Field and laboratory studies of fluorescence-based technologies for real-time tracking of cyanobacterial cell lysis and potential microcystins release.

Elevated levels of dissolved microcystins (MCs) in source water due to rapid cell lysis of harmful cyanobacterial blooms may pose serious challenges for drinking water treatment. Catastrophic cell lysis can result from outbreaks of naturally-occurring cyanophages - as documented in Lake Erie during the Toledo water crisis of 2014 and in 2019, or through the application of algaecides or water treatment chemicals. Real-time detection of cyanobacterial cell lysis in source water would provide a valuable tool for drinking water plant and reservoir managers. In this study we explored two real-time fluorescence-based devices, PhycoSens and PhycoLA, that can detect unbound phycocyanin (uPC) as a potential indication of cell lysis and MCs release. The PhycoSens was deployed at the Low Service pump station of the City of Toledo Lake Erie drinking water treatment plant from July 15 to October 19, 2022 during the annual cyanobacteria bloom season. It measured major algal groups and uPC in incoming lake water at 15-min intervals during cyanobacteria dominant and senescence periods. Intermittent uPC detections from the PhycoSens over a three-month period coincided with periods of increasing proportions of extracellular MCs relative to total (intracellular and extracellular) MCs, indicating potential for uPC use as an indicator of cyanobacterial cell integrity. Following exposures of laboratory-cultured MCs-producing Microcystis aeruginosa NIES-298 (120 µg chlorophyll/L) to cyanophage Ma-LMM01, copper sulfate (0.5 and 1 mg Cu/L), sodium carbonate peroxyhydrate (PAK® 27, 6.7 and 10 mg H2O2/L), and potassium permanganate (2.5 and 4 mg/L), appearance of uPC coincided with elevated fractions of extracellular MCs. The PhycoLA was used to monitor batch samples collected daily from Lake Erie water exposed to algaecides in the laboratory. Concurrence of uPC signal and surge of dissolved MCs was observed following 24-h exposures to copper sulfate and PAK 27. Overall results indicate the appearance of uPC is a useful indicator of the onset of cyanobacterial cell lysis and the release of MCs when MCs are present.

COVID-19 and the duration of operating room procedures in Ontario: a population-based retrospective study.

BACKGROUND: Studies have estimated that a large backlog of procedures was generated by emergency measures implemented in Ontario, Canada, at the onset of the COVID-19 pandemic, when nonessential and scheduled procedures were postponed. Understanding the impact of the COVID-19 pandemic on the time needed to perform a procedure may help to determine the resources needed to tackle the substantial backlog caused by the deferral of cases. The purpose of this study was to examine the duration of operating room (OR) procedures before and after the onset of the COVID-19 pandemic to inform planning around changes in required resources. METHODS: A population-based, retrospective cohort study was conducted using Ontario Health Insurance Plan claims data and other administrative health care data from Apr. 1, 2019, to Sept. 30, 2020. Statistical analysis was conducted using multivariate regression, with procedure duration as the outcome variable. RESULTS: Results showed that the average duration of nonelective procedures increased by 34 minutes during the COVID-19 period and by 19 minutes after the resumption of scheduled procedures. Controlling for physician, patient and hospital characteristics, and the procedure code submitted, procedure duration increased by 12 minutes in the nonelective COVID-19 period and by 5 minutes when scheduled procedures resumed, compared with the pre-COVID-19 period. CONCLUSION: Procedures may take longer in the COVID-19 period. This will affect wait times, which had already increased because of the deferral of procedures at the beginning of the pandemic, and will have an impact on Ontario's ability to provide patients with timely care.

Opioid use after outpatient elective general surgery: quantifying the burden of persistent use.

Purpose: Surgery is a major risk factor for chronic opioid use among patients who had not recently been prescribed opioids. This study identifies the rate of, and risk factors for, persistent opioid use following laparoscopic cholecystectomy and open inguinal hernia repair in patients not recently prescribed opioids. Methods: This retrospective population-based cohort study included all patients who had not been prescribed opioids in the 6 months prior to undergoing open inguinal hernia repair or laparoscopic cholecystectomy from January 2013 to July 2016 in Ontario. Opioid prescription was identified from the provincial Narcotics Monitoring System and data were obtained from the Institute for Clinical Evaluative Sciences. The primary outcome was persistent opioid use after surgery (3, 6, 9 and 12 months). Associated risk factors and prescribing patterns were also examined. Results: Among the 90,326 patients in the study cohort, 80% filled an opioid prescription after surgery, with 11%, 9%, 5% and 1% filling a prescription at 3, 6, 9 and 12 months, respectively. Significant variability was identified in the type of opioid prescribed (41% codeine, 31% oxycodone, 18% tramadol) and in regional prescribing patterns (mean prescription/region range, 135-225 oral morphine equivalents). Predictors of continued opioid use included age, female gender, lower income quintile and being operated on by less experienced surgeons. Conclusion: Most patients who undergo elective cholecystectomy and hernia repair will fill a prescription for an opioid after surgery, and many will continue to fill opioid prescriptions for considerably longer than clinically anticipated. There is important variability in opioid type, regional prescribing patterns and risk factors that identify strategic targets to reduce the opioid burden in this patient population.

The Lake Erie HABs Grab: A binational collaboration to characterize the western basin cyanobacterial harmful algal blooms at an unprecedented high-resolution spatial scale.

Monitoring of cyanobacterial bloom biomass in large lakes at high resolution is made possible by remote sensing. However, monitoring cyanobacterial toxins is only feasible with grab samples, which, with only sporadic sampling, results in uncertainties in the spatial distribution of toxins. To address this issue, we conducted two intensive "HABs Grabs" of microcystin (MC)-producing Microcystis blooms in the western basin of Lake Erie. These were one-day sampling events during August of 2018 and 2019 in which 100 and 172 grab samples were collected, respectively, within a six-hour window covering up to 2,270 km2 and analyzed using consistent methods to estimate the total mass of MC. The samples were analyzed for 57 parameters, including toxins, nutrients, chlorophyll, and genomics. There were an estimated 11,513 kg and 30,691 kg of MCs in the western basin during the 2018 and 2019 HABs Grabs, respectively. The bloom boundary poses substantial issues for spatial assessments because MC concentration varied by nearly two orders of magnitude over very short distances. The MC to chlorophyll ratio (MC:chl) varied by a factor up to 5.3 throughout the basin, which creates challenges for using MC:chl to predict MC concentrations. Many of the biomass metrics strongly correlated (r > 0.70) with each other except chlorophyll fluorescence and phycocyanin concentration. While MC and chlorophyll correlated well with total phosphorus and nitrogen concentrations, MC:chl correlated with dissolved inorganic nitrogen. More frequent MC data collection can overcome these issues, and models need to account for the MC:chl spatial heterogeneity when forecasting MCs.

Complication Rates after Endometrial Ablation in Ontario: A Cohort Analysis of 76 446 Patients.

STUDY OBJECTIVES: Endometrial ablation (EA) is an alternative to hysterectomy for the management of heavy menstrual bleeding; however, EA is not without risk. Our objective was to determine complication rates in women undergoing EA in the province of Ontario over a 15-year time period. The primary outcome was a composite of multiple complications within 30 to 180 days of surgery. The secondary outcomes included mortality, length of hospital stay, hospital readmission, and emergency department visit within 30 days of discharge. DESIGN: Retrospective cohort study using Cochran-Armitage test for trend. SETTING: Administrative data from the Canadian province of Ontario, assessing patients undergoing surgery in a publicly funded healthcare system. PATIENTS: Women in Ontario undergoing a primary EA over a 15-year time period. INTERVENTIONS: The intervention was a primary EA. MEASUREMENTS AND MAIN RESULTS: We assessed for genitourinary complication, fistula, gastrointestinal complication, pain, control of bleeding, blood transfusion, infectious complication, venous thromboembolism, fluid overload, thermal injury, and other injuries related to surgery. The secondary outcomes included 1-month and 6-month mortality, length of hospital stay, hospital readmission, and emergency department visit within 30 days of discharge. A total of 76 446 primary EAs were evaluated from 2002 to 2017, with the number of EAs per year increasing over the study period by 47%. Complications were seen in 4.8% of the cohort, with the complication rate being relatively stable over time. Although 6.2% of the cohort re-presented to the emergency department, <1% required readmission, and <0.05% died within 180 days. On multivariable analysis, the risk of complications increased with a preoperative diagnosis of other than bleeding (odds ratio [OR] 2.89; 95% confidence interval [CI], 2.61-3.21; p <.001), previous abdominal surgery (OR 1.42; 95% CI, 1.28-1.56; p <.001), and American Society of Anesthesiologists score 3+ (OR 1.37; 95% CI, 1.27-1.48; p <.001). CONCLUSION: Primary EA is associated with complications in <5% of the patients, with serious complications infrequent.

Access to bariatric surgery among older patients in a publicly funded regionalized care system.

BACKGROUND: Bariatric surgery in older patients is safe and effective. Current guidelines do not endorse age limits for surgery; however, older patients may encounter difficulties with access given perceived risks. This study compares the adjusted probability of failing to receive bariatric surgery between older (≥ 60 years) and younger (< 60 years) patients referred to a publicly funded program. STUDY DESIGN: This is a retrospective cohort study of adult patients referred to a bariatric surgery program in Ontario from 2010-2016. Ontario health administrative databases and the Ontario Bariatric Registry were used for the analysis. The primary outcome was receipt of bariatric surgery within 3 years of referral. A multivariable logistic regression analysis was performed to determine the adjusted effect of older age (≥ 60 years) on the probability of not receiving surgery. Sensitivity analysis was performed using only healthy patients. RESULTS: Among 19,510 patients referred to the program, 1,795 patients (9.2%) were ≥ 60 years old, of which 60% received bariatric surgery within 3 years compared to 90% in younger patients. The odds older patients do not receive surgery after adjustment were significantly higher compared to younger patients (OR 1.69 [1.52-1.88], P < .001). This effect persists even among a subgroup of older patients with a Charlson Comorbidity Index = 0 (OR 1.78 [1.56-2.04], P < .001). CONCLUSIONS: Age alone, rather than comorbidities had a more significant effect on the access to bariatric surgery in older patients. Given the demonstrated benefits of bariatric surgery in older populations, ensuring equity in access to bariatric surgery should be encouraged. Future research is required to explore the underlying reasons why older patients who could benefit from bariatric surgery may not have the opportunity.

Dissolved Microcystin Release Coincident with Lysis of a Bloom Dominated by Microcystis spp. in Western Lake Erie Attributed to a Novel Cyanophage.

Western Lake Erie (Laurentian Great Lakes) is prone to annual cyanobacterial harmful algal blooms (cHABs) dominated by Microcystis spp. that often yield microcystin toxin concentrations exceeding the federal EPA recreational contact advisory of 8 µg liter-1 In August 2014, microcystin levels were detected in finished drinking water above the World Health Organization 1.0 µg liter-1 threshold for consumption, leading to a 2-day disruption in the supply of drinking water for >400,000 residents of Toledo, Ohio (USA). Subsequent metatranscriptomic analysis of the 2014 bloom event provided evidence that release of toxin into the water supply was likely caused by cyanophage lysis that transformed a portion of the intracellular microcystin pool into the dissolved fraction, rendering it more difficult to eliminate during treatment. In August 2019, a similar increase in dissolved microcystins at the Toledo water intake was coincident with a viral lytic event caused by a phage consortium different in composition from what was detected following the 2014 Toledo water crisis. The most abundant viral sequence in metagenomic data sets was a scaffold from a putative member of the Siphoviridae, distinct from the Ma-LMM01-like Myoviridae that are typically documented to occur in western Lake Erie. This study provides further evidence that viral activity in western Lake Erie plays a significant role in transformation of microcystins from the particulate to the dissolved fraction and therefore requires monitoring efforts from local water treatment plants. Additionally, identification of multiple lytic cyanophages will enable the development of a quantitative PCR toolbox to assess viral activity during cHABs.IMPORTANCE Viral attack on cHABs may contribute to changes in community composition during blooms, as well as bloom decline, yet loss of bloom biomass does not eliminate the threat of cHAB toxicity. Rather, it may increase risks to the public by delivering a pool of dissolved toxin directly into water treatment utilities when the dominating Microcystis spp. are capable of producing microcystins. Detecting, characterizing, and quantifying the major cyanophages involved in lytic events will assist water treatment plant operators in making rapid decisions regarding the pool of microcystins entering the plant and the corresponding best practices to neutralize the toxin.

Caregiver availability for severe stroke results in improved functional ability at discharge from inpatient rehabilitation.

PURPOSE: To evaluate the predictive capacity of caregiver availability on functional ability at time of discharge from inpatient rehabilitation in individuals with severe first-time stroke. METHODS: A retrospective chart review was conducted of severe stroke inpatients admitted to a stroke rehabilitation unit between April 2005 and December 2009. Follow-up telephone interviews were conducted with patients to determine caregiver availability at time of discharge. Hierarchical linear regression analysis was performed to assess the predictive capacity of caregiver availability on functional ability at discharge from an inpatient rehabilitation unit after controlling for covariates. RESULTS: Data from 180 individuals were included in the analysis. Individuals with a caregiver had significantly higher levels of functional ability at discharge compared to those without (85.8 ± 23.6 versus 72.9 ± 20.3; p < 0.01), although both groups achieved a minimal clinically important difference. After controlling for age, gender, admission Functional Independence Measure, and length of hospital stay, caregiver availability explained 1.3% of additional variance, with the final model explaining 41.3% of total variance for functional ability at discharge (F (5,174) = 26.21, p < 0.001). CONCLUSIONS: The presence of a caregiver at time of discharge from inpatient rehabilitation is predictive of significantly higher functional ability at discharge in individuals with severe stroke. Implications for rehabilitation The availability of a caregiver at time of discharge from inpatient rehabilitation is predictive of improved functional ability at discharge in individuals with severe stroke. The presence of an available caregiver positively influences the functional recovery of individuals with severe stroke and may be an important element to successful rehabilitation.

Cardiac Surgeons after Vacation: Refreshed or Rusty?

Introduction: Many surgeons describe feeling a bit out of practice when they return from a vacation. There have been no studies assessing the impact of surgeon vacation on patient outcomes. Methods: We used administrative data from the province of Ontario to identify patients who underwent a coronary artery bypass grafting. Using a propensity score, we matched patients who underwent their procedure immediately after their surgeon returned from vacation of at least 7 days (n = 1,161) to patients who were not operated immediately before or after a vacation period (n = 2,138). Results: There was no significant difference in patient mortality (odds ratio: 1.23, p = 0.52), length of operation (relative risk [RR]: 1.00 p = 0.58), or intensive care unit/ hospital stay (RR: 0.97 p = 0.66/RR: 0.98 p = 0.54, respectively). Conclusion: There was not a significant change in risk of death, operative length, or hospital stay after a surgeon vacation.

The impact of teaching on the duration of common urological operations.

INTRODUCTION: The ability of academic (teaching) hospitals to offer the same level of efficiency as non-teaching hospitals in a publicly funded healthcare system is unknown. Our objective was to compare the operative duration of general urology procedures between teaching and non-teaching hospitals. METHODS: We used administrative data from the province of Ontario to conduct a retrospective cohort study of all adults who underwent a specified elective urology procedure (2002-2013). Primary outcome was duration of surgical procedure. Primary exposure was hospital type (academic or non-teaching). Negative binomial regression was used to adjust relative time estimates for age, comorbidity, obesity, anesthetic, and surgeon and hospital case volume. RESULTS: 114 225 procedures were included (circumcision n=12 280; hydrocelectomy n=7221; open radical prostatectomy n=22 951; transurethral prostatectomy n=56 066; or mid-urethral sling n=15 707). These procedures were performed in an academic hospital in 14.8%, 13.3%, 28.6%, 17.1%, and 21.3% of cases, respectively. The mean operative duration across all procedures was higher in academic centres; the additional operative time ranged from 8.3 minutes (circumcision) to 29.2 minutes (radical prostatectomy). In adjusted analysis, patients treated in academic hospitals were still found to have procedures that were significantly longer (by 10-21%). These results were similar in sensitivity analyses that accounted for the potential effect of more complex patients being referred to tertiary academic centres. CONCLUSIONS: Five common general urology operations take significantly longer to perform in academic hospitals. The reason for this may be due to the combined effect of teaching students and residents or due to inherent systematic inefficiencies within large academic hospitals.

A systematic review of studies reporting multivariable models to predict functional outcomes after post-stroke inpatient rehabilitation.

PURPOSE: This systematic review summarizes the utility of variables available at acute discharge after stroke for predicting functional independence at discharge from inpatient rehabilitation. METHODS: A systematic review of four electronic databases (Medline, EMBASE, PsycINFO and CINAHL) was conducted to identify studies reporting multivariable models predicting post-rehabilitation Barthel Index (BI) or Functional Independence Measure (FIM®) scores. In studies meeting inclusion criteria, the frequency with which candidate predictors were found statistically significant was calculated and summarized. RESULTS: A total of 3260 articles were screened, of which 27 were included and 63 multivariable models of discharge BI or FIM® were reported. In all, 126 candidate predictors of BI or FIM® were explored. Variables found to be significant most frequently included admission functional level (BI or FIM®), National Institute of Health Stroke Scale (NIHSS), dysphasia, impulsivity, neglect, previous stroke, and age. CONCLUSIONS: Only a selected group of variables have repeatedly proven to be significant predictors of functional ability after post-stroke inpatient rehabilitation. [Box: see text].

Stroke: More than a 'brain attack'.

Stroke is a life-altering event that potentially affects stroke survivors, their families, healthcare resources, and society in general. Stroke has often been described as 'brain attack', denoting emergency emphasis on the vascular pathology. Consequently, many national and provincial stroke strategies have emphasized vascular care through primary prevention strategies and thrombolysis. Despite being important initiatives, this has resulted in a stroke system that emphasizes the frontloading of stroke care, focusing on the vascular pathology. The advent of thrombolysis therapy has benefited a small proportion of patients while a vast majority are still affected by stroke-related impairments. Management of the vascular elements of stroke is important; however, the impact of rehabilitation on stroke recovery has been relatively undervalued. Stroke care is in need of a revolution toward a more comprehensive and balanced approach. It is anticipated that the major focus of stroke care will include promoting recovery, in line with the growing evidence on stroke rehabilitation interventions. A paradigm shift is necessary to ensure that comprehensive and balanced stroke care which incorporates rehabilitation is taken into account, leading to a stroke care system where patient needs are managed both as a 'brain attack' and an 'injured brain'.

Effectiveness of psychological interventions in chronic stage of stroke: a systematic review.

OBJECTIVE: To examine the effectiveness of interventions for psychological issues faced by individuals post stroke when initiated in the chronic stage of stroke. METHOD: MEDLINE, CINAHL, EMBASE, and Scopus databases were searched from 1980 to July 2012. A study was included if (1) the study was a randomized controlled trial (RCT); (2) at least 50% of individuals in the study were entered into the study at over 6 months post stroke; (3) the study examined the effect of an intervention on psychological functioning; and (4) study participants were ≥ 18 years of age. Similar interventions were grouped and results summarized. Data on the study design, participant characteristics, interventions, outcomes, and adverse events were extracted from each of the selected studies. RESULTS: Nine RCTs met inclusion criteria. All 9 studies examined effectiveness on mood and 3 on adjustment. Repetitive transcranial magnetic stimulation had the strongest evidence of effectiveness in improving mood followed by pharmacotherapy; whereas exercise appeared to be effective in improving adjustment and coping among individuals in the chronic stage of stroke. CONCLUSION: Overall, interventions provided in the chronic stage of stroke appear to be effective in improving mood and adjustment up to 3 months post intervention. The use of multidisciplinary interventions and acceptance models may be important in the overall adjustment process.

Determining the need for in-patient rehabilitation services post-stroke: results from eight ontario hospitals.

BACKGROUND: The number of patients requiring in-patient rehabilitation services following acute stroke is unknown. METHODS: All consecutive patients admitted with a diagnosis of stroke to eight community hospitals in southwestern Ontario from May 2008 to December 2009 were screened for in-patient rehabilitation eligibility using the Stroke Rehabilitation Candidacy Screening Tool. RESULTS: Three hundred ninety-six patients were included, of which 147 (37.1%) were identified as candidates for in-patient rehabilitation. Of these patients, 111 (75%) were discharged to an in-patient rehabilitation unit. The most frequently documented reason that candidates were not transferred was lack of an available bed (n=19). Two hundred forty-nine (62.9%) patients were not considered candidates. The majority (80%) of these patients had experienced either mildly or severely disabling stroke and went home or directly to long-term care upon discharge. CONCLUSION: The reported estimate of 37% who required in-patient rehabilitation services is important for the purposes of planning and allocation of healthcare resources.

CONTEXTE : On ne connaît pas bien le nombre de patients qui ont besoin de services de réadaptation après un accident cérébrovasculaire aigu. MÉTHODE : Tous les patients admis suite à un diagnostic d'accident cérébrovasculaire dans huit hôpitaux communautaires du sud-ouest ontarien entre mai 2008 et décembre 2009 ont été soumis au protocole de dépistage pour les candidats à la réadaptation après un accident cérébrovasculaire (Stroke Rehabilitation Candidacy Screening Tool). RÉSULTATS : Trois cent quatre-vingt-seize patients ont été considérés. Parmi eux, 147 (37,1 %) ont été désignés comme candidats à la réadaptation. De ces patients, 111 (75 %) ont été dirigés vers une unité de réadaptation pour patients hospitalisés. La raison la plus évoquée pour ne pas y diriger un patient était le manque de lits disponibles (n=19). Deux cent quarante-neuf (62,9 %) patients n'ont pas été désignés candidats. La majorité (80 %) de ces patients avaient subit un accident cérébrovasculaire causant une invalidité de moyenne à sévère et ont reçu leur congé ou sont allés directement aux soins de longue durée. CONCLUSION : La proportion estimée de 37 pour cent des patients ayant besoin de services de réadaptation pour patients hospitalisés est importante pour la panification et la répartition des ressources en santé.

Stroke rehabilitation: an international perspective.

There is a revolution underway in stroke rehabilitation. International comparative studies coupled with an impressive evidence base have provided a platform from which an ideal system for stroke rehabilitation can be envisioned. Using the concepts of structure and process of care, different systems of stroke rehabilitation can be compared and evaluated against best evidence. Two structures of care are examined: specialized interdisciplinary stroke rehabilitation units and outpatient programs. Although specialized interdisciplinary stroke rehabilitation units remain the "gold standard" of care, access to them is often limited. Outpatient programs are essential to stroke rehabilitation systems of care; however, while some countries are investing in outpatient programs, others are scaling back. Even though structures of care have been shown to affect processes of care, it is the processes of care that have proven to be more influential in altering patient outcomes. Four key processes of care are examined: time to admission, intensity of therapy, task-specific therapy, and discharge planning. Within international stroke rehabilitation systems, differences in these processes have resulted in significant differences in outcomes. This allows for "real-world" comparisons of how differing processes affect patient outcomes. Those systems whose structures and processes of care best reflect current best evidence appear to achieve better outcomes.