this study, the key components of such an educational session for Canadian family medicine trainees were determined, with a particular focus on improving trainee awareness of the importance of data discipline and their understanding of data consistency. We piloted our developed session in three academic teaching sites and found no statistically significant difference when comparing two instructional methods – exploratory case simulations versus didactic only. However, trainee performance in general was satisfactory, suggesting robust immediate learning regardless of teaching method. Trainees also confirmed a strong desire for education on data discipline. Going forward, the educational session can be improved, become embedded in curricula, and evaluated using real-world EMR data.M.Sc

Traffic control at the nuclear pore

The proper communication between organelles is essential for many aspects of eukaryotic life. The coordination of nuclear and cytoplasmic activities in particular is of pivotal importance and depends on transport in and out of the nucleus. The material which translocates through nuclear pores is diverse; it includes numerous proteins, RNAs and large ribonucleoprotein complexes like ribosomal subunits. To ensure the correct nucleocytoplasmic distribution of these components, appropriate mechanisms have to be in place which control traffic across the nuclear envelope. A growing number of studies support the notion that transport through nuclear pore complexes is intimately linked to cell physiology. As such, it has become evident that changes in the cellular environment, either by externally applied stress, aging or disease, alter nuclear traffic. Due to the progress made in the past few years, we are now beginning to understand these processes at the molecular level. Thus, the concept emerges that stress or disease conditions correlate with signaling events which aim at the nuclear transport apparatus. Here, we summarize results from recent publications that provide evidence for the hypothesis that changes in cell physiology modulate nuclear traffic by targeting multiple transport factors. We propose that this traffic control is at least in part mediated by specific signaling events

Oxidative Stress Inhibits Nuclear Protein Export by Multiple Mechanisms That Target FG Nucleoporins and Crm1

Nuclear transport of macromolecules is regulated by the physiological state of the cell and thus sensitive to stress. To define the molecular mechanisms that control nuclear export upon stress, cells were exposed to nonlethal concentrations of the oxidant diethyl maleate (DEM). These stress conditions inhibited chromosome region maintenance-1 (Crm1)-dependent nuclear export and increased the association between Crm1 and Ran. In addition, we identified several repeat-containing nucleoporins implicated in nuclear export as targets of oxidative stress. As such, DEM treatment reduced Nup358 levels at the nuclear envelope and redistributed Nup98. Furthermore, oxidative stress led to an increase in the apparent molecular masses of Nup98, Nup214, and Nup62. Incubation with phosphatase or β-N-acetyl-hexosaminidase showed that oxidative stress caused the phosphorylation of Nup98, Nup62, and Nup214 as well as O-linked N-acetylglucosamine modification of Nup62 and Nup214. These oxidant-induced changes in nucleoporin modification correlated first with the increased binding of Nup62 to the exporter Crm1 and second with the reduced interaction of Nup62 with other FxFG-containing nucleoporins. Together, oxidative stress up-regulated the binding of Crm1 to Ran and affected multiple repeat-containing nucleoporins by changing their localization, phosphorylation, O-glycosylation, or interaction with other transport components. We propose that the combination of these events contributes to the stress-dependent regulation of Crm1-mediated protein export

Blood pressure and blood glucose concentration amongst middle-aged men conceived and/or born on Guernsey during the 1940-45 German occupation

Session - Obesity, diet and exercisepublished_or_final_versio