Defining Standards for Hepatopancreatobiliary Cancer Surgery in Ontario, Canada: A Population-Based Cohort Study of Clinical Outcomes.

BACKGROUND: In 2006, Cancer Care Ontario created Surgical Oncology Standards for the delivery of hepatopancreatobiliary (HPB) surgery including hepatectomy and pancreaticoduodenectomy (PD). Our objective was to identify the impact of standardization on outcomes after HPB surgery in Ontario, Canada. STUDY DESIGN: This study was a population-level analysis of patients undergoing hepatectomy or PD (2003 to 2019). Logistic regression models were used to compare 30- and 90-day mortality and length of stay (LOS) before (2003 to 2006), during (2007 to 2011), and after (2012 to 2019) standardization. Interrupted time series models were used to co-analyze secular trends. RESULTS: A total of 7,904 hepatectomies and 5,238 PDs were performed. More than 80% of all cases were performed at a designated center (DC) before standardization. This increased to >98% in the poststandardization era. Median volumes at DCs increased from 55 to 67 hepatectomies/year and from 22 to 50 PDs/year over time. In addition, 30-day mortality after hepatectomy was 2.6% before standardization and 2.3% after standardization (p = 0.9); 30-day mortality after PD was 3.6% before standardization and 2.4% after standardization (p = 0.1). Multivariable analyses revealed a significant difference in 90-day mortality following PD poststandardization (4.3% vs 6.3%; adjusted odds ratio, 0.7; p = 0.03). Median LOS was shorter for hepatectomy (6 days vs 8 days) and PD (9 days vs 14 days; p < 0.0001) after standardization. Immediate and late effects on mortality and LOS were likely attributable to secular trends, which predated standardization. CONCLUSIONS: Standardization was associated with a higher volume of hepatectomy and PDs with further concentration of care at DCs. Pre-existing quality initiatives may have attenuated the effect of standardization on quality outcomes. Our data highlight the merits of a multifaceted provincial system for enabling consistent access to high quality HPB care throughout a region of 15 million people over a 16-year period.

Intraoperative vasopressor use does not increase complications in microvascular post-mastectomy breast reconstruction: Experience in 1729 DIEP flaps at a single center.

INTRODUCTION: Vasopressors are traditionally avoided in microsurgery due to concerns about their effect on free flap survival. We examine the impact of intraoperative vasopressors on microsurgical outcomes in a large series of DIEP flap breast reconstructions. METHODS: A retrospective chart review was performed of patients who underwent DIEP breast reconstruction between January 2010 and May 2020. Intraoperative and postoperative microsurgical outcomes were compared in patients who received vasopressors and those who did not. RESULTS: The study included 1102 women who underwent 1729 DIEP. 878 patients (79.7%) received intraoperative phenylephrine, ephedrine, or a combination of both. There was no significant difference in overall complications, intraoperative microvascular events, takebacks for microvascular complications, or partial or total flap loss between groups. Outcomes were not affected by vasopressor type, dose, or timing of administration. The vasopressor group received significantly lower intraoperative fluid volumes. Multivariate logistic regression found a significant association between overall complications and excessive fluids (OR 2.03, 99% CI 0.98-5.18, p = 0.03) but not vasopressor use (OR 0.79, 99% CI 0.64-3.16, p = 0.7) CONCLUSION: This study demonstrates that vasopressors do not adversely affect clinical outcomes after DIEP breast reconstruction. Withholding vasopressors results in excessive intravenous fluid administration and increased postoperative complications.

Extracorporeal Membrane Oxygenation for Graft Dysfunction Early After Heart Transplantation: A Systematic Review and Meta-analysis.

INTRODUCTION: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a prevailing option for the management of severe early graft dysfunction. This systematic review and individual patient data (IPD) meta-analysis aims to evaluate (1) mortality, (2) rates of major complications, (3) prognostic factors, and (4) the effect of different VA-ECMO strategies on outcomes in adult heart transplant (HT) recipients supported with VA-ECMO. METHODS AND RESULTS: We conducted a systematic search and included studies of adults (≥18 years) who received VA-ECMO during their index hospitalization after HT and reported on mortality at any timepoint. We pooled data using random effects models. To identify prognostic factors, we analysed IPD using mixed effects logistic regression. We assessed the certainty in the evidence using the GRADE framework. We included 49 observational studies of 1477 patients who received VA-ECMO after HT, of which 15 studies provided IPD for 448 patients. There were no differences in mortality estimates between IPD and non-IPD studies. The short-term (30-day/in-hospital) mortality estimate was 33% (moderate certainty, 95% confidence interval [CI] 28%-39%) and 1-year mortality estimate 50% (moderate certainty, 95% CI 43%-57%). Recipient age (odds ratio 1.02, 95% CI 1.01-1.04) and prior sternotomy (OR 1.57, 95% CI 0.99-2.49) are associated with increased short-term mortality. There is low certainty evidence that early intraoperative cannulation and peripheral cannulation reduce the risk of short-term death. CONCLUSIONS: One-third of patients who receive VA-ECMO for early graft dysfunction do not survive 30 days or to hospital discharge, and one-half do not survive to 1 year after HT. Improving outcomes will require ongoing research focused on optimizing VA-ECMO strategies and care in the first year after HT.

Comparing the Warshaw technique with vessel-preservation in laparoscopic spleen preserving distal pancreatectomy: is there a better approach?

BACKGROUND: Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) can be accomplished with either resection of the splenic vessels via the Warshaw Technique (WT) or via preservation of the splenic vessels (SVP). Our study aims to compare outcomes for the two methods of LSPDP. METHODS: We performed a retrospective chart review with intent-to-treat analysis of adults undergoing LSPDP at a single institution from 2009 to 2021. We compared demographic characteristics, operative parameters, oncologic pathology review, and postoperative outcomes. RESULTS: There were 102 consecutive cases of LSPDP (59 WT, 43 SVP) over 12 years. The rate of successful spleen preservation was not significantly different between the two groups (76.3%WT, 65.1%VSP,p = 0.27). Rates of conversion to laparotomy, postoperative complications including pancreatic fistulas and splenic infarcts and amount of intraoperative blood loss were similar between the groups. Median operative time was significantly shorter with the WT (141 vs. 177 min, p < 0.05). The median length of stay in hospital was not significantly different among the groups. CONCLUSION: Both techniques are safe and effective in preserving the spleen in laparoscopic distal pancreatectomy. Our experience suggests that the Warshaw Technique may be more efficient with respect to the use of limited operative resources.

Respiratory infectious disease outbreaks among people experiencing homelessness: a systematic review of prevention and mitigation strategies.

PURPOSE: People experiencing homelessness (PEH) are at increased risk of respiratory infections and associated morbidity and mortality. To characterize optimal intervention strategies, we completed a systematic review of mitigation strategies for PEH to minimize the spread and impact of respiratory infectious disease outbreaks, including COVID-19. METHODS: The study protocol was registered in PROSPERO (#2020 CRD42020208964) and was consistent with the preferred reporting in systematic reviews and meta-analyses guidelines. A search algorithm containing keywords that were synonymous to the terms "Homeless" and "Respiratory Illness" was applied to the six databases. The search concluded on September 22, 2020. Quality assessment was performed at the study level. Steps were conducted by two independent team members. RESULTS: A total of 4468 unique titles were retrieved with 21 meeting criteria for inclusion. Interventions included testing, tracking, screening, infection prevention and control, isolation support, and education. Historically, there has been limited study of intervention strategies specifically for PEH across the world. CONCLUSIONS: Staff and organizations providing services for people experiencing homelessness face specific challenges in adhering to public health guidelines such as physical distancing, isolation, and routine hygiene practices. There is a discrepancy between the burden of infectious diseases among PEH and specific research characterizing optimal intervention strategies to mitigate transmission in the context of shelters. Improving health for people experiencing homelessness necessitates investment in programs scaling existing interventions and research to study new approaches.

The value of active follow up of a newly acquired hepatitis B infection - lessons for current approaches.

Abstract: The standard practice of blood borne virus (BBV) follow-up in New South Wales is a passive approach of general-practitioner-led testing. The value of this approach is unknown. We undertook an active contact tracing method with the aims of investigating a potential hepatitis B source, along with accurately measuring the participation rate, to consider the value of this and other follow-up methods for future BBV investigations. Investigation of a newly-acquired hepatitis B infection was undertaken at a dental practice identified as a possible exposure site. To screen for hepatitis B infection among potential source or co-exposed clients, we actively followed up with staff and clients of the practice to request they undertake hepatitis B serology. Eligible staff and clients received up to four phone calls and were provided with a pathology request form by the public health unit (PHU). Access to free serology was offered to people who did not have access to Medicare. Reminder calls were made if serology results were not received by the PHU. As the ordering doctor, the public health physician was responsible for providing results and referring for follow-up care. Of 160 clients, 63 (39%) undertook hepatitis B serology. Of these 63, none were found to have hepatitis B infection. It was estimated the active investigation involved an extra 430 hours of PHU staff time at a cost in Australian dollars of $30,000. Active follow-up allows an accurate participation rate to be documented. Despite intense active follow-up, only 39% of clients undertook testing, bringing into question the yield of the usual approach in which active follow-up of potential mass BBV exposures is not undertaken. While active follow-up is resource intensive, it should be considered where the risks and consequences from the BBV infection are high.

Bondi and beyond. Lessons from three waves of COVID-19 from 2020.

OBJECTIVES: To describe local operational aspects of the coronavirus disease 2019 (COVID-19) response during the first three waves of outbreaks in New South Wales (NSW), Australia, which began in January, July and December 2020. Type of program or service: Public health outbreak response. METHODS: Narrative with epidemiological linking and genomic testing. RESULTS: Epidemiological linking and genomic testing found that during the first wave of COVID-19 in NSW, a large number of community transmissions went undetected because of limited testing for the virus and limited contact tracing of cases. The second wave of COVID-19 in NSW emerged following reintroduction from the second wave in Victoria, Australia in July 2020, and the third wave followed undetected introduction from overseas. By the second and third waves, cases could be more effectively detected and isolated through an increased ability to test and contact trace, and to rapidly genomic sequence severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) isolates, allowing most cases to be identified and epidemiologically linked. This greater certainty in understanding chains of transmission resulted in control of the outbreaks despite less stringent restrictions on the community, by using a refined strategy of targeted shutdown, restrictions on cases, their close contacts, identified hotspots and venues of concern rather than a whole of community lockdown. Risk assessments of potential transmission sites were constantly updated through our evolving experience with transmission events. However, this refined strategy did leave the potential for large point source outbreaks should any cases go undetected. [Addendum] A fourth wave that began in Sydney in June 2021 challenged this strategy due to the more transmissible nature of the Delta variant of SARS-CoV-2. LESSONS LEARNT: A wave of COVID-19 infections can develop quickly from one infected person. The community needs to remain vigilant, adhering to physical distancing measures, signing in to venues they visit, and getting tested if they have any symptoms. Signing out of venues on exit allows public health resources to be used more efficiently to respond to outbreaks.

Helping the Surgeon Recover: Peer-to-Peer Coaching after Bile Duct Injury.

BACKGROUND: Bile duct injury sustained during laparoscopic cholecystectomy is associated with high morbidity and mortality, and can be a devastating complication for a general surgeon. We introduce a novel, individualized surgical coaching program for surgeons who recently injured a bile duct in laparoscopic cholecystectomy. We aim to explore the perception of coaching among these surgeons and to assess surgeons' experiences in the coaching program. STUDY DESIGN: Six general surgeons who injured a bile duct at an emergency laparoscopic cholecystectomy participated in a 1-on-1 coaching session with a hepatopancreatobiliary surgeon. The session focused on debriefing the index case with video feedback, and discussion of strategies for safe laparoscopic cholecystectomy. The pilot program ran from March to November 2020. Exit interviews were then conducted. Themes covering perception of surgical training, perception of complications, and experience in the coaching program were explored. RESULTS: Surgeons were generally accepting of the coaching program, especially when the goals aligned with their self-identified areas of development. One-on-1 sessions with a local expert in the area, and the use of video feedback created a unique and interactive coaching opportunity. Peer coaching was identified as a valuable resource in helping surgeons regain confidence and maintain well-being after a bile duct injury. Maintaining a collegial, nonjudgmental relationship is critical in establishing positive coaching experiences. CONCLUSIONS: An individualized surgical coaching program creates a unique opportunity for professional development and may help promote safe laparoscopic cholecystectomy.

Mortality in patients with cardiogenic shock supported with VA ECMO: A systematic review and meta-analysis evaluating the impact of etiology on 29,289 patients.

BACKGROUND: Venoarterial extracorporeal membrane oxygenation (VA ECMO) is associated with variable outcomes. In this meta-analysis, we evaluated the mortality after VA ECMO across multiple etiologies of cardiogenic shock (CS). METHODS: In June 2019, we performed a systematic search selecting observational studies with ≥10 adult patients reporting on short-term mortality (30-day or mortality at discharge) after initiation of VA ECMO by CS etiology published after 2009. We performed meta-analyses using random effect models and used metaregression to evaluate mortality across CS etiology. RESULTS: We included 306 studies (29,289 patients): 25 studies on after heart transplantation (HTx) (771 patients), 13 on myocarditis (906 patients), 33 on decompensated heart failure (HF) (3,567 patients), 64 on after cardiotomy shock (8,231 patients), 10 on pulmonary embolism (PE) (221 patients), 80 on acute myocardial infarction (AMI) (7,774 patients), and 113 on after cardiac arrest [CA] (7,814 patients). With moderate certainty on effect estimates, we observed significantly different mortality estimates for various etiologies (p < 0.001), which is not explained by differences in age and sex across studies: 35% (95% CI: 29-42) for after HTx, 40% (95% CI: 33-46) for myocarditis, 53% (95% CI: 46-59) for HF, 52% (95% CI: 38-66) for PE, 59% (95% CI: 56-63) for cardiotomy, 60% (95% CI: 57-64) for AMI, 64% (95% CI: 59-69) for post‒in-hospital CA, and 76% (95% CI: 69-82) for post-out‒of-hospital CA. Univariable metaregression showed that variation in mortality estimates within etiology group was partially explained by population age, proportion of females, left ventricle venting, and CA. CONCLUSIONS: Using an overall estimate of mortality for patients with CS requiring VA ECMO is inadequate given the differential outcomes by etiology. To further refine patient selection and management to improve outcomes, additional studies evaluating patient characteristics impacting outcomes by specific CS etiology are needed.

A case of primary pulmonary Schizophyllum commune empyema treated with video-assisted thoracoscopic decortication.

Schizophyllum commune (S. commune) is an environmental basidiomycete bracket fungus that can rarely cause invasive fungal disease. Its diagnosis is challenging and often missed. We present a rare case of a 56-year-old diabetic gentleman with a 6-months history of progressive productive cough, small volume hemoptysis and non-resolving fungal empyema treated with video-assisted thoracoscopic decortication. Pulmonary infection of S. Commune is extremely rare and can manifest as complex fungal empyema. Close cooperation between respirologists, thoracic surgeons and microbiologists is critical in the diagnosis and treatment of such cases.

Synthetic modeling reveals HOXB genes are critical for the initiation and maintenance of human leukemia.

Mechanistic studies in human cancer have relied heavily on cell lines and mouse models, but are limited by in vitro adaptation and species context issues, respectively. More recent efforts have utilized patient-derived xenografts; however, these are hampered by variable genetic background, inability to study early events, and practical issues with availability/reproducibility. We report here an efficient, reproducible model of T-cell leukemia in which lentiviral transduction of normal human cord blood yields aggressive leukemia that appears indistinguishable from natural disease. We utilize this synthetic model to uncover a role for oncogene-induced HOXB activation which is operative in leukemia cells-of-origin and persists in established tumors where it defines a novel subset of patients distinct from other known genetic subtypes and with poor clinical outcome. We show further that anterior HOXB genes are specifically activated in human T-ALL by an epigenetic mechanism and confer growth advantage in both pre-leukemia cells and established clones.

Medical assessment of potential concussion in elite football: video analysis of the 2016 UEFA European championship.

OBJECTIVE: The objective is to determine if suspected concussions in elite football are medically assessed according to the International Conferences on Concussion in Sport consensus statement recommendations. SETTING: Men's Union of European Football Association (UEFA) Football Championship. PARTICIPANTS: All professional football players in the UEFA 2016 Championship Tournament. DESIGN: Observational study. OUTCOME MEASURES: Potential concussive events (PCEs) were defined as direct head collision incidents resulting in the athlete being unable to immediately resume play following impact. PCEs identified and description of PCE assessment and outcome were accomplished through direct standardised observation of video footage by trained observers in 51 games played in the Men's UEFA European Championship (10 June-10 July 2016). RESULTS: Sixty-nine total PCEs (1.35 per match) were identified in 51 games played during the 2016 Men's UEFA European Championship. Forty-eight PCEs (69.6%) resulted in two observable signs of concussion, 13 (18.8%) resulted in three signs and 1 (1.4%) resulted in four signs in the injured athletes. Nineteen (27.5%) PCEs were medically assessed by sideline healthcare personnel while 50 (72.5%) were not. Of the 50 PCEs that were not medically assessed, 44 (88%) PCEs resulted in two or more signs of concussion among injured athletes. Of the 19 medically assessed PCEs, 8 resulted in 3 signs of concussion, and 1 resulted in 4 signs; all assessments concluded in the same-game return for the injured athletes. CONCLUSIONS: PCEs were frequent events in the 2016 UEFA Euro championship, but were rarely assessed concordant with the International Conferences on Concussion in Sport consensus statement recommendations. There is an imperative need to improve the assessment and management of players suspected of concussion in elite football.

Systematic Review of Traumatic Brain Injuries in Baseball and Softball: A Framework for Prevention.

BACKGROUND: Traumatic brain injuries (TBIs) are an important public health challenge. The classification of baseball and softball as low contact sports and their association with extremity injuries cause individuals to overlook the risk of TBI in baseball and softball. PURPOSE: To summarize our knowledge of the epidemiology and risk factors of TBIs associated with baseball and softball with an aim to better design and implement preventive strategies. METHODS: A search algorithm containing keywords that were synonymous to the terms "TBI," "baseball" was applied to the following nine databases: MEDLINE, Scopus, PubMed, EMBASE, CINAHL, Healthstar, PsychINFO, AMED, Cochrane library. Cited reference lists of identified articles were also consulted yielding a total of eighty-eight articles for full review. The search was concluded on November 14, 2016. The level of evidence was evaluated according to the guidelines from Strengthening the Reporting of Observational Studies in Epidemiology statement. RESULTS: Twenty-nine articles published between 2000 and 2016 met the criteria for analysis. Collectively, they examined the years 1982-2015 and identified 242,731 baseball-and softball-related TBIs. The most explored outcome of TBI was concussion. The average injury rate per 1,000 athletic exposures was 0.13 (range 0.03-0.46). The most common mechanism of injury was being struck by bat for younger players and being struck by ball for older athletes (adolescent and beyond). Rates of TBI were on average 4.17 times greater in games compared to practices. Females were on average 2.04 times more likely to sustain a TBI than males. Severity of TBIs varied considerably from mild and returning to the field on the same day, to immediate death. Generally, there is poor compliance with helmet use and return-to-play post-concussion guidelines. An increase TBI rates was observed over time. Multifaceted preventive strategies must be implemented to reduce the frequency and burden of these injuries. CONCLUSION: It is difficult to compare the epidemiologic trends of TBI in baseball and softball due critical differences in the methods employed across the studies. Additional research is needed to provide a greater understanding of baseball- and softball-related TBI and to aid in the development of prevention and management modules.