Adherence to apixaban for extended thromboprophylaxis after major abdominal or pelvic surgery for cancer: A prospective cohort study.

BACKGROUND: Due to lack of data, direct oral anticoagulants are not considered by guidelines for venous thromboembolism (VTE) prophylaxis after cancer surgery. Adherence to low-molecular-weight heparin injections in this setting is sometimes poor. AIM: Analysis of adherence to oral apixaban for extended thromboprophylaxis. METHODS: Consecutive patients discharged after major surgery for abdominal/pelvic cancer and considered eligible for extended prophylaxis were offered apixaban 2.5 mg twice daily. Primary outcomes were adherence metrics-proportion of prescriptions filled, persistence (not prematurely discontinued), proportion of days covered (PDC) based on apixaban pill counts, and modified Morisky medication adherence scale at Days 28-30. Secondary outcomes were bleeding, VTE, and serious adverse events until Day 90. RESULTS: We included 53 patients, 51 were analyzed. Of 45 patients with prescriptions all had it filled (95% confidence interval [CI], 92%-100%). Persistence was 98% (95% CI, 90%-100%). PDC was ≥80% for 48 patients (94%; 95% CI, 84%-99%). We found good adherence (0/6 answers "yes") in 75% and moderate (1/6 answers "yes") in 25%. No major bleed or VTE occurred while on apixaban. CONCLUSION: Our results support good adherence with apixaban for VTE prophylaxis up to 28 days after major abdominal or pelvic cancer surgery.

Burnout among Academic Clinicians as It Correlates with Workload and Demographic Variables.

Burnout syndrome (BOS) in academic physicians is a psychological state resulting from prolonged exposure to job stressors. It leads to a decline in overall job performance, which could result in misjudgment and serious clinical errors. The current study identifies the prevalence, as well as the potential demographic and workload variables that contribute significantly to BOS in academic clinicians. We distributed a modified version of the Maslach Burnout Inventory (MBI) scale to the academic clinicians in our institution; 326/900 responded, with 56.21% male and 43.46% female. The MBI scale comprised of three dimensions of burnout: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Higher scores in EE and DP and lower scores in PA were associated with a higher risk for burnout. In considering the work-life of academic clinicians, this study used a modified version of the MBI to reflect three hypothesized sources of burnout: interactions with students/trainees, interactions with patients, and interactions with administration, as reflected in these three dimensions. Along both the EE and DP dimensions of the MBI, burnout was highest for interactions with administration (51% and 44.8%), moderate for interactions with patients (26.4% and 34.5%), and lowest for interactions with students (11.7% and 9.8%). The highest scores along the personal accomplishment component was found for interactions with students and patients (33.7% and 33.4%). Regression analyses identified several factors associated with higher scores on the EE and DP scales: younger age, surgical specialty, low academic rank, academic main practice, female gender, numerous night shifts, and living alone. Furthermore, higher patient volume contributed significantly to the increasing PA. This study suggests that administrative interaction contributes significantly to burnout amongst physicians, followed by patient care and trainees. Furthermore, surgeons, females, single, early career, and younger faculty staff members are at higher risk of suffering from burnout. Further studies are needed to characterize the nature of administrative interactions that contribute to burnout and to solidify other contributing variables.

Does exposure to anatomy education in medical school affect surgical residency applications? An analysis of Canadian residency match data

Background: The time dedicated to teaching gross anatomy, including cadaveric dissection, has been decreasing in North American medical schools. The impact of this trend on surgical residency applications is unknown. We sought to identify trends in surgical residency applications in Canada and to determine if medical schools with more gross anatomy instruction and mandatory cadaveric dissection produced more applicants ranking surgical residency programs as their first choice. Methods: Canadian Resident Matching Service (CaRMS) data from 1997 to 2016 were analyzed. A questionnaire was distributed to Canadian medical schools requesting current and historic information on their anatomy curricula and the number of hours of anatomy instruction. Results: The survey response rate was 35% (6 of the 17 Canadian medical schools responded); partial data were available for 16 (94%) of the 17 Canadian medical schools. A total of 4.3% of graduating students ranked general surgery as their first choice in the CaRMS match and 17.2% ranked any surgical program first. Over time, the percentage of graduating students who ranked surgical programs as their first choice decreased (p < 0.001). Three schools were significantly more likely than the others to produce graduates ranking general surgery as their first choice. Between 2012 and 2016 the percentage of graduating students ranking surgical programs first was significantly higher (2.2%, p = 0.024) in schools with mandatory cadaver dissection. There was no correlation between the number of hours of gross anatomy instruction and the percentage of graduates ranking any surgical program or a general surgical program first. Conclusion: The number of applications to surgical programs has decreased in Canada over the past 20 years. Certain schools are more likely than others to produce graduates ranking general surgery as their first choice. Programs with mandatory cadaver dissection produced more graduates favouring surgical programs.

Contexte: Le temps alloué à l'enseignement de l'anatomie macroscopique, y compris la dissection cadavérique, est en baisse dans les facultés de médecine nord-américaines. Les répercussions de cette tendance sur le nombre de demandes dans les programmes de résidence en chirurgie sont encore inconnues. Nous avons cherché à dégager des tendances concernant les demandes aux programmes de résidence en chirurgie au Canada et à déterminer si les facultés de médecine intégrant une plus grande proportion d'enseignement de l'anatomie macroscopique et de dissection cadavérique obligatoires produisaient plus de candidats indiquant la résidence en chirurgie comme premier choix. Méthodes: Nous avons analysé les données du Service canadien de jumelage des résidents (CaRMS) de 1997 à 2016. Un questionnaire recueillant les données actuelles et historiques sur la matière enseignée en anatomie et le nombre d'heures d'enseignement consacrées à la discipline a été distribué aux facultés de médecine canadiennes Résultats: Le taux de réponse au sondage était de 35 % (6 des 17 facultés de médecine canadiennes ont répondu), et des données partielles ont été recueillies pour 16 (94 %) des 17 facultés. Au total, 4,3 % des finissants ont mis la chirurgie générale comme premier choix au jumelage du CaRMS, et 17,2 % ont mis un programme de chirurgie comme premier choix. Le pourcentage de finissants ayant mis les programmes chirurgicaux comme premier choix a diminué avec le temps (p < 0,001). Trois écoles étaient toutefois significativement plus susceptibles que les autres de produire des étudiants indiquant la chirurgie générale comme premier choix. Entre 2012 et 2016, le pourcentage d'étudiants inscrivant un programme chirurgical comme premier choix était significativement plus élevé (2,2 %, p = 0,024) dans les facultés ayant des dissections cadavériques obligatoires. Aucune corrélation n'a été observée entre le nombre d'heures d'enseignement de l'anatomie macroscopique et le pourcentage d'étudiants mettant un programme chirurgical comme premier choix. Conclusion: Le nombre de demandes pour les programmes chirurgicaux est en baisse au Canada depuis les 20 dernières années. Certaines écoles sont toutefois plus susceptibles que les autres de produire des finissants indiquant la chirurgie générale comme premier choix de programme de résidence. Les programmes intégrant la dissection cadavérique obligatoire produisent plus d'étudiants choisissant les programmes chirurgicaux pour la résidence.

The TRAAGIC score: early predictors of inpatient mortality in adult trauma patients

Background: Scoring systems are important in prognostication and decision-making in the management of trauma patients. However, they often include an extensive list of factors not easily recalled by clinicians on admission. Additionally, multivariable analyses examining predictors of mortality in these patients is lacking. This study aimed to develop and validate a mortality prediction score for adult trauma inpatients. The intention was to create a scoring tool that could be easily remembered and implemented by clinicians. Methods: This is a retrospective analysis of 5175 adult trauma patients treated at a level 1 trauma centre in Hamilton, Ontario, from 2002 to 2013. For derivation of the score, logistic regression was applied to data collected from 2002 to 2006 to identify potential predictors. Variables with p ≤ 0.10 identified from univariable analysis were entered in the multivariable logistic regression. Statistical significance was set at a value of 0.05. The prediction performance of the score was then assessed and validated on data for trauma patients treated from 2007 to 2013. The discrimination ability and calibration of the validation model were assessed. Frequencies, odds ratios with 95% confidence intervals (CIs) and C-statistics were reported. Results: The TRAAGIC prediction score (transfusion, age, airway, hyperglycemia, international normalized ratio, creatinine) showed a C-index of 0.85 (95% CI 0.83­0.87) in the derivation cohort. The TRAAGIC score had high discrimination and good calibration when applied to the validation cohort. Conclusion: The TRAAGIC score is an easily remembered and straightforward toolthat can reasonably predict inpatient mortality for adult trauma patients.

Contexte: Les systèmes de classification sont importants pour le pronostic et le processus décisionnel relatifs à la prise en charge des patients de traumatologie. Par contre, ces systèmes incluent souvent une longue liste de facteurs dont les cliniciens peuvent difficilement se rappeler quand un patient est admis. De plus, on déplore l'absence d'analyses multivariées sur les prédicteurs de mortalité chez ces patients. La présente étude visait à concevoir et valider un score de prédiction de la mortalité pour les polytraumatisés adultes hospitalisés. L'intention était de créer pour les médecins un outil de classification facile à retenir et simple à utiliser. Méthodes: Il s'agit d'une analyse rétrospective de 5175 polytraumatisés adultes traités dans un centre de traumatologie de niveau 1 de Hamilton, en Ontario, de 2002 à 2013. Le score est dérivé de l'analyse de régression logistique appliquée aux données recueillies de 2002 à 2006 pour dégager les prédicteurs potentiels. Les variables identifiées à partir d'analyses univariées dont p ≤ 0,10 ont été incluses dans l'analyse de régression logistique multivariée. La portée statistique a été fixée à 0,05. Le rendement prédictif du score a alors été évalué et validé pour les polytraumatisés traités de 2007 à 2013. On a évalué le pouvoir discriminant et l'étalonnage du modèle de validation, et on a fait état des fréquences, des rapports des cotes avec intervalles de confiance (IC) de 95 % et de la statistique C. Résultats: Le score de prédiction TRAAGIC (transfusion, âge, voies aériennes, hyperglycémie, ratio international normalisé, créatinine) a produit un indice de concordance de 0,85 (IC de 95 % 0,83­0,87) dans la cohorte de dérivation. Le score TRAAGIC s'est révélé doté d'un important pouvoir discriminant et d'un bon étalonnage lorsqu'on l'a appliqué à la cohorte de validation. Conclusion: Le score TRAAGIC est un outil facile à retenir et simple à utiliser qui permet de prédire raisonnablement le risque de mortalité chez les polytraumatisés adultes hospitalisés.

Independent Heath Facility Meets Cancer Care Ontario and Canadian Association of Gastroenterology Guidelines for Endoscopic Procedure Wait Times While Meeting Quality Indicators: A Retrospective Review.

Background: Canadian independent health facilities (IHFs) have been implemented to reduce hospital endoscopy volume and expedite endoscopic evaluations for patients suspected to have underlying colorectal cancer. Methods: We conducted a retrospective review of a prospective database at a large-volume urban IHF. The primary outcomes were wait times, and the secondary outcomes were colonoscopy quality indicators and complication rates. Results: Median wait times from referral to colonoscopy met the recommendations set out by the Canadian Association of Gastroenterology and Cancer Care Ontario for all indications: chronic abdominal pain: 43 days; new onset change in bowel habits: 36 days; bright red rectal bleeding: 42 days; documented iron-deficiency anemia: 43 days; fecal occult blood test positive: 38 days; cancer likely based on imaging or physical exam: 23 days; chronic diarrhea and chronic constipation: 42 days; and screening colonoscopies: 55 days. Secondary outcomes of quality indicators and complication rates all met or exceeded the CCO and CAG recommendations. Conclusions: This IHF met the recommended wait times for all indications for colonoscopy while maintaining high procedural quality and safety. IHFs are one solution to help meet the increasing demand for colonoscopy in Ontario.

Optic nerve sheath diameter sonography for the diagnosis of increased intracranial pressure: a systematic review and meta-analysis protocol.

INTRODUCTION: Increased intracranial pressure (ICP) is a significant neurological issue that may lead to permanent neurological sequelae. When evaluating patients with traumatic brain injury, it is crucial to identify those with high ICP in order to expedite ICP lowering measures and maintain adequate cerebral perfusion. Several measures are used to recognise patients with increased ICP including CT scan, MRI, ICP monitor, and lumbar puncture (LP). However, these tests can be invasive, associated with radiation exposure, contraindicated, or not readily available. Ultrasonography measurement of the optic nerve sheath diameter (ONSD) is proposed as a non-invasive and quick measure to identify high ICP. The aim of this systematic review and meta-analysis will be to examine the accuracy of ONSD sonography for increased ICP diagnosis. METHODS AND ANALYSES: We will include published and unpublished randomised controlled trials, observational studies, and abstracts, with no publication type or language restrictions. Search strategies will be designed to peruse the MEDLINE, Embase, Web of Science, WHO Clinical Trials, ClinicalTrials.gov, CINAHL, and the Cochrane Library databases. We will also implement strategies to search grey literature. Two reviewers will independently complete data abstraction and conduct quality assessment. Included studies will be assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. We will construct the hierarchical summary receiver operating characteristic curve for included studies and pool sensitivity and specificity using the bivariate model. We also plan to conduct prespecified subgroup analyses to explore heterogeneity. The overall quality of evidence will be rated using Grading of Recommendations, Assessment, Development and Evaluations (GRADE). ETHICS AND DISSEMINATION: Research ethics board approval is not required for this study as it draws from published data and raises no concerns related to patient privacy. This review will provide a comprehensive assessment of the evidence on ONSD sonography diagnostic accuracy and is directed to a wide audience. Results from the review will be disseminated extensively through conferences and submitted to a peer-reviewed journal for publication. PROSPERO REGISTRATION NUMBER: CRD42017055485. CLINICAL TRIAL NUMBER: Trial registration number is NCT00783809.

Primary Breast Cancer Tumor and Patient Characteristics as Predictors of Adjuvant Radiation Therapy.

Adjuvant radiation therapy reduces the risk of local recurrence of breast cancer. Our study identifies patient and tumor characteristics that guide the use of adjuvant radiation therapy and evaluates our adherence to recommended guidelines. A retrospective review was undertaken of 1,667 stage I-III breast cancer patients treated at a regional cancer center from 2004 to 2007. Univariate analysis was used to select factors for entry into a multivariate stepwise logistic regression model. Descriptive statistics was used to compare use of radiation therapy of 382 stage I-III breast cancer patients diagnosed in 2013 to those from 2004 to 2007. The primary indicators for any radiation therapy (n = 935) were breast conserving surgery (OR 79.5, 95% CI [47.6-132.9]), four to nine positive lymph nodes (71.9, [17.0-304.7]), and greater than nine positive lymph nodes (60.5, [7.9-460.8]). In post-mastectomy patients (n = 408), the indicators for radiation therapy were four to nine positive lymph nodes (29.4, [12.9-67.4]) and greater than nine positive lymph nodes (108.3, [14.5-807.5]). In breast conserving surgery patients (n = 1,081) 96.1% were offered radiation therapy. Patients offered local-regional radiation therapy were more likely to have any positive nodes (ORs 4.3-91.0), have had a mastectomy (4.3, [2.2-8.4]), and had larger tumors (1.6, [1.3-2.0]). Local-regional radiation therapy was recommended less frequently in node positive patients in 2004-2007 (35.0%) compared to in 2013 (70.5%) [p < 0.001]. Patients who had a breast conserving surgery or had four or more positive lymph nodes were more likely to receive radiation therapy. Patients with any positive lymph nodes, larger tumors, or who had a mastectomy were more likely to receive local-regional radiation therapy. Our institution was more likely to offer local-regional radiation therapy in node positive breast cancer in 2013 compare to 2004-2007.

Mortality and reintervention following elective abdominal aortic aneurysm repair.

BACKGROUND: The objective of this study is to provide an up-to-date meta-analysis on the short- and long-term mortality rates of elective repair of abdominal aortic aneurysms (AAAs) via the open and endovascular approaches. METHODS: MEDLINE, EMBASE, and Cochrane Central Register of Controlled trials, conference proceeding from major vascular meetings were searched for randomized trials comparing open vs elective endovascular aneurysm repair (EVAR) of AAAs. A random-effects model was used for analysis. Risk ratio (RR) and 95% confidence intervals (CIs) of open vs EVAR were calculated for short- and long-term mortality and reintervention rates. RESULTS: The analysis encompassed four randomized controlled trials with a total of 2783 patients. The open repair group resulted in significantly increased 30-day postoperative all-cause mortality compared with EVAR repair group (3.2% vs 1.2%; RR, 2.81; 95% CI, 1.60-4.94); however, there is no statistical difference in the long-term all-cause mortality between both groups (RR, 0.97; 95% CI, 0.86-1.10). Interestingly, fewer patients underwent reintervention procedures in the open repair group compared with those who had EVAR repair (9.3% vs 18.9%; RR, 0.49; 95% CI, 0.40-0.60), but this finding is doubtful due to the large heterogeneity. Lastly, no statistical difference in long-term mortality rates attributable to cardiovascular disease (CVD), aneurysm related, or stroke were found between the two types of repair. CONCLUSIONS: Results of this meta-analysis demonstrate that the 30-day all-cause mortality rate is higher with open than with EVAR repair; however, there is no statistical difference in the long-term all-cause and cause-specific mortality between both groups. The reintervention rate attributable to procedural complication was higher in the EVAR group. Because of the equivalency of long-term outcomes and the short-term benefits of EVAR, an endovascular-first approach to AAAs can be supported by the meta-analysis.

The SCRAP Rule: The derivation and internal validation of a clinical decision rule for computed tomography of the chest in blunt thoracic trauma.

OBJECTIVE: To derive and internally validate a clinical decision rule that will rule out major thoracic injury in adult blunt trauma patients, reducing the unnecessary use of chest computed tomographic (CT) scans. METHODS: Data were retrospectively obtained from a chart review of all trauma patients presenting to a Canadian tertiary trauma care centre from 2005 to 2008, with those from April 2006 to March 2007 being used for the validation phase. Patients were included if they had an Injury Severity Score > 12 and chest CT at admission or a documented major thoracic injury noted in the trauma database. Patients with penetrating injury, a Glasgow Coma Scale (GCS) score ≤ 8, paralysis, or age < 16 years were excluded. RESULTS: There were 434 patients in the derivation group and 180 in the validation group who met the inclusion criteria. Using recursive partitioning, five clinical variables were found to be particularly predictive of injury. When these variables were normal, no patients had a major thoracic injury (sensitivity 100% [95% CI 98.4-100], specificity 46.9% [95% CI 44.2-46.9], and negative likelihood ratio 0.00 [95% CI 0.00-0.04]). The five variables were oxygen saturation (< 95% on room air or < 98% on any supplemental oxygen), chest radiograph, respiratory rate ≥ 25, chest auscultation, and thoracic palpation (SCRAP). In the validation group, the same five variables had a sensitivity of 100% (95% CI 96.2-100%), a specificity of 44.7% (95% CI 39.5-44.7%), and negative likelihood ratio of 0.00 (95% CI 0.00-0.10). CONCLUSIONS: In major blunt trauma with a GCS score > 8, the SCRAP variables have a 100% sensitivity for major thoracic injury in this retrospective study. These findings need to be prospectively validated prior to use in a clinical setting.

Is Canadian surgical residency training stressful?

BACKGROUND: Surgical residency has the reputation of being arduous and stressful. We sought to determine the stress levels of surgical residents, the major causes of stress and the coping mechanisms used. METHODS: We developed and distributed a survey among surgical residents across Canada. RESULTS: A total of 169 participants responded: 97 (57%) male and 72 (43%) female graduates of Canadian (83%) or foreign (17%) medical schools. In all, 87% reported most of the past year of residency as somewhat stressful to extremely stressful, with time pressure (90%) being the most important stressor, followed by number of working hours (83%), residency program (73%), working conditions (70%), caring for patients (63%) and financial situation (55%). Insufficient sleep and frequent call was the component of residency programs that was most commonly rated as highly stressful (31%). Common coping mechanisms included staying optimistic (86%), engaging in enjoyable activities (83%), consulting others (75%) and exercising (69%). Mental or emotional problems during residency were reported more often by women (p = 0.006), who were also more likely than men to seek help (p = 0.026), but men reported greater financial stress (p = 0.036). Foreign graduates reported greater stress related to working conditions (p < 0.001), residency program (p = 0.002), caring for family members (p = 0.006), discrimination (p < 0.001) and personal and family safety (p < 0.001) than Canadian graduates. CONCLUSION: Time pressure and working hours were the most common stressors overall, and lack of sleep and call frequency were the most stressful components of the residency program. Female sex and graduating from a non-Canadian medical school increased the likelihood of reporting stress in certain areas of residency.

Angiopoietin-1 and angiopoietin-2 as clinically informative prognostic biomarkers of morbidity and mortality in severe sepsis.

OBJECTIVE: To determine the utility of angiopoietin-1 and angiopoietin-2 as potentially novel biomarkers of morbidity and mortality in patients with severe sepsis. DESIGN: Multicenter longitudinal cohort study. SETTING: Three tertiary hospital intensive care units in Hamilton, Ontario, Canada. PATIENTS: A total of 70 patients with severe sepsis were enrolled within 24 hrs of meeting the inclusion criteria for severe sepsis and followed until day 28, hospital discharge, or death. INTERVENTIONS: Clinical data and plasma samples were obtained at intensive care unit admission for all 70 patients and then daily for 1 wk and weekly thereafter for a subset of 43 patients. Levels of angiopoietin-1 and angiopoietin-2 in stored plasma samples were measured and compared with clinical characteristics, including the primary outcomes of 28-day mortality and morbidity measured by the Multiple Organ Dysfunction score. MEASUREMENTS AND MAIN RESULTS: Lower angiopoietin-1 plasma levels (≤ 5.5 ng/mL) at admission were associated with increased likelihood of death (relative risk 0.49 [95% confidence interval of 0.25-0.98], p = .046). Lower angiopoietin-1 levels remained a significant predictor of 28-day mortality in a multiple logistic regression model (adjusted odds ratio of 0.282 [95% confidence interval of 0.086-0.93], p = .037). Analysis of serial data using linear mixed models confirmed that sepsis survivors had higher levels of angiopoietin-1 (p = .012) and lower daily levels of angiopoietin-2 (p = .022) than nonsurvivors. Furthermore, survivors had higher peak angiopoietin-1 levels (median 13 vs. 10 ng/mL, p = .019) and lower nadir angiopoietin-2 levels (median 2.8 vs. 6.2 ng/mL, p = .013) than nonsurvivors. A score incorporating angiopoietin-1 and angiopoietin-2 and three other markers of endothelial activation discriminated with high accuracy between fatal and nonfatal cases (c-index of 0.80 [95% confidence interval of 0.69-0.90], p < .001). Plasma levels of angiopoietin-2 correlated with clinical markers of organ dysfunction and molecular markers of endothelial cell activation. CONCLUSIONS: Angiopoietin-1 levels at admission and both angiopoietin-1 and angiopoietin-2 levels measured serially correlated with 28-day mortality in severe sepsis. Angiopoietin-2 levels also correlated with organ dysfunction/injury and a validated clinical sepsis score. These results suggest the use of angiopoietins as clinically informative biomarkers of disease severity and patient outcome in severe sepsis.

Primary tumor and patient characteristics in breast cancer as predictors of adjuvant therapy regimen: a regression model.

PURPOSE: Adjuvant therapy reduces the risk of recurrence of breast cancer. This study was undertaken to determine characteristics guiding choice of adjuvant therapy. METHODS: A retrospective review was completed of characteristics of patients with breast cancer (stages I-III) at a regional center from 2004 to 2007. Univariate analysis was used to select factors (P < 0.1) for entry into multivariate stepwise logistic regressions. Odds ratios with 95% confidence intervals were calculated. A P value of <0.05 was significant, and comparisons were two-tailed. RESULTS: Model 1 (n = 744) assessed the prescription of any adjuvant regimen (hormonal or chemotherapy). Indicators of choice of any regimen were positive lymph nodes [OR 16.5, CI (6.2, 44.0)], grade [4.0, (2.5, 6.0)], size [3.2, (2.1, 4.6)], PR [0.3, (0.1, 0.6)], and multicentricity [0.2 (0.04, 0.66)]. Model 2 (n = 663) assessed chemotherapy in ER+ patients. Indicators of addition of chemotherapy were stage [8.9 (4.3, 18.6), grade [5.5 (3.1, 9.6)], positive nodes [2.7 (1.1, 6.4)], physician experience [1.1 (1.0, 1.2)], age [0.8 (0.79, 0.86)], and year of treatment [0.8, (0.4, 0.9)]. Model 3 (n = 867) assessed prescription of a more aggressive chemotherapy regimen and indicators were treatment by a breast specialist oncologist [8.6 (1.7, 43.1)], stage [3.6 (2.4, 5.4)], positive nodes [2.6 (1.7, 4.1)], year of treatment [1.5 (1.3, 1.8)], size [1.2 (1.1, 1.4)], age [0.91 (0.89, 0.93)], and PR [0.4 (0.3, 0.6)]. CONCLUSIONS: This study verifies known factors for choice of adjuvant therapy, excludes others thought to be important, and quantifies effects at our center. Further studies are required to compare these models where risk stratification is different.

Plain radiography does not add any clinically significant advantage to multidetector row computed tomography in diagnosing cervical spine injuries in blunt trauma patients.

BACKGROUND: Cervical spine (c-spine) injuries (CSI) in trauma patients are common and potentially catastrophic. Numerous guidelines involving clinical and radiologic criteria have been devised to diagnose such injuries. It is not clear whether using plain X-ray films in addition to helical computed tomography (CT) provides any additional benefit in trauma patients who require radiologic clearance of their c-spine. We hypothesized that three standard X-ray views (anteroposterior, lateral, and odontoid) of the c-spine do not provide clinically significant advantage to Multidetector row CT in diagnosing CSI in trauma patients. METHODS: We reviewed the charts of consecutive adult patients with CSI who were admitted to the Trauma Service at a Level I Trauma Center between January 2001 and December 2004. Patients who had CT plus X-ray at admission were entered into the study. Exclusion criteria were age < or = 16 years, incomplete radiology reports, inadequate plain films, or no CSI identified. RESULTS: A total of 121 patients with diagnosed CSI were included in the study. CT picked up 100% of patients who had a CSI diagnosed on plain films and also detected 47 additional CSI that were missed by plain films. The sensitivity for CT was 100%, whereas that of plain films was 61%. Nine patients with CSI (19.1%) who had false-negative plain films required operative intervention. CONCLUSIONS: Three standard X-ray views of the c-spine provided no clinically significant advantage to Multidetector row CT in diagnosing CSI. Revision of current clinical guidelines on c-spine clearance is recommended.

Laparoscopic surgery for colon cancer: a systematic review.

INTRODUCTION: Colorectal cancer is the second leading cause of cancer-related death in western countries. The objective of this systematic review was to show that laparoscopic-assisted colon resection for cancer is not inferior to open colectomy with respect to cancer survival and perioperative outcomes. METHOD: We performed a comprehensive literature review. Inclusion criteria were adults aged over 16 years with a colon resection for documented colon cancer and randomized controlled trials with laparoscopic- assisted or open resections. We excluded studies that did not document colon cancer recurrence in their article. We assessed data extraction and study quality and performed a quantitative data analysis. RESULTS: Six published and 4 unpublished studies fulfilled our inclusion criteria, with a total of 1262 patients. All primary and secondary outcomes showed good homogeneity, except for morbidity, which was described heterogeneously between the studies. There was no disadvantage to laparoscopic colon resection in any of these primary and secondary outcomes, compared with the conventional open technique. CONCLUSION: The results of this study suggest that, although there is no definitive answer, present evidence indicates that laparoscopic colon cancer resection is as safe and efficacious as the conventional open technique.

Practice guidelines as multipurpose tools: a qualitative study of noninvasive ventilation.

OBJECTIVE: Although practice guidelines for noninvasive ventilation (NIV) for patients with acute respiratory failure (ARF) have the potential to improve processes of care and patient outcomes, clinicians' views about life support technology guidelines are not well understood. The objective was to understand the knowledge about and attitudes toward an NIV guideline for patients with ARF and potential barriers to its use. DESIGN: Qualitative study based on individual, in-depth, semistructured interviews. SETTING: St. Joseph's Healthcare, Hamilton, Ontario. SUBJECTS: Thirty clinicians (six attending physicians, five residents, 12 nurses, and seven respiratory therapists) who used NIV for chronic obstructive pulmonary disease and congestive heart failure patients with ARF, before and after NIV guideline implementation. INTERVENTIONS: We elicited knowledge and attitudes about, behaviors toward, and barriers to our institutional NIV guideline. We transcribed all interviews and analyzed data in triplicate using grounded theory to identify themes and develop a framework for understanding clinicians' views on guidelines. MEASUREMENTS AND MAIN RESULTS: The NIV guideline was perceived to define individual clinical responsibilities, improve clinician comfort with use of technology, increase patient safety, and reduce practice variability. Barriers to guideline use included lack of awareness of the guideline, unclear guideline format and presentation, and reluctance about changing practice. Contrary to previous research, participants in this study did not report that the practice guideline limited clinical autonomy. Clinicians used the guideline variously as an educational resource, to access monitored beds, to avoid clinical conflict, or to leverage professional credibility. CONCLUSIONS: This qualitative study illustrated how the NIV guideline at our institution is understood as a tool that facilitates the multidisciplinary care of patients with ARF. Guideline use may be enhanced through education to improve guideline awareness and increase comfort with recommended practices. Developers should be aware of the role of guidelines for purposes other than bedside decision making for individual patients.

Patients with severe sepsis vary markedly in their ability to generate activated protein C.

Activated protein C (APC) supplementation significantly reduces mortality in patients with severe sepsis, presumably by down-regulating coagulation, inflammation, and apoptosis. In vivo, endogenous APC is generated from protein C (PC) "on demand" in response to elevated thrombin levels. Thrombomodulin and endothelial cell protein C receptor are endothelial receptors required to generate APC endogenously. Since these receptors may be down-regulated in sepsis, we measured plasma markers of APC generation in 32 patients with severe sepsis to determine whether APC generation is impaired and whether markers of APC generation correlate with 28-day mortality. Relative to normals, all patients had elevated F1 + 2 and thrombin-antithrombin complex (TAT) levels (markers of thrombin generation and inhibition, respectively), and 28 of 32 patients had reduced PC levels. In 20 patients, APC levels paralleled elevated F1 + 2 levels, whereas 12 patients had low APC levels despite elevated F1 + 2 levels, suggesting that APC generation is impaired in the latter. No significant differences exist between survivors and nonsurvivors with respect to baseline PC levels, F1 + 2 levels, and APACHE II (acute physiology and chronic health evaluation) scores. Baseline APC levels were higher in survivors (P = .024), and baseline F1 + 2/APC ratios were lower in survivors (P = .047). Larger studies are warranted to establish whether APC generation profiles aid in managing sepsis.