Surgical Cancellations and Postponements by Surgeon and Patient Sex: A Retrospective Cohort Study in Alberta, Canada.

OBJECTIVE: The objective of this work was to estimate the association between surgeon sex with surgical postponements or cancellations. SUMMARY BACKGROUND DATA: Female surgeons receive lower hourly, per patient, and total compensation than their male colleagues. Bias in the decision to postpone or cancel surgical cases may contribute to compensation inequality, since this results in unpaid surgeon time. METHODS: This retrospective cohort study used administrative health data to identify surgeries performed at four hospitals in Calgary, Alberta, Canada that were cancelled or postponed due to surgeon/operating room overbooking or to accommodate an emergency case between April 1, 2015, and March 31, 2020. Surgeries performed in dedicated operating or procedure rooms (e.g., bronchoscopy, cardiac surgery, etc.) were excluded. The exposure of interest was surgeon sex, identified by matching their name to the provincial regulatory body record of self-identified sex, which allowed for selection between female and male only during the time of this study. RESULTS: There were 214,832 eligible surgical cases, of which 1,481 and 2,473 were postponed or cancelled due to overbooking and to accommodate an emergency, respectively. After adjusting for surgical specialty, whether the procedure was a day case, and for patient sex, female surgeons were more likely to be cancelled or postponed to accommodate an emergency case compared to male surgeons (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.05-1.38). CONCLUSION: There may be sex-bias in the decision about which surgical cases to postpone or cancel to accommodate emergency surgeries in our setting. This bias may contribute to compensation inequality in a fee-for-service setting.

Implementation of a surgical site infection prevention bundle in gynecologic oncology patients: An enhanced recovery after surgery initiative.

OBJECTIVE: To evaluate the clinical outcomes pre- and post-implementation of an evidence-informed surgical site infection prevention bundle (SSIPB) in gynecologic oncology patients within an Enhanced Recovery After Surgery (ERAS) care pathway. METHODS: Patients undergoing laparotomy for a gynecologic oncology surgery between January-June 2017 (pre-SSIPB) and between January 2018-December 2020 (post-SSIPB) were compared using t-tests and chi-square. Patient characteristics, surgical factors, and ERAS process measures and outcomes were abstracted from the ERAS® Interactive Audit System (EIAS). The primary outcomes were incidence of surgical site infections (SSI) during post-operative hospital admission and at 30-days post-surgery. Secondary outcomes included total postoperative infections, length of stay, and any surgical complications. Multivariate models were used to adjust for potential confounding factors. RESULTS: Patient and surgical characteristics were similar in the pre- and post-implementation periods. Evaluation of implementation suggested that preoperative and intraoperative components of the intervention were most consistently used. Infectious complications within 30 days of surgery decreased from 42.1% to 24.4% after implementation of the SSIPB (p < 0.001), including reductions in wound infections (17.0% to 10.8%, p = 0.02), urinary tract infections (UTI) (12.7% to 4.5%, p < 0.001), and intra-abdominal abscesses (5.4% to 2.5%, p = 0.05). These reductions were associated with a decrease in median length of stay from 3 to 2 days (p = 0.001). In multivariate analysis, these SSI reductions remained statistically significant after adjustment for potential confounders. CONCLUSION: Implementation of SSIPB was associated with a reduction in SSIs and infectious complications, as well as a shorter length of stay in gynecologic oncology patients.

Effect of Multifactorial Risk Factor Interventions on Atrial Fibrillation: A Systematic Review and Meta-Analysis.

Evidence supports the benefit of managing atrial fibrillation (AF) specific risk factors in secondary prevention of AF. However, a comprehensive summary of the effect of multifactorial risk factor interventions on outcomes of patients with AF over long-term is lacking. We searched MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL databases from inception to October 2021 for both randomized controlled trials (RCT) and observational studies comparing multifactorial risk factor interventions to usual care in patients with AF. Fifteen studies (10 RCT, 5 observational) with 3786 patients were included (mean age 63.8 years, 64.0% males). Follow-up ranged from 3 to 42 months. We found no significant effects of multifactorial risk factor interventions on AF recurrence [pooled relative risk (RR): 0.93, 95% CI: 0.74-1.16, P = 0.51, I2 = 54%], AF-related rehospitalization at 12 months (RR: 0.69, 95% CI: 0.43-1.11, P= 0.13, I2 = 0%), cardiovascular rehospitalization at 12 months (RR: 0.76, 95% CI: 0.53-1.09, P= 0.13, I2 = 53%), or AF-related adverse events at 12 and 15 months. However, multifactorial interventions were associated with reduced AF-related symptoms and improved health-related quality of life (HRQoL) at all studied time points. Current evidence does not support consistent associations between multifactorial risk factor interventions and AF recurrence after rhythm control therapy or AF-related or cardiovascular hospitalization in patients with AF. However, these interventions are associated with clinically relevant improvement in AF-related symptoms and HRQoL. Additional randomized studies are required to evaluate the impact of multifactorial risk factor interventions on patient-centered health outcomes.

Crowdsourcing trainees in a living systematic review provided valuable experiential learning opportunities: a mixed-methods study.

OBJECTIVES: To understand trainee experiences of participating in a living systematic review (LSR) for rheumatoid arthritis and the potential benefits in terms of experiential evidence-based medicine (EBM) education. STUDY DESIGN AND SETTING: We conducted a mixed-methods study with trainees who participated in the LSR and who were recruited broadly from training programs in two countries. Trainees received task-specific training and completed one or more tasks in the review: assessing article eligibility, data extraction, and quality assessment. Trainees completed a survey followed by a one-on-one interview. Data were triangulated to produce broad themes. RESULTS: Twenty one trainees, most of whom had a little prior experience with systematic reviews, reported a positive overall experience. Key benefits included learning opportunities, task segmentation (ability to focus on a single task, as opposed to an entire review), working in a supportive environment, international collaboration, and incentives such as authorship or acknowledgment. Trainees reported improvement in their competency as a Scholar, Collaborator, Leader, and Medical Expert. Challenges included communication and technical difficulties and appropriate matching of tasks to trainee skillsets. CONCLUSION: Participating in an LSR provided benefits to a wide range of trainees and may provide an opportunity for experiential EBM training, while helping LSR sustainability.

Canadian Rheumatology Association Recommendation for the Use of COVID-19 Vaccination for Patients With Autoimmune Rheumatic Diseases.

OBJECTIVE: To develop guidance on the use of coronavirus disease 2019 (COVID-19) vaccines in patients with autoimmune rheumatic diseases (ARD). METHODS: The Canadian Rheumatology Association (CRA) formed a multidisciplinary panel including rheumatologists, researchers, methodologists, vaccine experts, and patients. The panel used the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Outcomes were prioritized according to their importance for patients and clinicians. Evidence from the COVID-19 clinical trials was summarized. Indirect evidence for non-COVID-19 vaccines in ARD was also considered. The GRADE evidence-to-decision (EtD) framework was used to develop a recommendation for the use of the 4 COVID-19 vaccines approved in Canada as of March 25, 2021 (BNT162b2, mRNA-1273, ChAdOx1, and Ad26.COV2.S), over 4 virtual panel meetings. RESULTS: The CRA guideline panel suggests using COVID-19 vaccination in persons with ARD. The panel unanimously agreed that for the majority of patients, the potential health benefits of vaccination outweigh the potential harms in people with ARDs. The recommendation was graded as conditional because of low or very low certainty of the evidence on the effects in the population of interest, primarily due to indirectness and imprecise effect estimates. The panel felt strongly that persons with autoimmune rheumatic diseases who meet local eligibility should not be required to take additional steps compared to people without ARDs to obtain their vaccination. Guidance on medications, implementation, monitoring of vaccine uptake, and research priorities are also provided. CONCLUSION: This recommendation will be updated over time as new evidence emerges, with the latest recommendation, evidence summaries, and EtD available on the CRA website.

Prenatal bisphenol a exposure and dysregulation of infant hypothalamic-pituitary-adrenal axis function: findings from the APrON cohort study.

BACKGROUND: Animal models show that prenatal bisphenol A (BPA) exposure leads to sexually dimorphic disruption of the neuroendocrine system in offspring, including the hypothalamic-pituitary-adrenal (HPA) neuroendocrine system, but human data are lacking. In humans, prenatal BPA exposure is associated with sex-specific behavioural problems in children, and HPA axis dysregulation may be a biological mechanism. The objective of the current study was to examine sex differences in associations between prenatal maternal urinary BPA concentration and HPA axis function in 3 month old infants. METHODS: Mother-infant pairs (n = 132) were part of the Alberta Pregnancy Outcomes and Nutrition study, a longitudinal birth cohort recruited (2010-2012) during pregnancy. Maternal spot urine samples collected during the 2nd trimester were analyzed for total BPA and creatinine. Infant saliva samples collected prior to and after a blood draw were analyzed for cortisol. Linear growth curve models were used to characterize changes in infant cortisol as a function of prenatal BPA exposure. RESULTS: Higher maternal BPA was associated with increases in baseline cortisol among females (ß = 0.13 log µg/dL; 95% CI: 0.01, 0.26), but decreases among males (ß = -0.22 log µg/dL; 95% CI: -0.39, -0.05). In contrast, higher BPA was associated with increased reactivity in males (ß = .30 log µg/dL; 95% CI: 0.04, 0.56) but decreased reactivity in females (ß = -0.15 log µg/dL; 95% CI: -0.35, 0.05). Models adjusting for creatinine yielded similar results. CONCLUSIONS: Prenatal BPA exposure is associated with sex-specific changes in infant HPA axis function. The biological plausibility of these findings is supported by their consistency with evidence in rodent models. Furthermore, these data support the hypotheses that sexually dimorphic changes in children's behaviour following prenatal BPA exposure are mediated by sexually dimorphic changes in HPA axis function.

Bisphenol A exposure and children's behavior: A systematic review.

Bisphenol A (BPA) is an endocrine disrupting chemical used to synthesize polycarbonate plastics and epoxy resins. Previous research suggests that exposure to it can alter children's behavior. The objective of this study is to conduct a systematic review of the existing literature, examining associations between prenatal and childhood BPA exposure and behavior in children up to 12 years of age. We searched electronic bibliographic databases (MEDLINE, PubMed, EMBASE, PsycINFO, CINAHL, and ERIC), reference lists of included articles, and conference abstracts (American Psychiatric Association, American Academy of Neurology, Pediatric Academic Societies, and International Society of Environmental Epidemiology). We included original studies reporting on the association between prenatal and childhood BPA exposure that measured BPA metabolites in urine and children's behavioral outcomes. From 2811 citations, 11 articles met our inclusion criteria. Descriptive analyses indicated that prenatal exposure to maternal BPA concentrations were related to higher levels of anxiety, depression, aggression, and hyperactivity in children. BPA exposure in childhood was associated with higher levels of anxiety, depression, hyperactivity, inattention, and conduct problems. Limited observational evidence suggests an association between both prenatal and childhood exposure to BPA and adverse behavioral outcomes in children. Prospective cohort studies are needed to clarify these associations.

Urinary bisphenol A is associated with dysregulation of HPA-axis function in pregnant women: Findings from the APrON cohort study.

BACKGROUND: Bisphenol A (BPA) is associated with dysregulation of hypothalamic-pituitary-adrenal (HPA) axis activity in rodents, but evidence in humans is lacking. OBJECTIVE: To determine whether BPA exposure during pregnancy is associated with dysregulation of the HPA-axis, we examined the association between urinary BPA concentrations and diurnal salivary cortisol in pregnant women. Secondary analyses investigated whether the association between BPA and cortisol was dependent on fetal sex. METHODS: Diurnal salivary cortisol and urinary BPA were collected during pregnancy from 174 women in a longitudinal cohort study, the Alberta Pregnancy Outcomes and Nutrition (APrON) study. Associations between BPA and daytime cortisol and the cortisol awakening response (CAR) were estimated using mixed models after adjusting for covariates. RESULTS: Higher concentrations of total BPA uncorrected for urinary creatinine were associated with dysregulation of the daytime cortisol pattern, including reduced cortisol at waking, ß=-.055, 95% CI (-.100, -.010) and a flatter daytime pattern, ß=.014, 95% CI (.006, .022) and ß=-.0007 95% CI (-.001, -.0002) for the linear and quadratic slopes, respectively. Effect sizes in creatinine corrected BPA models were slightly smaller. None of the interactions between fetal sex and BPA were significant (all 95% CI's include zero). CONCLUSIONS: These findings provide the first human evidence suggesting that BPA exposure is associated with dysregulation of HPA-axis function during pregnancy.

Phthalate exposure and childrens neurodevelopment: A systematic review.

BACKGROUND: Emerging evidence from observational studies suggests that prenatal exposure to phthalates affects neurodevelopment in children. OBJECTIVE: To conduct a systematic review of the existing literature on the association between urinary phthalate concentrations and children's neurodevelopment. METHODS: We searched electronic bibliographic databases (MEDLINE, PubMed, EMBASE, PsycINFO, CINAHL, Global Health, CAB abstracts, and ERIC) (1910 to February 21st, 2014); reference lists of included articles, and conference abstracts (American Psychiatric Association, American Academy of Neurology, and Pediatric Academic Societies). Two independent reviewers screened abstracts and extracted data. We included original studies reporting on the association between prenatal or childhood urinary phthalate metabolites, and cognitive and behavioral outcomes (e.g., IQ scores, BASC-2 scores or equivalent) in children 0-12 years of age. RESULTS: Of 2804 abstracts screened, 11 original articles met our criteria for inclusion. CONCLUSIONS: A systematic review of the literature supports the contention that prenatal exposure phthalates is associated with adverse cognitive and behavioral outcomes in children, including lower IQ, and problems with attention, hyperactivity, and poorer social communication. Further research characterizing the associations between specific phthalate metabolites and children's neurodevelopmental outcomes is needed to support the development of mitigation strategies and enhance the development of appropriate health policy.

I was told it restarts your brain: knowledge, power, and women's experiences of ECT.

BACKGROUND: A discrepancy exists between clinician-led studies of people's experience of electroconvulsive therapy (ECT) and consumer-led studies, with the former typically being much more positive about the efficacy and side effects of ECT compared with the latter. Qualitative in-depth explorations of people's experiences of ECT are relatively rare, particularly those looking specifically at women's experience of ECT. AIMS: The aim of this qualitative study was to explore women's experiences of ECT, particularly their experience of knowledge and power related to ECT. RESULTS: Qualitative analysis of the interviews with nine women resulted in four main themes emerging from the interviews with the women: (i) "he really didn't say much," (ii) "I'm going to be very upset with you," (iii) "I was just desperate," and (iv) "it was like we were cattle." CONCLUSIONS: Overall, participants found their experiences with ECT to be quite negative, and characterized by a lack of knowledge during the procedure, and a lack of power throughout the entire process.

All I have is a void: women's perceptions of the benefits and side effects of ECT.

BACKGROUND: Recent reviews of the benefits and risks associated with electroconvulsive therapy (ECT) have often reported mixed and conflicting results. Although there are very few qualitative studies on ECT, qualitative research offers the advantage of in-depth explorations into how people perceive and experience ECT. OBJECTIVE: The objective of this qualitative study was to explore women's experiences and perceptions of the benefits and side effects associated with having ECT. METHODS: The authors used narrative inquiry and in-depth interviews to obtain nine women's accounts and stories of ECT, focusing particularly on their accounts of perceived benefits and side effects associated with ECT. RESULTS: Qualitative thematic analysis of the interviews with nine women resulted in four main themes emerging from the interviews: "it's sort of like housecleaning," "I don't remember the wedding," made me stupider," and "putting them in a cage with a bear." CONCLUSIONS: Three of the women were able to articulate some perceived benefit arising from ECT, although these women also acknowledged the benefits did not last more than two weeks. The majority of women complained of significant and persistent autobiographical memory loss, cognitive deficits, and fear of the procedure.

Chronic stress prior to hippocampal stroke enhances post-stroke spatial deficits in the ziggurat task.

Stress is one of the most important variables to determine recovery following stroke. We have previously reported that post-stroke exposure to either stress or corticosterone (CORT) alleviates hippocampal ischemic outcome. The present experiment expands previous findings by investigating the influence of exposure to stress prior to ischemic event. Rats received either daily restraint stress (1h/day; 16 consecutive days) or CORT (0.5mg/kg; 16 consecutive days) prior to focal ischemic stroke in the hippocampus induced by bilateral injection of endothelin-1 (ET-1). All experimental groups were then tested in the ziggurat task, a new task for spatial cognition. The stress+stroke group showed significant deficits in both hippocampal structure and function. No deleterious effect of pre-stroke exposure to CORT was found in the CORT+stroke group. Our results indicate that a history of chronic stress sensitizes hippocampal cells to the damaging consequences of focal ischemia. The opposing effects of CORT-related experiences in this study not only reflect the diversity of glucocorticoid actions in the stress response, but also provide evidence that elevated CORT in the absence of emotional disturbance is not sufficient to produce hippocampal deficit.