Fusion and patient-reported outcomes after navigated decortication and direct arthrodesis in minimally invasive sacroiliac joint fusion using cylindrical threaded implants: a case series and literature review.

OBJECTIVE: Sacroiliac joint (SIJ) dysfunction is a significant cause of back pain. Despite recent advances in minimally invasive (MIS) SIJ fusion, the fusion rate remains controversial. This study sought to demonstrate that a navigated decortication and direct arthrodesis technique in MIS SIJ fusion would result in satisfactory fusion rates and patient-reported outcomes (PROs). METHODS: The authors retrospectively reviewed consecutive patients who underwent MIS SIJ fusion from 2018 to 2021. SIJ fusion was performed using cylindrical threaded implants and SIJ decortication employing the O-arm surgical imaging system and StealthStation. The primary outcome was fusion, evaluated using CT at 6, 9, and 12 months postoperatively. Secondary outcomes included revision surgery, time to revision surgery, visual analog scale (VAS) score for back pain, and the Oswestry Disability Index (ODI), measured preoperatively and 6 and 12 months postoperatively. Patient demographics and perioperative data were also collected. PROs over time were analyzed using ANOVA followed by a post hoc analysis. RESULTS: One hundred eighteen patients were included in this study. The mean (± SD) patient age was 58.56 ± 13.12 years, and most patients were female (68.6% vs 31.4% male). There were 19 smokers (16.1%) with an average BMI of 29.92 ± 6.73. One hundred twelve patients (94.9%) underwent successful fusion on CT. The ODI improved significantly from baseline to 6 months (Δ7.73, 95% CI 2.43-13.03, p = 0.002) and from baseline to 12 months (Δ7.54, 95% CI 1.65-13.43, p = 0.008). Similarly, VAS back pain scores improved significantly from baseline to 6 months (Δ2.31, 95% CI 1.07-3.56, p < 0.001) and from baseline to 12 months (Δ1.63, 95% CI 0.25-3.00, p = 0.015). CONCLUSIONS: MIS SIJ fusion with navigated decortication and direct arthrodesis was associated with a high fusion rate and significant improvement in disability and pain scores. Further prospective studies examining this technique are warranted.

Attitudes toward allopathic and osteopathic candidates in the dermatologic residency application process.

Since the recent establishment of a single graduate medical education organization, there has been a declining match rate of osteopathic students to competitive specialties, particularly dermatology residency, despite the increasing number of osteopathic medical students in the United States. The aim of this study was to investigate attitudes and potential sources of bias affecting osteopaths in the dermatology residency application process. This was an online survey-based study to analyze dermatology faculty and resident considerations. Data were analyzed using descriptive and inferential statistics. Sixteen percent (3 of 18) of allopathic residents and 73.68% (14 of 19) of osteopathic residents experienced bias based on their allopathic or osteopathic status (P < .002). Compared with allopathic graduates, the main barrier for osteopathic graduates was research (P = .00105). Being an osteopathic candidate was associated with a lower likelihood of consideration for mentorship by both allopathic and osteopathic faculty (P = .044). Faculty members who mentor osteopathic candidates are 1.83 times more comfortable with knowledge of osteopathic schools and their respective curricula (P = .029) and 1.77 times more comfortable with reviewing letters of recommendation written by osteopathic faculty (P = .037). Limitations include self-selection bias, small sample size, and overrepresentation of faculty and residents who participate in research studies. Additional research opportunities for osteopathic students, more diverse mentorship programs, and education for faculty on osteopathic concepts may promote equity during the residency application process and professional diversity within the field of dermatology.

"COVID just kind of opened a can of whoop-ass": The rapid growth of safer supply prescribing during the pandemic documented through an environmental scan of addiction and harm reduction services in Canada.

OBJECTIVES: In the context of the ongoing overdose crisis, a stark increase in toxic drug deaths from the unregulated street supply accompanied the onset of the COVID-19 pandemic. Injectable opioid agonist treatment (iOAT - hydromorphone or medical-grade heroin), tablet-based iOAT (TiOAT), and safer supply prescribing are emerging interventions used to address this crisis in Canada. Given rapid clinical guidance and policy change to enable their local adoption, our objectives were to describe the state of these interventions before the pandemic, and to document and explain changes in implementation during the early pandemic response (March-May 2020). METHODS: Surveys and interviews with healthcare providers comprised this mixed methods national environmental scan of iOAT, TiOAT, and safer supply across Canada at two time points. Quantitative data were summarized using descriptive statistics; interview data were coded and analyzed thematically. RESULTS: 103 sites in 6 Canadian provinces included 19 iOAT, 3 TiOAT and 21 safer supply sites on March 1, 2020; 60 new safer supply sites by May 1 represented a 285% increase. Most common substances were opioids, available at all sites; most common settings were addiction treatment programs and primary care clinics, and onsite pharmacies models. 79% of safer supply services were unfunded. Diversity in service delivery models demonstrated broad adaptability. Qualitative data reinforced the COVID-19 pandemic as the driving force behind scale-up. DISCUSSION: Data confirmed the capacity for rapid scale-up of flexible, community-based safer supply prescribing during dual public health emergencies. Geographical, client demographic, and funding gaps highlight the need to target barriers to implementation, service delivery and sustainability.

Service delivery models for injectable opioid agonist treatment in Canada: 2 sequential environmental scans.

BACKGROUND: Injectable opioid agonist treatment (iOAT) is an emerging evidence-based option in the continuum of care for opioid use disorder in parts of Canada. Our study objective was to identify and describe iOAT programs operating during the ongoing opioid overdose crisis. METHODS: We conducted 2 sequential environmental scans. Programs were eligible to participate if they were in operation as of Sept. 1, 2018, and Mar. 1, 2019. Information was collected over 2-3 months for each scan (September-October 2018, March-May 2019). Programs that participated in the first scan and newly established programs were invited to participate in the second scan. The scans included questions about location, service delivery model, clinical and operational characteristics, numbers and demographic characteristics of clients, and program barriers and facilitators. Descriptive analysis was performed. RESULTS: We identified 14 unique programs across the 2 scans. Eleven programs located in urban centres in British Columbia and Ontario participated in the first scan. At the time of the second scan, 2 of these programs were on hold and 2 of 3 newly established programs were in Alberta. The total capacity of all participating programs was 420 clients at most. Four service delivery models were identified; iOAT was most commonly integrated within existing health and social services. All programs offered hydromorphone, and 1 program also offered diacetylmorphine. In the first scan, 73% of clients (133/183) were male; the mean age of clients was 47 years. Limited capacity, pharmacy operations and lack of diacetylmorphine access were among the most frequently reported barriers. The most commonly reported facilitators included client-centred care, client relationships and access to other health and social support. INTERPRETATION: Evidence indicates that iOAT can be successfully implemented using diverse service delivery models. Future work should facilitate scale-up of this evidence-based treatment where gaps persist in high-risk communities.

Spontaneous intracranial hypotension complicated by diffuse cerebral edema and episodes of severely elevated intracranial pressure: illustrative case.

BACKGROUND: Spontaneous intracranial hypotension (SIH) is a well-documented condition that typically follows a defined clinical course. Previously published studies describing the pathophysiology of SIH have demonstrated extensive evidence of low intracranial pressure (ICP) driving the clinical features of the condition. Through lumbar puncture and use of intracranial monitoring devices, however, both low and normal cerebrospinal fluid (CSF) pressures have been documented. This report outlined and discussed the unique finding of elevated ICP associated with clinical features of SIH. OBSERVATIONS: Here, the authors presented a case of a patient with spontaneous spinal CSF leak who developed tonsillar herniation, cerebral edema, and subsequent episodes of elevated ICP. Although more diverse presentations of SIH are being reported, the authors believed the case to be unique because SIH was accompanied by elevated ICP. LESSONS: This case adds to the growing body of literature surrounding SIH by demonstrating that patients can develop elevated CSF pressures associated with acute encephalopathy.

Physician performance feedback in a Canadian academic center.

Purpose This paper aims at the implementation and early evaluation of a comprehensive, formative annual physician performance feedback process in a large academic health-care organization. Design/methodology/approach A mixed methods approach was used to introduce a formative feedback process to provide physicians with comprehensive feedback on performance and to support professional development. This initiative responded to organization-wide engagement surveys through which physicians identified effective performance feedback as a priority. In 2013, physicians primarily affiliated with the organization participated in a performance feedback process, and physician satisfaction and participant perceptions were explored through participant survey responses and physician leader focus groups. Training was required for physician leaders prior to conducting performance feedback discussions. Findings This process was completed by 98 per cent of eligible physicians, and 30 per cent completed an evaluation survey. While physicians endorsed the concept of a formative feedback process, process improvement opportunities were identified. Qualitative analysis revealed the following process improvement themes: simplify the tool, ensure leaders follow process, eliminate redundancies in data collection (through academic or licensing requirements) and provide objective quality metrics. Following physician leader training on performance feedback, 98 per cent of leaders who completed an evaluation questionnaire agreed or strongly agreed that the performance feedback process was useful and that training objectives were met. Originality/value This paper introduces a physician performance feedback model, leadership training approach and first-year implementation outcomes. The results of this study will be useful to health administrators and physician leaders interested in implementing physician performance feedback or improving physician engagement.

Quality gaps identified through mortality review.

BACKGROUND: Hospital mortality rate is a common measure of healthcare quality. Morbidity and mortality meetings are common but there are few reports of hospital-wide mortality-review processes to provide understanding of quality-of-care problems associated with patient deaths. OBJECTIVE: To describe the implementation and results from an institution-wide mortality-review process. DESIGN: A nurse and a physician independently reviewed every death that occurred at our multisite teaching institution over a 3-month period. Deaths judged by either reviewer to be unanticipated or to have any opportunity for improvement were reviewed by a multidisciplinary committee. We report characteristics of patients with unanticipated death or opportunity for improved care and summarise the opportunities for improved care. RESULTS: Over a 3-month period, we reviewed all 427 deaths in our hospital in detail; 33 deaths (7.7%) were deemed unanticipated and 100 (23.4%) were deemed to be associated with an opportunity for improvement. We identified 97 opportunities to improve care. The most common gap in care was: 'goals of care not discussed or the discussion was inadequate' (n=25 (25.8%)) and 'delay or failure to achieve a timely diagnosis' (n=8 (8.3%)). Patients who had opportunities for improvement had longer length of stay and a lower baseline predicted risk of death in hospital. Nurse and physician reviewers spent approximately 142 h reviewing cases outside of committee meetings. CONCLUSIONS: Our institution-wide mortality review found many quality gaps among decedents, in particular inadequate discussion of goals of care.

Learning to account for the social determinants of health affecting homeless persons.

CONTEXT: Intersecting social determinants of health constrain access to care and treatment adherence among homeless populations. Because clinicians seldom receive training in the social determinants of health, they may be unprepared to account for or address these factors when developing treatment strategies for homeless individuals. OBJECTIVES: This study explored: (i) clinicians' preparedness to provide care responsive to the social determinants of health in homeless populations, and (ii) the steps taken by clinicians to overcome shortcomings in their clinical training in regard to the social determinants of health. METHODS: Qualitative interviews were conducted with doctors (n = 6) and nurses (n = 18) in six Canadian cities. Participants had at least 2 years of experience in providing care to homeless populations. Interview transcripts were analysed using methods of constant comparison. RESULTS: Participants highlighted how, when first providing care to this population, they were unprepared to account for or address social determinants shaping the health of homeless persons. However, participants recognised the necessity of addressing these factors to situate care within the social and structural contexts of homelessness. Participants' accounts illustrated that experiential learning was critical to increasing capacity to provide care responsive to the social determinants of health. Experiential learning was a continuous process that involved: (i) engaging with homeless persons in multiple settings and contexts to inform treatment strategies; (ii) evaluating the efficacy of treatment strategies through continued observation and critical reflection, and (iii) adjusting clinical practice to reflect observations and new knowledge. CONCLUSIONS: This study underscores the need for greater emphasis on the social determinants of health in medical education in the context of homelessness. These insights may help to inform the development and design of service-learning initiatives that integrate understandings of the social determinants of health, and thus potentially improve the readiness of clinicians to address the complex factors that shape the health of homeless populations.

Harm reduction services as a point-of-entry to and source of end-of-life care and support for homeless and marginally housed persons who use alcohol and/or illicit drugs: a qualitative analysis.

BACKGROUND: Homeless and marginally housed persons who use alcohol and/or illicit drugs often have end-of-life care needs that go unmet due to barriers that they face to accessing end-of-life care services. Many homeless and marginally housed persons who use these substances must therefore rely upon alternate sources of end-of-life care and support. This article explores the role of harm reduction services in end-of-life care services delivery to homeless and marginally housed persons who use alcohol and/or illicit drugs. METHODS: A qualitative case study design was used to explore end-of-life care services delivery to homeless and marginally housed persons in six Canadian cities. A key objective was to explore the role of harm reduction services. 54 health and social services professionals participated in semi-structured qualitative interviews. All participants reported that they provided care and support to this population at end-of-life. RESULTS: Harm reduction services (e.g., syringe exchange programs, managed alcohol programs, etc.) were identified as a critical point-of-entry to and source of end-of-life care and support for homeless and marginally housed persons who use alcohol and/or illicit drugs. Where possible, harm reduction services facilitated referrals to end-of-life care services for this population. Harm reduction services also provided end-of-life care and support when members of this population were unable or unwilling to access end-of-life care services, thereby improving quality-of-life and increasing self-determination regarding place-of-death. CONCLUSIONS: While partnerships between harm reduction programs and end-of-life care services are identified as one way to improve access, it is noted that more comprehensive harm reduction services might be needed in end-of-life care settings if they are to engage this underserved population.

The healthcare quality agenda in Canada.

Sullivan et al. have captured several important themes. One of the reasons that healthcare has been slow to adopt a culture of quality has been that it has taken a long time to recognize that quality is a continuous journey along several dimensions. Following advances in the early 1990s on appropriateness and effectiveness, there has been a decade-long preoccupation with accessibility that still remains an issue. Patient-centredness is one of the most recent dimensions to receive attention, and the overall goal of quality - improved patient outcomes - needs considerable work. Measurement and reporting are fundamental to quality improvement, but the provincial and territorial governments have not lived up to their Health Accord commitments to regular reporting on common indicators. At least six provinces have established health quality councils, but it remains to be seen if this bottom-up approach will lead to a common reporting framework that will support benchmarking. Canada would likely benefit from a pan-Canadian approach to innovation in healthcare quality.

Prevalence of methicillin-resistant Staphylococcus aureus in a Canadian inner-city shelter.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) colonization is increasingly of concern in community settings. However, despite a recent outbreak in Calgary, Alberta, data on the prevalence of MRSA in Canadian communities are lacking. Globally, few studies have been performed in high-risk groups such as inner-city populations. METHODS: A cross-sectional study of the prevalence of MRSA among residents and staff at three Ottawa, Ontario, shelters was conducted. All participants completed a questionnaire, and provided nasal swabs as well as one of rectal, anal or groin swabs. RESULTS: Among 84 participants, the prevalence of MRSA colonization was 2.4%. Among the resident subgroup, the prevalence was 4.5%, while no MRSA isolates were found among 40 staff participants. All isolates were USA100 (CMRSA-2) subtypes. CONCLUSIONS: The prevalence of MRSA colonization among residents is higher than baseline population rates, but is consistent with other inner-city populations. Although community outbreaks of USA300 and USA400 strains are increasingly reported, movement of nosocomial strains (ie, USA100 [CMRSA-2]) into communities remains an important avenue in the spread of MRSA and underscores the importance of nosocomial MRSA control.

Shelter-based palliative care for the homeless terminally ill.

BACKGROUND: The homeless have high rates of mortality, but live in environments not conducive to terminal care. Traditional palliative care hospitals may be reluctant to accept such patients, due to behavior or lifestyle concerns. The Ottawa Inner City Health Project (OICHP) is a pilot study to improve health care delivery to homeless adults. This is a retrospective analysis of a cohort of terminally ill homeless individuals and the effectiveness of shelter-based palliative care. As proof of principle, a cost comparison was performed. METHODS: 28 consecutive homeless terminally ill patients were admitted and died at a shelter-based palliative care hospice. Demographics, diagnoses at admission and course were recorded. Burden of illness was assessed by medical and psychiatric diagnoses, addictions, Karnofsky scale and symptom management. An expert panel was convened to identify alternate care locations. Using standard costing scales, direct versus alternate care costs were compared. RESULTS: 28 patients had a mean age 49 years; average length of stay 120 days. DIAGNOSES: liver disease 43%, HIV/AIDS 25%, malignancy 25% and other 8%. Addiction to drugs or alcohol and mental illness in 82% of patients. Karnofsky performance score mean 40 +/- 16.8. Pain management with continuous opiates in 71%. The majority reunited with family. Compared to alternate care locations, the hospice projected 1.39 million dollars savings for the patients described. CONCLUSION: The homeless terminally ill have a heavy burden of disease including physical illness, psychiatric conditions and addictions. Shelter-based palliative care can provide effective end-of-life care to terminally ill homeless individuals at potentially substantial cost savings.