Objective The prognostic significance of isolated tumor cells (≤0.2 mm) in sentinel lymph nodes (SLNs) of endometrial cancer patients is still unclear. Our aim was to assess the prognostic value of isolated tumor cells in patients with low risk endometrial cancer who underwent SLN biopsy and did not receive adjuvant therapy. Outcomes were compared with node negative patients. Methods Patients with SLNs–isolated tumor cells between 2013 and 2019 were identified from 15 centers worldwide, while SLN negative patients were identified from Mayo Clinic, Rochester, between 2013 and 2018. Only low risk patients (stage IA, endometrioid histology, grade 1 or 2) who did not receive any adjuvant therapy were included. Primary outcomes were recurrence free, non-vaginal recurrence free, and overall survival, evaluated with Kaplan–Meier methods. Results 494 patients (42 isolated tumor cells and 452 node negative) were included. There were 21 (4.3%) recurrences (5 SLNs–isolated tumor cells, 16 node negative); recurrence was vaginal in six patients (1 isolated tumor cells, 5 node negative), and non-vaginal in 15 (4 isolated tumor cells, 11 node negative). Median follow-up among those without recurrence was 2.3 years (interquartile range (IQR) 1.1–3.0) and 2.6 years (IQR 0.6–4.2) in the SLN–isolated tumor cell and node negative patients, respectively. The presence of SLNs-isolated tumor cells, lymphovascular space invasion, and International Federation of Obstetrics and Gynecology (FIGO) grade 2 were significant risk factors for recurrence on univariate analysis. SLN–isolated tumor cell patients had worse recurrence free survival (p<0.01) and non-vaginal recurrence free survival (p<0.01) compared with node negative patients. Similar results were observed in the subgroup of patients without lymphovascular space invasion (n=480). There was no difference in overall survival between the two cohorts in the full sample and the subset excluding patients with lymphovascular space invasion. Conclusions Patients with SLNs–isolated tumor cells and low risk profile, without adjuvant therapy, had a significantly worse recurrence free survival compared with node negative patients with similar risk factors, after adjusting for grade and excluding patients with lymphovascular space invasion. However, the presence of SLNs–isolated tumor cells was not associated with worse overall survival.
BACKGROUND Canadian data suggest that patients of lower socioeconomic status with acute myocardial infarction receive less beneficial therapy and have worse clinical outcomes, raising questions regarding care disparities even in universal health care systems. We assessed the contemporary association of marginalization with clinical outcomes and health services use. METHODS Using clinical and administrative databases in Ontario, Canada, we conducted a population-based study of patients aged ≥65 years hospitalized for their first acute myocardial infarction between April 1, 2010 and March 1, 2019. Patients receiving cardiac catheterization and surviving 7 days postdischarge were included. Our primary exposure was neighborhood-level marginalization, a multidimensional socioeconomic status metric. Neighborhoods were categorized by quintile from Q1 (least marginalized) to Q5 (most marginalized). Our primary outcome was all-cause mortality. A proportional hazards regression model with a robust variance estimator was used to quantify the association of marginalization with outcomes, adjusting for risk factors, comorbidities, disease severity, and regional cardiologist supply. RESULTS Among 53 841 patients (median age, 75 years; 39.1% female) from 20 640 neighborhoods, crude 1- and 3-year mortality rates were 7.7% and 17.2%, respectively. Patients in Q5 had no significant difference in 1-year mortality (hazard ratio [HR], 1.08 [95% CI, 0.95–1.22]), but greater mortality over 3 years (HR, 1.13 [95% CI, 1.03–1.22]) compared with Q1. Over 1 year, we observed differences between Q1 and Q5 in visits to primary care physicians (Q1, 96.7%; Q5, 93.7%) and cardiologists (Q1, 82.6%; Q5, 72.6%), as well as diagnostic testing. There were no differences in secondary prevention medications dispensed or medication adherence at 1 year. CONCLUSIONS In older patients with acute myocardial infarction who survived to hospital discharge, those residing in the most marginalized neighborhoods had a greater long-term risk of mortality, less specialist care, and fewer diagnostic tests. Yet, there were no differences across socioeconomic status in prescription medication use and adherence.
Background While the COVID-19 pandemic dramatically increased virtual care uptake across many health settings, it remains significantly underused in urgent care. Objective This study evaluated the implementation of a pilot virtual emergency department (VED) at an Ontario hospital that connected patients to emergency physicians through a web-based portal. We sought to (1) assess the acceptability of the VED model, (2) evaluate whether the VED was implemented as intended, and (3) explore the impact on quality of care, access to care, and continuity of care. Methods This evaluation used a multimethods approach informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. Data included semistructured interviews with patients and physicians as well as postvisit surveys from patients. Interviews were transcribed and analyzed using thematic analysis. Data from the surveys were described using summary statistics. Results From December 2020 to December 2021, the VED had a mean of 153 (SD 25) visits per month. Among them, 67% (n=677) were female, and 75% (n=758) had a family physician. Patients reported that the VED provided high-quality, timely access to care and praised the convenience, shorter appointments, and benefit of the calm, safe space afforded through virtual appointments. In instances where patients were directed to come into the emergency department (ED), physicians were able to provide a “warm handoff” to improve efficiency. This helped manage patient expectations, and the direct advice of the ED physician reassured them that the visit was warranted. There was broad initial uptake of VED shifts among ED physicians with 60% (n=22) completing shifts in the first 2 months and 42% (n=15) completing 1 or more shifts per month over the course of the pilot. There were no difficulties finding sufficient ED physicians for shifts. Most physicians enjoyed working in the VED, saw value for patients, and were motivated by patient satisfaction. However, some physicians were hesitant as they felt their expertise and skills as ED physicians were underused. The VED was implemented using an iterative staged approach with increased service capabilities over time, including access to ultrasounds, virtual follow-ups after a recent ED visit, and access to blood work, urine tests, and x-rays (at the hospital or a local community laboratory). Physicians recognized the value in supporting patients by advising on the need for an in-person visit, booking a diagnostic test, or referring them to a specialist. Conclusions The VED had the support of physicians and facilitated care for low-acuity presentations with immediate benefits for patients. It has the potential to benefit the health care system by seeing patients through the web and guiding patients to in-person care only when necessary. Long-term sustainability requires a focus on understanding digital equity and enhanced access to rapid testing or investigations.
This Clinical Practice Guideline (CPG) addresses the topic of acute fluid resuscitation during the first 48 hours following a burn injury for adults with burns ≥20% of the total body surface area (%TBSA). The listed authors formed an investigation panel and developed clinically relevant PICO (Population, Intervention, Comparator, Outcome) questions. A systematic literature search returned 5978 titles related to this topic and after 3 levels of screening, 24 studies met criteria to address the PICO questions and were critically reviewed. We recommend that clinicians consider the use of human albumin solution, especially in patients with larger burns, to lower resuscitation volumes and improve urine output. We recommend initiating resuscitation based on providing 2 mL/kg/% TBSA burn in order to reduce resuscitation fluid volumes. We recommend selective monitoring of intra-abdominal and intraocular pressure during burn shock resuscitation. We make a weak recommendation for clinicians to consider the use of computer decision support software to guide fluid titration and lower resuscitation fluid volumes. We do not recommend the use of transpulmonary thermodilution-derived variables to guide burn shock resuscitation. We are unable to make any recommendations on the use of high-dose vitamin C (ascorbic acid), fresh frozen plasma (FFP), early continuous renal replacement therapy, or vasopressors as adjuncts during acute burn shock resuscitation. Mortality is an important outcome in burn shock resuscitation, but it was not formally included as a PICO outcome because the available scientific literature is missing studies of sufficient population size and quality to allow us to confidently make recommendations related to the outcome of survival at this time.
Background Prior research has demonstrated that low- and low-middle-income countries (LLMICs) bear a higher burden of critical illness and have a higherrate of mortality from critical illness than high-income countries (HICs). Thereis a pressing need for improved critical care delivery in LLMICs to reduce thisinequity. This systematic review aimed to characterise the range of critical careinterventions and services delivered within LLMIC health care systems as re -ported in the literature. Methods A search strategy using terms related to critical care in LLMICs was implemented in multiple databases. We included English language articles withhuman subjects describing at least one critical care intervention or service in anLLMIC setting published between 1 January 2008 and 1 January 2020. Results A total of 1620 studies met the inclusion criteria. Among the included studies, 45% of studies reported on pediatric patients, 43% on adults, 23% oninfants, 8.9% on geriatric patients and 4.2% on maternal patients. Most of thecare described (94%) was delivered in-hospital, with the remainder (6.2%) tak-ing place in out-of-hospital care settings. Overall, 49% of critical care describedwas delivered outside of a designated intensive care unit. Specialist physiciansdelivered critical care in 60% of the included studies. Additional critical care wasdelivered by general physicians (40%), as well as specialist physician trainees(22%), pharmacists (16%), advanced nursing or midlevel practitioners (8.9%),ambulance providers (3.3%) and respiratory therapists (3.1%). Conclusions This review represents a comprehensive synthesis of critical caredelivery in LLMIC settings. Approximately 50% of critical care interventionsand services were delivered outside of a designated intensive care unit. Specialist physicians were the most common health care professionals involved incare delivery in the included studies, however generalist physicians were com-monly reported to provide critical care interventions and services. This study additionally characterised the quality of the published evidence guiding criticalcare practice in LLMICs, demonstrating a paucity of interventional and cost-ef-fectiveness studies. Future research is needed to understand better how to opti-mise critical care interventions, services, care delivery and costs in these settings. Registration PROSPERO CRD42019146802.
Importance Prior research has shown differences in postoperative outcomes for patients treated by female and male surgeons. It is important to understand, from a health system and payer perspective, whether surgical health care costs differ according to the surgeon’s sex. Objective To examine the association between surgeon sex and health care costs among patients undergoing surgery. Design, Setting, and Participants This population-based, retrospective cohort study included adult patients undergoing 1 of 25 common elective or emergent surgical procedures between January 1, 2007, and December 31, 2019, in Ontario, Canada. Analysis was performed from October 2022 to March 2023. Exposure Surgeon sex. Main Outcome and Measure The primary outcome was total health care costs assessed 1 year following surgery. Secondarily, total health care costs at 30 and 90 days, as well as specific cost categories, were assessed. Generalized estimating equations were used with procedure-level clustering to compare costs between patients undergoing equivalent surgeries performed by female and male surgeons, with further adjustment for patient-, surgeon-, anesthesiologist-, hospital-, and procedure-level covariates. Results Among 1 165 711 included patients, 151 054 were treated by a female surgeon and 1 014 657 were treated by a male surgeon. Analyzed at the procedure-specific level and accounting for patient-, surgeon-, anesthesiologist-, and hospital-level covariates, 1-year total health care costs were higher for patients treated by male surgeons ($24 882; 95% CI, $20 780-$29 794) than female surgeons ($18 517; 95% CI, $16 080-$21 324) (adjusted absolute difference, $6365; 95% CI, $3491-9238; adjusted relative risk, 1.10; 95% CI, 1.05-1.14). Similar patterns were observed at 30 days (adjusted absolute difference, $3115; 95% CI, $1682-$4548) and 90 days (adjusted absolute difference, $4228; 95% CI, $2255-$6202). Conclusions and Relevance This analysis found lower 30-day, 90-day, and 1-year health care costs for patients treated by female surgeons compared with those treated by male surgeons. These data further underscore the importance of creating inclusive policies and environments supportive of women surgeons to improve recruitment and retention of a more diverse and representative workforce.
The COVID-19 pandemic had a significant impact on all fields of medicine. This book chapter focuses on the impact that COVID-19 has had on dermatology clinical practice and research. This chapter will first highlight the creation of the COVID-19 registries; databases created to rapidly collect crowdsourced data in a centralized manner in an attempt to understand the effects of COVID-19 on existing dermatologic conditions and the new manifestations caused by COVID-19. This chapter will then aim to discuss the impacts that COVID-19 had on dermatology clinical practice as many practices faced disruptions in their workflow due to the pandemic, resulting in changes to practice volume, teledermatology, and treatment modifications. Finally, this chapter will explore the effects of COVID-19 on research topics related to dermatology including changes to publications and clinical trials.
The COVID-19 pandemic had innumerable impacts on healthcare delivery. In Canada, this included limitations on inpatient capacity, which resulted in an increased focus on outpatient surgery for non-emergent cases such as joint replacements. The objective of this study was to assess whether the pandemic and the shift towards outpatient surgery had an impact on access to joint replacement for marginalized patients. Data from Ontario’s administrative healthcare databases were obtained for all patients undergoing an elective hip or knee replacement between January 1, 2018 and August 31, 2021. All surgeries performed before March 15, 2020 were classified as “pre-COVID,” while all procedures performed after that date were classified as “post-COVID.” The Ontario Marginalization Index domains were used to analyze proportion of marginalized patients undergoing surgery pre- and post-COVID. A total of 102,743 patients were included—42,812 hip replacements and 59,931 knee replacements. There was a significant shift towards outpatient surgery during the post-COVID period (1.1% of all cases pre-COVID to 13.2% post-COVID, p < 0.001). In the post-COVID cohort, there were significantly fewer patients from some marginalized groups, as well as fewer patients with certain co-morbidities, such as congestive heart failure and chronic obstructive pulmonary disease. The most important finding of this population-level database study is that, compared to before the COVID-19 pandemic, there has been a change in the profile of patients undergoing hip and knee replacements in Ontario, specifically across a range of indicators. Fewer marginalized patients are undergoing joint replacement surgery since the COVID-19 pandemic. Further monitoring of access to joint replacement surgery is required in order to ensure that surgery is provided to those who are most in need.
The Canadian health system is reeling following the COVID-19 pandemic. Strains have become growing cracks, with long emergency department wait times, shortage of human health resources, and growing dissatisfaction from both clinicians and patients. To address long needed health system reform in Canada, a modernization of training is required for the next generation health leaders. The Canadian Institutes of Health Research Health System Impact Fellowship is an example of a well-funded and connected training program which prioritizes embedded research and embedding technically trained scholars with health system partners. The program has been successful in the scope and impact of its training outcomes as well as providing health system partners with a pool of connected and capable scholars. Looking forward, integrating aspects of evidence synthesis from both domestic and international sources and adapting a general contractor approach to implementation within the HSIF could help catalyze Learning Health System reform in Canada.
Anemia reduces the blood’s ability to carry and deliver oxygen. Following cardiac surgery, anemia is very common and affects up to 90% of patients. Nevertheless, there is a paucity of data examining the prognostic value of postoperative anemia. In this narrative review, we present findings from the relevant literature on postoperative anemia in cardiac surgery patients, focusing on the incidence, risk factors, and prognostic value of postoperative anemia. We also explore the potential utility of postoperative anemia as a therapeutic target to improve clinical outcomes. We conducted a targeted search of MEDLINE, Embase, and the Cochrane Database of Systematic Reviews up to September 2022, using a combination of search terms including postoperative (post-operative), perioperative (peri-operative), anemia (anaemia), and cardiac surgery. The reported incidence of postoperative anemia varied from 29% to 94% across the studies, likely because of variations in patient inclusion criteria and classification of postoperative anemia. Nonetheless, the weight of the evidence suggests that postoperative anemia is common and is an independent risk factor for adverse postoperative outcomes such as acute kidney injury, stroke, mortality, and functional outcomes. In cardiac surgery patients, postoperative anemia is a common and prognostically important risk factor for postoperative morbidity and mortality. Nevertheless, there is a lack of data on whether active management of postoperative anemia is feasible or effective in improving patient outcomes.
Background Timely diagnosis of viral respiratory infection is critical to control respiratory viral transmission in congregate care facilities. We conducted a quality improvement study to assess whether a point-of-care (POC) testing for detection of respiratory viruses could improve time to outbreak measures in congregate living facilities. Methods We implemented a POC cartridge based nucleic acid amplification test platform, which detects SARS-CoV-2, influenza A, and respiratory syncytial virus, at one long-term care home and three retirement homes between December 1, 2022 and April 15, 2023. Residents with respiratory symptoms underwent paired testing, whereby nasopharyngeal swabs were tested first on POC, then on multiplex respiratory virus panel (MRVP) polymerase chain reaction at an external laboratory. We determined difference in turn-around time (TAT), as well as sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), using MRVP as the reference standard. We also compared time to outbreak declaration (from MRVP result) to five other congregate care facilities without access to POC testing. Results A total of 189 tests were performed using POC testing, of which 39.7% (75/189) were positive. SARS-CoV-2 was the most common virus identified (90.7%, 68/75). Median difference in TAT between POC and MRVP was 34.0 hours (IQR 21.8–43.5 hours). Sensitivity, specificity, PPV and NPV of POC were 0.88, 0.87, 0.83 and 0.90, respectively. There were six outbreaks during the study period (all SARS-CoV-2), of which two were declared based on POC result alone, before MRVP was resulted. Median time to outbreak declaration from MRVP result for the remaining four outbreaks was 6.6 hours (IQR 4.6–9.2 hours). In comparison, there were nine outbreaks at the non-POC comparator facilities; median time to outbreak declaration was 15.2 hours (IQR 5.5–26.0 hours). Conclusion We demonstrated the feasibility of implementing a POC platform in congregate living facilities for identification of respiratory viral infection. The improved TAT resulted in more expedited detection and declaration of outbreaks. Disclosures Jerome A. Leis, MD MSc FRCPC, Ontario Hospital Association, Ministry of Attorney General of Ontario, Seneca College: Expert Testimony
Background Syndromic multiplex testing is the mainstay of viral respiratory surveillance, yet some evidence supports the use of asymptomatic testing for SARS-CoV-2 on patient admission. We conducted a prospective quality improvement study to determine the adherence and outcomes associated with a hybrid surveillance strategy for patients being admitted to an acute care hospital who underwent testing on admission. Methods In November, 2022, corporate education recommended that patients with compatible viral respiratory symptoms undergo respiratory multiplex testing for 15 viral pathogens, while those without viral respiratory symptoms (considered asymptomatic) undergo SARS-CoV-2 PCR testing alone. Between December 1, 2022 to March 30, 2023, we measured the testing strategy using positivity rate, rate of omission (i.e., SARS-CoV-2 testing for symptomatic patients, defined as needing a repeat swab for multiplex within 24-hours of admission), and rate of commission (i.e., multiplex testing for asymptomatic patients). Those with detection of non-SARS-CoV-2 respiratory viruses in absence of symptoms were prospectively assessed for 24 hours for development of symptoms and roommate contacts underwent syndromic surveillance for 72-hours. Results Among 5659 patients tested on admission, 2868(50.6%) underwent multiplex testing while 2791(49.3%) were tested only for SARS-CoV-2. The positivity rate for multiplex testing, positivity rate for COVID SARS-CoV-2 testing, omission rate and commission rate were 249/2868(8.7%), 81/2791 (2.9%), 259/1403(17.8%), 1618/4091(39.6%), respectively. Symptom status for 165 patients was not available. Asymptomatic non-SARS-CoV-2 positive patients made up 0.6% of all admissions, of whom none developed symptoms within 24 hours, and the attack rate among roommate contacts was zero (0/20). There were only 31 additional days of precautions for asymptomatic non-SARS-CoV-2 respiratory virus detection that made up 4.4% of overall precaution-days for respiratory virus infection. Conclusion A hybrid surveillance strategy for patients admitted to hospital based on presence of symptoms was implemented with relatively low rates of repeat testing and asymptomatic non-SARS-CoV-2 virus detection. Disclosures Jerome A. Leis, MD MSc FRCPC, Ontario Hospital Association, Ministry of Attorney General of Ontario, Seneca College: Expert Testimony
Background SARS-CoV-2 testing is recommended for symptomatic patients, and asymptomatic testing following known exposure or on admission during periods of high community incidence. The role of post-admission asymptomatic screening is less clear. We evaluated the impact of routine weekly asymptomatic testing in a 178 bed rehabilitation setting that was experiencing frequent COVID-19 outbreaks following the emergence of the Omicron variant. Methods At baseline (April 1, 2021 to March 31, 2022), all patients were tested for SARS-CoV-2 in 4 situations: 1) routinely on admission (≤5 days); 2) in response to the development of new symptoms consistent with COVID-19 infection; 3) following exposure to a patient with COVID-19; and 4) as part of unit wide prevalence testing during suspected or confirmed outbreak. Routine weekly unit wide asymptomatic prevalence screening was introduced April 1, 2022 to March 31, 2023. An uncontrolled before-after study was performed assessing yield of these testing strategies and the incidence of healthcare associated-COVID-19 (HA-COVID). A case was defined as a patient testing positive for SARS-CoV-2 who had not been previously infected with COVID-19 within the preceding 90 days. Patients deemed to be recovered positive based on prospective assessment were excluded. Results The intervention was associated with nearly double the number of SARS-CoV-2 tests (8857 vs. 4672), of which 8513 (96.1%) and 4582 (98.1%) were eligible for inclusion during intervention and baseline, respectively. The before-after comparison of testing positivity was similar for overall, admission, and suspect/confirmed outbreaks with yield of 1.4%/0.5%/3.2% versus 2.6%/1.8%/4.9%, respectively. The addition of routine weekly testing had extremely low yield of 0.2% (8/4022). The incidence of HA-COVID increased during the intervention period (3.4 vs. 1.1 per 1000 patient-days; p< 0.001). Conclusion In a rehabilitation setting, the addition of routine weekly asymptomatic prevalence testing of patients was of low yield when added to surveillance in place on admission, and for symptomatic or exposed patients. Despite the increased risk of HA-COVID associated with the emergence of the Omicron variant, these findings do not support routine weekly post-admission testing. Disclosures Jerome A. Leis, MD MSc FRCPC, Ontario Hospital Association, Ministry of Attorney General of Ontario, Seneca College: Expert Testimony
Background Over 4 million Canadians have been infected with COVID-19. The risk to the Canadian population has been dynamic over time, with changing demographics of patients at risk, differential uptake of vaccination, and potentially differential presentation, access, or acceptance of evolving treatments. Our study aims to evaluate the temporal change in patient characteristics, process of care and outcomes over the pandemic for patients with COVID-19 admitted to hospitals and enrolled in the Canadian Treatments for COVID-19 trial (CATCO). Methods The study included all patients admitted to 52 participating Canadian hospitals with laboratory confirmed SARS-COV-2 infection and enrolled in the CATCO trial. Data was analyzed temporally over six periods of enrollment, corresponding to approximately every 242-294 patients (Figure 1). Patient characteristics and outcomes were summarized using descriptive statistics (i.e., median, proportions). Results Mean age (63 years) and sex (30% female) among enrolled patients were similar across six pandmiec periods. Patient admission to ICU was most common at the beginning of the pandemic (period 1 n=75, 30.4%; period 2 n=67, 27.2%; approximately 20% in subsequent periods [p< 0.001]). The proportion of patients who identified as Black decreased from 10.2% to 3.1% between the first and sixth period, while the proportion of other minority groups remained stable (Figure 2.). Treatment with corticosteroids increased substantially after the first period (41.2% to over 90% in each subsequent period). Unadjusted in-hospital and 60-day mortality was similar over periods (p=0.501). Conclusion There were changes in treatments and a decreasing proportion of enrolled patients admitted to ICU as enrollment in CATCO progressed. In contrast to epidemiological data that showed a change in demographics of hospitalized persons shifting from predominantly Caucasians to predominantly minority groups overtime, our study found that there was not increasing enrollment of minority groups over time. In a dynamic pandemic, it may be important to include the potential for temporal changes in patient characteristics, treatments, and support when investigating the effect of medications on clincial outcomes over time. Disclosures All Authors: No reported disclosures
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