Patient and public involvement in international research: Perspectives of a team of researchers from six countries on collaborating with people with lived experiences of dementia and end-of-life.

BACKGROUND: Patient and public involvement (PPI) is a critical priority in research, policy, academia and advocacy organizations. PPI in dementia research is gaining momentum. However, these efforts are missing in international projects aimed at those living with advanced dementia in long-term care (LTC) homes. Additional complexities can arise in enacting PPI within the context of integration of a palliative approach to care and experiences around end-of-life in (EOL) dementia. The mySupport study involved implementing the Family Carer Decision Support (FCDS) intervention for care partners of those living with advanced dementia in LTC in six countries. RESEARCH DESIGN AND OBJECTIVE: An interpretive description study was conducted to explore the perspectives of international researchers from six countries on engaging people with lived experiences of dementia and EOL care in research processes. The findings from this study informed the development of a PPI strategy and a subsequent toolkit for the FCDS intervention. FINDINGS: Thirty-eight interviews were completed with project researchers: 12 from the United Kingdom, 8 from Canada, 7 from Ireland, 4 each from Italy and The Netherlands and 3 from the Czech Republic. Four broad themes describe international researchers' perspectives on advancing methods of engagement for people with lived experiences of dementia and EOL in international PPI activities: (1) Groundwork to engage in research; (2) planning for research activities is key; (3) focus on meaningful engagement and (4) having foresight for practical issues shaping PPI. DISCUSSION AND IMPLICATIONS: International projects that involve PPI can present many sources of challenges. The findings in this study highlight important considerations for foundational work for incorporating PPI in international projects. Learning from world leaders and those with lived experiences in various regions can be insightful and help share tools and resources. PATIENT OR PUBLIC CONTRIBUTION: PPI was envisioned as a critical part of conducting the mySupport study. The findings from this study informed the development of a PPI strategy and an international Strategic Guiding Council that included family carers of those living with advanced dementia in LTC homes in six countries. This manuscript focused on the perspectives of researchers on their engagement with people with lived experiences of dementia and EOL. The perspectives of persons with lived experiences on engaging in the mySupport research study will be reported in a forthcoming manuscript.

Impact of pre-operative abdominal MRI on survival for patients with resected pancreatic carcinoma: a population-based study.

Background: This study determined the impact of pre-operative abdominal MRI on all-cause mortality for patients with resected PDAC. Methods: All adult (≥18 years) PDAC patients who underwent pancreatectomy between January 2011 and December 2022 in Ontario, Canada, were identified for this population-based cohort study (ICD-O-3 codes: C250, C251, C252, C253, C257, C258). Patient demographics, comorbidities, PDAC stage, medical and surgical management, and survival data were sourced from multiple linked provincial administrative databases at ICES. All-cause mortality was compared between patients with and without a pre-operative abdominal MRI after controlling for multiple covariates. Findings: A cohort of 4579 patients consisted of 2432 men (53.1%) and 2147 women (46.9%) with a mean age of 65.2 years (standard deviation: 11.2 years); 2998 (65.5%) died while 1581 (34.5%) survived. Median follow-up duration post-resection was 22.4 months (interquartile range: 10.8-48.8 months), and median survival post-pancreatectomy was 25.9 months (95% confidence interval [95% CI]: 24.8, 27.5). Patients who underwent a pre-operative abdominal MRI had a median survival of 33.1 months (95% CI: 30.7, 37.2) compared to 21.1 months (95% CI: 19.8, 22.6) for all others. A total of 2354/4579 (51.4%) patients underwent a pre-operative abdominal MRI, which was associated with a 17.2% (95% CI: 11.0, 23.1) decrease in the rate of all-cause mortality, with an adjusted hazard ratio (aHR) of 0.828 (95% CI: 0.769, 0.890). Interpretation: Pre-operative abdominal MRI was associated with improved overall survival for PDAC patients who underwent pancreatectomy, possibly due to better detection of liver metastases than CT. Funding: Northern Ontario Academic Medicine Association (NOAMA) Clinical Innovation Fund.

Venous Thromboembolism in Surgically Treated Esophageal Cancer Patients: A Provincial Population-Based Study.

Objective Venous thromboembolism (VTE) is a major cause of morbidity and mortality in surgical patients. Surgery for esophageal cancer carries a high risk of VTE. This study identifies the risk factors and associated mortality of thrombotic complications among patients undergoing esophageal cancer surgery. Methods All patients in the province of Ontario undergoing esophageal cancer surgery from 2007 to 2017 were identified. Logistic regression identified VTE risk factors at 90 days and 1 year postoperatively. A flexible parametric survival analysis compared mortality and survival up to 5 years after surgery for patients with and without a postoperative VTE. Results Overall 9,876 patients with esophageal cancer were identified; 2,536 (25.7%) underwent surgery. VTE incidence at 90 days and 1 year postoperatively were 4.1 and 6.3%, respectively. Patient factors including age, sex, performance status, and comorbidities were not associated with VTE risk. VTE risk peaked at 1 month after surgery, with a subsequent decline, plateauing after 6 months. Adenocarcinoma was strongly associated with VTE risk compared with squamous cell carcinoma (SCC) (odds ratio [OR] 2.53, 95% confidence interval [CI] 1.38-4.63, p = 0.003). VTE risk decreased with adjuvant chemotherapy (OR = 0.58, 95% CI 0.36-0.94, p = 0.028). Postoperative VTE was associated with decreased survival at 1 and 5 years (hazard ratio = 1.57, 95% CI 1.23-2.00, p < 0.001). Conclusion Esophageal cancer patients with postoperative VTE have worse long-term survival compared with those without thrombotic complications. Adenocarcinoma carries a higher VTE risk compared with SCC. Strategies to reduce VTE risk should be considered to reduce the negative impacts on survival conferred by thrombotic events.

Impact of the COVID-19 pandemic on non-small-cell lung cancer pathologic stage and presentation.

BACKGROUND: It is believed that the cessation of normative cancer care services during the COVID-19 pandemic may be resulting in pathologic upstaging and higher long-term mortality rates. We aimed to understand how the pandemic has affected our patients diagnosed with non-small-cell lung cancer (NSCLC). METHODS: We conducted a single-centre retrospective analysis to assess how the COVID-19 pandemic has affected patient referrals, pathologic stage of NSCLC, mortality rates and surgical procedures at our cancer care centre in Ontario, Canada. At our centre, physicians advocated for and followed recommendations that operations in cancer patients should be among the last procedures to be delayed. Patients were included if they were aged 18 years or older, were not receiving palliative care, and had been screened, diagnosed and treated for NSCLC (primary tumours). We compared outcomes between a prepandemic period (January 2019 to February 2020) and a period during the pandemic (March 2020 to February 2021). RESULTS: A total of 695 patients were included for statistical analysis, of whom 650 underwent surgery. There was no statistically significant difference in any of the outcomes of interest between patients seen before (n = 330) and during (n = 320) the pandemic. CONCLUSION: Cancer care services at our centre were maintained during the COVID-19 pandemic, and potential adverse effects on prognosis and survival that have been seen in other countries were avoided. The results inform health care providers how the effects of future pandemics can be blunted by using proactive preservative strategies and surgeon advocacy.

Survival effects of time to surgery for Stage I lung cancer: A population-based study.

OBJECTIVES: To examine the impact of time to surgery (TTS) on survival among patients with stage I non-small cell lung cancer (NSCLC). METHODS: All patients in the Canadian province of Ontario with stage I NSCLC from 2007 to 2017 were included. A logistic regression identified the predictors of TTS and a flexible parametric model estimated survival rates based on TTS. RESULTS: Over the study period, 6428 patients with stage I NSCLC undergoing surgical resection were identified, of which 62.5% had TTS >28 days. Less than half these patients (40.8%) underwent open resection, with 19.3% undergoing open sublobar and 21.5% undergoing open lobectomy. Adenocarcinoma and squamous cell carcinoma tumors accounted for 33.3% and 22.0% of cases, respectively. The majority (85.6%) of patients lived in urban areas within 50 km of a regional cancer center (76.9%). Variables that predicted TTS >28 days include age and extent of resection. After adjustment for VATS vs. open resection, age, sex, frailty, year of diagnosis, histology of tumor, and extent of resection, the hazard ratio for TTS >28 days was 1.26 (95%CI:1.13-1.40), indicating a 26% increased risk of all-cause mortality (p < 0.0001). The highest 5-year survival was observed for patients with stage I disease undergoing resection within 28 days. CONCLUSIONS: The present study found age and extent of resection to be associated with increased TTS. Importantly, patients with TTS >28 days had reduced long-term survival.

The Effect of Major and Minor Complications After Lung Surgery on Length of Stay and Readmission.

The effect of post-operative adverse events (AEs) on patient outcomes such as length of stay (LOS) and readmissions to hospital is not completely understood. This study examined the severity of AEs from a high-volume thoracic surgery center and its effect on the patient postoperative LOS and readmissions to hospital. This study includes patients who underwent an elective lung resection between September 2018 and January 2020. The AEs were grouped as no AEs, 1 or more minor AEs, and 1 or more major AEs. The effects of the AEs on patient LOS and readmissions were examined using a survival analysis and logistic regression, respectively, while adjusting for the other demographic or clinical variables. Among 488 patients who underwent lung surgery, (Wedge resection [n = 100], Segmentectomy [n = 51], Lobectomy [n = 310], Bilobectomy [n = 10], or Pneumonectomy [n = 17]) for either primary (n = 440) or secondary (n = 48) lung cancers, 179 (36.7%) patients had no AEs, 264 (54.1%) patients had 1 or more minor AEs, and 45 (9.2%) patients had 1 or more major AEs. Overall, the median of LOS was 3 days which varied significantly between AE groups; 2, 4, and 8 days among the no, minor, and major AE groups, respectively. In addition, type of surgery, renal disease (urinary tract infection [UTI], urinary retention, or acute kidney injury), and ASA (American Society of Anesthesiology) score were significant predictors of LOS. Finally, 58 (11.9%) patients were readmitted. Readmission was significantly associated with AE group (P = 0.016). No other variable could significantly predict patient readmission. Overall, postoperative AEs significantly affect the postoperative LOS and readmission rates.

Venous Thromboembolism in Surgical Lung Cancer Patients: A Provincial Population-Based Study.

BACKGROUND: Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in surgical patients. Thoracic surgery patients are at increased risk due to inherent technical and disease-specific factors. Other surgical specialties have adopted postdischarge extended VTE prophylaxis; however evidence is scarce in thoracic surgery. This study aims to identify VTE risk factors and associated mortality among surgical lung cancer patients. METHODS: Using administrative databases all patients in the province of Ontario undergoing lung cancer surgery from 2007 to 2017 were identified. Logistic regression identified VTE risk factors at 90 days and 1 year postoperatively. A flexible parametric survival analysis compared mortality and survival up to 5 years after surgery between patients with and without VTE. RESULTS: Of 65,513 patients diagnosed with lung cancer, 12,626 (19.3%) underwent surgery. VTE incidence at 90 days and 1 year postoperatively was 1.3% and 2.7%, respectively. Open and more extensive resections carried an increased VTE risk, with pneumonectomy conferring the highest risk (odds ratio, 2.36; P < .001). Stage III and IV disease carried a 3.19 and 4.97 times higher risk of VTE, respectively, compared with stage I (P < .001). The hazard ratio for mortality at 1 year for patients with VTE was 2.01 (P < .001). Patients suffering a VTE had reduced 5-year survival. CONCLUSIONS: Patients undergoing pneumonectomy and those with advanced stage have an increased VTE risk. Patients suffering a thrombotic complication have an increased risk of mortality and decreased 5-year survival. Accordingly strategies to reduce VTE risk should be considered in patients undergoing high-risk operations to reduce the mortality of VTEs.

Efficacy of Early (≤ 24 Hours), Late (25-72 Hours), and Delayed (>72 Hours) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades C and D Acute Traumatic Central Cord Syndrome Caused by Spinal Stenosis.

The therapeutic significance of timing of decompression in acute traumatic central cord syndrome (ATCCS) caused by spinal stenosis remains unsettled. We retrospectively examined a homogenous cohort of patients with ATCCS and magnetic resonance imaging (MRI) evidence of post-treatment spinal cord decompression to determine whether timing of decompression played a significant role in American Spinal Injury Association (ASIA) motor score (AMS) 6 months following trauma. We used the t test, analysis of variance, Pearson correlation coefficient, and multiple regression for statistical analysis. During a 19-year period, 101 patients with ATCCS, admission ASIA Impairment Scale (AIS) grades C and D, and an admission AMS of ≤95 were surgically decompressed. Twenty-four of 101 patients had an AIS grade C injury. Eighty-two patients were males, the mean age of patients was 57.9 years, and 69 patients had had a fall. AMS at admission was 68.3 (standard deviation [SD] 23.4); upper extremities (UE) 28.6 (SD 14.7), and lower extremities (LE) 41.0 (SD 12.7). AMS at the latest follow-up was 93.1 (SD 12.8), UE 45.4 (SD 7.6), and LE 47.9 (SD 6.6). Mean number of stenotic segments was 2.8, mean canal compromise was 38.6% (SD 8.7%), and mean intramedullary lesion length (IMLL) was 23 mm (SD 11). Thirty-six of 101 patients had decompression within 24 h, 38 patients had decompression between 25 and 72 h, and 27 patients had decompression >72 h after injury. Demographics, etiology, AMS, AIS grade, morphometry, lesion length, surgical technique, steroid protocol, and follow-up AMS were not statistically different between groups treated at different times. We analyzed the effect size of timing of decompression categorically and in a continuous fashion. There was no significant effect of the timing of decompression on follow-up AMS. Only AMS at admission determined AMS at follow-up (coefficient = 0.31; 95% confidence interval [CI]:0.21; p = 0.001). We conclude that timing of decompression in ATCCS caused by spinal stenosis has little bearing on ultimate AMS at follow-up.

Wait times in the management of non-small cell lung carcinoma before, during and after regionalization of lung cancer care: a high-resolution analysis.

Background: Timeliness can have a substantial effect on treatment outcomes, prognosis and quality of life for patients with lung cancer. We sought to evaluate changes in wait times for patients with non-small cell lung carcinoma (NSCLC) and to identify bottlenecks in cancer care. Methods: We included patients who received treatment with curative intent or palliative treatment for NSCLC, diagnosed through mediastinal staging by a thoracic surgeon. Data were collected from 3 cohorts over 3 time periods: before the regionalization of lung cancer care (2005-2007, C1), immediately postregionalization (2011-2013, C2) and 5 years after regionalization (2016-2017, C3). Total wait time and delays along treatment pathways were compared across cohorts using multivariate Cox proportionality models. Results: Our total sample size was 299 patients. Overall, there was no significant difference in total wait time among the 3 cohorts. However, wait time from symptom onset to first physician visit significantly increased in C3 compared with C2 (hazard ratio [HR] 0.41, p < 0.01) and C1 (HR 0.43, p < 0.01). Time from first physician visit to computed tomography (CT) scan significantly decreased in C3 compared with C2 (HR 1.54, p < 0.01). Time from abnormal CT scan to first surgeon visit also significantly decreased in C2 (HR 1.43, p < 0.01) and C3 (HR 4.47, p < 0.01) compared with C1, and between C3 and C2 (HR 2.67, p < 0.01). In contrast, time from first surgeon visit to completion of staging significantly increased in C2 (HR 0.36, p < 0.01) and C3 (HR 0.24, p < 0.01) compared with C1, as well as between C3 and C2 (HR 0.60, p < 0.01). Time to first treatment after completion of staging was significantly shorter for C3 than C1 (HR 1.58, p < 0.01). Conclusion: Trends toward a reduction in wait time are evident 5 years after the regionalization of lung cancer care, primarily led by shorter wait times for CT scans and thoracic surgeon consults. However, wait times can further be reduced by addressing delays in staging completion and patient and provider education to identify the early signs of NSCLC.

Contexte: La rapidité d'intervention peut avoir un effet considérable sur l'issue du traitement, le pronostic et la qualité de vie des patients atteints d'un cancer du poumon. Nous avons voulu évaluer les changements des temps d'attente des patients ayant un carcinome pulmonaire non à petites cellules et recenser les obstacles aux soins oncologiques. Méthodes: Nous avons inclus des patients ayant reçu un traitement curatif ou palliatif pour un carcinome pulmonaire non à petites cellules diagnostiqué par stadification de lésions médiastinales par un chirurgien thoracique. Les données ont été recueillies auprès de 3 cohortes, à 3 moments : avant la régionalisation des soins oncologiques (2005­2007; C1), immédiatement après la régionalisation (2011­2013; C2) et 5 ans après la régionalisation (2016­2017; C3). Le temps d'attente total et les délais au cours du processus de traitement des cohortes ont été comparés au moyen de modèles à risques proportionnels de Cox multivariés. Résultats: Au total, l'échantillon comptait 299 patients. Dans l'ensemble, aucune différence statistiquement significative n'a été observée entre les 3 cohortes pour ce qui est du temps d'attente total. Cependant, la C3 présentait un temps d'attente entre l'apparition des symptômes et la première consultation médicale significativement plus long que la C2 (rapport de risque [RR] 0,41; p < 0,01) et que la C1 (RR 0,43; p < 0,01). Le temps d'attente entre la première consultation médicale et la tomodensitométrie (TDM) était par contre significativement plus court dans la C3 que dans la C2 (RR 1,54; p < 0,01). Le délai entre l'obtention d'un résultat anormal à la TDM et la première consultation chirurgicale était également significativement moindre dans la C2 (RR 1,43; p < 0,01) et dans la C3 (RR 4,47; p < 0,01) que dans la C1, mais aussi entre la C3 et la C2 (RR 2,67; p < 0,01). À l'inverse, le temps écoulé entre la première consultation chirurgicale et la fin de la stadification était significativement plus long dans la C2 (RR 0,36; p < 0,01) et la C3 (RR 0,24; p < 0,01) que dans la C1; il en était également ainsi entre la C3 et la C2 (RR 0,60; p < 0,01). Enfin, le délai entre le premier traitement et la fin de la stadification était significativement plus court dans la C3 que dans la C1 (RR 1,58; p < 0,01). Conclusion: Cinq ans après la régionalisation des soins oncologiques, on peut observer une réduction des temps d'attente, principalement une diminution du temps d'attente pour une TDM ou une consultation chirurgicale. Les temps d'attente pourraient être davantage raccourcis par une réduction des délais dans la stadification, ainsi que par la sensibilisation des patients et des fournisseurs de soins à l'égard de la reconnaissance des signes précoces de carcinome pulmonaire non à petites cellules.

Uptake and survival effects of minimally invasive surgery for lung cancer: A population-based study.

INTRODUCTION: Despite growing evidence supporting the safety of minimally invasive surgery (MIS) in the treatment of lung cancer, its uptake is still variable and its outcomes debated. This study examines the factors associated with MIS uptake and its effects on survival in patients with non-small cell lung cancer (NSCLC). METHODS: All patients in the Canadian province of Ontario with early stage NSCLC (stage I/II) from 2007 to 2017 were included. A logistic regression identified the predictors of MIS uptake, and a flexible parametric model was used to estimate survival rates based on MIS versus open resection. RESULTS: In total, 8,988 patients underwent surgical resection; 53.6% had MIS. Year of diagnosis was associated with MIS uptake (OR = 1.33, p < 0.001); patients in later years were more likely to receive MIS. Rurality was a significant predictor of MIS, though distance from nearest regional cancer center did not predict MIS utilization. Patients with stage II disease were less likely to receive MIS compared to those with stage I disease (OR = 0.44, p < 0.001). MIS had a significantly higher 5-year survival compared to open resection for stage I and II disease. Patients >70 years had the greatest 5-year survival benefit from MIS. CONCLUSIONS: We observed a substantial long-term survival benefit in patients undergoing MIS for early stage NSCLC. This difference was most pronounced in the oldest age group. These findings support the use of MIS in the treatment of lung cancer and challenge the notion that MIS compromises oncologic outcomes.

Treatment Modality and Trends in Survival for Gallbladder Cancer: a Population-Based Study.

PURPOSE: There are only a few reports on the treatment-based survival of gallbladder cancer (GBC). The primary objective of this study was to examine the change in treatment modality and the related trends in the survival of GBC. METHODS: This study includes all cases of primary GBC diagnosed in the province of Ontario, Canada, from January 2007 to December 2015 with known disease stage. Treatment modalities were classified as no treatment, radiation or chemotherapy, and surgical resection. We examined the association between surgical resection and demographics and tumor characteristics and estimated the trends in survival based on treatment modality. RESULTS: In total, 564 patients with GBC were identified, of which 374 (66.3%) were female. Although there were no significant trends in treatment modalities over the study period (p = 0.276), survival rates improved for all treatment modalities over time. There was a 35% increase in 5-year survival for the surgical resection group from 2007 to 2015. For patients with stage I-II disease, the 5-year survival rate increased 40% over time. The highest 5-year survival was observed for the surgical resection group in patients with stage I-II disease (0.533 (95% CI, 0.514-0.552)) while the average 5-year survival rate for all patients over the study period was 0.247 (95% CI, 0.228-0.266). CONCLUSIONS: Most cases of GBC continue to be diagnosed in the late stage. Five-year survival for the surgical resection group has markedly improved over time, specifically for patients with stage I-II disease which increased from 30% in 2007 to 70% in 2015.

Change in treatment modality and trends in survival among stage I non-small cell lung cancer patients: a population-based study.

BACKGROUND: A number of treatment modalities are available to patients with early non-small cell lung cancer (NSCLC) but there is inconsistency regarding their effects on survival. The associated survival of each treatment modality is crucial for patients in making informed treatment decisions. We aimed to examine the change in treatment modality and trends in survival for patients with stage I NSCLC and assess the association between treatment modality and survival. METHODS: All patients diagnosed with stage I NSCLC in the Canadian province of Ontario between 2007 and 2015 were included in this population-based study. We used a flexible parametric model to estimate the trends in survival rate. RESULTS: Overall, 11,910 patients were identified of which 7,478 patients (62.8%) received surgical resection and 2,652 (22.3%) radiation only. The proportion of patients who received radiation only increased from 13.2% in 2007 to 28.0% in 2015 (P-for-trend <0.001). Survival increased for all treatment modalities from 2007 to 2015. The increase in 5-year survival was more than 20% for all surgical groups and more than 35% for radiation-only group. CONCLUSIONS: The survival of patients with stage I NSCLC increased for all treatment modalities over the study period, most distinctly in elderly patients, which coincided with a rise in the use of radiation therapy. While surgical resection was associated with the best chance of 5-year survival, radiation therapy is a safe and effective treatment for medically inoperable patients with early disease.

Uptake of minimally invasive surgery for early stage colorectal cancer and its effect on survival: A population-based study.

PURPOSE: The uptake of minimally invasive surgery (MIS) for colorectal cancer (CRC) varies between jurisdictions. We aimed to identify the factors associated with the uptake of MIS for early-stage CRC and its oncologic outcomes in the Canadian province of Ontario. METHODS: This study includes all patients with CRC in Ontario from 2007 to 2017. A logistic regression analysis was used to identify the predictors of MIS and a flexible parametric survival model to estimate survival rates based on MIS versus open surgery. RESULTS: In total, 14,675 patients with CRC were identified of which 29.5% had MIS resections. The likelihood of undergoing MIS decreased with age, disease stage, and distance to the regional cancer center, and increased with year of diagnosis. The likelihood of mortality for MIS was significantly lower compared to open surgery (p < 0.001). In terms of survival, MIS was most beneficial to older patients with stage II disease, despite their lower likelihood of receiving MIS. CONCLUSIONS: Despite the lower uptake of MIS among older patients and patients with stage II disease, these patients had the greatest long-term survival benefit from MIS. This suggests further use of laparoscopy to patient populations that are often excluded.

Screening and Intervention Practices for Alcohol Use by Pregnant Women and Women of Childbearing Age: Results of a Canadian Survey.

OBJECTIVE: To determine health care providers' familiarity with and use of the Society of Obstetricians and Gynaecologists of Canada's (SOGC's) 2010 Alcohol Use and Pregnancy Consensus Clinical Guidelines and to identify barriers and enablers that affected guideline uptake. METHODS: We conducted an online pan-Canadian survey of midwives, obstetricians, family physicians, and nurses. The survey was divided into five sections: knowledge, SOGC guidelines, screening and intervention practices, attitudes and beliefs, and demographic information. RESULTS: Just over half of the 588 respondents who provided care to pregnant women or to women of childbearing age were familiar with and used the guidelines. Most respondents screened for alcohol use by asking women about alcohol consumption, but relatively few used a screening questionnaire. Approximately two-thirds of respondents provided brief intervention and referral to harm reduction or treatment services. Enablers of guideline adherence included knowledge about the risks of alcohol in pregnancy, perceived responsibility to identify and address at-risk drinking, and a belief that women are motivated to reduce their alcohol consumption if pregnant or planning to become pregnant. Lack of confidence in ability to use screening questionnaires and to provide brief intervention, as well as a lack of belief in the effectiveness of both practices, were barriers to use. CONCLUSION: Strategies are needed to improve familiarity with and uptake of the Alcohol Use and Pregnancy Consensus Clinical Guidelines. Particular attention should be given to education and training regarding the use of validated screening questionnaires and brief intervention practices.

Efficacy of Ultra-Early (< 12 h), Early (12-24 h), and Late (>24-138.5 h) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades A, B, and C Cervical Spinal Cord Injury.

In cervical traumatic spinal cord injury (TSCI), the therapeutic effect of timing of surgery on neurological recovery remains uncertain. Additionally, the relationship between extent of decompression, imaging biomarker evidence of injury severity, and outcome is incompletely understood. We investigated the effect of timing of decompression on long-term neurological outcome in patients with complete spinal cord decompression confirmed on postoperative magnetic resonance imaging (MRI). American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade conversion was determined in 72 AIS grades A, B, and C patients 6 months after confirmed decompression. Thirty-two patients underwent decompressive surgery ultra-early (< 12 h), 25 underwent decompressive surgery early (12-24 h), and 15 underwent decompressive surgery late (> 24-138.5 h) after injury. Age, gender, injury mechanism, intramedullary lesion length (IMLL) on MRI, admission ASIA motor score, and surgical technique were not statistically different among groups. Motor complete patients (p = 0.009) and those with fracture dislocations (p = 0.01) tended to be operated on earlier. Improvement of one grade or more was present in 55.6% of AIS grade A, 60.9% of AIS grade B, and 86.4% of AIS grade C patients. Admission AIS motor score (p = 0.0004) and pre-operative IMLL (p = 0.00001) were the strongest predictors of neurological outcome. AIS grade improvement occurred in 65.6%, 60%, and 80% of patients who underwent decompression ultra-early, early, and late, respectively (p = 0.424). Multiple regression analysis revealed that IMLL was the only significant variable predictive of AIS grade conversion to a better grade (odds ratio, 0.908; confidence interval [CI], 0.862-0.957; p < 0.001). We conclude that in patients with post-operative MRI confirmation of complete decompression following cervical TSCI, pre-operative IMLL, not the timing of surgery, determines long-term neurological outcome.

Trends in Survival Based on Treatment Modality in Non-Small Cell Lung Cancer Patients: A Population-Based Study.

Objectives: We examined the trends in survival based on treatment modality among non-small cell lung cancer (NSCLC) patients in the province of Ontario, Canada, from 2007 to 2015. Methods: We investigated the trends in survival based on treatment modality. Results: Among 56,417 identified patients, the mean age at diagnosis was 70.1 years (SD = 10.7). Treatment modalities varied significantly over time (p<.001). Overall, 23.0% of patients received surgical treatments. We observed more than 20% increase in five-year survival rates for all surgical groups over time. Conclusions: Patients undergoing sublobar/lobar resections had higher survival rate.

Trends in survival based on treatment modality for esophageal cancer: a population-based study.

OBJECTIVES: The primary objective was to examine the trends in treatment modalities and the respective survival rates for esophageal cancer in the province of Ontario, Canada. METHODS: This is a population-based study of all esophageal cancer cases diagnosed in Ontario between 2007 and 2015, including squamous cell carcinoma and adenocarcinoma, with known disease stage. Other characteristics include sex, age, date of diagnosis, and treatment modalities. Treatment modalities were classified as no-treatment, radiation only or chemotherapy only, chemoradiation, and surgical resection. RESULTS: In total, 2572 patients were identified with esophageal cancer from 2007 to 2015, of which 2014 (78.3%) were male. The mean age at diagnosis was 66.6 (SD = 11.7) years. Survival rate increased over time in patients who underwent chemoradiation or surgical resection but remained unchanged for the radiation-only or chemotherapy-only group and decreased for the no-treatment group. Survival considerably improved (15-20%) for patients with stages I-III disease. CONCLUSIONS: The positive trends in the survival rate for esophageal patients could be due to adoption of multimodal therapy. Despite a lower proportion of advanced disease among patients over 80, they received less curative treatments compared with other age groups. Further studies are required to identify strategies to maximize survival for patients with stage IV disease, and patients 80 years and older.

Condition-Specific Pamphlets to Improve End-of-life Communication in Long-term Care: Staff Perceptions on Usability and Use.

OBJECTIVES: This article reports findings on the usability and staff use of 5 condition- specific pamphlets of high prevalence in long-term care (LTC): dementia, heart failure, chronic obstructive pulmonary disease, renal failure, and frailty. The pamphlets were created in response to residents', families', and staff's recommendations for activating early reflections and communication about end-of-life care. DESIGN: A mixed-method (qualitative and quantitative) survey design was used. Step 1 collected survey data on the usability of the pamphlets. Step 2 collected survey data on pamphlet use. SETTINGS AND PARTICIPANTS: Two nurses with specialized palliative care training, 2 resident/family representatives, 10 condition-specific specialists, and 33 LTC palliative leads reviewed the pamphlets for usability prior to distribution. A total of 178 LTC home staff in 4 participating LTC homes reported on pamphlet use. MEASURES: Specialists and resident/family representatives were asked to provide open comments and LTC home palliative leads were asked to complete a survey on the accuracy, readability, and relevance of the pamphlets. After 6 months of distribution, all staff in participating LTC homes were asked to complete a survey on pamphlet use, usefulness, and comfort with distribution. RESULTS: The pamphlets were reportedly accurate, relevant, and easy to understand. Following 6 months of availability, most staff in LTC had read the pamphlets, found the information useful, and planned to share them. However, half of the staff questioned their role in pamphlet distribution and most had not distributed them. Regulated staff (ie, staff affiliated with a regulated profession) expressed more comfort sharing the pamphlets than care aides and support staff. CONCLUSIONS/IMPLICATIONS: Condition-specific pamphlets appear to hold promise in providing residents and families with relevant information that may activate early reflections and conversations about end-of-life care. However, structured implementation strategies, training, and discussions are required to improve staff comfort with distribution and explore roles in distribution and follow-up.

Intramedullary Lesion Length on Postoperative Magnetic Resonance Imaging is a Strong Predictor of ASIA Impairment Scale Grade Conversion Following Decompressive Surgery in Cervical Spinal Cord Injury.

BACKGROUND: Evidence indicates that, over time, patients with spinal cord injury (SCI) improve neurologically in various degrees. We sought to further investigate indicators of grade conversion in cervical SCI. OBJECTIVE: To detect predictors of ASIA impairment scale (AIS) grade conversion in SCI following surgical decompression. METHODS: In a retrospective study, demographics, clinical, imaging, and surgical data from 100 consecutive patients were assessed for predictors of AIS grade conversion. RESULTS: American Spinal Injury Association motor score was 17.1. AIS grade was A in 52%, B in 29%, and C in 19% of patients. Surgical decompression took place on an average of 17.6 h following trauma (≤12 h in 51 and >12 h in 49). Complete decompression was verified by magnetic resonance imaging (MRI) in 73 patients. Intramedullary lesion length (IMLL) on postoperative MRI measured 72.8 mm, and hemorrhage at the injury epicenter was noted in 71 patients. Grade conversion took place in 26.9% of AIS grade A patients, 65.5% of AIS grade B, and 78.9% of AIS grade C. AIS grade conversion had statistical relationship with injury severity score, admission AIS grade, extent of decompression, presence of intramedullary hemorrhage, American Spinal Injury Association motor score, and IMLL. A stepwise multiple logistic regression analysis indicated IMLL was the sole and strongest indicator of AIS grade conversion (odds ratio 0.950, 95% CI 0.931-0.969). For 1- and 10-mm increases in IMLL, the model indicates 4% and 40% decreases, respectively, in the odds of AIS grade conversion. CONCLUSION: Compared with other surrogates, IMLL remained as the only predictor of AIS grade conversion.

Care Delivery Patterns, Processes, and Outcomes for Primary Ovarian Cancer Surgery: A Population-Based Review Using a National Administrative Database.

OBJECTIVES: In this pan-Canadian study, we sought to elucidate the current state of surgical care for primary ovarian cancers and factors influencing selected short-term outcomes; these were in-hospital mortality (IHM), major complications (MCs), failure-to-rescue (FTR), and hospital length of stay (LOS). METHODS: We created a population cohort using inpatient admission records from the Canadian Institute of Health Information data set (2004-2012). Multilevel logistic regression and flexible parametric survival analyses, adjusted for hospital clustering effect, were conducted to determine the effect of patient-specific factors (i.e., age, comorbidities, and admission category); procedural complexity; and the surgical volume and specialty of each care provider on the outcomes of interest. RESULTS: A total of 16 089 women underwent surgeries for primary ovarian cancer across Canada. The crude rates of IHM, MC, and FTR were 0.89%, 5.7%, and 9.09%, respectively, with a median LOS of four days (interquartile range 3 to 6). The majority of surgical procedures were performed by surgeons and hospitals with annual surgical volumes of less than five such procedures. Hospitals with higher surgical volumes were associated with lower risk of IHM (OR 0.95, 95% CI 0.91 to 0.99) and FTR (OR 0.95, 95% CI 0.91 to 0.99) and a higher chance of earlier discharge (hazard ratio [HR] 1.03, 95% CI 1.00 to 1.06). Surgeons with higher surgical volumes were associated with lower odds of early discharge (HR 0.90, 95% CI 0.87 to 0.94) and a higher risk of MC (OR 1.12, 95% CI 1.02 to 1.23). Compared with gynaecologic oncologists, general surgeons had a significantly higher risk of IHM (OR 3.50, 95% CI 1.82 to 6.74) and MC (OR 2.13, 95% CI 1.36 to 3.33) and lower odds of early discharge (HR 0.43, 95% CI 0.40 to 0.47). CONCLUSION: Despite limitations in the administrative data set, valuable information was available for this pan-Canadian analysis. Our findings support centralization of surgical procedures for women with ovarian cancer in tertiary care centres with higher surgical volumes that are staffed by in-house multidisciplinary care teams and specialist surgeons.