Technical Performance as a Predictor of Clinical Outcomes in Laparoscopic Gastric Cancer Surgery.

OBJECTIVE: The purpose of this study was to evaluate the relationship between technical performance and patient outcomes in laparoscopic gastric cancer surgery. BACKGROUND: Laparoscopic gastrectomy for cancer is an advanced procedure with high rate of postoperative morbidity and mortality. Many variables including patient, disease, and perioperative management factors have been shown to impact postoperative outcomes; however, the role of surgical performance is insufficiently investigated. METHODS: A retrospective review was performed for all patients who had undergone laparoscopic gastrectomy for cancer at 3 teaching institutions between 2009 and 2015. Patients with available, unedited video-recording of their procedure were included in the study. Video files were rated for technical performance, using Objective Structured Assessments of Technical Skills (OSATS) and Generic Error Rating Tool instruments. The main outcome variable was major short-term complications. The effect of technical performance on patient outcomes was assessed using logistic regression analysis with backward selection strategy. RESULTS: Sixty-one patients with available video recordings were included in the study. The overall complication rate was 29.5%. The mean Charlson comorbidity index, type of procedure, and the global OSATS score were included in the final predictive model. Lower performance score (OSATS ≤29) remained an independent predictor for major short-term outcomes (odds ratio 6.49), while adjusting for comorbidities and type of procedure. CONCLUSIONS: Intraoperative technical performance predicts major short-term outcomes in laparoscopic gastrectomy for cancer. Ongoing assessment and enhancement of surgical skills using modern, evidence-based strategies might improve short-term patient outcomes. Future work should focus on developing and studying the effectiveness of such interventions in laparoscopic gastric cancer surgery.

Traumatic brain injury as an independent risk factor for problem gambling: a matched case-control study.

PURPOSE: To assess whether traumatic brain injury (TBI) increases the risks of subsequent problem gambling. METHODS: We conducted a matched case-control analysis of adults in Ontario, Canada. The study included those who self-reported their gambling activities in the Canadian Community Health Survey 2007-2008. Using Problem Gambling Severity Index, we defined cases as those who were problem gamblers and controls who were recreational gamblers. Cases were matched to controls 1:2 using propensity scores based on demographics, prior mental health, and self-reported behaviours. The main predictor was prior TBI defined as requiring emergency care and identified using ICD-10 codes from administrative health databases. We estimated the likelihood of prior TBI in problem gamblers compared to controls using conditional logistic regression. RESULTS: Of 30,652 survey participants, 16,002 (53%) reported gambling activity of whom 14,910 (49%) were recreational gamblers and 4% (n = 1092) were problem gamblers. A total of 1469 respondents (5%) had a prior TBI. Propensity score matching yielded 2038 matched pairs with 1019 cases matched to 2037 controls. Case-control analysis showed a significant association between prior TBI and subsequent problem gambling (odds ratio 1.27, 95% confidence interval 1.07-1.51, P = 0.007). The increased risk was mostly apparent in men aged 35 to 64 years who reported alcohol use or smoking. The relative risk of problem gambling in those with two or more TBIs equated to an odds ratio of 2.04 (95% confidence interval 1.05-3.99). CONCLUSIONS: We found that a prior TBI was associated with an increased subsequent risk of problem gambling. Our findings support more awareness, screening, and treating problem gambling risks among TBI patients.

Weight loss surgery and subsequent emergency care use: a population-based cohort study.

STUDY OBJECTIVE: This study assessed long-term emergency care utilization after weight loss surgery. METHODS: We conducted a self-matched longitudinal cohort analysis of weight loss surgery patients in Ontario operated between April 1, 2006, and March 31, 2011. Using population-wide registries, we compared emergency visits in the 3-year interval after surgery to the 3 years before surgery using incidence rate ratios with 95% confidence intervals. The study excluded patients with repeat surgeries, and the analysis excluded visits in the immediate perioperative interval (ie, 3 months before and after surgery). RESULTS: A total of 8815 patients were identified of whom most were women (81%), living in an urban area (84%), and treated with gastric bypass (99%). Approximately half (53%) were aged 25 to 45 years. Approximately half of the patients 4364 (49%) had at least 1 emergency in both preoperative and postoperative intervals, 1417 (16%) in the preoperative interval only and 1661 (19%) in the postoperative interval only. Total emergencies significantly increased from 852 per 1000 patient-years to 1000 per 1000 patient-years, equal to an incidence rate ratio of 1.17 (95% confidence interval, 1.13-1.21; P<.001). Compared to baseline, emergencies from gastrointestinal, genitourinary, substance misuse, trauma, and miscellaneous complaints increased significantly after surgery. Conversely, emergencies due to cardiovascular, ear, respiratory, and dermatology complaints decreased significantly after surgery. Ambulance use, triage urgency, and hospitalizations were significantly higher for emergencies after surgery. CONCLUSION: Persistent and resource-intensive emergency care utilization after weight loss surgery underscores the need of long-term patient support.

Hazard perception at high- and low-risk road sites: a pilot study of interurban roads in Pakistan and Cameroon.

OBJECTIVES: Interurban roads account for a significant proportion of traffic deaths in developing countries. In this pilot study, hazard perceptions of interurban road sites involved in ≥3 injury road traffic crashes were compared with those not involved in road traffic crashes on the same road sections. SETTINGS: Karachi-Hala (Pakistan) and Yaoundé-Douala (Cameroon) road sections were the main study settings. DATA: Videos of 26 high-risk sites and 26 low-risk sites from Karachi-Hala (Pakistan) and Yaoundé-Douala (Cameroon) roads, matched for the road section, were shown to 100 voluntary Pakistani drivers. Variations in perceived site hazardousness and preferred speed for each site pair were assessed. Analyses Factors associated with incorrect hazard perception of high-risk sites (perceived as safe) were assessed by multinomial logistic regression analyses. RESULTS: Drivers reported a higher hazard perception and a lower preferred speed for high-risk sites than for their matched low-risk sites in less than half of pairs (n=12, p≤0.02). Factors associated with increased likelihood of identifying a high-risk site as safe were as follows: flat road profile (adjusted OR=2.00, 95% CI 1.55 to 2.57), intersections (OR=1.96, 95% CI 1.43 to 2.68), irregular road surface (OR=3.56, 95% CI 2.68 to 4.71), nearby road obstacles (OR=2.57, 95% CI 1.96 to 3.39) and visible rain (OR=1.85, 95% CI 1.48 to 2.32). CONCLUSION: The methods used in this study might be useful in prioritising cost-effective improvements at high-risk sites.

Association of depression with treatment outcomes in Type 2 Diabetes Mellitus: a cross-sectional study from Karachi, Pakistan.

BACKGROUND: To assess the associations of depression with glycemic control and compliance to self-care activities in adult patients with Type 2 Diabetes Mellitus METHODS: This cross-sectional study was conducted at a tertiary-care hospital in Karachi (Aga Khan University Hospital). Equal numbers of depressed and non-depressed patients were consecutively recruited from the diabetic clinic. Information on demographic and clinical characteristics was collected in face-to-face interviews and from medical records. Hospital Anxiety Depression Scale (HADS) was used to measure depression. Associations of depressed status (HADS ≥ 8) with poor glycemic control (Hemoglobin A1c level ≥ 7%) and compliance to self-care activities were assessed by logistic regression analyses. RESULTS: A total of 286 patients were included in this study with a male-female ratio of 1.2:1. Mean age was 52 years and in 64.7% of them, the duration of diabetes was more than 3 years. Depressed patients were more likely to be female (adjusted odds ratio [OR] = 1.88; 95% confidence interval [95%CI] = 1.07-3.31), had a family history of diabetes (OR = 2.64; 95%CI = 1.26-5.55), and poor glycemic control (OR = 5.57; 95%CI = 2.88-10.76) compared with non-depressed patients. Depression was also associated with low compliance to self-care activities such as taking dose as advised (OR = 0.32; 95%CI = 0.14-0.73), dietary restrictions (OR = 0.45; 95%CI = 0.26-0.79) and foot care (OR = 0.38; 95%CI = 0.18-0.83). CONCLUSIONS: Adult patients with Type 2 Diabetes who have depression were more likely to have poor glycemic control and lower compliance to self-care activities, and they might need particular attention during follow-up visits.

Initial estimates of COVID-19 infections in hospital workers in the United States during the first wave of pandemic.

OBJECTIVE: We estimated the number of hospital workers in the United States (US) that might be infected or die during the COVID-19 pandemic based on the data in the early phases of the pandemic. METHODS: We calculated infection and death rates amongst US hospital workers per 100 COVID-19-related deaths in the general population based on observed numbers in Hubei, China, and Italy. We used Monte Carlo simulations to compute point estimates with 95% confidence intervals for hospital worker (HW) infections in the US based on each of these two scenarios. We also assessed the impact of restricting hospital workers aged ≥ 60 years from performing patient care activities on these estimates. RESULTS: We estimated that about 53,000 hospital workers in the US could get infected, and 1579 could die due to COVID19. The availability of PPE for high-risk workers alone could reduce this number to about 28,000 infections and 850 deaths. Restricting high-risk hospital workers such as those aged ≥ 60 years from direct patient care could reduce counts to 2,000 healthcare worker infections and 60 deaths. CONCLUSION: We estimate that US hospital workers will bear a significant burden of illness due to COVID-19. Making PPE available to all hospital workers and reducing the exposure of hospital workers above the age of 60 could mitigate these risks.

Impact of genetic polymorphisms on opioid misuse: a scoping review.

We conducted a scoping review on genetic polymorphisms associated with opioid intake-related adverse patient outcomes including behavioral, physiological and clinical outcomes. We searched for studies on Medline®, EMBASE®, CINAHL®, Psychinfo® and SNPedia® from January 2006 to January 2018. Our study identified 33 genes and 71 SNPs associated with opioid-intake related adverse patient outcomes: four studies showing associations of nine SNPs with clinical events (e.g., arrhythmia, length of stay and deaths); six studies showing associations of 13 SNPs with respiratory depression and 25 studies showing associations of 50 SNPs with opioid misuse behaviors. Available pharmacogenetic-tests covered polymorphisms associated with opioids metabolism and ignored polymorphisms associated with opioids transport, receptor-binding and signaling that were linked with respiratory depression and misuse behaviors.

Leisure Time Physical Activity Levels in Immigrants by Ethnicity and Time Since Immigration to Canada: Findings from the 2011-2012 Canadian Community Health Survey.

New immigrants to Canada are mostly from Asian/South Asian countries currently experiencing low levels of physical activity (PA) and high rates of overweight/obesity. Little is known about the leisure time PA (LTPA) patterns of recent immigrants. Study sample was extracted from Canadian Community Health Survey (2011-2012). Based on reported daily energy expenditure on LTPAs over past 3 months, participants were categorized as physically active, moderately active, and inactive. Likelihood of being physically inactive was estimated for recent immigrants versus established immigrants. Higher proportion of recent immigrants were inactive (60%) compared to established immigrants (53%). Adjusted models estimated a higher likelihood of inactivity among recent immigrants (OR 1.40, 95% CI 1.13, 1.72) versus established immigrants. Inactivity was higher among immigrants of visible minorities, 58.8 versus 46.7% of white immigrants. Recent immigrants of visible minorities are at higher risk of being inactive. This highlights importance of developing programs to increase PA in specific groups of new immigrants.

Gambling and Subsequent Road Traffic Injuries: A Longitudinal Cohort Analysis.

BACKGROUND: To compare the risks of a road traffic injury (RTI) crash among adults who were involved in high-risk gambling and those who did not gamble. METHODS: We conducted a linked longitudinal cohort analysis of adult persons in large population survey conducted during 2007 and 2008 in Ontario, Canada. We used responses to Problem Gambling Severity Index to distinguish persons as nongamblers, no-risk, low-risk, or high-risk gamblers. All persons were subsequently monitored for a subsequent RTI crash as a driver, pedestrian, or bicyclist up to March 31, 2014, through health insurance databases. We estimated relative risks as rate ratios (RRs) with 95% confidence intervals (95% CIs). RESULTS: In all, 30,652 adults were included, of whom 52% self-identified as gamblers, including 49% as no-risk gamblers, 2% as low-risk gamblers, and 1% as high-risk gamblers. During a median follow-up period of 6.8 years, 708 participants (2%) were involved in 821 RTI crashes. The absolute risks of an RTI were 6.4 per 1000 person-years (95% CI 3.7-10.4) in high-risk gamblers and 3.6 per 1000 person-years (95% CI 3.2-4.0) in nongamblers. The relative risks for RTI crashes were significantly higher in high-risk gamblers than in nongamblers (adjusted RR 1.68, 95% CI 1.03-2.76). The risks for RTI crashes as a driver were augmented in high-risk gamblers than in nongamblers (RR 1.97, 95% CI 1.13-3.43). CONCLUSIONS: We found an increased risk of an RTI crash among drivers who self-identified as high-risk gamblers. Further research exploring the underlying mechanisms of these associations might interest health professionals to monitor RTI risks in adults involved in high-risk gambling.

Impact of retirement on risky driving behavior and attitudes towards road safety among a large cohort of French drivers (the GAZEL cohort).

OBJECTIVES: This study investigated changes in driving behavior and attitudes towards road safety, following retirement, in a large cohort of road users. METHODS: In 2001, 14 226 participants of the GAZEL cohort in France reported their attitudes towards road safety and driving behavior using a self-administered driving behavior and road safety questionnaire. In 2004, 82% of the group (N=11 706) responded to the same questionnaire. Two complementary logistic regression analyses were performed to assess the association of (i) retirement with change in safe driving behavior and attitudes towards road safety between 2001 and 2004 and (ii) time since retirement with risky driving behavior and negative attitudes towards road safety in 2001. RESULTS: Among the participants who were active in 2001 (N=3927), those retiring between 2001 and 2004 (66%) were more likely to have discontinued sleepy driving [adjusted odds ratio (aOR) 2.12, P<0.001] and phone use while driving (aOR 1.74, P=0.006) than those who remained professionally active. The second analysis showed that the likelihood of sleepy driving and phone use while driving decreased soon after retirement, whereas that of speedy driving decreased over a longer interval. Retirement had no influence on driving while intoxicated or attitudes towards road safety. CONCLUSIONS: The results suggest that any professional activity may account for some risky road behavior. As work-related road traffic accidents are responsible for one out of every four road casualties in France, the monitoring and prevention of sleepy driving and phoning while driving among workers should be further considered.

Assessment of patients' medical fitness to drive by primary care physicians: A cross-sectional study.

OBJECTIVES: Motor vehicle collisions (MVCs) are a significant health burden in Saudi Arabia. The literature has consistently indicated that chronic medical conditions, such as diabetes, heart disease, stroke, obstructive sleep apnea, and neurodevelopmental disorders, increase the risk of MVCs. Therefore, assessment of driver fitness by primary care physicians (PCPs) remains a major health intervention that might reduce MVCs. We studied the practices of PCPs in assessing medical fitness to drive in at-risk patients. METHODS: We conducted a cross-sectional study of all 88 government-funded primary care centers in the city of Riyadh, Saudi Arabia. We administered a self-reported questionnaire to PCPs that inquired about their driving risk assessment for specific medical conditions. RESULTS: Among all PCPs and centers, 189 PCPs (63%) from 74 centers (84%) participated in our survey. The mean age of the PCPs was 40 ± 10 years, and 108 (57%) were men. The average clinical experience of the group was 13 ± 9 years. Fewer than half of PCPs considered diabetes mellitus (45%) and obstructive sleep apnea (46%) as potential risks for MVCs. Approximately 45% of PCPs did not notify any authority or relatives of potential driving issues that they noticed in their patients. Only 15% of the participants believed that PCPs were responsible for alerting authorities about their fitness to drive. CONCLUSIONS: PCPs did not adequately assess their patients' driving history and eligibility. Efforts are needed to improve awareness among PCPs regarding the effects of chronic medical conditions on driving.

Paediatric-appropriate facilities in emergency departments of community hospitals in Ontario: A cross-sectional study.

BACKGROUND: We assessed whether the paediatric-appropriate facilities were available at Emergency Departments (ED) in community hospitals in a Canadian province. METHODS: We conducted a cross-sectional survey of EDs in community hospitals in Ontario, Canada that had inpatient paediatric facilities and a neonatal intensive care unit. Key informants were ED chiefs, clinical educators, or managers. The survey included questions about paediatric facilities related to environment, triage, training, and staff in EDs. RESULTS: Of 52 hospitals, 69% (n=36) responded to our survey. Of them, 14% EDs (n=5) had some separated spaces available for paediatric patients. About 53% (n=19) of EDs lacked children activities, e.g., toys. Only 11% (n=4) EDs were using paediatric triage scales and 42% (n=15) had a designated paediatric resuscitation bay. Only half of the ED (n=18) required from their staff to update paediatric life support training. Only 31% (n=11) had a designated liaison paediatrician for the ED. Paediatric social worker was present in only 8% (n=3) of EDs in community hospitals. CONCLUSION: Most of the Ontario community hospital EDs included in this survey had inadequate facilities for paediatric patients such as specific waiting and treatment areas.

Driver's obesity and road crash risks in the United States.

OBJECTIVE: We assessed obesity trends in U.S. drivers involved in fatal crashes since 1999 and distinguished whether crash risk factors were different between obese and nonobese drivers. METHODS: We included only drivers of passenger cars involved in fatal traffic crashes between January 1, 1999, and December 31, 2012. Obesity was classified according to the World Health Organization guidelines and profiled between 1999 and 2012 using the adjusted prevalence ratio (aPR) from log-binomial regression models. Differences in crash risks (e.g., driver's fatality, drunk driving, seat belt nonuse) between obese and nonobese drivers were estimated as adjusted odds ratios (aORs) using logistic regression models. RESULTS: A total of 753,024 U.S. drivers were involved in fatal crashes, for which obesity information was available for 534,887. About 56% (n = 299,078) were driving passenger cars. The prevalence of class I obesity increased from 10% in 1999 to 14% in 2012 (aPR = 1.50, 95% confidence interval [CI], 1.42-1.58), class II obesity from 3 to 5% (aPR = 2.22, 95% CI, 2.05-3.01), and class III obesity from 1 to 2% (aPR = 2.65; 95% CI, 2.27-3.10). Compared to nonobese controls, obese drivers had significantly higher risks for fatality (1.10 ≤ aOR ≤ 1.47), seat belt nonuse (1.00 ≤ aOR ≤ 1.21), need for extrication (1.01 ≤ aOR ≤ 1.23), and ambulance transport time ≥30 min (1.01 ≤ aOR ≤ 1.28). Compared to nonobese controls, obese drivers were less likely to drink drive (0.41 ≤ aOR ≤ 0.72) or speed >65 mph (0.78 ≤ aOR ≤ 0.93). CONCLUSION: The rising national prevalence of obesity extends to U.S. drivers involved in fatal crashes and indicates the need to improve seat belt use, vehicle design, and postcrash care for this vulnerable population.

Traffic Crash Risks in Morbidly Obese Drivers Before and After Weight Loss Surgery.

Morbidly obese drivers have a higher risk of road crashes because of associated conditions such as obstructive sleep apnea. We assessed whether weight loss surgery has an impact on subsequent road crash risks in morbidly obese drivers. Our longitudinal self-matched cohort analyses suggest that road crash risks are three times higher in morbidly obese drivers than the population norm. Yet, weight loss surgery yields no significant reductions in crash risks. We found similar results in patients not previously diagnosed with sleep disorders, suggesting the need to clarify the relationship of obesity with road crash risk.

Program design for incentivizing ignition interlock installation for alcohol-impaired drivers: The Ontario approach.

INTRODUCTION: Drinking and driving is a major risk factor for traffic injuries. Although ignition interlocks reduce drinking and driving while installed, several issues undermine their implementation including delayed eligibility for installation, low installation once eligible, and a return to previous risk levels after de-installation. The Canadian province of Ontario introduced a "Reduced Suspension with Ignition Interlock Conduct Review" Program, significantly changing pre-existing interlock policy. The Program incentivizes interlock installation and an "early" guilty plea. It also attempts to reduce long-term recidivism through behavioural feedback and compliance-based removal. This evaluation is the first in assessing Program impact. METHODS: Ontario drivers with a first time alcohol-impaired driving conviction between July 1, 2005 and November 25, 2014 comprised the study cohort. Longitudinal analyses, using interrupted time series and Cox regression, were conducted in which exposure was the Program and the outcomes were ignition interlock installation (N=30,200), pre-trial elapsed time (N=30,200), and post-interlock recidivism (N=9326). RESULTS: After Program implementation, installation rates increased by 54% and pre-trial elapsed time decreased by 146 days. Results suggest no effect on post-interlock recidivism. CONCLUSIONS: Through an incentive-based design, this Program was effective at addressing two commonly cited barriers to interlock implementation- delayed eligibility for installation and low installation once eligible. Results reveal that installation rates are responsive not only to incentivization but also to other external factors, thus presenting an opportunity for policy makers to find unique ways to influence interlock uptake, and thereby, to extend their deterrent effects to a larger subset of the population. This study is one of the few that do not rely on proxy measures of installation rate.

Self-harm Emergencies After Bariatric Surgery: A Population-Based Cohort Study.

IMPORTANCE: Self-harm behaviors, including suicidal ideation and past suicide attempts, are frequent in bariatric surgery candidates. It is unclear, however, whether these behaviors are mitigated or aggravated by surgery. OBJECTIVE: To compare the risk of self-harm behaviors before and after bariatric surgery. DESIGN, SETTING, AND PARTICIPANTS: In this population-based, self-matched, longitudinal cohort analysis, we studied 8815 adults from Ontario, Canada, who underwent bariatric surgery between April 1, 2006, and March 31, 2011. Follow-up for each patient was 3 years prior to surgery and 3 years after surgery. MAIN OUTCOMES AND MEASURES: Self-harm emergencies 3 years before and after surgery. RESULTS: The cohort included 8815 patients of whom 7176 (81.4%) were women, 7063 (80.1%) were 35 years or older, and 8681 (98.5%) were treated with gastric bypass. A total of 111 patients had 158 self-harm emergencies during follow-up. Overall, self-harm emergencies significantly increased after surgery (3.63 per 1000 patient-years) compared with before surgery (2.33 per 1000 patient-years), equaling a rate ratio (RR) of 1.54 (95% CI, 1.03-2.30; P = .007). Self-harm emergencies after surgery were higher than before surgery among patients older than 35 years (RR, 1.76; 95% CI, 1.05-2.94; P = .03), those with a low-income status (RR, 2.09; 95% CI, 1.20-3.65; P = .01), and those living in rural areas (RR, 6.49; 95% CI, 1.42-29.63; P = .02). The most common self-harm mechanism was an intentional overdose (115 [72.8%]). A total of 147 events (93.0%) occurred in patients diagnosed as having a mental health disorder during the 5 years before the surgery. CONCLUSIONS AND RELEVANCE: In this study, the risk of self-harm emergencies increased after bariatric surgery, underscoring the need for screening for suicide risk during follow-up.