P.070 Introducing Stroke Endovascular Thrombectomy Into A Smaller Canadian Site, Is It Safe?

Background: Success of Endovascular Thrombectomy (EVT) requires ultra-fast access to specialized neuro imaging, neurological assessment and an angio suite with interventional radiologists. Prior access was via transport to Vancouver and outcomes were poor, with a high rate of disability or death. This appeared primarily due to long delays. Methods: Quality control process, in parallel to the introduction of a new intervention, EVT, to Vancouver Island, to determine if this intervention could be delivered with reasonable safety and good outcomes. Patients receiving EVT from May, 2016 until Sep, 2019 are included, with 90-day outcomes. Data was collected by stroke nurses. Results: The proportion of patients having a good outcome was comparable to that of the major clinical trial involving Canadian academic centres. The proportion sustaining a poor outcome was comparable to the control group in that trial population (who still received tPA treatment where possible). This was despite a median age 4.5 years greater than in that trial. Conclusions: EVT required coordination of multiple services. Victoria General Hospital performance in terms of speed to treatment was slower than in the published trials. This is a factor in determining outcome and is therefore an important quality improvement target moving forward.

A136 LIVING ON THE EDGE: EUS-DIRECTED TRANSGASTRIC ERCP (EDGE) IN PATIENTS WITH ROUX-EN-Y GASTRIC BYPASS ANATOMY

Background Roux-en-Y gastric bypass (RYGB) surgery imposes anatomic barriers to endoscopic retrograde cholangiopancreatography (ERCP). Potential options for biliary access in these patients include laparoscopic-assisted ERCP or balloon enteroscopy. However, these approaches require specialized equipment and/or operating room personnel and are associated with high rates of failure and adverse events compared to conventional ERCP. A recently described technique, EUS-directed transgastric ERCP (EDGE), is an entirely endoscopic approach which involves accessing the excluded stomach to facilitate conventional ERCP. Objectives To describe the results of EDGE procedures performed in two centres in British Columbia. Aims To describe the results of EDGE procedures performed in two centres in British Columbia. Methods Data were collected from five patient cases who had undergone an EDGE procedure at Victoria General Hospital (4) or Vancouver General Hospital (1) in British Columbia from 2019 to 2020. All patients had a history of RYGB bariatric surgery. In each of the procedures, a 20 mm diameter lumen-apposing metal stent (LAMS) was deployed under EUS-guidance to allow access from the gastric remnant or proximal jejunum to the excluded stomach. Subsequently, during a separate procedure 4 to 28 days later, a duodenoscope was passed through the LAMS to perform ERCP. Following ERCP, the LAMS was removed 0 to 38 days later and replaced with a double pigtail stent to facilitate controlled closure of the gastro-jejunal or gastro-gastric fistula. Results Of the five cases included in the case series, 4 patients underwent EDGE for treatment of choledocholithiasis and one patient underwent the procedure for gallstone pancreatitis. The technical success rate of the EDGE procedure in the five cases was 100%. Clinical success, defined by normalization of bilirubin and symptomatic relief, was observed in all of the cases. There were no adverse events related to the EDGE procedure in these five cases. Conclusions The results of this series support EDGE as a safe and minimally invasive approach to biliary access and therapy in patients with previous RYGB surgery. Funding Agencies None

Little hospital on the South Common: A history of the Victoria General Hospital

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LO011: Identification of mild acute cerebrovascular syndrome (ACVS) in the emergency department: validation of an ACVS clinical classifier to help distinguish mimics

Introduction: National guidelines (NICE, AHA) for management of Acute Cerebrovascular Syndrome (ACVS) in the Emergency Department (ED) recommend the use of ABCD2 score to risk stratify patients despite its poor specificity and low diagnostic accuracy. The SpecTRA project previously developed a clinical classifier for ACVS vs. Mimic derived from historical clinical data collected during a 5-year period at an outpatient stroke clinic (Victoria, BC). Here we present a prospective evaluation of the performance of our clinical classifier on prospectively collected ED patient data compared to the industry-standard ABCD2. Methods: The prospective cohort consisted of ED patients (N=555, Male=54%, Mean (SD) Age=68.7(15.5), ACVS=70%) enrolled between Jan 2014 and May 2015 at Victoria General Hospital (BC) and Foothills Medical Centre (Calgary, AB). ABCD2 and clinical classifier scores were calculated from clinical data from the ED. We compared the performance of the two classifiers using DeLong’s test of Dependent Receiver Operating Curves (ROC). In keeping with national guidelines, we used a score of 4 or more to assess sensitivity, specificity and accuracy (sens/spec and acc) of the ABCD2; for our clinical classifier, we used the cut point previously determined to maximize agreement between predictions and true class labels in the historical data. Results: Our new clinical classifier significantly outperformed the ABCD2 (z=2.44, p=0.015) with an AUC of 0.72, (95% CI: 0.68, 0.77) vs. 0.66 (0.61, 0.71). In terms of sens/spec and acc, our classifier achieved 0.78/0.55 with acc 71% compared to 0.75/0.46 with acc 66% for the ABCD2 (using the previously specified cut points). Conclusion: Our ACVS clinical classifier showed better performance than the ABCD2 score on a prospective sample of ED patients. The improved specificity of the clinical classifier relative to existing prognostic tools would reduce the number of non-ACVS patients referred for early treatment as well as conserve medical resources. Our ongoing multi-site study will evaluate the utility of the ACVS classifier embedded in a logic-enabled e-fillable form. This form will also provide risk-based thresholds guiding timely ordering of CTA as well as links to clinical treatment guidelines. Longer-term, the e-form and classifiers will be further enhanced to include plasma-based protein biomarker data.

Restricted: Increasing Access to the Reference Collection

<strong>Abstract: Introduction:</strong> The objective of this project was to determine whether or not a hospital library reference collection is still necessary or justified. Two academic hospital libraries moved all reference books to the general collection to see whether increased access to these materials would increase their use. <strong>Description:</strong> All reference books were updated to circulating status and shelved in the circulating collection. As these items were used, statistics were gathered in the integrated library system (ALMA). Statistics were gathered from August 2014 to January 2015. Circulation statistics for equivalent periods prior to and during the project were compared to determine whether changing access to the collection increased use. <strong>Outcomes:</strong> Uses of the reference collection items doubled at Seven Oaks General Hospital (SOGH) and more than tripled at Victoria General Hospital (VGH). The percentage of reference titles used tripled at SOGH and doubled at VGH. <strong>Discussion:</strong> The change to circulating status significantly increased access to and use of the reference collection. This borrowing policy change for the reference collection will be recommended to the other hospital libraries within the University of Manitoba.

Estimation of additional MRI resources needed in British Columbia for screening high-risk women for breast cancer.

51 Background: Screening women at high risk with MRI has been shown to detect breast cancer at an early stage. Therefore, MRI screening has been recommended in the UK and USA for women who are at a high risk of developing breast cancer. However, there is no information available in the province of British Columbia (BC) about the number of women who have a high risk of developing breast cancer. Therefore, we carried out a study to estimate the breast cancer risk distribution in three sample populations in BC using Tyrer-Cuzick (TC) risk prediction model so that additional resource requirement for MRI breast screening can be calculated. Methods: A survey questionnaire was designed based on the TC model, which includes family history, hormonal factors, and benign breast disease. Additional questions also include factors that are used in other models (Gail, Claus, and BCRAPRO) as well as factors that may be included in the future. Women were recruited by staff and volunteers at three screening mammography clinics: Kelowna, Victoria General Hospital, and BC Women’s Health Centre in Vancouver. The survey was available to women to complete on the web, by phone, or on paper. An online database was constructed to store and query the data. The 10-year risk of developing breast cancer for each woman was calculated using the Tyrer-Cuzick IBIS Risk Evaluator software and the risk distribution of the survey population was analyzed. Results: Data from 3,200 women recruited from three sites, gives a risk distribution showing 2.6% are at high risk of developing breast cancer, 31.2% are at moderate risk, and 66.2% are at low risk. Based on NICE guidelines (UK), high risk is defined as having a 10-year risk of greater than 8%, moderate risk as 3-8%, and low risk as less than 3%. Extrapolating this to the approximately 500,000 women who are eligible to attend for screening mammography in BC, 13,000 women are considered at high risk. Conclusions: Our results indicate that 2.6% of women ages 40-79 attending screening mammography in BC may have a very high risk of developing breast cancer based on personal and family history. Based on a 14-hour work day, three additional MRI scanners would be required to implement MRI screening for these high-risk women in BC.

The Contributions of W.D. Stevenson to the Development of Neurosurgery in Atlantic Canada

The establishment of a neurosurgical department in Halifax in January 1948 marked the beginnings of the first dedicated neurosurgical service in Atlantic Canada. The development of neurosurgery in Halifax occurred in a receptive place and time. The Victoria General Hospital, the region’s largest tertiary care centre, and the Dalhousie University Faculty of Medicine were in a period of growth associated with medical specialization and departmentalization, changes inspired in part by the Flexner Report of 1910. Atlantic Canadians during this period were increasingly looking to specialists for their medical care. Although this social environment encouraged the establishment of surgical specialty services, the development of neurosurgery in Halifax, as in other parts of Canada, was closely associated with the efforts of individual neurosurgeons, such as William D. Stevenson. After training with Kenneth G. McKenzie in Toronto, Stevenson was recruited to Halifax and established the first neurosurgical department in Atlantic Canada. From the outset and over his twenty-six years as Department Head at the Victoria General Hospital and Dalhousie University, Stevenson worked to maintain the department’s commitment to clinical practice, medical education, and research. Although Stevenson single-handedly ran the service for several years after its inception, by the time of his retirement in 1974 the neurosurgery department had grown to include five attending staff surgeons who performed over two thousand procedures each year. This paper highlights the importance of Stevenson’s contributions to the development of neurosurgery in Atlantic Canada within the context of the social and medical environment of the region.

Characterization and cloning of a 37.6-kb plasmid carried byLegionella pneumophilarecovered from patients and hospital water over a 12-year period

For 12 years, strains of Legionella pneumophila serogroup 1 harbouring a 37.6-kb (23 MDa) plasmid have predominated among patient and potable water isolates at the Victoria General Hospital, Halifax, N.S. Plasmid DNA recovered from 24 strains isolated between 1983 and 1995 was digested with the restriction endonucleases EcoRI, HindIII, KpnI, PvuII, XbaI, and BamHI. The distribution of cutting sites indicated that the 23-MDa size group had remained essentially unchanged during this period, suggesting the persistence of a single plasmid type. Further fragmentation pattern analysis permitted the construction of a physical map of the prototype 23-MDA plasmid, pLp4269. Double digestion with BamHI–HindIII enabled the cloning of 94.4% of pLp4269 into pBluescript vector. A 2.1-kb fragment was not clonable. Plasmid pLp4269 is the first of the smaller Legionella extrachromosomal DNAs to be characterized in this way.Key words: Legionella, plasmid, stability, map, cloning.

First Reported Case of Bacterial Endocarditis Attributable toActinomyces meyeri

A 48-year-old man presented to the Victoria General Hospital, Halifax, Nova Scotia in severe congestive heart failure. Echocardiographic studies revealed significant aortic valve insufficiency. Two anaerobic blood cultures performed two weeks apart were both positive forActinomyces meyeri. The patient was treated with high dose intravenous penicillin. Three weeks after antibiotics were begun, he underwent aortic valve replacement. Intraoperative cultures were negative. Histopathological examination revealed findings in keeping with subacute bacterial endocarditis. The patient completed a six-week course of penicillin and was doing well three months after surgery. This is the first case of endocarditis attributable toA meyerireported in the literature.