Exploring the Development of a Canadian Frostbite Care Network and the Future of Frostbite Care in Canada Using a Qualitative Approach.

INTRODUCTION: The Canadian Frostbite Collaborative project is exploring frostbite patient care needs and current practices in Canada to inform the development of a Canadian frostbite care network (CFCN) as a national quality improvement initiative. METHODS: Using a quantitative and qualitative approach, this study aimed to define the landscape of current frostbite practices, challenges, and interest in future work. RESULTS: Current frostbite care practices were initially assessed through semistructured phone interviews of Canadian healthcare providers. Canadian healthcare providers managing frostbite in a range of health disciplines and contexts then participated in focus group sessions discussing the potential roles and opportunities as well as potential challenges in developing a CFCN. Roles and opportunities for a network in advancing frostbite care included facilitating research, educating stakeholders, facilitating collaboration, standardizing care, and advocating for frostbite care. Challenges identified in frostbite care and network development included managing resources, navigating the Canadian healthcare system, overcoming low numbers, and communicating with policymakers and frontline providers. CONCLUSIONS: Formalizing a CFCN may provide important opportunities and support in overcoming critical barriers to providing high-quality frostbite care across Canada.

Prior use of medications for opioid use disorder in ED patients with opioid overdose: prevalence, misuse and overdose severity.

OBJECTIVES: Medications for opioid use disorder (MOUD) reduce opioid overdose (OD) deaths; however, prevalence and misuse of MOUD in ED patients presenting with opioid overdose are unclear, as are any impacts of existing MOUD prescriptions on subsequent OD severity. METHODS: This was a prospective observational cohort of ED patients with opioid OD at two tertiary-care hospitals from 2015 to 19. Patients with confirmed opioid OD (via urine toxicology) were included, while patients with alternate diagnoses, insufficient data, age < 18, and prisoners were excluded. OD severity was defined using: (a) hospital LOS (days); and (b) in-hospital mortality. Time trends by calendar year and associations between MOUD and study outcomes were calculated. RESULTS: In 2829 ED patients with acute drug OD, 696 with confirmed opioid OD were included. Overall, 120 patients (17%) were previously prescribed any MOUD, and MOUD prevalence was significantly higher in 2018 and 2019 compared to 2016 (20.1% and 27.8% vs. 8.8%, p < 0.05). Odds of MOUD misuse were significantly higher for methadone (OR 3.96 95% CI 2.57-6.12) and lowest for buprenorphine (OR 1.16, p = NS). Mean LOS was over 50% longer for methadone (3.08 days) compared to buprenorphine and naltrexone (both 2.0 days, p = NS). Following adjustment for confounders, buprenorphine use was associated with significantly shorter LOS (IRR -0.44 (95%CI -0.85, -0.04)). Odds of death were 30% lower for patients on any MOUD (OR 0.70, 95%CI 0.09-5.72), but highest in the methadone group (OR 0.82, 95%CI 0.10-6.74). CONCLUSIONS: While MOUD prevalence significantly increased over the study period, MOUD misuse occurred for patients taking methadone, and OD LOS overall was lower in patients with any prior buprenorphine prescription.

Is there a role for MRI in the preoperative assessment of patients with DCIS?

BACKGROUND: Breast magnetic resonance imaging (MRI) is used to identify residual and additional disease in patients with invasive carcinoma. The use of MRI in assessing extent of disease for ductal carcinoma in situ (DCIS) is less well defined. This study assessed the value of MRI in the preoperative evaluation of DCIS. MATERIALS AND METHODS: We identified 98 patients with DCIS in 2007. Of these, 63 underwent stereotactic biopsy, followed by MRI. There were 35 who underwent stereotactic biopsy alone. Concordance between MRI and histopathology was defined as the presence or absence of residual disease. RESULTS: There was no significant difference in mastectomy rates between the MRI and non-MRI group (20.3% vs 25.7%, P = .62). In patients undergoing breast-conserving surgery (BCS), there were fewer positive margins in the MRI versus the non-MRI group (21.2% vs 30.8%, P = .41). Of the 64 cases that underwent preoperative MRI, 43 (67.2%) were concordant. Also, 15 of 43 cases (34.8%) had MRI results that accurately predicted pathologic size. In 28 of 43 patients (65.2%), MRI overestimated disease in 20, by a mean of 1.97 cm. In patients with MRI tumor size >2 cm, MRI overestimated disease by a mean of 3.17 cm. Of the 64 cases, 21 (32.8%) were discordant. Also, 10 of 21 (47.6%) had a positive MRI and no residual disease on histopathology, and 11 of 21 (52.3%) had negative MRI and residual disease on pathology. CONCLUSIONS: MRI does not accurately predict extent of disease in patients with extensive DCIS. In patients with MRI tumor size < or = 2 cm, MRI may assist in surgical planning. MRI results in patients with DCIS should be interpreted with caution; decision for mastectomy should not be made on MRI findings alone.