Risk Factors for Surgical Site Infection after Lower Limb Revascularisation Surgery: a Systematic Review and Meta-Analysis of Prognostic Studies.

OBJECTIVE: To systematically review and meta-analyse adjusted risk factors for surgical site infection (SSI) after lower limb revascularisation surgery. DATA SOURCES: MEDLINE, Embase, Evidence Based Medicine Reviews, and the Cochrane Central Register of Controlled Trials (inception to 28 April 2022). REVIEW METHODS: Systematic review and meta-analysis conducted according to PRISMA guidelines. After protocol registration, databases were searched. Studies reporting adjusted risk factors for SSI in adults who underwent lower limb revascularisation surgery for peripheral artery disease were included. Adjusted odds ratios (ORs) were pooled using random effects models. GRADE was used to assess certainty. RESULTS: Among 6 377 citations identified, 50 studies (n = 271 125 patients) were included. The cumulative incidence of SSI was 12 (95% confidence interval [CI] 10 - 13) per 100 patients. Studies reported 139 potential SSI risk factors adjusted for a median of 12 (range 1 - 69) potential confounding factors. Risk factors that increased the pooled adjusted odds of SSI included: female sex (pooled OR 1.41, 95% CI 1.20 - 1.64; high certainty); dependent functional status (pooled OR 1.18, 95% CI 1.03 - 1.35; low certainty); being overweight (pooled OR 1.82, 95% CI 1.29 - 2.56; moderate certainty), obese (pooled OR 2.20, 95% CI 1.44 - 3.36; high certainty), or morbidly obese (pooled OR 1.65, 95% CI 1.08 - 2.52; moderate certainty); chronic obstructive pulmonary disease (pooled OR 1.42, 95% CI 1.17 - 1.71; high certainty); chronic limb threatening ischaemia (pooled OR 1.67, 95% CI 1.22 - 2.29; moderate certainty); chronic kidney disease (pooled OR 2.13, 95% CI 1.18 - 3.83; moderate certainty); intra-operative (pooled OR 1.23, 95% CI 1.02 - 1.49), peri-operative (pooled OR 1.92, 95% CI 1.27 - 2.90), or post-operative (pooled OR 2.21, 95% CI 1.44 - 3.39) blood transfusion (moderate certainty for all); urgent or emergency surgery (pooled OR 2.12, 95% CI 1.22 - 3.70; moderate certainty); vein bypass and or patch instead of endarterectomy alone (pooled OR 1.86, 95% CI 1.33 - 2.59; moderate certainty); an operation lasting ≥ 3 hours (pooled OR 1.86, 95% CI 1.33 - 2.59; moderate certainty) or ≥ 5 hours (pooled OR 1.60, 95% CI 1.18 - 2.17; moderate certainty); and early or unplanned re-operation (pooled OR 4.50, 95% CI 2.18 - 9.32; low certainty). CONCLUSION: This systematic review identified evidence informed SSI risk factors following lower limb revascularisation surgery. These may be used to develop improved SSI risk prediction tools and to identify patients who may benefit from evidence informed SSI prevention strategies.

Prediction Models for Forecasting Risk of Development of Surgical Site Infection after Lower Limb Revascularization Surgery: A Systematic Review.

BACKGROUND: Surgical site infections (SSIs) are a common and potentially preventable complication of lower limb revascularization surgery associated with increased healthcare resource utilization and patient morbidity. We conducted a systematic review to evaluate multivariable prediction models designed to forecast risk of SSI development after these procedures. METHODS: After protocol registration (CRD42022331292), we searched MEDLINE, EMBASE, CENTRAL, and Evidence-Based Medicine Reviews (inception to April 4th, 2023) for studies describing multivariable prediction models designed to forecast risk of SSI in adults after lower limb revascularization surgery. Two investigators independently screened abstracts and full-text articles, extracted data, and assessed risk of bias. A narrative synthesis was performed to summarize predictors included in the models and their calibration and discrimination, validation status, and clinical applicability. RESULTS: Among the 6,671 citations identified, we included 5 studies (n = 23,063 patients). The included studies described 5 unique multivariable prediction models generated through forward selection, backward selection, or Akaike Information Criterion-based methods. Two models were designed to predict any SSI and 3 Szyilagyi grade II (extending into subcutaneous tissue) SSI. Across the 5 models, 18 adjusted predictors (10 of which were preoperative, 3 intraoperative, and 5 postoperative) significantly predicted any SSI and 14 adjusted predictors significantly predict Szilagyi grade II SSI. Female sex, obesity, and chronic obstructive pulmonary disease significantly predicted SSI in more than one model. All models had a "good fit" according to the Hosmer-Lemeshow test (P > 0.05). Model discrimination was quantified using the area under the curve, which ranged from 0.66 to 0.75 across models. Two models were internally validated using non-exhaustive twofold cross-validation and bootstrap resampling. No model was externally validated. Three studies had a high overall risk of bias according to the Prediction model Risk Of Bias ASsessment Tool (PROBAST). CONCLUSIONS: Five multivariable prediction models with moderate discrimination have been developed to forecast risk of SSI development after lower limb revascularization surgery. Given the frequency and consequences of SSI after these procedures, development and external validation of novel prediction models and comparison of these models to the existing models evaluated in this systematic review is warranted.

Social factors associated with self-reported changes in mental health symptoms among youth in the COVID-19 pandemic: a cross-sectional survey.

BACKGROUND: Children and youth experienced marked impacts on day-to-day life in the COVID-19 pandemic that were associated with poorer familial and friend relationships, and greater mental health challenges. Few studies provide self-report data on mental health symptoms from children and youth themselves. We sought to examine the associations between social factors and child and youth self-reported symptoms of worsened mood, anxiety, and irritability during the COVID-19 pandemic. METHODS: A nationally representative cross-sectional survey was administered online to collect self-report data across 10 Canadian provinces among children (11-14 years) and youth (15-18 years), April-May 2022. Age-appropriate questions were based on The Partnership for Maternal, Newborn & Child Health and the World Health Organization of the United Nations H6 + Technical Working Group on Adolescent Health and Well-Being consensus framework and the Coronavirus Health and Impact Survey. Associations between a priori defined social factors (e.g., relationship quality) and respondent self-reported mental health were evaluated using ordinal logistic regression models adjusted for age, sex, and geographic location. RESULTS: We analyzed data from 483 (51.7%) children (11-14 years; 227, 47.0% girls) and 450 (48.3%) youth (15-18 years; 204, 45.3% girls). The parents of most children and youth had resided in Canada for over 20 years (678, 72.7%). Over one-quarter of children and youth self-identified as Black, Indigenous, or a Person of Color (134, 27.7%; 134, 29.8%, respectively). Over one-third of children and youth self-reported symptoms of worsened mood (149, 30.9%; 125, 27.8%, respectively), anxiety (181, 37.5%; 167, 37.1%, respectively), or irritability (160, 33.1%; 160, 35.6%, respectively) during, compared to pre-pandemic. In descending order of odds ratios (OR), for children and youth, worsened familial relationships (during compared to pre-pandemic) was associated with the self-reported symptoms of worsened mood (child: OR 4.22, 95%CI 2.51-6.88; youth: OR 6.65 95%CI 3.98-11.23), anxiety (child: OR 4.24, 95%CI2.69-6.75; youth: OR 5.28, 95%CI 3.17-8.86), and irritability (child: OR 2.83, 95%CI 1.76-4.56; youth: OR 6.46, 95%CI 3.88-10.90). CONCLUSIONS: Self-reported data from a nationally representative sample of children and youth suggest strong associations between social factors and mental health during the COVID-19 pandemic. Interventions targeting child and youth familial relationships may positively impact child and youth mental health.

Implementation of an audit and feedback module targeting low-value clinical practices in a provincial trauma quality assurance program: a cost-effectiveness study.

BACKGROUND: Audit and Feedback (A&F) interventions based on quality indicators have been shown to lead to significant improvements in compliance with evidence-based care including de-adoption of low-value practices (LVPs). Our primary aim was to evaluate the cost-effectiveness of adding a hypothetical A&F module targeting LVPs for trauma admissions to an existing quality assurance intervention targeting high-value care and risk-adjusted outcomes. A secondary aim was to assess how certain A&F characteristics might influence its cost-effectiveness. METHODS: We conducted a cost-effectiveness analysis using a probabilistic static decision analytic model in the Québec trauma care continuum. We considered the Québec Ministry of Health perspective. Our economic evaluation compared a hypothetical scenario in which the A&F module targeting LVPs is implemented in a Canadian provincial trauma quality assurance program to a status quo scenario in which the A&F module is not implemented. In scenarios analyses we assessed the impact of A&F characteristics on its cost-effectiveness. Results are presented in terms of incremental costs per LVP avoided. RESULTS: Results suggest that the implementation of A&F module (Cost = $1,480,850; Number of LVPs = 6,005) is associated with higher costs and higher effectiveness compared to status quo (Cost = $1,124,661; Number of LVPs = 8,228). The A&F module would cost $160 per LVP avoided compared to status quo. The A&F module becomes more cost-effective with the addition of facilitation visits; more frequent evaluation; and when only high-volume trauma centers are considered. CONCLUSION: A&F module targeting LVPs is associated with higher costs and higher effectiveness than status quo and has the potential to be cost-effective if the decision-makers' willingness-to-pay is at least $160 per LVP avoided. This likely represents an underestimate of true ICER due to underestimated costs or missed opportunity costs. Results suggest that virtual facilitation visits, frequent evaluation, and implementing the module in high-volume centers can improve cost-effectiveness.

Well-being approaches targeted to improve child and youth health post-COVID-19 pandemic: a scoping review.

BACKGROUND: Our previous work synthesized published studies on well-being interventions during COVID-19. As we move into a post-COVID-19 pandemic period there is a need to comprehensively review published strategies, approaches, and interventions to improve child and youth well-being beyond deleterious impacts experienced during COVID-19. METHODS: Seven databases were searched from inception to January 2023. Studies were included if they: (1) presented original data on an approach (i.e., approach applied) or (2) provided recommendations to inform development of a future approach (i.e., approach suggested), (3) targeted to mitigate negative impacts of COVID-19 on child and youth (≤18 year) well-being, and (4) published on or after December 2019. RESULTS: 39 studies (n = 4/39, 10.3% randomized controlled trials) from 2021 to 2023 were included. Twenty-two studies applied an approach (n = 22/39, 56.4%) whereas seventeen studies (n = 17/39, 43.6%) suggested an approach; youth aged 13-18 year (n = 27/39, 69.2%) were most frequently studied. Approach applied records most frequently adopted an experimental design (n = 11/22, 50.0%), whereas approach suggested records most frequently adopted a cross-sectional design (n = 13/22, 59.1%). The most frequently reported outcomes related to good health and optimum nutrition (n = 28/39, 71.8%), followed by connectedness (n = 22/39, 56.4%), learning, competence, education, skills, and employability (n = 18/39, 46.1%), and agency and resilience (n = 16/39, 41.0%). CONCLUSIONS: The rapid onset and unpredictability of COVID-19 precluded meaningful engagement of children and youth in strategy development despite widespread recognition that early engagement can enhance usefulness and acceptability of interventions. Published or recommended strategies were most frequently targeted to improve connectedness, belonging, and socialization among children and youth.

STOP Signs: A Population-based Interrupted Time Series Analysis of Antibiotic Duration for Complicated Intraabdominal Infection Before and After the Publication of a Landmark RCT.

OBJECTIVE: To determine if the STOP-IT randomized controlled trial changed antibiotic prescribing in patients with Complicated Intraabdominal Infection (CIAI). SUMMARY OF BACKGROUND DATA: CIAI is common and causes significant morbidity. In May 2015, the STOP-IT randomized controlled trial showed equivalent outcomes between four-day and clinically determined antibiotic duration. METHODS: This was a population-based retrospective cohort study using interrupted time series methods. The STOP-IT publication date was the exposure. Median duration of inpatient antibiotic prescription was the outcome. All adult patients admitted to four hospitals in Calgary, Canada between July 2012 and December 2018 with CIAI who survived at least four days following source control were included. Analysis was stratified by infectious source as appendix or biliary tract (group A) versus other (group B). RESULTS: Among 4384 included patients, clinical and demographic attributes were similar before vs after publication. In Group A, median inpatient antibiotic duration was 3 days and unchanged from the beginning to the end of the study period [adjusted median difference -0.00 days, 95% confidence interval (CI) -0.37 - 0.37 days]. In Group B, antibiotic duration was shorter at the end of the study period (7.87 vs 6.73 days; -1.14 days, CI-2.37 - 0.09 days), however there was no change in trend following publication (-0.03 days, CI -0.16 - 0.09). CONCLUSIONS: For appendiceal or biliary sources of CIAI, antibiotic duration was commensurate with the experimental arm of STOP-IT. For other sources, antibiotic duration was long and did not change in response to trial publication. Additional implementation science is needed to improve antibiotic stewardship.

Efficacy of Strategies Intended to Prevent Surgical Site Infection After Lower Limb Revascularization Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: The objective of this study is to evaluate the efficacy of strategies intended to prevent surgical site infection (SSI) after lower limb revascularization surgery. BACKGROUND: SSIs are common, costly complications of lower limb revascularization surgery associated with significant morbidity and mortality. METHODS: We searched MEDLINE, EMBASE, CENTRAL, and Evidence-Based Medicine Reviews (inception to April 28, 2022). Two investigators independently screened abstracts and full-text articles, extracted data, and assessed the risk of bias. We included randomized controlled trials (RCTs) that evaluated strategies intended to prevent SSI after lower limb revascularization surgery for peripheral artery disease. We used random-effects models to pool data and GRADE to assess certainty. RESULTS: Among 6258 identified citations, we included 26 RCTs (n=4752 patients) that evaluated 12 strategies to prevent SSI. Preincision antibiotics [risk ratio (RR)=0.25; 95% CI, 0.11-0.57; n=4 studies; I2 statistic=7.1%; high certainty] and incisional negative-pressure wound therapy (iNPWT) (RR=0.54; 95% CI, 0.38-0.78; n=5 studies; I2 statistic=7.2%; high certainty) reduced pooled risk of early (≤30 days) SSI. iNPWT also reduced the risk of longer-term (>30 days) SSI (pooled-RR=0.44; 95% CI, 0.26-0.73; n=2 studies; I2 =0%; low certainty). Strategies with uncertain effects on risk of SSI included preincision ultrasound vein mapping (RR=0.58; 95% CI, 0.33-1.01; n=1 study); transverse groin incisions (RR=0.33; 95% CI, 0.097-1.15; n=1 study), antibiotic-bonded prosthetic bypass grafts (RR=0.74; 95% CI, 0.44-1.25; n=1 study; n=257 patients), and postoperative oxygen administration (RR=0.66; 95% CI, 0.42-1.03; n=1 study) (low certainty for all). CONCLUSIONS: Preincision antibiotics and iNPWT reduce the risk of early SSI after lower limb revascularization surgery. Confirmatory trials are required to determine whether other promising strategies also reduce SSI risk.

Interventions to improve well-being among children and youth aged 6-17 years during the COVID-19 pandemic: a systematic review.

BACKGROUND: The COVID-19 pandemic is an example of a global infectious disease outbreak that poses a threat to the well-being of children and youth (e.g., physical infection, psychological impacts). The consequences of challenges faced during COVID-19 may be longstanding and newly developed interventions are being deployed. We present a narrative synthesis of available evidence from the first 2 years of the COVID-19 pandemic on the feasibility, accessibility, and effects of interventions to improve well-being among children and youth to inform the development and refinement of interventions relevant to post-pandemic recovery. METHODS: Six databases were searched from inception to August 2022. A total of 5484 records were screened, 39 were reviewed in full text, and 19 studies were included. The definition of well-being and the five domains of well-being as defined by the Partnership for Maternal, Newborn & Child Health and the World Health Organization in collaboration with the United Nations H6 + Technical Working Group on Adolescent Health and Well-Being were used. RESULTS: Nineteen studies (74% randomized controlled trials) from 10 countries were identified, involving a total of 7492 children and youth (age range: 8.2-17.2 years; 27.8-75.2% males) and 954 parents that occurred during the COVID-19 pandemic (March 2020 to March 2021). Nearly all interventions (n = 18, 95%) targeted health and nutrition, followed by connectedness (n = 6, 32%), while fewer studies targeted agency and resilience (n = 5, 23%), learning and competence (n = 2, 11%), or safety and support (n = 1, 3%). Five interventions (26%) were self-guided while 13 interventions (68%) were guided synchronous by a trained professional, all of which targeted physical and mental health subdomains within health and nutrition; one intervention (5%) was unclear. CONCLUSIONS: Studies deploying synchronous interventions most often reported improved well-being among children and youth largely in the domain of health and nutrition, specifically physical and mental health. Targeted approaches will be crucial to reach sub-groups of children and youth who are most at risk of negative well-being outcomes. Further research is needed to determine how interventions that best supported children and youth early in the pandemic are different from interventions that are required now as we enter into the post-pandemic phase.

Efficacy of sustained knowledge translation (KT) interventions in chronic disease management in older adults: systematic review and meta-analysis of complex interventions.

BACKGROUND: Chronic disease management (CDM) through sustained knowledge translation (KT) interventions ensures long-term, high-quality care. We assessed implementation of KT interventions for supporting CDM and their efficacy when sustained in older adults. METHODS: Design: Systematic review with meta-analysis engaging 17 knowledge users using integrated KT. ELIGIBILITY CRITERIA: Randomized controlled trials (RCTs) including adults (> 65 years old) with chronic disease(s), their caregivers, health and/or policy-decision makers receiving a KT intervention to carry out a CDM intervention for at least 12 months (versus other KT interventions or usual care). INFORMATION SOURCES: We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from each database's inception to March 2020. OUTCOME MEASURES: Sustainability, fidelity, adherence of KT interventions for CDM practice, quality of life (QOL) and quality of care (QOC). Data extraction, risk of bias (ROB) assessment: We screened, abstracted and appraised articles (Effective Practice and Organisation of Care ROB tool) independently and in duplicate. DATA SYNTHESIS: We performed both random-effects and fixed-effect meta-analyses and estimated mean differences (MDs) for continuous and odds ratios (ORs) for dichotomous data. RESULTS: We included 158 RCTs (973,074 participants [961,745 patients, 5540 caregivers, 5789 providers]) and 39 companion reports comprising 329 KT interventions, involving patients (43.2%), healthcare providers (20.7%) or both (10.9%). We identified 16 studies described as assessing sustainability in 8.1% interventions, 67 studies as assessing adherence in 35.6% interventions and 20 studies as assessing fidelity in 8.7% of the interventions. Most meta-analyses suggested that KT interventions improved QOL, but imprecisely (36 item Short-Form mental [SF-36 mental]: MD 1.11, 95% confidence interval [CI] [- 1.25, 3.47], 14 RCTs, 5876 participants, I2 = 96%; European QOL-5 dimensions: MD 0.01, 95% CI [- 0.01, 0.02], 15 RCTs, 6628 participants, I2 = 25%; St George's Respiratory Questionnaire: MD - 2.12, 95% CI [- 3.72, - 0.51] 44 12 RCTs, 2893 participants, I2 = 44%). KT interventions improved QOC (OR 1.55, 95% CI [1.29, 1.85], 12 RCTS, 5271 participants, I2 = 21%). CONCLUSIONS: KT intervention sustainability was infrequently defined and assessed. Sustained KT interventions have the potential to improve QOL and QOC in older adults with CDM. However, their overall efficacy remains uncertain and it varies by effect modifiers, including intervention type, chronic disease number, comorbidities, and participant age. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018084810.

Deep Learning-Based Recurrent Delirium Prediction in Critically Ill Patients.

OBJECTIVES: To predict impending delirium in ICU patients using recurrent deep learning. DESIGN: Retrospective cohort study. SETTING: Fifteen medical-surgical ICUs across Alberta, Canada, between January 1, 2014, and January 24, 2020. PATIENTS: Forty-three thousand five hundred ten ICU admissions from 38,426 patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used ICU and administrative health data to train deep learning models to predict delirium episodes in the next two 12-hour periods (0-12 and 12-24 hr), starting at 24 hours after ICU admission, and to generate new predictions every 12 hours. We used a comprehensive set of 3,643 features, capturing patient history, early ICU admission information (first 24 hr), and the temporal dynamics of various clinical variables throughout the ICU admission. Our deep learning architecture consisted of a feature embedding, a recurrent, and a prediction module. Our best model based on gated recurrent units yielded a sensitivity of 0.810, a specificity of 0.848, a precision (positive predictive value) of 0.704, and an area under the receiver operating characteristic curve (AUROC) of 0.909 in the hold-out test set for the 0-12-hour prediction horizon. For the 12-24-hour prediction horizon, the same model achieved a sensitivity of 0.791, a specificity of 0.807, a precision of 0.637, and an AUROC of 0.895 in the test set. CONCLUSIONS: Our delirium prediction model achieved strong performance by applying deep learning to a dataset that is at least one order of magnitude larger than those used in previous studies. Another novel aspect of our study is the temporal nature of our features and predictions. Our model enables accurate prediction of impending delirium in the ICU, which can potentially lead to early intervention, more efficient allocation of ICU resources, and improved patient outcomes.

Safety Outcomes of Direct Discharge Home From ICUs: An Updated Systematic Review and Meta-Analysis (Direct From ICU Sent Home Study).

OBJECTIVE: To evaluate the impact of direct discharge home (DDH) from ICUs compared with ward transfer on safety outcomes of readmissions, emergency department (ED) visits, and mortality. DATA SOURCES: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature from inception until March 28, 2022. STUDY SELECTION: Randomized and nonrandomized studies of DDH patients compared with ward transfer were eligible. DATA EXTRACTION: We screened and extracted studies independently and in duplicate. We assessed risk of bias using the Newcastle-Ottawa Scale for observational studies. A random-effects meta-analysis model and heterogeneity assessment was performed using pooled data (inverse variance) for propensity-matched and unadjusted cohorts. We assessed the overall certainty of evidence for each outcome using the Grading Recommendations Assessment, Development and Evaluation approach. DATA SYNTHESIS: Of 10,228 citations identified, we included six studies. Of these, three high-quality studies, which enrolled 49,376 patients in propensity-matched cohorts, could be pooled using meta-analysis. For DDH from ICU, compared with ward transfers, there was no difference in the risk of ED visits at 30-day (22.4% vs 22.7%; relative risk [RR], 0.99; 95% CI, 0.95-1.02; p = 0.39; low certainty); hospital readmissions at 30-day (9.8% vs 9.6%; RR, 1.02; 95% CI, 0.91-1.15; p = 0.71; very low-to-low certainty); or 90-day mortality (2.8% vs 2.6%; RR, 1.06; 95% CI, 0.95-1.18; p = 0.29; very low-to-low certainty). There were no important differences in the unmatched cohorts or across subgroup analyses. CONCLUSIONS: Very low-to-low certainty evidence from observational studies suggests that DDH from ICU may have no difference in safety outcomes compared with ward transfer of selected ICU patients. In the future, this research question could be further examined by randomized control trials to provide higher certainty data.

Outcomes After Neuraxial or Regional Anaesthesia Instead of General Anaesthesia for Lower Limb Revascularisation Surgery: A Systematic Review and Meta-Analysis of Randomised and Non-Randomised Studies.

OBJECTIVE: To determine whether receipt of neuraxial or regional anaesthesia instead of general anaesthesia for lower limb revascularisation surgery affects patient outcomes. DATA SOURCES: MEDLINE, EMBASE, Evidence Based Medicine Reviews, and Google Scholar. REVIEW METHODS: After protocol registration, the data sources were searched for randomised and non-randomised studies comparing neuraxial or regional anaesthesia with general anaesthesia for lower limb revascularisation surgery in adults. Two investigators independently selected articles, extracted data, and assessed risks of bias. Data were pooled using random effects models. GRADE was used to assess certainty in cumulative evidence. RESULTS: From 10 755 citations identified, five randomised (n = 970) and 13 non-randomised (n = 96 800) studies were included. Use of neuraxial instead of general anaesthesia for lower limb revascularisation surgery was associated with no statistically significant reduction in short term (in hospital or 30 day) mortality in randomised studies (pooled odds ratio [OR] 0.77; 95% confidence interval [CI] 0.33 - 1.81; low certainty) and a statistically significant reduction in adjusted short term mortality in non-randomised studies (pooled OR 0.67; 95% CI 0.56 - 0.81; low certainty). Adults allocated to neuraxial anaesthesia in randomised studies had fewer pulmonary complications (pooled OR 0.35; 95% CI 0.16 - 0.76; low certainty). In non-randomised studies, neuraxial instead of general anaesthesia was associated with a lower adjusted odds of any morbidity (pooled OR 0.66; 95% CI 0.52 - 0.84), cardiac complications (pooled OR 0.68; 95% CI 0.58 - 0.79), pneumonia (pooled OR 0.81; 95% CI 0.64 - 1.02), prolonged mechanical ventilation (OR 0.09; 95% CI 0.002 - 0.55), and bypass graft thrombosis (OR 0.70; 95% CI 0.59 - 0.85), as well as a shorter operative duration (low certainty for all). Use of a nerve block instead of general anaesthesia was associated with a lower adjusted odds of delirium (OR 0.16; 95% CI 0.06 - 0.42) and a shorter operative duration (low certainty for both). CONCLUSION: Randomised and non-randomised data suggest that neuraxial anaesthesia for lower limb revascularisation surgery reduces morbidity and possibly mortality. Until randomised trials with a low risk of bias become available, this study supports use of neuraxial anaesthesia for these procedures where appropriate.

Exploring data reduction strategies in the analysis of continuous pressure imaging technology.

BACKGROUND: Science is becoming increasingly data intensive as digital innovations bring new capacity for continuous data generation and storage. This progress also brings challenges, as many scientific initiatives are challenged by the shear volumes of data produced. Here we present a case study of a data intensive randomized clinical trial assessing the utility of continuous pressure imaging (CPI) for reducing pressure injuries. OBJECTIVE: To explore an approach to reducing the amount of CPI data required for analyses to a manageable size without loss of critical information using a nested subset of pressure data. METHODS: Data from four enrolled study participants excluded from the analytical phase of the study were used to develop an approach to data reduction. A two-step data strategy was used. First, raw data were sampled at different frequencies (5, 30, 60, 120, and 240 s) to identify optimal measurement frequency. Second, similarity between adjacent frames was evaluated using correlation coefficients to identify position changes of enrolled study participants. Data strategy performance was evaluated through visual inspection using heat maps and time series plots. RESULTS: A sampling frequency of every 60 s provided reasonable representation of changes in interface pressure over time. This approach translated to using only 1.7% of the collected data in analyses. In the second step it was found that 160 frames within 24 h represented the pressure states of study participants. In total, only 480 frames from the 72 h of collected data would be needed for analyses without loss of information. Only ~ 0.2% of the raw data collected would be required for assessment of the primary trial outcome. CONCLUSIONS: Data reduction is an important component of big data analytics. Our two-step strategy markedly reduced the amount of data required for analyses without loss of information. This data reduction strategy, if validated, could be used in other CPI and other settings where large amounts of both temporal and spatial data must be analysed.

A Meta-Analysis to Derive Population-Based Quality Benchmarks of the Incidence of Surgical Site Infection after Lower Limb Revascularization Surgery.

BACKGROUND: The reported incidence of surgical site infection (SSI) after lower limb revascularization surgery varies. We conducted a systematic review and meta-analysis of population-based studies reporting the incidence of SSI in adults who underwent these surgeries in high-income countries to derive SSI quality benchmarks. METHODS: We searched MEDLINE, EMBASE, CENTRAL, and Evidence-Based Medicine Reviews (inception-to-April 28th, 2022) for population-based studies estimating the cumulative incidence of SSI among adults who underwent lower limb revascularization surgery for peripheral artery disease (PAD) in high-income countries. Two investigators independently screened abstracts and full-text articles, extracted data, and assessed risks of bias. We used random-effects models to pool data and GRADE to assess certainty. RESULTS: Among 6,258 citations, we included 53 studies (n = 757,726 patients); 8 of which (n = 435,769 patients) reported nonoverlapping data that were meta-analyzed. The pooled cumulative incidence of any SSI was 6.0 in 100 patients [95% confidence interval (CI) = 4.3-8.0 in 100 patients; n = 8 studies; n = 435,769 patients; moderate certainty]. The cumulative incidence of Szilagyi grade I (cellulitis), grade II (subcutaneous tissue), and grade III (prosthetic graft) SSI was 6.5 in 100 patients (95% CI = 4.3-8.6 in 100 patients; n = 2 studies; n = 39,645 patients; low certainty), 2.1 in 100 patients (95% CI = 2.0-2.3 in 100 patients; n = 2 studies; low certainty), and 0.4 in 100 patients (95% CI = 0.4-0.4 in 100 patients; n = 1 study; n = 333,275 patients; low certainty), respectively. The pooled cumulative incidence of any early (in-hospital/≤30-days) and late (>30-days) SSI was 6.2 in 100 patients (95% CI = 4.4-8.0 in 100 patients; n = 7 studies; n = 431,273 patients; moderate certainty) and 3.7 in 100 patients (95% CI = 2.2-5.2 in 100 patients; n = 2 studies; n = 10,565 patients; low certainty), respectively. CONCLUSIONS: This systematic review derived population-based benchmarks of the incidence of any SSI; Szilagyi I, II, and III SSI; and early and late SSI after lower limb revascularization surgery. These may be used by practicing surgeons and healthcare leaders/administrators to guide quality improvement efforts in the United States and perhaps other countries.

Liberation from Invasive Mechanical Ventilation with Continued Receipt of Vasopressor Infusions.

Rationale: Weaning protocols for discontinuation of invasive mechanical ventilation often mandate resolution of shock. Whether extubation while receiving vasopressors is associated with harm is uncertain. Objectives: To examine whether extubation while still receiving vasopressors is associated with worse outcomes. Methods: We performed a retrospective cohort study of adults in Calgary ICUs who received vasopressors with invasive mechanical ventilation and an extubation attempt. The primary exposure was continued vasopressor use at extubation. The primary outcome was reintubation within 96 hours. Secondary outcomes included in-hospital mortality and ICU/hospital length of stay (LOS). We assessed associations of vasopressor use at extubation with outcomes using multivariable competing-risk (reintubation/LOS) and Cox proportional-hazards (mortality) models. Measurements and Main Results: Of 6,140 patients who received invasive mechanical ventilation while on vasopressors, 721 (11.7%) were extubated while receiving vasopressors, and 5,419 (88.3%) after discontinuation. Extubation on vasopressors was not, in aggregate, significantly associated with an increased hazard of reintubation (subhazard ratio [SHR], 1.81 [95% confidence interval, 0.91-3.61]; P = 0.09). Both mortality (hazard ratio, 1.22 [1.02-1.47]; P = 0.03) and time to hospital discharge (SHR for remaining hospitalized, 0.78 [0.68-0.91]; P < 0.01) were increased. Extubation on high-dose vasopressors (>0.1 µg/kg/min) was associated with a greater hazard of reintubation (SHR, 2.25 [1.01-4.98]; P = 0.046) compared with extubation after vasopressor discontinuation. Meanwhile, extubation on low-dose vasopressors (⩽0.1 µg/kg/min) was associated with a lower mortality (hazard ratio, 0.69 [0.51-0.91]; P = 0.01) and a shorter ICU LOS (SHR, 1.34 [1.09-1.65]; P = 0.01), but no difference in reintubation or hospital LOS as compared with those weaned off vasopressors. Conclusions: Extubation while receiving high-dose but not low-dose vasopressors was associated with an increased risk of reintubation.

Exploring the influence of behavioural, normative and control beliefs on intentions to adhere to public health guidelines during the COVID-19 pandemic: a qualitative interview based study.

BACKGROUND: Perceived severity and susceptibility of disease are predictors of individual behaviour during health crises. Little is known about how individual beliefs influence intentions to adhere to public health guidelines during periods of health crises, and how access to and consumption of information influence these intentions. This study investigated behavioural beliefs, normative beliefs, and control beliefs, and their influence on behavioural intentions to adhere to public health guidelines during the COVID-19 pandemic. METHODS: Participants were recruited from a related COVID-19 study conducted by our team, and through snowball sampling in subsequent. Using a maximum variation sampling technique, we recruited a diverse group of participants representing six major regions in Canada. Participants took part in one-on-one semi-structured interviews from February 2021 to May 2021. Data were analyzed independently in duplicate by thematic analysis. The Theory of Planned Behaviour (TPB) was the conceptual framework used to organize dominant themes. RESULTS: We conducted a total of 60 individual interviews (137 eligible individuals contacted, 43.8% response rate) and identified six themes organized according to the three constructs of behavioural, normative and control beliefs as described in the TPB: (1) Behavioural: My "New Normal," Individual Rights and Perceived Pandemic Severity, Fatigue with COVID-19, (2) Normative: COVID-19 Collective, (3) Control: Practicality of Public Health Guidelines, and (6) Conflicting Public Health Messages. Most (n = 43, 71.7%) participants perceived individuals in their geographic community to be following public health guidelines adequately. Several participants (n = 15, 25.0%) commented on the unequal impact of restrictions based on socioeconomic factors (i.e., class, race, age). CONCLUSION: Individual perceptions of risk, loss of control, access to resources (i.e., childcare), and societal expectations, shaped intentions to engage in disease preventative behaviours (i.e., social distancing) during the COVID-19 pandemic.

Injury outcomes across Canadian trauma systems: a historical cohort study.

PURPOSE: Most North American trauma systems have designated trauma centres (TCs) including level I (ultraspecialized high-volume metropolitan centres), level II (specialized medium-volume urban centres), and/or level III (semirural or rural centres). Trauma system configuration varies across provinces and it is unclear how these differences influence patient distributions and outcomes. We aimed to compare patient case mix, case volumes, and risk-adjusted outcomes of adults with major trauma admitted to designated level I, II, and III TCs across Canadian trauma systems. METHODS: In a national historical cohort study, we extracted data from Canadian provincial trauma registries on major trauma patients treated between 2013 and 2018 in all designated level I, II, or III TCs in British Columbia, Alberta, Quebec, and Nova Scotia; level I and II TCs in New Brunswick; and four TCs in Ontario. We used multilevel generalized linear models to compare mortality and intensive care unit (ICU) admission and competitive risk models for hospital and ICU length of stay (LOS). Ontario could not be included in outcome comparisons because there were no population-based data from this province. RESULTS: The study sample comprised 50,959 patients. Patient distributions in level I and II TCs were similar across provinces but we observed significant differences in case mix and volumes for level III TCs. There was low variation in risk-adjusted mortality and LOS across provinces and TCs but interprovincial and intercentre variation in risk-adjusted ICU admission was high. CONCLUSIONS: Our results suggest that differences in the functional role of TCs according to their designation level across provinces leads to significant variations in the distribution of patients, case volumes, resource use, and clinical outcomes. These results highlight opportunities to improve Canadian trauma care and underline the need for standardized population-based injury data to support national quality improvement efforts.

RéSUMé: OBJECTIF: La plupart des systèmes de traumatologie nord-américains disposent de centres de traumatologie (CT) désignés, y compris de niveau I (centres métropolitains ultraspécialisés à volume élevé), de niveau II (centres urbains spécialisés à volume moyen) et/ou de niveau III (centres semi-ruraux ou ruraux). La configuration des systèmes de traumatologie varie d'une province à l'autre et nous ne savons pas comment ces différences influent sur la répartition de la patientèle et sur les issues. Notre objectif était de comparer le mélange de cas des patient·es, le volume de cas et les issues ajustées en fonction du risque des adultes ayant subi un traumatisme majeur admis·es dans des CT désignés de niveaux I, II et III dans l'ensemble des systèmes de traumatologie canadiens. MéTHODE: Dans une étude de cohorte historique nationale, nous avons extrait des données des registres provinciaux canadiens de traumatologie sur les patient·es ayant subi un traumatisme majeur traité·es entre 2013 et 2018 dans tous les CT désignés de niveau I, II ou III en Colombie-Britannique, en Alberta, au Québec et en Nouvelle-Écosse, les CT de niveau I et II au Nouveau-Brunswick, et dans quatre CT en Ontario. Nous avons utilisé des modèles linéaires généralisés à plusieurs niveaux pour comparer la mortalité, les admissions en unité de soins intensifs (USI) et les modèles de risque compétitif pour la durée du séjour à l'hôpital et à l'USI. L'Ontario n'a pas pu être inclus dans les comparaisons des devenirs parce qu'il n'y avait pas de données démographiques pour cette province. RéSULTATS: L'échantillon de l'étude comptait 50 959 patient·es. La répartition des patient·es dans les CT de niveaux I et II était similaire d'une province à l'autre, mais nous avons observé des différences significatives dans le mélange des cas et les volumes pour les CT de niveau III. Il y avait une faible variation de la mortalité ajustée en fonction du risque et des durées de séjour entre les provinces et les CT, mais la variation interprovinciale et intercentre des admissions à l'USI ajustées en fonction du risque était élevée. CONCLUSION: Nos résultats suggèrent que les différences dans le rôle fonctionnel des CT selon leur niveau de désignation d'une province à l'autre entraînent des variations importantes dans la répartition des patient·es, le nombre de cas, l'utilisation des ressources et les issues cliniques. Ces résultats mettent en évidence les possibilités d'amélioration des soins de traumatologie au Canada et soulignent la nécessité de disposer de données normalisées sur les blessures dans la population pour appuyer les efforts nationaux d'amélioration de la qualité.

Clinical Practice Guideline Recommendations in Pediatric Orthopaedic Injury: A Systematic Review.

BACKGROUND: Lack of adherence to recommendations on pediatric orthopaedic injury care may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aimed to identify CPGs for pediatric orthopaedic injury care, appraise their quality, and synthesize the quality of evidence and the strength of associated recommendations. METHODS: We searched Medline, Embase, Cochrane CENTRAL, Web of Science and websites of clinical organizations. CPGs including at least one recommendation targeting pediatric orthopaedic injury populations on any diagnostic or therapeutic intervention developed in the last 15 years were eligible. Pairs of reviewers independently extracted data and evaluated CPG quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. We synthesized recommendations from high-quality CPGs using a recommendations matrix based on the GRADE Evidence-to-Decision framework. RESULTS: We included 13 eligible CPGs, of which 7 were rated high quality. Lack of stakeholder involvement and applicability (i.e., implementation strategies) were identified as weaknesses. We extracted 53 recommendations of which 19 were based on moderate or high-quality evidence. CONCLUSIONS: We provide a synthesis of recommendations from high-quality CPGs that can be used by clinicians to guide treatment decisions. Future CPGs should aim to use a partnership approach with all key stakeholders and provide strategies to facilitate implementation. This study also highlights the need for more rigorous research on pediatric orthopaedic trauma. LEVEL OF EVIDENCE: Level II-therapeutic study.

Interhospital Variations in Resource Use Intensity for In-hospital Injury Deaths: A Retrospective Multicenter Cohort Study.

OBJECTIVE: Evaluate interhospital variation in resource use for in-hospital injury deaths. BACKGROUND: Significant variation in resource use for end-of-life care has been observed in the US for chronic diseases. However, there is an important knowledge gap on end-of-life resource use for trauma patients. METHODS: We conducted a multicenter, retrospective cohort study of injury deaths following hospitalization in any of the 57 trauma centers in a Canadian trauma system (2013-2016). Resource use intensity was measured using activity-based costing (2016 $CAN) according to time of death (72 h, 3-14 d, ≥14 d). We used multilevel log-linear regression to model resource use and estimated interhospital variation using intraclass correlation coefficients (ICC). RESULTS: Our study population comprised 2044 injury deaths. Variation in resource use between hospitals was observed for all 3 time frames (ICC = 6.5%, 6.6%, and 5.9% for < 72 h, 3-14 d, and ≥14 d, respectively). Interhospital variation was stronger for allied health services (ICC = 18 to 26%), medical imaging (ICC = 4 to 10%), and the ICU (ICC = 5 to 6%) than other activity centers. We observed stronger interhospital variation for patients < 65 years of age (ICC = 11 to 34%) than those ≥65 (ICC = 5 to 6%) and for traumatic brain injury (ICC = 5 to 13%) than other injuries (ICC = 1 to 8%). CONCLUSIONS: We observed variation in resource use intensity for injury deaths across trauma centers. Strongest variation was observed for younger patients and those with traumatic brain injury. Results may reflect variation in level of care decisions and the incidence of withdrawal of life-sustaining therapies.

A Multicenter Cohort Study of Falls Among Patients Admitted to the ICU.

OBJECTIVES: To determine the incidence of falls, risk factors, and adverse outcomes, among patients admitted to the ICU. DESIGN: Retrospective cohort study. SETTING: Seventeen ICUs in Alberta, Canada. PATIENTS: Seventy-three thousand four hundred ninety-five consecutive adult patient admissions between January 1, 2014, and December 31, 2019. MEASUREMENTS AND MAIN RESULTS: A mixed-effects negative binomial regression model was used to examine risk factors associated with falls. Linear and logistic regression models were used to evaluate adverse outcomes. Six hundred forty patients experienced 710 falls over 398,223 patient days (incidence rate of 1.78 falls per 1,000 patient days [95% CI, 1.65-1.91]). The daily incidence of falls increased during the ICU stay (e.g., day 1 vs day 7; 0.51 vs 2.43 falls per 1,000 patient days) and varied significantly between ICUs (range, 0.37-4.64 falls per 1,000 patient days). Male sex (incidence rate ratio [IRR], 1.37; 95% CI, 1.15-1.63), previous invasive mechanical ventilation (IRR, 1.82; 95% CI, 1.40-2.38), previous sedative and analgesic medication infusions (IRR, 1.60; 95% CI, 1.15-2.24), delirium (IRR, 3.85; 95% CI, 3.23-4.58), and patient mobilization (IRR, 1.26; 95% CI, 1.21-1.30) were risk factors for falling. Falls were associated with longer ICU (ratio of means [RM], 3.10; 95% CI, 2.86-3.36) and hospital (RM, 2.21; 95% CI, 2.01-2.42) stays, but lower odds of death in the ICU (odds ratio [OR], 0.09; 95% CI, 0.05-0.17) and hospital (OR, 0.21; 95% CI, 0.14-0.30). CONCLUSIONS: We observed that among ICU patients, falls occur frequently, vary substantially between ICUs, and are associated with modifiable risk factors, longer ICU and hospital stays, and lower risk of death. Our study suggests that fall prevention strategies should be considered for critically ill patients admitted to ICU.