Inter-Establishment Complex Musculoskeletal Care Pathways in Montreal: Timeline of a Collaboration Involving a Research Team Within a Continuous Quality Improvement Initiative.

Children and adolescents with complex musculoskeletal conditions may receive health care that requires at least 1 transfer between 4 specialized pediatric establishments in the Montreal region (Québec, Canada). This may result in challenges in navigating the system. A collaborative approach, aiming to make the inter-establishment care pathways seamless and to improve the integration of musculoskeletal health services, brought together key stakeholders including a research team. The aim of this paper is to describe the timeline of the collaborative approach's key milestones and activities and, more specifically, to describe the context, process, and outputs of the involvement of researchers in support of a continuous quality improvement project based on an integrated approach. The descriptive timeline was constructed from a qualitative document analysis of the project-related gray literature (n = 80 documents) and was validated and interpreted with key stakeholders. The results showed how the collaborative project was set up and operated, as well as what solutions were developed and implemented. The strategies on how the research team was involved in the integrated approach in addition to its research activities were also described. Conclusions suggest practice recommendations for creating change processes by integrating research, service evaluation and clinical audit into quality improvement projects.

Classifying clinical phenotypes of functional recovery for acute traumatic spinal cord injury. An observational cohort study.

PURPOSE: Identify patient subgroups with different functional outcomes after SCI and study the association between functional status and initial ISNCSCI components. METHODS: Using CART, we performed an observational cohort study on data from 675 patients enrolled in the Rick-Hansen Registry(RHSCIR) between 2014 and 2019. The outcome was the Spinal Cord Independence Measure (SCIM) and predictors included AIS, NLI, UEMS, LEMS, pinprick(PPSS), and light touch(LTSS) scores. A temporal validation was performed on data from 62 patients treated between 2020 and 2021 in one of the RHSCIR participating centers. RESULTS: The final CART resulted in four subgroups with increasing totSCIM according to PPSS, LEMS, and UEMS: 1)PPSS < 27(totSCIM = 28.4 ± 16.3); 2)PPSS ≥ 27, LEMS < 1.5, UEMS < 45(totSCIM = 39.5 ± 19.0); 3)PPSS ≥ 27, LEMS < 1.5, UEMS ≥ 45(totSCIM = 57.4 ± 13.8); 4)PPSS ≥ 27, LEMS ≥ 1.5(totSCIM = 66.3 ± 21.7). The validation model performed similarly to the original model. The adjusted R-squared and F-test were respectively 0.556 and 62.2(P-value <0.001) in the development cohort and, 0.520 and 31.9(P-value <0.001) in the validation cohort. CONCLUSION: Acknowledging the presence of four characteristic subgroups of patients with distinct phenotypes of functional recovery based on PPSS, LEMS, and UEMS could be used by clinicians early after tSCI to plan rehabilitation and establish realistic goals. An improved sensory function could be key for potentiating motor gains, as a PPSS ≥ 27 was a predictor of a good function.

After a traumatic Spinal Cord Injury (SCI), early neurological examination using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is recommended to determine initial injury severity and prognosis.This study identified three initial ISNCSCI components defining four subgroups of SCI patients with different expectations in functional outcomes, namely the initial pinprick sensory score, the Lower Extremity Motor Score, and the Upper Extremity Motor Score.Clinicians could use these subgroups early after tSCI to plan rehabilitation and set realistic therapeutic goals regarding functional outcomes.In clinical practice, careful and accurate assessment of pinprick sensation early after the SCI is crucial when predicting function or stratifying patients based on the expected function.

Does Improvement in American Spinal Injury Association Impairment Scale Grade Correlate With Functional Recovery in All Patients With a Traumatic Spinal Cord Injury?

OBJECTIVE: The aim of the study is to determine what improvement on the American Spinal Injury Impairment Scale correlates with functional status after a traumatic spinal cord injury. DESIGN: We performed an observational cohort study, analyzing prospective data from 168 patients with traumatic spinal cord injury admitted to a single level 1 trauma center. A multivariable analysis was performed to assess the relationship between functional status (from the Spinal Cord Independence Measure) at 1-year follow-up and American Spinal Injury Impairment Scale grade (baseline and 1-yr follow-up), while taking into account covariables describing the sociodemographic status, trauma severity, and level of neurological injury. RESULTS: Individuals improving to at least American Spinal Injury Impairment Scale grade D had significantly higher Spinal Cord Independence Measure score compared with those not reaching American Spinal Injury Impairment Scale D (89.3 ± 15.2 vs. 52.1 ± 20.4) and were more likely to reach functional independence (68.5% vs. 3.6%), regardless of the baseline American Spinal Injury Impairment Scale grade. Higher final Spinal Cord Independence Measure was more likely with an initial American Spinal Injury Impairment Scale grade D (ß = 1.504; 95% confidence interval = 0.46-2.55), and a final American Spinal Injury Impairment Scale grade D (ß = 3.716; 95% CI = 2.77-4.66) or E (ß = 4.422; 95% CI = 2.91-5.93). CONCLUSIONS: Our results suggest that reaching American Spinal Injury Impairment Scale grade D or better 1 yr after traumatic spinal cord injury is highly predictive of significant functional recovery, more so than the actual improvement in American Spinal Injury Impairment Scale grade from the injury to the 1-yr follow-up.

OBJECTIVE: The aim of the study is to determine what improvement on the American Spinal Injury Impairment Scale correlates with functional status after a traumatic spinal cord injury. DESIGN: We performed an observational cohort study, analyzing prospective data from 168 patients with traumatic spinal cord injury admitted to a single level 1 trauma center. A multivariable analysis was performed to assess the relationship between functional status (from the Spinal Cord Independence Measure) at 1-year follow-up and American Spinal Injury Impairment Scale grade (baseline and 1-yr follow-up), while taking into account covariables describing the sociodemographic status, trauma severity, and level of neurological injury. RESULTS: Individuals improving to at least American Spinal Injury Impairment Scale grade D had significantly higher Spinal Cord Independence Measure score compared with those not reaching American Spinal Injury Impairment Scale D (89.3 ± 15.2 vs. 52.1 ± 20.4) and were more likely to reach functional independence (68.5% vs. 3.6%), regardless of the baseline American Spinal Injury Impairment Scale grade. Higher final Spinal Cord Independence Measure was more likely with an initial American Spinal Injury Impairment Scale grade D (ß = 1.504; 95% confidence interval = 0.46­2.55), and a final American Spinal Injury Impairment Scale grade D (ß = 3.716; 95% CI = 2.77­4.66) or E (ß = 4.422; 95% CI = 2.91­5.93). CONCLUSIONS: Our results suggest that reaching American Spinal Injury Impairment Scale grade D or better 1 yr after traumatic spinal cord injury is highly predictive of significant functional recovery, more so than the actual improvement in American Spinal Injury Impairment Scale grade from the injury to the 1-yr follow-up.

Ultrasound Assessment of Ankle Syndesmotic Injuries in a Pediatric Population.

OBJECTIVE: To determine sensitivity and specificity for anterior-inferior tibiofibular ligament (AiTFL) integrity and tibiofibular clear-space (TFCS) cut-off points for dynamic evaluation using ultrasound (US) in a pediatric population. DESIGN: Prospective cohort study. SETTING: Tertiary care university-affiliated pediatric hospital patients between the ages of 12 and 18 sustaining acute ankle trauma with syndesmotic injury. INTERVENTIONS: Participants were assigned to the syndesmotic injury protocol that included a standardized MRI and US. MAIN OUTCOME MEASURES: Anterior-inferior tibiofibular ligament integrity for static assessment and TFCS measurements for dynamic assessment on US. For dynamic assessment, the distance between the distal tibia and fibula was first measured in neutral position and then in external rotation for each ankle. The US results on AiTFL integrity were compared with MRI, considered as our gold standard. Optimal cut-off points of TFCS values were determined with receiver operating characteristics curve analysis. RESULTS: Twenty-six participants were included. Mean age was 14.8 years (SD = 1.3 years). Sensitivity and specificity for AiTFL integrity were 79% and 100%, respectively (4 false negatives on partial tears). For dynamic assessment, the cut-off points for the differences in tibiofibular distance between the 2 ankles in 1) neutral position (TFCS N I-U ) and 2) external rotation (TFCS ER I-U ) were 0.2 mm (sensitivity = 83% and specificity = 80%) and 0.1 mm (sensitivity = 83% and specificity = 80%), respectively. CONCLUSIONS: Static US could be used in a triage context as a diagnostic tool for AiTFL integrity in a pediatric population as it shows good sensitivity and excellent specificity.

Evaluation of the implementation of single points of access for unattached patients in primary care and their effects: a study protocol.

INTRODUCTION: Attachment to a primary care provider is an important component of primary care as it facilitates access. In Québec, Canada, attachment to a family physician is a concern. To address unattached patients' barriers to accessing primary care, the Ministry of Health and Social Services mandated Québec's 18 administrative regions to implement single points of access for unattached patients (Guichets d'accès première ligne (GAPs)) that aim to better orient patients towards the most appropriate services to meet their needs. The objectives of this study are to (1) analyse the implementation of GAPs, (2) measure the effects of GAPs on performance indicators and (3) assess unattached patients' experiences of navigation, access and service utilisation. METHODS AND ANALYSIS: A longitudinal mixed-methods case study design will be conducted. Objective 1. Implementation will be analysed through semistructured interviews with key stakeholders, observations of key meetings and document analysis. Objective 2. GAP effects on indicators will be measured using performance dashboards produced using clinical and administrative data. Objective 3. Unattached patients' experiences will be assessed using a self-administered electronic questionnaire. Findings for each case will be interpreted and presented using a joint display, a visual tool for integrating qualitative and quantitative data. Intercase analyses will be conducted highlighting the similarities and differences across cases. ETHICS AND DISSEMINATION: This study is funded by the Canadian Institutes of Health Research (# 475314) and the Fonds de Soutien à l'innovation en santé et en services sociaux (# 5-2-01) and was approved by the CISSS de la Montérégie-Centre Ethics Committee (MP-04-2023-716).

Parents can reliably and accurately detect trunk asymmetry using an inclinometer smartphone app.

PURPOSE: An inclinometer smartphone application has been developed to enable the measurement of the angle of trunk inclination (ATI) to detect trunk surface asymmetry. The objective was to determine the reliability and validity of the smartphone app in the hands of non-professionals. METHODS: Three non-professional observers and one expert surgeon measured maximum ATI twice in a study involving 69 patients seen in the spine clinics to rule out scoliosis or for regular follow-up (10-18 y.o., Cobb [0°-58°]). Observers were parents not familiar with scoliosis screening nor use of an inclinometer. They received training from a 4-minute video. Intra and inter-observer reliability was determined using the generalizability theory and validity was assessed from intraclass correlation coefficients (ICC), agreement with the expert on ATI measurements using Bland-Altman analysis, and correct identification of the threshold for consultation (set to ≥6° ATI). RESULTS: Intra-observer and inter-observer reliability coefficients were excellent ϕ = 0.92. The standard error of measurement was 1.5° (intra-observer, 2 measurements) meaning that a parent may detect a change of 4° between examinations 95% of the time. Comparison of measurements between non-professionals and the expert resulted in ICC varying from 0.82 [0.71-0.88] to 0.84 [0.74-0.90] and agreement on the decision to consult occurred in 83 to 90% of cases. CONCLUSION: The use of a smartphone app resulted in excellent reliability, sufficiently low standard error of measurement (SEM) and good validity in the hands of non-professionals. The device and the instructional video are adequate means to allow detection and regular examination of trunk asymmetries by non-professionals.

Advanced practice physiotherapy in paediatrics: Implementation results.

Objectives: This study aimed to evaluate the implementation of an advanced practice physiotherapist (APP) clinic in our paediatric institution and assess APP and orthopaedic surgeon satisfaction. Methods: In this retrospective cohort study, all patient records from the APP clinic's second year (March 2017 to March 2018) at CHU Sainte-Justine were reviewed. These were compared with the records of patients seen by orthopaedic surgeons within the gait clinic the year before implementing the clinic. The following data were collected: demographic, professional issuing referral, reason for referral, consultation delay, clinical impression, investigation, and treatment plan. We also documented every subsequent follow-up to rule out any diagnostic change and identify surgical patients. Clinician satisfaction was assessed by the Minnesota Satisfaction and PROBES Questionnaires along with a short electronic survey. Results: Four hundred and eighteen patients were assessed by APPs and 202 by orthopaedic surgeons. APPs managed patients independently in 92.6% of cases. Nearly 86% of patients were discharged following the initial visit, and 7.4% were referred to a physiotherapist. Only 1% of APP patients eventually required surgery compared with nearly 6% in the orthopaedic group. The mean waiting time for consultation was greater in the APP group (513.7 versus 264 days). However, there was a significant reduction in mean waiting time over the last 3 months surveyed (106.5 days). Conclusions: The feedback from all clinicians involved was positive, with a greater mean score on the Minnesota Satisfaction and PROBES Questionnaire for APPs. The APP gait clinic appears to be an effective triage clinic. Level of evidence: III.

Development of a model of interprofessional support interventions to enhance brace adherence in adolescents with idiopathic scoliosis: a qualitative study.

PURPOSE: Brace treatment for adolescent idiopathic scoliosis is recognized as effective if the brace is worn as prescribed (20 to 23 hrs/day). Because of its negative biopsychosocial impact on adolescent patients' quality of life, brace adherence is a common problem (average bracewear of 12 hrs/day). The purpose of this paper is to develop an interprofessional support intervention model to enhance brace adherence in adolescents with scoliosis. METHODS: We enrolled 9 health professionals working with braced patients to participate in individual interviews. Interview guides were built following the Information-Motivation-Strategy Model (DiMatteo et al., Health Psychol Rev 6:74-91, 2012) and the Interprofessional Care Competency Framework (Education UoTCfI, Toronto Acad Health Sci Network, 2017). Thematic analysis was performed to identify the most relevant concepts for designing the intervention model. A panel of 5 clinical experts was recruited to review and validate the intervention model. RESULTS: Participants suggested educational, motivational, functional, psychological and interprofessional teamwork strategies to improve the support provided to patients and parents and potentially increase brace adherence. Using the emerging themes and their relationships, we designed an Interprofessional Adherence Support (IPAS) intervention model that identifies the actors, activities, structure and intended impacts of the intervention. According to the expert panel, the IPAS model is highly relevant to respond to the brace adherence problem and has potential for implementation in practice. CONCLUSION: We designed an interprofessional support intervention model based on professional perspectives in response to the brace adherence problem in adolescents with scoliosis. Plans for implementation of the IPAS model at our scoliosis clinic are under development and considered essential for improving brace treatment outcomes.

Strategies to reduce waiting times in outpatient rehabilitation services for adults with physical disabilities: A systematic literature review.

OBJECTIVE: Identifying effective strategies to reduce waiting times is a crucial issue in many areas of health services. Long waiting times for rehabilitation services have been associated with numerous adverse effects in people with disabilities. The main objective of this study was to conduct a systematic literature review to assess the effectiveness of service redesign strategies to reduce waiting times in outpatient rehabilitation services for adults with physical disabilities. METHODS: We conducted a systematic review, searching three databases (MEDLINE, CINAHL and EMBASE) from their inception until May 2021. We identified studies with comparative data evaluating the effect of rehabilitation services redesign strategies on reducing waiting times. The Mixed Methods Appraisal Tool was used to assess the methodological quality of the studies. A narrative synthesis was conducted. RESULTS: Nineteen articles including various settings and populations met the selection criteria. They covered physiotherapy (n = 11), occupational therapy (n = 2), prosthetics (n = 1), exercise physiology (n = 1) and multidisciplinary (n = 4) services. The methodological quality varied (n = 10 high quality, n = 6 medium, n = 3 low); common flaws being missing information on the pre-redesign setting and characteristics of the populations. Seven articles assessed access processes or referral management strategies (e.g. self-referral), four focused on extending/modifying the roles of service providers (e.g. to triage) and eight changed the model of care delivery (e.g. mode of intervention). The different redesign strategies had positive effects on waiting times in outpatient rehabilitation services. CONCLUSIONS: This review highlights the positive effects of many service redesign strategies. These findings suggest that there are several effective strategies to choose from to reduce waiting times and help better respond to the needs of persons experiencing physical disabilities.

Perceptions on barriers, facilitators, and recommendations related to mental health service delivery during the COVID-19 pandemic in Quebec, Canada: a qualitative descriptive study.

BACKGROUND: There was an increase in self-reported mental health needs during the COVID-19 pandemic in Canada, with research showing reduced access to mental health services in comparison to pre-pandemic levels. This paper explores 1) barriers and facilitating factors associated with mental health service delivery via primary care settings during the first two pandemic waves in Quebec, Canada, and 2) recommendations to addressing these barriers. METHODS: A qualitative descriptive study design was used. Semi-structured interviews with 20 participants (health managers, family physicians, mental health clinicians) were conducted and coded using a thematic analysis approach. RESULTS: Barriers and facilitating factors were organized according to Chaudoir et al. (2013)'s framework of structural, organizational, provider- and patient-related, as well as innovation (technological modalities for service delivery) categories. Barriers included relocation of mental health staff to non-mental health related COVID-19 tasks (structural); mental health service interruption (organizational); mental health staff on preventive/medical leave (provider); the pandemic's effect on consultations (i.e., perceptions of increased demand) (patients); and challenges with the use of technological modalities (innovation). Facilitating factors included reinforcements to mental health care teams (structural); perceptions of reductions in wait times for mental health evaluations during the second wave due to diminished FP referrals in the first wave, as well as supports (i.e., management, private sector, mental health trained staff) for mental health service delivery (organizational); staff's mental health consultation practices (provider); and advantages in increasing the use of technological modalities in practice (innovation). CONCLUSIONS: To our knowledge, this is the first study to explore barriers and facilitating factors to mental health service delivery during the pandemic in Quebec, Canada. Some barriers identified were caused by the pandemic, such as the relocation of staff to non-mental health services and mental health service interruption. Offering services virtually seemed to facilitate mental health service delivery only for certain population groups. Recommendations related to building and strengthening human and technological capacity during the pandemic can inform mental health practices and policies to improve mental health service delivery in primary care settings and access to mental health services via access points.

Cervical spine injury response to direct rear head impact.

BACKGROUND: Direct rear head impact can occur during falls, road accidents, or sports accidents. They induce anterior shear, flexion and compression loads suspected to cause flexion-distraction injuries at the cervical spine. However, post-mortem human subject experiments mostly focus on sled impacts and not direct head impacts. METHODS: Six male cadavers were subjected to a direct rear head impact of 3.5 to 5.5 m/s with a 40 kg impactor. The subjects were equipped with accelerometers at the forehead, mouth and sternum. High-speed cameras and stereography were used to track head displacements. Head range of motion in flexion-extension was measured before and after impact for four cadavers. The injuries were assessed from CT scan images and dissection. FINDINGS: Maximum head rotation was between 43 degrees and 78 degrees, maximum cranial-caudal displacement between -12 mm and - 196 mm, and antero-posterior displacement between 90 mm and 139 mm during the impact. Four subjects had flexion-distraction injuries. Anterior vertebral osteophyte identification showed that fractures occurred at adjacent levels of osteophytic bridges. The other two subjects had no anterior osteophytes and suffered from C2 fracture, and one subject also had a C1-C2 subluxation. C6-C7 was the most frequently injured spinal level. INTERPRETATION: Anterior vertebral osteophytes appear to influence the type and position of injuries. Osteophytes would seem to provide stability in flexion for the osteoarthritic cervical spine, but to also lead to stress concentration in levels adjacent to the osteophytes. Clinical management of patients presenting with osteophytes fracture should include neck immobilization and careful follow-up to ensure bone healing.

Numerical Investigation of Spinal Cord Injury After Flexion-Distraction Injuries at the Cervical Spine.

Flexion-distraction injuries frequently cause traumatic cervical spinal cord injury (SCI). Post-traumatic instability can cause aggravation of the secondary SCI during patient care. However, there is little information on how the pattern of disco-ligamentous injury affects the SCI severity and mechanism. This study objective was to analyze how posterior disco-ligamentous injuries affect spinal cord compression and stress and strain patterns in the spinal cord during post-traumatic flexion and extension. A cervical spine finite element model including the spinal cord was used and different combinations of partial or complete intervertebral disc (IVD) rupture and disruption of various posterior ligaments were modeled at C4-C5, C5-C6, or C6-C7. In flexion, complete IVD rupture combined with posterior ligamentous complex rupture was the most severe injury leading to the highest von Mises stress (47-66 kPa), principal strains p1 (0.32-0.41 in white matter) and p3 (-0.78 to -0.96 in white matter) in the spinal cord and the highest spinal cord compression (35-48%). The main post-trauma SCI mechanism was identified as the compression of the anterior white matter at the injured level combined with distraction of the posterior spinal cord during flexion. There was also a concentration of the maximum stresses in the gray matter during post-traumatic flexion. Finally, in extension, the injuries tested had little impact on the spinal cord. The capsular ligament was the most important structure to protect the spinal cord. Its status should be carefully examined during the patient's management.

Exploring the implementation and underlying mechanisms of centralized referral systems to access specialized health services in Quebec.

BACKGROUND: In 2016, Quebec, a Canadian province, implemented a program to improve access to specialized health services (Accès priorisé aux services spécialisés (APSS)), which includes single regional access points for processing requests to such services via primary care (Centre de répartition des demandes de services (CRDS)). Family physicians fill out and submit requests for initial consultations with specialists using a standardized form with predefined prioritization levels according to listed reasons for consultations, which is then sent to the centralized referral system (the CRDS) where consultations with specialists are assigned. We 1) described the APSS-CRDS program in three Quebec regions using logic models; 2) compared similarities and differences in the components and processes of the APSS-CRDS models; and 3) explored contextual factors influencing the models' similarities and differences. METHODS: We relied on a qualitative study to develop logic models of the implemented APSS-CRDS program in three regions. Semi-structured interviews with health administrators (n = 9) were conducted. The interviews were analysed using a framework analysis approach according to the APSS-CRDS's components included in the initially designed program, Mitchell and Lewis (2003)'s logic model framework, and Chaudoir and colleagues (2013)'s framework on contextual factors' influence on an innovation's implementation. RESULTS: Findings show the APSS-CRDS program's regional variability in the implementation of its components, including its structure (centralized/decentralized), human resources involved in implementation and operation, processes to obtain specialists' availability and assess/relay requests, as well as monitoring methods. Variability may be explained by contextual factors' influence, like ministerial and medical associations' involvement, collaborations, the context's implementation readiness, physician practice characteristics, and the program's adaptability. INTERPRETATION: Findings are useful to inform decision-makers on the design of programs like the APSS-CRDS, which aim to improve access to specialists, the essential components for the design of these types of interventions, and how contextual factors may influence program implementation. Variability in program design is important to consider as it may influence anticipated effects, a next step for the research team. Results may also inform stakeholders should they wish to implement similar programs to increase access to specialized health services via primary care.

An exploration of youth and parents' experiences of child mental health service access.

Youth experience an increased prevalence of mental health issues, while access to timely and quality services remains problematic. This study examined the experiences of adolescents and their parents surrounding mental health care access. A 4-month focused ethnography was conducted at a mental health clinic for adolescents experiencing difficulties with emotional regulation. Findings revealed major barriers to service access, including a lack of knowledge, information, and guidance, long wait times, and stigma. Facilitators to access included social support, having a contact person, and good rapport with healthcare providers. The study highlights the importance of timely mental health service access for adolescents and provides insights for the improvement of service accessibility.

Early Predictors of Neurological Outcomes After Traumatic Spinal Cord Injury: A Systematic Review and Proposal of a Conceptual Framework.

BACKGROUND: Neurological outcomes after traumatic spinal cord injury are variable and depend on patient-, trauma-, and treatment-related factors as well as on spinal cord injury characteristics, imaging, and biomarkers. OBJECTIVE: The aims of the study were to identify and classify the early predictors of neurological outcomes after traumatic spinal cord injury. DATA SOURCES: The Medline, PubMed, Embase, and the Cochrane Central Database were searched using medical subject headings. The search was extended to the reference lists of identified studies. STUDY ELIGIBILITY CRITERIA: The study eligibility criteria were assessment of neurological outcomes as primary or secondary outcome, predictors collected during the acute phase after traumatic spinal cord injury, and multivariate design. PARTICIPANTS: The participants were adult patients with traumatic spinal cord injury followed at least 3 mos after injury. STUDY APPRAISAL AND SYNTHESIS METHODS: The quality of studies was assessed by two independent reviewers using the Study Quality Assessment Tools for Observational Cohort and Cross-sectional Studies. The studies' narrative synthesis relied on a classification of the predictors according to quantity, quality, and consistency of the evidence. Results were summarized in a conceptual framework. RESULTS: Forty-nine articles were included. The initial severity of traumatic spinal cord injury (American Spinal Injury Association Impairment Scale, motor score, and neurological level of injury) was the strongest predictor of neurological outcomes: patients with more severe injury at admission presented poor neurological outcomes. Intramedullary magnetic resonance imaging signal abnormalities were also associated with neurological outcomes, as the presence of intramedullary hemorrhage was a factor of poor prognosis. Other largely studied predictors, such as age and surgical timing, showed some inconsistency in results depending on cutoffs. Younger age and early surgery were generally associated with good outcomes. Although widely studied, other factors, such as vertebral and associated injuries, failed to show association with outcomes. Cerebrospinal fluid inflammatory biomarkers, as emerging factors, were significantly associated with outcomes. CONCLUSIONS: This study provides a comprehensive review of predictors of neurological outcomes after traumatic spinal cord injury. It also highlights the heterogeneity of outcomes used by studies to assess neurological recovery. The proposed conceptual framework classifies predictors and illustrates their relationships with outcomes.

Use of Regression Tree Analysis for Predicting the Functional Outcome after Traumatic Spinal Cord Injury.

Predicting the long-term functional outcome after traumatic spinal cord injury (TSCI) is needed to adapt medical strategies and plan an optimized rehabilitation. This study investigates the use of regression trees for the development of predictive models based on acute clinical and demographic predictors. This prospective study was performed on 172 patients hospitalized after TSCI. Functional outcome was quantified using the Spinal Cord Independence Measure (SCIM) collected within the first-year post-injury. Age, delay before surgery, and Injury Severity Score (ISS) were considered as continuous predictors whereas energy of injury, trauma mechanisms, neurological level of injury, injury severity, occurrence of early spasticity, urinary tract infection, pressure ulcer, and pneumonia were coded as categorical inputs. A simplified model was built using only American Spinal Injury Association Impairment Scale grade, neurological level, energy, and age as predictor and was compared to a more complex model considering all 11 predictors mentioned above. The models built using 4 and 11 predictors were found to explain 51.4% and 62.3% of the variance of the SCIM total score after validation, respectively. Severity of the neurological deficit at admission was found to be the most important predictor. Other important predictors were the ISS, age, neurological level, and delay before surgery. Regression trees offer promising performances for predicting the functional outcome after a TSCI. It could help to determine the number and type of predictors leading to a prediction model of the functional outcome that can be used clinically in the future.

Patient outcomes in idiopathic scoliosis are associated with biological endophenotypes: 2020 SOSORT award winner.

PURPOSE: Bracing is the treatment of choice for idiopathic scoliosis (IS), unfortunately factors underlying brace response remain unknown. Clinicians are currently unable to identify patients who may benefit from bracing, and therefore, better molecular stratification is critically needed. The aim of this study is to evaluate IS patient outcomes at skeletal maturity in relation to biological endophenotypes, and determine specific endophenotypes associated to differential bracing outcomes. This is a retrospective cohort with secondary cross-sectional comparative studies. METHODS: Clinical and radiological data were collected from 563 IS patients, stratified into biological endophenotypes (FG1, FG2, FG3) based on a cell-based test. Measured outcomes were maximum Cobb angle at skeletal maturity, and if severe, spinal deformity (≥ 45°) or surgery was attained. Treatment success/failure was determined by standard progression thresholds (Cobb ≥ 45° or surgery; Cobb angle progression ≥ 6°). Multivariable analyses were performed to evaluate associations between endophenotypes and clinical outcome. RESULTS: Higher Cobb angles at maturity for FG1 and FG2 patients were observed (p = 0.056 and p = 0.05), with increased likelihood of ≥ 45° and/or surgery for FG1 (OR = 2.181 [1.002-4.749] and FG2 (OR = 2.141 [1.038-4.413]) compared to FG3. FG3 was 9.31 [2.58-33.61] and 5.63 [2.11-15.05] times more likely for bracing success at treatment termination and based on the < 6° progression criterion, respectively, compared to FG1. CONCLUSION: Associations between biological endophenotypes and outcomes suggest differences in progression and/or bracing response among IS patients. Outcomes were most favorable in FG3 patients. The results pave the way for establishing personalized treatments, distinguishing who may benefit or not from treatment.

3D reconstruction of the human trunk for designing personalized braces : Precision study.

The customized design of braces for adolescent idiopathic scoliosis (AIS) treatment requires the acquisition of the 3D external geometry of the patients' trunks. Three body scanning systems are available at CHU Sainte-Justine in Montreal: a fixed system of InSpeck Capturor II LF digitizers and two portable scanners, BodyScan and Structure Sensor. The aim of this study is to compare them by evaluating their accuracy and repeatability. To achieve this, we placed 46 surface markers on an anthropomorphic manikin and scanned it three times with each system. We also measured the 3D coordinates of the same markers using a coordinate measuring machine (CMM), serving as ground-truth. We evaluated the repeatability and accuracy of the three systems: the former, by measuring the bidirectional mean distance between the three surfaces acquired with a given modality; the latter, by calculating the residual normal distance separating each of the 3D surfaces and the CMM point cloud. We also compared texture mapping accuracy between InSpeck and Structure Sensor by examining the CMM point cloud versus the marker 3D coordinates selected on the trunk surface. The results show good accuracy and repeatability for all three systems, with slightly better geometric accuracy for BodyScan (p-value ≈ 10-6). In terms of texture mapping, InSpeck showed better accuracy than Structure Sensor (p-value = 0.0059).

How the design and implementation of centralized waiting lists influence their use and effect on access to healthcare - A realist review.

CONTEXT: Many health systems have centralized waiting lists (CWLs), but there is limited evidence on CWL effectiveness and how to design and implement them. AIM: To understand how CWLs' design and implementation influence their use and effect on access to healthcare. METHODS: We conducted a realist review (n = 21 articles), extracting context-intervention-mechanism-outcome configurations to identify demi-regularities (i.e., recurring patterns of how CWLs work). RESULTS: In implementing non-mandatory CWLs, acceptability to providers influences their uptake of the CWL. CWL eligibility criteria that are unclear or conflict with providers' role or judgement may result in inequities in patient registration. In CWLs that prioritize patients, providers must perceive the criteria as clear and appropriate to assess patients' level of need; otherwise, prioritization may be inconsistent. During patients' assignment to service providers, providers may select less-complex patients to obtain CWLs rewards or avoid penalties; or may select patients for other policies with stronger incentives, disregarding the established patient order and leading to inequities and limited effectiveness. CONCLUSION: These findings highlight the need to consider provider behaviours in the four sequential CWL design components: CWL implementation, patient registration, patient prioritization and patient assignment to providers. Otherwise, CWLs may result in limited effects on access or lead to inequities in access to services.