Dose selection for aztreonam-avibactam, including adjustments for renal impairment, for Phase IIa and Phase III evaluation.

PURPOSE: A series of iterative population pharmacokinetic (PK) modeling and probability of target attainment (PTA) analyses based on emerging data supported dose selection for aztreonam-avibactam, an investigational combination antibiotic for serious Gram-negative bacterial infections. METHODS: Two iterations of PK models built from avibactam data in infected patients and aztreonam data in healthy subjects with "patient-like" assumptions were used in joint PTA analyses (primary target: aztreonam 60% fT > 8 mg/L, avibactam 50% fT > 2.5 mg/L) exploring patient variability, infusion durations, and adjustments for moderate (estimated creatinine clearance [CrCL] > 30 to ≤ 50 mL/min) and severe renal impairment (> 15 to ≤ 30 mL/min). Achievement of > 90% joint PTA and the impact of differential renal clearance were considerations in dose selection. RESULTS: Iteration 1 simulations for Phase I/IIa dose selection/modification demonstrated that 3-h and continuous infusions provide comparable PTA; avibactam dose drives joint PTA within clinically relevant exposure targets; and loading doses support more rapid joint target attainment. An aztreonam/avibactam 500/137 mg 30-min loading dose and 1500/410 mg 3-h maintenance infusions q6h were selected for further evaluation. Iteration 2 simulations using expanded PK models supported an alteration to the regimen (500/167 mg loading; 1500/500 mg q6h maintenance 3-h infusions for CrCL > 50 mL/min) and selection of doses for renal impairment for Phase IIa/III clinical studies. CONCLUSION: A loading dose plus 3-h maintenance infusions of aztreonam-avibactam in a 3:1 fixed ratio q6h optimizes joint PTA. These analyses supported dose selection for the aztreonam-avibactam Phase III clinical program. CLINICAL TRIAL REGISTRATION: NCT01689207; NCT02655419; NCT03329092; NCT03580044.

Association between virtual primary care and emergency department use during the first year of the COVID-19 pandemic in Ontario, Canada.

BACKGROUND: Uptake of virtual care increased substantially during the first year of the COVID-19 pandemic. The aim of this study was to evaluate whether a shift from in-person to virtual visits by primary care physicians was associated with increased use of emergency departments among their enrolled patients. METHODS: We conducted an observational study of monthly virtual visits and emergency department visits from Apr. 1, 2020, to Mar. 31, 2021, using administrative data from Ontario, Canada. We used multivariable regression analysis to estimate the association between the proportion of a physician's visits that were delivered virtually and the number of emergency department visits among their enrolled patients. RESULTS: The proportion of virtual visits was higher among female, younger and urban physicians, and the number of emergency department visits was lower among patients of female and urban physicians. In an unadjusted analysis, a 1% increase in a physician's proportion of virtual visits was found to be associated with 11.0 (95% confidence interval [CI] 10.1-11.8) fewer emergency department visits per 1000 rostered patients. After controlling for covariates, we observed no statistically significant change in emergency department visits per 1% increase in the proportion of virtual visits (0.2, 95% CI -0.5 to 0.9). INTERPRETATION: We did not find evidence that patients substituted emergency department visits in the context of decreased availability of in-person care with their family physician during the first year of the COVID-19 pandemic. Future research should focus on the long-term impact of virtual care on access and quality of patient care.

Surgical wait times and socioeconomic status in a public healthcare system: a retrospective analysis.

BACKGROUND: One aim of publicly-funded health care systems is to provide equitable access to care irrespective of ability to pay. At the same time, differences in socioeconomic status (SES) are associated with health outcomes and access to care, including waiting times for surgery. In public systems where both high- and low-SES patients use the same resources, low-SES patients may be adversely impacted in surgical waiting times. The purpose of this study was to determine whether a publicly-funded health system can provide equitable access to surgical care across socioeconomic status. METHODS: Patient-level records were obtained from a comprehensive provincially-administered surgical wait time database, encompassing years 2006-2015 and 98% of Ontario hospitals. Patient SES was determined by linking postal code with the Material and Social Deprivation Index. Surgical waiting times (time in days between decision to treat and surgery) accounted for patient-initiated delays in treatment, and regression analysis considered age, SES, rurality, sex, priority level for surgical urgency (assigned by surgeons), surgical subspecialty, number of visits, and procedure year. RESULTS: For the 4,253,305 surgical episodes, the mean wait time was 62.3 (SD 75.4) days. Repeated measures least squares regression analysis showed the least deprived SES quintile waited 3 days longer than the most deprived quintile. Wait times dropped in the initial study period but then increased. The proportion of procedures exceeding wait time access targets remained low at 11-13%. CONCLUSIONS: The least deprived SES quintile waited the longest, although the absolute difference was small. This study demonstrates that publicly-funded healthcare systems can provide equitable access to surgical care across SES.

COVID-19 and the duration of operating room procedures in Ontario: a population-based retrospective study.

BACKGROUND: Studies have estimated that a large backlog of procedures was generated by emergency measures implemented in Ontario, Canada, at the onset of the COVID-19 pandemic, when nonessential and scheduled procedures were postponed. Understanding the impact of the COVID-19 pandemic on the time needed to perform a procedure may help to determine the resources needed to tackle the substantial backlog caused by the deferral of cases. The purpose of this study was to examine the duration of operating room (OR) procedures before and after the onset of the COVID-19 pandemic to inform planning around changes in required resources. METHODS: A population-based, retrospective cohort study was conducted using Ontario Health Insurance Plan claims data and other administrative health care data from Apr. 1, 2019, to Sept. 30, 2020. Statistical analysis was conducted using multivariate regression, with procedure duration as the outcome variable. RESULTS: Results showed that the average duration of nonelective procedures increased by 34 minutes during the COVID-19 period and by 19 minutes after the resumption of scheduled procedures. Controlling for physician, patient and hospital characteristics, and the procedure code submitted, procedure duration increased by 12 minutes in the nonelective COVID-19 period and by 5 minutes when scheduled procedures resumed, compared with the pre-COVID-19 period. CONCLUSION: Procedures may take longer in the COVID-19 period. This will affect wait times, which had already increased because of the deferral of procedures at the beginning of the pandemic, and will have an impact on Ontario's ability to provide patients with timely care.

Trends in prevalence of chronic disease and multimorbidity in Ontario, Canada.

BACKGROUND: New case-mix tools from the Canadian Institute for Health Information offer a novel way of exploring the prevalence of chronic disease and multimorbidity using diagnostic data. We took a comprehensive approach to determine whether the prevalence of chronic disease and multimorbidity has been rising in Ontario, Canada. METHODS: In this observational study, we applied case-mix methodology to a population-based cohort. We used 10 years of patient-level data (fiscal years 2008/09 to 2017/18) from multiple care settings to compute the rolling 5-year prevalence of 85 chronic diseases and multimorbidity (i.e., the co-occurrence of 2 or more diagnoses). Diseases were further classified based on type and severity. We report both crude and age- and sex-standardized trends. RESULTS: The number of patients with chronic disease increased by 11.0% over the 10-year study period to 9.8 million in 2017/18, and the number with multimorbidity increased 12.2% to 6.5 million. Overall increases from 2008/09 to 2017/18 in the crude prevalence of chronic conditions and multimorbidity were driven by population aging. After adjustments for age and sex, the prevalence of patients with ≥ 1 chronic conditions decreased from 70.2% to 69.1%, and the prevalence of multimorbidity decreased from 47.1% to 45.6%. This downward trend was concentrated in minor and moderate diseases, whereas the prevalence of many major chronic diseases rose, along with instances of extreme multimorbidity (≥ 8 conditions). Age- and sex-standardized resource intensity weights, which reflect relative expected costs associated with patient diagnostic profiles, increased 4.6%. INTERPRETATION: Evidence of an upward trend in the prevalence of chronic disease was mixed. However, the change in case mix toward more serious conditions, along with increasing patient resource intensity weights overall, may portend a future need for population health management and increased health system spending above that predicted by population aging.

Adoption of a laboratory EMR system and inappropriate laboratory testing in Ontario: a cross-sectional observational study.

BACKGROUND: Electronic medical record (EMR) systems have the potential to facilitate appropriate laboratory testing. We examined three common medical tests in primary care-hemoglobin A1c (HbA1c), lipid, and thyroid stimulating hormone (TSH)- to assess whether adoption of a laboratory EMR system in Ontario had an impact on the rate of inappropriate testing among primary care physicians. METHODS: We used FY2016-17 population-level laboratory data to estimate the association between adoption of a laboratory EMR system and the rate of inappropriate testing. Inappropriate testing was assessed based on recommendations for screening, monitoring, and follow-up that take into account risk factors related to patient age and certain clinical conditions. To overcome the problem of potential endogeneity of physician choice to use the EMR, the EMR penetration rate in the physician's geographical area of practice was used as an instrumental variable in an ordinary least squares (OLS) regression. We then simulated the change in the rate of inappropriate testing, by physician payment model, as the EMR penetration rate increased from the baseline percentage. RESULTS: The simulation models showed that an increase in the rate of EMR penetration from a baseline average was associated with a statistically significant decrease in inappropriate hbA1c and lipid testing, but a statistically insignificant increase in inappropriate TSH testing. The impact of EMR penetration also varied by payment model. CONCLUSIONS: This study demonstrated a positive association between availability of an EMR system and appropriate service utilization. Varying impacts of the EMR system availability by primary care payment model may be reflective of different incentives or attributes inherent in payment models. Policies to encourage physicians to increase their use of laboratory EMR systems could improve the quality and continuity of patient care.

Use of the Population Grouping Methodology of the Canadian Institute for Health Information to predict high-cost health system users in Ontario.

BACKGROUND: Prior research has consistently shown that the heaviest users account for a disproportionate share of health care costs. As such, predicting high-cost users may be a precondition for cost containment. We evaluated the ability of a new health risk predictive modelling tool, which was developed by the Canadian Institute for Health Information (CIHI), to identify future high-cost cases. METHODS: We ran the CIHI model using administrative health care data for Ontario (fiscal years 2014/15 and 2015/16) to predict the risk, for each individual in the study population, of being a high-cost user 1 year in the future. We also estimated actual costs for the prediction period. We evaluated model performance for selected percentiles of cost based on the discrimination and calibration of the model. RESULTS: A total of 11 684 427 individuals were included in the analysis. Overall, 10% of this population had annual costs exceeding $3050 per person in fiscal year 2016/17, accounting for 71.6% of total expenditures; 5% had costs above $6374 (58.2% of total expenditures); and 1% exceeded $22 995 (30.5% of total expenditures). Model performance increased with higher cost thresholds. The c-statistic was 0.78 (reasonable), 0.81 (strong) and 0.86 (very strong) at the 10%, 5% and 1% cost thresholds, respectively. INTERPRETATION: The CIHI Population Grouping Methodology was designed to predict the average user of health care services, yet performed adequately for predicting high-cost users. Although we recommend the development of a purpose-designed tool to improve model performance, the existing CIHI Population Grouping Methodology may be used - as is or in concert with additional information - for many applications requiring prediction of future high-cost users.

Using Diagnoses to Estimate Health Care Cost Risk in Canada.

OBJECTIVE: Until recently, the options for summarizing Canadian patient complexity were limited to health risk predictive modeling tools developed outside of Canada. This study aims to validate a new model created by the Canadian Institute for Health Information (CIHI) for Canada's health care environment. RESEARCH DESIGN: This was a cohort study. SUBJECTS: The rolling population eligible for coverage under Ontario's Universal Provincial Health Insurance Program in the fiscal years (FYs) 2006/2007-2016/2017 (12-13 million annually) comprised the subjects. MEASURES: To evaluate model performance, we compared predicted cost risk at the individual level, on the basis of diagnosis history, with estimates of actual patient-level cost using "out-of-the-box" cost weights created by running the CIHI software "as is." We next considered whether performance could be improved by recalibrating the model weights, censoring outliers, or adding prior cost. RESULTS: We were able to closely match model performance reported by CIHI for their 2010-2012 development sample (concurrent R=48.0%; prospective R=8.9%) and show that performance improved over time (concurrent R=51.9%; prospective R=9.7% in 2014-2016). Recalibrating the model did not substantively affect prospective period performance, even with the addition of prior cost and censoring of cost outliers. However, censoring substantively improved concurrent period explanatory power (from R=53.6% to 66.7%). CONCLUSIONS: We validated the CIHI model for 2 periods, FYs 2010/2011-2012/2013 and FYs 2014/2015-2016/2017. Out-of-the-box model performance for Ontario was as good as that reported by CIHI for the development sample based on 3-province data (British Columbia, Alberta, and Ontario). We found that performance was robust to variations in model specification, data sources, and time.

Effects of bracing in adolescents with idiopathic scoliosis.

BACKGROUND: The role of bracing in patients with adolescent idiopathic scoliosis who are at risk for curve progression and eventual surgery is controversial. METHODS: We conducted a multicenter study that included patients with typical indications for bracing due to their age, skeletal immaturity, and degree of scoliosis. Both a randomized cohort and a preference cohort were enrolled. Of 242 patients included in the analysis, 116 were randomly assigned to bracing or observation, and 126 chose between bracing and observation. Patients in the bracing group were instructed to wear the brace at least 18 hours per day. The primary outcomes were curve progression to 50 degrees or more (treatment failure) and skeletal maturity without this degree of curve progression (treatment success). RESULTS: The trial was stopped early owing to the efficacy of bracing. In an analysis that included both the randomized and preference cohorts, the rate of treatment success was 72% after bracing, as compared with 48% after observation (propensity-score-adjusted odds ratio for treatment success, 1.93; 95% confidence interval [CI], 1.08 to 3.46). In the intention-to-treat analysis, the rate of treatment success was 75% among patients randomly assigned to bracing, as compared with 42% among those randomly assigned to observation (odds ratio, 4.11; 95% CI, 1.85 to 9.16). There was a significant positive association between hours of brace wear and rate of treatment success (P<0.001). CONCLUSIONS: Bracing significantly decreased the progression of high-risk curves to the threshold for surgery in patients with adolescent idiopathic scoliosis. The benefit increased with longer hours of brace wear. (Funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and others; BRAIST ClinicalTrials.gov number, NCT00448448.).

Increasing Compliance With an Antibiotic Prophylaxis Guideline to Prevent Pediatric Surgical Site Infection: Before and After Study.

OBJECTIVES: To evaluate an intervention for improving antibiotic prophylaxis (AP) guideline compliance to prevent surgical site infections in children. BACKGROUND: Although appropriate AP reduces surgical site infection, and guidelines improve quality of care, changing practice is difficult. To facilitate behavioral change, various barriers need to be addressed. METHODS: A multidisciplinary task force at a pediatric hospital developed an evidence-based AP guideline. Subsequently, the guideline was posted in operating rooms and the online formulary, only recommended antibiotics were available in operating rooms, incoming trainees received orientation, antibiotic verification was included in time-out, computerized alerts were set for inappropriate postoperative prophylaxis, and surgeons received e-mails when guideline was not followed. AP indication and administration were documented for surgical procedures in July 2008 (preintervention), September 2011 (postintervention), and April-May 2013 (follow-up). Compliance was defined as complete--appropriate antibiotic, dose, timing, redosing, and duration when prophylaxis was indicated; partial--appropriate drug and timing when prophylaxis was indicated; and appropriate use--complete compliance when prophylaxis was indicated, no antibiotics when not indicated. Compliance at preintervention and follow-up was compared using χ(2) tests. RESULTS: AP was indicated in 43.9% (187/426) and 62.0% (124/200) of surgical procedures at preintervention and follow-up, respectively. There were significant improvements in appropriate antibiotic use (51.6%-67.0%; P < 0.001), complete (26.2%-53.2%; P < 0.001) and partial compliance (73.3%-88.7%, P = 0.001), correct dosage (77.5%-90.7%; P = 0.003), timing (83.3%-95.8%; P = 0.001), redosing (62.5%-95.8%, P = 0.003), and duration (47.1%-65.3%; P < 0.002). CONCLUSIONS: A multifaceted intervention improved compliance with a pediatric AP guideline.

Antibiotic Prophylaxis to Prevent Surgical Site Infections in Children: A Prospective Cohort Study.

OBJECTIVE: To investigate the association between antibiotic prophylaxis (AP) and surgical-site infection in pediatric patients. BACKGROUND: Surgical-site infections (SSIs) are a major cause of postoperative morbidity and mortality. Despite numerous studies in adults, benefit of AP in preventing SSIs in children is uncertain. METHODS: Patients aged 0 to 21 years who underwent surgical procedures at a pediatric acute care hospital from April 1, 2009, to December 31, 2010, were assessed. Antibiotic prophylaxis indication and administration according to an evidence-based guideline were recorded. Complete compliance was defined as AP given, when indicated, within 60 minutes before incision. Surgical-site infections were identified using the Centers for Disease Control and Prevention criteria and documented in the medical records using the International Classification of Diseases, Tenth Revision. Multiple logistic regressions adjusting for age, sex, American Society of Anesthesiologists status, wound classification, admission status, surgical discipline, and surgical duration evaluated association of AP compliance and SSI. RESULTS: Of 5309 patients for whom antibiotics were indicated, 3901 (73.5%) with complete compliance had an infection rate of 3.0%, whereas 1408 (26.5%) who were not compliant had an infection rate of 4.3% (adjusted relative risk: 0.7; 95% confidence interval: 0.5-0.9; P = 0.02). Of 4156 patients for whom antibiotics were not indicated, the 895 (21.5%) who received antibiotics had an infection rate of 1.7% compared with 0.7% in the 3261 (78.5%) who did not receive antibiotics (adjusted relative risk: 1.6; 95% confidence interval: 0.8-3.1; P = 0.18). CONCLUSIONS: In pediatric surgery, complete compliance with AP was associated with 30% decreased risk of SSI.

Simple bone cysts: better with age?

PURPOSE: The purpose of this study was to evaluate whether simple bone cysts (SBC) resolve with age. METHODS: Twenty four subjects with SBC who participated in a prior randomized clinical trial but had not healed at trial conclusion were evaluated for cyst healing. The following clinical and radiographic data were evaluated: age, sex, pain (Visual Analogue Scale), functional health (Short Form 36), subsequent fracture, involved bone, cyst area (cm), distance from physis (cm), endosteal thickening (yes/no), scalloping (no new scalloping/new scalloping), opacity/radiolucency (as is), loculation (yes/no), trabeculation (yes/no), tubulation (yes/no), transition zone (sharp/wide), geographic borders (geographic nonpermeative/nongeographic permeative), radiodense rim (>50%/no rim), and growth plate status (open/closed). Cyst healing was graded as: 1-cyst clearly visible; 2-cyst visible but multilocular and opaque; 3-sclerosis around or within a partially visible cyst; or 4-complete healing with obliteration of cyst. Healing was defined as grade 4. RESULTS: Of 24 subjects, 15 (63%) were male, 18 (75%) cysts were located in the humerus, and 4 (25%) in the femur. Patients were followed for 7.0±1.0 years following initial treatment with a mean age at follow-up of 17.2±3.2 years and 14 (87%) of growth plates were closed. Pain was minimal (0.6/10), function was high (91/100), and none of the patients had experienced subsequent fractures. Although distance from physeal scar had increased (P<0.0001), cyst area reduction (P<0.1) and overall cyst healing (P<0.2) had not changed. Of the 24 subjects, none were graded as healed at time of follow-up. Of the remaining radiographic variables, only decreased loculation (P<0.02) and increased endosteal thickening (P<0.04) showed significant changes. CONCLUSION: Despite the assumption that most SBC will resolve with skeletal maturity, this study indicates that none of the cysts were graded as completely healed although 87% of growth plates were closed. SIGNIFICANCE: Growth plate closure may not signify healing of SBC and although symptoms and fractures are rare, further studies are needed to follow patients with SBC through early adulthood.

A small grant funding program to promote innovation at an academic research hospital.

Innovation is important for the improvement of health care. A small grant innovation funding program was implemented by the Hospital for Sick Children(SickKids) for the Perioperative Services group, awarding relatively small funds (approximately $10 000) in order to stimulate innovation. Of 48 applications,26 (54.2%) different innovation projects were funded for a total allocation of $227 870. This program demonstrated the ability of small grants to stimulate many applications with novel ideas, a wide range of innovations and reasonable academic productivity.

Outcomes of infection following pediatric spinal fusion.

BACKGROUND: Removal of instrumentation is often recommended as part of treatment for spinal infections, but studies have reported eradication of infection even with instrumentation retention by using serial débridements and adjuvant antibiotic pharmacotherapy. We sought to determine the effect of instrumentation retention or removal on outcomes in children with spinal infections. METHODS: We retrospectively reviewed the cases of patients who experienced early (< 3 mo) or late (≥ 3 mo) infected spinal fusions. Patients were evaluated at least 2 years after eradication of the infection using the following protocol outcomes: follow-up Cobb angle, curve progression and nonunion rates. RESULTS: Our sample included 35 patients. The mean age at surgery was 15.1 ± 6.0 years, 65.7% were girls, and mean follow-up was 41.7 ± 26.9 months. The mean Cobb angle was 63.6° ± 14.5° preoperatively, 29.4° ± 16.5° immediately after surgery and 37.2° ± 19.6° at follow-up. Patients in the implant removal group (n = 21) were more likely than those in the implant retention group (n = 14) to have a lower ASA score (71.4% v. 28.6%, p = 0.03), fewer comorbidities (66.7% v. 21.4%, p = 0.03), late infections (81.0% v. 14.3%, p = 0.01) and deep infections (95.2% v. 64.3%, p = 0.03). Implants were retained in 12 of 16 (75.0%) patients with early infections and 2 of 19 (10.5%) with late infections. Patients with implant removal had a higher pseudarthrosis rate (38.1% v. 0%, p = 0.02) and a faster curve progression rate (5.8 ± 9.8° per year v. 0.2 ± 4.7° per year, p = 0.04). CONCLUSION: Implant retention should be considered, irrespective of the timing or depth of the infection.

CONTEXTE: Le retrait des implants est souvent recommandé lors du traitement des infections rachidiennes, mais des études ont démontré qu'il est possible d'éliminer les infections tout en maintenant les implants en place, en ayant recours à des débridements répétés et à une antibiothérapie adjuvante. Nous avons voulu mesurer l'effet de la préservation ou du retrait des implants sur les résultats chez les enfants souffrant d'infections rachidiennes. MÉTHODES: Nous avons passé en revue de manière rétrospective des cas de fusions rachidiennes infectées à un stade précoce (< 3 mois) ou tardif (≥ 3 mois). Les patients ont été évalués au moins 2 ans après l'éradication de l'infection à l'aide des paramètres suivants : angle de Cobb, progression de la courbure et taux de non fusion au moment du suivi. RÉSULTANTS: Notre échantillon comprenait 35 patients. L'âge moyen au moment de la chirurgie était de 15,1 ± 6,0 ans; 65,7 % étaient des filles et le suivi moyen s'est échelonné sur 41,7 ± 26,9 mois. L'angle de Cobb moyen était de 63,6 ° ± 14,5 ° en période préopératoire, de 29,4 ° ± 16,5 ° immédiatement après la chirurgie et de 37,2 ° ± 19,6 ° au moment du suivi. Les patients du groupe soumis au retrait de l'implant (n = 21) étaient plus susceptibles que les patients du groupe chez qui l'implant est demeuré en place (n = 14) de présenter un score ASA plus bas (71,4 % c. 28,6 %, p = 0,03) et un nombre moindre de comorbidités (66,7 % c. 21,4 %, p = 0,03), d'infections tardives (81,0 % c. 14,3 %, p = 0,01) et d'infections profondes (95,2 % c. 64,3 %, p = 0,03). Les implants sont demeurés en place chez 12 patients sur 16 (75,0 %) atteints d'infections précoces et chez 2 patients sur 19 (10,5 %) atteints d'infections tardives. Les patients chez qui l'implant a été retiré ont présenté un taux plus élevé de pseudarthrose (38,1 % c. 0 %, p = 0,02) et un taux de progression plus rapide de la courbure (5,8 ± 9,8 ° par année c. 0,2 ± 4,7 ° par année, p = 0,04). CONCLUSION: Il y a lieu d'envisager le maintien des implants, indépendamment du moment d'apparition de l'infection et de sa profondeur.

Outcomes of infection following pediatric spinal fusion.

BACKGROUND: Removal of instrumentation is often recommended as part of treatment for spinal infections, but studies have reported eradication of infection even with instrumentation retention by using serial débridements and adjuvant antibiotic pharmacotherapy. We sought to determine the effect of instrumentation retention or removal on outcomes in children with spinal infections. METHODS: We retrospectively reviewed the cases of patients who experienced early (< 3 mo) or late (≥ 3 mo) infected spinal fusions. Patients were evaluated at least 2 years after eradication of the infection using the following protocol outcomes: follow-up Cobb angle, curve progression and nonunion rates. RESULTS: Our sample included 35 patients. The mean age at surgery was 15.1 ± 6.0 years, 65.7% were girls, and mean follow-up was 41.7 ± 26.9 months. The mean Cobb angle was 63.6° ± 14.5° preoperatively, 29.4° ± 16.5° immediately after surgery and 37.2° ± 19.6° at follow-up. Patients in the implant removal group (n = 21) were more likely than those in the implant retention group (n = 14) to have a lower ASA score (71.4% v. 28.6%, p = 0.03), fewer comorbidities (66.7% v. 21.4%, p = 0.03), late infections (81.0% v. 14.3%, p = 0.01) and deep infections (95.2% v. 64.3%, p = 0.03). Implants were retained in 12 of 16 (75.0%) patients with early infections and 2 of 19 (10.5%) with late infections. Patients with implant removal had a higher pseudarthrosis rate (38.1% v. 0%, p = 0.02) and a faster curve progression rate (5.8 ± 9.8° per year v. 0.2 ± 4.7° per year, p = 0.04). CONCLUSION: Implant retention should be considered, irrespective of the timing or depth of the infection.

CONTEXTE: Le retrait des implants est souvent recommandé lors du traitement des infections rachidiennes, mais des études ont démontré qu'il est possible d'éliminer les infections tout en maintenant les implants en place, en ayant recours à des débridements répétés et à une antibiothérapie adjuvante. Nous avons voulu mesurer l'effet de la préservation ou du retrait des implants sur les résultats chez les enfants souffrant d'infections rachidiennes. MÉTHODES: Nous avons passé en revue de manière rétrospective des cas de fusions rachidiennes infectées à un stade précoce (< 3 mois) ou tardif (≥ 3 mois). Les patients ont été évalués au moins 2 ans après l'éradication de l'infection à l'aide des paramètres suivants : angle de Cobb, progression de la courbure et taux de non fusion au moment du suivi. RÉSULTANTS: Notre échantillon comprenait 35 patients. L'âge moyen au moment de la chirurgie était de 15,1 ± 6,0 ans; 65,7 % étaient des filles et le suivi moyen s'est échelonné sur 41,7 ± 26,9 mois. L'angle de Cobb moyen était de 63,6 ° ± 14,5 ° en période préopératoire, de 29,4 ° ± 16,5 ° immédiatement après la chirurgie et de 37,2 ° ± 19,6 ° au moment du suivi. Les patients du groupe soumis au retrait de l'implant (n = 21) étaient plus susceptibles que les patients du groupe chez qui l'implant est demeuré en place (n = 14) de présenter un score ASA plus bas (71,4 % c. 28,6 %, p = 0,03) et un nombre moindre de comorbidités (66,7 % c. 21,4 %, p = 0,03), d'infections tardives (81,0 % c. 14,3 %, p = 0,01) et d'infections profondes (95,2 % c. 64,3 %, p = 0,03). Les implants sont demeurés en place chez 12 patients sur 16 (75,0 %) atteints d'infections précoces et chez 2 patients sur 19 (10,5 %) atteints d'infections tardives. Les patients chez qui l'implant a été retiré ont présenté un taux plus élevé de pseudarthrose (38,1 % c. 0 %, p = 0,02) et un taux de progression plus rapide de la courbure (5,8 ± 9,8 ° par année c. 0,2 ± 4,7 ° par année, p = 0,04). CONCLUSION: Il y a lieu d'envisager le maintien des implants, indépendamment du moment d'apparition de l'infection et de sa profondeur.

Reoperations after tarsal coalition resection: a population-based study.

Few studies have evaluated the incidence of subsequent operations after tarsal coalition resection. Using administrative databases, we followed up a cohort of patients who had undergone tarsal coalition resection to determine the rates and possible risk factors for subsequent resection or arthrodesis. Patients (aged 8 years or older) who had been treated from July 1994 to August 2009 in Canada were identified and included. Those with nonidiopathic coalitions were excluded. The time-to-event data for the earliest subsequent procedure were fit to a Cox proportional hazards model that evaluated the patient, operative, and provider factors. Controlling for covariates, the hazard ratios were computed; however, the laterality of any subsequent operation could not be confirmed. A total of 304 patients underwent tarsal coalition resection at an average age of 24.2 ± 17.5 years. Of these 304 patients, 26 (8.6%) underwent subsequent resection and 16 (5.3%) mid- or hindfoot arthrodesis. Of all the factors, the need for future fusion was more likely only if the primary resection had been performed at an academic hospital or if the patient had undergone concomitant arthrodesis at primary resection of the coalition (hazard ratio 3.0, 95% confidence interval 1.1 to 8.5; and hazard ratio 9.7, 95% confidence interval 1.7 to 56.1, respectively). The incidence of reoperation after primary tarsal coalition resection was low in our cohort. More than 85% of our patients never required additional operative intervention an average of 9 years after the initial resection. Our data also suggest that primary treatment of tarsal coalition with resection and concomitant arthrodesis increases the risk of requiring a second fusion in the future.

A simple strategy to reduce stereotype threat for orthopedic residents.

BACKGROUND: Stereotype threat, defined as the predicament felt by people in either positive or negative learning experiences where they could conform to negative stereotypes associated with their own group membership, can interfere with learning. The purpose of this study was to determine if a simple orientation session could reduce stereotype threat for orthopedic residents. METHODS: The intervention group received an orientation on 2 occasions focusing on their possible responses to perceived poor performance in teaching rounds and the operating room (OR). Participants completed a survey with 7 questions typical for stereotype threat evaluating responses to their experiences. The questions had 7 response options with a maximum total score of 49, where higher scores indicated greater degree of experiences typical of stereotype threat. RESULTS: Of the 84 eligible residents, 49 participated: 22 in the nonintervention and 27 in the intervention group. The overall scores were 29 and 29.4, and 26.2 and 25.8 in the nonintervention and intervention groups for their survey responses to perceived poor performance in teaching rounds (p = 0.85) and the OR (p = 0.84), respectively. Overall, responses typical of stereotype threat were greater for perceived poor performance at teaching rounds than in the OR (p = 0.001). CONCLUSION: Residents experience low self-esteem following perceived poor performance, particularly at rounds. A simple orientation designed to reduce stereotype threat was unsuccessful in reducing this threat overall. Future research will need to consider longer-term intervention as possible strategies to reduce perceived poor performance at teaching rounds and in the OR.

CONTEXTE: La menace du stéréotype, définie comme un malaise ressenti chez des individus en situation d'apprentissage positive ou négative où ils pourraient se conformer au stéréotype négatif associé à leur groupe d'appartenance, peut nuire à l'apprentissage. Le but de cette étude était de déterminer s'il est possible de réduire la menace du stéoréotype chez des résidents en orthopédie au moyen d'une simple séance d'orientation. MÉTHODES: Le groupe soumis à l'intervention a assisté à 2 séances d'orientation visant leurs réactions possibles à un piètre rendement perçu lors de cours cliniques ou au bloc opératoire. Les participants ont répondu à un sondage de 7 questions typiques concernant la menace du stéréotype pour évaluer leurs réactions à de telles expériences. Les questions comportaient 7 choix de réponse, pour un score total maximum de 49; les scores les plus élevés indiquaient un degré plus marqué d'expériences concordant avec la menace du stéréotype. RÉSULTATS: Parmi les 54 résidents admissibles, 49 ont participé : 22 dans le groupe non soumis à l'intervention et 27 dans le groupe soumis à l'intervention. Les scores globaux ont été de 29 et de 29,4, et de 26,2 et 25,8 dans les groupes non soumis à l'intervention et soumis à l'intervention (p = 0,85), respectivement, pour leurs réponses au sondage liées à un piètre rendement perçu lors des cours cliniques ou au bloc opératoire. Dans l'ensemble, les réponses typiques de la menace du stéréotype ont été plus marquées en ce qui concerne un piètre rendement perçu lors des cours cliniques qu'au bloc opératoire (p = 0,001). CONCLUSION: Les résidents ont une faible estime d'eux-mêmes après un piètre rendement perçu, particulièrement lors des cours cliniques. Une simple séance d'orientation conçue pour réduire la menace du stéréotype n'a pas réussi à l'atténuer dans l'ensemble. Il faudra approfondir la recherche pour envisager une intervention à plus long terme comme stratégie envisageable pour réduire la perception d'un piètre rendement lors des cours cliniques et au bloc opératoire.

Dedicated operating room for emergency surgery improves access and efficiency.

BACKGROUND: Scheduling emergency cases among elective surgeries often results in prolonged waits for emergency surgery and delays or cancellation of elective cases. We evaluated the benefits of a dedicated operating room (OR) for emergency procedures available to all surgical services at a large children's hospital. METHODS: We compared a 6-month period (January 2009 to June 2009) preimplementation with a 6-month period (January 2010 to June 2010) postimplementation of a dedicated OR. We evaluated OR use, wait times, percentage of cases done within and outside of access targets, off-hours surgery, cancellations, overruns and length of stay. RESULTS: Preimplementation, 1069 of the 5500 surgeries performed were emergency cases. Postimplementation, 1084 of the 5358 surgeries performed were emergency cases. Overall use of the dedicated OR was 53% (standard deviation 25%) postimplementation. Excluding outliers, the average wait time for priority 3 emergency patients decreased from 11 hours 8 minutes to 10 hours 5 minutes (p = 0.004). An increased proportion of priority 3 patients, from 52% to 58%, received surgery within 12 hours (p = 0.020). There was a 9% decrease in the proportion of priority 3 cases completed during the evening and night (p < 0.001). The elective surgical schedule benefited from the dedicated OR, with a significant decrease in cancellations (1.5% v. 0.7%, p < 0.001) and an accumulated decrease of 5211 minutes in overrun minutes in elective rooms. The average hospital stay after emergency surgery decreased from 16.0 days to 14.7 days (p = 0.12) following implementation of the dedicated OR. CONCLUSION: A dedicated OR for emergency cases improved quality of care by decreasing cancellations and overruns in elective rooms and increasing the proportion of priority 3 patients who accessed care within the targeted time.

CONTEXTE: Ajouter des chirurgies urgentes à l'horaire des chirurgies non urgentes prolonge souvent l'attente pour les premières et entraîne des retards ou des annulations pour les secondes. Nous avons évalué les avantages d'un bloc opératoire dédié aux urgences et accessible à toutes les spécialités chirurgicales dans un grand hôpital pédiatrique. MÉTHODES: Nous avons comparé 2 périodes de 6 mois chacune, soit avant la création du bloc opératoire dédié (de janvier 2009 à juin 2009) et après sa création (de janvier 2010 à juin 2010). Nous avons évalué l'utilisation du bloc opératoire, les temps d'attente, le pourcentage de cas réglés à l'intérieur et à l'extérieur des temps cibles, les chirurgies effectuées en dehors des heures normales, les annulations, les dépassements du temps prévu et la durée des séjours hospitaliers. RÉSULTANTS: Avant, 1069 chirurgies sur les 5500 effectuées ont été des interventions d'urgence. Après, 1084 chirurgies sur les 5358 effectuées ont été des interventions d'urgence. Globalement, le recours au bloc opératoire dédié a été de 53 % (écart-type 25 %) après son ouverture. À part les cas particuliers, le temps d'attente moyen pour les urgences de niveau 3 est passé de 11 heures 8 minutes à 10 heures 5 minutes (p = 0,004). Pour une plus grande proportion (de 52 % à 58 %) des patients prioritaires de niveau 3, la chirurgie nécessaire a été effectuée en l'espace de 12 heures (p = 0,020). On a observé une baisse de 9 % de la proportion des cas de niveau 3 réglés le soir et la nuit (p < 0,001). L'horaire des chirurgies non urgentes a bénéficié du bloc opératoire dédié, comme en témoigne une baisse significative du nombre d'annulations (1,5 % c. 0,7 %, p < 0,001) et une réduction cumulative de 5211 minutes des dépassements du temps prévu dans les blocs opératoires destinés aux chirurgies non urgentes. Le séjour hospitalier moyen après les chirurgies urgentes est passé de 16,0 jours à 14,7 jours (p = 0,12) après l'ouverture du bloc opératoire dédié. CONCLUSIONS: La création d'un bloc opératoire dédié a amélioré la qualité des soins en réduisant le nombre d'annulations et les dépassements dans les blocs opératoires destinés aux chirurgies non urgentes et en augmentant la proportion de patients prioritaires de niveau 3 qui ont eu accès aux soins à l'intérieur des délais cibles.

Long-term functional outcomes of resected tarsal coalitions.

BACKGROUND: There are few long-term studies evaluating tarsal coalition resections. The purpose of this study was to compare patient outcomes following resection of calcaneonavicular (CN) and talocalcaneal (TC) bars and to determine the relationship between the extent of a coalition and the outcome of resection. METHODS: Patients younger than 18 years receiving resection for symptomatic tarsal coalition (1991-2004 inclusive) were eligible to participate. Follow-up evaluation included clinical examination to assess range of motion and self-reported functional outcome questionnaires. Two validated functional scales were used: the American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Module, and the Foot Function Index (FFI). Twenty-four patients with 32 tarsal coalition resections (19 CN and 13 TC feet) were included in this study. For CN and TC patients, the mean age at the time of surgery was 11.8 ± 1.1 and 11.9 ± 2.5 years, and the mean age at follow-up was 27.1 ± 1.1 and 25.0 ± 2.5 years, respectively. RESULTS: Inversion and eversion were significantly less for TC feet when compared with CN (P = .03 and P = .01, respectively). No difference was noted between the CN and TC groups with respect to outcome scores. Furthermore, no association was noted between the size of TC coalition or hindfoot valgus angle with respect to outcome scores. CONCLUSION: Resected CN and TC bars behaved similarly in the long term in terms of function and patient satisfaction. Favorable results were attained when resections were performed on TC coalitions that were greater than 50% of the posterior facet and hindfoot valgus angles greater than 16 degrees. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Technostress as source of physician burnout: An exploration of the associations between technology usage and physician burnout.

BACKGROUND: The cause of physician burnout is multifactorial. Health care systems pressures, excessive workloads, fatigue, poor self-care, administrative burdens, work hours, technological advancements, and work-home life conflicts, are all prominent themes throughout the literature. To date, little is known about whether, and to what extent, stressors related to the use of information and communication technology (ICT) use, other than electronic health records, outside of working hours, contribute to physician burnout. PURPOSE: The purpose of this study was to explore whether work related ICT use outside of working hours is associated with physician burnout. METHOD: A cross-sectional survey delivered online using The Maslach Burnout Inventory (MBI), a Physician Technology Usage Scale (PTUS) (and 7 personal characteristics questions. Data were analyzed using bivariate correlations, analysis of variance (ANOVA) and t-tests, and multiple linear regression. RESULTS: Of 2,108 participants invited to complete the survey, 403 responded to and completed the survey (19% response rate). Results identified two significant factors associated with physician burnout: work related technology use outside of working hours, and the number of years in practice. CONCLUSION: This research highlights the need for additional in-depth research into areas such as: 1. work-home life issues and how the use of technology outside of work hours may affect or be affected by burnout; 2. physician age and experience and burnout; 3. The differences between specialties and whether and how specialty-specific factors are related to burnout.