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Background: Our previous research showed that, in Alberta, Canada, a higher proportion of visits to emergency departments and urgent care centres by First Nations patients ended in the patient leaving without being seen or against medical advice, compared with visits by non–First Nations patients. We sought to analyze whether these differences persisted after controlling for patient demographic and visit characteristics, and to explore reasons for leaving care. Methods: We conducted a mixed-methods study, including a population-based retrospective cohort study for the period of April 2012 to March 2017 using provincial administrative data. We used multivariable logistic regression models to control for demographics, visit characteristics, and facility types. We evaluated models for subgroups of visits with pre-selected illnesses. We also conducted qualitative, in-person sharing circles, a focus group, and 1-on-1 telephone interviews with health directors, emergency care providers, and First Nations patients from 2019 to 2022, during which we reviewed the quantitative results of the cohort study and asked participants to comment on them. We descriptively categorized qualitative data related to reasons that First Nations patients leave care. Results: Our quantitative analysis included 11 686 287 emergency department visits, of which 1 099 424 (9.4%) were by First Nations patients. Visits by First Nations patients were more likely to end with them leaving without being seen or against medical advice than those by non–First Nations patients (odds ratio 1.96, 95% confidence interval 1.94–1.98). Factors such as diagnosis, visit acuity, geography, or patient demographics other than First Nations status did not explain this finding. First Nations status was associated with greater odds of leaving without being seen or against medical advice in 9 of 10 disease categories or specific diagnoses. In our qualitative analysis, 64 participants discussed First Nations patients' experiences of racism, stereotyping, communication issues, transportation barriers, long waits, and being made to wait longer than others as reasons for leaving. Interpretation: Emergency department visits by First Nations patients were more likely to end with them leaving without being seen or against medical advice than those by non–First Nations patients. As leaving early may delay needed care or interfere with continuity of care, providers and departments should work with local First Nations to develop and adopt strategies to retain First Nations patients in care. [ABSTRACT FROM AUTHOR]

Avian pathogenic Escherichia coli (APEC), such as O1, O2 and O78, are important serogroups relating to chicken health, being responsible for colibacillosis. In this study, we isolated and characterized bacteriophages (phages) from hen feces and human sewage in Alberta with the potential for controlling colibacillosis in laying hens. The lytic profile, host range, pH tolerance and morphology of seven APEC-infecting phages (ASO1A, ASO1B, ASO2A, ASO78A, ASO2B, AVIO78A and ASO78B) were assessed using a microplate phage virulence assay and transmission electron microscopy (TEM). The potential safety of phages at the genome level was predicted using AMRFinderPlus and the Virulence Factor Database. Finally, phage genera and genetic relatedness with other known phages from the NCBI GenBank database were inferred using the virus intergenomic distance calculator and single gene-based phylogenetic trees. The seven APEC-infecting phages preferentially lysed APEC strains in this study, with ECL21443 (O2) being the most susceptible to phages (n = 5). ASO78A had the broadest host range, lysing all tested strains (n = 5) except ECL20885 (O1). Phages were viable at a pH of 2.5 or 3.5–9.0 after 4 h of incubation. Based on TEM, phages were classed as myovirus, siphovirus and podovirus. No genes associated with virulence, antimicrobial resistance or lysogeny were detected in phage genomes. Comparative genomic analysis placed six of the seven phages in five genera: Felixounavirus (ASO1A and ASO1B), Phapecoctavirus (ASO2A), Tequatrovirus (ASO78A), Kayfunavirus (ASO2B) and Sashavirus (AVIO78A). Based on the nucleotide intergenomic similarity (<70%), phage ASO78B was not assigned a genus in the siphovirus and could represent a new genus in class Caudoviricetes. The tail fiber protein phylogeny revealed variations within APEC-infecting phages and closely related phages. Diverse APEC-infecting phages harbored in the environment demonstrate the potential to control colibacillosis in poultry. [ABSTRACT FROM AUTHOR]

Rationale: Obstructive sleep apnea (OSA) is a common treatable condition with important health and societal consequences. Objectives: We aimed to assess the annual incidence and prevalence of clinically recognized and geographic clustering of OSA in Alberta, Canada, using administrative health data case definitions. Methods: We used two administrative health databases in Alberta to identify ICD-9 and ICD-10 (International Classification of Diseases, Ninth and 10th Revisions, respectively) diagnostic codes for adults and children at least 2 years old diagnosed with OSA between 2003 and 2020. We defined OSA using an algorithm developed and validated in Alberta: at least three claims or one hospitalization within 2 years. We mapped residential postal codes to 70 subregional health authorities (SRHAs). Crude, age group- and sex-specific incidence and prevalence, and age group- and sex-standardized rates were calculated for Alberta and SRHAs. Spatial scan statistics identified clusters of SRHAs in which OSA cases were higher (hot spots) or lower (cold spots) than expected. Results: Between 2003 and 2020, OSA prevalence increased from 0.14% to 4.59%. The annual incidence of OSA increased after 2013. Incidence and prevalence were higher in older adults and children aged 2-11 years compared with 12-17 years. Cluster analysis revealed regional variation in OSA incidence and prevalence over time with no consistent pattern except for cold spots in one large metropolitan center (Calgary). Conclusions: From 2003 to 2020, the incidence and prevalence of clinically recognized OSA increased but varied by geography. Administrative health data can be used to guide interventions aimed at improving health service delivery and the quality of OSA care. [ABSTRACT FROM AUTHOR]

In the wake of the massive Canadian wildfire of May 2016 in the area of Fort McMurray Alberta, we observed increased rates of mental health problems, particularly post-traumatic stress disorder (PTSD), in school-aged adolescents (ages 11–19). Surprisingly, we did not see these rates decline over the 3.5-year follow-up period. Additionally, our research suggested that the impact of this mass incident resulted in other unanticipated effects, including the finding that children who were not present for and relatively unaffected by the wildfire showed a similar PTSD symptom profile to children more directly involved, suggesting some degree of spillover or stress contagion. A potential explanation for these high rates in individuals who were not present could be undiagnosed retraumatization in some of the students. To investigate this possibility, we compared two groups of students: those who reported the wildfire as their most significant trauma (n = 740) and those who had their most significant trauma prior to the wildfire (n = 295). Those with significant pre-existing trauma had significantly higher rates of both depression and PTSD symptoms, although, unexpectedly the groups exhibited no differences in anxiety level. Taken together, this evidence suggests retraumatization is both longer-lasting and more widespread than might be predicted on a case-by-case basis, suggesting the need to reconceptualize the role of past trauma history in present symptomatology. These findings point to the need to recognize that crises instigated by natural disasters are mass phenomena which expose those involved to numerous unanticipated risks. New trauma-informed treatment approaches are required that incorporate sensitivity to the collective impact of mass crises, and recognize the risk of poorer long-term mental health outcomes for those who experienced trauma in the past. [ABSTRACT FROM AUTHOR]

Background: The care of rural trauma patients in northern Alberta can be extremely challenging because of the vast geographic area, the limited access to health care facilities and the lack of adequate resources to manage severe injuries. Identifying gaps in equipment and personnel in rural centres can provide opportunities for improving the care of injured patients in these environments. We conducted a survey based on Canadian Accreditation Council quality indicators to evaluate trauma infrastructure and human resources in rural centres across northern Alberta.Methods: A standardized survey was developed to assess the availability of trauma-specific equipment and personnel across the prehospital and emergency department (ED) settings. The survey was distributed to 50 peripheral hospitals biannually from January 2017 to September 2018. Two-tailed paired t tests were used to evaluate changes in survey responses; a p value of less than 0.05 was considered statistically significant.Results: The survey response rate was 100%. By the end of the study period, there were significant improvements in the number of providers (p = 0.04), nurses (p = 0.01) and dedicated trauma resuscitation bays (p = 0.04) in the ED for managing injured patients. There were also significant increases in the availability of equipment, including advanced airway management tools (p = 0.02), rapid infusion devices (p = 0.02) and warmers (p = 0.04). Access to x-ray equipment (p = 0.03) and computed tomography (CT) scanners (p = 0.04) as well as equipment to support telehealth and teleconferencing (p = 0.04) increased during the study period. Access to, and supply of, blood products also increased significantly (p = 0.02) during the study period.Conclusion: Our study demonstrates that the trauma resources of rural health care centres may be evaluated in a standardized fashion centres, and the results point to opportunities to remedy gaps in equipment and personnel. Our methods may be applied to any trauma network that serves geographically large areas with a sparse distribution of health care facilities, to provide critical information for the optimization of resources in rural trauma. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to investigate the characteristics and the outcomes of primary colorectal lymphomas using a population-based registry.Methods: All cases of colorectal lymphoma diagnosed between 1980 and 2007 were identified using a provincial cancer registry. Patients meeting Dawson's criteria and having a negative bone marrow biopsy were included.Results: One hundred ten cases of colorectal lymphoma were identified, 43 met the inclusion criteria. The majority of patients was male (86%), and the median age at diagnosis was 62 (range 26-82) years. Tumors were mostly located in the cecum (51.1%) and rectum (20.9%). The 5-year overall survival rate calculated by the Kaplan-Meier method was 57%. Age under 60 was associated with a better median survival time (265 vs 54 months; p < 0.0001). The surgical treatment was associated with a better overall survival compared to medical treatment alone (110 vs 56 months; p = 0.083). Tumors located in the rectum were associated with a decreased overall survival (41 months vs 110 months; p = 0.065).Conclusions: Primary colorectal lymphoma is a rare disease. The age at diagnosis is an important predictor of outcome. Surgical resection may be associated with improved survival. Rectal lymphoma appears to be associated with a worse outcome and may warrant more aggressive therapy. [ABSTRACT FROM AUTHOR]

Aim The ileocaecal junction ( ICJ) region is an epithelial transition zone in which carcinomas are frequently diagnosed. However, it is currently unknown whether ICJ carcinomas ( ICJ- CAs) have distinctive features. This study aimed to characterize the clinicopathological features of ICJ- CAs. Method All ileal and colorectal resections for carcinoma, performed in Calgary, Canada between January 2009 and June 2012, were reviewed. Carcinomas in which the epicentre was within 5 cm of the ileocaecal valve ( ICV) were defined as ICJ- CAs. Of 1003 carcinomas studied, 199 (19.8%) were ICJ- CAs, including 93 (9.3%) that crossed the ICV. Comparison of clinicopathological features with carcinomas of the other ileo-colorectal regions was made. Survival was also assessed. Results Clinically, ICJ-CAs were more common in female than male patients (56.3% female) compared with left-colonic (42.9% female) and rectal (37.9% female) carcinomas, and were more common in older age-groups of patients (71.8 ± 12.7 years) compared with appendiceal (62.6 ± 11.3 years), left-colonic (69.4 ± 12.3 years) and rectal (67.1 ± 11.9 years) carcinomas. Macroscopically, ICJ- CAs were similar to other colorectal carcinomas and were mostly described as ulcerated (63.3%). Histologically, ICJ- CAs had more mucinous, signet-ring cell and/or neuroendocrine features (39.7%, 8.0% and 7.5%, respectively) than did carcinomas of the left colon (16.8%, 1.6% and 1.1%, respectively) and the rectum (14.1%, 1.0% and 0.0%, respectively). They were higher grade (20.1% were high grade) than those of the left-colon (10.3%) and the rectum (9.8%). ICJ- CAs presented at a higher T-stage (25.6% were T4) compared with rectal carcinomas (11.6%). Most significantly, ICJ- CAs presented at a higher N-stage (25.6% were N2) than did right-colonic (14.1%) and rectal (16.2%) carcinomas. Although survival of patients with ICJ- CAs did not differ from those with right-colonic carcinomas, those with carcinomas directly involving the ICV did show a significantly decreased survival. Conclusion ICJ- CAs display several distinct clinicopathological features that may require special diagnostic, prognostic and management attention. [ABSTRACT FROM AUTHOR]

In this paper, the authors reflect on their experience of engaging faculty members as members of reflective panels following the screening of films used as part of a longitudinal narrative reflective practice module in the pre-clinical, Patient-Centred Care course in first and second year at the University of Alberta. Having experienced both highly reflective and more didactic panelist approaches over the course of several years’ experience, the authors wonder about what medical students may be ‘reading between the lines’ when they experience curricula that is not always consistent with stated curriculum aims and intentions. The authors suggest the value of closely considering both the texts and contexts that comprise medical education, particularly in relation to how these may shape medical student socialization into the profession of medicine. [ABSTRACT FROM PUBLISHER]

Background: Medical students struggle with varied stressors and developing adequate coping mechanisms is essential.Purpose: This study examined medical student perceptions of the well-being impact of a theatre-based course.Methods: Eighteen 1st-year medical students at the University of Alberta participated in 3 focus groups following the conclusion of a theatre-based module that was piloted in the first quarter of 2010. A semistructured protocol was used to guide the focus groups, which were audiotaped and transcribed. Along with general feedback, impact on personal development and student well-being were discussed. Thematic aspects of these discussions were qualitatively analyzed.Findings: During the focus groups, medical students identified three aspects of the theatre-based module that contributed to their sense of overall well-being. These included (a) fun/relaxation, (b) enhanced relationships with each other, and (c) personal growth/resilience.Conclusion: Our findings suggest that participating in an optional theatre module can enhance medical student well-being. Our analysis suggests the need to consider novel, humanities-based curriculum offerings in relation to personal development and well- being. [ABSTRACT FROM AUTHOR]

Abstract: Background: Acute care surgery (ACS) services are becoming increasingly popular. Methods: Assessment, flow, and disposition of adult ACS patients (acute, nontrauma surgical conditions) through the emergency department (ED) in a large health care system (Calgary) were prospectively analyzed. Results: Among 447 ACS ED consultations over 3 centers (70% admitted to ACS), the median wait time from the consultation request to ACS arrival was 36 minutes, and from ACS arrival to the admission request it was 91 minutes. The total ACS-dependent time was 127 minutes compared with 261 minutes for initial ED activities and 104 minutes for transfer to a hospital ward (P < .05). Forty percent of patients underwent computed tomography (CT) imaging (76% before consultation). The time to ACS consultation was 305 minutes when a CT scan was performed first. Conclusions: An ACS service results in rapid ED assessment of surgical emergencies. Patient waiting is dominated by the time before requesting ACS consultation and/or waiting for transfer to the ward. [Copyright &y& Elsevier]

OBJECTIVE To identify and describe the important rewards and challenges that affect family physicians in Alberta. DESIGN Web-based qualitative study using the Delphi method. SElliNG Province of Alberta. PARTICIPANTS Twenty-eight family physicians practising in Alberta. METHODS The study website presented a description of the project, ethical information, a calendar of events, and contact information. Delphi surveys and demographic questionnaires were password protected. Five rounds of surveys were conducted between May 2004 and January 2005. Participants were notified of each round of surveys and prompted by e-mail if they did not respond. FINDINGS Participants identified 8 key rewards and 9 key challenges. The research team identified 2 additional challenges that were validated by participants. In order of perceived importance, key rewards were providing diverse and comprehensive care; providing preventive care; having relationships with patients and their families; being an immersed witness to the human condition; providing continuity of care and receiving ongoing feedback; having flexibility and control of practice and job security; maintaining and acquiring skills and knowledge; teaching and sharing knowledge and gaining experience and mentoring. The challenges, in order of perceived need to be addressed, were workload and time pressures and meeting demands; the need to promote the rewards of family practice to those considering joining the profession; overhead and income inequities; getting respect from specialists; the need to ensure that the rewards identified are not adversely affected by primary care reform; lack of availability of specialists, procedures, tests, and other resources; running a practice as a small business; paperwork, telephone calls, and forms; maintaining and acquiring skills and knowledge; patients' expectations; and medicolegal issues, insurance paperwork, and dealing with medical claims related to motor vehicle accidents. CONCLUSION The rewards and challenges reported by participants outline the positive and negative factors in family practice. The challenges provide a focus for further work. [ABSTRACT FROM AUTHOR]

All of the pollutants found in stormwater runoff at airports, including surface and aircraft de-icing/anti-icing glycols, can be treated and removed to low levels in well-designed sub-surface flow (SSF) constructed wetland systems. There are two common forms of constructed wetlands used for pollution control: those where water flows over the surface among wetland plants (free water surface or marsh type wetlands); and SSF types where the wastewater flows below the normally dry surface of a gravel substrate in which the wetland plants grow. SSF wetlands have no open water to attract waterfowl and are particularly suitable for use at airports. Of the glycol used at Edmonton International Airport (EIA), 80 to 90% eventually entered surface runoff. Edmonton International Airport's operator, the Edmonton Regional Airports Authority (Edmonton Airports) evaluated a number of glycol management options, including constructed wetlands. As a result, a very large SSF wetland system was installed to handle glycol-contaminated stormwater. This paper reviews results of a feasibility study carried out to define design parameters and scale up kinetics for this wetland system, the detailed design that resulted, the SSF wetland's construction, and the start-up of the Edmonton facilities in August of 2000. It also compares the Edmonton wetland system with a similar facility at Heathrow Airport in the United Kingdom. [ABSTRACT FROM AUTHOR]

Despite the economic benefits of the oil and gas industry in Northern Alberta, significant concerns exist regarding the impacts of increased oil production on the environment and human health. Several studies have highlighted increases in the concentrations of polycyclic aromatic compounds (PACs) and other hydrocarbons in the atmosphere, water, soil and sediments, plants, wildlife and fish in the Athabasca Oil Sands Region (AOSR) as a result of oil sands industrial activity. Sediment cores can provide information on the temporal trends of contaminants to the environment and provide important baseline information when monitoring data are absent. Here we combined analytical chemistry and a mammalian cell-based bioassay in dated lake sediment cores to assess paleotoxicity in freshwater systems in the AOSR. Sediment intervals were radiometrically dated and subsequently analysed for PACs. PAC extracts from select dated intervals were used in cell-based bioassays to evaluate their endocrine disrupting properties. We demonstrated spatial and temporal variability in the PAC composition of sediment cores around the AOSR with some of the highest concentrations of PACs detected near oil sands industrial activity north of Fort McMurray (AB) in La Saline Natural Area. Recent sediment had positive enrichment factors across most PAC analytes at this site with heavier pyrogenic compounds such as benz(a)anthracene/chrysene and benzofluoranthene/benzopyrene dominating. Our study is the first to link chemical analysis of sediment cores with biological effect assessments of endocrine activity showing feasibility of extending the usefulness of sediment cores in monitoring programs interested in complex mixture assessments. While we observed no spatial or temporal differences in ERα mediated signaling, AhR CALUX results mirrored those of the chemical analysis, demonstrating the utility of coupling biological effects assessments to historical reconstructions of contaminant inputs to the natural environment. [Display omitted] • We looked at paleotoxicity of sediments with ERα and AhR bioassays on dated intervals. • No change in ERα signaling, but AhR CALUX activity increased in recent sediments. • Our method gives a historical account of sediment toxicity in an industrial region. [ABSTRACT FROM AUTHOR]

In 1988, the Energy Efficiency Branch of Alberta's Department of Energy launched a computerized transportation audit program. Its purpose is to identify possible savings in the consumption of energy in the transportation sector. In the first 18 audits completed, the potential annual fuel savings averaged 34 percent. The program consists of four segments: vehicle selection, vehicle maintenance, driver training, and vehicle routing. We concentrate here on the development and implementation of the vehicle routing component and its use by Scott National to save 10 percent of its annual fuel costs. [ABSTRACT FROM AUTHOR]

The authors discuss the educational exhibition, "Harry Potter's World: Renaissance Science, Magic and Medicine," created by the National Library of Medicine (NLM) at University of Alberta, Edmonton, Alberta. Historical materials and scientific references, such as potions, herbology, muggle studies, from J K Rowling's Harry Potter book series were used to introduce children to the science behind the series. The authors aimed to instill the idea that medical schools can be fun and accessible.

The article reviews the exhibition "Living with X: A Body Mapping Exhibit Depicting the Realities of Living with HIV," at The Carrot Community Arts Coffeehouse in Edmonton, Alberta in August 2008.

Abstract: Companion animals closely share their domestic environment with people and have the potential to, act as sources of zoonotic diseases. They also have the potential to be sentinels of infectious and noninfectious, diseases. With the exception of rabies, there has been minimal ongoing surveillance of, companion animals in Canada. We developed customized data extraction software, the University of, Calgary Data Extraction Program (UCDEP), to automatically extract and warehouse the electronic, medical records (EMR) from participating private veterinary practices to make them available for, disease surveillance and knowledge creation for evidence-based practice. It was not possible to build, generic data extraction software; the UCDEP required customization to meet the specific software, capabilities of the veterinary practices. The UCDEP, tailored to the participating veterinary practices’, management software, was capable of extracting data from the EMR with greater than 99%, completeness and accuracy. The experiences of the people developing and using the UCDEP and the, quality of the extracted data were evaluated. The electronic medical record data stored in the data, warehouse may be a valuable resource for surveillance and evidence-based medical research. [Copyright &y& Elsevier]

A method combining life cycle assessment (LCA) and real options analyses is developed to predict project environmental and financial performance over time, under market uncertainties and decision-making flexibility. The method is applied to examine alternative uses for oil sands coke, a carbonaceous byproduct of processing the unconventional petroleum found in northern Alberta, Canada. Under uncertainties in natural gas price and the imposition of a carbon price, our method identifies that selling the coke to China for electricity generation by integrated gasification combined cycle is likely to be financially preferred initially, but eventually hydrogen production in Alberta is likely to be preferred. Compared to the results of a previous study that used life cycle costing to identify the financially preferred alternative, the inclusion of real options analysis adds value as it accounts for flexibility in decision-making (e.g., to delay investment), increasing the project's expected net present value by 25% and decreasing the expected life cycle greenhouse gas emissions by 11%. Different formulations of the carbon pricing policy or changes to the natural gas price forecast alter these findings. The combined LCA/real options method provides researchers and decision-makers with more comprehensive information than can be provided by either technique alone. [ABSTRACT FROM AUTHOR]

Life cycle greenhouse gas (GHG) emissions associated with two major recovery and extraction processes currently utilized in Alberta's oil sands, surface mining and in situ, are quantified. Process modules are developed and integrated into a life cycle model-GHOST (GreenHouse gas emissions of current Oil Sands Technologies) developed in prior work. Recovery and extraction of bitumen through surface mining and in situ processes result in 3-9 and 9-16 g CO2eq/MJ bitumen, respectively; upgrading emissions are an additional 6-17 g CO2eq/MJ synthetic crude oil (SCO) (all results are on a HHV basis). Although a high degree of variability exists in well-to-wheel emissions due to differences in technologies employed, operating conditions, and product characteristics, the surface mining dilbit and the in situ SCO pathways have the lowest and highest emissions, 88 and 120 g CO2eq/MJ reformulated gasoline. Through the use of improved data obtained from operating oil sands projects, we present ranges of emissions that overlap with emissions in literature for conventional crude oil. An increased focus is recommended in policy discussions on understanding interproject variability of emissions of both oil sands and conventional crudes, as this has not been adequately represented in previous studies. [ABSTRACT FROM AUTHOR]

Importance: Engaging multidisciplinary care teams in surgical practice is important for the improvement of surgical outcomes., Objective: To evaluate the association of multiple Enhanced Recovery After Surgery (ERAS) pathways with ERAS guideline adherence and outcomes., Design, Setting, and Participants: This quality improvement study compared a pre-ERAS cohort (2013-2017) with a post-ERAS cohort (2014-2018). All patients were from Alberta Health Services in Alberta, Canada, and had available ERAS and up to 1-year postsurgery administrative data. Data collected included age, sex, body mass index, tobacco and alcohol use, diabetes, comorbidity index, and surgical characteristics. Data analysis was performed from May 7, 2020, to February 1, 2021., Interventions: Implementation of 5 ERAS pathways (colorectal, liver, pancreas, gynecologic oncology, and radical cystectomy) across 9 sites., Main Outcomes and Measures: Adherence to ERAS guidelines was measured by the percentage of patients whose care met the common ERAS pathway care element criteria. Surgical procedures were grouped by complexity; complications were classified by severity. Outcome measures for the pre-post-ERAS cohorts included length of stay (LOS), readmission, complications, and mortality., Results: A total of 7757 patients participated in the study, including 984 in the pre-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 526 [53.5%] female) and 6773 in the post-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 3470 [51.2%] male). In the total cohort, care-element adherence improved from 52% to 76% (P < .001), no significant differences were found in serious complications (from 6.2% to 4.9%; P = .08) or 30-day mortality (from 0.71% to 0.93%; P = .50), 1-year mortality decreased from 7.1% to 4.6% (P < .001), mean (SD) LOS decreased from 9.4 (7.0) to 7.8 (5.0) days (P < .001), and 30-day readmission rates were unchanged (from 13.4% to 11.7%; P = .12). After adjustment for patient characteristics, the LOS mean difference decreased 0.71 days (95% CI, -1.13 to -0.29 days; P < .001), with no significant differences in adjusted 30-day readmission (-3.5%; 95% CI, -22.7% to 20.4%; P = .75), serious complications (1.3%; 95% CI, -26.2% to 39.0%; P = .94), or mortality (30-day mortality: 42% [95% CI, -35.4% to 212.3%]; P = .38; 1-year mortality: 8% [95% CI, -20.5% to 46.8%]; P = .62). The adjusted 1-year readmission rate was -15.6% (95% CI, -27.7% to -1.5%; P = .03) in favor of ERAS, and readmission LOS was shorter by 1.7 days (95% CI, -3.3 to -0.1 days; P = .04)., Conclusions and Relevance: The results of this quality improvement study suggest that implementation of ERAS across multiple pathways may improve health care practitioner adherence to ERAS guidelines, LOS, and readmission rates at a system level.

Background: The pathogenesis of appendicitis is unclear. We evaluated whether exposure to air pollution was associated with an increased incidence of appendicitis., Methods: We identified 5191 adults who had been admitted to hospital with appendicitis between Apr. 1, 1999, and Dec. 31, 2006. The air pollutants studied were ozone, nitrogen dioxide, sulfur dioxide, carbon monoxide, and suspended particulate matter of less than 10 micro and less than 2.5 micro in diameter. We estimated the odds of appendicitis relative to short-term increases in concentrations of selected pollutants, alone and in combination, after controlling for temperature and relative humidity as well as the effects of age, sex and season., Results: An increase in the interquartile range of the 5-day average of ozone was associated with appendicitis (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.03-1.25). In summer (July-August), the effects were most pronounced for ozone (OR 1.32, 95% CI 1.10-1.57), sulfur dioxide (OR 1.30, 95% CI 1.03-1.63), nitrogen dioxide (OR 1.76, 95% CI 1.20-2.58), carbon monoxide (OR 1.35, 95% CI 1.01-1.80) and particulate matter less than 10 micro in diameter (OR 1.20, 95% CI 1.05-1.38). We observed a significant effect of the air pollutants in the summer months among men but not among women (e.g., OR for increase in the 5-day average of nitrogen dioxide 2.05, 95% CI 1.21-3.47, among men and 1.48, 95% CI 0.85-2.59, among women). The double-pollutant model of exposure to ozone and nitrogen dioxide in the summer months was associated with attenuation of the effects of ozone (OR 1.22, 95% CI 1.01-1.48) and nitrogen dioxide (OR 1.48, 95% CI 0.97-2.24)., Interpretation: Our findings suggest that some cases of appendicitis may be triggered by short-term exposure to air pollution. If these findings are confirmed, measures to improve air quality may help to decrease rates of appendicitis.