The Revolutionary Changes in Hepatitis C Treatment

March 2019; 61:2 IN THIS ISSUE: Pages 57–100 When vitamin supplements lead to harm: Biotin and its impact on laboratory testing Access to safe drinking water in First Nations communities and beyond Concussions and return-to-work considerations

The revolutionary changes in hepatitis C treatment

www.bcmj.org March 2019 Volume 61 • Number 2 contents Pages 57–100

61 Editorials A laughing matter, David R. Richardson, MD (61) Lessons, priorities, mindfulness, challenges, and epiphanies, David B. Chapman, MB (62)

63 President’s Comment Let’s be real, we need more failure Eric Cadesky, MD

65 News What Doctors of BC does for me, Jessie Wang (65) On the cover Changes to GPSC fees (65) Some pregnant women don’t believe cannabis is harmful to their fetus (88) The hepatitis C treatment revolution Preventing overdose deaths among people recently released from a The development of direct-acting correctional facility (88) antiviral agents has reduced A model of global health engagement, Arun K. Garg, MD, Reza disease burden, expanded Alaghehbandan, MD, Suman Kollipara, MD (89) treatment options for patients with different hepatitis C UBC research examines living well while dying (90) genotypes or other pre-existing comorbidities, and significantly improved cure rates, which now exceed 95% with newer antiviral Clinical Articles agents. Eliminating hepatitis C infections in British Columbia is 66 now a realistic goal. When vitamin supplementation leads to harm: The growing popularity of biotin The BCMJ is published by and its impact on laboratory testing Doctors of BC. The journal John Fan, Morris Pudek, PhD, Andre Mattman, MD, Marshall Dahl, MD, Sophia provides peer-reviewed clinical Wong, MD and review articles written primarily by BC physicians, for BC physicians, along with 72 debate on medicine and medical The revolutionary changes in hepatitis C politics in editorials, letters, and treatment: A concise review essays; BC medical news; career Monica Dahiya, BSc, Trana Hussaini, PharmD, Eric M. Yoshida, MD and CME listings; physician profiles; and regular columns. Print: The BCMJ is distributed monthly, other than in January and August. 78 BC Centre for Disease Control Web: Each issue is available at Using population-level integrated health data to monitor and assess www.bcmj.org. patients’ progression across care and treatment continuums Subscribe to print: Email Sophia R. Bartlett, PhD, Terri Buller-Taylor, PhD, Mel Krajden, MD, Naveed Z. [email protected]. Janjua, MBBS Single issue: $8.00 Canada per year: $60.00 Foreign (surface mail): $75.00 79 Special Feature Subscribe to notifications: To receive the table of contents Access to safe drinking water in First Nations communities by email, visit www.bcmj.org and and beyond click on “Free e-subscription.” Helena Swinkels, MD, Sylvia Struck, PhD, Linda Pillsworth, Btech Prospective authors: Consult the “Guidelines for Authors” at www.bcmj.org for submission requirements.

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BC Medical Journal Vancouver, Canada 604 638-2815 81 General Practice Services Committee [email protected] Physician networks: Improving practice coverage, patient care, and www.bcmj.org physician support Afsaneh Moradi

Editor 83 David R. Richardson, MD Obituaries

Editorial Board Dr Peter Doris, John O’Brien-Bell, MB (83) Jeevyn Chahal, MD Dr Ralph William Spitzer, Arun K. Garg, MD (83) David B. Chapman, MBChB Elizabeth J. Watt, MD (84) Brian Day, MB Dr W. Donald Watt, David Esler, MD Amanda Ribeiro, MD Yvonne Sin, MD 85 Council on Health Promotion Cynthia Verchere, MD Can frailty be prevented? Or is it the inevitable decline in function that Managing editor Jay Draper accompanies aging? Steven Larigakis, MD Associate editor Joanne Jablkowski Senior editorial and 86 Special Feature production coordinator Kashmira Suraliwalla Ready or not for the CCFP exam Copy editor Paul Dhillon, MBBChBAO, Simon Moore, MD Barbara Tomlin

Proofreader Ruth Wilson 92 WorkSafeBC Web and social media Concussions and return-to-work considerations coordinator David J. Rhine, MD Amy Haagsma

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Postage paid at Vancouver, BC. Advertisements and enclosures carry no endorsement of Doctors of BC or BCMJ. Canadian Publications Mail, Product Sales Agreement #40841036. © British Columbia Medical Journal, 2019. All rights reserved. No part of this journal may be reproduced, stored in a retrieval Return undeliverable copies to BC Medical Journal, system, or transmitted in any form or by any other means—electronic, mechanical, photocopying, recording, or otherwise—without 115–1665 West Broadway, Vancouver, BC V6J 5A4; prior permission in writing from the British Columbia Medical Journal. To seek permission to use BCMJ material in any form for tel: 604 638-2815; email: [email protected]. any purpose, send an email to [email protected] or call 604 638-2815. Statements and opinions expressed in the BCMJ reflect the opinions of the authors and not necessarily those of Doctors of BC or the institutions they may be associated with. Doctors of BC does not assume responsibility or liability for damages arising from errors or omissions, or from the use of information or advice contained in the BCMJ. The BCMJ reserves the right to refuse advertising.

60 bc medical journal vol. 61 no. 2, march 2019 bcmj.org editorials

A laughing matter

“ o you have time to come in he used to be, and I am very thankful make fun of him when he no longer and say ‘hi’ to your sister?” that his underlying personality hasn’t made any sense. D “I have a sister? Why changed. He remains happy, pleas- Now, don’t get me wrong, this didn’t anyone ever tell me?” ant, appreciative, and easygoing. So disease is terrible and causes much This is a conservation I recently far he hasn’t demonstrated any sig- sadness. I am losing my father, my had with my father. He was referring nificant irritability or agitation and is mother has lost her partner, and my to my mother, but his addled brain blissfully unconcerned about his de- children have lost their grandfather. often mixes things up. You see, my clining mental functions. When I remember the man he was, father has Alzheimer disease. Over If you asked friends and family I suffer a little despair as to all that the last few years he has gradually to describe my father in one word, is missing. However, the humorous deteriorated to the point where his I’m pretty sure it would be jokester. things he does make the progression cognitive issues are now obvious to My father would never turn down of his dementia more tolerable, and I everyone. However, I suspect this an opportunity to goof around, make know he would encourage everyone dementing process has been going someone laugh, or dress up in some to laugh along if he could. So, if I gig- on for much longer than we know. funny—often inappropriate—cos- gle a little, I feel less guilty because My father is outgoing and constantly tume. This is the man most likely to I remind myself that making people joking, so he can make it seem like be found at the office in a gorilla suit, laugh has been his lifelong mission. he knows someone without ever ac- not necessarily on Halloween. I dis- Recently friends took him to vis- tually having to identify them. He tinctly remember him coming to my it my mother in hospital, which is a still talks to everyone, and he’ll tell parent-teacher interviews and draw- 30-minute drive from his house. Lat- me that he used to play golf with ing funny faces on the chalkboard. In er, I asked him how he got there, and complete strangers he meets at the old party photos he is often dressed after thinking for a while he stated, “I store. These confabulations fit seam- up as a woman holding a liquor bottle, think I walked.” lessly into the day-to-day situations but that’s another story. My parents’ After a chuckle, I thought to my- he is confronted with. (As an aside, house was often adorned with singing self that living with his dementia re- I suspect that he has been making Christmas trees, fish, dogs, etc. If my ally is a journey, and as we walk up his golf scores for years.) I’m not father knew he was going to get de- together I will do my best to support sure he is even aware of who I am at mentia, he would have probably made him with grace, love, and laughter. times. I still get glimpses of the man jokes about it and encouraged me to —DRR

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bc medical journal vol. 61 no. 2, march 2019 bcmj.org 61 editorials

Lessons, priorities, mindfulness, challenges, and epiphanies

e buried a colleague re- fully retired or had relinquished their at 2:15 a.m. from a different nurse recently. To be more precise, hospital privileges years ago. None of garding the same patient. I asked the W we said farewell to a now- them ever expressed regret over their nurse, in my most polite voice, why deceased colleague. He was a true decision to leave the hospital, and he was calling me at that hour as op- gentleman, an excellent surgeon, and many of them told stories of the mo- posed to calling the doctor on call for notably, possessed an incredible ca- ments that were the proverbial straw our group. He told me that it was be- pacity to make his family, his friends, that broke the camel’s back. cause he thought I was the doctor re- and his patients feel special. What was sponsible for the patient on any day really astounding about him, though, at any hour. The nurse soon realized was how he navigated all of the chal- I had been using that I wasn’t even this patient’s fam- lenges of his personal and professional work to escape from ily doctor, so he told me that he would life with such grace and balance. (He some of the personal call my colleague instead. Hastily, I was the only surgeon in town when he challenges I faced. I corrected him and referred him to the first arrived, and is the only surgeon call schedule for our group. He must have stopped doing I’ve ever known to do house calls.) have been new, as he was completely How did he do it? How did he cultivate that and am now oblivious to the on-call system at our a resiliency adequate to the demands enjoying having the hospital. So, at 2:15 in the morning, of his life? And, as his former col- majority of my instead of getting a good amount of league who is struggling with similar weekends completely sleep, I found myself in a highly ir- demands, how can I do the same? free to exercise, cook, ritated state trying to politely school Most of his (and my) colleagues this nurse into figuring out which doc- read, relax, and spend who were at his memorial were either tor was on call. time with my The following day I came this loved ones. close (my right thumb and index fin- Dragon® Medical ger are just millimetres apart) to giving up my hospital privileges. After Practice Edition 4 I almost had one of those mo- venting to colleagues and practising (it’s the version you have been ments a few weekends ago after a some mindfulness, I was able to calm waiting for) particularly grueling overnight call down. But the events of that week- shift and group ward rounds over the end along with personal factors in same weekend. Although these irri- my life have made me re-evaluate my tants don’t happen often, when they priorities. do it is extremely upsetting. After be- I had had an epiphany a few weeks ing at the hospital from early Saturday prior. I had been using work to escape morning to early Sunday afternoon, from some of the personal challenges I was about to pull into my garage I faced. I have stopped doing that and when my pager went off. The call am now enjoying having the major- was from a nurse asking me to return ity of my weekends completely free to the hospital to provide a consent to exercise, cook, read, relax, and for transfusion on a patient who was spend time with my loved ones. I’m about to be transfused for the 16th starting to feel like a normal person, Dragon Software time over the previous year. I asked perhaps for the first time since I quali- Installation & Support politely for her to check the patient’s fied as a doctor. I feel more resilient EMR Integration & Training file, as he had received a transfusion and happier in my work and personal as recently as 10 days prior. The nurse life. When I remarked on this to my CONTACT US TODAY! looked through his file, found the nec- 18-year-old son, he informed me that speakeasysolutions.com essary document, and a return trip to he had known for years what I had 1-888-964-9109 the hospital was avoided. just realized about myself. What a speech technology specialists I planned an early night with the smart kid he is. Hopefully he won’t for 18 years hope of getting a good recovery sleep. take after his dad! It was not to be. My home phone rang —DBC

62 bc medical journal vol. 61 no. 2, march 2019 bcmj.org president’s comment

Let’s be real, we need more failure

s we scroll through Facebook and frustrations of working hard—of- Dr Paul Ehr photos and Instagram stories, ten to the point of burnout, or worse— lich to found it’s easy to think that every- to compensate for a health care the field of A 2 one else is winning at life with their system that hasn’t evolved to meet the immunology. perfect meals, epic beach vacations, increasing needs of our patients and And thanks to and overachieving children. While communities. Yet just as we wouldn’t Wilson Great- sometimes opportunity does meet improve as cooks, planners, and par- batch’s use of preparation, reality is usually full of ents without the occasional defeat the wrong tran- burned dinners, rainouts, and excru- along the way, we cannot have prog- sistor while ciating tantrums. ress in health care without failure. trying to record In health care, we have our own a heartbeat, the implantable cardiac culture of perfection where success defibrillator was discovered.3 We’ve all experienced the is rightly celebrated, but we are slow However, conditions necessary to move away from the traditionally disappointments and for the productive process of failure judgmental nature of morbidity and frustrations of working are rarely in place. So how can we mortality rounds or the stoked com- hard—often to the point of change this? petition of quantifying our learners burnout, or worse—to through hallway pop quizzes. We’ve compensate for a health Move past blame all experienced the disappointments “Remember that failure is an event, care system that hasn’t not a person.” —Zig Ziglar evolved to meet the Despite the politicized times we live increasing needs of our in, we must move past blaming others BC Medical Journal @BCMedicalJournal patients and communities. and recognize that health care is extremely complex, and failure is in- The Multiple Sclerosis Society of evitable. We experience this in our Canada released evidence-based recommendations for vitamin D History has shown that success clinical lives: some couples require supplementation and maintenance of rarely comes quickly or easily—and more IVF treatments than others; vitamin D serum levels to help people certainly not without failure. The next some cancers respond to a certain affected by multiple sclerosis. time you fix your squeaky door you chemotherapy while others don’t; Read the article: bcmj.org/news/ can thank the engineers who failed and some patients develop postsur- vitamin-d-recommendations-people- 39 times before finding the water-dis- gery complications while others who living-ms placing formula that is still used more have undergone the same procedure, than 65 years later in WD-40.1 And in the same hospital, with the same while you may not remember Apple’s team, don’t. Depersonalizing failure desktop computer, Lisa, Steve Jobs will allow us to fairly assess outcomes learned from that mistake and focused and reassure others that they won’t be his vision on creating the Macintosh, judged solely by their outcomes, but which paved the way for the iPhones rather by their efforts, intentions, it- and iPads so central in our lives to- erations, and inclusivity. day. And millions of us have seen the SpaceX landing, but how could we Encourage and BCMJ.ORG possibly dock a rocket on a raft with- support failure 4 3 Shares out a number of unexpected ocean “I have not failed. I’ve just found Like Comment Share splashes? 10 000 ways that won’t work.” In health care, a teenager’s fail- —Thomas Edison ure to create a synthetic form of an Like any process, failure requires re- Like @BCMedicalJournal antimalarial drug led to the creation sources. Although there are hundreds and join in the conversation. of purple dye, which in turn allowed Continued on page 64

bc medical journal vol. 61 no. 2, march 2019 bcmj.org 63 comment

Continued from page 63 The goal is not to fail, but rather to cause only by recognizing the value of books on the importance of failing courageously try our best, and when of failure and supporting innovation fast, our clinical, family, and other failure occurs, as it often will, to ana- can we ever truly succeed. personal commitments often act as lyze and learn from the experience. —Eric Cadesky, MDCM, CCFP, barriers to our involvement at the sys- Our biggest mistake is not in failing, FCFP tems level. But we need to encourage but in failing to learn from our fail- Doctors of BC President participation and create a culture that ures.4 The health care landscape is rewards innovation and doesn’t de- full of ambitious ideas and projects References cry failure—surely we can find ways such as one person/one record EMRs, 1. WD-40 history. Accessed 1 January 2019. to allow people to give their time, alternative payment models, pooled www.wd40.com/cool-stuff/his ideas, and feedback. Sure, there is a referrals, primary care networks, and tory. financial cost to failing—at least in urgent primary care centres. They 2. Androutsos G. Paul Ehrlich (1854–1915): the short term—but without a proper, will not—cannot—all succeed every- Founder of chemotherapy and pioneer of protected budget, governments and where at once. And these bumps in haematology, immunology and oncology. health authorities have no incentives the road will inform the rest of the J BUON 2004;9:485-491. to be ambitious, and instead continue journey, giving us the opportunity to 3. Aquilina O. A brief history of cardiac pac- down the safer path, making small improve all aspects of these projects, ing. Images Paediatr Cardiol 2006;8: changes or blaming foundational from change management, to fund- 17-81. issues on those who came before. ing, to local needs, to leadership, even 4. Edmondson AC. Strategies for learning the assessment process itself. from failure. Harvard Business Review. Learn and iterate So let’s move beyond the curated Accessed 14 January 2019. https://hbr “It is fine to celebrate success, but it personas we see online and get real .org/2011/04/strategies-for-learning is more important to heed the les- about helping our patients and build- -from-failure. sons of failure.” —Bill Gates ing a better health care system, be-

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64 bc medical journal vol. 61 no. 2, march 2019 bcmj.org news

What Doctors of BC also free through all 4 years. That’s rural medicine, and a $1000 Change- does for me saving me at least $925 in premiums! maker Award for demonstrating lead- As a student on a budget, I love the I knew about the rural-rotation ership in advocacy. word free, so I took an inventory of travel stipend of up to $800, but I al- Of course, Doctors of BC hosts what’s free out there for medical stu- most forgot about the $250 weekly the much-anticipated annual Back- dents. I knew that my Doctors of BC housing allowance for up to 8 weeks: pack Day for first-year students, but membership is free during my 4 years all the more reason to do a rural elec- this year I attended the other big (and of medical school, but I had forgotten tive in fourth year. arguably more important) annual that this includes a free CMA mem- I knew that Doctors of BC pro- event—Find Your Match, where I and bership, which means free access to vides some of the needs-based bursa- other students got insider tips from handy resources such as RxTx and ries applied through the UBC Student physicians from various disciplines DynaMed Plus, not to mention vari- Service Centre (up to $250 000 is do- while enjoying a scrumptious, fully ous additional deals and discounts. nated each year), but I was not aware catered meal. I knew that I received free life in- of other ways to win money. I could Free membership plus all those surance with Doctors of BC through win a $1000 prize for submitting an extras—that’s a lot of value. my 4 years of medical school as well, article to the BCMJ, a $250 prize for —Jessie Wang but as of the 2018–19 school year writing a BCMJ blog post, a $5000 Medical Student Intern, Doctors of BC disability insurance is award for demonstrating interest in Doctors of BC

Changes to GPSC fees The GPSC has made changes to some of its fees to enable delegation, simplify billing, and clarify requirements. These changes are part of the GPSC’s continued efforts to support full-service family doctors to improve access to care and services.

Enabling delegation Clarifying documentation As part of the service requirements for the GPSC plan- To reflect a recent change to MSP’s counseling fee ning fees, doctors may now delegate non-face-to-face 0120, the GPSC added the following note to some of its planning tasks to College-certified allied care providers mental health fees: “Documentation of the effect(s) of working in a GP practice. This change affects the fol- the condition on the patient and what advice or service lowing four GPSC incentives: was provided is required.” This note has been added to • G14033: GP Complex Care Planning and Manage- the following five GPSC fees: ment Fee • G14044: GP Mental Health Management Fee age • G14043: GP Mental Health Planning Fee 2–49 • G14063: GP Palliative Care Planning Fee • G14045: GP Mental Health Management Fee age • G14075: GP Frailty Complex Care Planning and 50–59 Management Fee • G14046: GP Mental Health Management Fee age 60–69 Simplifying billing • G14047: GP Mental Health Management Fee age The Personal Health Risk Assessment (Prevention) 70–79 (G14066) has been amended to align with the GPSC • G14048: GP Mental Health Management Fee age 80+ planning fees. Physicians are no longer required to bill It is recommended that GPs ensure that clinical a visit fee in addition to the G14066 fee. A visit fee may notes for any 0120 or GPSC mental health management still be billed in addition if medically required and does fee billing include the required documentation as of 1 not take place concurrently with the face-to-face plan- December 2018. ning included under G14066. This change is effective For details on all of these changes, including links 1 January 2019. to updated GPSC billing guides, visit www.gpscbc.ca.

News continued on page 88

bc medical journal vol. 61 no. 2, march 2019 bcmj.org 65 John Fan, Morris Pudek, PhD, FCACB, Andre Mattman, MD, FRCPC, Marshall Dahl, MD, PhD, FRCPC, Sophia Wong, MD, FRCPC

When vitamin supplementation leads to harm: The growing popularity of biotin and its impact on laboratory testing

High biotin concentrations in blood samples for immunoassays that employ biotin-streptavidin interactions can interfere with investigations for cardiac disease, endocrine disorders, malignancies, anemias, and infectious diseases and lead to falsely low or falsely high results.

ABSTRACT: Biotin, also known as to biotin use have been reported in 54-year-old female was be- vitamin B7 or vitamin H, has seen a the medical literature. The results ing assessed for thyroid surge in popularity in recent years can be falsely low or falsely high, A dysfunction following self- based on limited evidence that it en- and in either case can lead to pa- reported symptoms of weight gain hances hair, skin, and nail growth. tient misdiagnosis and misman- and lethargy. The patient had no neck Due to its water-soluble properties, agement. Mitigation is possible tenderness and exhibited no symp- biotin is excreted through the uri- when biotin interference is iden- toms of goiter. Past medical history nary system and is considered non- tified. Patients can be advised to was significant for relapsing-remitting toxic even at large doses. However, a discontinue the supplement before multiple sclerosis and anxiety. Labo- high concentration of biotin in blood follow-up testing or physicians can ratory investigations were ordered can interfere with laboratory tests order an alternative testing meth- and the results were consistent with that use technology dependent on od. While laboratory professionals thyrotoxicosis: thyroid-stimulating biotin-streptavidin interactions. have been aware of biotin interfer- hormone (TSH) of 0.08 mU/L (ref- These tests include immunoassays ence for many years, greater aware- erence range 0.34–4.82 mU/L), free used to investigate or monitor car- ness among health care providers thyroxine (FT4) of 33.2 pmol/L (10.0– diac disease, endocrine disorders, in general is needed to ensure that 20.0 pmol/L), and free triiodothyro- malignancies, anemias, and infec- biotin supplementation is identi- nine (FT3) of 46.1 pmol/L (3.5–6.5 tious diseases. Increasingly, cases fied and mitigation strategies are pmol/L). Given that these laboratory of erroneous laboratory results due considered. values were not supported by the clini-

Mr Fan is an undergraduate student at the is a staff medical biochemist at St. Paul’s the Division of Endocrinology at UBC. He University of British Columbia. Dr Pudek Hospital. He is also a clinical associate pro- is also the current president of the Society is the regional medical lead for clinical fessor in the Department of Pathology and of Endocrinology and Metabolism of chemistry for Vancouver Coastal Health Laboratory Medicine at UBC and serves British Columbia. Dr Wong is the regional laboratories. He is also a clinical profes- as the medical biochemistry discipline medical lead for pre- and post-analysis for sor in the Department of Pathology and lead at BC’s Agency for Pathology and Vancouver Coastal Health laboratories, Laboratory Medicine at UBC. Dr Mattman Laboratory Medicine. Dr Dahl is the divi- and a clinical assistant professor in the sion head of endocrinology at Vancouver Department of Pathology and Laboratory This article has been peer reviewed. General Hospital and a clinical professor in Medicine at UBC.

66 bc medical journal vol. 61 no. 2, march 2019 bcmj.org When vitamin supplementation leads to harm: The growing popularity of biotin and its impact on laboratory testing

cal presentation, new blood work was of biotin (up to 300 mg/day) have Biotin interference ordered. When a similar pattern of shown promise in secondary progres- with laboratory tests values was found (TSH 0.01 mU/L, sive multiple sclerosis.7 As biotin is readily available over the FT4 > 103.0 pmol/L, FT3 > 46.1 In the past decade, biotin supple- counter and is perceived to be harm- pmol/L), a referral was made to en- mentation in doses up to 20 mg a day less, patients may not disclose their docrinology. Upon being questioned has been marketed to promote hair, biotin use to physicians unless spe- by the endocrinologist, the patient skin, and nail growth. Although there cifically asked. Further, health care described taking high-dose biotin for is limited evidence to support this providers may also view biotin sup- her multiple sclerosis. The patient was claim, marketing led to biotin sales plementation as innocuous. However, advised to stop the biotin for 1 week of up to 49.6 million units in the US when found in high concentrations before repeat testing. Follow-up blood work revealed the patient to be euthy- roid, with a TSH level of 1.78 mU/L, FT4 of 12.6 pmol/L, and FT3 of 3.7 pmol/L, along with an undetectable TSH receptor antibody titre.

Clinical and commercial use of biotin Increasingly, biotin consumption is Biotin, also known as vitamin B7 or vitamin H, is a water-soluble vitamin being found to result in inaccurate that serves as a cofactor for a number laboratory findings that lead to of carboxylase reactions, making it essential to the functioning of various misdiagnosis and mismanagement. metabolic pathways.1-4 It is involved in fatty acid synthesis, catabolism of branched-chain amino acids, gluco- neogenesis, islet cell gene expres- sion, insulin secretion, and the Krebs cycle.4 The recommended dietary reference intake for biotin is 30 μg/day. The vitamin is found in various foods, including egg yolk, pork, liver, whole cereals, soybeans, avocado, cauli- alone between July 2016 and July in blood, biotin can interfere with flower, and leafy greens.1-4 Because 2017.1 Biotin is currently the top- laboratory tests that employ biotin- of its abundance in a typical North selling multivitamin supplement on streptavidin interactions as part of the American diet, biotin deficiency is Amazon.ca. Locally, a survey of 660 assay technology. Biotin-streptavidin uncommon, and supplementation is patients visiting the Diamond Health binding is commonly used in immuno- rarely indicated. Clinically, biotin Care Centre Outpatient Laboratory at assays due to its avidity and stability, may be prescribed in patients with Vancouver General Hospital found which facilitate immunoassay sensi- malabsorptive disorders or in those on that 50 respondents (7.6%) were tak- tivity and specificity. A 2017 study total parenteral nutrition. It may also ing biotin. The majority of users were by Holmes and colleagues found that be useful in relieving muscle cramps female (92%) and biotin users tended out of the 374 methods operated by in hemodialysis patients.5 High doses to be younger than non-users: age 49 8 of the most popular immunoassay of biotin (5 to 30 mg/day) are recom- (19 to 85) years versus age 54 (19 to analyzers in the US, 221 (59%) were mended in certain inborn errors of 98) years. The prevalence of biotin biotin-based.4 Depending on the lab- metabolism, such as in biotinidase supplementation in our survey popu- oratory and the analytical platforms deficiency, propionic acidemia, or lation was similar to that reported by used, a broad range of tests may be in holocarboxylase synthetase dis- the Mayo Clinic, which found 7.7% affected by biotin supplementation, orders.6 More recently, mega-doses of outpatients to be ingesting biotin.1 including those used in the diagnosis

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or monitoring of cardiac disease, to streptavidin-coated beads. With In the Holmes study referred to endocrine disorders, malignancies, a smaller volume of reagent biotin- above, 37% of the biotin-based im- anemias, and infectious diseases streptavidin complexes formed, the munoassays evaluated were affected ( Table 1 ).6 assay signal is decreased and a facti- by serum biotin levels of less than Biotin-containing blood samples tiously low result is reported. This is 51 ng/mL.4 Mean peak serum biotin can affect laboratory tests by com- in contrast to competitive immunoas- concentrations of 8.6 ng/mL have peting with biotinylated reagents for says, which are generally used to mea- been reported following consumption binding to streptavidin. Depending sure small molecules such as FT4 or of a single dose of 1 mg, while con- on whether the assay is noncompeti- FT3, where the assay signal is inverse- centrations of 495 ng/mL have been tive or competitive, the result may be ly proportional to the analyte concen- reported following consumption of falsely low or falsely high ( Figure ). In tration. In these immunoassays, biotin 100 mg.4 In a study by Grimsey and noncompetitive or sandwich immu- competes with labelled biotinylated colleagues, ingestion of biotin for 5 noassays, supplemental biotin com- analyte for binding to streptavidin and consecutive days was found to pro- petes with reagent biotin for binding results can be spuriously high. duce peak median serum biotin levels of 46 ng/mL (5 mg dose daily), 103 ng/mL (10 mg dose daily), and Table 1. Immunoassays at high risk for analytic interference from biotin supplementation. 184 ng/mL (20 mg dose daily).8 The higher the dose of biotin ingested, the Conditions Immunoassays more likely that biotin-based labora- Cardiac • Troponin I, troponin T tory assays will be impacted. disease • Brain natriuretic peptide (BNP), N-terminal pro brain natriuretic peptide Increasingly, biotin consumption (NT-pro BNP) is being found to result in inaccurate Endocrine • Thyroid stimulating hormone (TSH), free thyroxine (FT4), laboratory findings that lead to mis- disorders free triiodothyronine (FT3), anti-thyroid peroxidase (TPO) antibodies, diagnosis and mismanagement. Mis- anti-TSH receptor antibodies, thyroglobulin leading thyroid function results are • Estradiol, progesterone, luteinizing hormone (LH), follicle stimulating often described in the medical litera- hormone (FSH), testosterone, sex hormone binding globulin (SHBG), 2,3,9-13 dehydroepiandrosterone sulfate (DHEAS) ture, as biotin causes falsely high • Human chorionic gonadotropin (hCG), prolactin, growth hormone FT4 and FT3 values and falsely low • 25-hydroxyvitamin D, parathyroid hormone (PTH) TSH results that mimic hyperthyroid- • Cortisol ism. In one reported case, a newborn female with a positive screening test Malignancies • Gastrin, alpha fetoprotein (AFP), carcinoembryonic antigen (CEA) for congenital hypothyroidism was • Cancer antigen (CA) 19-9, CA 125, CA 15-3 found to have decreasing TSH levels • Calcitonin and elevated FT4 levels on subsequent • Prostate-specific antigen (PSA) testing.12 Further investigations re- Anemias • Ferritin vealed that the neonate had been start- • Folate, vitamin B12 ed on a vitamin cocktail containing 10 Infectious • Hepatitis A virus (HAV) serologies: HAV total, anti-HAV total, anti-HAV IgM mg of biotin daily because the baby’s diseases • Hepatitis B virus (HBV) serologies: HBsAg, anti-HBs, anti-HBc total, sibling had died of organic acidosis anti-HBc IgM, HBeAg, anti-HBe a few years prior. Discontinuation • Hepatitis C virus (HCV) serologies: anti-HCV of biotin supplementation and repeat • Herpes simplex virus (HSV) serologies: HSV-1 IgG, HSV-2 IgG thyroid function testing using an alter- • Rubella serologies: rubella IgG, rubella IgM native methodology confirmed the initial diagnosis of hypothyroidism, and Others • C-reactive protein (CRP) thyroxine therapy was initiated. • Procalcitonin In another case, a 64-year-old fe- • Anti-CCP (cyclic citrullinated peptide) antibodies male with end-stage renal disease was • IgE thought to have adynamic bone dis- • Digoxin, cyclosporine, sirolimus ease due to a low normal parathyroid Adapted from Holmes E, Samarasinghe S, Emanuele A, Meah F.4 hormone (PTH) level, intermittently

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Mitigating biotin Competitive immunoassay interference While laboratory professionals have been aware of biotin interference for many years, the problem has been Biotinylated antibody Normal amplified recently with increasing use of the supplement. In November 2017 a growing number of adverse events Labeled analyte analog associated with biotin, including one Detected labeled patient death following an incorrect analogs Undetected labeled (attached to analogs cardiac troponin assessment second- microparticles via biotin) (unattached) ary to biotin interference, led the US Analyte (e.g., fT4) Food and Drug Administration (FDA) to warn the public, health care providers, and laboratory personnel that Excess biotin biotin may interfere with certain lab- Streptavidin- oratory tests and cause misleading

coated 15 microparticles test results. It is paramount that health care providers and patients be informed of the potential errors in laboratory Noncompetitive (sandwich) immunoassay results with biotin use. Physicians should always ask their patients about biotin supplementation during Normal history taking. The question should Labeled antibody be thoughtfully posed (e.g., “Are you taking any supplement for hair, skin, or nail benefits?”) since patients may Biotinylated antibody not be aware of the ingredients in a Detected labeled supplement, as these are not always Undetected labeled antibodies antibodies listed clearly on the label. (attached to microparticles (unattached) Patients taking biotin should be via biotin) Analyte (e.g., TSH) advised to discontinue the vitamin for at least 1 day before a blood test, Excess biotin or up to a week before testing if high doses have been consumed. The half- Streptavidin-coated life of biotin is dependent on various microparticles factors, including the patient’s kidney function and the dose and duration of biotin use. In individuals with normal Figure. Mechanism of biotin interference with competitive and noncompetitive renal parameters, the half-life of bio- immunoassays. tin after a single dose of 0.6 mg has been reported as less than 2 hours. In increased serum calcium level, and of biotin per day for restless leg syn- contrast, the half-life following a sin- severe osteoporosis.14 However, her drome. Repeat testing on a different gle biotin dose of 100 mg to 300 mg increased alkaline phosphatase result analytical perform that did not use is between 8 and 19 hours.4,16 was inconsistent with the low bone biotin-streptavidin technology found When patients on biotin require turnover observed in adynamic bone the patient’s PTH concentration to be urgent blood work, such as when they disease. It was later discovered that markedly elevated, consistent with present to the emergency department, the patient had been ingesting 10 mg secondary hyperparathyroidism. the ordering physician should consult

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local laboratory staff. Laboratory While responses from a recent tion pharmacokinetics of exogenous bio- physicians can provide information survey completed by endocrinologists tin and the relationship between biotin on which particular assays on the test in BC indicate a good level of under- serum levels and in vitro immunoassay menu may be affected by biotin, the standing where biotin interference is interference. Int J Pharmacokinet 2017; magnitude and direction of interfer- concerned, more must be done to en- 2:247-256. ence, and whether some laboratory sure that physicians working within 9. Arya VB, Ajzensztejn M, Appleby G, et al. tests on the same analytical platform and outside the laboratory become fa- High-dose biotin in infants mimics bio- are more vulnerable to biotin in- miliar with the potential of biotin to chemical hyperthyroidism with some terference than others. Further, the interfere with test results. commercial assays. Clin Endocrinol (Ox- laboratory physician can arrange for ford) 2018;88:507-510. alternative testing using a different Competing interests 10. Koehler V, Ulrike M, Nassour A, Mann methodology not affected by biotin or None declared. WA. Fake news? Biotin interference in may be able to request removal of bi- thyroid immunoassays. Clin Chim Acta otin from the sample via pretreatment References 2018;484:320-322. with streptavidin-coated beads.6,17 1. Katzman BM, Lueke AJ, Donato LJ, et al. 11. De Roeck Y, Philipse E, Twickler T, Van Fortunately, the results of a re- Prevalence of biotin supplement usage in Gaal L. Misdiagnosis of Graves’ hyperthy- cent survey completed by 18 endo- outpatients and plasma biotin concentra- roidism due to therapeutic biotin interven- crinologists in BC indicate a good tions in patients presenting to the emer- tion. Acta Clin Belg 2018;73:372-376. understanding of biotin interference gency department. Clin Biochem 2018; 12. Henry JG, Sobki S, Arafat N. Interference ( Table 2 ). However, endocrinology 60:11-16. by biotin therapy on measurement of TSH is not the only specialty affected, and 2. Chun K. Biotin interference in diagnostics and FT4 by enzyme immunoassay on further work is needed to ensure in- tests. Clin Chem 2017;63:619-620. Boehringer Mannheim ES700 analyser. formation about the impact of biotin 3. Samarasinghe S, Meah F, Singh V, et al. Ann Clin Biochem 1996;33:162-163. on laboratory testing is disseminated Biotin interference with routine clinical im- 13. Kwok JS, Chan IH, Chan MH. Biotin to all physicians. munoassays: Understand the causes and interference on TSH and free thyroid hor- mitigate the risks. Endocr Pract 2017; mone measurement. Pathology 2012;44: Summary 23:989-998. 278-280. The case of a 54-year-old female be- 4. Holmes E, Samarasinghe S, Emanuele A, 14. Meany DL, Jan de Beur SM, Bill MJ, So- ing assessed for thyroid dysfunction Meah F. Biotin interference in clinical im- koll LJ. A case of renal osteodystrophy demonstrates the harm vitamin sup- munoassays: A cause for concern [letter with unexpected serum intact parathyroid plementation can cause. In this case, to the editor]. Arch Pathol Lab Med 2017; hormone concentrations. Clin Chem laboratory findings erroneously indi- 141:1459-1460. 2009;55:1737-1739. cated thyrotoxicosis—findings that 5. Oguma S, Ando I, Hirose T, et al. Biotin 15. US Food and Drug Administration. The were eventually determined to be ameliorates muscle cramps of hemodialy- FDA warns that biotin may interfere with the result of high-dose biotin supple- sis patients: A prospective trial. Tohoku J lab tests: FDA safety communication. Is- mentation when the patient received Exp Med 2012;227:217-223. sued 28 November 2017. Accessed 23 follow-up testing, and she was ultim- 6. Clinical Microbiology Proficiency Testing October 2018. www.fda.gov/medical ately diagnosed as euthryoid. website. Wong S, Pudek M. Biotin supple- devices/safety/alertsandnotices/ucm When found in high concentra- mentation and laboratory interference: An 586505.htm. tions in blood, biotin can interfere unintended consequence in the pursuit of 16. Li D, Radulescu A, Shrestha RT, et al. As- with laboratory tests that employ beauty. Posted 27 April 2018. Accessed 14 sociation of biotin ingestion with perfor- biotin-streptavidin interactions as January 2019. http://cmpt.ca/biotin-sup mance of hormone and non-hormone as- part of the assay technology. Depend- plementation-and-laboratory-interference/. says in healthy adults. JAMA 2017; ing on whether the assay is noncom- 7. Tourbah A, Lebrun-Frenay C, Edan G, et 318:1150-1160. petitive or competitive, the result may al. MD1003 (high-dose biotin) for the treat- 17. Trambas C, Lu Z, Yen T, Sikaris K. Deple- be falsely low or falsely high. Increas- ment of progressive multiple sclerosis: tion of biotin using streptavidin-coated ingly, biotin consumption is being A randomised, double-blind, placebo- microparticles: A validated solution to the found to result in inaccurate labora- controlled study. Mult Scler 2016;22: problem of biotin interference in streptav- tory findings that can lead to misdiag- 1719-1731. idin-biotin immunoassays. Ann Clin Bio- nosis and mismanagement. 8. Grimsey P, Frey N, Bendig G, et al. Popula- chem 2018;55:216-226.

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Table 2. Responses from June 2018 survey about biotin supplementation completed by 18 BC endocrinologists.

Question Possible answers Responses Percentage a. Immunoassays 14 78% b. Electrolytes 0 0% 1. Biotin supplements are known to affect certain laboratory c. Liver and/or muscle related enzymes 0 0% tests when taken in high doses. Which tests are most likely to be affected? d. Creatinine and albumin 0 0% e. Mass spectrometry tests 0 0% f. I don’t know 4 22% Answer: a. Immunoassays Immunoassays are the most common methodology used in endocrinology testing. Many immunoassay methods employ streptavidin-biotin technology and are known to be affected by biotin supplementation. a. < 0.1% 3 17% b. 1% 3 17% 2. What percentage of patients are taking enough biotin to c. 5% 4 22% significantly bias one or more laboratory test results? d. > 10% 3 17% e. I don’t know 5 28% Answer: c. 5% Estimates are that approximately 5% of the population is taking enough biotin to bias one or more laboratory test results. a. Falsely elevated 3 18% b. Falsely depressed 0 0% 3. Does biotin cause positive biases (e.g., falsely elevated) or c. Neither 0 0% negative biases (e.g., falsely depressed) on test results? d. Both 13 76% e. I don’t know 1 6% Answer: d. Both Depending on the assay, laboratory results may be falsely high or falsely low. a. Overnight (8–12 hours) 0 0% b. 24 hours 0 0% 4. If a patient were taking biotin, how long should they stop the supplement before going to the laboratory for blood c. 2 days 10 59% tests? d. 7 days 6 35% e. I don’t know 1 6% Answer: There is no single biotin washout period that will guarantee interference-free test results. Interference thresholds differ widely among assays. Also, high biotin doses take more time to clear than low doses, and clearance takes longer in patients with impaired renal function.

As a general rule: • If a patient has been taking 10 mg of biotin per day, we recommend laboratory testing 24 hours following discontinuation of biotin for tests listed in Table 1. • If a patient has been taking 300 mg of biotin per day, we recommend laboratory testing 7 days following discontinuation of biotin for tests listed in Table 1. a. Yes 0 0% 5. If the patient takes a high dose of biotin prior to the blood sample collection, will the laboratory be able to detect b. No 16 94% interference before issuing a report? c. Not sure 1 6% Answer: b. No The laboratory will not be able to detect the interference.

We recommend health care providers always ask about biotin supplementation . If the patient is taking biotin, be sure to communicate this information to the laboratory. If you encounter a laboratory result that is inconsistent with the patient’s clinical presentation, contact the laboratory to perform additional investigations or arrange for alternate testing, as needed.

bc medical journal vol. 61 no. 2, march 2019 bcmj.org 71 Monica Dahiya, BSc, Trana Hussaini, PharmD, Eric M. Yoshida, MD, MHSc, FRCPC

The revolutionary changes in hepatitis C treatment: A concise review

The replacement of interferon-based therapy with highly effective and well-tolerated direct-acting antiviral therapy makes eliminating hepatitis C infections in British Columbia a realistic goal.

ABSTRACT: Since hepatitis C was comorbidities, and significantly im- orldwide, hepatitis C is a discovered in 1989, the pharmaco- proved cure rates, which now exceed major public health con- logical management of infections 95% with newer antiviral agents. W cern, with an estimated caused by the virus has undergone Barriers to using this therapy in 71 million people being chronically revolutionary changes, significant- British Columbia include subopti- infected with the virus (www.who ly improving cure rates and reduc- mal population screening and diag- .int/news-room/fact-sheets/detail/ ing patient morbidity and mortality. nosis, variable patient and physician hepatitis-c). Individuals with untreat Early treatment options included in- knowledge, high drug costs, lack of ed hepatitis C infection have an terferon and ribavirin, which were insurance coverage for some antivi- approximate fivefold increase in associated with significant side ef- rals, and difficulty accessing cover- all-cause mortality and a twentyfold fects and poor efficacy. In 2011 the age under Pharmacare. Reinfection increase in liver-related mortality.1 first direct-acting antiviral agents is also an ever-present risk. Using Acute hepatitis C infections can pres- were introduced and since have con- the antiviral therapies currently ent asymptomatically, and approxi- tinued to improve both the efficacy available and ensuring patients mately 85% of acute infections will and tolerability of treatment. The have better access to care would develop into chronic disease.2 Chron- development of the direct-acting make eliminating hepatitis C pos- ic hepatitis C infections can cause antiviral agents has reduced disease sible in British Columbia, especial- significant liver damage, including burden, expanded treatment options ly if health care providers, patient the development of cirrhosis and he- for patients with different hepatitis communities, and government agen- patocellular carcinoma.3,4 In addition C genotypes or other pre-existing cies all strive to achieve this goal. Ms Dahiya is a student in the MD Under- graduate Program at the University of Brit- ish Columbia. Dr Hussaini is a pharmaco- therapy specialist in liver transplantation at Vancouver General Hospital and a clinical assistant professor in the Faculty of Phar- maceutical Sciences at UBC. Dr Yoshida is a professor in the Department of Medicine and past head of the Division of Gastroen- terology at UBC. He is also head of the BC This article has been peer reviewed. Hepatitis Program.

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to the hepatic manifestations, acute diagnosis and, ultimately, eradica- tionally, serology is recommended to and chronic hepatitis C can have tion of hepatitis C. The Canadian As- exclude other infections (HIV, hepa- extra-hepatic manifestations, includ- sociation for the Study of the Liver titis B) and common liver diseases ing disease processes associated with released updated guidelines in 2018 (transferrin saturation for hemochro- the virus and more specific immune- that include recommendations on the matosis evaluation, IgG for autoim- related end-organ effects.5 Disease assessment, evaluation, and manage- mune hepatitis).8 Furthermore, all processes associated with hepatitis C ment of hepatitis C.8 The 2018 guide- patients with hepatitis C should un- infection include renal insufficiency, lines recommend taking a risk-based dergo staging of their liver disease, type 2 diabetes, and insulin resis- and population-based approach to including a baseline ultrasound and tance, while more specific hepatitis screening.8 Chronic hepatitis C infec- evaluation for fibrosis.8 C immune-related manifestations in- tion is prevalent in individuals born Other recommendations include clude sicca syndrome, arthralgia, my- from 1945 to 1975.8 Despite the high resistance testing, if indicated, and algia, and mixed cryoglobulinemia.5 prevalence of hepatitis C infection in genotype testing.8 Six hepatitis C gen- The hepatic and extra-hepatic mani- this birth cohort, screening rates are otypes have been identified based on festations contribute to the huge bur- low8 and the guidelines recommend nucleotide differences. In turn, these den of disease that negatively impacts one-time screening in all individuals numbered genotypes have been fur- patient well-being and quality of life. in the 1945 to 1975 birth cohort, in- ther classified by letter (1a, 2b, 3c, In British Columbia, more new- dependent of individual risk factors.8 etc.).7 Geographic differences are seen ly reported hepatitis C cases are re- For those with risk factors, testing for in the prevalence of some variants, ported than elsewhere in Canada,1 hepatitis C infection is recommended. with genotypes 1, 2, and 3 being com- with the Metro Vancouver area hav- Some notable risk factors for hep- mon throughout the world, genotype ing an alarmingly high incidence rate atitis C are: 4 being common in the Middle East, of 37.3 per 100 person-years among • A history of injection drug use. and genotype 1 being overwhelmingly young injection drug users.6 In a re- • Having received a blood transfu- dominant in North America. Knowing cent study of more than 1.1 million sion, blood products, or an organ a patient’s genotype can help select individuals in BC tested for hepati- transplant in Canada before 1992. the most effective treatment. tis C, a prevalence rate of 5.8% was • A history of or current incarceration. reported.1 While high incidence rates • Having received chronic hemo Early treatment options are associated with sex-trade work, dialysis. The first pharmacological regimen incarceration, and injection drug use, • HIV infection. for hepatitis C was introduced in the high prevalence rates in British Co- Initial screening includes a test for 1990s and consisted of non-pegylated lumbia are associated with the fol- hepatitis C antibodies.8 If test results interferon alpha-2a or alpha-2b mono lowing: male gender, a birthdate from are positive, active infection should therapy.9 The treatment duration was 1945 to 1964, HIV or hepatitis B co- be confirmed with an RNA screen for 24 or 48 weeks, depending on the hepa- infection, a mental health condition, hepatitis C.8 Subsequently, patients titis C genotype, and required thrice a substance and/or alcohol abuse dis- should be referred to practitioners weekly injections.9 As well as being order, and low socioeconomic status.1 with experience in hepatitis C man- cumbersome to patients and having Despite advances in management agement to optimize treatment and significant side effects, the treatment and better understanding of viral gen- outcomes.8 was not very successful in achieving otypes,7 hepatitis C infection contin- The 2018 guidelines also recom- viral clearance as measured by the ues to pose a threat to public health in mend that patients with confirmed sustained virological response—un- Canada and other countries.2 hepatitis C infections undergo further detectable hepatitis C RNA levels at testing to help establish a baseline 12 weeks or 24 weeks following the Screening and individualize treatment.8 Sug- end of therapy. To increase the rates A high proportion of Canadians with gested testing includes routine blood of sustained virological response, chronic hepatitis C infection remain work with a complete blood count, ribavirin was added to the interferon undiagnosed,8 making it important liver enzymes (alanine transaminase, alpha treatment regimen, which im- for physicians and other health care aspartate transaminase, alkaline phos- proved outcomes and increased the providers to understand screening phatase), liver function (bilirubin, response rates to approximately recommendations that will help with INR, albumin), and creatinine.8 Addi- 30% to 40%.9 However, treatment

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response was heavily dependent on cases of patients with treatment expe- tential systemic toxicities and com- the hepatitis C genotype, with rela- rience, the response to previous treat- plications, interferon therapy was tively poor cure rates reported in ment (i.e., relapse vs nonresponse) contraindicated in many patients. cases of genotype 1 and 4.9 was also a factor.11,12 Although pa- For genotype 1, the most common In the latter half of the 1990s, tients treated with pegylated interfer- genotype in Canada, the likelihood pegylated interferon alpha formu- on plus ribavirin required only one of achieving a sustained virological lations were introduced. Pegylation rather than multiple injections per response was a disappointing 40%, slows down the rate of drug absorp- week, the therapy had a number of at best, in noncirrhotic patients af- tion, reduces distribution, and de- side effects.10 Adverse effects associ- ter 48 weeks of therapy.14 For the creases the rate of elimination.10 With ated with interferon therapy includ- combined genotype 2 and 3 patients, pegylation, ideal plasma concentra- ed neutropenia, thrombocytopenia, 24 weeks of pegylated interferon and tions for inhibiting viral replication alopecia, hypothyroidism, hyperthy- ribavirin yielded a sustained virologi- are better maintained, improving roidism, flu-like symptoms, nausea, cal response of 76%.15 Cirrhotic pa- drug efficacy and increasing rates vomiting, and weight loss.13 Interfer- tients in general responded less well of sustained virological response.10 on therapy was also associated with to any interferon-based therapy, and However, response rates for pegylat- neuropsychiatric side effects, namely those with advanced cirrhosis required interferon were found to be heavily impaired memory and concentration, ing a liver transplant tolerated the dependent on patient-specific charac- depression, and irritability.13 Addi- therapy poorly and experienced sig- teristics: body mass index, degree of tional side effects associated with nificant adverse side effects, includ- pretreatment hepatic damage (specif- ribavirin specifically included ane- ing worsening decompensation and ically, cirrhosis), IL-28B genotype, mia, respiratory complications, and death.16 In short, interferon-based and hepatitis C RNA viral load. In teratogenicity.13 Due to the many po- therapies were associated with significant side effects and suboptimal treatment success rates, and the use of interferon was contraindicated in patients with advanced liver disease. NS3/4A protease inhibitors: Telaprevir (2011) Current treatment options Boceprevir (2011) In 2011 the first direct-acting antiviral Simeprevir (2013) NS5B polymerase Paritaprevir (2014) inhibitors: agents were developed and approved Asunaprevir (2016) Sofosbuvir (2013) for the treatment of hepatitis C infec- Grazoprevir (2016) Dasabuvir (2014) tion.17 These novel antiviral medica- Voxilaprevir (2017) Glecaprevir (2017) tions include the following classes of drugs: NS3/4A protease inhibitors, NS5A replication complex inhibitors, 5’– –3’ and NS5B polymerase inhibitors. As shown in the Figure ,18 direct-acting antiviral agents were developed to Structural Nonstructural target the products of the nonstructural coding sequence of hepatitis C, NS5A inhibitors: Ledipasvir (2014) thus directly impairing the replicative Ombitasvir (2014) machinery of the virus rather than Daclatasvir (2015) relying on the nonspecific antiviral ef- Elbasvir (2016) Velpatasvir (2016) fects of pegylated interferon and riba- Pibrentasvir (2017) virin.7 The Table shows a list of the currently available products and their pivotal registration clinical trials.19-53 Figure. Direct-acting antiviral agents used to target products of the nonstructural Each product uses a combination of coding sequence of hepatitis C. The year each agent received FDA approval is indicated in drugs to achieve an additive or syner- 6,18 brackets. gistic effect. The cure rates with these

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extremely well tolerated antiviral ineffective to being well tolerated tion, direct-acting antivirals do not formulations is 95% to 99%. and highly effective. But although work for a small but real minority, and good treatment options exist, the reinfection is an ever-present risk.54 Barriers to overcome complete eradication of the disease in The World Health Organization Treatment of hepatitis C has under- British Columbia will require over- has declared that eliminating hepatitis gone revolutionary changes since coming some barriers. These include C globally by 2030 is feasible.55 Using the early 1990s. The introduction of suboptimal population screening and the antiviral therapies currently avail- direct-acting antivirals in particular diagnosis, variable patient and phys- able and ensuring patients have better has improved cure rates and reduced ician knowledge, high drug costs, access to care would make eliminat- patient all-cause and liver-specific lack of insurance coverage for some ing hepatitis C a realistic goal in Brit- mortality and morbidity. Treatment antivirals, and difficulty accessing ish Columbia, especially if health has gone from being cumbersome and coverage under Pharmacare. In addi- care providers, patient communities,

Table. Commonly used direct-acting antiviral agents in Canada.

Brand Manufacturer Geno Drugs and doses Treatment Common Notable Important BC Pharma Additional name type duration side drug-drug drug trials care Comments effects interactions coverage Harvoni Gilead 1a, 1b, 90 mg ledipasvir, 8–24 Fatigue, Amiodarone, ION I, ION II, ION Yes Sciences19 4, 5, 68 400 mg sofosbuvir19, 20 weeks8 nausea, P-glycoprotein III, SYNERGY, headache, inducers (e.g., SOLAR-I, ION-IV, diarrhea, rifampin, St. ELECTRON-221–26 insomnia19 John’s wort)20

Epclusa Gilead 1–68 400 mg sofosbuvir, 12 weeks8 Headache, Amiodarone, ASTRAL 1, Yes Sciences27 100 mg velpatasvir27 fatigue27 proton-pump ASTRAL 2, inhibitors, ASTRAL 3, digoxin, ASTRAL 4, rosuvastatin, ASTRAL 527– 31 tenofovir, P-glycoprotein inducers27 Zepatier Merck32 1a, 1b, 50 mg elbasvir, 12–16 Fatigue, CYP3A inducers C-EDGE TN, Yes For use in 48 100 mg grazoprevir32 weeks8 nausea, (e.g., efavirenz), C-EDGE TE, patients headache33 CYP3A C-SWIFT, with inhibitors (e.g., C-WORTHY, chronic lopinavir)33 C-EDGE, kidney C-SURFER, disease C-EDGE (including CO-STAR33–39 dialysis patients)39 Vosevi Gilead 1–68 400 mg sofosbuvir, 12 weeks8 Headache, Amiodarone, POLARIS 1, Yes Sciences41 100 mg velpatasvir, fatigue, CYP inducers, POLARIS 2, 100 mg voxilaprevir41,42 nausea, P-glycoprotein POLARIS 3, diarrhea41 inducers, strong POLARIS 443, 44 inducers of OATP1B1/B3 (e.g., rifampin) 41 Maviret AbbVie45 1–68 100 mg glecaprevir, 8–16 Headache, Amiodarone, SURVEYOR-I, No For use in 40 mg pibrentasvir45 weeks8 fatigue46 HMG CoA SURVEYOR-II, patients reductase ENDURANCE-I, with inhibitors, ENDURANCE-II, chronic carbamazepine, ENDURANCE-III, kidney efavirenz, EXPEDITION-I, disease proton-pump EXPEDITION-II, (including inhibitors46 EXPEDITION IV, dialysis MAGELLAN-I, patients)53 MAGELLAN-II47–52

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and government agencies all strive to Opportunities for prevention: Hepatitis C Peginterferon alfa-2a plus ribavirin for achieve this goal. prevalence and incidence in a cohort of chronic hepatitis C virus infection. N Engl young injection drug users. Hepatology J Med 2002;347:975-982. Competing interests 2002;36:737-742. 16. Crippen JS, McCashland T, Terrault N, et Over the past 22 years Dr Yoshida has been 7. Zein NN. Clinical significance of hepatitis al. A pilot study of the tolerability and ef- an investigator in hepatitis C clinical trials C virus genotypes. Clin Microbiol Rev ficacy of antiviral therapy in hepaitits C vi- sponsored by Gilead Sciences, Merck (pre- 2000;13:223-235. rus-infected patients awaiting liver trans- viously Schering-Plough), Janssen, AbbVie, 8. Shah H, Bilodeau M, Burak KW, et al. The plantation. Liver Transpl 2002;8:350-355. Vertex, Hoffmann-La-Roche, Boerhinger Ingel management of chronic hepatitis C: 2018 17. Alexopoulou A, Karayiannis P. Interferon- heim, Pfizer, Human Genome Sciences, and guideline update from the Canadian As- based combination treatment for chronic Novartis. In the past 2 years he has received sociation for the Study of the Liver. CMAJ hepatitis C in the era of direct acting anti- honoraria for CME/Ad Board lectures from 2018;190:E677-E687. virals. Ann Gastroenterol 2015;28:55-65. Gilead Sciences Canada, Merck Canada, and 9. Burstow NJ, Mohamed Z, Gomaa AI, et 18. FDA. Drugs@FDA: FDA Approved drug AbbVie Canada. al. Hepatitis C treatment: Where are we products. Accessed 4 April 2018. www .accessdata.fda.gov/scripts/cder/daf. 19. Keating GM. Ledipasvir/sofosbuvir: A review of its use in chronic hepatitis C. Drugs 2015;75:675-685. 20. Gritsenko D, Hughes G. Ledipasvir/sofosbuvir (Harvoni): Improving options for hepatitis C virus infection. P T 2015;40: Treatment of hepatitis C 256-259. has undergone revolutionary 21. Afdhal N, Zeuzem S, Kwo P, et al. Ledipas- vir and sofosbuvir for untreated HCV gen- changes since the early 1990s. otype 1 infection. N Engl J Med 2014; 370:1889-1898. 22. Afdhal N, Reddy KR, Nelson DR, et al. Le- dipasvir and sofosbuvir for previously treated HCV genotype 1 infection. N Engl J Med 2014;370:1483-1493. 23. Kowdley KV, Gordon SC, Reddy KR, et al. References now? Int J Gen Med 2017;10:39-52. Ledipasvir and sofosbuvir for 8 or 12 1. Janjua NZ, Yu A, Kuo M, et al. Twin epi- 10. Medina J, Garcia-Buey L, Moreno-Mon- weeks for chronic HCV without cirrhosis. demics of new and prevalent hepatitis C teagudo JA, et al. Combined antiviral op- N Engl J Med 2014;370:1879-1888. infections in Canada: BC Hepatitis Testers tions for the treatment of chronic hepatitis 24. Kohli A, Kapoor R, Sims Z, et al. Ledipasvir Cohort. BMC Infect Dis 2016;16:334. C. Antiviral Res 2003;60:135-143. and sofosbuvir for hepatitis C genotype 4: 2. Blackard J, Shata MT, Shire NJ, Sherman 11. deLemos AS, Chung RT. Hepatitis C treat- A proof-of-concept, single-centre, open- KE. Acute hepatitis C infection: A chronic ment: An incipient therapeutic revolution. label phase 2a cohort study. Lancet Infect problem. Hepatology 2008;47:321-331. Trends Mol Med 2014;20:315-321. Dis 2015;15:1049-1054. 3. Wook Kim C, Chang KM. Hepatitis C virus: 12. Pearlman BL. Hepatitis C treatment up- 25. Charlton M, Everson GT, Flamm SL, et al. Virology and life cycle. Clin Mol Hepatol date. Am J Med 2004;117:344-352. Ledipasvir and sofosbuvir plus ribavirin for 2013;19:17-25. 13. Andronescu D, Diaconu S, Tiuca N, et al. treatment of HCV infection in patients 4. Chen SL, Morgan TR. The natural history Hepatitis C treatment & management. J with advanced liver disease. Gastroenter- of hepatitis C virus (HCV) infection. Int J Med Life 2014;7:31-36. ology 2015;149:649-659. Med Sci 2006;3:47-52. 14. McHutchison JG, Lawitz EJ, Shiffman 26. Gane EJ, Hyland RH, An D, et al. Efficacy 5. Cacoub P, Comarmond C, Domont F, et al. ML, et al. Peginterferon alfa-2b or alfa-2a of ledipasvir and sofosbuvir, with or with- Extrahepatic manifestations of chronic with ribavirin for treatment of hepatitis C out ribavirin, for 12 weeks in patients with hepatitits C virus infection. Ther Adv Infect infection. N Engl J Med 2009;361: HCV genotype 3 or 6 infection. Gastroen- Dis 2016;3:3-14. 580-593. terology 2015;149:1454-1461. 6. Miller CL, Johnston C, Spittal PM, et al. 15. Fried MW, Shiffman ML, Reddy KR, et al. 27. Abramowicz M, Zuccotti G, Pflomm JM,

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et al. Sofosbuvir/velpatasvir (Epclusa) for THY): A randomised, open-label phase 2 virus therapy. Hepatol Int 2018;12:211- hepatitis C. JAMA 2017;317:639-640. trial. Lancet 2015;385(9973):1087-1097. 214. 28. Feld JJ, Jacobson IM, Hezode C, et al. So- 38. Rockstroh JK, Nelson M, Katlama C, et al. 47. Kwo PY, Poordad F, Asatryan A, et al. Gle- fosbuvir and velpatasvir for HCV genotype Efficacy and safety of grazoprevir (MK- caprevir and pibrentasvir yield high re- 1, 2, 4, 5 and 6 infection. N Engl J Med 5172) and elbasvir (MK-8742) in patients sponse rates in patients with HCV geno- 2015;373:2599-2607. with hepatitis C virus and HIV co-infection type 1-6 without cirrhosis. J Hepatol 29. Foster GR, Afdhal N, Roberts SK, et al. (C-EDGE CO-INFECTION): A non-ran- 2017;67:263-271. Sofosbuvir and velpatasvir for HCV geno- domised, open-label trial. Lancet HIV 48. Asselah T, Kowdley KV, Zadeikis N, et al. type 2 and 3 infection. N Engl J Med 2015;2:319-327. Efficacy of glecaprevir/pibrentasvir for 8 or 2015;373:2608-2617. 39. Roth D, Nelson DR, Bruchfeld A, et al. 12 weeks in patients with hepatitis C virus 30. Curry MP, O’Leary JG, Bzowej N, et al. Grazoprevir plus elbasvir in treatment-na- genotype 2, 4, 5, or 6 infection without Sofosbuvir and velpatasvir for HCV in pa- ive and treatment-experienced patients cirrhosis. Clin Gastroenterol Hepatol tients with decompensated cirrhosis. N with hepatitis C virus genotype 1 infection 2018;16:417-426. Engl J Med 2015;373:2618-2628. and stage 4-5 chronic kidney disease 49. Forns X, Lee SS, Valdes J, et al. Glecapre- 31. Wyles D, Brau N, Kottilil S, et al. Sofosbu- (the C-SURFER study): A combination vir plus pibrentasvir for chronic hepatitis C vir and velpatasvir for the treatment of phase 3 study. Lancet 2015;386(10003): virus genotype 1, 2, 4, 5, or 6 infection in hepatitis C virus in patients coinfected 1537-1545. adults with compensated cirrhosis (EXPE- with human immunodeficiency virus type 40. Dore GJ, Atlice F, Litwin AH, et al. Elbasvir- DITION-1): A single-arm, open-label, mul- 1: An open-label, phase 3 study. Clin Infect grazoprevir to treat hepatitis C virus infec- ticentre phase 3 trial. Lancet Infect Dis Dis 2017;65:6-12. tion in persons receiving opioid agonist 2017;17:1062-1068. 32. Keating GM. Elbasvir/grazoprevir: First therapy: A randomized trial. Ann Intern 50. Rockstroh J, Lacombe K, Viani RM, et al. global approval. Drugs 2016;76:617-624. Med 2016;165:625-634. Efficacy and safety of glecaprevir/pibren- 33. Vallet-Pichard A, Pol S. Grazoprevir/elbas- 41. Heo YA, Deeks ED. Sofosbuvir/velpatas- tasvir in patients co-infected with hepatitis vir combination therapy for HCV infection. vir/voxilaprevir: A review in chronic hepa- C virus and human immunodeficiency vi- Ther Adv Gastroenterol 2017;10:155-167. titis C. Drugs 2018;78:577-587. rus-1: The EXPEDITION-2 study. Clin In- 34. Zeuzem S, Ghalih R, Reddy KR, et al. 42. Gilead Sciences Inc. Vosevi (sofosbuvir/ fect Dis 2018;67:1010-1017. Grazoprevir-elbasvir combination therapy velpatasvir/voxilaprevir) tablets 400 51. Poordad F, Felizarta F, Asatryan A, et al. for treatment-naive cirrhotic and noncir- mg/100 mg/100 mg. Product monograph. Glecaprevir and pibrentasvir for 12 weeks rhotic patients with chronic HCV geno- 18 April 2018. Accessed 3 June 2018. for hepatitis C virus genotype 1 infection type 1, 4, or 6 infection. Ann Intern Med www.gilead.ca/application/files/3215/ and prior direct-acting antiviral treatment. 2015;163:1-13. 2589/3935/Vosevi_English_PM_e Hepatology 2017;66:389-397. 35. Kwo P, Gane E, Peng CY, et al. Efficacy and 192340-GS-001.pdf. 52. Reau N, Kwo PY, Rhee S, et al. MAGEL- safety of grazoprevir/elbasvir ± ribavirin 43. Bourliere M, Gordon SC, Flamm SL, et al. LAN-2: Safety and efficacy of glecaprevir/ (RBV) for 12 or 16 weeks in patients with Sofosbuvir, velpatasvir, and voxilaprevir pibrentasvir in liver or renal transplant HCV G1, G4, or G6 infection who previ- for previously treated HCV infection. adults with chronic hepatitis C genotype ously failed peginterferon/RBV: C-EDGE N Engl J Med 2017;376:2134-2146. 1-6 infection. J Hepatol 2017;66:90-91. treatment-experienced trial. Gastroenter- 44. Jacobson IM, Lawitz E, Gane EJ, et al. Ef- 53. Gane E, Lawitz E, Pugatch D, et al. Gleca- ology 2015;148:S1194-S1195. ficacy of 8 weeks of sofosbuvir, velpatas- previr and pibrentasvir in patients with 36. Lawitz E, Poordad F, Gutierrez JA, et al. vir, and voxilaprevir in patients with chron- HCV and severe renal impairment. N Engl Short-duration treatment with elbasvir/ ic HCV infection: 2 phase 3 randomized J Med 2017;377:1448-1455. grazoprevir and sofosbuvir for hepatitis C: trials. Gastroenterology 2017;153:113- 54. Konerman MA, Lok ASF. Hepatitis C treat- A randomized trial. Hepatology 2017; 122. ment and barriers to eradication. Clin 65:439-450. 45. AbbVie Inc. Mavyret (glecaprevir/pibren- Transl Gastroenterol 2016;7:e193. 37. Sulkowski M, Hezode C, Gerstoft J, et al. tasvir 100 mg/40 mg tablets). Highlights 55. World Health Organization. Combating Efficacy and safety of 8 weeks versus 12 of prescribing information. 2017. Acces hepatitis B and C to reach elimination by weeks of treatment with grazoprevir (MK- sed 3 June 2018. www.rxabbvie.com/ 2030. 2016. Accessed 18 June 2018. 5172) and elbasvir (MK-8742) with or with- pdf/mavyret_pi.pdf. www.who.int/hepatitis/publications/ out ribavirin in patients with hepatitis C 46. Abutaleb A, Kottilil S, Wilson E. Glecapre- hep-elimination-by-2030-brief/en/. virus genotype 1 mono-infection and HIV/ vir/pibrentasvir expands reach while re- hepatitis C virus co-infection (C-WOR- ducing cost and duration of hepatitis C

bc medical journal vol. 61 no. 2, march 2019 bcmj.org 77 bc centre for disease control

Using population-level integrated health data to monitor and assess patients’ progression across care and treatment continuums

Care cascades eliminates many biases associated tinuum,3 such as many patients not re- Care cascades are visual tools used to with other types of data sources (e.g., ceiving confirmatory hepatitis C virus track patients’ journeys across illness clinical or cohort studies). RNA testing after a positive hepatitis and care stages such as screened or C virus antibody test. These findings diagnosed, referred to care, treatment Care cascades for supported improved care-provider assessment, treatment, and status of hepatitis C training, resources for care provid- treatment goal (e.g., viral suppression While hepatitis C virus infection is ers and patients, and a reflexive hepa- or cure). They can be constructed at associated with various liver and titis C virus RNA testing pilot study various levels, from groups of pa- nonliver complications and high mor- at the BCCDC Public Health Labo- tients at one or more clinics to entire bidity and mortality, the advent of ratory. Having multiple data sources geographic areas such as a health au- highly effective direct-acting anti- in the BC-HTC permits hepatitis C thority or province. Care cascades1 virus care cascades to be stratified are usually presented as bar graphs, by age, gender, geographic location, showing stages of care for a particu- In BC, the stage of disease stage, comorbidities, and lar disease, and the number or por- care with the largest co-infections. Stratification of hepa- tion of people progressing through improvement in recent titis C virus care cascades based on each stage, thereby helping to rapidly years has been driven these characteristics identified gaps identify stages where patients fall out in urban, rural, and remote services by the availability of of care and where barriers to care pro- delivery, and highlighted how well gression may be occurring; determine direct-acting antiviral population-specific needs are being program effectiveness; and monitor medications, shown to met. progress toward achieving desired improve all-cause In BC, the stage of care with the health outcomes. mortality and reduce largest improvement in recent years the risk of cirrhosis has been driven by the availability of Using integrated health data direct-acting antiviral medications, and liver cancer. Tracking patients across disease and shown to improve all-cause mortality care stages at the population level and reduce the risk of cirrhosis and requires integrating data from mul- viral medications has revolution- liver cancer. However, the cascade tiple sources, such as surveillance ized its management, prompting the of care in BC demonstrates contin- and diagnostic laboratory data, health World Health Organization to issue ued gaps in treatment uptake among care utilization and prescription medi- global hepatitis elimination goals.2 To people with a history of injection drug cation dispensing data, disease regis- monitor progress toward achieving use.4 Curing hepatitis C virus among tries, and vital statistics records. Data these goals, systems tracking patient people who inject drugs can prevent linked at the patient level are used to progress across hepatitis C virus ill- transmission to others, but to improve produce population-level estimates of ness and care stages are needed. To real-world health outcomes and meet care and treatment progress, which this end, in British Columbia, lab- hepatitis C virus elimination goals, are visualized as a care cascade. Be- oratory testing, prescription dispen- more comprehensive harm reduction, cause health and administrative data sation, mortality, and other health addiction, and mental health supports already exist, integrating them to es- care administrative data have been are required. timate these measures is an efficient integrated to create the BC Hepatitis method to assess care cascades, and Testers Cohort (BC-HTC), which Care cascades for other contains health information on over 2 health conditions This article is the opinion of the BC Centre million BC residents. Care cascades have been used to track for Disease Control and has not been peer BC-HTC has helped identify gaps care and treatment progress for HIV reviewed by the BCMJ Editorial Board. along the hepatitis C virus care con- Continued on page 80

78 bc medical journal vol. 61 no. 2, march 2019 bcmj.org special feature

Access to safe drinking water in First Nations communities and beyond

The First Nations Health Authority reports on the successes, the struggles, and the work still required to ensure all Canadians have potable water in their homes.

Helena Swinkels, MD, MHSc, FCFP, FRCPC, Sylvia Struck, PhD, Linda Pillsworth, Btech, CPHI(C)

s public health professionals issues of scale, and treatment accep- Canadian guidelines for safe drink- at the First Nations Health tance (chlorination), among others. ing water, additional progress can A Authority (FNHA), which In general, however, and unlike in and must be made to improve sup- serves First Nations communities in some areas of Canada, in First Na- port for systems under advisory and BC, we read with great interest Dr tions communities in BC all homes for smaller systems (those with fewer Charuka Maheswaran’s article, “Wa- that are occupied year round have than five connections), which current- ter, water everywhere but not a drop access to piped water, and there is ly do not receive infrastructure fund- to drink!” in the May 2018 issue of ing through the federal government. the BCMJ.1 We would like to thank The following key activities are sup- Dr Maheswaran and the Environmen- Out of the porting progress toward sustainable tal Health Committee of the Doctors 334 community and access to safe drinking water: of BC’s Council on Health Promotion public water systems • First Nations communities work for their interest in this very important that the FNHA reports with the FNHA to assess if water topic. We agree that it should indeed meets or exceeds federal and pro- on, 4% of drinking be possible for all Canadians to have vincial guidelines for drinking wa- potable water in their homes, and are water systems are ter quality, and support access to working on this in partnership with currently under safe drinking water. First Nations communities in BC and drinking water • The FNHA and First Nations com- the Department of Indigenous Servic- advisories. munities work together to increase es Canada (ISC). the capacity and ownership of wa- There are common issues across ter systems in communities. The remote, rural, and very small systems a low frequency of significant wa- FNHA trains and funds members in Canada, including lack of access to ter quality issues such as E. coli and of First Nations communities as and ability to retain trained operators, chemical exceedances in community community-based water monitors and public water systems. Out of the to sample and test drinking water This article has been peer reviewed. 334 community and public water sys- using in-community and accredited tems that the FNHA reports on, 4% of labs, and fully supports and funds Dr Swinkels is the senior medical officer drinking water systems are currently this testing. public health for the First Nations Health under drinking water advisories (as • ISC provides funding for commu- Authority. Dr Struck is the manager, drink- of 31 October 2018).2 The number of nity water systems infrastructure ing water safety program, for the First Na- advisories can fluctuate mainly due to and operation and has commit- tions Health Authority. Ms Pillsworth is the short-term advisories. ted additional funding to support manager, environmental health services, While the majority of First Na- the resolution of drinking water for the First Nations Health Authority. tions community water systems meet Continued on page 79

bc medical journal vol. 61 no. 2, march 2019 bcmj.org 79 special feature

Continued from page 79 Water Net) to support and advocate and men as water treatment plant op- advisories. The FNHA’s drinking for their profession. erators and caretakers of their water, water safety program manager and This great work needs to be sus- installation of modern-day treatment environmental health officers work tained and expanded. Community facilities, and a supportive network of with ISC to resolve drinking water or public water systems may not ad- community, government, and FNHA issues and provide sustainable ac- dress all water needs in First Nations staff have all contributed to a reduc- cess to safe drinking water in First communities; the federal fiduciary tion in the number and duration of ad- Nations communities. responsibility to these communities visories. The excellent work carried • ISC provides training for First Na- needs to be extended to fund and out by First Nations water treatment tions water systems operators, and support smaller systems, which also plant operators, community-based supports the Circuit Rider Program, serve residents in First Nations com- drinking water monitors, community which provides training and men- munities. We also need to recognize health staff, and many others in com- torship by highly experienced and that First Nations view water holisti- munities who support provision of certified operators and works with cally, extending beyond what comes safe drinking water is but one exam- operators in First Nation communi- from the tap to source water and is- ple of First Nations individuals and ties to support operation of drinking sues that arise in watersheds. Joint communities leading wellness. water systems. collaboration across First Nations • First Nations leaders have expressed communities, local governments, References interest in determining and devel- provincial ministries and regional 1. Maheswaran C. Water, water every- oping priorities and strategies for health authorities, and land owners where but not a drop to drink! BCMJ safe drinking water legislation and is needed to achieve effective source 2018;60:195. www.bcmj.org/cohp/ a framework that would effectively water protection. water-water-everywhere-not-drop-drink. support safe and sustainable drink- While supporting the continued 2. First Nations Health Authority. Drinking ing water for communities. drive to improve services, we also water safety program. Accessed 31 Janu- • First Nations water operators in BC need to highlight what is going well ary 2019. www.fnha.ca/what-we-do/ and Yukon have launched their own in First Nations communities. The de- environmental-health/drinking-water network (First Nations’ Operators velopment of highly skilled women -safety-program.

bccdc

Continued from page 78 References infection, tuberculosis, substance use Department of Pathology and 1. BC hepatitis testers cohort, UBC Centre treatment, and syphilis partner notifi- Laboratory Medicine, UBC for Disease Control. Hepatitis C cascade cation. This concept can easily adapt —Mel Krajden, MD, FRCPC of care in BC, 2012. Accessed 24 January to other diseases to improve health Medical Director, BCCDC 2019. https://bchtc.med.ubc.ca/hepatitis outcomes. However, various data Professor, Department of -c-cascade-of-care-in-bc. sources need to be integrated and up- Pathology and Laboratory 2. World Health Organization. Global health dated at the provincial level in order Medicine, UBC sector strategy on viral hepatitis 2016- to track gaps in services, which in turn —Naveed Z. Janjua, MBBS, DrPH 2021. Accessed 24 January 2019. www can inform how services are best de- Senior Scientist, BCCDC .who.int/hepatitis/strategy2016-2021/ livered to improve health outcomes. Clinical Associate Professor, ghss-hep/en. —Sofia R. Bartlett, PhD School of Population and Public 3. Janjua NZ, Kuo M, Yu A, et al. The popula- Postdoctoral Fellow, BCCDC, Health, UBC tion level cascade of care for hepatitis C in and Department of Pathology and British Columbia, Canada: The BC hepati- Laboratory Medicine, UBC Disclaimer tis testers cohort (BC-HTC). EBioMedi- Adjunct Associate Lecturer, Kirby All inferences, opinions, and conclusions cine 2016;12:189-195. Institute, University of New South drawn in this article are those of the au- 4. Janjua NZ, Islam N, Wong J, et al. Shift in Wales, Australia thors and do not reflect the opinions or disparities in hepatitis C treatment from —Terri Buller-Taylor, PhD policies of the BC Ministry of Health and interferon to DAA era: A population-based Research Manager, Hepatitis data stewards. cohort study. J Viral Hepat 2017;24: Education Canada, BCCDC, and 624-630.

80 bc medical journal vol. 61 no. 2, march 2019 bcmj.org gpsc

Physician networks: Improving practice coverage, patient care, and physician support hysician networks are con- amples of how physician networks are works2—geographically clustered nections between doctors that enabling physicians to better support groups of GPs—with the belief that Pare built on formal or informal each other and their patients. enhancing support to physicians at relationships. They enable doctors to the practice level would create paral- rely on each other for practice cover- Division maternity care projects lel effects of enhanced patient experi- age, and to support each other with The division and Shared Care mater- ence.3 By fostering and supporting clinical services to meet the compre- nity care projects highlighted in the collegial relationships between local hensive care needs of their patients. GPSC column in the January/Feb- GPs, Neighbourhood Networks cre- The supportive, connected nature of ruary issue of the BCMJ1 represent ate a systemic approach to coordin- physician networks will place them networks that enable family doctors, ating multidisciplinary care, patient at the foundation of primary care net- midwives, and obstetricians to pro- attachment, physician recruitment, works as they are built. vide coverage for patients—and for peer support, and practice coverage. In physician networks, GPs can The division has created a series increase their capacity to support pa- of papers outlining what they have tients, access shared team-based care By fostering and learned and recommendations for resources, provide peer support for supporting collegial creating Neighbourhood Networks, clinical matters, and increase work- relationships between local which are available on their website.2 life balance. A network can comprise GPs, Neighbourhood a group of doctors and a combina- Chilliwack Gender Care Network Networks create a systemic tion of relationships: GP to GP, GP to The Chilliwack Division of Family specialist, and patient medical home approach to coordinating Practice supports the Chilliwack to patient medical home. Physicians multidisciplinary care, Gender Care Network, with the goal determine the makeup of their net- patient attachment, of improving the quality of care for works and decide which services they physician recruitment, transgender, two-spirit, and gender- will collectively provide to best sup- peer support, and diverse clients in the community. This port local needs. Patients benefit from network consists of a physician and practice coverage. these relationships through increased nurse practitioner who have received access to continuous, comprehensive additional training through the PHSA primary care, improved coordination each other. Maternity care provides for hormone readiness assessment, of specialist care, and better access to an example of how networks can be hormone therapy, and surgical readi- after-hours care. organized in different ways—for in- ness assessments. Network members Physicians in some areas are al- stance, the Burnaby Maternity Clin- are also members of the Chilliwack ready part of a network or on-call ic is a GP-to-GP network, while the Gender Care Committee, which in- group, or are starting networks with South Okanagan Maternity Centre cludes patients, parents, service pro- colleagues to provide care for specific networks GPs and midwives to providers, and organizations that work patient populations, including resi- vide patients with collaborative care. with transgender clients to promote dential care, maternity, in-hospital, public education and stigma reduc- and end-of-life care. In many commu- Richmond Neighbourhood tion. Visit www.gendersupportnet- nities, divisions of family practice are Networks work.com to learn more. actively involved in (or planning for) Richmond is a city that comprises the development of formal physician many small, unique neighborhoods, Sunshine Coast Addictions networks with funding from the GPSC each with distinct socioeconomic, Network and Shared Care. Here are some ex- cultural, language, and health care The Sunshine Coast Division’s Ad- needs. To enhance primary care cap- dictions Network consists of GPs, This article is the opinion of the GPSC and acity in these diverse communities, specialists, an addictions nurse, and a has not been peer reviewed by the BCMJ the Richmond Division of Family pharmacist. The goal of this work is to Editorial Board. Practice created Neighbourhood Net- Continued on page 82

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Continued from page 81 laborated to create the FP Palliative sites to learn more about physician enhance pathways for patients seeking Network. This network links togeth- networks. addiction treatment on the Sunshine er a group of geographically diverse —Afsaneh Moradi Coast. The division has sponsored two South Island and Victoria physicians Director, Community Partnership education sessions for physicians on who accept unattached end-of-life and Integration addiction medicine and is planning to patients based on referrals from Vic- conduct a short research project that toria Hospice and the BCCA Pain and References will track patients who go to an ER in Symptom Management Clinic. 1. Moradi A. Division maternity care proj- part due to substance use. Physician networks are an evolv- ects: Closing gaps in care through net- ing area of work, and these are just a works and innovation. BCMJ 2019;61: Surrey–North Delta Opioid few examples that have been formed 42-43. Agonist Therapy Network around the province. As work unfolds 2. Richmond Division of Family Practice. The Surrey–North Delta Division’s on primary care networks—including Neighbourhood networks. Accessed 14 Opioid Agonist Therapy Network is data gathering and evaluation—more January 2019. www.divisionsbc.ca/ a mentoring and support system for information will become available richmond/our-impact/neighbourhood family physicians interested in tak- about how connecting GPs, special- -networks. ing on patients who need opioid ag- ists, nurse practitioners, and other 3. Richmond Division of Family Practice. onist therapy, with a focus on stigma care providers through physician net- Neighbourhood networks white paper: reduction, trauma-informed practice, works will help to improve physician Envisioning and evaluating transformative and effective buprenorphine-naloxone experience and patient access to care work. Page 2. Accessed 14 January 2019. therapy in full-service family practice. in communities around the province. www.divisionsbc.ca/sites/default/files/ Visit the GPSC (www.gpscbc Divisions/Richmond/FINAL-Envisioning Victoria and South Island FP .ca/what-we-do/patient-medical -Evaluating-October%202016.pdf. Palliative Network -homes/physician-networks) and the The Victoria and South Island Div- Shared Care (www.sharedcarebc.ca/ isions of Family Practice have col- our-work/spread-networks) web-

Doctors Helping Doctors

The Physician Health Program of British Columbia offers help 24/7 to B.C. doctors and their families for a wide range of personal and professional problems: physical, psychological and social. If something is on your mind, give us a call at 1-800-663-6729. Or for more information about our services, visit www.physicianhealth.com.

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Dr Peter Doris to press for physician involvement in vision. I am eternally grateful. 1948–2018 the hospital’s development. He spoke Ralph was a unique individual about the role of the physician in the with a strong commitment to a plural- hospital system at the 2016 College istic and diverse society. He lived his of Physicians and Surgeons of BC values and supported many initiatives annual general meeting, and his pre- that were embedded in those values. sentation was so popular that it was He had a brilliant mind, graduat- repeated twice during the day. ing from Cornell University in Ithaca, Struck by sudden illness, Dr Do- New York, with a BSc in chemistry at ris lingered in hospital care, and it is the age of 20, and completing a PhD at saddening that in his final months he the age of 23. His PhD mentor was Dr didn’t have the attention he needed Linus Pauling, winner of two Nobel and deserved. prizes. Ralph pursued an academic —John O’Brien-Bell, MB career at Oregon State University as Surrey an associate professor in biochemistry. In 1949, he became a victim of the Dr Peter Doris grew up in Ontario. Dr Ralph William Spitzer McCarthy era in the United States and He was a medical student at Queen’s 1918–2018 was fired from the university for his University at Kingston and later a political views. In 1950, while travel- general surgeon at affiliated hospi- ing and lecturing in Europe, he was tals. Mid-career he moved to Surrey, arrested, incarcerated, and held in iso- BC, where he was quickly recognized lation in Rotterdam. His passport con- as an outstanding surgeon, especially fiscated, he was forced to return to the for abdominal pathology. On appoint- United States. In 1954 Ralph decided ment as chief of the Department of to move to Canada, which benefited Surgery at Surrey Memorial Hospital, Canada greatly. He completed medi- he addressed the management of sur- cal school at the University of Mani- gical services in the emergency room toba, and in 1958 the family moved and moved to 24-hour surgical care. to New Westminster, where he began As surgical chief he found himself his long career as a chemical patholo- on numerous committees, where he gist with the newly formed group, Dr was a popular advocate. On executive C.J. Coady and Associates, which committees he found himself increas- Dr Ralph William Spitzer passed operated BC Biomedical Medical ingly involved with Surrey Memorial away in Victoria, BC, on 17 October Laboratories and provided consulta- Hospital’s role in the rapid expansion 2018 at the age of 100. He is survived tive services to the Royal Columbian of Surrey’s community and its multi- by his loving family: wife, Hisako Hospital regional laboratory system. cultural development. Dr Doris’s Kurotaki; daughter, Eloise (Rob); and Ralph contributed to the academ- dream was that Surrey Memorial granddaughter, Kali. Ralph was pre- ic world and was a professor at the would be the link, as a teaching hospi- deceased by his first wife of 59 years, UBC School of Medicine. He was a tal, between the University of British Therese, and their son, Matthew. true pioneer, being the first medical Columbia and the Surrey campus of Ralph’s contribution to building a biochemist in the province, devel- Simon Fraser University. He had the superb laboratory medicine–chemical oping both a high-level community- support of the medical staff but not of pathology service in the Lower Main- based laboratory service as well as the administration, which over subse- land was immense. I was fortunate contributing to academic excellence. quent years removed physicians from to have been chosen by him in the He took the practice of biochemis- roles in the hospital’s development. postdoctoral program in clinical bio- try to patients’ bedsides, thus ben- Despite having a busy surgical chemistry that he had set up at Royal efiting thousands of patients who practice, his door was always open to Columbian Hospital in 1970; thus, received care at the Royal Columbian colleagues seeking advice on patients my career in the medical biochemis- Hospital. Laboratory medicine also or hospital issues, and he continued try field was launched because of his Continued on page 84

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Continued from page 83 benefited from Ralph’s creative en- predeceased by his wife of 57 years, UCC hospitals across Canada. A gift- ergy, innovative mind, and commit- (Victoria) June Watt; his parents, Rev ed orator, he spent the next 24 years ment to excellence. He was generous (William) John Watt and Edith Cath- traveling to UCC medical outposts in teaching and mentored several erine Watt; his six older siblings and from BC to Newfoundland negotiat- postdoctoral students for successful their partners; and his first grandchild, ing the building of new hospitals and careers in clinical biochemistry. Lorraine. He is survived by his chil- acquiring new equipment, recruiting Ralph was a man of many seasons. dren, (William) David Watt (Cindy), dedicated staff, encouraging local hir- Besides being a brilliant scientist, cli- George Donald Watt (Ying), Victoria ing, and ensuring local representation nician, and teacher, he had many out- Joy Manson (Bradley), and Elizabeth on hospital boards. He continued to side interests. He was an avid skier June Watt (Denis Durand). practise medicine as a relief physician and a mountaineer. He became a bon- Don joined the Royal Canadian wherever needed. sai gardener, and he learned to play Air Force after high school and re- While in Vancouver, Don served the organ in retirement, building an ceived his wings as World War II was on the boards of St. Michael’s Cen- organ in his living room that had over ending. He graduated from the Uni- tre, Chalmers Lodge, St. Stephen’s 2000 pipes. He traveled widely well versity of Toronto with his MD in United Church, and the Alcohol- into his 90s, visiting Europe, Turkey, 1950, then interned and worked at the Drug Education Service. A proponent China, Japan, Southeast Asia, India, Wellesley Hospital, Hospital for Sick of full-service family medicine, Don South America, and Antarctica. Children, and Toronto Western Hos- received his CCFP in 1971 and his Stenciled at the base of Ralph’s pital for the next 2 years where he met FCFP in 1974. Beginning in 1980 he massive pipe organ is a phrase that June, a nurse and former World War II served two terms as president of the perfectly captured his perspective on Wren (member of the Women’s Royal BC College of Family Physicians, life: ars longa, vita brevis (art is long, Canadian Naval Service). and in 1986 was president of the Col- life is short). He was loved and ad- In 1952 Don began a 38-year ca- lege of Family Physicians Canada. A mired by his colleagues, friends, and reer working for the United Church of champion of the 2-year family prac- family. He will be missed by his col- Canada (UCC), Board of Home Mis- tice residency, he spent 25 years as a leagues and students, whose lives he sions. Initially placed as the lone MD clinical instructor for the UBC Medi- influenced significantly. on the Queen Charlotte Islands (now cal School. Don received an honor- —Arun K. Garg, PhD, MD Haida Gwaii), he delivered medical ary doctorate of divinity from Union New Westminster care via plane, truck, and boat, with College, UBC, in 1970, and the Da- June volunteering by his side. He was vid M. Bachop Gold Medal in 1989 Dr W. Donald Watt soon assigned the position of coro- in recognition of “his successful and 1924–2018 ner, justice of the peace, and medi- resourceful efforts to bring care to cal health officer. He set up clinics small, isolated communities.” in Sandspit, Skidegate Village, Mas- Don and June will be forever set, and in logging camps at Juskatla missed, but their legacy of hospital- and Cumshewa Inlet, and facilitated ity, selflessness, humor, grace, and building the 21-bed Queen Charlotte excellence in delivering medical care City Hospital, which opened in 1955. to those who needed it most remains. In 1956 Don moved to Bella Coo- More of their story can be found in the la, where he spent 7 years as physi- book Healing in the Wilderness, by cian, hospital superintendent, and Rev. Bob Burrows. A memorial ser- caregiver to lighthouses and remote vice and celebration of this extraor- logging camps in the area. He was dinary life was held at Trinity United later adopted into the Nuxalk (Bella Memorial Church in Abbotsford on Coola) Nation by the Walkus and Ed- 2 February. gar families and named Nooskumiich —Elizabeth J. Watt, MD It is with sadness that we announce the (one who heals with his hands) and Abbotsford passing of Dr (William) Donald Watt. Nenetsmlayc (one who brings back to Don was born in Allendale (now Bar- life) at the opening of the new Bella rie) Ontario on 14 November 1924, Coola Hospital in 1980. and passed away peacefully in his In the early 1960s Don moved to sleep on 29 December 2018 at the Prince Rupert and then Vancouver age of 94 in Abbotsford, BC. He was as medical superintendent for all the

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Can frailty be prevented? Or is it the inevitable decline in function that accompanies aging?

What is frailty? assessment and coaching to prevent For a home-based program, the Frailty is a state of increased vulner- frailty. A patient’s comprehensive Go4Life website9 from the National ability and decreased physiologic re- geriatric assessment is loaded into Institute for Aging provides seniors serve that impedes the body’s ability the physician’s EMR, which calcu- with simple tools to prevent frailty to withstand and recover from minor lates a frailty index. Once the frailty and maintain independence. This in- challenges.1 Frailty is multidimen- index is determined, supports such as cludes exercises and videos focused sional and consists of psychological, health coaches can be put in place to on improving flexibility, strength, social, and physical aspects, and puts assist the pre-frail senior. Preliminary balance, and endurance. people at risk of adverse health outcomes, including falls, disability, ad- How early should frailty mission to hospital, and death, and be addressed? Despite what one has been reviewed in the CMAJ.2 We know that obesity rates are in- Despite what one might intuit, might intuit, frailty is creasing in both children and adults, frailty is not an inevitable part of ag- not an inevitable part and obesity is associated with type ing, although its prevalence does rise of aging, although its 2 diabetes, cardiovascular disease, with age, from 16% of people 65 prevalence does rise and musculoskeletal impairments. years old to over 50% of those over with age, from 16% of We also know exercise improves 85.3 Mounting evidence suggests that cardiorespiratory fitness, enhances people 65 years old to early identification and intervention psychosocial well-being, and reduces can not only slow the progression over 50% of those obesity.10 Habits established in child- of frailty but even prevent it. The over 85. hood and reinforced throughout life interventions include physical activ- are more likely to endure later in life. ity, nutritional support, and social Additionally, regular exercisers are networking.4 data from a pilot CARES study show less likely to live with chronic dis- that with 6 months of coaching, the eases that contribute to frailty. BC pro- How can frailty number of participants exercising fre- grams such as Be Active Every Day11 be assessed? quently increased by 65%, and walk- are one way for family physicians and One can start assessing frailty with ing independently increased by 30%. educators to collaborate in establish- the PRISMA 7 questionnaire5 and the Moreover, participants endorsing a ing healthy exercise and eating habits Timed Up and Go test.6 Additionally, positive health attitude increased by early in school-age children. the Clinical Frailty Scale, developed 59%.7 As our population ages, frailty and validated in 2005, is still in use to- becomes an increasingly prevalent day. More recently, the Fraser Health What programs are condition that threatens the health of Authority launched the Community feasible to address frailty? seniors and the viability of our health Actions and Resources Empowering In a current project targeting sen- care system. We know it can be pre- Seniors (CARES) model in BC, a col- iors (but including other ages), the vented by targeted assessments at the laborative primary care model using White Rock–South Surrey Division primary care level with specific inter- an electronic comprehensive geriatric of Family Practice partnered with the ventions that can begin early in life. Peace Arch Hospital and Community Preventing frailty is consistent with This article is the opinion of the Athletics Foundation to offer subsidized per- the foundational concepts of the pa- and Recreation Committee, a subcommit- sonal exercise prescriptions through tient medical home, and should be tee of Doctors of BC’s Council on Health the MOVE for LIFE program.8 Other considered in the evolution of pri- Promotion, and is not necessarily the opin- divisions can team up with local mary care networks and public policy ion of Doctors of BC. This article has not groups such as the YMCA to offer decisions. been peer reviewed by the BCMJ Editorial programs suitable for their commun- —Steven Larigakis, MD Board. ities, and many already are. References on page 86

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Continued from page 85

References 1. Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness Ready or not and frailty in elderly people. CMAJ 2005;173:489-495. for the CCFP exam 2. Abbasi M, Rolfson D, Khera AS, et al. Identification and management of frailty in the primary care setting. CMAJ 2018; An environmental scan and resident rating of 190:E1134-E1140. available study and exam-preparation resources 3. Hoover M, Rotermann M, Sanmartin C, for the Canadian Certification Examination Bernier J. Validation of an index to esti- mate the prevalence of frailty among in Family Medicine. community-dwelling seniors. Health Rep 2013;24:10-17. Paul Dhillon, MBBChBAO, LRCP&SI, EMDM, CCFP, DRCOG, 4. Puts MTE, Toubasi S, Atkinson E, et al. DTM&H(Lon), FRGS, Simon Moore, MD, CCFP Interventions to prevent or reduce the level of frailty in community-dwelling older adults: A protocol for a scoping re- he College of Family Physi- While the view of the literature and international cians Canada (CFPC) con- heterogeneity of policies. BMJ Open 2016;6:e010959. Tducts a biannual Certification the listed resources 5. BC Guidelines. PRISMA-7 question- Examination in Family Medicine. may complement the naire. Accessed 15 January 2019. There is a disparity between the pass https://www2.gov.bc.ca/assets/gov/ rates of practice-eligible candidates wide variety of study health/practitioner-pro/bc-guidelines/ and residency-trained candidates. strategies that frailty-prisma7.pdf. The Table (page 87) provides a candidates employ, 6. Centers for Disease Control and Preven- current and comprehensive list of the quality of these tion. Timed Up and Go assessment. Ac- resources available to physicians resources is cessed 15 January 2019. https://www preparing for the CCFP exam. This highly variable. .cdc.gov/steadi/pdf/TUG_Test-print.pdf. list contains resources beyond those 7. Garm A, Park GH, Song X. Using an elec- on the CFPC’s study resources web tronic comprehensive geriatric assess- page. While the heterogeneity of the search for resources clearly identi- ment and health coaching to prevent listed resources may complement fied as specific to preparation for the frailty in primary care: The CARES mod- the wide variety of study strate- CCFP exam. Current residents and el. Med Clin Rev 2017;3:9. doi: 10.21767/ gies that candidates employ, the practice-eligible candidates were 2471-299X.1000051. quality of these resources is highly surveyed nationally to critique the 8. Peace Arch Hospital Foundation. Move variable. We conducted an online completeness of the list and name For Life South Surrey White Rock. Ac- missing resources. Over a 3-month cessed 15 January 2019. www.pah period, 495 CCFP exam candidates foundation.ca/projects/move-for-life. Dr Dhillon is an assistant professor of Ac- from across Canada attending The 9. National Institute on Aging at NIH. Go- ademic Family Practice at the University Review Course in Family Medicine 4Life. Accessed 15 January https:// of Saskatchewan, and a clinical assistant were asked to peer-review and rate go4life.nia.nih.gov. professor in the Department of Family the resources. The survey response 10. Paes S, Bouzas Marins JC, Andreazzi Practice at the University of British Co- rate across all five sites was 48% AE. Metabolic effects of exercise on lumbia. Dr Moore is a clinical assistant (n = 236). A complete list of peer rat- childhood obesity: A current view. Rev professor in the Department of Family ings derived from survey data of the Paul Pediatr 2015;33:122-129. Practice at the University of British Co- resources is available online at www 11. Doctors of BC. Be Active Every Day. Ac- lumbia. Drs Dhillon and Moore are co- .thereviewcourse.com/resources. cessed 15 January 2019. https://be founders of The Review Course in Family -active.ca. Medicine. Competing interests Dr Dhillon and Dr Moore are founders of This article has been peer reviewed. The Review Course in Family Medicine.

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Table. Preparation resources for the Canadian Certification Examination in Family Medicine in alphabetical order.

Resources Cost Books Dash M, Arnold A. Guide to the Canadian Family Medicine Examination. McGraw-Hill Education. 2017. Paperback and e-book. $100.95 O’Toole D. Family Medicine Notes. Preparing for the CCFP Exam. 2019. Hard copy and e-book. $80.00–$120.00 Ranev D, Pabani W. The Ninety-Nine: Study Guide for Canadian Family Medicine Residents. 2019. Paperback and e-book $47.61 Courses [in person] BC College of Family Physicians Exam Practice Session (Vancouver):* https://bccfp.bc.ca/professional-development/ $575.00 resources-for-all/ccfp-certification ([email protected]) Ontario College of Family Physicians, CFPC Certification Exam Workshop (Toronto):* https://ocfp.on.ca/cpd/credit-login/ $1500 cfpc-certification-exam-workshop The Review Course in Family Medicine (Vancouver, Calgary, Toronto, Montreal): www.thereviewcourse.com $979.00† University of Calgary, Preparation Course for the CCFP Exam (Calgary):* https://cumming.ucalgary.ca/cme/event/2018-03-17/ $1550.00 preparation-course-ccfp-exam E-newsletter The Review Course in Family Medicine, Exam Study Tips Newsletter: www.thereviewcourse.com/studytips Free Podcasts Dr Brady Bouchard podcasts: https://99topics.drbouchard.ca Free Dr Mike Kirlew podcasts: http://siouxlookoutareadocs.libsyn.com Free Online resources 99 Topics for the CCFP, Study Notes (2016): http://99topics.drbouchard.ca/studynotes.pdf Free CCFP, Exam Preparation: www.CCFPexams.com $150.00 CFPC, Evaluation Objectives: www.cfpc.ca/EvaluationObjectives Free CFPC, FAQs for the Certification Examination in Family Medicine: www.cfpc.ca/certification_FAQs Free CFPC, Sample SAMPs: www.cfpc.ca/uploadedFiles/Education/Sample-SAMPs.pdf Free CFPC, Self Learning Program: https://selflearning.cfpc.ca/#/lng-en/ $236.00 ‡ CFPC, Self Study: www.cfpc.ca/HomeStudy Free CFPC, Simulated Office Orals (SOOs): www.cfpc.ca/SOOs Free CFPC, Preparing for the Certification Examination in Family Medicine: www.cfpc.ca/PreparingfortheFamilyMedicineExamination Free CFPC, Priority Topics and Key Features: www.cfpc.ca/PriorityTopics Free Family Medicine Study Guide (app): www.familymedicinestudyguide.com $19.99 McGill Family Medicine Exam Orientation Manual (2015/16): www.mcgill.ca/familymed/education/postgrad/exam Free Preparing for the CCFP exam 2015 (blog by a UBC resident): www.ccfpprep.com Free Review Course in Family Medicine, selected guidelines and helpful links: www.thereviewcourse.com/guidelines Free UBC CCFP Exam Prep: https://postgrad.familymed.ubc.ca/resident-resources/exam-information/exam-prep-resources Free UBC Wiki, Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics: https://wiki.ubc.ca/Course:PostgradFamilyPractice/ Free ExamPrep/99_Priority_Topics University of Calgary, Family Medicine, SAMP Overview (PowerPoint 2017): http://calgaryfamilymedicine.ca/residency/images/ Free images/SAMPR1s.pdf University of Manitoba CCFP study tips: http://umanitoba.ca/faculties/health_sciences/medicine/education/cpd/sdl/ccfp Free _studytips.html

Prices are in Can$ and reflect prices listed online at the time of article submission. * Practice-eligible physicians only. † Cost reimbursed for residents at some sites as part of their residency program or Resident Education Fund. ‡ Provided for free to residents by the CFPC.

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Continued from page 65 Most pregnant users reported using Some pregnant women cannabis to treat nausea early in their 80% pregnancy. In one study involving don’t believe cannabis is 60% harmful to their fetus 306 pregnant women, 35% reported Up to one-third of pregnant women do being cannabis users when they real- 40%

not believe cannabis is harmful to their ized they were pregnant. Two-thirds 20% fetus, according to a review by Uni- of those women quit after finding out 0 versity of British Columbia research- they were pregnant, but among those Alcohol Tobacco Cannabis ers. In some cases, women perceived who continued to use cannabis, half a lack of communication from their reported using almost daily or twice a Figure. Pregnant women’s perception of health care providers about the risks week. When women were asked about substances most likely to harm the baby of cannabis as an indication that the their perception of general harm asso- during pregnancy. drug is safe to use during pregnancy. ciated with cannabis use, 70% of both The findings are outlined in a pregnant and nonpregnant cannabis Institute. The review article, “Wom- new review, published in Preventive users responded that they perceived en’s perspectives about cannabis Medicine, in which UBC researchers slight or no risk of harm. In another use during pregnancy and the post- sought to identify the latest evidence study, when asked if they believed partum period: An integrative re- on women’s perspectives on the health cannabis is harmful to a baby during view,” is available online at www aspects of cannabis use during preg- pregnancy, 30% of pregnant women .sciencedirect.com/science/article/pii/ nancy and postpartum, and whether responded “no.” When women were S0091743518303773?via%3Dihub their perceptions influence decision asked to identify substances most (login required). making about using the drug. The likely to harm the baby during preg- research suggests that, over the past nancy, 70% chose alcohol, 16% chose Preventing overdose decade, more women seem to be us- tobacco, and 2% chose cannabis (see deaths among people ing cannabis during pregnancy, even Figure ). recently released from though evidence of its safety is lim- While research on the health ef- a correctional facility ited and conflicting. For the review, fects of cannabis is limited, some A new project aimed at supporting researchers identified six studies con- studies have shown an increased risk people transitioning back to their ducted in the United States that looked of problems for pregnant women, communities when they are released at women’s perceptions about canna- including anemia, low birth weight, from a correctional facility could pre- bis use during pregnancy. Across the stillbirth, and newborn admission to vent overdoses and help clients get on studies, the rate of cannabis use among the neonatal intensive care unit. Due a healthier path. pregnant women varied considerably. to the risk of potential problems, many Roughly two-thirds of British Co- In a large US population-based study, professional organizations, including lumbians who died of an illegal drug nearly 4% of women self-reported us- the Society of Obstetricians and Gyn- overdose between 1 January 2016 and ing cannabis within the past month, aecologists of Canada, recommend 31 July 2017 had recent contact with while 7% self-reported using cannabis women not use cannabis when trying the criminal justice system, accord- within the past year. In another study to conceive, during pregnancy, and ing to a death review panel report1 that saw researchers also test hair and while breastfeeding. Still, some wom- released by the BC Coroners Service urine samples, the rate of cannabis use en reported that not having specific in 2018. Of those, 10% (333 people) increased to 28%. counseling provided about the risks of died within their first month of release Pregnant cannabis users were cannabis use suggests that the drug is from a correctional facility. more likely to be under age 25, unem- safe. One finding revealed that some Five new community transition ployed, single or uninsured, African- people don’t consider cannabis to be teams stationed throughout BC aim to American, and to have low income a drug, making it especially important address this problem by helping peo- and education, or use other substanc- for health care providers to ask specif- ple with opioid-use disorders access es such as tobacco and alcohol. A di- ic questions about cannabis use during treatment in their communities after agnosis of anxiety or depression was pregnancy and breastfeeding. release from a corrections facility. also associated with cannabis use dur- Lead author, Hamideh Bayram- The teams are currently stationed ing pregnancy. Researchers found that pour, is an assistant professor in the in Surrey, Prince George, Kamloops, cannabis use rates were highest dur- UBC Department of Family Prac- Nanaimo, and Port Coquitlam. Each ing the first trimester (7.4%) and low- tice and an affiliate investigator at consists of a social worker and a est during the third trimester (1.8%). BC Children’s Hospital Research peer—a person with lived experience

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with drugs, the correctional system, or and Substance Use Services, reports Role of peers in recovery is vital both. The teams will work with clients that currently about 40% of people Andrew MacFarlane, provincial exec- for approximately 30 days following in corrections facilities receive opi- utive director for Correctional Health their release to connect with a commu- oid agonist treatment, which includes Services, has spent 20 years working nity physician, fill prescriptions, and medications such as Suboxone and with people with mental health and access other recovery supports. methadone to treat opioid use disor- substance use issues, and the last 5 der. He says people are at heightened working with people on Vancouver’s Recently incarcerated clients at risk when they leave corrections and Downtown Eastside. MacFarlane and greater risk of overdose no longer have access to the facility’s his team designed the community Dr Nader Sharifi, medical director for physician. Additional risk factors transition team project after consult- Correctional Health Services and ad- include lowered tolerance and the ing with regional health authorities dictions lead for BC Mental Health trauma associated with release. Continued on page 90

A model of global health engagement The Canada India Network Society addressed the approaching tsuna- journeys. Presentations covered the was established in 2010 to connect mi of diabetes. importance of integrative medicine leaders from Canada and India in or- • Mental Illness. Dr Nitasha Puri in the prevention of dementia, sup- der to build collaborative opportun- spoke about the need for immedi- portive cancer care, food as medi- ities among the countries’ academic ate action in the prevention and cine, traditional Chinese medicine, institutions and industries. The Can- cure of addictions in the context of Indigenous medicine, and inte- ada India Network Initiative 2018 her work with Fraser Health’s Ro- grated yoga therapy. The overall was the society’s third conference. shni Clinic. Dr Suman Kollipara message was that chronic disease Though focused on a subset of the focused on alternative and inte- requires an integrative approach to South Asian population, the confer- grated approaches like meditation care. ence vision was global engagement and self-empowerment tools for • Technology and Innovation. Dis- and building links between people prevention of mental illness. cussions centred on artificial intel- through health care. • Public Health Approaches to Pal- ligence in health care, taking ac- The conference started with wel- liative Care in India and BC, look- tion against tuberculosis, the role come remarks from the Honourable ing at the work done by the Two of technology in access to health Adrian Dix, Minister of Health, and Worlds Cancer Collaboration, was information, mobile technologies, Dr Arun Garg, the conference chair. presented by Drs Doris Barwich and using neuroethology in youth Sessions included: and Gillian Fyles and facilitated by depression and addiction. Kathy • War on Diabetes. Deljit Bains, Dr Simon Sutcliffe. Kinloch, BCIT President, and the leader at the South Asian Health • Leadership in Health. Drs Arvind Honourable Bruce Ralston, Minis- Institute, advocated for transfor- Lal, Anupam Sibal, and Robert ter of Jobs, Trade and Technology, mation in the community in health Woollard brought decades of expe- were featured speakers. promotion through direct engage- rience to shed light on the need for • Two roundtable discussions on ment at places like gurudwaras better practices in health care. technology and integrative medi- and temples. Dr Gulzar Cheema • Empowering Physicians. This ses cine focused on identifying re- shared his work on the interCul- sion was presented using the LEADS search opportunities between India tural Online Health Network, a framework, including principles and Canada—building bridges be- community-driven health-promo- of leading self, engaging others, tween modern innovation and an- tion initiative that supports mul- achieving results, developing coali- cient technologies. ticultural communities, patients, tions, and transforming systems. For more information about the and caregivers across BC to opti- • Integrative Medicine and Health. conference and the organization, vis- mize chronic disease prevention Medical professionals, research it www.thecins.org. and self-management. Sean McK- scientists, traditional Chinese med- —Arun K. Garg, MD elvey shared his work in making icine practitioners, and yoga prac- —Reza Alaghehbandan, MD diabetes care drug-free. The final titioners reflected on their personal —Suman Kollipara, MD speaker, Dr JST Thakur of India, journeys as well as their patients’

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Continued from page 89 cancer, but little is known about how and the First Nations Health Author- it is done or how to support it. ity, and analyzing other evidence- The study analyzed 22 interviews based models across Canada. with Spanish adults involved in previ- The community transition team ous research that explored their expe- peers have been chosen strategical- rience of living with advanced cancer. ly—they work with community or- The researchers found the partici- ganizations throughout the province pants engaged in a five-phase itera- that will keep helping clients after tive process: struggling, accepting, Students: the short-term work with community living with advanced cancer, sharing Cash prizes for writing transition teams concludes. The teams the illness experience, and recon- began connecting with their first cli- structing life. This process revolved ents in January. The Provincial Health around participants’ awareness of dy- J.H. MacDermot Writing Award Services Authority hopes to scale the ing, which differed from people living The BCMJ invites writing sub- project up next year based on results. with chronic illness, and was a unique missions from student authors, A short video about the community aspect of this new research. and each year awards a prize transition teams is available at https:// Each phase was revisited and, as of $1000 for the best medical youtu.be/JuUqCPOlJvs. the disease advanced, living well got student submission accepted for more challenging. Participants talked print and online publication. Stu- Reference about strategies for living with ad- dents are encouraged to submit 1. BC Coroners Service death review panel: vanced cancer, including making life full-length scientific articles and A review of illicit drug overdoses. 5 April adjustments, maintaining a positive essay pieces for consideration. 2018. Accessed 31 January 2019. www2 attitude, normalizing, and hoping. .gov.bc.ca/assets/gov/birth-adoption Over time, participants realized The J.H. Mac- -death-marriage-and-divorce/deaths/coro struggling against the disease created Dermot Writing ners-service/death-review-panel/bccs additional difficulties. They under- Award, spon- _illicit_drug_overdose_drp_report.pdf. stood it was counterproductive so they sored by Doctors made a conscious choice to let go of of BC, honors UBC research examines struggling. Some referred to it as being John Henry Mac- living well while dying the only choice they could make while Dermot, who A University of British Columbia pro- living with the uncertainty of advanced served as editor for 34 years fessor in the Faculty of Health and So- cancer. This enabled accepting their (1932–1968), overseeing the pub- cial Development, School of Nursing, life circumstances at some level and lication’s transition from the Van- Kelowna, has determined that people learning to live alongside their illness. couver Medical Association diagnosed with terminal cancer—who Robinson says that the importance Bulletin to the BCMJ in 1959. Dr have hope, positivity, and family sup- of family love and support cannot be MacDermot also served as BCMA port—are able to live well during the underestimated. For all the participants, president in 1926. advanced stage of the disease. she adds, awareness of dying led them Carole Robinson, professor emeri- to focus on living well. Sharing the ex- tus with the UBC Okanagan School of perience with loved ones softened suf- BCMJ Blog Writing Prize Nursing, recently published a paper fering remarkably. They were aware To encourage med students to with co-authors explaining the pro- they did not have time to lose. Robinson take their first foray into medi- cess of living well with an awareness says the key takeaways to living well cal writing, the BCMJ awards an of dying. Robinson notes that glob- encompass a balance between depen- additional writing prize of $250 ally there are 14.1 million new cancer dence and independence, being able to twice per year for the best 200- cases diagnosed each year, 8.2 million see the positive, and maintaining hope to 400-word blog submission cancer deaths, and 32.6 million peo- even in the end stages of the disease. accepted for online publication. ple living with cancer. Historically, re- The study, “People with advanced searchers have studied the concept of cancer: The process of living well with For submission guidelines and living well with a chronic illness, but awareness of dying,” was published in contest deadlines, please visit not specifically cancer. Robinson says Qualitative Health Research. It is avail- www.bcmj.org/submit-article those studies convey the idea it may able online at https://journals.sagepub. -award. be possible to live well with advanced com/doi/10.1177/1049732318816298.

90 bc medical journal vol. 61 no. 2, march 2019 bcmj.org HELP MAKE DOCTORS OF BC MORE DIVERSE AND INCLUSIVE

BC doctors are a diverse group — comprised of different genders, nationalities, religiousBC doctors affiliations, are a diverse sexual group identity, – comprised ages, and of differentmore. genders, nationalities, religious affiliations, sexual Yet, the representativeorientations, ages, structures practice at locationsDoctors of and BC more. don’t reflect the full range of our diverse members. This is a challenge because only when we are truly Doctorsinclusive, of can BC weis seeking do a better to find job ofways strategizing to be more and inclusive planning for the futureof of all the these whole groups profession. within our governance structures – the Board, Representative Assembly and committees. We need your help to figure this out. Over the next few months, we will ask for your views Over theon next how few we months can do we this. will Our be goal reaching is to bringout to new you. and As a first step, we’d likefresh to find perspectives out what barriersfrom those you whoencounter are currently if or when under- you are considering represented,applying for aso position that we in can a committee do a better or job on of our planning Board or RA. for the future of the whole profession.

We hope you will engage with us – because we all have our mark to make. Make your mark. Find out how you can get involved at doctorsofbc.ca. For more information, visit: _____ Questions? E-mail us at [email protected].

We all havebc medicalour journal mark vol. 61 no. 2, marchto 2019 make. bcmj.org 91 worksafebc

Concussions and return-to-work considerations

o better understand concussion exacerbation, the injured worker can Primary care physicians can play a and optimize care of concus- consider returning to work part-time, significant role in identifying injured Tsion patients injured at work, with adaptations to the work environ- workers with significant multiple there are two valuable resources: the ment (sunglasses, earplugs, quieter risk modifiers who should be consid- Concussion in Sport Group consensus workspace, area with less movement) ered for early referral to a multidisci- statement that arose from the Berlin for specific symptoms. plinary clinic, such as WorkSafeBC’s Conference of October 2016;1,2 and the Early introduction of aerobic Head Injury Assessment and Treat- Ontario Neurotrauma Foundation’s physical activity is a major factor in ment Service (HIATS). Significant Guidelines for Concussion and Minor rapid recovery. Lawrence and col- modifiers include a history of prior Traumatic Brain Injury and Persistent leagues reported that, “for each suc- concussions or migraine headaches, Symptoms,3 which includes advice cessive day in delay to initiation of and patients for whom headache is the for returning to work after concussion aerobic exercise, individuals had a predominant symptom. and many helpful algorithms for the less favorable recovery trajectory.”5 For more information or assis- management of common symptoms. Dr John Leddy of the University of tance with treatment of work-related The following concepts are empha- Buffalo Concussion Clinic pioneered concussion in a worker patient, or to sized in these documents. the concept of subsymptom exercise discuss referral to HIATS, please con- Rest is no longer recommended threshold rehabilitation.6 Patients can tact a medical advisor in your nearest for an indefinite period of time.4 Af- be exercise-challenged to determine WorkSafeBC office. ter an initial 24 to 48 hours of rest, the the level, duration, and intensity of —David J. Rhine, MD, FRCPC worker should be activated. Activa- activity at which symptoms appear WorkSafeBC Medical Advisor and tion begins using a concept of symp- and peak no more than 2 out of 10 HIATS Medical Consultant tom threshold wherein key symptoms above their baseline symptoms. The are provoked at certain levels of ag- doctor can then prescribe an indi- References gravation. Producing a slight aggrava- vidualized exercise regimen, gradu- 1. Gerschman T. Canada advances concus- tion of symptoms is not harmful and ally increasing intensity and duration sion education. BCMJ 2017;59:325-355. is thought that, over time, will set the to the endpoint of submaximal heart 2. McCrory P, Meeuwisse W, Dvorak J, et al. threshold higher and higher until nor- rate exercise for 30 minutes without Consensus statement on concussion in mal activities both in and out of work symptom exacerbation. This has been sport – the 5th international conference on are no longer symptom provoking. shown to accelerate recovery. concussion in sport held in Berlin, October Individuals should gradually re- Interventions that are associated 2016. Br J Sports Med 2017;51:838-847. sume normal physical and cognitive with better outcomes include early 3. Ontario Neurotrauma Foundation. Guide- work-related activities. While this is education and early psychological line for concussion/mild traumatic brain sometimes difficult to initiate and un- and physical support.7,8 Setting a pa- injury & persistent symptoms. 3rd edition, derstand, a rule of thumb that I have tient’s expectations of recovery and for adults over 18 years of age. Accessed incorporated into my practice is to be- reentry into the workplace and es- 26 October 2018. https://braininjuryguide gin with the 10-20-30 rule. Cognitive tablishing a goal of returning to their lines.org/concussion. activity can be initiated in 10-minute previous job early in the course of 4. Howard A, Schwaiger T, Silverberg N, periods followed by 30-minute rest treatment and management is rec- Paneka W. This Changed My Practice periods. If doing this three successive ommended. Occupational therapists (UBC CPD). Concussion management: times does not exacerbate the symp- have a 4-P strategy for assisting re- Time to give “brain rest” a rest. Accessed toms, progress to 20-minute activity turn to work: prioritize, pace, plan, 22 October 2018. http://thischanged periods followed by 30-minute rest and position (that is, change positions mypractice.com/concussions-and-rest. periods, three times. Once the 30-min- frequently and switch up activities).9 5. Lawrence DW, Richards D, Comper P, ute level is reached without symptom This approach can be initiated by the Hutchison MG. Earlier time to aerobic ex- patient’s primary care physician and ercise is associated with faster recovery This article is the opinion of WorkSafeBC supported by allied health care pro- following acute sport concussion. PLoS and has not been peer reviewed by the fessionals such as physiotherapists or One 2018;13:e0196062. BCMJ Editorial Board. occupational therapists. References continued on page 94

92 bc medical journal vol. 61 no. 2, march 2019 bcmj.org cme calendar

OBESITY SUMMIT der to facilitate improved communi- genital dermatology: The good, the Vancouver, 6 Apr (Sat) cation with patients about health bad, and the unexpected; New drugs To be held at the Morris J. Wosk Cen- promotion, disease prevention, and for overactive bladder; Menopause tre for Dialogue, UBC CPD’s 7th an- preferences for treatment. This group and HRT 2019; Current approach to nual Obesity Summit aims to connect learning program has been certified UTIs and bacterial vaginosis in preg- health care practitioners with specific by the College of Family Physicians nancy; Microscopic hematuria: When interests in caring for patients who of Canada for up to 5.75 Mainpro+ to be concerned and what to do. The are obese. Expert and guest speak- credits. At the conclusion of this ac- next session is 10 May (internal ers from the obesity discipline will tivity, participants will be able to cri- medicine). To register and for more discuss a broad range of topics on tique current evidence for nutritional information visit ubccpd.ca, call 604 obesity and bariatrics. Target audi- support in several conditions com- 675-3777, or email [email protected]. ence: family physicians, surgeons, monly encountered in primary care, registered dietitians, nurses, physio- including the prevention of dementia MINDFULNESS IN MEDICINE therapists, occupational therapists, and support of cardiovascular health; WORKSHOPS AND RETREATS residents, and others interested in evaluate claims for potential health Tofino, 26–29 Apr (Fri–Mon) caring for patients who are obese. benefits or adverse effects resulting Cortes Island, 14–19 Jun (Fri–Wed) Topics covered: medical and dietary from popular weight loss diets; ex- Join Dr Mark Sherman for an explor- management of obesity, challenging plain nutritional biochemistry re- ation of mindfulness and meditation medico-surgical case rounds, pre- lated to specific metabolic pathways and how these practices support the operative and postoperative patient and physiological processes influen- work you do, the life you live, and the care, and obesity management with cing stress and adrenal health; and person you are. Tofino: Foundations additional medical issues. Course for- communicate knowledgeably with of Theory and Practice Workshop for mat consists of collaborative didactic patients about their preferences for Physicians and Partners. Cortes Is- lectures and interactive small-group treatment, including the use of specif- land (Hollyhock): A Physician Medi- workshops and panel discussions. ic diets and nutritional supplements. tation Retreat. For more information Time has been set aside for network- Download the program brochure for or to register please go to www.living ing. Join us at the end of the day for additional information. Scholarships thismoment.ca/events. a reception to meet with friends and are available to undergraduate and colleagues. Program details and on- graduate medical students. Online TROPICAL AND GEOGRAPHIC line registration: https://ubccpd.ca/ registration: https://isom.ca/event/ MEDICINE INTENSIVE SHORT course/BCOS2019. BC Obesity Soci- npc-bc/. Email [email protected]. COURSE ety website http://bcobesity.net/. Tel Vancouver, 6–10 May 604 675-3777, email cpd.info@ubc. CME ON THE RUN The University of British Columbia ca; ubccpd.ca. VGH and various videoconference Faculty of Medicine is pleased to offer locations, 12 Apr–10 May (Fri) this 6th annual CME course for health NUTRITION IN PRIMARY CME on the Run sessions are held at care providers who seek to learn an CARE the Paetzold Lecture Theatre, Van- approach to preventing, diagnosing, Vancouver, 6 Apr (Sat) couver General Hospital, and there evaluating, treating, and managing Nutrition in Primary Care: Update are opportunities to participate via tropical diseases. It is especially use- and Controversies 2019 will be held videoconference from various hospi- ful for those who intend to practise at SFU Harbour Centre. This program tal sites. Each program runs on Friday in areas endemic for these diseases. is designed to enhance primary care afternoons from 1 p.m. to 5 p.m. and Three broad areas are emphasized: providers’ knowledge of applied nu- includes great speakers and learning clinical tropical medicine, parasitol- tritional biochemistry and the asso- materials. Date and topics: 12 Apr ogy, and public health. Material to ciated research literature pertaining (gynecology & urology). Topics in- be covered includes clinical descrip- to several conditions commonly en- clude: Current STI guidelines; Man- tions and approaches to evaluation countered in clinical practice. Various agement and prevention of kidney and treatment of tropical diseases and levels of evidence will be presented stones; What’s that in my sack? As- strategies for infection control within for evaluation and discussion in or- sessing testicular masses; Female Calendar continued on page 94

bc medical journal vol. 61 no. 2, march 2019 bcmj.org 93 calendar

Continued from page 93 fun intermissions, contests, entertain- GP IN ONCOLOGY TRAINING communities that makes a critical dif- ment, and videos. Come laugh and Vancouver, 9–20 Sep and 3–14 Feb ference to survival. Participants will learn. Saturday night mixer with spe- 2020 (Mon–Fri) gain practical experience through lab- cial guest Dr Brian Goldman. Course The BC Cancer’s Family Practice oratory and problem-solving exercis- features at the new venue will now Oncology Network offers an 8-week es. Register early as space is limited. include the critical care compon- General Practitioner in Oncology More information at www.spph.ubc. ent. Great speakers: Drs Grant Innes, training program beginning with a ca/continuing-education/tgm2019/. Peter Rosen, David Williscroft, and 2-week introductory session every Contact: [email protected], tel 604 more. There may also be an APLS spring and fall at the Vancouver Cen- 822-9599. pre-conference course—stay tuned. tre. This program provides an oppor- Accommodation: The Beach Club tunity for rural family physicians, ORTHOMOLECULAR Resort: http://bit.ly/viec2019rooms. with the support of their community, MEDICINE TODAY Group code: UBC CPD-Vancouver to strengthen their oncology skills so CONFERENCE Island Emergency Conference. Book- that they may provide enhanced care Vancouver, 31 May–2 Jun ing deadline: 30 Apr. Program details for local cancer patients and their To be held at the Fairmont Hotel, the and registration: https://ubccpd.ca/ families. Following the introductory 48th annual International Orthomo course/viec2019. Tel 604 675-3777, session, participants complete a fur- lecular Medicine Today conference is a email [email protected]. ther 30 days of customized clinic ex- continuing education event for medic- perience at the cancer centre where al doctors, naturopathic doctors, nurse PRACTICE SURVIVAL SKILLS their patients are referred. These can practitioners, pharmacists, and other Vancouver, 15 Jun (Sat) be scheduled flexibly over 6 months. health care professionals. The confer- The 12th annual Practice Survival Participants who complete the pro- ence is presented by the International Skills—What I Wish I Knew in My gram are eligible for credits from the Society for Orthomolecular Medicine, First Years of Practice conference College of Family Physicians of Can- which brings together orthomolecu- will be held at the UBC AMS Nest ada. Those who are REAP-eligible lar associations established in more and emphasize practical, nonclinical receive a stipend and expense cover- than 20 countries around the world. knowledge crucial for your career. age through UBC’s Enhanced Skills Orthomolecular Medicine Today pro- Topics include billing and billing Program. For more information or to vides a forum for leading clinicians forms, rural incentives, MSP audits, apply, visit www.fpon.ca, or contact and researchers to present current ad- medicolegal advice and report writ- Jennifer Wolfe at 604 219-9579. vances in orthomolecular oncology, ing, job finding and locums, financial immunology, and general medicine. and insurance planning, practice man- Learn about the safe and effective agement and incorporation, licensing use of non-patentable molecules for and credentialing, and digital com- improving patient outcomes. Addi- munication advice. Target audience: worksafebc tional information and online registra- family physicians, specialty phys- tion at https://isom.ca/event/omt2019/. icians, locums, IMGs, physicians new Continued from page 92 Email: [email protected] to BC, family practice and specialty 6. Leddy JJ, Haider MN, Ellis M, Willer B. residents, and physicians working in Exercise is medicine for concussion. Curr EMERGENCY AND CRITICAL episodic care settings. Course for- Sports Med Rep 2018;17:262-270. CARE CONFERENCE mat comprises collaborative didactic 7. Grabowski P, Wilson J, Walker A, et al. Parksville, 1–2 Jun (Sat–Sun) lectures and interactive small group Multimodal impairment-based physical Join us in Parksville on Vancouver workshops; plenty of networking op- therapy for the treatment of patients with Island for this year’s Vancouver Is- portunities, and practice-based ex- post-concussion syndrome: A retrospec- land “Top 5 in 10” Emergency and hibits. Join us in the afternoon for a tive analysis on safety and feasibility. Phys Critical Care conference. This course job fair and networking reception to Ther Sport 2017;23:22-30. will be held at the Parksville Com- meet with colleagues and make career 8. Putukian M, Kutcher J. Current concepts munity Centre and is geared to emer- connections. Program details and on- in the treatment of sports concussions. gency physicians, family physicians, line registration at https://ubccpd.ca/ Neurosurgery 2014;75(Suppl 4):S64-S70. registered nurses, residents, and stu- course/practice-survival-skills-2019. 9. InMotion Health Centre Inc. Return to dents. This event has been expanded Tel 604 675-3777, email cpd.info@ work after a concussion. Accessed 26 Oc- to 2 days and will maintain the same ubc.ca. tober 2018. www.inmotionhealthcentre great format of 10-minute lectures, .ca/returning-work-concussion.

94 bc medical journal vol. 61 no. 2, march 2019 bcmj.org classifieds

Classified advertising (limited to 700 characters) Rates: Payment is required at the time that you Doctors of BC members: $50 + GST per place the ad. month for each insertion of up to 350 charac- Deadlines: Ads must be submitted or can- ters. $75 + GST for insertions of 351 to 700 celled by the first of the month preceding the characters. Payment is required at the time month of publication, e.g., by 1 November that you place the ad. for December publication. Non-members: $60 + GST per month for Visit www.bcmj.org/classified-advertising for each insertion of up to 350 characters. $90 + more information. Place your classified ad on GST for insertions of 351 to 700 characters. line at www.bcmj.org/classified-advertising.

today! Email CV to PhysicianRecruitment@ practices available BC—PHYSICIANS FOR YOU, MEDICAL InteriorHealth.ca. VANCOUVER (DOWNTOWN)—WALK- RECRUITMENT Looking for a physician for your clinic? Or IN CLINIC OR BUILD PRACTICE GOLDEN—FP AND FP ANESTHETIST are you a physician looking for work? For the New openings for physician shifts at Van- Seeking family practitioner and FP anesthetist last 10 years we have assisted clinics looking couver’s historic, original walk-in clinic in in Golden, BC! Our position is 60% full-ser- for family physicians and specialists, and as- the heart of downtown! Work alongside ex- vice rural generalist family practice (including sisted physicians looking for short-, medium-, perienced family practice physician. Flexible ER and hospital inpatients) and 40% FP anes- and long-term positions across Canada. We hours with guaranteed minimum. Alternative- thesia. Our OR is evolving and includes local provide expert guidance, advice, and support ly, you can work walk-in to build your own general surgery and GP C/S capability. We throughout the entire recruitment process. We full-service practice. Contact 604 313-5318 for have a robust endoscopy program and regular are available for you 24/7 to make the process more information. visiting orthopedic consultants. Our ER pro- as efficient and hassle-free as it can be for all involved. Based in Vernon, BC. Please contact vides FPA opportunities in procedural seda- VANCOUVER (W BROADWAY)—FP us for further details. Email: info@physicians tions and airway management, particularly in Well-equipped, well-established, busy turnkey foryou.ca. Tel: 778 475-7995. trauma. Enjoy a great work-life balance with family practice for sale. OSCAR EMR, fibre- our flexible scheduling to accommodate both optic Internet. Lovely patients, lovely view, clinic and hospital work. Apply today! Email lovely setting. Email broadwayfamilypractice BURNABY—P/T, F/T AT WALK-IN CV to PhysicianRecruitment@InteriorHealth @gmail.com. CLINIC/GROUP FAMILY PRACTICE .ca. We are looking for a P/T or F/T physician to join our busy practice. We offer a bright, mod- VICTORIA—FAMILY PRACTICE ern medical office with a convenient/central NANAIMO—GP GP retiring; long-established solo family price location, payment the next day (optional), free General practitioner required for locum or available. Start time flexible (over several parking, OSCAR EMR, and a team of support- permanent positions. The Caledonian Clinic months). All equipment, including computer, ive physicians and well-trained staff. Some of is located in Nanaimo on beautiful Vancou- furniture, included for price of the strata title the services in our medical/professional build- ver Island. Well-established, very busy clinic of 820 sq. ft. office, or rent. Full general prac- ing: internal medicine, optometry/ophthalmol- with 26 general practitioners and 2 specialists. tice. Can add obstetrics if wanted. Office is one ogy, an onsite pediatrician, psychology/coun- Two locations in Nanaimo; after-hours walk-in block from Royal Jubilee Hospital in a medical- seling, a pharmacy, a laboratory, a rehabilita- clinic in the evening and on weekends. Com- rental professional building with recent reno- tion center, a dental office, a hearing clinic, puterized medical records, lab, and pharmacy vations. If interested, please email ejmathes and a cafe. These various offices/specialists are on site. Contact Lisa Wall at 250 390-5228 or @hotmail.com or phone 250 598-9223. very collegial and are often a phone call or a email [email protected]. Visit our short walk away. Not sure? Feel free to try a website at www.caledonianclinic.ca. shift or two. Contact [email protected] for employment more information. NEW WEST (ROYAL COLUMBIAN)— ARMSTRONG—FT FAMILY GPs, SHARED CARE: PT, LONG-TERM PHYSICIAN GOLDEN—FP GENERAL SURGERY Join the RCH Shared Care team and add variety Haugen Medical Group, located in the heart of Opportunity for a family practitioner with ESS to your practice! We are family doctors tending the North Okanagan, is in need of a full-time training to join the medical team in beautiful to medical issues on psychiatric inpatients. The family physician to join a busy family practice Golden, BC! This is a full-service rural fam- patient-centred team comprises Shared Care group. Flexible hours, congenial peers, and ily practice that includes ER and hospital care. physicians, psychiatrists (MRP), nurses, resi- competent nursing and MOA staff will pro- The GP surgical component is 40% and the dents, and medical students. We assess newly vide exceptional support with very competitive full-service rural family practice with ER is admitted patients medically and follow them overhead rates. Obstetrics, nursing home, and 60% of the practice. Golden District Hospital through their stay. The adult patients (all ages) inpatient hospital care are not required, but re- has local general surgery, GP C/S capability, have a variety of medical problems. Daily main optional. Payment schedule: fee for ser- and a robust endoscopy program. We are a visits M-F, timing flexible. Supported by full vice. If you are looking for a fulfilling career close and collegial team and we seek a collab- medical, surgical, pharmacy, diagnostic servic- balanced with everything the Okanagan life- orative colleague to help ensure that our surgi- es; should be willing to learn about psychiatric style has to offer, please contact Maria Varga cal program thrives. Get in touch to learn how medications and the interaction of medical and for more information at mariavarga86@gmail you can have a challenging but rewarding prac- psychiatric health issues. Interested candidates .com. tice and still have an amazing lifestyle. Apply submit cv to: [email protected].

bc medical journal vol. 61 no. 2, march 2019 bcmj.org 95 classifieds

administrative support. Paul Foster, 604 572- available to work with you with research trials NORTH VAN—FP LOCUM 4558 or [email protected]. if you are interested. Office space, EMR, and Physician required for the busiest clinic/fam- full staff support for your practice will be pro- ily practice on the North Shore! Our MOAs TRAIL—OTOLARYNGOLOGY vided. If you would like further information, are known to be the best, helping your day run The Department of Otolaryngology at East please contact [email protected]. smoothly. Lucrative 6-hour shifts and no head- Kootenay Regional Hospital in Trail is seeking aches! For more information, or to book shifts a general otolaryngologist. The ENT program online, please contact Kim Graffi at kimgraffi VICTORIA—GP/WALK-IN currently has one full-time otolaryngologist @hotmail.com or by phone at 604 987-0918. Shifts available at three beautiful, busy clinics: who offers the full range of ENT services. This Burnside (www.burnsideclinic.ca), Tillicum is a new position due to needs of the growing (www.tillicummedicalclinic.ca), and Uptown POWELL RIVER—LOCUM community. Flexibility within work schedules The Medical Clinic Associates is looking for (www.uptownmedicalclinic.ca). Regular and can be arranged. There are currently 1.5 OR occasional walk-in shifts available. FT/PT GP short- and long-term locums. The medical com- days per week that will be divided equally be- post also available. Contact drianbridger@ munity offers excellent specialist backup and tween the two surgeons. Join us in Trail and gmail.com. has a well-equipped 33-bed hospital. This beau- enjoy breathtaking vistas year round and a wel- tiful community offers outstanding outdoor coming community atmosphere. Apply today recreation. For more information contact Lau- and live work and play where others only va- WILLIAMS LAKE—FAMILY rie Fuller: 604 485-3927, email: clinic@tmca cation! Email CV to PhysicianRecruitment@ PRACTITIONER WITH ANESTHESIA -pr.ca, website: powellrivermedicalclinic.ca. InteriorHealth.ca. Fantastic opportunity for a general practitioner with GPA residency year to join our team at RICHMOND—HOSPITALIST VANCOUVER (INNER CITY)—PT/FT Cariboo Memorial Hospital in Williams Lake. Looking for hospitalist locum to work with a GENERAL PRACTITIONER In addition to your GP practice you will pro- group of congenial physicians at Richmond The Vancouver Native Health Society medical vide GP anesthesia services 2 days a week, Hospital. Community hospital, well supported clinic is seeking general practitioners to join with only 1 night of call/week, and 1:5 week- by other specialist colleagues. Great place to us in providing primary health care promot- end call. Our group supports complex surgical work for new or recent grads with an interest in ing both Indigenous and Western approaches and OB/GYN cases, as well as airway man- teaching. For more information, please contact to health and wellness, healing and medicines, agement of critical care patients in the ER, David at [email protected]. and culturally safe care. Payment schedule: and does scope sedation for colonoscopies sessional. In addition to providing general pri- gastroscopies. Enjoy working in a stimulating SALMON ARM—FAMILY PRACTICE mary care in a community setting, the clinic environment alongside other dedicated health Part-time and full-time position available in also has robust addiction medicine and HIV/ care providers in a prosperous community with a well-established family practice. Office is HCV programs. The VNHS medical clinic is abundant recreational opportunities at your a fully computerized, thriving eight-practice a multidisciplinary comprehensive care clinic doorstep. Apply today! Email CV to Physician clinic in beautiful, sunny Shuswap. Modern responding to the needs of the Indigenous and [email protected]. clinic, congenial colleagues, excellent staff. non-Indigenous community. We welcome ap- The area offers the opportunity of year-round plications and inquiries from interested phy- activities—hiking, skiing, hockey, water sicians. Contact recruitment: VNHS at hra@ WILLIAMS LAKE—FAMILY sports—and is very lifestyle focused. Please vnhs.info. PRACTITIONER WITH EMERGENCY contact the office manager at tawood@live. Opportunity for FP physicians with ER experience to practise emergency medicine, CCFP- com. VANCOUVER (VGH)—CLINICAL EM is not required. Join our team at Cariboo ASSOCIATE/HOSPITALIST, Memorial Hospital in Williams Lake and prac- SOUTH SURREY/WHITE ROCK—FP VANCOUVER ACUTE KIDNEY tise in a welcoming setting where the lifestyle Busy family/walk-in practice in South Surrey TRANSPLANT PROGRAM opportunities are endless. We see a broad range requires GP to build family practice. The com- The Kidney Transplant Program at VGH per- munity is growing rapidly and there is great forms over 130 kidney transplants per year and of interesting cases involving numerous proce- need for family physicians. Close to beaches provides continuing care to over 900 kidney dures and we are well supported by specialists and recreational areas of Metro Vancouver. transplant patients. The clinical associate will in internal medicine, OB/GYN, general sur- OSCAR EMR, nurses/MOAs on all shifts. function within a multidisciplinary team sup- gery, pediatrics, and psychiatry. Emergency ex- CDM support available. Competitive split. porting three transplant nephrologists with the perience would be an asset but we have the ca- Please contact Carol at Peninsulamedical@ preoperative, postoperative, and continuing pacity to mentor new Canadian graduates or in- live.com or 604 916-2050. care of kidney transplant patients. The role will ternational graduates. Apply today! Email CV include inpatient and outpatient clinical care to [email protected]. SOUTH VAN/RICHMOND—FP/ Monday to Friday with no weekend, evening, SPECIALIST or overnight coverage. The applicant must be The South Vancouver Medical Clinic seeks licensed with CPSBC and have FCFP. Please medical office space family physicians and specialists. Split is up submit a letter of interest and curriculum vi- to 80/20. Closing your practice? Want to work tae in confidence by 1 March 2019 to: Olwyn CUMBERLAND (VANCOUVER part-time? Join us to see only booked patients [email protected]. ISLAND)—OFFICE SPACE FOR or add walk-ins for variety. OSCAR EMR. Po- GENERAL PRACTICE sitions in Richmond also available. Contact Dr VANCOUVER (W BROADWAY)— Office space available for a family medical Balint Budai at [email protected]. SEEKING PHYSICIANS practice in Cumberland, BC. If you desire an LAIR Centre (Fairmont Medical Building, incredible work-life balance, Cumberland is SURREY/DELTA/ABBOTSFORD—GPs/ West Broadway) is excited to welcome physi- the perfect community in which to work and SPECIALISTS cians to join our team! We are seeking endocri- raise a family. This office space is currently Considering a change of practice style or loca- nologists, specialists, and general practitioners used as a family medical practice, so setting tion? Or selling your practice? Group of seven who have keen interest in viral liver disease up can be very easy, along with a captive and locations has opportunities for family, walk-in, and NAFLD/NASH. Our LAIR Centre clinical growing patient population. Please contact or specialists. Full-time, part-time, or locum research trials team (regulatory administrator, [email protected] or 250 622- doctors guaranteed to be busy. We provide nurse coordinator, study coordinator) would be 4290 for more details.

96 bc medical journal vol. 61 no. 2, march 2019 bcmj.org classifieds

tion tips at www.2ascribe.com/tips. Contact us them at various career and professional stages. NEW WEST—NEWLY RENOVATED at www.2ascribe.com, [email protected], or The tax area is complex, and practitioners are OFFICE SPACE toll free at 1 866 503-4003. often not aware of solutions available to them Medical office space available directly across and which avenues to take. My goal is to help from Royal Columbian Hospital in the Keary FREE MEDICAL RECORD STORAGE you navigate and keep more of what you earn Medical Centre. Ideal for two-practitioner of- Retiring, moving, or closing your family prac- by minimizing overall tax burdens where pos- fice or allied health staff. Fresh renovations in- tice? RSRS is Canada’s #1 and only physician- sible, while at the same time providing you cluding floors, ceiling, walls, and cabinets have managed paper and EMR medical records stor- with personalized service. Website: www.rwm created a modern, sleek office space to enjoy age company. Since 1997. No hidden costs. cga.com, email: [email protected], phone: for years to come. Contact Dave at shu.dave@ Call for your free practice closure package: 778 552-0229. gmail.com for more details. everything you need to plan your practice closure. Phone 1 866 348-8308 (ext. 2), email vacation properties [email protected], or visit www.RSRS.com. PROVENCE, FRANCE—YOUR VILLA PATIENT RECORD STORAGE—FREE Les Geraniums, a luxury 3-bedroom, 2½ bath Retiring, moving, or closing your family or Doctors villa, is your home in the heart of Provence. general practice, physician’s estate? DOCU- Helping Expansive terrace with pool and panoramic davit Medical Solutions provides free storage views. Walk to lovely market town. One hour for your active paper or electronic patient re- Doctors to Aix and Nice, 45 minutes to Mediterranean cords with no hidden costs, including a patient 24 hrs/day, coast. Come and enjoy the sun of southern mailing and doctor’s web page. Contact Sid France! 604 522-5196. [email protected]. Soil at DOCUdavit Solutions today at 1 888 7 days/week 781-9083, ext. 105, or email ssoil@docudavit .com. We also provide great rates for closing miscellaneous specialists. Call at 1-800-663-6729 or CANADA-WIDE—MED VANCOUVER—TAX & ACCOUNTING visit www.physicianhealth.com. TRANSCRIPTION Services Medical transcription specialists since 2002, Rod McNeil, CPA, CGA: Tax, accounting, Canada wide. Excellent quality and turn- and business solutions for medical and health around. All specialties, family practice, and professionals (corporate and personal). Spe- IME reports. Telephone or digital recorder. cializing in health professionals for the past 11 Fully confidential, PIPEDA compliant. Dicta- years, and the tax and financial issues facing

KEY CONTACTS: Directory of senior staff

Mr Allan Seckel Ms Margaret English Ms Afsaneh Moradi Chief Executive Officer Director, Shared Care Committee Director, Community Partnership & 604 638-2888; [email protected] 604 638-2947 Integration; 604 638-5845 [email protected] [email protected] Ms Marisa Adair Executive Director of Communications and Ms Alana Godin Ms Cindy Myles Public Affairs; 604 638-2809 Director, Community Practice and Quality Director, Facility Physician Engagement [email protected] 250 218-3924 604 638-2834; [email protected] [email protected] Mr Jim Aikman Ms Carol Rimmer Executive Director of Economics Dr Brenda Hefford Director, Technology and Operations, and Policy Analysis; 604 638-2893 Executive Director, Community Practice, Doctors Technology Office [email protected] Quality, and Integration 604 638-5775; [email protected] 604 638-7855; [email protected] Dr Sam Bugis Mr Paul Straszak Executive Director of Physician Mr Rob Hulyk Executive Director of Negotiations and and External Affairs; 604 638-8750 Director of Physician Advocacy Chief Negotiator; 604 638-2869 [email protected] 604 638-2883; [email protected] [email protected]

Dr Andrew Clarke Mr Adrian Leung Ms Sarah Vergis Executive Director, Physician Health Director, Specialist Services Committee Chief Financial Officer Program; 604 398-4301 604 638-2884; [email protected] 604 638-2862; [email protected] [email protected] Ms Sinden Luciuk Ms Deborah Viccars Ms Amanda Corcoran Executive Director of Members’ Products Director of Policy Chief People & Technology Officer and Services; 604 638-2886 604 638-7865; [email protected] 604 638-2812; [email protected] [email protected]

Ms Cathy Cordell Mr Tod MacPherson General Counsel Director of Negotiations; 604 638-2885 604 638-2822; [email protected] [email protected]

bc medical journal vol. 61 no. 2, march 2019 bcmj.org 97 back page

Proust questionnaire: Dr Judith Hall

Who are your heroes? Which words or phrases do you Women physicians who listen to their most overuse? patients and take the time needed. Fantastic, fabulous, appalling, and pathetic. What is your idea of perfect happiness? What is your favorite place? Being active, alert, engaged, and The Pacific Northwest. regularly close to nature. What medical advance do you What is your greatest fear? most anticipate? Having a preventable accident. Finding ways to alter epigenetic pro- gramming; in other words, to break What is the trait you most the cycle of three-generational pov- deplore in yourself? erty, abuse, and illness. Allowing myself to become too busy to listen and be empathetic. What is your most marked Where do you live? characteristic? Vancouver, on UBC Campus. What characteristic do your Curiosity, along with gratitude and favorite patients share? generosity. What profession might you have Wanting what’s best for their kids and pursued, if not medicine? providing tough love for themselves What do you most value in your Anthropology/archaeology, because and their children. colleagues? the differences in societies and cul- Sharing their curiosity and kindness. tures are so interesting. Which living physician do you most admire? What are your favorite books? Which talent would you most like Dr Cynthia Curry, a clinical geneti- Aging Well by George Vaillant, and to have? cist working in a difficult situation, The Lacuna by Barbara Kingsolver. Extrasensory perception, so I could providing exemplary care in spite of actually know what others are think- horrendous systemic and financial What is your greatest regret? ing, instead of just guessing. barriers, and working hard to make a Not understanding the role of elders diagnosis in the ever-changing land- in our society until I became one. What do you consider your scape of clinical genetics. greatest achievement? What is the proudest moment of Surviving and thriving in a patriarchal What is your favorite activity? your career? profession (which has been changing Pulling diverse concepts together, Having my whole family come when over my career). exploring unchartered territory, and I was inducted into the Canadian providing new concepts or options to Medical Hall of Fame. trainees, patients, and peers. What is your motto? On what occasion do you lie? There are always three possible Dr Hall is a clinical geneticist and pediatri- It’s not really lying, it’s just not bring- solutions. cian. She is currently a professor emerita ing up or taking up subjects and topics and is active in the new UBC Emeritus that lead to conflict. How would you like to die? College. Dr Hall was head of the Clinical At over 100, healthy and vigorous, in Genetics Unit and chair of pediatrics at BC my sleep. Children’s Hospital, and has published ex- tensively on congenital anomalies.

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