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Background: Unused opioid prescriptions can be a driver of opioid misuse. Our objective was to determine the optimal quantity of opioids to prescribe to patients with acute pain at emergency department discharge, in order to meet their analgesic needs while limiting the amount of unused opioids. Methods: In a prospective, multicentre cohort study, we included consecutive patients aged 18 years and older with an acute pain condition present for less than 2 weeks who were discharged from emergency department with an opioid prescription. Participants completed a pain medication diary for real-time recording of quantity, doses, and names of all analgesics consumed during a 14-day follow-up period. Results: We included 2240 participants, who had a mean age of 51 years; 48% were female. Over 14 days, participants consumed a median of 5 (quartiles, 1-14) morphine 5 mg tablet equivalents, with significant variation across pain conditions (p < 0.001). Most opioid tablets prescribed (63%) were unused. To meet the opioid need of 80% of patients for 2 weeks, we found that those experiencing renal colic or abdominal pain required fewer opioid tablets (8 morphine 5 mg tablet equivalents) than patients who had fractures (24 tablets), back pain (21 tablets), neck pain (17 tablets), or other musculoskeletal pain (16 tablets). Interpretation: Two-thirds of opioid tablets prescribed at emergency department discharge for acute pain were unused, whereas opioid requirements varied significantly based on the cause of acute pain. Smaller, cause-specific opioid prescriptions could provide adequate pain management while reducing the risk of opioid misuse. Trial registration: ClinicalTrials.gov, no. NCT03953534., Opioid overdoses killed 68 630 people in the United States (1) in 2020 and 7560 in Canada (2) in 2021, and these numbers are projected to continue to rise until [...]

We've all felt that twinge of annoyance when Toronto masquerades as someplace else on screen. But, lately, the city has been starring as itself. This year, Turning Red beamed cotton-candy-coloured [...]

Study Design Retrospective cohort study.Objective The primary objective was to evaluate the impact of the upper instrumented level (UIV) being at C2 vs C3 in posterior cervical construct on patient reported outcomes (PROs) up to 24 months after surgery for cervical degenerative myelopathy (DCM). Secondary objectives were to compare operative time, intra-operative blood loss (IOBL), length of stay (LOS), adverse events (AEs) and re-operation.Methods Patients who underwent a posterior cervical instrumented fusion (3 and + levels) with a C2 or C3 UIV, with 24 months follow-up were analyzed. PROs (NDI, EQ5D, SF-12 PCS/MCS, NRS arm/neck pain) were compared using ANCOVA. Operative duration, IOBL, AEs, and re-operation were compared. Subgroup analysis was performed on patient presenting with pre-operative malalignment (cervical sagittal vertical axis ≥40 mm and/or T1slope- cervical lordosis >15°).Results 173 patients were included, of which 41 (24%) had a C2 UIV and 132 (76%) a C3 UIV. There was no statistically significant difference between the groups for the changes in PROs up to 24 months. Subgroup analysis of patients with pre-operative malalignment showed a trend towards greater improvement in the NDI at 12 months with a C2 UIV (P= .054). Operative time, IOBL and peri-operative AEs were more in C2 group (P< .05). There was no significant difference in LOS and re-operation (P> .05).Conclusion In this observational study, up to 24 months after surgery for posterior cervical fusion in DCM greater than 3 levels, PROs appear to evolve similarly.

This document provides information on eight different Canadian cities that offer affordable housing options. The first four cities mentioned are Charlottetown, Halifax, St. Catharines, and Quebec City. Charlottetown is experiencing a population boom and offers affordable detached homes. Halifax has seen a rise in housing prices but remains accessible due to development in its outskirts. St. Catharines is experiencing a reverse migration with new jobs and affordable housing options. Quebec City is a tech hub with affordable housing in historical neighborhoods. The next four cities mentioned are Sherbrooke, Kingston, Fredericton, and Windsor. Sherbrooke is described as a picturesque spot with bike paths, beaches, and a nature reserve. Kingston is highlighted for its recent building boom and affordable homes in neighborhoods like Polson Park and Hillendale. Fredericton is presented as a bargain option with a median house price of $304,000 and a high income per capita. Windsor is described as a desirable place to live with increasing house prices, new developments, and a connection to Detroit. Each city is also described in terms of its cultural attractions and amenities. [Extracted from the article]

Study Design Retrospective analysis was performed of a multi-center Canadian Spine Outcomes and Research Network (CSORN) surgical database.Objective To determine the rate and time to return to work (RTW) based on workload intensity after elective degenerative lumbar spine surgery.Methods Patients working pre-operatively, aged greater than 18, who underwent a primary one- or two-level elective lumbar spine surgery for degenerative conditions between January 2015 and October 2020 were evaluated. The percentage of patients who returned to work at 1 year and the time to RTW post-operatively were analyzed based on workload intensity.Results Of the 1290 patients included in the analysis, the overall rate of RTW was 82% at 1 year. Based on workload there was no significant difference in time to RTW after a fusion procedure, with median time to RTW being 10 weeks. For non-fusion procedure, the sedentary group had a statistically significantly quicker time to RTW than the light-moderate (P< .005) and heavy-very heavy (<.027) groups.Conclusions The rate of RTW ranged between 84% for patients with sedentary work to 77% for patient with a heavy-very heavy workload. Median time to resumption of work was about 10 weeks following a fusion regardless of work intensity. There was more variability following non-fusion surgeries such as laminectomy and discectomy reflecting the patient’s job demands.

The article utilizes the adaptive learning computer system AlphaZero in order to examine how variations of the game of chess would proceed at what is referred to as a superhuman level. According to the article, AlphaZero marks a significant milestone in the field of artificial intelligence (AI) and the use of algorithms in computer chess.

This study is the result of a collaborative project with the YMCAs of Québec (Canada), whose tool “Maximize Participation of all Campers” (MPC) aims to support camp staff in implementing inclusive practices. The objectives were to examine the evolution of their camp staff’s attitudes towards inclusion and to compare their perceptions regarding the implementation of the strategies suggested in the MPC tool subsequent to its use. Data were collected from 32 participants (companions = 17; counsellors = 15) who completed two questionnaires (June and August 2021). Companions’ and counsellors’ attitudes were positive despite a small significant decrease in companions’ attitudes regarding outcomes of inclusion, and both camp stakeholders reported positive perceptions.In conclusion, to support the inclusion of children in summer camps, it is important to nurture the camp staff’s positive attitudes towards inclusion. Accordingly, the MPC tool appears effective, as the staff reported positive perceptions regarding its use.

BackgroundAmong plasma biomarkers for Alzheimer’s disease (AD), pTau181 and pTau217 are the most promising. However, transition from research to routine clinical use will require confirmation of clinical performance in prospective cohorts and evaluation of cofounding factors.MethodpTau181 and pTau217 were quantified using, Quanterix and ALZpath, SIMOA assays in the well-characterised prospective multicentre BALTAZAR (Biomarker of AmyLoid pepTide and AlZheimer's diseAse Risk) cohort of participants with mild cognitive impairment (MCI).ResultsAmong participants with MCI, 55% were Aβ+ and 29% developed dementia due to AD. pTau181 and pTau217 were higher in the Aβ+ population with fold change of 1.5 and 2.7, respectively. MCI that converted to AD also had higher levels than non-converters, with HRs of 1.38 (1.26 to 1.51) for pTau181 compared with 8.22 (5.45 to 12.39) for pTau217. The area under the curve for predicting Aβ+ was 0.783 (95% CI 0.721 to 0.836; cut-point 2.75 pg/mL) for pTau181 and 0.914 (95% CI 0.868 to 0.948; cut-point 0.44 pg/mL) for pTau217. The high predictive power of pTau217 was not improved by adding age, sex and apolipoprotein E ε4 (APOEε4) status, in a logistic model. Age, APOEε4 and renal dysfunction were associated with pTau levels, but the clinical performance of pTau217 was only marginally altered by these factors. Using a two cut-point approach, a 95% positive predictive value for Aβ+ corresponded to pTau217 >0.8 pg/mL and a 95% negative predictive value at <0.23 pg/mL. At these two cut-points, the percentages of MCI conversion were 56.8% and 9.7%, respectively, while the annual rates of decline in Mini-Mental State Examination were −2.32 versus −0.65.ConclusionsPlasma pTau217 and pTau181 both correlate with AD, but the fold change in pTau217 makes it better to diagnose cerebral amyloidosis, and predict cognitive decline and conversion to AD dementia.

With the advent of high throughput systems to experimentally determine the three-dimensional (3-D) structure of proteins, molecular biologists are in urgent need of systems to automatically store, maintain and explore the vast structural databases that are thus being created. We have designed and implemented the Capri/MR system which makes it possible to identify families of protein structures, as contained in such very large 3-D protein structure databases. Our system is able to automatically index and search a database of proteins by three-dimensional shape, structural and/or physicochemical properties. For each of these diverse protein structure representations, we create a compact rotation and translation invariant index (or signature) which is placed in a database for future querying. A similarity search algorithm performs an exhaustive search against the entire database. Our search algorithm takes advantage of the compact signatures to rapidly find protein structures that are similar in 3-D shape and/or two-dimensional (2-D) properties. As a result, queries in our Capri/MR system run within a fraction of a second, and we are able to accurately group protein structures into the correct families, with very high precision and recall. In addition, our system dynamically processes new protein structures as they become available. We demonstrate the power of Capri/MR against the Protein Data Bank, which contains all known, experimentally determined, 3-D protein structures (48.000 as of January 2008). The main applications of our Capri/MR system lie in structural proteomics, protein evolution and mutation, as well as in drug design, in particular for studying the docking problem and the computer aided design of non-toxic drugs.

Wheelchairs need to be secured properly during transit to reduce the risk of passenger injury. New wheelchair securement systems have been developed in an attempt to provide increased usability and independence for passengers who need to use them. This field study evaluated newer wheelchair securement system usage through a retrospective review of on-board video surveillance recordings and large accessible transit vehicle (LATV) operators’ perceived usability of two newer wheelchair securement systems on fixed-route LATVs. Results showed that nonuse and misuse of securement systems were more prevalent with trips using the 3-point, forward-facing (3P-FF) tiedown system compared with trips using the semi-automated, rear-facing (SA-RF) system. While a majority of nonuse and misuse of the 3P-FF system was because of LATV operator error, the reasons for nonuse and misuse of the SA-RF system were more complex and mostly involved system design and transit policy issues. Operators most preferred using the 3P-FF system on the LATV rather than the SA-RF system. Findings support the need for further development and implementation of wheelchair securement with improved usability, innovative securement systems that can be operated independently by wheelchair users, and improved securement training for bus operators and wheelchair passengers.

Background: To assess the clinical effects of diabetic peripheral neuropathy (DPN) in patients with chronic limb-threatening ischemia (CLTI) treated by primary infrapopliteal angioplasty for neuro-ischemic Rutherford 5, foot wounds.Materials and methods: Over a 10-year period (2009–2019), a series of 304 diabetic ischemic limbs adding or not evincible neuropathic affectation were treated by primary infrapopliteal angioplasty and their files were retrospectively reviewed. Mean length of treated arterial lesions was 6.1 cm (range 1–22 cm). Inferior limb vibration perception threshold diagnostic was performed for comparing and scoring detectable DPN in all studied diabetic patients (classed from 0 to 10 points). There were 19% limbs with normal (0–1 points) perception (group 1), 55% others with “mild” and “moderate” (2–6 points) neuropathic impairment (group 2), and 26% limbs showing “severe” (7–10 points) DPN (group 3).Results: Primary infrapopliteal angioplasty succeeded in 89% cases in group 1, in 82% in group 2, and in 68% of limbs in group 3. This latest group assembled the heaviest neuropathic affectation and arterial calcifications and proved the lowest clinical benefit at 36 months: 35% (95% confidence interval [CI]=22% to 48%) of primary patency, 36% (95% CI=22% to 50%) wound healing, and 54% (95% CI=39% to 69%) limb preservation rates. A comparison between groups 1 vs 3 and 2 vs 3 of primary patency (p=0.014 and p=0.043), tissue healing (p=0.049 and p=0.01), and limb salvage (p=0.006 and p=0.023) proved significant, yet without statistical weight for group 1 vs 2 (p>0.05). Overall survival was not significantly affected between groups (p=0.34).Conclusion: The presence of severe DPN may jeopardize the results of infrapopliteal angioplasty in terms of patency, tissue cicatrization, and limb preservation, yet without significance on survival of these patients. When present, DPN requires appropriate stratification as specific indicator in CLTI treatment.

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Les pathologies hépatiques sont nombreuses en médecine vétérinaire et font partie des difficultés diagnostiques rencontrées chaque semaine en médecine des animaux de compagnie. La biopsie hépatique est un outil diagnostique qui nécessite un travail pluridisciplinaire dans lequel beaucoup d’efforts et de ressources sont déployés. Malheureusement, le rapport de biopsie est habituellement écrit dans une terminologie descriptive et diagnostique qui peut être ardue à comprendre et parfois même décevante pour le vétérinaire en clinique. De plus, les attentes du clinicien en médecine envers le rapport d’histopathologie sont parfois trop élevées ou mal orientées. Cet article vise à fournir quelques outils et lignes directrices afin de faciliter l’interprétation du rapport et permettre une meilleure compréhension de l’histopathologie des biopsies hépatobiliaires.

BACKGROUND: Evidence for an association between opioid use and risk of falls or fractures in older adults is inconsistent. We examine the association between recent opioid use and the risk, as well as the clinical outcomes, of fall-related injuries in a large trauma population of older adults. METHODS: In a retrospective, observational, multicentre cohort study conducted on registry data, we included all patients aged 65 years and older who were admitted (hospital stay > 2 d) for injury in 57 trauma centres in the province of Quebec, Canada, between 2004 and 2014. We looked at opioid prescriptions filled in the 2 weeks preceding the trauma in patients who sustained a fall, compared with those who sustained an injury through another mechanism. RESULTS: A total of 67929 patients were retained for analysis. Mean age was 80.9 ([+ or -] 8.0) years and 69% were women. The percentage of patients who had filled an opioid prescription in the 2 weeks preceding an injury was 4.9% (95% confidence interval [CI] 4.7%-5.1%) for patients who had had a fall, compared with 1.5% (95% CI 1.2%-1.8%) for those who had had an injury through another mechanism. After we controlled for confounding variables, patients who had filled an opioid prescription within 2 weeks before injury were 2.4 times more likely to have a fall rather than any other type of injury. For patients who had a fall-related injury, those who used opioids were at increased risk of in-hospital death (odds ratio 1.58; 95% CI 1.34-1.86). INTERPRETATION: Recent opioid use is associated with an increased risk of fall and an increased likelihood of death in older adults., The rate of opioid prescription for pain treatment has been increasing rapidly in North America in the past 20 years. (1,2) For example, between 2001 and 2010, the percentage of [...]

ABSTRACT Danny Boyle's Anglo-American film The Beach (2000) is adapted from Alex Garland's 1996 cult book of the same name. Both opuses capture the Zeitgeist of the late 1990s, but [...]

Study Design Ambispective cohort study.Objective Canada has a government-funded universal health care system. The United States utilizes a multitier public and private system. The objective is to investigate differences in clinical outcomes between those surgically treated for lumbar disc herniation in a universal health care and multitier health system.Methods Surgical lumbar disc herniation patients enrolled in the Canadian Spine Outcome Research Network (CSORN) were compared with the surgical cohort enrolled in the Spine Patients Outcome Research Trial (SPORT) study. Baseline demographics and spine-related patient-reported outcomes (PROs) were compared at 3 months and 1 year post-operatively.Results The CSORN cohort consisted of 443 patients; the SPORT cohort had 763 patients. Patients in the CSORN cohort were older (46.4 ± 13.5 vs 41.0 ± 10.8, P< .001) and were more likely to be employed (69.5% vs 60.3%, P= .003). The CSORN cohort demonstrated significantly greater rates of satisfaction after surgery at 3 months (87.2% vs 64.8%, P< .0001) and 1 year (85.6% vs 69.6%, P< .0001). Improvements in back and leg pain followed similar trajectories in the two cohorts, but there was less improvement on ODI in the CSORN cohort (P< .01). On multivariable logistic regression, the CSORN cohort was a significant independent predictor of patient satisfaction at 1-year follow-up (P< .001).Conclusions Despite less improvement on ODI, patients enrolled in CSORN, as part of a universal health care system, reported higher rates of satisfaction at 3 months and 1 year post-operatively compared to patients enrolled within a multitier health system.

•What is the primary question addressed by this study?Do patients with severe behavioral and psychological symptoms of dementia show specific neuropsychiatric patterns on symptoms depending on etiology?•What is the main finding of this study?Patients with Lewy body dementia / Parkinson's disease dementia (LBD/PD) displayed more hallucinations, more delusion and more anxiety than patients with cognitive impairment of other origin while patients with frontotemporal dementia showed more disinhibition and less delusion.•What is the meaning of the finding?Different profiles were identified depending on etiology in patients with severe behavioral and psychological symptoms of dementia suggesting that precise characterization might be performed regardless of the severity of neuropsychiatric symptoms to adapt management.

ABSTRACT:Objective:To examine differences in surgical practices between salaried and fee-for-service (FFS) surgeons for two common degenerative spine conditions. Surgeons may offer different treatments for similar conditions on the basis of their compensation mechanism.Methods:The study assessed the practices of 63 spine surgeons across eight Canadian provinces (39 FFS surgeons and 24 salaried) who performed surgery for two lumbar conditions: stable spinal stenosis and degenerative spondylolisthesis. The study included a multicenter, ambispective review of consecutive spine surgery patients enrolled in the Canadian Spine Outcomes and Research Network registry between October 2012 and July 2018. The primary outcome was the difference in type of procedures performed between the two groups. Secondary study variables included surgical characteristics, baseline patient factors, and patient-reported outcome.Results:For stable spinal stenosis (n= 2234), salaried surgeons performed statistically fewer uninstrumented fusion (p< 0.05) than FFS surgeons. For degenerative spondylolisthesis (n= 1292), salaried surgeons performed significantly more instrumentation plus interbody fusions (p< 0.05). There were no statistical differences in patient-reported outcomes between the two groups.Conclusions:Surgeon compensation was associated with different approaches to stable lumbar spinal stenosis and degenerative lumbar spondylolisthesis. Salaried surgeons chose a more conservative approach to spinal stenosis and a more aggressive approach to degenerative spondylolisthesis, which highlights that remuneration is likely a minor determinant in the differences in practice of spinal surgery in Canada. Further research is needed to further elucidate which variables, other than patient demographics and financial incentives, influence surgical decision-making.

AbstractObjectives:In Québec, Canada, we evaluated the risk of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection associated with (1) the demographic and employment characteristics among healthcare workers (HCWs) and (2) the workplace and household exposures and the infection prevention and control (IPC) measures among patient-facing HCWs.Design:Test-negative case-control study.Setting:Provincial health system.Participants:HCWs with PCR-confirmed coronavirus disease 2019 (COVID-19) diagnosed between November 15, 2020, and May 29, 2021 (ie, cases), were compared to HCWs with compatible symptoms who tested negative during the same period (ie, controls).Methods:Adjusted odds ratios (aORs) of infection were estimated using regression logistic models evaluating demographic and employment characteristics (all 4,919 cases and 4,803 controls) or household and workplace exposures and IPC measures (2,046 patient-facing cases and 1,362 controls).Results:COVID-19 risk was associated with working as housekeeping staff (aOR, 3.6), as a patient-support assistant (aOR, 1.9), and as nursing staff (aOR, 1.4), compared to administrative staff. Other risk factors included being unexperienced (aOR, 1.5) and working in private seniors’ homes (aOR, 2.1) or long-term care facilities (aOR, 1.5), compared to acute-care hospitals. Among patient-facing HCWs, exposure to a household contact was reported by 9% of cases and was associated with the highest risk of infection (aOR, 7.8). Most infections were likely attributable to more frequent exposure to infected patients (aOR, 2.7) and coworkers (aOR, 2.2). Wearing an N95 respirator during contacts with COVID-19 patients (aOR, 0.7) and vaccination (aOR, 0.2) were the measures associated with risk reduction.Conclusion:In the context of the everchanging SARS-CoV-2 virus with increasing transmissibility, measures to ensure HCW protection, including vaccination and respiratory protection, and patient safety will require ongoing evaluation.

Study Design Retrospective cohort.Objectives To compare outcomes of minimally invasive surgery (MIS) vs open surgery (OPEN) for lumbar spinal stenosis (LSS) in patients with diabetes.Methods Patients with diabetes who underwent spinal decompression alone or with fusion for LSS within the Canadian Spine Outcomes and Research Network (CSORN) database were included. MIS vs OPEN outcomes were compared for 2 cohorts: (1) patients with diabetes who underwent decompression alone (N = 116; MIS n = 58 and OPEN n = 58), (2) patients with diabetes who underwent decompression with fusion (N = 108; MIS n = 54 and OPEN n = 54). Modified Oswestry Disability Index (mODI) and back and leg pain were compared at baseline, 6–18 weeks, and 1-year post-operation. The number of patients meeting minimum clinically important difference (MCID) or minimum pain/disability at 1-year was compared.Results MIS approaches had less blood loss (decompression alone difference 100 mL, P= .002; with fusion difference 244 mL, P< .001) and shorter length of stay (LOS) (decompression alone difference 1.2 days, P= .008; with fusion difference 1.2 days, P= .026). MIS compared to OPEN decompression with fusion had less patients experiencing adverse events (AEs) (difference 13 patients, P= .007). The MIS decompression with fusion group had lower 1-year mODI (difference 14.5, 95% CI [7.5, 21.0], P< .001) and back pain (difference 1.6, 95% CI [.6, 2.7], P= .002) compared to OPEN. More patients in the MIS decompression with fusion group exceeded MCID at 1-year for mODI (MIS 75.9% vs OPEN 53.7%, P= .028) and back pain (MIS 85.2% vs OPEN 70.4%, P= .017).Conclusions MIS approaches were associated with more favorable outcomes for patients with diabetes undergoing decompression with fusion for LSS.

Nutritional risk has been linked to individual social factors, but the relationship with the overall social environment has not been assessed.

Study Design: Retrospective cohort study.Objective: We evaluated the effectiveness of minimally invasive (MIS) tubular discectomy in comparison to conventional open surgery among patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN).Methods: We performed an observational analysis of data that was prospectively collected. We implemented Minimum Clinically Important Differences (MCIDs), and we adjusted for potential confounders with multiple logistic regression. Adverse events were collected according to the Spinal Adverse Events Severity (SAVES) protocol.Results: Three hundred thirty-nine (62%) patients underwent MIS tubular discectomy and 211 (38%) underwent conventional open discectomy. There were no significant differences between groups for improvement of leg pain and disability, but the MIS technique was associated with reduced odds of achieving the MCID for back pain (OR 0.66, 95% CI 0.44 to 0.99, P< 0.05). We identified statistically significant differences in favor of MIS for each of operating time (MIS mean (SD) 72.2 minutes (30.0) vs open 93.5 (40.9)), estimated blood loss (MIS 37.9 mL (36.7) vs open 76.8 (71.4)), length of stay in hospital (MIS 73% same-day discharge vs open 40%), rates of incidental durotomy (MIS 4% vs open 8%), and wound-related complications (MIS 3% vs open 9%); but not for overall rates of reoperation.Conclusions: Open and MIS techniques yielded similar improvements of leg pain and disability at up to 12 months of follow-up, but MIS patients were less likely to experience improvement of associated back pain. Small differences favored MIS for operating time, blood loss, and adverse events but may have limited clinical importance.

Thoracic endovascular aortic repair (TEVAR) explantation remains a challenge due to endovascular graft ingrowth into the aortic wall with time. Surgical access into the aortic arch can be difficult either via sternotomy or thoracotomy, and proximal barbs become engaged firmly into the aortic wall. Explantation often requires extensive thoracic aortic resection, sometimes from the distal aortic arch to the abdominal aorta, followed by reconstruction, risking injury to surrounding neurovascular structures and even death. In cases of blunt thoracic aortic injury, the original injury is often healed, and failed TEVAR could theoretically be removed when thrombotic complications occur. We present a novel technique to facilitate TEVAR recapture with limited distal thoracic aorta replacement.

Congratulations on your recent article on the works of Med Hondo ('A Cinema on the Run: The Trailblazing Career of Med Hondo,' by Clarence Tsui, Cineaste, Fall 2021). At a [...]