Use of alpha-adrenergic antagonists for lower urinary tract symptoms is not associated with worsening cognitive function.

INTRODUCTION: Alpha-adrenergic antagonists are widely prescribed for lower urinary tract symptoms (LUTS), however there has been a report that their use is associated with dementia. Our objective was to investigate if new users of alpha-adrenergic antagonists with varying levels of cognitive impairment had an increased risk of cognitive decline compared to non-users. METHODS: This was a retrospective cohort study, utilizing data from the National Alzheimer's Coordinating Center (NACC) data set. After applying relevant exclusion criteria, 916 people who were newly using alpha-antagonist medications were matched with a propensity score to 916 who were not using these medications. The primary outcome was a clinically relevant cognitive decline measured by the Clinical Dementia Rating (CDR) Dementia Staging Instrument or the mini mental state examination (MMSE). Secondary outcomes included scores from other cognitive assessment tools. RESULTS: The matched cohorts did not differ significantly in baseline characteristics. There were no statistically significant differences in baseline or follow-up cognitive scores between those exposed and nonexposed to alpha-adrenergic antagonists. Clinically significant cognitive decline (as defined by the CDR) occurred in 9.72% of the exposed group and 8.19% of the nonexposed group. There was no observed effect of alpha-adrenergic antagonists on cognitive decline, as measured with the CDR (odds ratio [OR] 1.34, p = 0.14) or the MMSE (OR 0.98, p = 0.92). Stratified analyses by cognitive status and apolipoprotein E genotype interaction assessment also demonstrated no significant associations. CONCLUSION: Alpha-adrenergic antagonists for LUTS do not appear to increase the risk of cognitive decline, offering reassurance to clinicians and patients.

Association Between Complications after Vascular Surgery and Prolonged Postoperative Opioid Use.

BACKGROUND: Few studies have looked at the long-term risk of opioid use following major vascular surgery and no study has investigated the potential association between major complications and prolonged opioid use. We analyzed a population-based database linked to a prescription database to investigate factors associated with prolonged opioid use following major vascular surgery. METHODS: This population-based cohort study included all adults who underwent open lower extremity revascularization (LER) or nonruptured abdominal aortic aneurysm repair (open [AAA] and endovascular [EVAR]) in the province of Ontario, Canada, between 2013 and 2018. Prolonged opioid use was defined as 2 or more opioid prescriptions filled 6-12 months following surgery. Potential predictors of prolonged use were explored using modified Poisson regression with a generalized estimating equation approach to account for the clustering of patients within physicians and institutions. RESULTS: This study included a total of 11,104 patients with 5,652 patients undergoing open LER, 3,285 patients undergoing EVAR, and 2,167 patients undergoing AAA. The rates of prior opioid use were 35.4% for LER, 15.8% for AAA and 14.3% for EVAR. Major complication rates following each procedure were 59.5% for AAA, 35.1% for LER, and 21.0% for EVAR. Following surgery, prolonged opioid use was identified in 26.1% of LER, 13.2% of AAA, and 11.6% of EVAR patients. The strongest predictor of prolonged opioid use was prior use with an odds ratio (OR) of 13.27 (95% CI: 10.63-16.57) for AAA, 11.24 (95% CI: 9.18-13.75) for EVAR, and 4.69 (95% CI: 4.16-5.29) for LER. The occurrence of a major complication was only associated with prolonged opioid use for patients undergoing LER (OR 1.10; 95% CI: 1.03-1.19), while it had a protective effect on patients undergoing EVAR (OR 0.83; 95% CI: 0.69-0.99) and no association for patients undergoing open AAA repair (OR 1.11; 95% CI: 0.95-1.29). Older age was also protective with a reduced rate of prolonged opioid use for every 10 years of age increase: AAA (OR 0.87; 95% CI: 0.77-0.99); EVAR (OR 0.83; 95% CI: 0.76-0.91); and LER (OR 0.91; 95% CI: 0.87-0.94). CONCLUSIONS: Prolonged opioid use is common following major vascular surgery, occurring in over 10% of patients undergoing either open or endovascular aneurysm repair and over 25% of patients undergoing open LER. Prior opioid use is the strongest predictor for prolonged use, while the occurrence of postoperative complications is associated with a slight increased risk of prolonged use in patients undergoing LER. These patient populations should be targeted for multimodal methods of opioid reduction following their procedures.

Predictors of Undergoing Revision Within 5 Years of Total Knee Arthroplasty: A Population-Based Study.

BACKGROUND: The objective of this study was to identify the rate and risk factors for revision total knee arthroplasty (TKA) within the first 5 years postoperative. Our secondary objective was to identify the rate of additional surgical procedures and death. METHODS: We conducted a retrospective cohort study among patients in Ontario, Canada who underwent an elective, primary TKA between April 1, 2007, and March 31, 2014, for osteoarthritis. We excluded patients under 40 years and who had undergone a TKA within the previous 15 years. Our final study cohort included 94,193 patients. We reported the proportion of the study cohort who experienced revision surgery within 2 and 5 years of the primary TKA; secondary surgery within 5 years. We conducted Cochran-Armitage tests for trends to assess changes in the proportion of patients who experienced each of the study outcomes, and multivariable logistic regressions to evaluate predictors of a revision TKA. RESULTS: There were 3,112 (3.3%) patients who had a revision within 5 years, and 1,866 (2.0%) within 2 years of their primary TKA. 3,316 (3.5%) had a secondary surgery (0.6% patellar resurfacing; 1.6% manipulation; 1.3% synovectomy; 0.5% washout; 0.9% debridement). Lower age, men, lower income, higher comorbidity score, depression, previous arthroscopy, lower surgeon volume, and general anesthesia were all significant positive predictors of revision. CONCLUSIONS: In our study cohort, 2.0% of patients had a revision TKA within 2 years, and 3.3% within 5 years of their primary TKA. Preoperative identification of risk factors may reduce the future prevalence of revision TKAs.

Unnecessary interventions for the management of hip osteoarthritis: a population-based cohort study.

BACKGROUND: Patients aged 40-60 years who require total hip arthroplasty (THA) often first receive unindicated hip arthroscopy or magnetic resonance imaging (MRI). Our objective was to identify potentially inappropriate resource utilization before THA, specifically reporting on the proportion of patients aged 40-60 years who underwent hip arthroscopy or MRI in the year before THA. METHODS: We conducted a retrospective, population-based study at the provincial level. We retrieved data from the Canadian Institute for Health Information (CIHI). We included all Ontario residents who underwent an elective, primary THA for osteoarthritis between Apr. 1, 2004, and Mar. 31, 2016. We identified the rates and timing of patients who underwent an MRI or hip arthroscopy before their index THA. RESULTS: The percentage of patients who underwent an MRI before THA increased significantly over the study period, from 8.7% in 2004 to 23.8% in 2015. There was also a significant but variable trend in the percentage of patients who underwent a hip arthroscopy before THA. CONCLUSION: Our results demonstrate a high, gradually increasing proportion of patients who received a hip MRI and a low but increasing proportion of patients who received hip arthroscopy in close proximity to THA. Multidisciplinary collaboration may improve knowledge translation and help reduce the rate of clinically unnecessary diagnostic and therapeutic interventions in this population of patients who require THA.

The Reduction of Male Lower Urinary Tract Symptoms Is Associated With a Decreased Risk of Death.

PURPOSE: Male lower urinary tract symptoms have been correlated with an increased risk of death; however, it is unclear if treatment will reduce this risk. Our objective was to determine whether a reduction in lower urinary tract symptoms is associated with a reduced risk of mortality. MATERIALS AND METHODS: We conducted a secondary analysis of the MTOPS (Medical Treatment of Prostate Symptoms) randomized trial of placebo, doxazosin, finasteride, or doxazosin and finasteride. Men in the United States between 1993 and 1998 who were >50 years of age with moderate to severe lower urinary tract symptoms were included. We used various Cox regression models to assess the relationship between AUA Symptom Score (modeled as a time-varying exposure) and death. RESULTS: A total of 3,046 men (median age 62, quartiles 57-68) were randomized and had a baseline AUA Symptom Score. For each 1-point improvement in the AUA Symptom Score, the hazard ratio for death was 0.96 (0.94-0.99, P = .01). Our sensitivity analyses found a similar significant reduction in the hazard ratio for death within men who had active treatment, but not among men who were randomized to the placebo arm; our results did not change when men were censored at the time of transurethral prostate resection, with adjustment for potential confounders, or with a shorter observation period after the last study visit. A comparable significant reduction in death was seen with 1-point improvements in the storage (HR 0.94, 95% CI 0.88-0.99, P = .04) and voiding (HR 0.95, 95% CI 0.91-0.99, P = .03) subscales individually. CONCLUSIONS: Improvement in male lower urinary tract symptoms was associated with a reduced risk of death. Further study is warranted to determine if the male treatment paradigm should shift toward symptom treatment independent of bother.

Total Hip Arthroplasty in Patients Aged 40 to 60 Years Old: A Population-Based Study.

BACKGROUND: Contemporary total hip arthroplasty (THA) has resolved many implant longevity concerns in younger patients. Patients in their fourth and fifth decades of life are projected to be the fastest-growing demographic of THA patients. We aimed to assess this demographic to: 1) evaluate the rate of THA over time; 2) evaluate the cumulative incidence of revision; and 3) identify risk factors for revision. METHODS: A retrospective population-based study of patients between 40 and 60 years old undergoing primary THA was conducted using administrative data from a large clinical data repository. A total of 28,414 patients were included for analysis with a mean age of 53 years (range, 40-60 years) and median follow-up of 9 years (range, 0-17 years). Linear regressions were used to assess annual rates of THA in this cohort over time. Kaplan-Meier analysis was used to determine cumulative incidence of revision. Multivariate Cox proportional hazards models were used to determine association of variables with revision risk. RESULTS: The annual rate of THA in our population increased by 60.7% over the study period (P < .0001). Cumulative incidence of revision was 2.9% at 5 years and 4.8% at 10 years. Younger age, women, non-osteoarthritis diagnosis, medical complications, and annual surgeon volume ≤ 60 THA were associated with increased revision risk. CONCLUSION: Demand for THA continues to dramatically increase in this cohort. Risk of revision was low but multiple risk factors were identified. Future studies will help delineate the effect of these variables on revision risk and assess implant survivorship beyond 10 years.

Defining major surgical complications using administrative data in Ontario: a validation study.

BACKGROUND: Although surgical complications are often included as an outcome of surgical research conducted using administrative data, little validation work has been performed. We sought to evaluate the diagnostic performance of an algorithm designed to capture major surgical complications using health administrative data. METHODS: This retrospective study included patients who underwent high-risk elective general surgery at a single institution in Ontario, Canada, from Sept. 1, 2016, to Sept. 1, 2017. Patients were identified for inclusion using the local operative database. Medical records were reviewed by trained clinicians to abstract postoperative complications. Data were linked to administrative data holdings, and a series of code-based algorithms were applied to capture a composite indicator of major surgical complications. We used sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy to evaluate the performance of our administrative data algorithm, as compared with data abstracted from the institutional charting system. RESULTS: The study included a total of 270 patients. According to the data from the chart audit, 55% of patients experienced at least 1 major surgical complication. Overall sensitivity, specificity, PPV, NPV and accuracy for the composite outcome was 72%, 80%, 82%, 70% and 76%, respectively. Diagnostic performance was poor for several of the individual complications. CONCLUSION: Our results showed that administrative data holdings can be used to capture a composite indicator of major surgical complications with adequate sensitivity and specificity. Additional work is required to identify suitable algorithms for several specific complications.

From Formation to Closure: Aggregate Morbidity and Mortality Associated With Defunctioning Loop Ileostomies.

BACKGROUND: Defunctioning loop ileostomies are used commonly, but there are significant morbidities. OBJECTIVE: This study aimed to describe the morbidity and mortality associated with the formation and closure of defunctioning loop ileostomies. DESIGN: This descriptive study is based on electronic health records and claims data. SETTINGS: This study was conducted at academic and community hospitals in Ontario, Canada. PATIENTS: Adult patients who had a low anterior resection with concurrent defunctioning loop ileostomy from 2002 to 2014 were included. MAIN OUTCOME MEASURES: Outcomes of interest included 30-day major complications, acute kidney injury, transfusion, and deep space infection. The rate of ileostomy reversal and the percentage of permanent ostomies were also collected. RESULTS: The cohort consists of 4658 patients who underwent low anterior resection with concurrent defunctioning loop ileostomy. The 30-day, 90-day, and 1-year mortality rates of these patients were 1.2%, 2.2%, and 5.1%. The rate of reoperation was 5.5%, the rate of hospital readmission was 13.4%, the rate of major complications was 28.5%, the rate of deep organ/space infection requiring percutaneous intervention was 5.2%, and the rate of acute kidney injury requiring hospitalization was 10.4%. Eighty-six percent had their ileostomy reversed, leaving 13.2% with a permanent ostomy. After ileostomy reversal, 30-day and 90-day mortality rates were 0.6% and 0.9%. The rate of major complications was 10.3%, bowel obstruction 7%, ventral hernia 10.5%, deep space infection 1.7%, and repeat operation 2.3%. LIMITATIONS: This study is based on electronic health records and claims data and, thus, the accuracy of results depends on the accuracy of data administration' which can be variable across institutions. CONCLUSIONS: Morbidity and mortality of defunctioning loop ileostomies are significant. One in 8 patients will have a permanent ostomy. See Video Abstract at http://links.lww.com/DCR/B810 . DESDE LA FORMACIN HASTA EL CIERRE AGREGADA MORBILIDAD Y MORTALIDAD ASOCIADA CON LAS ILEOSTOMAS EN ASA DERIVATIVA: ANTECEDENTES:Las ileostomías en asa derivativa se utilizan con frecuencia, pero existen morbilidades importantes.OBJETIVO:Describir la morbilidad y mortalidad asociadas con la formación y cierre de ileostomías en asa derivativa.DISEÑO:Estudio descriptivo basado en historias clínicas electrónicas y datos de reclamaciones.ENTORNO CLINICO:Hospitales académicos y comunitarios en Ontario, Canadá.PACIENTES:Pacientes adultos sometidos a resección anterior baja con concurrente ileostomía en asa derivativa de 2002 a 2014.PRINCIPALES MEDIDAS DE VALORACION:Los resultados de interés incluyeron complicaciones mayores a los 30 días, lesión renal aguda, transfusión e infección del espacio profundo. También se recolectó la tasa de reversión de la ileostomía y el porcentaje de ostomías permanentes.RESULTADOS:La cohorte consistió de 4658 pacientes sometidos a resección anterior baja con concurrente ileostomía en asa derivativa. La mortalidad de estos pacientes, a treinta días, 90 días y un año, fue del 1,2%, 2,2% y 5,1%, respectivamente. La tasa de reintervención fue del 5,5%, el reingreso hospitalario fue del 13,4%, la complicación mayor fue del 28,5%, la infección profunda de órganos / espacios que requirieron intervención percutánea fue del 5,2%, y la lesión renal aguda que requirió hospitalización fue del 10,4%. Ochenta y seis por ciento tuvieron reversión de su ileostomía, dejando al 13.2% con una ostomía permanente. Después de la reversión de la ileostomía, la mortalidad a los 30 días y 90 días fue de 0,6% y 0,9%, respectivamente. La tasa de complicaciones mayores fue del 10,3%, obstrucción intestinal del 7%, hernia ventral del 10,5%, infección del espacio profundo del 1,7% y reintervención del 2,3%.LIMITACIONES:El estudio se basa en registros médicos electrónicos y datos de reclamos y, por lo tanto, la precisión de los resultados depende de la precisión en la administración de datos, que pueden variar entre instituciones.CONCLUSIONES:La morbilidad y la mortalidad de las ileostomías en asa derivativa son significativas. Uno de cada 8 pacientes tendrá una ostomía permanente. Consulte Video Resumen en http://links.lww.com/DCR/B810 . (Traducción-Dr. Fidel Ruiz Healy ).

Hip arthroscopy utilization and reoperation rates in Ontario: a population-based analysis comparing different age cohorts.

BACKGROUND: Older age (> 40 yr) and osteoarthritis are negative prognostic variables for hip arthroscopy, but their impact has not been quantified from a population standpoint. The purpose of this study was to perform a population-based analysis of hip arthroscopy utilization and associated 2- and 5-year reoperation rates and complications in different age cohorts. METHODS: Administrative databases from Ontario, Canada, were retrospectively reviewed to identify patients aged 18-60 years who underwent hip arthroscopy between 2006 and 2016. Patients were stratified into 2 cohorts: 18-39 and 40-60 years of age. Patients were followed for 2 and 5 years to capture the occurrence of subsequent surgery (repeat arthroscopy or total hip arthroplasty) and postoperative complications. RESULTS: A total of 1906 patients underwent hip arthroscopy, 818 (42.9%) of whom were aged 40-60 years. In the entire cohort, revision surgery occurred in 6.5% and 15.1% of cases at 2 and 5 years, respectively. Revision surgery rates were significantly higher among patients aged 40-60 years at 2 (10.8% v. 3.2%, p < 0.001) and 5 years (22.7% v. 8.2%, p < 0.001) than among those aged 18-39 years. Revision rates were higher among patients aged 50-60 years than among those aged 40-49 years at 2 years (14.3% v. 9.1%, p = 0.027). Complication rates did not differ between cohorts. Regression analysis revealed higher 2- and 5-year odds of secondary surgery in patients aged 40-49 years (odds ratio [OR] 2.68, 95% confidence interval [CI] 1.70-4.22; OR 2.82, 95% CI 1.87-4.25; p < 0.001), patients aged 50-60 years (OR 4.39, 95% CI 2.67-7.22; OR 3.44, 95% CI 2.11-5.62; p < 0.001) and those with osteoarthritis (OR 2.41, 95% CI 1.39-4.20; p = 0.002; OR 1.76, 95% CI 1.00-3.09; p = 0.049). CONCLUSION: Revision surgery rates following hip arthroscopy are significantly higher among older patients and those with concomitant osteoarthritis. Although the data have limitations, they provide useful information to guide surgical decision-making.

The rate of unnecessary interventions for the management of knee osteoarthritis: a population-based cohort study.

BACKGROUND: Several commonly used procedures for knee osteoarthritis (OA) are not supported by evidence-based guidelines. The objective of this study was to identify the proportion of patients who underwent knee arthroscopy or magnetic resonance imaging (MRI) and the timing of these procedures before total knee arthroplasty (TKA). METHODS: We conducted a retrospective cohort study using administrative data sets from Ontario, Canada. We identified the proportion of patients who underwent knee arthroscopy in the previous 10 years or an MRI in the 3 years before their primary TKA. We also evaluated the rate of arthroscopies by diagnosis. We report the timing of each outcome in relation to the TKA, rates by geographical area, and differences in rates over time. RESULTS: We included 142 275 patients, of whom 36 379 (25.57%) underwent knee arthroscopy (median time 2.8 [interquartile range (IQR) 1.1-6.0] years); 22% of those were within 1 year of TKA and 52% were within 3 years. The rates of arthroscopies for a diagnosis of osteoarthritis (OA) steadily decreased, while those for meniscal-related diagnoses increased over the study period (p < 0.0001). There was significant variation by region. Of the cohort, 23.2% (n = 32 989) had an MRI before their TKA, with rates significantly increasing over time (p < 0.0001). CONCLUSION: A substantial proportion of patients with knee OA received diagnostic and therapeutic interventions before TKA that are contrary to clinical practice guidelines.

Fracture profiles of a 4-year cohort of 266,324 first incident upper extremity fractures from population health data in Ontario.

BACKGROUND: Understanding the profiles of different upper extremity fractures, particularly those presenting as a 1st incident can inform prevention and management strategies. The purpose of this population-level study was to describe first incident fractures of the upper extremity in terms of fracture characteristics and demographics. METHODS: Cases with a first adult upper extremity (UE) fracture from the years 2013 to 2017 were extracted from administrative data in Ontario. Fracture locations (ICD-10 codes) and associated characteristics (open/closed, associated hospitalization within 1-day, associated nerve, or tendon injury) were described by fracture type, age category and sex. Standardized mean differences of at least 10% (clinical significance) and statistical significance (p < 0.01) in ANOVA were used to identify group differences (age/sex). RESULTS: We identified 266,324 first incident UE fractures occurring over 4 years. The most commonly affected regions were the hand (93 K), wrist/forearm(80 K), shoulder (48 K) or elbow (35 K). The highest number of specific fractures were: distal radius (DRF, 47.4 K), metacarpal (30.4 K), phalangeal (29.9 K), distal phalangeal (24.4 K), proximal humerus (PHF, 21.7 K), clavicle (15.1 K), radial head (13.9 K), and scaphoid fractures (13.2 K). The most prevalent multiple fractures included: multiple radius and ulna fractures (11.8 K), fractures occurring in multiple regions of the upper extremity (8.7 K), or multiple regions in the forearm (8.4 K). Tendon (0.6% overall; 8.2% in multiple finger fractures) or nerve injuries were rarely reported (0.3% overall, 1.5% in distal humerus). Fractures were reported as being open in 4.7% of cases, most commonly for distal phalanx (23%). A similar proportion of females (51.5%) and males were present in this fracture cohort, but there were highly variant age-sex profiles across fracture subtypes. Fractures most common in 18-40-year-old males included metacarpal and finger fractures. Fractures common in older females were: DRF, PHF and radial head, which exhibited a dramatic increase in the over-50 age group. CONCLUSIONS: UE fracture profiles vary widely by fracture type. Fracture specific prevention and management should consider fracture profiles that are highly variable according to age and sex.

Persistent post-operative opioid use following hip arthroscopy is common and is associated with pre-operative opioid use and age.

PURPOSE: Hip arthroscopy utilization continues to increase worldwide. Post-operative pain management is essential to allow appropriate rehabilitation. While multimodal analgesic protocols have been described, consensus agreement is lacking and opioid analgesia remains a mainstay of treatment. Unfortunately, the risk of persistent opioid use among opioid-naïve and non-naïve patients following hip arthroscopy remains unclear. Therefore, the purpose of this study was to identify rates of persistent post-operative opioid use, as well as to identify factors associated with persistent use. METHODS: A retrospective cohort study was conducted using linked administrative data from Ontario, Canada. Participants were adults who underwent hip arthroscopy between 2013 and 2018. Patients < 18 or > 60 years of age as well as those who had undergone prior hip arthroscopy were excluded. The primary exposure was whether patients had filled ≥ 2 opioid prescriptions within 1 year prior to their hip arthroscopy to define the opioid naïve and non-naïve populations. The primary outcome was persistent opioid use, defined as 2 + prescriptions filled between 9 and 15 months post-op. A regression analysis was performed to identify factors associated with persistent opioid usage. RESULTS: Of the 1909 patients, 1525 (79.9%) were opioid-naïve, while 384 (20.1%) had a prior history of opioid use within 1 year of surgery. 224 patients (11.7%) demonstrated persistent opioid use, with ≥ 2 prescriptions filled between 9 and 15 months post-op. Of those, 42 (18.8%) cases were among opioid-naïve patients, while the remaining 182 (81.2%) were among non-naïve patients. The risk of persistent post-operative use was significantly higher in those with prior opioid use (OR 31.95, 95% CI 22.15-46.09; p < 0.0001). Regression analysis confirmed that pre-operative opioid use (OR 23.79, 95% CI 17.06-33.17; p < 0.0001) and older age (OR 1.04, 95% CI 1.02-1.05, p < 0.0001) were associated with increased risk of persistent post-operative opioid use. CONCLUSION: Following hip arthroscopy, persistent opioid use is common. New persistent use was identified in 2.7% of opioid-naïve patients, compared with continued use in 47.4% of non-naïve patients. Pre-operative opioid use and older age were associated with the greater risk of persistent post-operative opioid use. LEVEL OF EVIDENCE: Level III.

Trends in immediate breast reconstruction and radiation after mastectomy: A population study.

In the last decade, there has been an increase in women undergoing immediate breast reconstruction (IBR) at the time of mastectomy. Recent literature suggests a shift in practice: Surgeons are becoming more comfortable with IBR in the setting of possible postoperative adjuvant radiotherapy, despite the known complications. This study sought to investigate, at a population level, the patient and surgeon characteristics associated with the use of IBR and which of these factors were predictive of adjuvant radiotherapy. This retrospective population-based cohort study included all adult women who underwent mastectomy in the province of Ontario from 2007 to 2014. The Canadian Institute for Health Information (CIHI) administrative data base was used to generate patient demographic and clinical data. The Ontario Health Insurance Plan (OHIP) data base was used to elicit surgeon characteristics including clinical experience and volume of practice dedicated to breast surgery. Outcome variables included reconstruction concurrent with mastectomy, alloplastic vs autologous reconstruction, and use of radiation. A total of 25 861 patients underwent mastectomy and 2972 had IBR (11.5%). The rate of IBR after mastectomy increased over time from 7.2% in 2007 to 17.2% in 2014 (P < .001). There was also an increase in the proportion of patients with IBR who received radiation over the time period, from 19.4% in 2007 to 28.2% in 2014 (P = .003). In the first regression analysis, IBR was associated with younger patient age, residing in closer proximity to cancer clinics, absence of malignant breast disease (ie, prophylactic mastectomy), having a younger surgeon performing the mastectomy, and receiving care at a teaching hospital. A second analysis showed that patient variables predictive of radiation after IBR were a younger age and a more advanced cancer stage and no variables specific to surgeon or institution were predictive of radiation in patients with IBR. A significant increase in the rate of IBR as well as the use of radiation occurred over the 7-year study period. Multiple patient and surgeon factors were associated with IBR. Variables associated with radiation in IBR were harder to predict. Given the increase in the use of radiation in IBR, further research is needed to look at long-term outcomes in these patients at the population level.

Resident Trainees Increase Surgical Time: A Comparison of Obstetric and Gynaecologic Procedures in Academic Versus Community Hospitals.

OBJECTIVE: The impact of resident involvement in the operating room for common procedures in obstetrics and gynaecology can shed light on the resource demands of teaching. The objective of this study was to quantify the increased surgical time associated with teaching obstetrics and gynaecology resident trainees across a range of procedures known to require surgical assistance. METHODS: This population-based retrospective cohort study compared surgical duration between academic (teaching) hospitals and community (non-teaching) hospitals. The cohort was made up of adult residents of Ontario between fiscal years 2002 and 2013 who were undergoing commonly performed obstetrics and gynaecologic procedures. The most commonly billed procedures requiring surgical assistance were included: cesarean section, anterior or posterior repair, anterior and posterior repair, salpingo-oophorectomy, myomectomy, ectopic pregnancy, total or subtotal hysterectomy, vaginal hysterectomy, and laparoscopic hysterectomy. Linked administrative databases held at the Institute of Clinical Evaluative Sciences (ICES) were used to define patient-, surgeon-, institution-, and procedure-related variables to limit confounding. Surgical duration, determined by anaesthetic billing records, was analyzed using a negative binomial regression. RESULTS: The total cohort included 337 389 surgical procedures. Of these procedures, 28% (94 203 procedures) were conducted in academic settings. The mean surgical duration of the procedures of interest (excluding vaginal hysterectomy) was significantly longer in academic hospitals compared with community hospitals. With many controls for case variability, this time differential reflects the burden of teaching resident trainees and other learners in the academic environment. The operating time increased between 6% and 20% for cases completed in academic centres versus in the community. As an example, the mean surgical duration of cesarean sections was 20.6 minutes (19%) longer in academic centres. Furthermore, the data highlighted a trend of increased teaching time for laparoscopic procedures compared with open procedures. The time ratio was the greatest for salpingo-oophortectomy and surgical management of ectopic pregnancies. The additional cost of carrying out these nine procedures in academic centres during the study period was $16.3 million. CONCLUSION: The cost of teaching resident trainees is increased operative time. This increased surgical cost in a publicly funded system must be considered as funding models evolve.

Hysterectomy in Ontario: A Population-Based Study of Outcomes and Complications in Minimally Invasive Compared with Abdominal Approaches.

OBJECTIVE: As quality-based procedures (QBPs) are being established across the province of Ontario, it is important to identify reliable quality indicators (QIs) to ensure that compensation coincides with quality. Hysterectomy is the most commonly performed gynaecologic procedure and as such is a care process for which a QBP is being developed. The aim of this study was to evaluate the technicity index (TI) as a QI for hysterectomy by defining it in the context of specific surgical outcomes and complications. METHODS: This population-based, retrospective cohort study included all women who underwent hysterectomy from April 2003 to October 2014 in the province of Ontario. Unadjusted and adjusted generalized linear models were created to assess the effect of a minimally invasive hysterectomy (MIH) approach on the primary outcome measure: all hysterectomy-associated complications (Canadian Task Force Classification II-2). RESULTS: Of the procedures meeting the study's inclusion criteria, 56.8% were performed using an abdominal hysterectomy approach, whereas 43.2% were performed using an MIH approach. Over the study period, TI improved significantly from 33.23% in 2003 to 58.47% in 2014. During this time span, the overall incidence of all hysterectomy-associated complications was 13.1%. CONCLUSION: The composite risk of all hysterectomy-associated complications was reduced by 46% with an MIH approach. The uptake of MIH improved significantly in Ontario from 2003 to 2014 and is adequately assessed by the TI. The TI is an appropriate QI for hysterectomy that can be used to track patients' outcomes and direct hysterectomy funding.

Association between day of the week of elective surgery and postoperative mortality.

BACKGROUND: In prior studies, higher mortality was observed among patients who had elective surgery on a Friday rather than earlier in the week. We investigated whether mortality after elective surgery was associated with day of the week of surgery in a Canadian population and whether the association was influenced by surgeon experience and volume. METHODS: We conducted a population-based retrospective cohort study in the province of Ontario, Canada. We included adults who underwent 1 of 12 elective daytime surgical procedures from Apr. 1, 2002, to Dec. 31, 2012. The primary outcome was 30-day mortality. We used generalized estimating equations to compare outcomes for surgeries performed on different days of the week, adjusting for patient and surgeon factors. RESULTS: A total of 402 899 procedures performed by 1691 surgeons met our inclusion criteria. The median length of hospital stay was 6 (interquartile range 5-8) days. Surgeon experience varied significantly by day of week (p < 0.001), with surgeons operating on Fridays having the least experience. Nearly all of the patients who had their procedure on a Friday had postoperative care on the weekend, as compared with 49.1% of those whose surgery was on a Monday (p < 0.001). We found no difference in the 30-day mortality between procedures performed on Fridays and those performed on Mondays (adjusted odds ratio 1.08, 95% confidence interval 0.97-1.21). INTERPRETATION: Although surgeon experience differed across days of the week, the risk of 30-day mortality after elective surgery was similar regardless of which day of the week the procedure took place.

Pharmacotherapy for Depression Posttraumatic Brain Injury: A Meta-analysis.

OBJECTIVE: To examine the effectiveness of pharmacotherapy for the treatment of depression following traumatic brain injury (TBI). DESIGN: Systematic review and meta-analysis. Multiple electronic databases were searched to identify relevant studies examining effectiveness of pharmacotherapy for depression post-TBI. Clinical trials evaluating the use of pharmacotherapy in individuals with depression at baseline and using standardized assessments of depression were included. Data abstracted included sample size, antidepressant used, treatment timing/duration, method of assessment, and results pertaining to impact of treatment. Study quality was assessed using a modified Jadad scale. RESULTS: Nine studies met criteria for inclusion. Pooled analyses based on reported means (standard deviations) from repeated assessments of depression showed that, over time, antidepressant treatment was associated with a significant effect in favor of treatment (Hedges g = 1.169; 95% confidence interval, 0.849-1.489; P < .001). Similarly, when limited to placebo-controlled trials, treatment was associated with a significant reduction in symptoms (standardized mean difference = 0.84; 95% confidence interval, 0.314-1.366; P = .002). CONCLUSION: Pharmacotherapy after TBI may be associated with a reduction in depressive symptomatology. Given limitations within the available literature, further well-powered, placebo-controlled trials should be conducted to confirm the effectiveness of antidepressant therapy in this population.

Teaching surgery takes time: the impact of surgical education on time in the operating room.

BACKGROUND: It is generally accepted that surgical training is associated with increased surgical duration. The purpose of this study was to determine the magnitude of this increase for common surgical procedures by comparing surgery duration in teaching and nonteaching hospitals. METHODS: This retrospective population-based cohort study included all adult residents of Ontario, Canada, who underwent 1 of 14 surgical procedures between 2002 and 2012. We used several linked administrative databases to identify the study cohort in addition to patient-, surgeon- and procedure-related variables. We determined surgery duration using anesthesiology billing records. Negative binomial regression was used to model the association between teaching versus nonteaching hospital status and surgery duration. RESULTS: Of the 713 573 surgical cases included in this study, 20.8% were performed in a teaching hospital. For each procedure, the mean surgery duration was significantly longer for teaching hospitals, with differences ranging from 5 to 62 minutes across individual procedures in unadjusted analyses (all p < 0.001). In regression analysis, procedures performed in teaching hospitals were associated with an overall 22% (95% confidence interval 20%-24%) increase in surgery duration, adjusting for patient-, surgeon- and procedure-related variables as well as the clustering of patients within surgeons and hospitals. CONCLUSION: Our results show that a wide range of surgical procedures require significantly more time to perform in teaching than nonteaching hospitals. Given the magnitude of this difference, the impact of surgical training on health care costs and clinical outcomes should be a priority for future studies.

CONTEXTE: Il est généralement admis que la formation chirurgicale est associée à des interventions plus longues. L'objectif de la présente étude était de déterminer l'ampleur de cette augmentation pour les chirurgies courantes en comparant la durée des interventions dans les hôpitaux universitaires et les autres hôpitaux. MÉTHODES: Dans le cadre d'une étude de cohorte rétrospective basée sur la population, nous avons recensé tous les résidents adultes de l'Ontario (Canada) qui ont subi une intervention chirurgicale parmi une liste de 14 entre 2002 et 2012. À l'aide de plusieurs bases de données administratives reliées, nous avons constitué la cohorte de l'étude et recueilli des variables associées aux patients, aux chirurgiens et aux interventions. Nous avons déterminé la durée des opérations à partir des dossiers de facturation d'anesthésiologie. Une régression binomiale négative a été utilisée pour modéliser le lien entre le statut des hôpitaux ­ universitaires ou non ­ et la durée. RÉSULTANTS: Des 713 573 chirurgies à l'étude, 20,8 % ont eu lieu dans un hôpital universitaire. Dans tous les cas, la durée moyenne était significativement plus longue dans les hôpitaux universitaires, les écarts variant de 5 à 62 minutes pour chaque intervention dans les analyses non corrigées (p < 0,001 dans tous les cas). Selon l'analyse de régression, les chirurgies effectuées dans les hôpitaux universitaires étaient associées à une augmentation globale de la durée de 22 % (intervalle de confiance à 95 %, 20 %­24 %), après ajustement pour les variables liées aux patients, aux chirurgiens et aux interventions ainsi que pour la densité de patients pris en charge par les chirurgiens et les hôpitaux. CONCLUSION: Nos résultats montrent que de nombreuses interventions chirurgicales durent considérablement plus longtemps dans les hôpitaux universitaires que dans les autres hôpitaux. Étant donné l'ampleur de cet écart, l'étude de l'incidence de la formation chirurgicale sur les coûts des soins de santé et les résultats cliniques devrait être une priorité pour les recherches futures.

Fasciotomy and rate of amputation after tibial fracture in adults: a population-based cohort study.

Objectives: Limb amputation is a possible outcome of acute compartment syndrome. We undertook this study to investigate the occurrence of fasciotomy and amputation in patients with tibial fractures in the Ontario adult population, aiming to evaluate variables that may be associated with each of these outcomes. Design: Retrospective, population-based cohort study (April 1, 2003-March 31, 2016). Setting: Canadian province of Ontario. Participants: Patients with tibial fracture, aged 14 years and older. Interventions: Fasciotomy after tibial fracture. Main Outcomes and Measures: The primary outcomes were fasciotomy and amputation within 1 year of fasciotomy. Secondary outcomes included repeat surgery, new-onset renal failure, and mortality, all within 30 days of fasciotomy. Results: We identified 76,299 patients with tibial fracture; the mean (SD) age was 47 (21) years. Fasciotomy was performed in 1303 patients (1.7%); of these, 76% were male and 24% female. Patients who were younger, male, or experienced polytrauma were significantly more likely to undergo fasciotomy. Limb amputation occurred in 4.3% of patients undergoing fasciotomy, as compared with 0.5% in those without fasciotomy; older age, male sex, presence of polytrauma, and fasciotomy were associated with an increased risk of amputation (age odds ratio [OR] of 1.03 [95% CI, 1.02-1.03], P < 0.0001; sex OR of 2.04 [95% CI, 1.63-2.55], P < 0.0001; polytrauma OR of 9.37 [95% CI, 7.64-11.50], P < 0.0001; fasciotomy OR of 4.35 [95% CI, 3.21-5.90], P < 0.0001), as well as repeat surgery within 30 days (sex OR of 1.54 [95% CI, 1.14-2.07], P = 0.0053; polytrauma OR of 4.24 [95% CI, 3.33-5.38], P < 0.0001). Conclusions: Among tibial fracture patients, those who were male and who experienced polytrauma were at significantly higher risk of undergoing fasciotomy and subsequent amputation. Fasciotomy was also significantly associated with risk of amputation, a finding that is likely reflective of the severity of the initial injury.