Leslie Shepherd

India has avoided one million child deaths since 2005, new U of T study concludes

rasbachn — Thu, 21 Sep 2017 19:12:48 +0000

India has avoided one million child deaths since 2005, new U of T study concludes

rasbachn Thu, 09/21/2017 - 15:12

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Child mortality is a huge issue in India: About six million children die around the world each year and progress in reducing that number depends greatly on India, which accounts for about a fifth of the deaths (photo by Venkataramesh Kommoju)

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India has avoided about one million deaths of children under the age of five since 2005, driven by significant reductions in mortality from pneumonia, diarrhea, tetanus and measles, according to new University of Toronto research.

But nearly three times that number could have been saved if national progress in child health matched that reached in some states, Dr. Prabhat Jha, a professor in the U of T's Dalla Lana School of Public Health and head of the Centre for Global Health Research of St. Michael’s Hospital.

The study was published in The Lancet.

A steeper decline in the number of girls dying narrowed a previously observed girl-boy mortality gap, said Jha. An almost equal number of boys and girls under the age of five died in 2015.

This research is part of the Million Death Study, one of the largest studies of premature deaths in the world. Jha is the lead investigator of the survey, based in India, where most deaths occur at home and without medical attention. Hundreds of specially trained census staff in India knocked on doors of more than 1.3 million homes to interview household members about deaths. Two physicians independently examined these “verbal autopsies” to establish the most probable cause of death.

Read the study in The Lancet

Dr. Prabhat Jha, a professor in U of T's Dalla Lana School of Public Health and head of the Centre for Global Health Research of St. Michael’s Hospital.

“You get the truth when you knock on doors and talk to parents,” said Jha. “We knocked on the doors of 100,000 homes where children died. If the health system failed these families, they will tell you all about it. These are far more reliable numbers than models or projections from small studies.”

The study found a 3.3 per cent annual decline in mortality rates of neonates (infants less than one month old) and 5.4 per cent for those ages one month to 59 months. The declines accelerated starting in 2005 and were fastest between 2010 and 2015, and in urban areas and richer states.

Per 1,000 live births, the mortality rates among neonates fell from 45 in 2000 to 27 in 2015. The one-59 month mortality rate fell from 45.2 to 19.6.

Looking at specific causes of death, mortality rates from neonatal tetanus and measles fell by at least 90 per cent; neonatal infection and birth trauma fell more than 66 per cent. For children ages one to 59 months, mortality rates from pneumonia and diarrhea fell more than 60 per cent.

About six million children die around the world each year and progress in reducing that number depends greatly on India, which accounts for about a fifth of the deaths. About 29 million Indian children died between 2000 and 2015. Had the mortality rates of 2000 continued unchanged, about 39 million children would have died.

The authors noted that in the last decade the government of India has modestly increased its traditionally low level of public spending on health. The government launched a program to encourage women to give birth in hospitals and for children to have a second dose of measles vaccine.

Read about the study in the Hindustan Times

Jha said that to meet the United Nations' sustainable development goals of halving its child mortality rates by 2030, India must maintain its current trajectory for children ages one to 59 months and accelerate declines in neonatal mortality.

Reducing the number of neonatal deaths will require efforts to reduce deaths caused by premature delivery and low birthweights, especially in poorer states, he said. Both are strongly linked to largely modifiable maternal and prenatal factors, such as health care during pregnancy, education, nutrition, anemia and tobacco use.

In an accompanying commentary for The Lancet, leading scientists from Bangladesh and Tanzania wrote that the “Million Death Study can be a model for other countries where vital registration systems are still fragmented.”

This work received funding from the U.S. National Institutes of Health, the Disease Control Priorities Network, the Maternal and Child Epidemiology Estimation Group and the University of Toronto.

Leslie Shepherd is a writer with St. Michael's Hospital, where this article originally appeared.

Ebola: controlling outbreak in West Africa most effective way to decrease international risk, paper says

sgupta — Tue, 21 Oct 2014 11:15:42 +0000

Ebola: controlling outbreak in West Africa most effective way to decrease international risk, paper says sgupta Tue, 10/21/2014 - 07:15

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Placing international travel restrictions on countries with high rates of Ebola could compromise efforts to control the outbreak, says Associate Professor Kamran Khan (photo by Nelson L via Flicker)

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Focus on "exit screening" not "entry screening" says Dr. Kamran Khan

Controlling the Ebola virus outbreak at the source in West Africa is the most effective way to decrease international risk of transmission, a new study published in The Lancet has found.

If the epidemic persists and grows, it’s likely there will be more cases of the deadly virus exported to other countries, including Canada, via air travel, said Dr. Kamran Khan, an associate professor at the University of Toronto's department of medicine, division of infectious diseases, department of health policy, management and evaluation, and a researcher at St. Michael’s Hospital.

His work is making headlines around the world. (Read articles in the The Guardian and the Wall Street Journal.)

Khan, who examines global airline travel patterns to predict the spread of diseases, said that every month, three Ebola-infected travellers are likely to leave West Africa, which is experiencing a widespread outbreak of the virus – and this number would only increase as the epidemic grows.

Khan and his co-authors said it is essential that other countries, their public health agencies and hospitals be prepared. The risk of international spread would be further compounded if this epidemic were to take hold in other countries, especially those with weak public health systems.

“The international community must be mindful and be ready to support the early detection and control of cases should they be imported into resource-limited countries,” Khan said.

Khan noted that of the almost 500,000 travellers who flew on commercial flights out of Guinea, Liberia or Sierra Leone in 2013, more than half were headed to destinations in five countries: Ghana (17.5 per cent), Senegal (14.4 per cent), the United Kingdom (8.7 per cent), France (7.1 per cent) and Gambia (6.8 per cent). More than 60 per cent of travellers from those countries in 2014 are expected to have final destinations in low- or lower-middle income countries.

“Given that these countries have limited medical and public health resources, they may have difficulty quickly identifying and effectively responding to imported Ebola cases,” said Khan.

He also said that international travel restrictions on countries with high rates of Ebola could have economic, health and humanitarian consequences that could compromise efforts to control the outbreak.

“There is a great danger that excessive travel restrictions could disrupt supply chains of necessary food, people, medicine and equipment to help fight the epidemic and cause severe economic hardship.”

The 2005 International Health Regulations, signed by 196 countries, specify that steps to control the international spread of diseases should “avoid unnecessary interference with international traffic and trade.”

Khan said that supporting humanitarian aid, increasing the number of health care workers, and providing logistical support and equipment would be the most effective way to prevent the international spread of Ebola from West Africa. In addition, focusing on “exit screening” travelers as they leave affected countries would be more efficient than “entry screening” as they arrive in cities around the world.

Khan said that while a number of countries, including Canada, the United States and England are implementing entry screening by far the most efficient approach is exit screening of passengers leaving the three West African countries that are affected by Ebola – as recommended by the World Health Organization.

Exit screening is a preventative measure and can be focused on three major international airports in affected countries, whereas entry screening would require far greater resources to implement. Entry screening may detract resources from other important public health activities in countries with limited public health infrastructure, he said.

Leslie Shepherd is a writer with St. Michael's Hospital, a partner of the University of Toronto. (Read more articles about St. Michael's Hospital.)

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Beans, peas, chickpeas, lentils increase fullness and could help manage weight

sgupta — Fri, 08 Aug 2014 12:22:53 +0000

Beans, peas, chickpeas, lentils increase fullness and could help manage weight sgupta Fri, 08/08/2014 - 08:22

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Many varieties of beans, chickpeas and lentils are quite filling (photo by International Crops Research Institute for the Semi-Arid Tropics via Flickr)

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Eating about one serving a day of beans, peas, chickpeas or lentils can increase fullness, which may lead to better weight management and weight loss, a new study from a University of Toronto expert has found.

A systematic review and meta-analysis of all available clinical trials found that people felt 31 per cent fuller after eating on average 160 grams of "pulses" — a dietary group including beans, peas, chickpeas and lentils — compared with a control diet, according to senior author and U of T alumnus Dr. John Sievenpiper of St. Michael’s Hospital’s Clinical Nutrition and Risk Factor Modification Centre, an organization fully affiliated with the University of Toronto.

His group’s findings were published in the August issue of the journal Obesity.

Sievenpiper said that despite their known health benefits, only 13 per cent of Canadians eat pulses on any given day and most do not eat a full serving, which is 130 grams or three-quarters of a cup. That's despite beans, peas and lentils being common Canadian crops.

“That means eating local, being more sustainable and receiving many health benefits,” he said.

Pulses have a low glycemic index (meaning that they are foods that break down slowly) and can be used to reduce or displace animal protein as well as “bad” fats such as trans fat in a dish or meal.

Dr. Sievenpiper noted that 90 per cent of weight loss interventions fail, resulting in weight regain, which may be due in part to hunger and food cravings. Knowing which foods make people feel fuller longer may help them lose weight and keep it off.

He said the finding that pulses make people feel fuller was true across various age categories and body mass indexes.

Although the analysis found pulses had little impact on “second meal food intake” — the amount of food someone eats at his or her next meal — these findings support longer term clinical trials that have shown a weight loss benefit of dietary pulses.

Sievenpiper’s systematic review and meta-analysis included nine clinical trials involving 126 participants out of more than 2,000 papers screened.

This trial was funded by Pulse Canada and the Canadian Institutes for Health Research.

Another recently published systematic review and meta-analysis by Dr. Sievenpiper’s research group found that eating on average one serving a day of beans, peas, chickpeas or lentils can also reduce “bad cholesterol” by five per cent and therefore lower the risk of cardiovascular disease.

About St. Michael’s Hospital

St Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future health care professionals in 27 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among the hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael’s Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.

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Cerebral palsy rates higher among children with Canadian-born mothers

sgupta — Mon, 14 Jul 2014 14:32:47 +0000

Cerebral palsy rates higher among children with Canadian-born mothers sgupta Mon, 07/14/2014 - 10:32

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(photo by William Petruzzo via Flickr)

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Lower rates for children of mothers who immigrated to Ontario

Babies born to mothers who immigrated to Ontario from other countries have significantly lower rates of cerebral palsy than those of Canadian-born mothers, especially those from the Caribbean and East Asia, new research has found.

“Predicting who is at highest risk of having a child with CP remains an international priority,” said lead author Dr. Joel Ray, who notes that CP rates have not declined much over the last decade.

CP is the most common motor disability in childhood and appears by the age of four. The underlying injury to the brain with CP is thought to occur before birth, rather than during delivery. Most damage is to the motor neurons of the brain affecting coordination and muscle strength.

A professor in the Department of Medicine and a researcher at St. Michael’s Hospital, Ray looked at data from the Institute for Clinical Evaluative Sciences (ICES) on all single births in Ontario from 2002 to 2008. Each child was assessed up to age four.

In a paper published July 2014 in the online journal PLoS One, he reported there were 1,346 cases of CP among 744,058 live single births. For immigrants, there were 1.45 cases of CP for every 1,000 births, a 23 per cent lower risk than for non-immigrants who had 1.92 CP diagnoses per 1,000 births.

However, immigrants living in high-income areas were not at lower risk of CP than their non-immigrant counterparts. Ray, also a scientist at ICES, said this may be because wealthier immigrants, who have lived in Canada longer, lose the “healthy immigrant effect,” where immigrants are generally healthier than people born in Canada.

Ray noted that we still have a poor understanding of how CP arises, so the more scientists can understand the underlying risk factors that predispose someone to CP the closer they may come to developing interventions to prevent CP. Knowing why immigrants are at lower risk of having a child with CP offers clues to discovering ways to prevent CP among all Canadians.

About 80 per cent of CP cases are due to prenatal injury of the brain and only 10 per cent to adverse events after birth. The most common risk factors are low and high birth weights as well as premature birth – although half of all children who develop CP are born at term and most cases occur in children with an apparently uncomplicated pregnancy.

Ray said it’s also thought that CP and stillbirths share many common risk factors, including placental vascular disease in the mother – such things as preeclampsia, gestational hypertension, placental abruption and placental infarction. Yet, even upon adjusting for these conditions, the risk of CP was still lower among immigrant mothers.

This study was funded by the Ontario Federation for Cerebral Palsy and its research fund.

Leslie Shepherd is a writer with St. Michael's Hospital, a partner of the University of Toronto.

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Researchers create “black box” for use in operating rooms to improve patient care

sgupta — Tue, 08 Jul 2014 09:07:07 +0000

Researchers create “black box” for use in operating rooms to improve patient care sgupta Tue, 07/08/2014 - 05:07

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Associate Professor Teodor Grantcharov (in multicoloured cap) with surgical team (all images courtesy St. Michael's Hospital)

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"We will reduce the risk and complications and show how to make the OR more efficient"

Associate Professor Teodor Grantcharov and his team of researchers have developed a “black box” for using in operating rooms, similar to that used in the airline industry.

Dr. Grantcharov said the goal is to improve patient safety and outcomes by identifying where errors occur in the OR and teaching surgeons how to prevent them. He said that when black boxes were introduced in the aviation industry, preventable errors dropped significantly.

Grantcharov has been testing the prototype of his black box for about a month in the operating rooms at St. Michael’s Hospital, where he specializes in advanced minimally invasive surgeries, such as gastric bypasses. It’s also being tested at two hospitals in Copenhagen, Denmark, with more international sites to be involved soon.

The device (pictured at right) is about the size of a box of tissues or a thick book and it records almost everything that goes on in the OR, such as video of the surgical procedure, conversations among health care workers, room temperature and decibel levels. It works only for laparoscopic or minimally invasive surgeries that insert video cameras in thin plastic tubes into small incisions in the body that allow the surgeon to see what’s going on inside the patient.

“We want to see where errors happen in surgery so that we can understand how errors lead to adverse events and develop training curricula to prevent these errors from ever happening again,” Grantcharov said. “It doesn’t mean that we will have perfect surgeries, because we are not perfect. But it means we will learn from our errors, which will make us safer. We will train future surgeons better because we can show them what are the most critical situations and how to avoid them.”

Research has already shown that 84 per cent of errors in bypass surgery happen during the same two steps, Grantcharov said, so training has been adapted to help surgeons master those two skills. Grantcharov said he’s looking at performance issues – something the surgeon did or didn’t do, such as apply enough force when grabbing a bowel, which might make it slip and tear. But he’s also looking at less tangible factors that can lead to errors, such as communication and team dynamics.

“Say a surgeon picked up the wrong instrument. Then he got angry or frustrated and started to make technical errors. The more mistakes he made, the worse communications became.”

Grantcharov’s team has done extensive research on surgical error analysis. According to this framework, an error is a minor deviation from an optimal course of action. Errors happen during each procedure; however very few lead to adverse events and go unnoticed by the surgical team.

The landmark study on hospital medical errors in Canada, a 2004 paper by Ross Baker, a professor at the University of Toronto's Institute of Health Policy, Management and Evaluation, found that 7.5 per cent of patients admitted to acute care hospitals in Canada in 2000 experienced one or more adverse events, which can include everything from reactions to wrongly administered medications to bed sores, falls, infections and surgical errors.

Most of these events did not result in any serious harm, the study found, but almost 37 per cent were preventable. More recent studies have shown rates of adverse events in hospital between 10 and 14 per cent. Such events cost taxpayers billions of dollars, usually in longer hospital stays.

Grantcharov noted that professional athletes have coaches who point out their wrong moves and help them improve their performance.

"For surgeons, we will have data that will allow better coaching and improvements and therefore better patient care,” he said. “We will reduce the risk and complications and show how to make the OR more efficient, which will also allow us to save money and do more cases.”

Grantcharov said he also hoped his black box would bring more transparency to the OR for patients and help change the “blame-and-shame” culture that traditionally has made doctors and nurses reluctant to report mistakes.

Leslie Shepherd is a writer with St. Michael's Hospital, a partner of the University of Toronto.

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Foreign-trained physicians frustrated at lack of residency positions in higher-income countries

sgupta — Thu, 26 Jun 2014 12:28:15 +0000

Foreign-trained physicians frustrated at lack of residency positions in higher-income countries sgupta Thu, 06/26/2014 - 08:28

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Alumna and Assistant Professor Dr. Aisha Lofters (photo courtesy St. Michael's Hospital)

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Just 55 per cent of those surveyed are now working as doctors in Canada

Foreign-trained physicians feel there are not enough residency positions for them in countries such as Canada and the United States and this information was not communicated to them before they emigrated, a new study has found.

Dr. Aisha Lofters, an assistant professor with the University of Toronto's Department of Family & Community Medicine, and a clinician scientist at St. Michael’s Hospital, surveyed international medical graduates to better understand the concepts of “brain drain,” the migration of health care workers from low- and middle-income countries to higher-income countries, and “brain waste,” where their skills are under-utilized or not utilized in their new country.

Many were older physicians who had spent a considerable amount of time and money trying to obtain a medical residency position – the mandatory stage of graduate medical training in which someone who has received a medical degree works in a teaching hospital for two to five years learning from senior doctors.

Lofters, a family physician and researcher in the hospital’s Centre for Research on Inner City Health, said only about 55 per cent of international medical graduates, or IMGs, living in Canada are currently working as physicians. In 2011, 1,800 applicants competed for 191 residency spots designated for foreign trained physicians in Ontario, Canada’s largest province. The success rate that year was about 20 per cent for Canadians who had gone abroad for their medical training compared to six per cent for immigrant IMGs.

The numbers are similar in the United States where almost half of international medical graduates are unsuccessful in their first attempt at securing a residency position. In 2013, 47.6 per cent of non-American citizen applicants secured a residency position compared to 53.1 per cent of U.S. citizens trained in international schools. IMGs who are originally from the United States ultimately have a 91 per cent success rate, while only 73 per cent of IMGs born outside of the United States are ultimately successful.

In a paper published in the Journal of Risk Management and Healthcare Policy, Lofters said those statistics for IMGs in Canada and the United States are not specific to immigrants from low- and middle-income countries, so it’s possible their numbers might be even lower.

Of the 462 people whose survey results were studied, Lofters said the top five reasons for choosing to emigrate were: socioeconomic or political situations in their home countries, better education for their children, concerns about where to raise children, quality of facilities and equipment and lack of opportunities for professional advancement. Those same responses were the top five reasons given for choosing to immigrate to Canada.

“When asked if they had any other comments they would like to share regarding their migration experience, a substantial number of respondents reported feeling that they were misinformed as to their actual chances of obtaining a residency position in Canada,” Dr. Lofters said. “Because they were skilled workers and allowed to migrate to Canada, many reported assuming that they would be easily able to find employment in medicine and expressed anger that their assumption was incorrect.”

She said many spoke of the shame they felt in taking what they viewed as “survival jobs,” delivering pizzas or driving a cab instead of practicing medicine. Many said they regretted their decision to move to Canada.

“Our findings suggest that brain waste is pervasive for physicians who migrate to Ontario and that both brain drain and brain waste have no easy or quick solutions,” Dr. Lofters said. “Restricting emigration and immigration for health care workers would be very difficult from an ethical and moral standpoint.”

She said that where feasible, low- and middle-income countries should implement incentives to encourage their physicians and other health care workers to stay in their home countries, such as improved working conditions, or financial incentives for working in rural or underserved regions.

At the same time, she said, countries like Canada need to ensure that the immigration process clearly outlines the relatively low likelihood of obtaining a career in medicine after immigration, the low number of post-graduate training positions available for non-Canadian IMGs and the average time and financial commitment required.

Leslie Shepherd is a writer with St. Michael's Hospital, a partner of the University of Toronto.

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Worried your insomnia might cause high blood pressure?

sgupta — Wed, 25 Jun 2014 09:50:15 +0000

Worried your insomnia might cause high blood pressure? sgupta Wed, 06/25/2014 - 05:50

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("Insomnia" photo by Alyssa L. Miller via Flickr)

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You can stop worrying about those studies that linked sleeplessness with high blood pressure, researcher finds

There’s good news for the 30 per cent or more of adults who suffer from insomnia – difficulty falling asleep, waking up for prolonged periods during the night or unwanted early morning awakenings.

New research from Assistant Professor Nicholas Vozoris, a respirologist at St. Michael’s Hospital, has found that insomnia does not put them at increased risk of developing high blood pressure.

Dr. Vozoris said there is growing concern among patients and health care providers about the potential medical consequences of insomnia, especially on the cardiovascular system.

If there were a link, this would have at least two major implications for the health care system. First, because insomnia is a common problem and often chronic in duration, a large portion of the population would need long-term screening for the possible development of high blood pressure.

Second, doctors might prescribe sleeping pills more often in an effort to treat insomnia from a possible blood-pressure lowering perspective. Vozoris said sleeping pills are already used too often and associated with a number of serious side effects, including addiction, overdose, car accidents and falls.

Vozoris said previous studies that suggested a link between insomnia and high blood pressure were often based on small numbers of people. He examined data from nearly 13,000 Americans who participated in the National Health and Nutrition Examination Survey, a series of studies designed to assess the health and nutritional status of adults and children in the United States. The survey is unique in that it combines interviews and physical examinations.

Participants were asked about their insomnia symptoms, and their responses were correlated with whether they had doctor-diagnosed hypertension, were taking anti-hypertension drugs, or had measured high blood pressure.

“After adjusting for many factors, including whether or not participants were receiving blood pressure pills or sleeping pills, there were generally no associations between insomnia and high blood pressure, even among people who were suffering from insomnia the most often,” said Vozoris. “These results should reassure patients and their doctors that insomnia and high blood pressure are unlikely to be linked.”

His findings were published June 25 in the Journal of Clinical Psychiatry.

The study is believed to be the first to examine for hypertension among individuals who self-reported various frequencies of insomnia symptoms.

“Patients who are suffering from insomnia and physicians who are trying to take care of them shouldn’t worry so much about insomnia affecting their heart in an adverse way,” he said.

“By showing there is no link between this very common sleep disorder and high blood pressure, physicians can be more selective when prescribing sleeping pills and refrain from prescribing these medications from a cardio-protective perspective.”

Leslie Shepherd is a writer with St. Michael's Hospital, a partner of the University of Toronto.

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Canola oil cuts bad cholesterol, blood glucose levels

sgupta — Sat, 14 Jun 2014 12:03:30 +0000

Canola oil cuts bad cholesterol, blood glucose levels sgupta Sat, 06/14/2014 - 08:03

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Canadian researchers developed canola oil was from rapeseed in the 1970s (photo by Erin Howe)

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Findings are key for Type 2 diabetics

Canola is Canada’s oil, and new research from the University of Toronto suggests it should also be one of the oils of choice for people with Type 2 diabetes.

Dr. David Jenkins, a professor in the Department of Nutritional Sciences and Department of Medicine, compared people with Type 2 diabetes who ate either a low glycemic index diet that included bread made with canola oil, or a whole wheat diet known to reduce the risk of cardiovascular disease.

His study, published in the journal Diabetes Care, found that those on the canola bread diet experienced both a reduction in blood glucose levels and a significant reduction in LDL, or “bad,” cholesterol.

Even more exciting, he said, was the finding that the canola bread diet seemed to have the most significant impact on people who needed help the most — those whose HbA1c test measuring blood glucose over the previous two or three months was highest.

Jenkins, who is head of the Clinical Nutrition and Risk Factor Modification Centre at St. Michael’s Hospital, said the reduction in LDL cholesterol observed in his study of 141 people could translate into a seven per cent reduction in cardiovascular events. He said the benefit could also be translated into an additional 20mg dose of one of the cholesterol-reducing drugs known as statins — a doubling of a standard dose.

The word canola is a contraction of Canada and ola, meaning oil. It was developed from rapeseed at the University of Manitoba in the 1970s. Canola oil contains only seven per cent saturated fat, less than half that of olive oil, widely touted for its health benefits.

Jenkins said another interesting finding of the study was that patients on the whole wheat diet seemed to have better blood flow after 12 weeks than those on the canola bread diet, as measured by the EndoPat test that uses a cuff on the arm similar to a blood pressure test. He said the significance of that finding was not entirely clear, but this positive result may be an indication of why whole wheat foods have consistently been shown to reduce the risk of cardiovascular disease.

Jenkins and his colleagues developed the concept of the glycemic index in the early 1980s as a way of explaining how different carbohydrates affect blood glucose and to find out which foods were best for people with diabetes. High GI foods — such as white bread, most breakfast cereals, potatoes and rice — produce a large rise in blood glucose and insulin, which may damage eyes, kidneys and heart. The carbohydrates in low GI foods — including pasta, beans, lentils, berries, apples and certain whole grains such as barley and oats — are broken down more slowly, so that people get more gentle raises in blood glucose and insulin and so get less tissue damage to eyes and kidneys etc.

Other studies have linked low GI diets with a reduction in both diabetes and cardiovascular events, and have shown monounsaturated fats such as canola and olive oil reduced the risk of cardiovascular disease. Dr. Jenkins said the combination of a low GI diet supplemented with canola oil had not been tested before on people with Type 2 diabetes.

This research was funded by the Canola Council of Canada, Agriculture and Agri-Food Canada, Loblaw Companies, and the Canada Research Chairs Program.

Leslie Shepherd is a writer with St. Michael's Hospital, a partner of the University of Toronto.

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Does a resident's shift length affect patient safety?

sgupta — Tue, 20 May 2014 14:28:19 +0000

Does a resident's shift length affect patient safety? sgupta Tue, 05/20/2014 - 10:28

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Reducing residents' hours may result in an increase in errors associated with the handover of patients (photo by Maria Fleischmann, World Bank Photo Collection)

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Sleeplessness, fatigue raise concerns but so do patient handovers

Medical residents in Canada may work longer hours per shift and per week than their counterparts in Europe, Australia and New Zealand but there is conflicting evidence whether shorter shifts improve patient safety, a new study has found.

In fact, reducing medical resident duty hours may have unforeseen consequences and changes must be made carefully to ensure both patient safety and resident well-being, says University of Toronto medical resident Dr. Reena Pattani, the chief resident at St. Michael’s Hospital.

Her analysis of resident duty hours was published May 20 in the Canadian Medical Association Journal (CMAJ).

Pattani said residents work an average of 60-90 hours a week in Canada under agreements negotiated between provincial residents’ associations and employers. Residents are limited to 24 to 26 hours of consecutive work, except in Quebec, where on-call shifts were limited to 16 hours after a provincial arbitrator ruled in 2011 that a 24-hour shift posed a danger to residents’ health and violated the Charter of Rights.

In New Zealand, residents are limited to 72 hours of work in a week and 16 hours of continuous work in any one shift. The Australian Medical Association has said that work in excess of 50 hours a week puts the resident at risk. The European Collective Agreement limits residents to 48 hours of work a week.

In the United States, senior residents may work up to 80 hours a week, averaged over four weeks and up to 24 hours continuously, but junior interns are limited to 16 hours of continuous work.

Last year a National Steering Committee on Resident Duty hours said the status quo in Canada was unacceptable and that shifts of 24 hours or longer without sleep should be avoided. It urged all provinces and health care institutions to develop comprehensive strategies to minimize fatigue and fatigue-related risks during residency.

However, concerns that patient care may suffer under the watch of sleep-deprived residents are not borne out by existing evidence, much of which is conflicting over the perceived benefits of shorter hours. Reducing resident hours would also increase workloads of staff physicians and would reduce time for teaching and for learning the practice of medicine. Some studies suggest reduced hours increases the number of errors because it increases the number of shift handovers.

“Although the National Steering Committee challenged the notion of a one-size fits all solution, in doing so it has left out important details, such as how individual residency programs should design fatigue risk management plans,” Pattani and colleagues said in the report. “Will scheduled naps during 24-hour call shifts be sufficient, or will residency programs inexorably move toward shifts that are no longer than 16 hours?”

Pattani (pictured at right; photo courtesy St. Michael's Hospital) said if residents’ work hours are curtailed, it may mean their overall residency periods have to be lengthened so they can see a wide variety and high volume of patients, or teaching hospitals may have to come up with innovative teaching methods, such as greater use of simulation.

Or, they may have to move toward competency-based programs, such as that used by the University of Toronto to train orthopedic surgeons, who can graduate in three or four years, depending on how quickly they attain the necessary skills.

A recent study by Dr. Najma Ahmed, assistant professor at U of T and a trauma surgeon at St. Michael’s, also warned about strictly limiting the number of hours surgical residents can work, saying it has not improved patient outcomes but may have increased complications for some patients and led to higher failure rates on certification exams.

Pattani will attend Harvard University next year to study for her Master of Public Health, with a focus on Health and Social Behavior. She received a prestigious Frank Knox Memorial Fellowship for students from some Commonwealth countries.

Leslie Shepherd is a writer with St. Michael's Hospital, a partner of the University of Toronto.

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Most common genetic heart valve abnormality associated with risk of aneurysm

sgupta — Tue, 13 May 2014 13:35:18 +0000

Most common genetic heart valve abnormality associated with risk of aneurysm sgupta Tue, 05/13/2014 - 09:35

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Up to two per cent of the population has bicuspid aortic valves and may be at higher risk for aortic aneurysms, researchers say (photo by Nicolas Fleury via Flickr)

Leslie Shepherd

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Leslie Shepherd

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St. Michael's Hospital

The most common heart valve abnormality has now been linked to an increased risk of aneurysms.

Researchers estimate up to two per cent of the population has a genetic abnormality in which their aortic valve has only two cusps or hinges ensuring that oxygenated blood from the heart is directed to the rest of the body—a condition known as bicuspid aortic valve. Most people have three such cusps.

Physicians have known for years that many people with bicuspid aortic valves may require open heart surgery in early adulthood to replace their aortic valve with an artificial valve. Bicupsid aortic valve is responsible for more deaths and complications than the combined effects of all other congenital heart defects.

University of Toronto Associate Professor Subodh Verma, a cardiac surgeon at St. Michael’s Hospital, said it’s becoming increasingly clear that such people may also be at a higher risk of developing aortic aneurysms, which can lead to catastrophic complications such as aortic dissection (tear) and sudden death.

Dr. Verma published a review paper in the New England Journal of Medicine May 14 providing new insights about the link between this genetic abnormality and aneurysms, and advising patients and physicians about optimal screening and management of this potentially fatal condition.

In his paper, Verma also questions whether the aneurysms form because of genetic problems with the structure of the aorta or because of changes in the blood flow that cause excessive stress on the wall of the aorta.

The authors describe three patterns of aneurysm formation in such patients, and suggest that two of the most common patterns may not be genetic as previously thought.

Verma said that patients with a bicuspid aortic valve need to know that they are at risk of developing not just valve failure but an aortic aneurysm. If they do have dilatation of the aorta or an aneurysm they must seek the advice of a cardiologist or cardiac surgeon to help understand the timing and extent of surgery.

"These operations are complex and at times require not only stopping the heart but also ceasing blood supply to the brain,” said Verma, who is also a scientist in the hospital’s Keenan Research Centre for Biomedical Science. “Therefore, it is paramount that the risk of complications from the surgery be weighed against the risk of aneurysm rupture or dissection.”

The authors suggest that once an aneurysm has developed patients should avoid strenuous activities that may increase blood pressure and cause the aneurysm to grow.

Many patients with bicuspid aortic valves will neither require surgery on their valve or their aorta, but will require routine surveillance with either an echocardiogram. Verma said close relatives of people with bicuspid aortic valves should also be screened to see if they have the condition.

This study was funded by the Heart and Stroke Foundation of Canada, the Canadian Institutes for Health Research and Canada Research Chairs.

Leslie Shepherd is a writer with St. Michael's Hospital, a partner of the University of Toronto.

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