Geoff Koehler

One in every three women undergoing a mastectomy could potentially be spared chronic post-operative pain if anesthesiologists used a regional anesthetic technique in combination with standard care, says Faraj Abdallah, an assistant professor in the department of anesthesia at the 91�Թ�.

Standard care for mastectomies is a general anesthetic, whereby anesthesiologists use gas to keep the patient asleep and narcotics to control pain. Up to 60 per cent of women experience chronic pain three months after they’ve had the surgery and at least half of those suffer from this pain one year later.

“Sadly, the pain these women experience can be so severely debilitating that it may require treatment by a pain specialist and pain killers,” said Abdallah, who is also an anesthesiologist at St. Michael’s Hospital.

The regional anesthetic technique Abdallah added to standard care – called ultrasound-guided paravertebral blocks – is similar to a dental freeze. Trained anesthesiologists use a local anesthetic to freeze nerves in the breast area.

Paravertebral blocks allow excellent pain control immediately after surgery and help with long-term pain reduction, Abdallah said.

“Six months after breast cancer surgery, we found that women who received paravertebral blocks immediately before their mastectomies had more than 50 per cent lower risk of developing chronic pain compared to those who received standard care,” said Abdallah.

The study, published in the journal PAIN, showed that these nerve blocks most significantly reduced neuropathic pain, which is the most common form of chronic pain affecting women after mastectomies. Unlike the soreness and aching associated with conventional pain – which may also affect these patients – neuropathic pain also affects sensation.

“One patient will lose sensation and not be able to feel a pin prick, another will experience severe pain if the skin is even lightly touched and the next patient may feel constant tingling or pins and needles,” said Abdallah. “Grading pain on a scale of one to 10 fails to capture neuropathic pain symptoms and frequently leads to under-diagnosis.”

Because each patient may experience different neuropathic symptoms pain, Abdallah said clinicians needed a reliable tool to assess this pain in women after breast cancer surgery and to measure how effective their interventions are at preventing this pain.

In this same study, the researchers also showed that a pain assessment test called the DN-4 can be used by clinicians to reliably identify chronic neuropathic pain in women after breast cancer surgery.

The DN-4 combines interview questions with a physical assessment performed by a clinician. It tests the patient’s sensation in the four areas where post-mastectomy pain is likely to occur – the breast, the chest, the shoulder and the arm.

“Breast cancer survival rates have improved significantly with advances in diagnosis and management, but chronic pain management after breast cancer surgery has not kept pace,” said Abdallah. “Proving that the DN-4 is a reliable test for this patient group is important because it gives clinicians a diagnostic tool to identify this pain, monitor its progress and measure the success of treatment.”

Abdallah began this randomized controlled trial while at Women’s College Hospital. Since joining St. Michael’s Hospital, Abdallah has continued this research and incorporated the paravertebral block technique into his practice at the hospital.

Research was supported by a grant from the Ontario Ministry of Health and Long Term Care’s Alternate Funding Plan Innovation Fund.

Geoff Koehler is a writer with St, Michael's Hospital, a partner of the 91�Թ�.

picpath

sites/default/files/2015-02-27-mammogram-(2).jpg

Children who drink non-cow's milk twice as likely to have low vitamin D

sgupta — Tue, 21 Oct 2014 12:49:45 +0000

Children who drink non-cow's milk twice as likely to have low vitamin D sgupta Tue, 10/21/2014 - 08:49

Cutline

In North America, cow’s milk is required to be fortified with vitamin D (photo by Ella Alfon via Flickr)

Geoff Koehler

Author legacy

Geoff Koehler

Topic

Breaking Research

More News

St. Michael's Hospital

Subheadline

In children, low levels of vitamin D can cause bone weakness or, in severe cases, rickets

Children who drink non-cow’s milk such as rice, almond, soy or goat’s milk, have lower levels of vitamin D in their blood than those who drink cow’s milk, new research published in the Canadian Medical Association Journal has found.

Non-cow’s milk is becoming increasingly popular because of perceived health benefits, milk allergies or lactose intolerance.

“Children drinking only non-cow’s milk were more than twice as likely to be vitamin D deficient as children drinking only cow’s milk,” said Dr. Jonathon Maguire, an assistant professor in the 91�Թ� departments of pediatrics and health policy, management and evaluation, and a researcher with St. Michael’s Hospital.

“Among children who drank non-cow’s milk, every additional cup of non-cow’s milk was associated with a five per cent drop in vitamin D levels per month.”

Vitamin D is an essential nutrient produced through sun exposure or found in fortified cow’s milk, fish and other foods. It plays an important role in the development and strengthening of bones. In children, low levels of vitamin D can cause bone weakness and, in severe cases, rickets – a condition causing the bones to become soft and weak and potentially leading to bone deformities.

In North America, every 100 millilitres of cow’s milk is required to be fortified with 40 units of vitamin D. Adding vitamin D to non-cow’s milk, however, is voluntary.

“It is difficult for consumers to tell how much vitamin D is in non-cow’s milk,” said Maguire. “Caregivers need to be aware of the amount of vitamin D, calcium and other nutrients in alternative milk beverages so they can make informed choices for their children.”

The study involved 3,821 healthy children ages one to six. Researchers looked at differences in blood levels of vitamin D associated with drinking cow’s milk and non-cow’s milk. The children were recruited from seven Toronto pediatric or family medicine practices that are part of a research network called TARGet Kids!.

“Our findings may also be helpful to health care providers working with children who regularly consume non-cow’s milk due to cow’s milk allergy, lactose intolerance or dietary preference,” said Maguire.

Eighty-seven per cent of children involved in the study drank predominantly cow’s milk and 13 per cent drank non-cow’s milk.

Overall support for the TARGet Kids! program is provided by the Canadian Institutes of Health Research’s Institute of Human Development, Child and Youth Health and the Institute Nutrition Metabolism and Diabetes, as well as the St. Michael’s Hospital Foundation. The Pediatric Outcomes Research Team is supported by a grant from The Hospital for Sick Children Foundation.

Geoff Koehler is a writer with St. Michael's Hospital, a partner of the 91�Թ�. (Read more stories about St. Michael's Hospital.)

picpath

sites/default/files/2014-10-21-cows-milk-vitamin-d.jpg

Breast cancer: women with severe, chronic health issues screened less often than healthier women

sgupta — Fri, 22 Aug 2014 14:38:15 +0000

Breast cancer: women with severe, chronic health issues screened less often than healthier women sgupta Fri, 08/22/2014 - 10:38

Cutline

(photo by Rhoda Baer, National Cancer Institute)

Geoff Koehler

Author legacy

Geoff Koehler

Topic

Breaking Research

Top Stories

St. Michael's Hospital

Subheadline

Researcher finds women with "severe disability, multiple chronic conditions, low income and lower education" have fewer screens

Women with severe disabilities and multiple chronic conditions are screened for breast cancer less often than women with no disabilities or no chronic conditions, a new study has found.

They are also screened less often than women with moderate disabilities or women with only one chronic condition, according to research by Dr. Sara Guilcher of the Health System Performance Research Network at the 91�Թ�’s Institute of Health Policy, Management and Evaluation and affiliate scientist with the Li Ka Shing Knowledge Institute of St. Michael’s Hospital.

Guilcher, who conducted the study with colleagues at 91�Թ�’s Faculty of Medicine, said women with disabilities often have other measures of social vulnerability, such as low income and low education levels.

Her research, published in the journal Preventive Medicine, is consistent with other studies showing that low income and education were also associated with lower breast cancer screening rates. Previous research has shown that having a certain level of disability is associated with higher breast cancer screening rates, perhaps because those women have more frequent contact with the health care system.

However, in contrast to previous research, this study identified higher screening rates for women with moderate disabilities compared to those with severe disabilities – who also have greater contact with physicians than other women with no disabilities.

“Despite the presence of a universal health insurance system in Ontario, our research highlights the persistence of significant health disparities in breast cancer screening, particularly for women who are more vulnerable due to severe disability, multiple chronic conditions, low income and lower education,” said Guilcher, who has a PhD in Clinical Epidemiology from 91�Թ�'s Institute of Health Policy, Management and Evaluation.

The highest rate of screening was 75 per cent, which was among women with moderate level of disability and one chronic condition. Women with severe disability, across levels of chronic conditions, had the lowest rate of breast cancer screening at 61 per cent. Women with two or more chronic conditions were screened particularly less often.

“Women who are at a lower socioeconomic position may be less likely to be assertive and to be strong advocates for their health care management,” said Guilcher.

Guilcher noted that in Ontario, women can refer themselves to the Ontario Breast Screening Program, which sends them reminders of when they are due for mammograms and can provide results at the same time the test is done. Further research could explore the demographics of the women who enroll in this program, she said.

Guilcher said that worldwide, breast cancer is the most prevalent cancer among women and the second leading cause of cancer-related deaths. Deaths have significantly dropped due to advances in prevention and treatment. In Ontario, mortality rates fell 37 per cent for women between the ages of 50 and 74 between 1990 and 2009.

Her study was done in conjunction with the Institute for Clinical Evaluative Studies (ICES), based on health records of 10,363 women in Ontario ages 50-69 whose health records are stored in databases at ICES.

This research was supported by a research grant from the Ontario Ministry of Health and Long Term Care (MOHLTC) to the Health System Performance Research Network and by the MOHLTC support for ICES.

Geoff Koehler is a writer with S. Michael's Hospital, a partner of the 91�Թ�.

picpath

sites/default/files/2014-08-22-breast-cancer-sara-guilcher.jpg

Drugs a leading cause of premature death among young adults

sgupta — Tue, 08 Jul 2014 09:20:32 +0000

Drugs a leading cause of premature death among young adults sgupta Tue, 07/08/2014 - 05:20

Cutline

Assistant Professor Tara Gomes of 91�Թ�'s Leslie Dan Faculty of Pharmacy

Geoff Koehler

Author legacy

Geoff Koehler

Topic

Breaking Research

More News

St. Michael's Hospital

Subheadline

One of eight deaths related to opiod use, research finds

One of every eight deaths among young adults in Ontario is related to opioids, making the drugs a leading cause of premature death, researchers have found.

The study, published July 7 in Addiction, found that opioid-related deaths more than doubled in the province over 19 years – rising from 127 deaths in 1991 to 550 deaths in 2010.

“Alarmingly, we found that approximately one of every 170 deaths in Ontario may be related to opioid overdose,” said Assistant Professor Tara Gomes, lead author of the study and a scientist at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital and the Institute for Clinical Evaluative Sciences.

“That number jumps to one in eight deaths among those aged 25 to 34.”

Opioids include strong painkillers like morphine, codeine and oxycodone. The misuse and abuse of opioids has become increasingly prevalent across North America due to a variety of factors, including their broad accessibility and the perception that opioids are safe because they are prescription drugs.

Researchers reviewed 5,935 opioid-related deaths between 1991 and 2010. Such overdoses result in 21,927 years of potential life lost annually – which exceeds losses due to alcohol use disorders, pneumonia, HIV/AIDS and influenza.

“The extraordinary toll of early death related to opioids highlights the public health and social burden of opioid overdose, especially among young adults,” said Gomes, who is also a scientist at ICES.

This study was supported by a grant from the Ontario Ministry of Health and Long-Term Care Drug Innovation Fund and ICES, a non-profit research institute sponsored by the Ontario Ministry of Health and Long-Term Care.

Geoff Koehler is a writer with St. Michael's Hospital, a partner of the 91�Թ�.

picpath

sites/default/files/2014-07-08-tara-gomes.jpg

Men and women use mental health services differently

sgupta — Thu, 26 Jun 2014 09:32:37 +0000

Men and women use mental health services differently sgupta Thu, 06/26/2014 - 05:32

Cutline

Men may not be as comfortable seeking help for mental health, or may experience lesser symptoms, researchers say (photo by Lloyd Morgan via Flickr)

Geoff Koehler

Author legacy

Geoff Koehler

Topic

Breaking Research

Dalla Lana School of Public Health

St. Michael's Hospital

Subheadline

More research needed to understand why women access mental health services earlier, more often

Women with chronic physical illnesses are more likely to use mental health services than men with similar illnesses; they also seek out mental health services six months earlier than those same men, according to new research from medical sociologist Flora Matheson.

An assistant professor at the 91�Թ�'s Dalla Lana School of Public Health, and a scientist at the Centre for Research on Inner City Health in the Institute for Clinical Evaluative Sciences (ICES) at St. Michael’s Hospital, Matheson is also an associate graduate faculty member at the Centre for Criminology & Sociolegal Studies at 91�Թ�.

“Chronic physical illness can lead to depression,” said Matheson. “We want to better understand who will seek mental health services when diagnosed with a chronic physical illness so we can best help those who need care.”

The findings, published June 26 in the British Medical Journal’s Journal of Epidemiology & Community Health, looked at people diagnosed with at least one of four physical illnesses: diabetes, high blood pressure, asthma or chronic obstructive pulmonary disease.

Researchers found that among those with at least one of these four illnesses, women were 10 per cent more likely to use mental health services than men. Furthermore, within any three-year period, women with physical illness used medical services for mental health treatment six months earlier than men.

“Our results don’t necessarily mean that more focus should be paid to women, however,” said Matheson. “We still need more research to understand why this gender divide exists.”

The results may imply that women are more comfortable seeking mental health support than men. Alternatively, the gender discrepancy might mean that symptoms are worse among women, requiring more women to seek help and sooner, or that men defer seeking treatment for mental health concerns.

The study used data from the Canadian Community Health Survey, physician claims and inpatient medical records from ICES. Mental illness service use was defined as one visit to a physician or specialist for mental health reasons, such as depression, anxiety, smoking addiction or marital difficulties.

The research was funded by the Social Sciences and Humanities Research Council of Canada.

Geoff Koehler is a writer with St. Michael's Hospital, a partner of the 91�Թ�.

picpath

sites/default/files/2014-06-26-depression-one.jpg

Diabetes research: how your doctor is paid affects your care

sgupta — Thu, 05 Jun 2014 08:56:29 +0000

Diabetes research: how your doctor is paid affects your care sgupta Thu, 06/05/2014 - 04:56

Cutline

(World Diabetes Day photo by Carol Garcia/GOVBA via Flickr)

Geoff Koehler

Author legacy

Geoff Koehler

Topic

Subheadline

“Not all Ontarians are getting equal care”

From 2006 to 2008, nearly 75 per cent of Ontarians with diabetes did not receive all of the tests recommended to properly monitor their disease – and how their doctor was paid was one of the factors determining the care they received.

That was the finding of a study published June 5 by researchers at the 91�Թ�, St. Michael’s Hospital and the Institute for Clinical Evaluative Sciences (ICES).

“Limited access to good primary care can lead to poor management of chronic diseases, fragmented care through walk-in clinics, and overburdened emergency departments,” said 91�Թ� professor Dr. Rick Glazier, a senior scientist at ICES and research director in the Department of Family and Community Medicine of St. Michael's Hospital.

The study, published June 5 in the Canadian Journal of Diabetes, found that patients who were not actively enrolled with a family doctor were least likely to receive optimum diabetes care. The researchers found that more than 200,000 Ontarians with diabetes were not formally enrolled with a family doctor – either because they didn’t have a family doctor or because their doctor practiced in a traditional fee-for-service model.

Over the last decade, in an effort to improve Ontarians’ access to family doctors and provide more timely care, the province began implementing different payment models for physicians. Traditionally, family doctors in Ontario were paid a fee for each service they provided, billing OHIP for each patient visit. In newer models, doctors’ pay is more complicated – a combination of fee-for-service payment and a lump sum payment for every patient enrolled in their practice. Many doctors now receive the majority of their pay through a lump sum payment per patient, called capitation. All new models emphasize formally enrolling patients with a family doctor or group of doctors.

“When it comes to diabetes, not all Ontarians are getting equal care,” said lead author and family physician Dr. Tara Kiran. “Ontarians whose doctors are paid a lump sum per patient are more likely to get the diabetes tests they need.

"Lump sum funding gives family physicians the flexibility to spend more time with complex patients, collaborate with other professionals, and integrate email and phone calls into their practices,” said Kiran, an assistant professor at 91�Թ�'s Department of Family and Community Medicine and an associate scientist in the Li Ka Shing Knowledge Institute of St. Michael's Hospital.

Ontario has transitioned 40 per cent of its family physicians to capitation models in the hopes of improving quality of care and reducing costs. Capitation models require evening and weekend clinics, formally enrol patients, and have incentive payments to physicians for immunizations, cancer screening, smoking cessation and management of chronic diseases such as diabetes. The still-existing and traditional physician payment model pays doctors a fee for each service they provide and does not require evening and weekend clinics or include the additional step of formal enrolment.

Because the study looked at one point in time, more research is needed to see if new payment models caused improvements in care over time or if higher-performing physicians were the doctors to join the newer payment models.

The Canadian Diabetes Association’s clinical practice guidelines recommend that over the course of two years patients with diabetes undergo four HbA1C laboratory tests to measure blood sugar control, two cholesterol tests and a retinal eye exam. Researchers defined optimum diabetes care as receiving all three types of testing at the recommended intervals.

Researchers analyzed data for 757,928 people with Type 1 and Type 2 diabetes who were aged 40 or older – approximately 12 per cent of Ontario’s population. They found that between 2006 and 2008:

68 per cent of Ontarians with diabetes received one or more retinal eye exams;
78 per cent of Ontarians with diabetes underwent at least one HbA1C laboratory test to measure blood sugar control and 37 per cent had four or more tests, as recommended;
80 per cent of Ontarians with diabetes received at least one cholesterol test and 59 per cent received the optimal two cholesterol tests.

Geoff Koehler is a writer with St. Michael's Hospital, a partner of the 91�Թ�.

picpath

sites/default/files/2014-06-05-diabetes.jpg

Is this low-carb, vegan diet your best bet to lose weight, reduce heart disease risk?

sgupta — Fri, 23 May 2014 11:03:55 +0000

Is this low-carb, vegan diet your best bet to lose weight, reduce heart disease risk? sgupta Fri, 05/23/2014 - 07:03

Cutline

Renowned researcher Dr. David Jenkins (photo by John Hryniuk)

Geoff Koehler

Author legacy

Geoff Koehler

Topic

Breaking Research

Features

St. Michael's Hospital

Subheadline

Eco-Atkins may cut risk of heart disease by 10 per cent over a decade, study finds

For the first time, researchers have shown that, in addition to weight loss, a specific low-carbohydrate diet may also reduce the risk of heart disease by 10 per cent over 10 years.

The diet, often called Eco-Atkins, is a low-carbohydrate vegan diet. Many low-carbohydrate diets have been proven to improve weight loss but most emphasize eating animal proteins and fats, which may raise cholesterol. Diets that are high in vegetable proteins and oils may reduce the risk of heart disease by lowering “bad cholesterol.”

“We killed two birds with one stone – or, rather, with one diet,” explained lead author Dr. David Jenkins, who is director of the Clinical Nutrition and Risk Modification Centre of St. Michael's Hospital and a professor in both the Department of Nutritional Sciences and the Department of Medicine at the 91�Թ�.

“We designed a diet that combined both vegan and low-carb elements to get the weight loss and cholesterol-lowering benefits of both.”

The findings, which were published in British Medical Journal Open, compared Eco-Atkins to a high-carbohydrate, low-fat diet. The Eco-Atkins diet reduced cholesterol by 10 per cent while also helping participants lose an average of four more pounds than the high-carbohydrate, low-fat diet over six months.

"We could expect similar results in the real world because study participants selected their own diets and were able to adjust to their needs and preferences," said Jenkins, who is a vegan.

Participants were given menu plans that outlined food items and amounts. Rather than requiring fixed meals, the menus served as a reference guide and participants were given a list of suitable food alternatives. With an exchange list of interchangeable food items, participants were better able to adapt the diet to their personal tastes – which helped to encourage adherence to the diet.

Twenty-three obese men and women completed the six-month diet. Participants were encouraged to eat only 60 per cent of their estimated caloric requirements – the amount of calories that should be consumed daily to maintain their current weight.

Eco-Atkins participants aimed for a balance of 26 per cent of calories from carbohydrates, 31 per cent from proteins and 43 per cent from fat – coming primarily from vegetable oils.

Carbohydrate sources included high-fibre foods such as oats and barley and low-starch vegetables such as okra and eggplant. Proteins came from gluten, soy, vegetables, nuts and cereals. Predominant fat sources for the Eco-Atkins diet were nuts, vegetable oils, soy products and avocado.

Geoff Koehler is a writer with St. Michael's Hospital, a partner of the 91�Թ�.

picpath

sites/default/files/2014-05-22-jenkins-diet.jpg

History of gambling problems found in more than a third of clients served by homelessness organization

sgupta — Wed, 21 May 2014 10:13:33 +0000

History of gambling problems found in more than a third of clients served by homelessness organization sgupta Wed, 05/21/2014 - 06:13

Cutline

(Photo courtesy Medical Media Centre, St. Michael’s Hospital)

Geoff Koehler

Author legacy

Geoff Koehler

Topic

Breaking Research

More News

St. Michael's Hospital

Medicine

Health

Dalla Lana School of Public Health

Research

Subheadline

Research offers clues for those seeking to better understand, assist or treat homeless

Homeless clients using services at Toronto’s Good Shepherd Ministries are nearly nine times more likely to have a history of problem or pathological gambling than the general population, a new study has found.

“Intuitively, one might think there’s a connection between problem gambling and homelessness but very few studies have explored this in any depth,” said Flora Matheson assistant professor at the Dalla Lana School of Public Health at the 91�Թ� and research scientist with St. Michael’s Centre for Research on Inner City Health at St. Michael's Hospital.

“By doing this kind of research, we help community organizations to better understand their clients and provide more holistic, effective treatment.”

The findings, published in the June issue of Journal of Gambling Studies, looked at the prevalence of problem gambling and pathological gambling among 254 clients at Good Shepherd. A community-based organization in Toronto, Good Shepherd provides a range of services for homeless clients. Its administrators were concerned that an organizational focus on substance addiction and mental health issues might mean that gambling was a “blind spot” for its staff.

Of the 254 interviewed at Good Shepherd, 35 per cent indicated that at some point in their lives they had been either a problem or pathological gambler. The prevalence of gambling in the general population is around 0.6 to 4 per cent.

"Toronto shelters now have a sense of how important screening for gambling history is among people who are homeless,” said Matheson. “Further research is still needed to know whether similar rates exist across the country or the globe.”

Matheson suggests shelters should consider implementing screening for gambling as part of intake. Organizations that identify similarly high rates of problem gambling could then improve services by:

Training staff on the signs of gambling addiction
Equipping staff with referral resources for gambling addiction programs
Forming partnerships with organizations that offer gambling addiction programs
Considering potential in-house responses to gambling addictions

Gambling was defined as betting money or something of material value on an event with an uncertain outcome – such as horse races, dice, scratch cards, bingo or even a card game with friends. While gambling can be a harmless pastime for some, for others it can become an addiction affecting daily life.

Those who experience gambling as a harmful addiction are often classified as problem gamblers and have difficulty limiting money or time spent on gambling. There are varying degrees of problem gambling but pathological gambling is the most severe form; an example would be when money is spent gambling rather than on basic life necessities such as food or shelter.

Geoff Koehler is a writer with St. Michael's Hospital, a partner of the 91�Թ�.

picpath

sites/default/files/2014-05-22-flora-matheson.jpg

Women with breast cancer likely to opt for double mastectomy unless counselled otherwise

sgupta — Wed, 30 Apr 2014 11:17:20 +0000

Women with breast cancer likely to opt for double mastectomy unless counselled otherwise sgupta Wed, 04/30/2014 - 07:17

Cutline

(photo by Rhoda Baer via the National Cancer Institute)

Geoff Koehler

Author legacy

Geoff Koehler

Top Stories

Medicine

Cancer

Subheadline

91�Թ� study examines how surgeons and health care settings influence surgery decisions in North America

North American women are more likely to opt for precautionary breast surgery - removing both a healthy breast and a cancerous breast at the same time - when physicians don’t specifically counsel against it, according to a new study from 91�Թ� researchers.

The study, led by 91�Թ� general surgery resident Dr. Andrea Covelli, demonstrates how clarity during consultations and the capability of clinical facilities play important roles influencing a woman’s breast cancer treatment choices, as breast cancer is one of the few major illnesses for which physicians may not recommend a specific treatment option.

While there is more than one type of preventative breast surgery, Covelli's study looked only at cases where cancer has been diagnosed in only one breast. This form of prophylactic breast surgery, called a contralateral prophylactic mastectomy, entails removing the healthy breast at the same time as the cancerous breast.

The procedure can reduce the risk of breast cancer recurrence in women who have a strong family history of breast or ovarian cancers and in women who have a genetic mutation that makes breast cancer more likely.

“While effective for such groups, the number of prophylactic mastectomies across North America has risen among women without these underlying conditions – among women who have only an average risk of developing cancer in their non-cancerous breast," explained Covelli, whose research work was supervised by 91�Թ� Associate Professor Dr. Nancy Baxter at St. Michael’s Hospital. The findings were presented today at the American Society of Breast Surgeons Annual Meeting in Las Vegas.

Previous national studies have shown that instances of prophylactic breast surgery among early-stage, average risk women have increased nearly twelvefold in the United States over the last decade. In Canada, rates increased by 140 per cent between 2008 and 2010.

Dr. Covelli interviewed 45 surgeons in North America to identify factors that determine the course of treatment. In the United States, some states legislate that surgeons present all treatment options to patients. The research found that surgeons complied in the 20 states with such legislation but generally surgeons did not recommend one procedure over another.

Instead, they encouraged patient choice. Canadian surgeons discussed similar surgical options with their patients. However, they more often specifically recommended breast-conserving surgery and counselled against prophylactic mastectomies.

“We learned that surgeons' recommendations and detailed consultations influenced women’s decisions for breast cancer treatment,” said Covelli. “Consultations were especially important when it came to MRI findings. When MRI results were presented without detailed explanations, women were more likely to opt for prophylactic mastectomies.”

MRI exams have a high rate of false-positive results so patients who were given their exam results without detailed explanations were often concerned about new disease in addition to the recently diagnosed tumour.

Findings show that MRI exams were ordered less frequently in Canada than in the United States. It also showed that Canada’s surgeons often had more opportunity to discuss potential for inaccuracies with patients.

If women were being treated at health care facilities with access to immediate reconstruction, they were also more likely to choose prophylactic surgery.

“The availability of immediate breast reconstruction was another main factor in patients’ decisions,” said Covelli.

Immediate reconstruction was associated with the choice of prophylactic mastectomy and is more widely available in the United States than in Canada. In both countries, many patients requested a prophylactic mastectomy after returning from a consult with a reconstructive surgeon.

“We need to look at what happens during that consult to better understand patient decision-making,” said Covelli. “Patients should ask for their doctor’s opinion if helpful to them. Most surgeons have years of experience treating breast cancer and can provide valuable counsel and advice.”

picpath

sites/default/files/2014-02-13-mammogram_0.jpg

Eclampsia and preeclampsia higher in female immigrants from Sub-Saharan Africa

sgupta — Thu, 24 Apr 2014 14:51:40 +0000

Eclampsia and preeclampsia higher in female immigrants from Sub-Saharan Africa sgupta Thu, 04/24/2014 - 10:51

Cutline

Young mum Edith Amos, 18 (at right) rests while her mother holds the twin boys she delivered by caesarean section after suffering preeclampsia (photo by Lindsay Mgbor/U.K. Department for International Development via Flickr)

Geoff Koehler

Author legacy

Geoff Koehler

Subheadline

Pregnancy complications pose risks for mothers and babies

Pregnant immigrants from Sub-Saharan Africa, Latin America and Caribbean islands may require increased monitoring during pregnancy, according to new research from Dr. Marcelo Urquia of St. Michael’s Hospital and the 91�Թ�.

The study, published April 24 in the British Journal of Obstetrics and Gynaecology, assessed the differences in preeclampsia and eclampsia rates among immigrants and native-born women in six high-immigration countries – Australia (Victoria), Canada (Ontario), Denmark, Sweden, Spain (Catalonia and Valencia) and the United States (California, New Jersey and New York City).

Researchers found that Sub-Saharan Africans have consistently higher risk of preeclampsia and eclampsia compared to immigrants from other world regions or non-immigrant women from the six countries studied.

In some, but not all, of the six countries, Latin Americans and Caribbean islanders were also shown to be at higher risk.

“Obstetricians and midwives should consider pregnancies for immigrants from these regions as high risk,” said Urquia, lead author of the study and an assistant professor of the Dalla Lana School of Public Health. “They need enhanced surveillance and culturally sensitive care.”

An epidemiologist at the Centre for Research on Inner City Health of St. Michael’s Hospital, Urquia said preeclampsia is most common in first-time pregnancies. It affects two to seven per cent of women who have never given birth. Mothers with preeclampsia can experience several complications, including high blood pressure and high amounts of protein in the urine. Preeclampsia can cause premature birth and stunt fetus growth in the womb.

If undiagnosed, preeclampsia can lead to eclampsia – a serious condition that puts mothers and children at higher risk. Mothers can suffer long-term cardiovascular health issues. Eclampsia can lead to lost pregnancies and even cause long-term adult health problems in the babies.

“There's no cure for preeclampsia – which does disappear when the baby is born,” said Urquia, who is also an adjunct scientist at the Institute for Clinical Evaluative Sciences. “But when caught early, it's easier to manage. That’s why it’s so important to identify these high-risk groups.”

While it’s not known why some immigrant groups had higher rates than others, even in their home countries Sub-Saharan Africans exhibit the highest rates of preeclampsia and eclampsia in the world. It’s possible that immigrants may carry higher susceptibility even after arriving in their new country.

Using each country’s most recently available birthing data, researchers analyzed more than nine million births – more than a third of which were to immigrant women. Immigrants were divided into regions of origin:

Latin America and the Caribbean islands
Middle East
Western Europe
Eastern Europe
East Asia
Southeast Asia
North Africa
Sub-Saharan Africa

Not all immigrants groups had increased rates of preeclampsia or eclampsia, however. Immigrant women from regions of the world such as East Asia, Southeast Asia, North Africa and the Middle East seem to be at lower risk of developing preeclampsia than native-born women and Eastern Europe women are at lower odds of developing eclampsia.

“It’s also important to note that differences exist even within these regional groupings,” said Dr. Urquia. “In Ontario, for example, Caribbean and Central American women had greater risk than South Americans – who had similar rates to Canadian-born women.”

Western European immigrants acted as a control group for the study – a population that had endured the immigrant experience but ethnically most resembles those born in the native countries.

“We need to look more at factors affecting immigrant health,” said Urquia. “Future research should continue to look at global evidence.”

The study was partially funded by a Canadian Institutes of Health Research grant.

Geoff Koehler is a writer with St. Michael's Hospital, a partner of the 91�Թ�.

picpath

sites/default/files/2014-04-25-preeclampsia.jpg