Rethinking cervical spine clearance in obtunded trauma patients: An updated systematic review and meta-analysis.

BACKGROUND: Cervical spine injuries (CSI) are often challenging to diagnose in obtunded adult patients with blunt trauma and the optimal imaging modality remains uncertain. This study systematically synthesized the last decade of evidence to determine the type of imaging required to clear the c-spine in obtunded patients with blunt trauma. METHODS: A systematic review with meta-analysis was conducted and reported using PRISMA 2020 guidelines. The protocol was registered on June 22, 2022 (PROSPERO CRD42022341386). MEDLINE (Ovid), EMBASE, and Cochrane Library were searched for studies published between January 1, 2012, and October 17, 2023. Studies comparing CT alone to CT combined with MRI for c-spine clearance were included. Two independent reviewers screened articles for eligibility in duplicate. Meta-analysis was conducted using a random-effect model. Risk of bias and quality assessment were performed using the ROBINS-I and QUADAS-2. The certainty of evidence was assessed using the GRADE methodology. RESULTS: 744 obtunded trauma patients from six included studies were included. Among the 584 that had a negative CT scan, the pooled missed rate of clinically significant CSI using CT scans alone was 6 % (95 % CI: 0.02 to 0.17), and the pooled missed rate of CSI requiring treatment was 7 % (95 % CI: 0.02 to 0.18). High heterogeneity was observed among included studies (I² > 84 %). The overall risk of bias was moderate, and the quality of evidence was low due to the retrospective nature of the included studies and high heterogeneity. CONCLUSIONS: Limited evidence published in the last decade found that CT scans alone may not be sufficient for detecting clinically significant CSI and injuries requiring treatment in obtunded adult patients with blunt trauma. IMPLICATIONS OF KEY FINDINGS: Clinicians should be aware of the limitations of CT scans and consider using MRI when appropriate. Future research should focus on prospective studies with standardized outcome measures and uniform reporting.

Mapping a shared care model in complex gastrointestinal surgery: A qualitative study of queues and stakeholders within a Canadian general surgery practice.

Shared Care Models (SCMs), in which a team of clinicians share in patient care and resource utilization, represent an opportunity for surgeon-level system change. We aimed to identify the queues and stakeholders within a complex gastrointestinal surgical care pathway to demonstrate the implications of a SCM on system efficiency. A multidisciplinary group of surgeons and care navigators working in SCMs were asked to develop a patient encounter map through consensus to illustrate relevant queues and stakeholders within a SCM. Fifteen surgeon-related queues were identified, each representing a point of potential delay to care in the patient's journey that could be addressed by shared care. A final patient encounter map was created, and advantages and challenges of SCMs were also described from multidisciplinary group discussions. The numerous queues identified in this map ultimately reflected opportunities for more efficient care navigation under a SCM through increased surgeon availability and shared resource utilization.

The impact of time to hemostatic intervention and delayed care for patients with traumatic hemorrhage: A systematic review.

BACKGROUND: Uncontrolled bleeding is a common cause of preventable mortality in trauma. While it is intuitive that delays to hemostasis may lead to worse outcomes, the impacts of these delays remain incompletely explored. This systematic review aimed to characterize the extant definitions of delayed hemostatic intervention and to quantify the impacts of delays on clinical outcomes. METHODS: We searched EMBASE, MEDLINE, and Web of Science from inception to August 2022. Studies defining "delayed intervention" and those comparing times to intervention among adults presenting to hospital with blunt or penetrating injuries who required major hemostatic intervention were eligible. The coprimary outcomes were mortality and the definition of delay to hemostasis used. Secondary outcomes included units of packed red blood cells received, length of stay in hospital, and length of stay in intensive care. RESULTS: We identified 2,050 studies, with 24 studies including 10,168 patients meeting the inclusion criteria. The majority of studies were retrospective observational cohort studies, and most were at high risk of bias. A variety of injury patterns and hemostatic interventions were considered, with 69.6% of studies reporting a statistically significant impact of increased time to intervention on mortality. Definitions of delayed intervention ranged from 10 minutes to 4 hours. Conflicting data were reported for impact of time on receipt of blood products, while one study found a significant impact on intensive care length of stay. No studies assessed length of stay in hospital. CONCLUSION: The extant literature is heterogeneous with respect to injuries included, methods of hemostasis employed, and durations of delay examined. While the majority of the included studies demonstrated a statistically significant relationship between time to intervention and mortality, an evidence-informed definition of delayed intervention for bleeding trauma patients at large has not been solidified. In addition, standardized research is needed to establish targets, which could reduce morbidity and mortality. LEVEL OF EVIDENCE: Systematic Review; Level IV.

Feasibility and Safety of a "Shared Care" Model in Complex Hepatopancreatobiliary Surgery: A 5-year Observational Study of Outcomes in Pancreaticoduodenectomy.

OBJECTIVE: To determine the safety of a fully functioning shared care model (SCM) in hepatopancreatobiliary surgery through evaluating outcomes in pancreaticoduodenectomy. BACKGROUND: SCMs, where a team of surgeons share in care delivery and resource utilization, represent a surgeon-level opportunity to improve system efficiency and peer support, but concerns around clinical safety remain, especially in complex elective surgery. METHODS: Patients who underwent pancreaticoduodenectomy between 2016 and 2020 were included. Adoption of shared care was demonstrated by analyzing shared care measures, including the number of surgeons encountered by patients during their care cycle, the proportion of patients with different consenting versus primary operating surgeon (POS), and the proportion of patients who met their POS on the day of surgery. Outcomes, including 30-day mortality, readmission, unplanned reoperation, sepsis, and length of stay, were collected from the institution's National Surgical Quality Improvement Program (NSQIP) database and compared with peer hospitals contributing to the pancreatectomy-specific NSQIP collaborative. RESULTS: Of the 174 patients included, a median of 3 surgeons was involved throughout the patients' care cycle, 69.0% of patients had different consenting versus POS and 57.5% met their POS on the day of surgery. Major outcomes, including mortality (1.1%), sepsis (5.2%), and reoperation (7.5%), were comparable between the study group and NSQIP peer hospitals. Length of stay (10 day) was higher in place of lower readmission (13.2%) in the study group compared with peer hospitals. CONCLUSIONS: SCMs are feasible in complex elective surgery without compromising patient outcomes, and wider adoption may be encouraged.

A regional effort: the current landscape of inguinal hernia repair and postoperative opioid prescription practices in Eastern Ontario.

Inguinal hernia repairs are commonly performed by general surgeons in academic and community centres. The optimal strategy for postoperative analgesia is evolving, particularly because of concerns over opioid prescribing given the current opioid crisis. Efforts to address opioid overprescribing have been emphasized in our academic hospital system. Our survey of general surgeons in Eastern Ontario shows similarities in postoperative prescriptions of nonopioid and opioid analgesics across practice environments. Importantly, awareness of opioid-reduction initiatives was similar between academic and community surgeons. This regional effort is a result of local and national communities of practice fostered by organizations such as the Canadian Association of General Surgeons.

Timing of pharmacologic venous thromboembolism prophylaxis initiation for trauma patients with nonoperatively managed blunt abdominal solid organ injury: a systematic review and meta-analysis.

BACKGROUND: Blunt abdominal solid organ injury is common and is often managed nonoperatively. Clinicians must balance risk of both hemorrhage and thrombosis. The optimal timing of pharmacologic venous thromboembolism prophylaxis (VTEp) initiation in this population is unclear. The objective was to evaluate early (< 48 h) compared to late initiation of VTEp in adult trauma patients with blunt abdominal solid organ injury managed nonoperatively. METHODS: Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials were searched from inception to March 2021. Studies comparing timeframes of VTEp initiation were considered. The primary outcome was failure of nonoperative management (NOM) after VTEp initiation. Secondary outcomes included risk of transfusion, other bleeding complications, risk of deep vein thrombosis (DVT) and pulmonary embolism, and mortality. RESULTS: Ten cohort studies met inclusion criteria, with a total of 4642 patients. Meta-analysis revealed a statistically significant increase in the risk of failure of NOM among patients receiving early VTEp (OR 1.76, 95% CI 1.01-3.05, p = 0.05). There was no significant difference in risk of transfusion. Odds of DVT were significantly lower in the early group (OR 0.36, 95% CI 0.22-0.59, p < 0.0001). There was no difference in mortality (OR 1.50, 95% CI 0.82-2.75, p = 0.19). All studies were at serious risk of bias due to confounding. CONCLUSIONS: Initiation of VTEp earlier than 48 h following hospitalization is associated with an increased risk of failure of NOM but a decreased risk of DVT. Absolute failure rates of NOM are low. Initiation of VTEp at 48 h may balance the risks of bleeding and VTE.

Leveraging financial incentives and behavioural economics to engage physicians in achieving quality-improvement process measures.

BACKGROUND: Dedicated quality-improvement (QI) initiatives within health care systems are of clear benefit, and physicians respond to financial incentivization. The Canadian health care system often lacks this lever, and many financially incentivized QI programs rely on traditional economic principles. We describe our evaluation of financial incentivization for the implementation of QI process metrics in a department of surgery at a Canadian academic hospital system and its impact over a 4-year period. METHODS: Quality-improvement processes informed by extant QI incentivization literature and guided by the principles of behavioural economics were implemented within our institution's Department of Surgery. Disbursement of supplemental government funding was modified to be contingent on the ability of divisions within the department to meet predefined QI metrics, including regular multidisciplinary meetings, morbidity and mortality rounds with documented feedback of systemic issues to division members, reviews of adverse events, and implementation of annual patient experience projects. We evaluated the effect of the QI processes from 2015/16 to 2018/19. RESULTS: There was a significant increase in the number of divisions that satisfied all the QI metrics over the study period, from 2 (28%) in 2015/16, to 5 (71%) in 2016/17, to 7 (100.0%) in 2017/18 and 2018/19 (p < 0.01). The application of behavioural economics principles, such as reward versus penalty payoff, loss aversion, payment separation, aligning of values, and relative social ranking, was important to the outcome of the study. CONCLUSION: Incentivizing QI activities in the Canadian health care system is possible and led to improvement in QI processes as a whole in our department. This paper lays out a method of financial reimbursement to facilitate engagement of physicians and establishment of a foundation of important QI processes and measures within a department.

Exploring human factors in the operating room: scoping review of training offerings for healthcare professionals.

BACKGROUND: Human factors (HF) integration can improve patient safety in the operating room (OR), but the depth of current knowledge remains unknown. This study aimed to explore the content of HF training for the operative environment. METHODS: We searched six bibliographic databases for studies describing HF interventions for the OR. Skills taught were classified using the Chartered Institute of Ergonomics and Human Factors (CIEHF) framework, consisting of 67 knowledge areas belonging to five categories: psychology; people and systems; methods and tools; anatomy and physiology; and work environment. RESULTS: Of 1851 results, 28 studies were included, representing 27 unique interventions. HF training was mostly delivered to interdisciplinary groups (n = 19; 70 per cent) of surgeons (n = 16; 59 per cent), nurses (n = 15; 56 per cent), and postgraduate surgical trainees (n = 11; 41 per cent). Interactive methods (multimedia, simulation) were used for teaching in all studies. Of the CIEHF knowledge areas, all 27 interventions taught 'behaviours and attitudes' (psychology) and 'team work' (people and systems). Other skills included 'communication' (n = 25; 93 per cent), 'situation awareness' (n = 23; 85 per cent), and 'leadership' (n = 20; 74 per cent). Anatomy and physiology were taught by one intervention, while none taught knowledge areas under work environment. CONCLUSION: Expanding HF education requires a broader inclusion of the entirety of sociotechnical factors such as contributions of the work environment, technology, and broader organizational culture on OR safety to a wider range of stakeholders.

Multi-View 3-D Fusion Echocardiography: Enhancing Clinical Feasibility with a Novel Processing Technique.

A novel system for fusing 3-D echocardiography data sets from complementary acoustic windows was evaluated in 12 healthy volunteers and 12 patients with heart failure. We hypothesized that 3-D fusion would enable 3-D echocardiography in patients with limited acoustic windows. At least nine 3-D data sets were recorded, while three infrared cameras tracked the position and orientation of the transducer and chest respiratory movements. Corresponding 2-D planes of the fused 3-D data sets and of single-view 3-D data sets were assessed for image quality and compared with measurements of left ventricular function obtained with contrast 2-D echocardiography. The signal-to-noise ratio in accurately fused 3-D echocardiography recordings improved by 55% in systole (p < 0.001) and 47% in diastole (p < 0.00001) compared with the apical single-view recordings. The 3-D data sets acquired during short breath holds were successfully fused in 11 of 12 patients. The improvement in endocardial border definition (from 11.7 ± 6.0 to 24.0 ± 3.3, p < 0.01) enabled quantitative assessment of left ventricular function in 10 patients, with no significant difference in ejection fraction compared with contrast 2-D echocardiography. In patients with heart failure and limited acoustic windows, the novel fusion protocol provides 3-D data sets suitable for quantitative analysis of left ventricular function.

A chance for reform: The environmental impact of travel for general surgery residency interviews.

BACKGROUND: In light of the global climate emergency, it is worth reconsidering the current practice of medical students traveling to interview for residency positions. We sought to estimate carbon dioxide (CO2) emissions associated with travel for general surgery residency interviews in Canada, and the potential avoided emissions if interviews were restructured. METHODS: An eight-item survey was constructed to collect data on cities visited, travel modalities, and costs incurred. Applicants to the University of Ottawa General Surgery Program during the 2019/20 Canadian Resident Matching Service (CaRMS) cycle were invited to complete the survey. Potential reductions in CO2 emissions were modeled using a regionalized interview process with either one or two cities. RESULTS: Of a total of 56 applicants, 39 (70%) completed the survey. Applicants on average visited 10 cities with a mean total cost of $4,866 (95% CI=3,995-5,737) per applicant. Mean CO2 emissions were 1.82 (95% CI=1.50-2.14) tonnes per applicant, and the total CO2 emissions by applicants was estimated to be 101.9 (95% CI=84.0 - 119.8) tonnes. In models wherein interviews are regionalized to one or two cities, emissions would be 57.9 tonnes (43.2% reduction) and 84.2 tonnes (17.4% reduction), respectively. Overall, 74.4% of respondents were concerned about the environmental impact of travel and 46% would prefer to interview by videoconference. CONCLUSION: Travel for general surgery residency interviews in Canada is associated with a considerable environmental impact. These findings are likely generalizable to other residency programs. Given the global climate crisis, the CaRMS application process must consider alternative structures.

CONTEXTE: Compte tenu de la situation d'urgence climatique mondiale, il convient de reconsidérer l'usage actuel selon lequel les étudiants en médecine se déplacent pour se présenter aux entrevues en vue d'obtenir un poste de résidence. Nous avons tenté d'estimer les émissions de dioxyde de carbone (CO2) causées par les déplacements pour les entretiens de résidence en chirurgie générale au Canada, et les émissions potentielles évitées si les entretiens étaient organisés autrement. MÉTHODES: Un sondage comportant huit questions a été élaboré pour recueillir les données sur les villes visitées, les modalités de voyage et les coûts encourus. Les candidats au programme de chirurgie générale de l'Université d'Ottawa au cours du cycle 2019/20 du Service canadien de jumelage des résidents (CaRMS) ont été invités à y répondre. Les réductions potentielles des émissions de CO2 ont été modélisées à l'aide d'un processus d'entrevue régionalisé avec une ou deux villes. RÉSULTATS: Sur un total de 56 candidats, 39 (70 %) ont répondu au sondage. Les candidats ont visité en moyenne 10 villes, pour un coût total moyen de 4 866 dollars (IC 95 % = 3 995-5 737) par candidat. Les émissions moyennes de CO2 étaient de 1,82 (IC 95 % = 1,50-2,14) tonne par candidat, et le total des émissions de CO2 pour l'ensemble des candidats était estimé à 101,9 (IC 95 % = 84,0 - 119,8) tonnes. D'après les modèles où les entrevues sont régionalisées avec une ou deux villes, les émissions seraient respectivement de 57,9 tonnes (43,2 % de réduction) et 84,2 tonnes (17,4 % de réduction). Dans l'ensemble, 74,4 % des personnes interrogées se disent préoccupées par l'impact environnemental des déplacements et 46 % préféreraient que l'entretien se fasse par vidéoconférence. CONCLUSION: Les déplacements pour les entrevues de résidence en chirurgie générale au Canada ont un impact environnemental considérable. Ces conclusions sont probablement généralisables à d'autres programmes de résidence. Compte tenu de la crise climatique mondiale, il conviendrait d'envisager d'autres modalités d'organisation des entrevues pour le processus de candidatures du CaRMS.

Targeted next generation sequencing as a tool for precision medicine.

BACKGROUND: Targeted next-generation sequencing (NGS) enables rapid identification of common and rare genetic variation. The detection of variants contributing to therapeutic drug response or adverse effects is essential for implementation of individualized pharmacotherapy. Successful application of short-read based NGS to pharmacogenes with high sequence homology, nearby pseudogenes and complex structure has been previously shown despite anticipated technical challenges. However, little is known regarding the utility of such panels to detect copy number variation (CNV) in the highly polymorphic cytochrome P450 (CYP) 2D6 gene, or to identify the promoter (TA)7 TAA repeat polymorphism UDP glucuronosyltransferase (UGT) 1A1*28. Here we developed and validated PGxSeq, a targeted exome panel for pharmacogenes pertinent to drug disposition and/or response. METHODS: A panel of capture probes was generated to assess 422 kb of total coding region in 100 pharmacogenes. NGS was carried out in 235 subjects, and sequencing performance and accuracy of variant discovery validated in clinically relevant pharmacogenes. CYP2D6 CNV was determined using the bioinformatics tool CNV caller (VarSeq). Identified SNVs were assessed in terms of population allele frequency and predicted functional effects through in silico algorithms. RESULTS: Adequate performance of the PGxSeq panel was demonstrated with a depth-of-coverage (DOC) ≥ 20× for at least 94% of the target sequence. We showed accurate detection of 39 clinically relevant gene variants compared to standard genotyping techniques (99.9% concordance), including CYP2D6 CNV and UGT1A1*28. Allele frequency of rare or novel variants and predicted function in 235 subjects mirrored findings from large genomic datasets. A large proportion of patients (78%, 183 out of 235) were identified as homozygous carriers of at least one variant necessitating altered pharmacotherapy. CONCLUSIONS: PGxSeq can serve as a comprehensive, rapid, and reliable approach for the detection of common and novel SNVs in pharmacogenes benefiting the emerging field of precision medicine.

Resident Physicians Choices of Anticoagulation for Stroke Prevention in Patients With Nonvalvular Atrial Fibrillation.

Atrial fibrillation (AF) is a common cardiac arrhythmia and is associated with an increased risk of ischemic stroke. The aim of this study was to identify practice patterns of Canadian resident physicians pertaining to stroke prevention in nonvalvular AF according to the Canadian Cardiovascular Society guidelines. A Web-based survey consisting of 16 multiple-choice questions was distributed to 11 academic centres. Questions involved identification of risks of stroke, bleeding, and selection of appropriate therapy in clinical scenarios that involve a patient with AF with a Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack (CHADS2) score of 3 and no absolute contraindications to anticoagulation. There were 1014 total respondents, of whom 570 were internal, 247 family, 137 emergency medicine, and 60 adult cardiology residents. For a patient with a new diagnosis of AF, warfarin was chosen by 80.3%, novel oral anticoagulants (NOACs) by 60.3%, and acetylsalicylic acid (ASA) by 7.2% of residents. To a patient with a history of gastrointestinal bleed during ASA treatment, warfarin was recommended by 75.1%, NOACs by 36.1%, ASA by 12.1%, and 4% were unsure. For a patient with a history of an intracranial bleed, warfarin was recommended by 38.8%, NOACs by 23%, ASA by 24.8%, and 18.2% were unsure. For a patient taking warfarin who had a labile international normalized ratio, 89% would switch to a NOAC and 29.5% would continue warfarin. This study revealed that, across a wide sampling of disciplines and centres, resident physician choices of anticoagulation in nonvalvular AF differ significantly from contemporary Canadian Cardiovascular Society guidelines.

Comparison of two oscillometric blood pressure monitors in subjects with atrial fibrillation.

OBJECTIVE: To compare blood pressure readings obtained with two commonly used oscillometric monitors: Omron HEM 711 AC (OM) and Welch-Allyn 52000 series NIBP/oximeter (WA) with mercury sphygmomanometers (Merc) in subjects with atrial fibrillation. METHODS: We recruited 51 hemodynamically stable subjects with atrial fibrillation. Fifty four subjects in normal sinus rhythm served as controls. Supine blood pressure readings in each arm were recorded simultaneously using one monitor and Merc. The second monitor then replaced the first and readings were repeated. Merc was then switched to the opposite arm, and both monitors retested. Apical heart rates were ascertained with a stethoscope. We used the averaged, same arm Merc readings as "gold standard". RESULTS: Automated blood pressure readings were obtained in all control subjects and in all but three of those with atrial fibrillation. Both monitors, and operators, noted a difference between apical and radial/brachial pulse rates: apical-recorded: Merc 6.1 + or - 15.0; OM 5.5 + or - 13.7; WA 10.0 + or - 21.2 beats per minute. Both monitors were accurate in controls: over 90% of readings were within 10 mmHg of averaged Merc, and both achieved European Hypertension Society standards. In subjects with atrial fibrillation, about one quarter of all oscillometric readings differed from Merc by more than 10 mmHg. Both falsely high and falsely low readings occurred, some up to 30 mmHg. There was no relation between accuracy and heart rate. CONCLUSIONS: Single blood pressure readings, taken with oscillometric monitors in subjects with atrial fibrillation differ, often markedly, from those taken manually. Health care professionals should record multiple readings manually, using validated instruments when making therapeutic decisions.