Associations of neighborhood greenspace, and active living environments with autism spectrum disorders: A matched case-control study in Ontario, Canada.

BACKGROUND: Increasing evidence links early life residential exposure to natural urban environmental attributes and positive health outcomes in children. However, few studies have focused on their protective effects on the risk of autism spectrum disorder (ASD). The aim of this study was to investigate the associations of neighborhood greenspace, and active living environments during pregnancy with ASD in young children (≤6 years). METHODS: We conducted a population-based matched case-control study of singleton term births in Ontario, Canada for 2012-2016. The ASD and environmental data was generated using the Ontario Autism Spectrum Profile, the Better Outcomes Registry & Network Ontario, and Canadian Urban Environmental Health Research Consortium. We employed conditional logistic regressions to estimate the odds ratio (OR) between ASD and environmental factors characterizing selected greenspace metrics and neighborhoods conducive to active living (i.e., green view index (GVI), normalized difference vegetation index (NDVI), tree canopy, park proximity and active living environments index (ALE)). RESULTS: We linked 8643 mother-child pairs, including 1554 cases (18%). NDVI (OR 1.034, 0.944-1.024, per Inter Quartile Range [IQR] = 0.08), GVI (OR 1.025, 95% CI 0.953-1.087, per IQR = 9.45%), tree canopy (OR 0.992, 95% CI 0.903-1.089, per IQR = 6.24%) and the different categories of ALE were not associated with ASD in adjusted models for air pollution. In contrast, living closer to a park was protective (OR 0.888, 0.833-0.948, per 0.06 increase in park proximity index), when adjusted for air pollution. CONCLUSIONS: This study reported mixed findings showing both null and beneficial effects of green spaces and active living environments on ASD. Further investigations are warranted to elucidate the role of exposure to greenspaces and active living environments on the development of ASD.

Maternal First-Trimester Alpha-Fetoprotein and Placenta-Mediated Pregnancy Complications.

BACKGROUND: Maternal serum markers used for trisomy 21 screening are associated with placenta-mediated complications. Recently, there has been a transition from the traditional first-trimester screening (FTS) that included PAPP-A (pregnancy-associated plasma protein-A) and beta-hCG (human chorionic gonadotropin), to the enhanced FTS test, which added first-trimester AFP (alpha-fetoprotein) and PlGF (placental growth factor). However, whether elevated first-trimester AFP has a similar association with placenta-mediated complications to that observed for elevated second-trimester AFP remains unclear. Our objective was to estimate the association of first-trimester AFP with placenta-mediated complications and compare it with the corresponding associations of second-trimester AFP and other first-trimester serum markers. METHODS: Retrospective population-based cohort study of women who underwent trisomy 21 screening in Ontario, Canada (2013-2019). The association of first-trimester AFP with placenta-mediated complications was estimated and compared with that of the traditional serum markers. The primary outcome was a composite of stillbirth or preterm placental complications (preeclampsia, birthweight less than third centile, or placental abruption). RESULTS: A total of 244 990 and 96 167 women underwent FTS and enhanced FTS test screening, respectively. All markers were associated with the primary outcome, but the association for elevated first-trimester AFP (adjusted relative risk [aRR], 1.57 [95% CI, 1.37-1.81]) was weaker than that observed for low PAPP-A (aRR, 2.48 [95% CI, 2.2-2.8]), low PlGF (aRR, 2.28 [95% CI, 1.97-2.64]), and elevated second-trimester AFP (aRR, 1.97 [95% CI, 1.81-2.15]). When the models were adjusted for all 4 enhanced FTS test markers, elevated first-trimester AFP was no longer associated with the primary outcome (aRR, 0.77 [95% CI, 0.58-1.02]). CONCLUSIONS: Unlike second-trimester AFP, elevated first-trimester AFP is not an independent risk factor for placenta-mediated complications.

Maternal age and pregnancy outcomes in twin compared with singleton gestations.

OBJECTIVE: To estimate the association of advanced maternal age with pregnancy complications in twin pregnancies and compare it with that observed in singleton pregnancies. METHODS: A population-based retrospective cohort study of all patients with a singleton or twin hospital birth in Ontario, Canada, between 2012 and 2019. The primary outcome was preterm birth (PTB) less than 34 weeks. Pregnancy outcomes were stratified by maternal age groups in twin pregnancies and, separately, in singleton pregnancies. RESULTS: A total of 935 378 patients met the study criteria: 920503 (98.4%) had a singleton pregnancy and 14 875 (1.6%) had twins. In singletons, the rate of PTB less than 34 weeks increased progressively with increasing maternal age and was highest for patients aged 45 years or more (3.4%; adjusted risk ratio [aRR] 1.56, 95% confidence interval [CI] 1.05-2.33). By contrast, in twins, although the rate of PTB less than 34 was highest patients under 20 years of age (25.3%) and was lowest among patients aged 35-39 years (11.7%), the associations between maternal age group and the risk of PTB were not statistically significant in the adjusted analysis. CONCLUSION: Although the absolute rates of pregnancy complications are higher in twin pregnancies, there are considerable differences in the relationship between maternal age and the risk of certain complications between twin and singleton pregnancies.

Practice Variation among Canadian Stroke Prevention Clinics: Pre, During, and Post-COVID-19.

BACKGROUND: Stroke is a common and serious disorder. With optimal care, 90-day recurrent stroke risk can be reduced from 10% to about 1%. Stroke prevention clinics (SPCs) can improve patient outcomes and resource allocation but lack standardization in patient management. The extent of variation in patient management among SPCs is unknown. Our aims were to assess baseline practice variation between Canadian SPCs and the impact of COVID-19 on SPC patient care. METHODS: We conducted an electronic survey of 80 SPCs across Canada from May to November 2021. SPC leads were contacted by email with up to five reminders. RESULTS: Of 80 SPCs contacted, 76 were eligible from which 38 (50.0%) responded. The majority (65.8%) of SPCs are open 5 or more days a week. Tests are more likely to be completed before the SPC visit if referrals were from clinic's own emergency department compared to other referring sources. COVID-19 had a negative impact on routine patient care including longer wait times (increased for 36.4% clinics) and higher number of patients without completed bloodwork prior to arriving for appointments (increased for 27.3% clinics). During COVID-19 pandemic, 87.9% of SPCs provided virtual care while 72.7% plan to continue with virtual care post-COVID-19 pandemic. CONCLUSION: Despite the time-sensitive nature of transient ischemic attack patient management, some SPCs in Canada are not able to see patients quickly. SPCs should endeavor to implement strategies so that they can see high-risk patients within the highest risk timeline and implement strategies to complete some tests while waiting for SPC appointment.

Do bony pelvis parameters affect perioperative outcomes in open radical prostatectomy?

Objective: The present study aimed to evaluate the predictive value of bony pelvic parameters measured by computerized tomography (CT) for use in the estimation of the likely technical difficulties that may be encountered when performing open radical prostatectomy (RP) for localized prostate cancer. Material and methods: One hundred patients, undergoing open RP for localized prostate cancer, were evaluated between October 2016 to November 2018. All operations were performed by the same experienced surgeon. Pelvic parameters were measured using spiral CT images. Data were retrospectively collected from medical, operative, radiology, and pathology records and analyzed. Positive surgical margin (PSM), presence of vesicourethral anastomosis stricture (VUAS) and urine leakage, operative time, urethral catheterization time, and estimated blood loss were used as indicators of operative difficulty. Univariate and multivariate analyses were performed to determine the significance of these variables. Results: There was no significant correlation between the pelvic parameters of the patients and the presence of PSM, VUAS, and urine leakage. Only PSA levels and pathological tumor stage were higher in patients with PSM (p = 0.002 and p = 0.001). On univariate and multivariate analyses, none of the individual pelvic parameters assessed showed a significant relationship with the operation time, estimated blood loss, and urethral catheterization time. In univariate analysis, there was a significant relationship between PSA levels and pathological tumor stage and operation time (p = 0.048 and p = 0.001, respectively). Conclusion: Bony pelvic parameters may not be a significant factor in influencing the perioperative outcomes of open RP. Higher PSA levels and pathological tumor stage may lead to surgical margin positivity and longer operative time.

Quality and transparency of reporting derivation and validation prognostic studies of recurrent stroke in patients with TIA and minor stroke: a systematic review.

BACKGROUND: Clinical prediction models/scores help clinicians make optimal evidence-based decisions when caring for their patients. To critically appraise such prediction models for use in a clinical setting, essential information on the derivation and validation of the models needs to be transparently reported. In this systematic review, we assessed the quality of reporting of derivation and validation studies of prediction models for the prognosis of recurrent stroke in patients with transient ischemic attack or minor stroke. METHODS: MEDLINE and EMBASE databases were searched up to February 04, 2020. Studies reporting development or validation of multivariable prognostic models predicting recurrent stroke within 90 days in patients with TIA or minor stroke were included. Included studies were appraised for reporting quality and conduct using a select list of items from the Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD) Statement. RESULTS: After screening 7026 articles, 60 eligible articles were retained, consisting of 100 derivation and validation studies of 27 unique prediction models. Four models were newly derived while 23 were developed by validating and updating existing models. Of the 60 articles, 15 (25%) reported an informative title. Among the 100 derivation and validation studies, few reported whether assessment of the outcome (24%) and predictors (12%) was blinded. Similarly, sample size justifications (49%), description of methods for handling missing data (16.1%), and model calibration (5%) were seldom reported. Among the 96 validation studies, 17 (17.7%) clearly reported on similarity (in terms of setting, eligibility criteria, predictors, and outcomes) between the validation and the derivation datasets. Items with the highest prevalence of adherence were the source of data (99%), eligibility criteria (93%), measures of discrimination (81%) and study setting (65%). CONCLUSIONS: The majority of derivation and validation studies for the prognosis of recurrent stroke in TIA and minor stroke patients suffer from poor reporting quality. We recommend that all prediction model derivation and validation studies follow the TRIPOD statement to improve transparency and promote uptake of more reliable prediction models in practice. TRIAL REGISTRATION: The protocol for this review was registered with PROSPERO (Registration number CRD42020201130 ).

Attitudes and acceptability of organ and tissue donation registration in the emergency department: a national survey of emergency physicians.

PURPOSE: There is a worldwide shortage of organs for transplantation. One method to increase the number of organs available for transplant is to increase the number of registered organ donors. The emergency department (ED) may be a suitable venue to disseminate knowledge to patients about organ donation, and to offer an immediate or future opportunity to register as an organ donor. This study aimed to assess emergency physicians' attitudes and acceptability of an ED-based organ donation registration initiative. METHODS: We developed and distributed a national postal survey using a modified Dillman's tailored design technique to a random sample of emergency physicians selected from the Canadian Medical Directory. RESULTS: From a total of 474 delivered surveys, we received 228 responses (48.1%). 98.5% of emergency physicians support the concept of deceased organ donation. 85.1% felt that the emergency department is an appropriate setting to disseminate information regarding organ donation and 77.6% felt that it is an appropriate location to offer an immediate opportunity to register as an organ donor. 74.1% of physicians who responded report to be personally registered as an organ donor. CONCLUSION: Most emergency physicians are supportive of organ donation promotion in the ED, including offering an immediate opportunity to register.

RéSUMé: OBJECTIF: Il y a une pénurie mondiale d'organes destinés à la transplantation. Une méthode pour augmenter le nombre d'organes disponibles pour la transplantation est d'augmenter le nombre de donneurs d'organes enregistrés. Le service des urgences (SU) peut être un lieu approprié pour informer les patients sur le don d'organes et leur offrir la possibilité, immédiate ou future, de s'inscrire comme donneur d'organes. Cette étude visait à évaluer les attitudes des médecins urgentistes et l'acceptabilité d'une initiative d'enregistrement des dons d'organes aux urgences. MéTHODES: Nous avons élaboré et distribué une enquête postale nationale en utilisant une technique modifiée de conception sur mesure de Dillman à un échantillon aléatoire de médecins urgentistes sélectionnés à partir de l'annuaire médical canadien. RéSULTATS: Sur un total de 474 questionnaires remis, nous avons reçu 228 réponses (48,1%). 98,5 % des médecins urgentistes soutiennent le concept du don d'organes de personnes décédées. 85,1 % ont estimé que le service des urgences est un lieu approprié pour diffuser des informations sur le don d'organes et 77,6 % ont estimé que c'est un lieu approprié pour offrir une possibilité immédiate de s'inscrire comme donneur d'organes. 74,1 % des médecins qui ont répondu déclarent être personnellement inscrits comme donneurs d'organes. CONCLUSION: La plupart des médecins urgentistes sont favorables à la promotion du don d'organes dans les urgences, notamment en offrant la possibilité de s'inscrire immédiatement.

Endovascular Treatment of a Giant Renal Vein Aneurysm Arising from a High-Flow Arteriovenous Fistula.

Background: Renal vein aneurysms (RVAs) are considered rare clinical entities. RVAs can be secondary to thrombosis, venous hypertension, or renal arteriovenous fistula (RAVF). RVAs secondary to RAVF are rare. Patients with RVA may present with hypertension, abdominal pain, hematuria, or may even be asymptomatic. However, there may be life-threatening emergencies including aneurysm rupture, thrombosis, and pulmonary embolism. The treatment of RVAs includes reconstruction of the renal vein, nephrectomy, and endovascular treatment. Purpose: In this technical note, we report the endovascular treatment of a giant RVA that developed secondary to an acquired RAVF by the placement of multiple vascular plugs. Conclusion: Endovascular occlusion of the RAVF with vascular plugs is effective to prevent a life-threatening rupture of RVA. Clinical follow-up is crucial to detect leakage or migration of the vascular plugs.

Predictors of neurologists confirming or overturning emergency physicians' diagnosis of TIA or stroke.

BACKGROUND: Transient ischemic attack (TIA) and non-disabling stroke are common emergency department (ED) presentations. Currently, there are no prospective multicenter studies determining predictors of neurologists confirming a diagnosis of cerebral ischemia in patients discharged with a diagnosis of TIA or stroke. The objectives were to (1) calculate the concordance between emergency physicians and neurologists for the outcome of diagnosing TIA or stroke, and (2) identify characteristics associated with neurologists diagnosing a stroke mimic. METHODS: This was a planned sub-study of a prospective cohort study at 14 Canadian EDs enrolling patients diagnosed with TIA or non-disabling stroke from 2006 to 2017. Logistic regression was used to identify factors associated with neurologists' diagnosis of cerebral ischemia. Our primary outcome was the composite outcome of cerebral ischemia (TIA or non-disabling stroke) based on the neurologists' assessment. RESULTS: The diagnosis of cerebral ischemia was confirmed by neurologists in 5794 patients (55.4%). The most common identified stroke mimics were migraine (18%), peripheral vertigo (7%), syncope (4%), and seizure (3%). Over a third of patients (38.4%) ultimately had an undetermined aetiology for their symptoms. The strongest predictors of cerebral ischemia confirmation were infarct on CT (OR 1.83, 95% CI 1.65-2.02), advanced age (OR comparing 75th-25th percentiles 1.67, 1.55-1.80), language disturbance (OR 1.92, 1.75-2.10), and smoking (OR 1.67, 1.46-1.91). The strongest predictors of stroke mimics were syncope (OR 0.59, 0.48-0.72), vertigo (OR 0.52, 0.45-0.59), bilateral symptoms (OR 0.60, 0.50-0.72), and confusion (OR 0.50, 0.44-0.57). CONCLUSION: Physicians should have a high index of suspicion of cerebral ischemia in patients with advanced age, smoking history, language disturbance, or infarcts on CT. Physicians should discriminate in which patients to pursue stroke investigations on when deemed at minimal risk of cerebral ischemia, including those with isolated vertigo, syncope, or bilateral symptoms.

RéSUMé: CONTEXTE: L'accident ischémique transitoire (AIT) et l'accident vasculaire cérébral (AVC) non invalidant sont des présentations courantes dans les services d'urgence. Actuellement, il n'existe pas d'études prospectives multicentriques déterminant les facteurs prédictifs de la confirmation par les neurologues d'un diagnostic d'ischémie cérébrale chez les patients sortis de l'hôpital avec un diagnostic d'AIT ou d'AVC. Les objectifs étaient de (1) calculer la concordance entre les urgentistes et les neurologues pour le résultat du diagnostic de l'AIT ou de l'AVC, et (2) identifier les caractéristiques associées au diagnostic par les neurologues d'une imitation d'AVC. MéTHODES: Il s'agissait d'une sous-étude planifiée d'une étude de cohorte prospective dans 14 services d'urgence canadiens recrutant des patients diagnostiqués avec un AIT ou un AVC non invalidant de 2006 à 2017. Une régression logistique a été utilisée pour identifier les facteurs associés au diagnostic d'ischémie cérébrale par les neurologues. Notre résultat principal était le résultat composite de l'ischémie cérébrale (AIT ou accident vasculaire cérébral non invalidant) selon l'évaluation des neurologues. RéSULTATS: Le diagnostic d'ischémie cérébrale a été confirmé par des neurologues chez 5 794 patients (55,4 %). Les imitateurs d'AVC identifiés les plus courants étaient la migraine (18 %), le vertige périphérique (7 %), la syncope (4 %) et les convulsions (3 %). Plus d'un tiers des patients (38,4 %) avaient finalement une étiologie indéterminée pour leurs symptômes. Les prédicteurs les plus forts de la confirmation de l'ischémie cérébrale étaient l'infarctus au scanner (OR 1.83, IC 95 % 1.65­2.02), l'âge avancé (OR comparant les 75e et 25e percentiles 1.67, 1.55­1.80), les troubles du langage (OR 1.92, 1.75­2.10) et le tabagisme (OR 1.67, 1.46­1.91). Les prédicteurs les plus forts d'imitateurs d'AVC étaient la syncope (OR 0.59, 0.48­0.72), le vertige (OR 0.52, 0.45­0.59), les symptômes bilatéraux (OR 0.60, 0.50­0.72) et la confusion (OR 0.50, 0.44­0.57). CONCLUSION: Les médecins devraient avoir un indice élevé de suspicion d'ischémie cérébrale chez les patients ayant un âge avancé, des antécédents de tabagisme, des troubles du langage ou des infarctus au scanner. Les médecins doivent distinguer les patients sur lesquels poursuivre des investigations sur un AVC lorsqu'ils sont jugés à risque minimal d'ischémie cérébrale, y compris ceux présentant des vertiges isolés, une syncope ou des symptômes bilatéraux.

Outcomes Associated With Hypertensive Disorders of Pregnancy in Twin Compared With Singleton Gestations.

OBJECTIVE: To evaluate whether pregnancy outcomes associated with hypertensive disorders of pregnancy in twin pregnancies differ relatively from those in singleton pregnancy. METHODS: We conducted a retrospective, population-based cohort study of all women with a liveborn singleton or twin hospital birth in Ontario, Canada, between 2012 and 2019. Data were obtained from the Better Outcomes Registry & Network Ontario. Pregnancy outcomes were compared between women with and without hypertensive disorders of pregnancy in twin gestations, and separately in singleton gestations. Adjusted relative risks (aRRs) and 95% CIs were generated using modified Poisson regression and were compared between twins and singletons using relative risk ratios. RESULTS: Overall, 932,218 women met the study criteria, of whom 917,542 (98.4%) and 14,676 (1.6%) had singleton and twin gestations, respectively. The incidence of hypertensive disorders of pregnancy was higher in women with twin compared with singleton gestations (14.4% vs 6.4%, aRR 1.85 [1.76-1.94]). Hypertensive disorders of pregnancy were associated with certain adverse outcomes in singleton gestations only and with other adverse outcomes in both the singleton and twin gestations, but the aRR was lower in twins. For example, preterm birth before 37 weeks of gestation (singletons: 15.2% [hypertensive disorders of pregnancy] vs 5.4% [no hypertensive disorders of pregnancy], aRR 2.42; twins: 67.5% [hypertensive disorders of pregnancy] vs 50.4% [no hypertensive disorders of pregnancy], aRR 1.30) and neonatal respiratory morbidity (singletons: 16.3% [hypertensive disorders of pregnancy] vs 8.7% [no hypertensive disorders of pregnancy], aRR 1.50; twins: 39.8% [hypertensive disorders of pregnancy] vs 32.7% [no hypertensive disorders of pregnancy], aRR 1.13). These findings persisted in the subgroups of women with preeclampsia and early-onset preeclampsia. CONCLUSIONS: Although the absolute risk of adverse maternal and neonatal outcomes is higher in twin compared with singleton pregnancies, the incremental risk of adverse outcomes associated with hypertensive disorders in twin pregnancies is lower than the incremental risk in singleton pregnancies. These findings may be attributed in part to the higher baseline risk of preterm birth and adverse maternal and perinatal outcomes in twin compared with singleton pregnancies.

Changes in rate of preterm birth and adverse pregnancy outcomes attributed to preeclampsia after introduction of a refined definition of preeclampsia: A population-based study.

INTRODUCTION: Since 2013, various guidelines for hypertension in pregnancy have been refined, no longer requiring proteinuria as a requisite criterion for preeclampsia. We aimed to evaluate the impact of the new definition on preterm birth (PTB) and adverse pregnancy outcomes. MATERIAL AND METHODS: Women delivering in Ontario between April 2012 and November 2016 were included. Delivery <24+0/7 weeks, major fetal anomalies or preexisting renal disease were excluded. The primary outcome was livebirth <37, <34 or <32 weeks. Rates, adjusted rate ratios (aRR) and ratio of the rate ratio (RRR) were used to compare outcomes in the 2 years after the new Society of Obstetricians and Gynaecologists of Canada (SOGC) guideline (December 2014-November 2016; period 2) vs the 2 years before (April 2012-March 2014; period 1), among women with and without preeclampsia. RESULTS: In all, 268 543 and 267 964 births in periods 1 & 2, respectively, were included. Respective preeclampsia rates increased significantly from 3.9% to 4.4% (p < 0.001), with no change in maternal morbidity rates. In preeclamptic women, respective rates of PTB <37 weeks were 21.0% and 20.7% (aRR 1.01, 95% confidence interval [CI] 1.00-1.02), with significant aRR for PTB <34 (0.86, 95% CI 0.77-0.96) and <32 weeks (0.79, 95% CI 0.67-0.94). A similar aRR was observed in women without preeclampsia. In preeclamptic women, composite severe neonatal morbidity decreased after guideline change (aRR 0.95, 95% CI 0.91-0.99), a finding not observed in women without preeclampsia (RRR 0.95, 95% CI 0.91-0.99). CONCLUSIONS: The new definition of preeclampsia was associated with increased disease rates, a modest reduction in adverse neonatal outcomes and no change in maternal outcomes.

Early identification of the need for major intervention in patients with traumatic hemorrhage: development and internal validation of a simple bleeding score.

BACKGROUND: Failure to rapidly identify bleeding in trauma patients leads to substantial morbidity and mortality. We aimed to develop and validate a simple bedside score for identifying bleeding patients requiring escalation of care beyond initial resuscitation. METHODS: We included patients with major blunt or penetrating trauma, defined as those with an Injury Severity Score greater than 12 or requiring trauma team activation, at The Ottawa Hospital from September 2014 to September 2017. We used logistic regression for derivation. The primary outcome was a composite of the need for massive transfusion, embolization or surgery for hemostasis. We prespecified clinical, laboratory and imaging predictors using findings from our prior systematic review and survey of Canadian traumatologists. We used an AIC-based stepdown procedure based on the Akaike information criterion and regression coefficients to create a 5-variable score for bedside application. We used bootstrap internal validation to assess optimism-corrected performance. RESULTS: We included 890 patients, of whom 133 required a major intervention. The main model comprised systolic blood pressure, clinical examination findings suggestive of hemorrhage, lactate level, focused assessment with sonography in trauma (FAST) and computed tomographic imaging. The C statistic was 0.95, optimism-corrected to 0.94. A simplified Canadian Bleeding (CAN-BLEED) score was devised. A score cut-off of 2 points yielded sensitivity of 97.7% (95% confidence interval [CI] 93.6 to 99.5) and specificity 73.2% (95% CI 69.9 to 76.3). An alternative version that included mechanism of injury rather than CT had lower discriminative ability (C statistic = 0.89). CONCLUSION: A simple yet promising bleeding score is proposed to identify highrisk patients in need of major intervention for traumatic bleeding and determine the appropriateness of early transfer to specialized trauma centres. Further research is needed to evaluate the performance of the score in other settings, define interrater reliability and evaluate the potential for reduction of time to intervention.

CONTEXTE: Les délais dans la détection des saignements actifs chez les patients en traumatologie entraînent une morbidité et une mortalité élevées. L'objectif était d'élaborer et de valider une échelle simple, à utiliser en contexte clinique pour repérer les patients qui présentent un saignement actif et qui nécessitent une intensification des soins après la réanimation initiale. MÉTHODES: Les critères d'inclusion étaient les suivants : admission à l'Hôpital d'Ottawa entre septembre 2014 et septembre 2017 pour un traumatisme contondant ou pénétrant, et score de gravité de la blessure supérieur à 12 ou mobilisation de l'équipe de traumatologie. Nous avons fait la dérivation par régression logistique. Le principal critère d'évaluation était la nécessité d'une transfusion massive, d'une embolisation ou d'une opération pour rétablir l'hémostase. Nous avons établi les facteurs prédictifs décelables en clinique, en laboratoire et à l'imagerie en fonction des résultats que nous avons obtenus dans le cadre d'une revue systématique et d'un sondage mené auprès de traumatologues canadiens. Nous avons utilisé une procédure avec ajustement selon le critère d'information d'Akaike (AIC) et des coefficients de régression afin de créer une échelle à 5 variables applicable en contexte clinique. Pour ce qui est de la validation interne, nous avons ajusté les valeurs dites « optimistes ¼ à l'aide de la méthode d'autoamorçage (bootstrap). RÉSULTATS: Nous avons inclus 890 patients, dont 133 nécessitaient une intervention majeure. Le modèle de base intégrait la pression artérielle systolique, les constatations cliniques indiquant une hémorragie, le taux de lactate, les résultats de l'échographie ciblée en traumatologie (FAST) et les résultats de la tomodensitométrie (TMD). La statistique C s'élevait à 0,95 (0,94 après ajustement). Nous avons conçu une échelle canadienne simplifiée d'évaluation des saignements actifs (CANBLEED). Un seuil de 2 points a généré une sensibilité de 97,7 % (intervalle de confiance [IC] à 95 % de 93,6 à 99,5) et une spécificité de 73,2 % (IC à 95 % de 69,9 à 76,3). Une deuxième version, qui tient compte du mécanisme de blessure plutôt que des résultats de la TMD, avait un pouvoir de discrimination inférieur (statistique C = 0,89). CONCLUSION: Nous proposons une échelle d'évaluation des saignements actifs simple, mais prometteuse. Celle-ci vise à repérer les patients à haut risque qui nécessitent une intervention majeure pour un saignement d'origine traumatique ainsi qu'à déterminer la pertinence d'un transfert précoce dans un centre de traumatologie. Des études complémentaires seront nécessaires afin d'évaluer l'échelle dans d'autres milieux, d'établir sa fiabilité interévaluateurs et d'évaluer le potentiel de réduction des délais d'intervention.

Surgery for colorectal cancer in elderly patients: is there such a thing as being too old?

INTRODUCTION: The overall increase in life expectancy causes a rapid increase in number of elderly patients needing colorectal surgery. It remains unclear if there is a significant risk factor in patients over 80 years of age for postoperative morbidity and mortality. For this reason we investigated the perioperative, outcome and long-term survival after surgery for colorectal cancer in our hospital. MATERIALS AND METHODS: We retrospectively analysed a database containing information about patients who underwent surgery for colorectal cancer from January 2010 to December 2015 at the St. Bernhard Hospital in Kamp-Lintfort, Germany. The last follow-up date was 31th of December 2017. RESULTS: A total of 232 patients were enrolled and analysed in this study. All patients were separated in tow groups depending in age. The first group was ≥80 years old (n=49). The second group was <80 years old (n=183). High ASA-Scores (≥3) were detectable more often in elderly patients (p<0,05). Elderly and young patients had a similar risk for postoperative anastomosic leakages (p=0,047). Likewise there were no significant differences regarding the Dindo-Clavien-Classification (p=0,13). The mortality within the first 30 days after surgery was significant elevated for elderly patients compared to younger patients (p=0,04). Also the overall 1-year survival was 90% for the younger and 73,5% for the older study group (p<0,05) Conclusion. Both the short-term outcome and long-term survival rate after colorectal surgery for cancer are worse for patients older than 80 years of age. After interpretation of all data it remains unclear if the age itself is still the biggest risk factor. When old patients have a good ASA-Score and no severe comorbidities, colorectal surgery remains safe even for patients older than 80 years.

Personalized risk communication for personalized risk assessment: Real world assessment of knowledge and motivation for six mortality risk measures from an online life expectancy calculator.

In the clinical setting, previous studies have shown personalized risk assessment and communication improves risk perception and motivation. We evaluated an online health calculator that estimated and presented six different measures of life expectancy/mortality based on a person's sociodemographic and health behavior profile. Immediately after receiving calculator results, participants were invited to complete an online survey that asked how informative and motivating they found each risk measure, whether they would share their results and whether the calculator provided information they need to make lifestyle changes. Over 80% of the 317 survey respondents found at least one of six healthy living measures highly informative and motivating, but there was moderate heterogeneity regarding which measures respondents found most informative and motivating. Overall, health age was most informative and life expectancy most motivating. Approximately 40% of respondents would share the results with their clinician (44%) or social networks (38%), although the information they would share was often different from what they found informative or motivational. Online personalized risk assessment allows for a more personalized communication compared to historic paper-based risk assessment to maximize knowledge and motivation, and people should be provided a range of risk communication measures that reflect different risk perspectives.

National survey of family physicians to define functional decline in elderly patients with minor trauma.

BACKGROUND: Failing to assess elderly patients for functional decline at the time around a minor injury may result in adverse health outcomes. This study was conducted to define what constitutes clinically significant functional decline and the sensitivity required for a clinical decision instrument to identify such functional decline after an injury in previously independent elderly patients. METHODS: After a thorough development process, a survey questionnaire was administered to a random sample of 178 family physicians. The surveys were distributed using a modified Dillman technique. RESULTS: From 143 eligible surveys, we received 67 completed surveys (response rate, 46.9 %). Respondents indicated that a drop of at least 3 points on the 28-point Older Americans Resources and Services (OARS) ADL Scale was considered clinically significant by 90 % of physicians. Ninety percent (90 %) of physicians would be satisfied with a sensitivity of 90 % or more for a clinical decision instrument to detect patients at risk of functional decline at 6 months following an injury. The majority of family physicians do not routinely assess the majority of the tasks on the OARS scale for injured elderly patients. CONCLUSIONS: A high proportion of physicians (90 %) would consider a drop of 3 points on the OARS ADL Scale as significant to define functional decline and would be satisfied with a sensitivity of 90 % for a clinical decision instrument to detect such a decline. Any instrument to identify patients at elevated risk for subsequent decline should consider these outcome measures to be clinically useful.

TNF-alpha antibody treatment in refractory collagenous sprue: report of a case and review of the literature.

Collagenous sprue (CS) is a rare disease characterized by celiac type small bowel malabsorption that is resistant to gluten free diet (GFD) and is associated with a poor prognosis. Our aim was to assess the properties of the monoclonal TNF-alpha antibody infliximab in a patient with high-dose steroid refractory CS. A 27-year-old man developed watery diarrhea with weight loss and abdominal pain. Duodenal biopsies showed a subtotal villous atrophy with an extensive subepithelial layer of collagenous fibers. An apparent GFD did not reduce symptoms. High dose steroid treatment (75 mg prednisone) in combination with azathioprine (150 mg) reduced diarrhea but did not induce complete remission. Based on strongly elevated mucosal TNF-alpha transcript concentrations we introduced infliximab (5 mg/kg body weight) into therapy. After two applications the patient's symptoms quickly improved. During the following year no recurrence of diarrhea has been observed. This case suggests that infliximab is an effective treatment in complicated cases of collagenous sprue.

Covered transjugular intrahepatic portosystemic stents maintain lower portal pressure and require fewer reinterventions than uncovered stents.

BACKGROUND: The purpose of this study was to evaluate the patency, functional and haemodynamic results of expanded-polytetrafluoroethylene (ePTFE)-covered transjugular intrahepatic portosystemic shunts in patients with liver cirrhosis. METHODS: Thirteen patients with an ePTFE-covered transjugular intrahepatic portosystemic shunt stent (TIPSS) were prospectively evaluated at 6 and 12 months and compared with matched controls with mesh-wire uncovered TIPSS. RESULTS: At 6 months, ePTFE-TIPSS showed a significantly lower porto-caval pressure gradient (PCPG) (9 (3-21) mmHg, P = 0.006), a lower rate of dysfunction (8% versus 54%, P = 0.03) and required fewer reinterventions (2 versus 13, P = 0.02); similar results were obtained after 12 months. This resulted in a reduction in the median cost for angiographic surveillance in the covered TIPSS group at 6 and 12 months (36% and 56% compared to the uncovered TIPSS group, P = 0.002), but total procedure-related costs were higher with the ePTFE-TIPSS (6 months: 3730 (3245-6759) versus 1850 (1466-5479) euro/patient; 12 months: 3945 (3460-6759) versus 2295 (1728-5694) euro/patient) due to the higher initial cost of the ePTFE-covered TIPSS. CONCLUSIONS: The insertion of ePTFE-covered TIPSS results in better maintenance of lowered portal pressure and fewer reinterventions in patients with liver cirrhosis. There is strong evidence that the use of ePTFE-TIPSS does not require regular surveillance to maintain primary patency, which may then improve cost-effectiveness.

Adsorptive stripping voltammetric determination of antihypertensive agent: diltiazem.

Adsorptive stripping voltammetry was used to determine the antihypertensive agent diltiazem in phosphate buffer (pH 7.0). The adsorptive cathodic peak was observed at -1.72 V vs. Ag/AgCl. The peak response was characterized with respect to pH, preconcentration time, possible interferences, accumulation potential and supporting electrolytes. The obtained results were analyzed and the statistical parameters were calculated. The proposed method was applied to determine the mentioned drug in pharmaceutical formulation (capsule) and urine. The detection limit is 1x10(-8) M (4.5 ng ml(-1)) using 180 s preconcentration time, whereas the lower limit of detection is 6x10(-9) M (2.7 ng ml(-1)).