The effect of recreational cannabis legalization and commercialization on substance use, mental health, and injury: a systematic review.

OBJECTIVE: To determine the effect of recreational cannabis legalization (RCL) and/or recreational cannabis commercialization (RCC) on emergency department (ED) visits, hospitalizations, and deaths due to substance use, injury, and mental health among those aged 11 years and older. METHODS: A systematic review of six electronic databases up to February 1, 2023. Original, peer-reviewed articles with interrupted time series or before and after designs were included. Four independent reviewers screened articles and assessed risk of bias. Outcomes with 'critical' risk of bias were excluded. Protocol registered on PROSPERO (# CRD42021265183). RESULTS: After screening and risk of bias assessment, 29 studies were included which examined ED visits or hospitalizations for cannabis use or alcohol (N = 10), opioid mortality (N = 3), motor vehicle fatalities or injury (N = 11), and intentional injury/mental health (N = 5). Rates or number of cannabis-related hospitalizations increased after RCL in Canada and the USA. Immediate increases in rates of cannabis-related ED visits were found after both RCL and RCC in Canada. Rates of traffic fatalities increased after RCL and RCC in certain jurisdictions in the USA. CONCLUSIONS: RCL was associated with increased rates of cannabis-related hospitalizations. RCL and/or RCC was associated with increased rates of cannabis-related ED visits, consistently shown across sex and age groups. The effect on fatal motor vehicle incidents was mixed, with observed increases found after RCL and/or RCC. The effect of RCL or RCC on opioids, alcohol, intentional injury, and mental health is not clear. These results inform population health initiatives and international jurisdictions considering RCL implementation.

Patient engagement study to identify and improve surgical experience.

BACKGROUND: Patient engagement is the establishment of active partnerships between patients, families, and health professionals to improve healthcare delivery. The objective of this project was to conduct a series of patient engagement workshops to identify areas to improve the surgical experience and develop strategies to address areas identified as high priority. METHODS: Faculty surgeons and patients were invited to participate in three in-person meetings. Evaluation included identifying and developing strategies for three priority areas to improve the surgical experience and level of engagement achieved at each meeting. RESULTS: Sixteen faculty surgeons and 32 patients participated. Some 63 themes to improve the surgical experience were identified; the three highest-priority themes were physician communication, discharge process, and expectations at home after discharge. Individual improvement strategies for these three prioritized themes (12, 36 and 6 respectively) were used to develop a formal strategic plan, and included a physician communication survey, discharge process worksheet and video, and guideline regarding what to expect at home after discharge. Overall, the level of engagement achieved was considered high by over 85 per cent of the participants. CONCLUSION: A high level of patient engagement was achieved. Priorities were identified with patients and surgeons to improve surgical experience, and strategies were developed to address these areas.

Invasive thymoma metastatic to the cavernous sinus.

BACKGROUND: Thymomas are typically benign tumors of thymic epithelium. Metastases to distal sites, particularly intracranial locations, are extremely rare. Herein, we present the third case of thymoma and the second invasive thymoma to metastasize to the cavernous sinus, adjacent to the pituitary. CASE DESCRIPTION: A 41-year-old female patient presented with headaches, stuffy nose, and drooping of the right face. A magnetic resonance imaging scan revealed a complex, multilobulated mass centered upon the right cavernous sinus. The mass was removed via transsphenoidal surgery, and histopathological investigation confirmed the diagnosis of metastatic thymoma. A positron emission tomography-computed tomography scan demonstrated a large anterior mediastinal mass. A biopsy confirmed the diagnosis of invasive thymoma morphologically identical to the World Health Organization type B2 sellar region metastasis. CONCLUSION: Although rare, thymomas can metastasize to the central nervous system. Our case is the second invasive thymoma to metastasize to the cavernous sinus, adjacent to the pituitary.

Body mass index as a risk factor for increased serum lactate during craniotomy.

BACKGROUND: An increase in serum lactate can occur in patients undergoing craniotomy. We hypothesized that prolonged craniotomy for brain tumor resection leads to inadequate tissue perfusion as demonstrated by increased level of lactate. This study attempts to determine the mechanism and identify any modifiable risk factors. METHODS. Prospective, observational study of 18 patients undergoing craniotomy for brain tumor resection. The primary outcome was that peak serum lactate would correlate with length of surgery. Secondary outcomes included lactate at 3, 6 and 9 hours, creatine kinase (CK) and myoglobinuria overtime. These values were correlated with expected risk factors for lactatemia including length of surgery, Body Mass Index (BMI), hypotension, hemoglobin and mannitol therapy. RESULTS. Serum lactate consistently increased in the first 3 hours in all patients (2.21±1.22 mmol/L) with a peak increase at 9 hours (3.73±1.62 mmol/L) (P<0.05 for both). The peak serum lactate did not correlate with length of surgery (P=0.799). However, the change in lactate over 3 hours (Δ3hrLactate) did correlate with BMI (P=0.010). Serum CK was increased at 12 hours (P<0.05) and reached a peak level greater than 1000 U/L in 8 of 18 patients. Six of these patients experienced myoglobinuria. No other parameters correlated with increased lactate. CONCLUSION: We observed a consistent and early increase in serum lactate in patients undergoing craniotomy, which correlated with BMI, but not length of surgery. Associated increases in CK and myoglobinuria support the hypothesis that elevated BMI contributed to muscle ischemia and tissue breakdown during craniotomy. Future studies are required to establish the overall clinical significance and mechanism of hyperlactatemia during neurosurgery.

Normal-pressure hydrocephalus: is there a genetic predisposition?

BACKGROUND: Normal-pressure hydrocephalus (NPH) is characterized by gait disturbance, cognitive impairment, with or without urinary incontinence, enlarged ventricles with or without cerebral atrophy and normal cerebrospinal fluid pressure. METHODS: We report two sisters with NPH who lived together their entire lives and whose natural history might provide insights into genetic and environmental mechanisms underlying this disorder. Both patients were in their early seventies, single, had similar daily habits and hypertension. No other family members had NPH. RESULTS: They both underwent shunt placement and showed improvement documented by history and neuropsychological assessment. Both showed a delayed deterioration due to vasculopathy. Both patients were homozygous for the apolipoprotein E (ApoE) e3 allele on chromosome 19. No environmental factors that might have influenced the development of NPH were identified. CONCLUSION: Our report of two sisters with NPH may indicate the presence of genetic predisposition and further studies involving genetics and environmental factors are necessary to elucidate their role in the pathogenesis of NPH.

Estrogen receptors alpha and beta immunohistochemical expression: clinicopathological correlations in pituitary adenomas.

AIM: We investigated the immunohistochemical expression of estrogen receptors alpha (ERalpha) and beta (ERbeta) in pituitary adenoma subtypes combined with clinicopathological factors. MATERIALS AND METHODS: Pituitary adenomas (n=75) were immunostained for ERalpha and ERbeta using the streptavidin-biotin-peroxidase complex method with a monoclonal ERalpha antibody and polyclonal ERbeta antibody. RESULTS: Nuclear immunoreactivity for both receptors was highest among PRL, FSH/LH, null cell, and GH adenomas. ACTH, silent subtypes I and II corticotrophs, and subtype III adenomas were the least immunoreactive for both receptors. ACTH adenomas expressed significantly less ERalpha than FSH-LH, GH, and null cell adenomas. A significantly elevated ERalpha expression was observed in macroadenomas compared to microadenomas and non-invasive compared to invasive tumors. CONCLUSION: ERalpha and ERbeta are differentially expressed in the various pituitary adenoma subtypes suggesting a cell-specific function for these receptors. To elucidate the role of ERalpha in tumor size and invasiveness, additional studies are required.

Effectiveness of multifaceted fall-prevention programs for the elderly in residential care.

BACKGROUND: Unintentional falls are particularly prevalent among older people and constitute a public health concern. Not much is known about the implications of multifaceted intervention programs implemented in residential care settings. OBJECTIVES: To evaluate the effectiveness of multifaceted intervention programs in reducing the number of falls, fallers, recurrent fallers, and injurious falls among older people living in residential care facilities. SEARCH STRATEGY: Comprehensive searches of Medline, PubMed, and EMBASE up to July 2007, the cited literature lists of each included study, and the internet engines Google Scholar, Yahoo, and Dogpile were performed to identify eligible studies. SELECTION CRITERIA: Eligible studies for this review were those that had randomized, controlled trials with adequate follow-up study components in their design. Studies that included elderly people in residential care who participated in multifaceted falls-prevention programs were included. DATA COLLECTION AND ANALYSIS: Two authors independently extracted the necessary data. Studies were assessed for quality by the criteria of Downs and Black. The results of the included studies have been reviewed narratively. MAIN RESULTS: From 21 articles potentially relevant to the topic, five studies met the inclusion criteria and all were reasonably well conducted. Three reported significant reductions in the number of recurrent fallers, two reported significant reductions in the number of falls, and one reported significant reductions in the number of fallers. One other reported a reduction in the number of injurious falls in those who received the multifaceted prevention program compared with the control group. However, the analyses of this specific study were not based on intent-to-treat, so the effect of intervention on the number of injurious falls remains inconclusive. No study reported on adverse events, costs, or sustainability of the interventions. CONCLUSIONS: Multifaceted programs that encompass a wide range of intervention strategies have shown some evidence of efficacy. However, more well-designed research is required that assesses effects on injurious falls, quality of life, cost-effectiveness, and sustainability.

Geomatics in injury prevention: the science, the potential and the limitations.

BACKGROUND: Geomatics describes the activities involved in acquiring and managing geographical data and producing geographical information for scientific, administrative and technical endeavors. As an emerging science, geomatics has a great potential to support public health. Geomatics provides a conceptual foundation for the development of geographic information systems (GIS), computerized tools that manage and display geographical data for analytical applications. As descriptive epidemiology typically involves the examination of person, place and time in the occurrence of disease or injury, geomatics and GIS can play an important role in understanding and preventing injury. AIM: This article provides a background to geomatics for those in the injury prevention field who are unfamiliar with spatial analysis. We hope to stimulate researchers and practitioners to begin to use geomatics to assist in the prevention of injury. METHODS: The authors illustrate the potential benefits and limitations of geomatics in injury prevention in a non-technical way through the use of maps and analysis. RESULTS: By analysing the location of patients treated for fall injuries in Central Toronto using GIS, some demographic and land use variables, such as household income, age, and the location of homeless shelters, were identified as explanatory factors for the spatial distribution. CONCLUSION: By supporting novel approaches to injury prevention, geomatics has a great potential for efforts to combat the burden of injury. Despite some limitations, those with an interest in injury prevention could benefit from this science.

Child safety education and the world wide web: an evaluation of the content and quality of online resources.

The purpose of this study was to assess the content, quality, and type of internet resources available for safety education. Using 19 search engines with search strings targeting major forms of injury, identified resources were classified by audience group, accessibility, and authorship. Two independent reviewers rated each resource on the basis of its content and a set of quality criteria using a three point scale. Overall, 10 (18.2%) resources were of highest quality, four (7.3%) were intermediate, and 41 (74.5%) were not recommended. Eighteen months after the original search, 67.3% of all resources and 90% of the highest quality resources were still on the internet. This study provides a methodology for evaluating child safety resources on the world wide web and demonstrates that most internet resources for safety education are of dubious quality. A rating system such as the one developed for this study may be used to identify valuable internet materials.

Evaluation of the ThinkFirst Canada, Smart Hockey, brain and spinal cord injury prevention video.

OBJECTIVE: The ThinkFirst Canada Smart Hockey program is an educational injury prevention video that teaches the mechanisms, consequences, and prevention of brain and spinal cord injury in ice hockey. This study evaluates knowledge transfer and behavioural outcomes in 11-12 year old hockey players who viewed the video. DESIGN: Randomized controlled design. SETTING: Greater Toronto Minor Hockey League, Toronto Ontario. SUBJECTS: Minor, competitive 11-12 year old male ice hockey players and hockey team coaches. INTERVENTIONS: The Smart Hockey video was shown to experimental teams at mid-season. An interview was conducted with coaches to understand reasons to accept or refuse the injury prevention video. MAIN OUTCOME MEASURES: A test of concussion knowledge was administered before, immediately after, and three months after exposure to the video. The incidence of aggressive penalties was measured before and after viewing the video. RESULTS: The number of causes and mechanisms of concussion named by players increased from 1.13 to 2.47 and from 0.67 to 1.22 respectively. This effect was maintained at three months. There was no significant change in control teams. There was no significant change in total penalties after video exposure; however, specific body checking related penalties were significantly reduced in the experimental group. CONCLUSION: This study showed some improvements in knowledge and behaviours after a single viewing of a video; however, these findings require confirmation with a larger sample to understand the sociobehavioural aspects of sport that determine the effectiveness and acceptance of injury prevention interventions.

A novel approach to endourological training: training at the Surgical Skills Center.

PURPOSE: We investigated the effects of didactic teaching and supervised hands-on practice on endourological skills using high fidelity genitourinary bench models at a surgical skills laboratory. We also validated a global rating scale and checklist designed specifically for endourological tasks. MATERIALS AND METHODS: We assessed 17 urology residents for the ability to remove a mid ureteral stone using a high fidelity genitourinary model on 3 occasions, including a pre-test at the beginning of the study to assess baseline skills, after a didactic teaching session and after a supervised practice session on high fidelity models. Performance was graded according to a global rating scale, checklist, pass rating and time needed to complete task. RESULTS: Senior residents achieved significantly higher pre-test global rating scores than junior residents (p <0.01). One-way repeated measures analysis of variance revealed a significant effect of training on the endoscopic global rating score (p <0.001). Post-hoc tests demonstrated significant improvement in the global rating scores from the pre-test to the post-didactic session (p <0.05) and from the post-didactic to the post-practice session (p <0.01). Interrater reliability using the global rating scale was high (Pearson's r = 0.82, p <0.01). Significant but less powerful results were observed in the checklist score, pass rating and time. CONCLUSIONS: There was a positive effect of training at the surgical skills laboratory on endourological skills. The global rating scale showed good construct validity and reliability for assessing endourological tasks, more so than the checklist, pass rating or time.

Surgical exposure and resection of the vertical portion of the petrous internal carotid artery: anatomic study.

OBJECTIVE: The goals were to determine which surgical approaches, i.e., the preauricular subtemporal infratemporal fossa (PSI), postauricular transtemporal (PAT), and/or subtemporal middle fossa (SMF) approaches, provide optimal exposure of the anterior, posterior, medial, and lateral aspects of the vertical segment of the petrous internal carotid artery (VPCA) and to determine the length of the VPCA that can be resected before a vein graft is necessary. METHODS: Using 22 cadaveric specimens, we compared the length of exposure of the VPCA provided by the PSI, PAT, and SMF approaches. The segment of the VPCA that was exposed with each approach was measured in millimeters and expressed as a percentage of the total length of the VPCA. Resection of the VPCA in 1-mm increments was performed until a graft would be necessary; the total length of the resected segment was recorded in millimeters and was also expressed as a percentage of the total length of the VPCA. RESULTS: The PSI approach provided average exposures of 14.1 mm (95% of the total exposure possible) of the anterior aspect and 14.3 mm (96%) of the lateral aspect of the VPCA; resection of less than 2.3 mm (16%) of the VPCA could be repaired with an end-to-end anastomosis. The PAT approach provided average exposures of 10.5 mm (71 %) of the lateral aspect and 10.0 mm (76%) of the posterior aspect of the VPCA; resection of less than 2.8 mm of the VPCA could be repaired with an end-to-end anastomosis. The SMF approach provided average exposures of 6.1 mm (45%) of the anterior aspect and 5.4 mm (41 %) of the lateral aspect of the VPCA; resection of less than 2.4 mm (24%) of the VPCA could be repaired with an end-to-end anastomosis. CONCLUSION: Lesions on the anterior and lateral aspects of the VPCA can be fully exposed with the PSI approach or partially exposed with the less invasive SMF approach. Lesions on the posterior aspect of the artery are best exposed with the PAT approach. Lesions on the medial aspect of the VPCA cannot be exposed unless the VPCA is mobilized in the PSI approach. Resection of less than approximately 2.5 mm (20%) can be repaired with an end-to-end anastomosis, regardless of the approach used.

Evaluating surgical resident selection procedures.

PURPOSE: The purposes of this study were to develop and assess a rating form for selection of surgical residents, determine the criteria most important in selection, determine the reliability of the assessment form and process both within and across sites, and document differences in procedure and structure of resident selection processes across Canada. METHODS: Twelve of 13 English-speaking orthopedic surgery training programs in Canada participated during the 1999 selection year. The critical incident technique was utilized to determine the criteria most important in selection. From these criteria a 10-item rating form was developed with each item on a 5-point scale. Sixty-six candidates were invited for interviews across the country. Each interviewer completed one assessment form for each candidate, and independently ranked all candidates at the conclusion of all interviews. Consensus final rank orders were then created for each residency program. Across all programs, pairwise program-by-program correlations for each assessment parameter were made. RESULTS: The internal consistency of assessment form ratings for each interviewer was moderately high (mean Cronbach's alpha = 0.71). A correlation between each item and the final rank order for each program revealed that the items work ethic, interpersonal qualities, orthopedic experience, and enthusiasm correlated most highly with final candidate rank orders (r = 0.5, 0.48, 0.48, 0.45, respectively). The interrater reliabilities (within panels) and interpanel reliabilities (within programs) for the rank orders were 0.67 and 0.63, respectively. Using the Spearman-Brown prophecy formula, it was found that two panels with two interviewers on each panel are required to obtain a stable measure of a given candidate (reliabilities of 0.80). The average pairwise program-by-program correlations were low for the final candidate rank orders (0.14). CONCLUSIONS: A method was introduced to develop a standard, reliable candidate assessment form to evaluate residency selection procedures. The assessment form ratings were found to be consistent within interviewers. Candidate assessments within programs (both between interviewers and between panels) were moderately reliable suggesting agreement within programs regarding the relative quality of candidates, but there was very little agreement across programs.

Idiopathic normal pressure hydrocephalus: a systematic review of diagnosis and outcome.

OBJECTIVE: Patient selection for cerebrospinal fluid diversion is difficult, because idiopathic normal pressure hydrocephalus (INPH) mimics other neurodegenerative disorders and no findings reliably predict outcome. The literature was reviewed to identify diagnostic criteria that predict shunt response and to formulate prognostic expectations. METHODS: MEDLINE was searched, and 44 articles meeting predetermined criteria were included. RESULTS: Clinical series were frequently retrospective with small patient numbers and unstandardized outcome evaluation. Clinical findings suggestive of shunt responsiveness were the complete triad (gait disturbance, urinary incontinence, and dementia) with early gait disturbance. Degree of hydrocephalus was not correlated with clinical improvement. Reduction of the subcortical low-blood flow area was correlated with improvement in three small studies. Clinical response to prolonged cerebrospinal fluid drainage predicted shunt outcome in all cases in two small series. Overall, 59% (range, 24-100%) of patients improved after shunting, and 29% (range, 10-100%) of patients experienced prolonged improvement. Complications occurred in 38% (range, 5-100%) of patients, additional surgery was required in 22% (range, 0-47%) of patients, and there was a 6% (range, 0-35%) combined rate of permanent neurological deficit and death. CONCLUSION: Shunting INPH is associated with an approximately 29% rate of significant improvement and a 6% significant complication rate. Enlargement of the subcortical low-flow area and clinical improvement secondary to prolonged lumbar drainage may provide additive predictive value above clinical and computed tomographic criteria. A multicenter clinical trial that focuses on the value of ancillary tests, defines the clinical course of a patient with a ventriculoperitoneal shunt, and evaluates the cost effectiveness of shunting INPH is needed to better describe outcome from shunting in INPH.

Combined pleomorphic xanthoastrocytoma-ganglioglioma of the cerebellum.

Combined pleomorphic xanthoastrocytoma-ganglioma is a rare neoplasm, occurring in patients younger than 30 years. The clinical course of these tumors is difficult to predict because of their rarity. We report a case of combined pleomorphic xanthoastrocytoma-ganglioma that, in addition to the patient's age, is unusual in several respects. The lesion was located in the cerebellar vermis of a 60-year-old man and was radiographically solid. Histologically, there was an admixture of markedly pleomorphic astrocytic cells and neoplastic ganglion cells, with permeation of the overlying leptomeninges and surrounding cerebellum. In addition, there was focal capillary endothelial proliferation. There was no necrosis, and mitotic activity was rare at 1 mitotic figure per 40 high-power fields. The patient underwent a near gross total resection and postoperative radiotherapy and remains well through 16 months of follow-up.

A computer-based trauma simulator for teaching trauma management skills.

BACKGROUND: The management of multiply injured trauma patients is a skill requiring broad knowledge, sound judgment, and leadership capabilities. The purpose of this study was to evaluate the effectiveness of a computer-based trauma simulator as a teaching tool for senior medical students. METHODS: All year-4 clinical clerks at the University of Toronto were approached to participate in a focused, 2-hour trauma management course. The volunteer rate for the course was 79%. Students were randomized to either computer-based simulator or seminar-based teaching groups. Outcome measures in this study were students' trauma objective structured clinical examination (OSCE) scores. RESULTS: Both the trauma simulator and seminar teaching groups performed significantly better than the comparison group (no additional teaching) on the trauma OSCE patient encounter component, but not the written component of the examination. There was no significant difference in the performances of the trauma simulator and seminar teaching groups. Students overwhelmingly felt the trauma simulator was effective for their trauma teaching, and improved their overall confidence in clinical trauma scenarios. CONCLUSIONS: There is a significant benefit associated with a focused, clinically based trauma management course for senior medical students. No additional improvement was noted with the use of a high fidelity computer-based trauma simulator.

Craniotomy revisited: techniques for improved access and reconstruction.

OBJECTIVE: To describe simple modifications of the technique of opening and closure of the craniotomy to improve basal exposure and reconstruction. METHODS: The modifications involve: a) additional soft-tissue dissection which is carried downward to the base of the ear and to the orbital rim, exposing the orbital rim and malar eminence without removing the bone; b) cutting the bone flap so that 'bridges' of bone remain that help to stabilize the flap when it is returned to the cranium at the end of the operation; c) the wedging of bone chips between the bone flap and native cranium at the time the bone is being reaffixed so as to provide firm stability by diminishing movement of the bone flap; d) the use of bone dust and bone chips mixed with the patient's blood to seal and bridge the gap between the bone flap and the native bone; e) reattachment of the temporalis muscle with the bone flap sutures. An 'inlay' technique of duraplasty is also described. RESULTS AND CONCLUSION: These simple modifications of craniotomy provide better basal exposure and reconstruction with little additional operating time at no additional cost.

An analysis of attrition from Canadian neurosurgery residency programs.

PURPOSE: To determine the magnitude of and reasons for attrition from neurosurgical residency programs in Canada. METHOD: Directors of the 13 Canadian neurosurgery residency programs were asked to complete questionnaires on their programs, magnitude of attrition, reasons for attrition, and selection criteria. Open-ended questions were assessed with content analysis and quantified with dual-scaling techniques. Similar questionnaires were sent to 30 residents who had completed training; six residents who had voluntarily withdrawn were interviewed. RESULTS: Twelve of the 13 directors (92%) responded. Forty-two residents voluntarily withdrew from residency training between 1980 and 1992; withdrawal rates grew during that period. The number of dismissals--approximately 1.8 per year--remained constant. Reasons for voluntary withdrawal focused on excessive workloads and unexpected residency demands, whereas reasons for dismissal related primarily to deficits in professional attitudes and behaviors such as interpersonal skills and ethics. In selecting residents, programs with low attrition rates gave more importance to a candidate's work ethic than did programs with high attrition rates. The low-attrition programs also gave more importance to the relationship developed with residents during training. CONCLUSION: These results suggest that voluntary attrition from neurosurgical residency is significant and is related to issues of lifestyle control. Dismissal is rarely related to cognitive or psychomotor deficits, but usually occurs for concerns about professionalism such as ethics and interpersonal skills and behaviors. Further studies are necessary to confirm these findings across specialties and countries.

Quality-of-Life Assessment in Patients with Lesions of the Cranial Base.

Lesions of the cranial base have a propensity to affect physical, mental and social well-being of the patient. Cranial Base surgeons have a duty to go beyond the standard outcome measures of survival and morbidity in presenting the results of surgery for lessions of the cranial base. This paper reviews the fundamental features of quality of life outcome measures as applied to the field of skull base surgery.The author reviews the The Glasgow Outcome Scale, the Karnofsky Score, Spitzer Quality of Life Index, the Sickness Impact Profile, the Rand 36 (MOS-SF 36), the FACT G health-related quality of life scale and the University of Washington Quality of Life Scale for their use in the field cranial base surgery.Major advances in cranial base surgery will be facilitated by the use of scientifically sound and practical health-related quality of life outcome measures.