Isolated Intracranial Hypertension as a Presentation of Pediatric Lyme Borreliosis: A Case Report and Literature Review.

BACKGROUND: It is extremely rare for Lyme borreliosis to present solely with features of increased intracranial pressure. The treatment of pediatric Lyme neuroborreliosis with oral versus intravenous antibiotics remains controversial. METHODS: Case report and literature review. RESULTS: A 13-year-old male presented with five days of binocular diplopia, several weeks of headache, and a history of multiple tick bites six weeks prior. His examination showed a left eye abduction deficit and bilateral optic disc edema. Magnetic resonance imaging (MRI) of the brain with contrast showed tortuosity of the optic nerves, prominence of the optic nerve sheaths, and enhancement of the left fifth and bilateral sixth cranial nerves. Lumbar puncture showed an elevated opening pressure and a lymphocytic pleocytosis. Lyme IgM and IgG antibodies were positive in the serum and cerebrospinal fluid. The patient was treated with intravenous ceftriaxone for two days empirically followed by doxycycline by mouth for 19 days. Symptoms began improving after 48 hours. The strabismus resolved after two weeks, and the papilledema improved slowly with complete resolution at six months. CONCLUSIONS: Lyme neuroborreliosis can present as isolated intracranial hypertension in the pediatric population; it can be differentiated from idiopathic intracranial hypertension on MRI, and lumbar puncture and can be confirmed with serum antibody testing. Oral doxycycline can be considered for Lyme neuroborreliosis in children.

Trends in Canadian ophthalmology residency match outcomes.

BACKGROUND: To date, there exists no formal assessment of the competitiveness of the residency match for Canadian ophthalmology programs. The primary objective of this study was to use Canadian Resident Matching Service (CaRMS) data to describe trends in the number of positions, number of applicants and level of competition for the Canadian ophthalmology match. METHODS: The number of positions and the number of applicants for each ophthalmology program were received from CaRMS for each cycle of the match from 2006-2017. The level of competition was calculated by dividing total number of applicants by the total number of positions in any given year. RESULTS: The level of competition was consistently high with a median number of 2.0 applicants per anglophone Canadian Medical Graduate (CMG) position, 2.6 applicants per francophone CMG position and 32.5 applicants per International Medical Graduate (IMG) position. Over the study period, the level of competition decreased for francophone CMG and IMG positions and did not change for anglophone CMG positions. CONCLUSION: Consistently there are a greater number of applicants than positions for Canadian ophthalmology residency programs and therefore CMG applicants should be encouraged to apply to more than one discipline. The trends in the number of residency positions can be used to update supply projections for ophthalmologists and guide human resource planning.

CONTEXTE: À ce jour, il n'existe aucune évaluation officielle de la compétitivité du jumelage des résidents pour les programmes canadiens d'ophtalmologie. L'objectif principal de cette étude était d'utiliser les données du Service canadien de jumelage des résidents (CaRMS) pour décrire les tendances dans le nombre de postes, le nombre de candidats et le niveau de compétitivité pour le jumelage canadien en ophtalmologie. MÉTHODES: Le nombre de postes et le nombre de candidats pour chaque programme d'ophtalmologie ont été reçus du CaRMS pour chaque cycle du jumelage de 2006 à 2017. Le niveau de compétitivité a été calculé en divisant le nombre total de candidats par le nombre total de postes pour chaque année. RÉSULTATS: Le niveau de compétitivité était constamment élevé avec un nombre médian de 2,0 candidats par poste pour les diplômés canadiens en médecine (DCM) anglophones, 2,6 candidats par poste pour les DCM francophones et 32,5 candidats par poste pour les dipl00F4més internationaux en médecine (DIM). Au cours de la période de l'étude, le niveau de compétitivité a diminué pour les postes pour les DCM et DIM francophones et est demeuré inchangé pour les postes pour les DCM anglophones. CONCLUSIONS: On retrouve constamment un plus grand nombre de candidats que de postes pour les programmes canadiens de résidence en ophtalmologie et, par conséquent, les candidats DCM doivent être encouragés à postuler dans plus d'une discipline. Les tendances dans le nombre de postes de résidence peuvent être utilisées pour mettre à jour les prévisions de postes pour les ophtalmologistes et guider la planification des ressources humaines.

Transjugular intrahepatic portosystemic shunt for the treatment of refractory ascites: A population-based cohort study.

Background: Randomized trials have shown that transjugular intrahepatic portosystemic shunt (TIPS) improves control of ascites compared with serial large volume paracentesis (LVP) in patients with refractory ascites. However, the effect of TIPS on liver transplant-free (LTF) survival is controversial. Our objective was to compare TIPS versus serial LVP on LTF survival in the general population of patients with refractory ascites. Methods: This is a retrospective, population-based cohort study using linked administrative health data from Ontario, Canada. Adult patients identified with refractory ascites from January 1, 2008 to December 31, 2016 were included and followed until December 31, 2017. A propensity score was used to match patients treated with serial LVP to those who received TIPS in a 2:1 ratio. LTF survival was evaluated using Kaplan-Meier analysis and Cox proportional hazards regression with TIPS treated as a time-varying exposure. Results: Overall, 4,935 patients with refractory ascites were identified and 488 patients were matched (325 serial LVP, 163 TIPS). The mean age was 58 years, 70% were male, 50% had viral hepatitis, the median model for end-stage liver disease (MELD) score was 12, 13% received liver transplant and the 1-year LTF survival was 72%. After TIPS, 80 patients (49%) had no further requirement for LVP by 6 months and 61 patients (37%) never required a repeat paracentesis. In survival analysis, there was marginally worse LTF survival in patients receiving TIPS (TIPS HR 1.29, 95% CI 1.00-1.67; p = .052). Conclusion: In this population-based study of patients with refractory ascites, TIPS was associated with improved control of ascites but not improved LTF survival.

Association Between Institutional Factors and Long-Term Survival Following Transjugular Intrahepatic Portosystemic Shunt.

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure designed to treat portal hypertension. Hospital teaching status is an institutional factor found to be predictive of outcomes following several complex procedures; however, its impact on outcomes following TIPS is unknown. The aim of this study was to determine the association between hospital teaching status and long-term survival in patients with cirrhosis receiving TIPS. We performed a retrospective population-based cohort study using linked administrative health data from Ontario, Canada. Adult patients with cirrhosis who received TIPS between January 1, 1998, and December 31, 2016, with follow-up until December 31, 2017, were included. Hospital teaching status was defined based on hospital participation in the instruction of medical students and/or resident physicians. Liver transplant-free (LTF) survival was evaluated using Kaplan-Meier analysis, and overall survival was assessed using competing risks regression analysis, which accounted for hospital clustering. A total of 857 unique patients were included (mean age 57.1 years; 69.1% male). The TIPS procedures were performed in teaching hospitals (84.3%) as well as nonteaching hospitals (15.7%). Median LTF survival was more than twice as long for procedures performed in teaching hospitals compared to nonteaching hospitals (2.2 years versus 0.9 year, respectively; P < 0.001). After adjusting for confounders and clustering, hospital teaching status was not independently associated with mortality (nonteaching subdistribution hazard ratio [sHR], 1.32; 95% confidence interval [CI], 0.97-1.81; P = 0.08); however, annual hospital procedure volume was (per unit increase sHR, 0.96; 95% CI, 0.93-0.99; P = 0.003). Conclusion: Hospital procedure volume is associated with long-term survival following TIPS. These results further support the centralization of TIPS to high-volume hospitals to improve long-term outcomes in this population.

Early hospital readmission and survival in patients with cirrhosis: A population-based study.

Background: Readmission in patients with cirrhosis is common. We aimed to determine the association between early hospital readmission and survival in the general population of patients with cirrhosis. Methods: This retrospective cohort study used routinely collected health care data from Ontario. We identified adults with cirrhosis using a validated case definition, and included those with at least one hospital admission between 1992 and 2016 resulting in discharge. Patients were classified into two groups based on timing of readmission after index admission: 1) ≤90 days, or 2) >90 days or no readmission. We described overall survival (OS) 90 days after the index hospitalization by readmission status using Kaplan-Meier curves and the log-rank test. The association between readmission and OS was evaluated using a multivariate Cox proportional hazards regression model. Results: Our study included 115,081 patients. The median OS was shorter in patients readmitted in ≤90 days (4.1 years, IQR 0.9, 13.1) compared with those readmitted in >90 days or not readmitted during the study period (9.6 years, IQR 3.2, 21.9, p <0.001). Adjusting for potential confounders, those readmitted in ≤90 days had a higher hazard of death than those not readmitted (hazard ratio [HR] 1.56, 95% CI 1.53 to 1.59, p <0.001). Conclusions: Early readmission in patients with cirrhosis is a strong predictor of decreased OS. Our results suggest that patients with cirrhosis who have an early readmission should be further studied to determine whether this risk is modifiable. They can also be used to discuss long-term prognosis with patients and family members.

Incidence of cirrhosis in young birth cohorts in Canada from 1997 to 2016: a retrospective population-based study.

BACKGROUND: Recent data show that the prevalence of chronic liver disease and cirrhosis is increasing in adolescents and young adults in the USA. We aimed to describe the epidemiology of cirrhosis using an age-period-cohort approach to define birth-cohort effects on the incidence of cirrhosis in Ontario, Canada. METHODS: We did a retrospective population-based cohort study in Ontario, Canada, using linked administrative health data from the databases of ICES, formerly the Institute for Clinical Evaluative Sciences. Patients aged at least 18 years with cirrhosis were identified by use of a validated case definition (defined as at least one inpatient or outpatient visit with a diagnosis of cirrhosis or oesophageal varices without bleeding). We calculated annual standardised incidence and prevalence in the general population. We used an age-period-cohort approach to assess the independent association between birth cohort and incidence of cirrhosis in men and women. FINDINGS: Between Jan 1, 1997, and Dec 31, 2016, 165 979 individuals with cirrhosis were identified. The age-standardised incidence increased over the study (from 70·6 per 100 000 person-years in 1997 to 89·6 per 100 000 person-years in 2016) as did the prevalence (from 0·42% in 1997 to 0·84% in 2016). Using age-period-cohort modelling and the median birth year as the reference, the incidence of cirrhosis was higher in participants born in 1980 (incidence rate ratio 1·55, 95% CI 1·50-1·59, p<0·0001); and in participants born in 1990 (2·16, 95% CI 2·06-2·27, p<0·0001) compared with a person of the same age born in 1951. The increase in incidence of cirrhosis was greater in women than in men (eg, women born in 1990: 2·60, 95% CI 2·41-2·79; men born in 1990: 1·98, 1·85-2·12). INTERPRETATION: The incidence of cirrhosis has increased over the past two decades, and more so in younger birth cohorts and in women. Future studies to define the cause and natural history of cirrhosis in these groups are essential to develop strategies that could reverse these trends for future generations. FUNDING: Southeastern Ontario Academic Medical Association New Clinician Scientist Award; American Association for the Study of Liver Disease (AASLD) Foundation Clinical, Translational and Outcomes Research Award in Liver Disease (JAF).

Operative Stabilization of Flail Chest Injuries Reduces Mortality to That of Stable Chest Wall Injuries.

OBJECTIVE: To determine the prevalence, management and outcomes of patients with flail chest injuries, compared to patients without flail chest injuries (single rib fractures and multiple rib fractures without a flail segment). DESIGN: Retrospective cohort study. SETTING: Ontario, Canada. PARTICIPANTS: Ontario residents over the age of 16 years who had been admitted to hospital with a chest wall injury from 2004 to 2015 were identified using administrative health care databases. MAIN OUTCOME MEASUREMENTS: Outcomes included treatment modalities such as rate of surgical repair, days on mechanical ventilation, days in the intensive care unit, days in hospital, rate of chest tube placement; and rates of complication, including pneumonia, tracheostomy, readmission, and death. RESULTS: In total 117,204 patients with fractures of the chest wall were identified. Of the entire cohort, 1.5% of them had a flail chest injury, 41% had multiple rib fractures, and 58% had single rib fractures. Patients with flail chest injuries had significantly worse outcomes compared to patients with multiple rib fractures in all categories (P < 0.0001). Similarly, patients with multiple rib fractures had significantly worst outcomes compared with patients with single rib fractures (P < 0.0001). Only 4.5% of patients with flail chest injuries were treated surgically, however, the number increased from 1% before 2010 to 10% after 2010 (P < 0.0001). After adjustment for potential confounders, patients with flail chest injuries treated surgically had a reduced risk of early mortality compared to those treated nonoperatively (OR 0.16, P = 0.019). CONCLUSIONS: Surgical stabilization of flail chest injuries has increased significantly in recent years. The results of this study provide preliminary evidence that the increasing rate of surgical intervention may be warranted by reducing mortality. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

General Health Status After Nonoperative Versus Operative Treatment for Acute, Complete Acromioclavicular Joint Dislocation: Results of a Multicenter Randomized Clinical Trial.

OBJECTIVE: To assess the general health status of patients after nonoperative (Non-op) versus operative (OP) treatment for acromioclavicular (AC) joint dislocations. DESIGN: Multicenter randomized controlled clinical trial conducted in 11 Canadian trauma centers. A total of 83 patients with acute (≤28 days old), complete (Rockwood grades III, IV, or V) dislocations of the AC joint were included in this study. INTERVENTION: Participants were randomized to Non-op treatment or OP treatment with hook plate fixation. MAIN OUTCOME MEASURES: Physical and mental health were evaluated using the Short Form-36 version 2 survey at baseline, 6 weeks, 3 months, 6 months, 1 year, and 2 years. RESULTS: In the Non-op group, 33 patients had grade III injuries, 3 patients had grade IV injuries, 5 patients had grade V injuries, and the injury grade was unknown for 2 patients. In the OP group, 37 patients had grade III injuries and 3 patients had grade V injuries (no difference in Type IV and V Non-op vs. OP, P = 0.12). Fifty-eight percent of patients in the Non-op group and 63% of patients in the OP group completed the 2-year follow-up. The Non-op group had better physical health scores than the OP group at 3 months after treatment (52.13 vs. 45.75, P < 0.001). There were no significant differences between the physical health scores of the 2 groups at any other point (6 weeks, 45.81 vs. 41.21, P = 0.03; 6 months, 54.50 vs. 51.61, P = 0.02; 1 year, 55.10 vs. 53.96, P = 0.37; 2 years, 55.24 vs. 57.13, P = 0.17). Mental health scores were similar between the Non-op and OP groups at each follow-up interval (6 weeks, 49.29 vs. 51.27, P = 0.49; 3 months, 52.24 vs. 55.84, P = 0.13; 6 months, 54.89 vs. 55.05, P = 0.93; 1 year, 55.35 vs. 56.72, P = 0.35; 2 years, 56.41 vs. 55.43, P = 0.56). In both treatment groups, the preinjury physical and mental health scores were better than published population norms before declining to a level equal to or below the norm after dislocation. Physical health recovered to a level above the norm at 6 months in the Non-op group and 2 years in the OP group. Mental health recovered at 3 months in the OP group and 6 months in the Non-op group. CONCLUSIONS: Hook plate fixation does not lead to improved general health status compared with Non-op treatment. Presently, there is no definitive evidence that hook plate fixation is superior to Non-op treatment for acute complete AC joint dislocations. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.