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This article explores the potential benefits and defined risks associated with prophylactic surgical procedures for astronauts before extended-duration space flight. This includes, but is not limited to, appendectomy and cholecystesctomy. Furthermore, discussion of treatment during space flight, potential impact of an acute illness on a defined mission and the ethical issues surrounding this concept are debated in detail. [ABSTRACT FROM AUTHOR]

Background: For patients with breast cancer, a negative surgical margin at first breast-conserving surgery (BCS) minimizes the need for reoperation and likely reduces postoperative anxiety. We assessed technical factors, surgeon and hospital case volume and margin status after BCS in early-stage breast cancer.Methods: We performed a retrospective cohort study using a regional cancer centre database of patients who underwent BCS for breast cancer from 2000 to 2002. We considered the influence of patient, tumour and technical factors (e.g., size of specimen and preoperative diagnosis of cancer available) and surgeon and hospital case volume on margin status at first and final operation. We performed univariate and multivariate regression analyses.Results: We reviewed 489 cases. There were no differences in patient or tumour characteristics among the low-, medium- and high-volume surgeon groups. High-volume surgeons were significantly more likely than other surgeons to operate with a confirmed preoperative diagnosis and to resect a larger volume of tissue. In our univariate analysis and at first operation, the rates of positive margins were 16.4%, 32.9% and 29.1% for high-, medium- and low-volume surgeons, respectively (p = 0.002). In the multivariate analysis, tumour factors (palpability, size, histology), presence of a confirmed preoperative diagnosis and size of resection specimen significantly predicted negative margins. However, when we controlled for these and other factors, high surgeon volume was not a predictor of negative margins at first surgery (odds ratio 1.8, 95% confidence interval 0.9-3.8, p = 0.09). Increased hospital volume was not associated with a lower rate of positive margins at first surgery.Conclusion: Various tumour and technical factors were associated with negative margins at first BCS, whereas surgeon and hospital volume status were not. Technical steps that are under the control of the operating surgeon are likely effective targets for quality initiatives in breast cancer surgery. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Several studies have shown that the quality of reports of randomized controlled trials (RCTs) in medicine is variable and often poor, whereas the quality of those in surgery is unknown. We aimed to assess the quality of reports of RCTs in coronary artery bypass grafting (CABG) surgery when comparing off- and on-pump techniques. METHODS: From electronic searches of MEDLINE, the Cochrane Library, CINAHL, HealthSTAR and EMBASE, we identified RCTs published between 2000 and 2005 comparing off- and on-pump CABG. We assessed the report quality, using 35 items from the Consolidated Standards for Reporting Trials (CONSORT) statement and 54 additional indicators relevant to CABG surgery. Some of the indicators comprised several small parts, making the maximum possible total score 105. Two authors independently reviewed and assessed the reporting quality of each RCT. The level of agreement was assessed with kappa statistics, and disagreements were resolved by consensus. We expressed descriptive analyses as median and interquartile range; we used a generalized estimating equation (GEE) for data analysis. RESULTS: We included 50 trials, for a total of 5134 patients. The kappa value was greater than 0.6 for 73 of 105 (70%) indicators. The overall report quality score varied from 35 to 93 of 105. The CONSORT score reporting quality varied from 16 to 39 of 42. The quality of reporting was poor and insufficient for the methods (particularly, the sample size, allocation and blinding subsections), results and discussion sections. With GEE modelling, the reporting quality had a strong association with trial size, publication year, trial location and funding source, but not with the results and type of primary outcome. CONCLUSION: The quality of the publications' reporting methods, results and discussion sections was suboptimal. It is critical that, in reporting surgical trials, authors follow the CONSORT guidelines as well as consider the surgical factors. [ABSTRACT FROM AUTHOR]

BACKGROUND: This study investigates the feasibility of performing advanced minimally invasive surgery (MIS) in a nonspecialized practice environment. METHODS: We conducted a cross-sectional survey of all community general surgeons currently practising in Ontario. RESULTS: Few community surgeons perform a high volume (> 10 procedures per yr) of advanced MIS. Most (70%) believe it is important to acquire additional skills in advanced MIS. The most appropriate methods for learning advanced MIS are believed to be expert mentoring (79.7%), courses (77.2%) and a colleague mentor (63.9%). A total of 57.6% of respondents have attended a course in MIS while in practice, and most have access to a reasonable variety of instrumentation. Respondents believe that 57.6% of assistants, 54.8% of nurses and 43.4% of anaesthetists are relatively inexperienced with advanced MIS. Barriers to establishing advanced MIS include limited operating room access (50%), resources or equipment (45.2%) and limited expert mentoring (43.6%). Surgeons with less than 10 years of practice found lack of trained nursing staff (7.9% v. 4.2%, p = 0.01) and experienced assistants (12% v. 6.2%, p = 0.008) to be more important barriers than did those with over 10 years of practice, respectively. CONCLUSION: Most general surgeons working in Ontario are self-taught with respect to MIS skills, and few perform a high volume of advanced MIS. Only one-half of all respondents have access to skilled MIS operating room nurses, surgical assistants or anesthesiology. Despite this, general surgeons perceive the greatest barriers to introducing advanced MIS procedures to be limited access to operating rooms, resources or equipment and limited mentoring. This study has shown that the role of the surgical team in advanced MIS may be underestimated by many general surgeons. These data have important implications in training general surgeons and in incorporating additional advanced MIS procedures into the armamentarium of general surgeons. [ABSTRACT FROM AUTHOR]

Background Current debate on treatment options for anterior cruciate ligament (ACL) reconstruction complicate the choice between hamstring and bone patellartendon bone autografts. We hypothesized a priori that cumulative meta-analysis (a form of sensitivity analysis) might show that the evidence for reduction of morbidity by hamstring grafts could have been reached at an earlier time. Furthermore, we hypothesized a priori that modern state-of-the-art hamstring graft fixation technique would give similar results regarding stability as bone-patellar tendon-bone autografts. Methods We performed a cumulative meta-analysis and sensitivity analysis based on femoral graft fixation techniques to compare hamstring autograft and bonepatellar tendon-bone autografts in ACL reconstruction derived from a previously published meta-analysis. Results Cumulatively, that hamstring autograft reduces anterior knee pain had already reached statistical significance in 2001 (relative risk 0.49 (95%CI: 0.32-0.76; p = 0.001, I2 = 0%)). The modern endobutton hamstring graft fixation technique (2 studies) yielded similar stability in the Lachman test as bone-patellar tendon-bone grafts, with a relative risk of 1.1 (95%CI: 0.82-1.5; p = 0.6, I2 = 0%). Exclusion of the endobutton group explains the increased laxity in the hamstring graft group. Interpretation Cumulative meta-analysis strengthens the evidence for reduced morbidity using hamstring tendon autograft for anterior cruciate ligament reconstruction. Sensitivity analysis focusing on state-of-the-art hamstring graft fixation techniques further weakens the evidence that bone-patellar tendon-bone autografts provide better stability. [ABSTRACT FROM AUTHOR]

Metastatic disease of the acetabulum is a common and challenging surgical problem. We asked whether acetabular reconstruction for metastatic bone disease improves functional outcome with an acceptable risk of surgical morbidity. We also asked if primary tumor type and the presence of visceral metastases predicted patient survival. We analyzed prospectively accumulated records of 62 consecutive patients who underwent 63 hip arthroplasties with acetabular reconstruction. Operative technique was guided by the extent of dome and column involvement. Demographics, functional status in the form of the Eastern Cooperative Oncology Group (ECOG) score, and survival data were analyzed. Functional scores improved from an average of 2.6 preoperatively to 1.1 postoperatively. Four patients had postoperative complications for which we performed further surgery. Mean survival for the patients with breast cancer was longer at 21 months compared to 9 months for the patients with other primary malignancies. Patients who did not present with visceral metastases had longer survival than those with visceral metastases. Despite the moderate risk of operative complications, an anatomically based approach to reconstruction of acetabular defects from metastatic disease improves functional outcome. Breast cancer as the primary malignancy and the absence of visceral metastases predicted longer survival.Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Randomization, concealment of treatment allocation, and blinding are all known to limit bias in clinical research. Nonsurgical studies that fail to meet these standards have been reported to inflate the differences between treatment and control groups. While surgical trials can rarely blind surgeons or patients, they can often blind outcome assessors. The aim of this systematic review was threefold: (1) to examine the reporting of outcome measures in orthopaedic trials, (2) to determine the feasibility of blinding in published orthopaedic trials, and (3) to examine the association between the magnitude of treatment differences and the blinding of outcome assessors.Methods: We identified and reviewed thirty-two randomized, controlled trials published in The Journal of Bone and Joint Surgery (American Volume) in 2003 and 2004 for the appropriate use of outcome measures. These trials represented 3.4% of all 938 studies published during that time-period. All thirty-two trials were reviewed by two authors for (1) the outcome measures used and (2) the blinding of outcomes assessors. We calculated the magnitude of the treatment effect of the use of blinded compared with unblinded outcome assessors.Results: Ten (31%) of the thirty-two randomized controlled trials used a modified outcome instrument. Of the ten trials, four failed to describe how the outcome instrument was modified. Nine of the ten articles did not describe how the modified instrument was validated and retested. Sixteen of the thirty-two randomized controlled trials did not report blinding of outcome assessors when blinding would have been possible. Among the studies with continuous outcome measure, unblinded outcomes assessment was associated with significantly larger treatment effects than blinded outcomes assessment (standardized mean difference, 0.76 compared with 0.25; p = 0.01). Similarly, in the studies with dichotomous outcomes, unblinded outcomes assessments were associated with significantly greater treatment effects than blinded outcomes assessments (odds ratio, 0.13 compared with 0.42; p < 0.001). The ratio of odds ratios (unblinded to blinded outcomes assessment) was 0.31, suggesting that unblinded outcomes assessment was associated with a potential for exaggeration of the benefit of the effectiveness of a treatment in our cohort of studies.Conclusions: In future orthopaedic randomized controlled trials, emphasis should be placed on detailed reporting of outcome measures to facilitate generalization and the outcome assessors should be blinded, when possible, to limit bias. [ABSTRACT FROM AUTHOR]

Introduction: Colorectal cancer is the second leading cause of cancer-related death in western countries. The objective of this systematic review was to show that laparoscopic-assisted colon resection for cancer is not inferior to open colectomy with respect to cancer survival and perioperative outcomes. Method: We performed a comprehensive literature review. Inclusion criteria were adults aged over 16 years with a colon resection for documented colon cancer and randomized controlled trials with laparoscopic-assisted or open resections. We excluded studies that did not document colon cancer recurrence in their article. We assessed data extraction and study quality and performed a quantitative data analysis. Results: Six published and 4 unpublished studies fulfilled our inclusion criteria, with a total of 1262 patients. All primary and secondary outcomes showed good homogeneity, except for morbidity, which was described heterogeneously between the studies. There was no disadvantage to laparoscopic colon resection in any of these primary and secondary outcomes, compared with the conventional open technique. Conclusions: The results of this study suggest that, although there is no definitive answer, present evidence indicates that laparoscopic colon cancer resection is as safe and efficacious as the conventional open technique. [ABSTRACT FROM AUTHOR]

Background: The Journal of Bone and Joint Surgery, American Volume (The Journal) recently initiated a section called "Evidence-Based Orthopaedics." Furthermore, a level-of-evidence rating is now used in The Journal to help readers in clinical decision-making. Little is known about whether this recent emphasis has influenced surgeons' perceptions about and competence in evidence-based medicine. Therefore, we examined perceptions and competence in evidence-based medicine among Dutch orthopaedic surgeons.Methods: Members of the Dutch Orthopaedic Association were surveyed to examine their attitudes toward evidence-based medicine and their competence in evidence-based medicine. We evaluated competences using a newly developed instrument tailored to surgical practice.Results: Of the 611 members, 367 surgeons (60%) responded. Orthopaedic surgeons welcomed evidence-based medicine. Practical evidence-based medicine resources were perceived as the best method to move from opinion-based or experience-based to evidence-based practice. Four variables were significantly and positively associated with the competence instrument: (1) a younger age, particularly between thirty-six and forty-five years (p = 0.007), (2) experience of less than ten years (p = 0.032), (3) having a PhD degree (p < 0.001), and (4) working in an academic or teaching setting (p = 0.004). The majority of the respondents were aware of The Journal's evidence-based medicine section (84%) and level-of-evidence ratings (65%), and 20% used The Journal's evidence-based medicine abstracts in clinical decision-making. This increased awareness of evidence-based medicine was also reflected in the frequent use of Cochrane reviews in clinical decision-making (27% of the respondents). Surgeons who used and those who were aware of but did not use The Journal's evidence-based medicine abstracts or Cochrane reviews in clinical decision-making had significantly higher competence instrument scores than those who were unaware of these resources (p = 0.03 and p < 0.001, respectively).Conclusions: Evidence-based medicine is welcomed by Dutch orthopaedic surgeons. The recent emphasis on evidence-based medicine is reflected in an increased awareness about The Journal's evidence-based medicine section, levels of evidence, and the largest evidence-based medicine resource: the Cochrane reviews. Younger orthopaedic surgeons had better knowledge about evidence-based medicine. The development and use of evidence-based resources as well as preappraised summaries such as The Journal's evidence-based medicine abstracts and Cochrane reviews were perceived as the best way to move from opinion-based to evidence-based orthopaedic practice. [ABSTRACT FROM AUTHOR]

BACKGROUND: There are no comprehensive evidence-based guidelines for deep vein thrombosis (DVT) prophylaxis in patients undergoing minimal-access surgery (MAS). METHODS: We completed a cross-sectional survey of general surgeons practising in Ontario, in order to establish current practice patterns for DVT prophylaxis for MAS procedures. RESULTS: The mean duration of practice of respondents was 15.4 years, with most (67.0%) practising outside an academic centre. For minor MAS, most surgeons do not give DVT prophylaxis (73.8% in laparoscopic cholecystectomy and 63.7% in laparoscopic inguinal hernia repair). For major MAS, a minority of surgeons do not give DVT prophylaxis (4.1% in laparoscopic colorectal surgery and 13.6% in laparoscopic splenectomy). However, there remains considerable variation in the mechanism (pharmacological, mechanical), approach and duration (perioperative, postoperative) of DVT prophylaxis among respondents in all case scenarios evaluated. Academic surgeons and surgeons in practice for 15 years or less are more aggressive with preoperative heparin administration. CONCLUSIONS: There is substantial and important variability in the current practice of general surgeons with respect to DVT prophylaxis for MAS. Considerable benefit will be derived from clinical trials that provide data to establish appropriate DVT prophylaxis guidelines for MAS. [ABSTRACT FROM AUTHOR]

Abstract Background Deep infection following endoprosthetic limb reconstruction for sarcoma of the long bones is a devastating complication occurring in 15% of sarcoma patients. Optimizing infection protocols and conducting definitive surgical trials are critical to improving outcomes. In this study, the PARITY (Prophylactic Antibiotic Regimens in Tumor Surgery) investigators aimed to examine surgeon preferences in antibiotic prophylaxis and perceptions about current evidence, as well as to ascertain interest in resolving uncertainty in the evidence with clinical trials. Methods We used a cross-sectional survey to examine current practice in the prescription of prophylactic antibiotics in Musculoskeletal Tumor Surgery. The survey was approved by our institution’s Ethics Board and emailed to all Active Members of the Musculoskeletal Tumor Society (MSTS) and Canadian Orthopaedic Oncology Society (CANOOS). Survey answers were collected using an anonymous online survey tool. Results Of the 96 surgeons who received the questionnaire, 72 responded (75% response rate (% CI: 65.5, 82.5%)). While almost all respondents agreed antibiotic regimens were important in reducing the risk of infection, respondents varied considerably in their choices of antibiotic regimens and dosages. Although 73% (95% CI: 61, 82%) of respondents prescribe a first generation cephalosporin, 25% favor additional coverage with an aminoglycoside and/or Vancomycin. Of those who prescribe a cephalosporin, 33% prescribe a dosage of one gram for all patients and the reminder prescribe up to 2 grams based on body weight. One in three surgeons (95% CI: 25, 48%) believes antibiotics could be discontinued after 24 hours but 40% (95% CI: 30, 53%) continue antibiotics until the suction drain is removed. Given the ongoing uncertainty in evidence to guide best practices, 90% (95% CI: 81, 95%) of respondents agreed that they would change their practice if a large randomized controlled trial showed clear benefit of an antibiotic drug regimen different from what they are currently using. Further support for a clinical trial was observed by an overwhelming surgeon interest (87%; 95% CI: 77, 93%) in participating in a multi-center randomized controlled study. Conclusion The current lack of guidelines for the prescription of prophylactic antibiotics in Musculoskeletal Tumor Surgery has left Orthopaedic Oncologists with varying opinions and practices. The lack of current evidence and strong surgeon support for participating in a definitive study provides strong rationale for clinical trials.

Background: Surgical residency has the reputation of being arduous and stressful. We sought to determine the stress levels of surgical residents, the major causes of stress and the coping mechanisms used.Methods: We developed and distributed a survey among surgical residents across Canada.Results: A total of 169 participants responded: 97 (57%) male and 72 (43%) female graduates of Canadian (83%) or foreign (17%) medical schools. In all, 87% reported most of the past year of residency as somewhat stressful to extremely stressful, with time pressure (90%) being the most important stressor, followed by number of working hours (83%), residency program (73%), working conditions (70%), caring for patients (63%) and financial situation (55%). Insufficient sleep and frequent call was the component of residency programs that was most commonly rated as highly stressful (31%). Common coping mechanisms included staying optimistic (86%), engaging in enjoyable activities (83%), consulting others (75%) and exercising (69%). Mental or emotional problems during residency were reported more often by women (p = 0.006), who were also more likely than men to seek help (p = 0.026), but men reported greater financial stress (p = 0.036). Foreign graduates reported greater stress related to working conditions (p < 0.001), residency program (p = 0.002), caring for family members (p = 0.006), discrimination (p < 0.001) and personal and family safety (p < 0.001) than Canadian graduates.Conclusion: Time pressure and working hours were the most common stressors overall, and lack of sleep and call frequency were the most stressful components of the residency program. Female sex and graduating from a non-Canadian medical school increased the likelihood of reporting stress in certain areas of residency. [ABSTRACT FROM AUTHOR]

Purpose: Guidelines on clinical margins for basal cell carcinoma (BCC) excisions were recently published, yet the ambiguity regarding the margin continues for surgeons and pathologists. The purpose of this study was to determine the incomplete excision rate of BCC, determine the factors associated with incomplete excision, and evaluate the completeness of reporting between surgeon and pathologist., Methods: A single-center retrospective analysis was conducted on pathology reports from single excisions of BCC specimens between January 1, 2019 to December 31, 2020. The primary outcome was the incomplete excision rate (positive margins) as reported by pathologist. Logistic regression was used to determine the relationship between incomplete excision rate and anatomical location, pathologist, and surgeon. The completeness of surgeon pathology requisition forms was evaluated qualitatively., Results: Seven hundred and fifty-six pathology reports were included. The incomplete excision rate was 12% (n = 94). The most common site of incomplete excision was head and neck (n = 87, 15%), followed by trunk (n = 5, 7%), and extremities (n = 2, 2%). Five hundred and seventy-nine specimens from 6 surgeons and 9 pathologists were included in the logistic regression analysis. The Wald test showed that the location was significantly associated with incomplete excision (p < 0.05), whereas surgeon and pathologist reports were not (p > 0.05). Regarding missing information, only 47 (6%) pathology reports included "excision" in the requisition form. Four hundred and three (53%) specimens had no clinical history., Conclusions: The incomplete excision rate found in this study falls within the report range in the literature. Neither surgeon nor pathologist had significant association with incomplete excision. Incomplete excision rate of BCC may be inflated owing to the lack of standardization in requisition form and pathology reporting., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Introduction: Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) for lung cancer staging is operator dependent, resulting in high rates of non-diagnostic lymph node (LN) samples. We hypothesized that an artificial intelligence (AI) algorithm can consistently and reliably predict nodal metastases from the ultrasound images of LNs when compared to pathology., Methods: In this analysis of prospectively recorded B-mode images of mediastinal LNs during EBUS-TBNA, we used transfer learning to build an end-to-end ensemble of three deep neural networks (ResNet152V2, InceptionV3, and DenseNet201). Model hyperparameters were tuned, and the optimal version(s) of each model was trained using 80% of the images. A learned ensemble (multi-layer perceptron) of the optimal versions was applied to the remaining 20% of the images (Test Set). All predictions were compared to the final pathology from nodal biopsies and/or surgical specimen., Results: A total of 2,569 LN images from 773 patients were used. The Training Set included 2,048 LNs, of which 70.02% were benign and 29.98% were malignant on pathology. The Testing Set included 521 LNs, of which 70.06% were benign and 29.94% were malignant on pathology. The final ensemble model had an overall accuracy of 80.63% (95% confidence interval [CI]: 76.93-83.97%), 43.23% sensitivity (95% CI: 35.30-51.41%), 96.91% specificity (95% CI: 94.54-98.45%), 85.90% positive predictive value (95% CI: 76.81-91.80%), 79.68% negative predictive value (95% CI: 77.34-81.83%), and AUC of 0.701 (95% CI: 0.646-0.755) for malignancy., Conclusion: There now exists an AI algorithm which can identify nodal metastases based only on ultrasound images with good overall accuracy, specificity, and positive predictive value. Further optimization with larger sample sizes would be beneficial prior to clinical application., (© 2024 S. Karger AG, Basel.)

Pierre-Robin Sequence (PRS) is a sequence of micrognathia, glossoptosis, and airway obstruction. There is no standardized consensus on the management of respiratory distress for patients with PRS, and operative interventions have associated complications. The purpose of this study is to identify all modalities of non-operative airway intervention for PRS infants. Following PRISMA 2020 guidelines, Embase, Medline, Cochrane, EMCARE, and Web of Science electronic databases were searched from 1992 to 2022 reporting on PRS infants under one year of age who were managed non-operatively. Publications with non-original research designs, an exclusive focus on surgical interventions, case reports, and non-English language articles were excluded. Analysis was performed using non-pooled and pooled proportions (PP). 3280 abstracts were screened, and 88 articles included. Retrospective methodologies were most common. Of the 60 studies where both operative and non-operative interventions were included, 2924 of 4708 PRS infants were administered a non-operative intervention (PP 65.8 % [95%CI 58.5, 72.7]). Reported definitive non-operative interventions, either alone or in combination with another non-operative intervention, included infant positioning (n = 1664), orthodontic appliances (n = 1299), nasopharyngeal tube insertion (n = 983), supplemental oxygen (n = 306), non-invasive ventilation (n = 290), oral airway (n = 46), endotracheal intubation (n = 36), and other (n = 40). The mean MINORS risk of bias score was 6.3 (range 1-12), indicating that the present review was limited by moderate methodological quality for included studies. This is the largest systematic review of non-operative interventions for PRS infants thus far. Most infants are managed non-operatively, with positioning, orthodontic appliances, and nasopharyngeal tubes being the most commonly reported modalities., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: Full-thickness macular holes (FTMH) are defects in the fovea involving all neural retinal layers. They reduce patients' visual acuity (VA) and impact their quality of life. FTMHs are repaired with pars plana vitrectomy (PPV) with intraocular gas tamponade and post-operative face-down positioning (FDP). There is no consensus regarding the ideal positioning requirements following FTMH repair and there lacks clear guidelines on the topic. While analysis of global practice patterns indicates that between 5-7 days is the most common duration suggested by surgeons, there is significant heterogeneity in surgeon preferences. There is, however, biological plausibility to support minimal or even no FDP following surgery and given the disabling nature of FDP for patients, there is a need to better assess key patient outcomes with different FDP durations. As such, this prospective randomized controlled pilot trial will compare 3-days of FDP to 7-days of FDP following PPV for FTMH., Methods: This single-centered, parallel-group randomized controlled pilot trial will randomize patients 1:1 following PPV to 3 days or 7 days of FDP. This investigation has been approved by the local ethics board (HiREB # 16100) and has been registered on clinicaltrials.gov (NCT06000111). The primary objective will be focused on assessing the feasibility of a larger trial; this will be determined through an assessment of the recruitment rate, retention rate, completion rate and recruitment time. The secondary outcomes involve assessment of the following patient-important outcomes a) macular hole closure rate, b) best-recorded VA, c) a general quality of life measure and vision-specific quality of life measure, d) patient compliance and e) complication rates. Outcomes will be evaluated at 3 months following surgery., Discussion: The results of this pilot study will determine the feasibility of a larger-scale trial that will answer a patient important question with clinical equipoise., Competing Interests: KN: Dr. Nanji has no conflicts of interest to disclose. PO: Dr. Oquendo has no conflicts of interest to disclose. SS: Dr. Srinivasan has no conflicts of interest to disclose. CV: Dr. Vyas has no conflicts of interest to disclose. FP: Dr. Prasad has no conflicts of interest to disclose. FF: Dr. Farrohkhyar has no conflicts of interest to disclose. VC: Dr. Chaudhary reports acting as an advisory board member, grants and other from Novartis, acting as an advisory board member, grants and other from Bayer, grants from Allergan, and acting as an advisory board member, and grants from Roche. The conflicts of interest disclosed as part of the submission do not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Nanji et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: This study aimed to assess the impact of the implementation of legally sanctioned supervised consumption sites (SCS) in the Canadian province of Ontario on opioid-related deaths, emergency department (ED) visits and hospitalisations at the public health unit (PHU) level., Methods: Monthly rates per 100,000 population of opioid-related deaths, ED visits and hospitalisations for PHUs in Ontario between December 2013 and March 2022 were collected. Aggregated and individual analyses of PHUs with one or more SCS were conducted, with PHUs that instituted an SCS being matched to control units that did not. Autoregressive integrated moving average models were used to estimate the impact of SCS implementation on opioid-related deaths, ED visits and hospitalisations., Results: Twenty-one legally sanctioned SCS were implemented across nine PHUs in Ontario during the study period. Interrupted time series analyses showed no statistically significant changes in opioid-related death rates in aggregated analyses of intervention PHUs (increase of 0.02 deaths/100,000 population/month; p = 0.27). Control PHUs saw a significant increase of 0.38 deaths/100,000 population/month; p < 0.001. No statistically significant changes were observed in the rates of opioid-related ED visits in intervention PHUs (decrease of 0.61 visits/100,000 population/month; p = 0.39) or controls (increase of 0.403 visits; p = 0.76). No statistically significant changes to the rates of opioid-related hospitalisations were observed in intervention PHUs (0 hospitalisations/100,000 population/month; p = 0.98) or controls (decrease of 0.05 hospitalisations; p = 0.95)., Discussion and Conclusions: This study did not find significant mortality or morbidity effects associated with SCS availability at the population level in Ontario. In the context of a highly toxic drug supply, additional interventions will be required to reduce opioid-related harms., (© 2024 The Author(s). Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Objective: To determine whether targeted sampling (TS), which omits biopsy of triple- normal lymph nodes (LNs) on positron emission tomography, computed tomography, and endobronchial ultrasound (EBUS), is noninferior to systematic sampling (SS) of mediastinal LNs during EBUS for staging of patients with early-stage non-small cell lung cancer (NSCLC)., Methods: Patients who are clinical nodal (cN)0-N1 with suspected NSCLC eligible for EBUS based on positron emission tomography/computed tomography were enrolled in this prospective, multicenter trial. During EBUS, all patients underwent TS and then crossed over to SS, whereby at least 3 mediastinal LN stations (4R, 4L, 7) were routinely sampled. Gold standard of comparison was pathologic results. Based on the previous feasibility trial, a noninferiority margin of 6% was established for difference in missed nodal metastasis (MNM) incidence between TS and SS. The McNemar test on paired proportions was used to determine MNM incidence for each sampling method. Analysis was per-protocol using a level of significance of P < .05., Results: Between November 2020 and April 2022, 91 patients were enrolled at 6 high-volume Canadian tertiary care centers. A total of 256 LNs underwent TS and SS. Incidence of MNM was 0.78% in SS and 2.34% in TS, with an absolute difference of 1.56% (95% confidence interval, -0.003% to 4.1%; P = .13). This falls within the noninferiority margin. A total of 6/256 LNs from 4 patients who were not sampled by TS were found to be malignant when sampled by SS., Conclusions: In high-volume thoracic endosonography centers, TS is not inferior to SS in nodal staging of early-stage NSCLC. This results in change of clinical management for a minority of patients., Competing Interests: Conflict of Interest Statement Dr Turner serves on an advisory board and has received speaker honoraria from Astra Zeneca. Dr Yasufuku has received unrestricted grants from Olympus Medical Systems for continuing medical education. Dr Hanna serves on an advisory board for AstraZeneca, data safety committee for Roche/Genentech, and speaker’s bureau for Minogue Medical. Dr Nayak has received speaker honoraria from Merck and Co. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Endobronchial ultrasound elastography produces a color map of mediastinal lymph nodes, with the color blue (level 60) indicating stiffness. Our pilot study demonstrated that predominantly blue lymph nodes, with a stiffness area ratio greater than 0.496, are likely malignant. This large-scale study aims to validate this stiffness area ratio compared with pathology., Methods: This is a single-center prospective clinical trial where B-mode ultrasound and endobronchial ultrasound elastography lymph node images were collected from patients undergoing endobronchial ultrasound transbronchial needle aspiration for suspected or diagnosed non-small cell lung cancer. Images were fed to a trained deep neural network algorithm (NeuralSeg), which segmented the lymph nodes, identified the percent of lymph node area above the color blue threshold of level 60, and assigned a malignant label to lymph nodes with a stiffness area ratio above 0.496. Diagnostic statistics and receiver operating characteristic analyses were conducted. NeuralSeg predictions were compared with pathology., Results: B-mode ultrasound and endobronchial ultrasound elastography lymph node images (n = 210) were collected from 124 enrolled patients. Only lymph nodes with conclusive pathology results (n = 187) were analyzed. NeuralSeg was able to predict 98 of 143 true negatives and 34 of 44 true positives, resulting in an overall accuracy of 70.59% (95% CI, 63.50-77.01), sensitivity of 43.04% (95% CI, 31.94-54.67), specificity of 90.74% (95% CI, 83.63-95.47), positive predictive value of 77.27% (95% CI, 64.13-86.60), negative predictive value of 68.53% (95% CI, 64.05-72.70), and area under the curve of 0.820 (95% CI, 0.758-0.883)., Conclusions: NeuralSeg was able to predict nodal malignancy based on endobronchial ultrasound elastography lymph node images with high area under the receiver operating characteristic curve and specificity. This technology should be refined further by testing its validity and applicability through a larger dataset in a multicenter trial., Competing Interests: A.A.G.: ACLIP LLC (Owner/Co-Owner Founder/Co-Founder, Ownership Interest (stocks, stock options, patent or other intellectual property or other ownership interest excluding diversified mutual funds)), NeuralSeg Ltd (Owner/Co-Owner Founder/Co-Founder). W.C.H.: Hamilton Academic Health Sciences Organization AFP Innovation Grant, Advisory Board and Speakers Bureau AstraZeneca, Data Safety Monitoring Committee for Roche/Genentech, Speakers Bureau for Minogue Medical, and Grant Funding from Intuitive Surgical. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (© 2024 The Author(s).)

Background: Infections after elective colorectal surgery remain a significant burden for patients and the healthcare system. Adult studies suggest that the combination of oral antibiotics and mechanical bowel preparation is effective at reducing infections after colorectal surgery. In children, there is limited evidence for either of these practices and the utility of combining oral antibiotics with mechanical bowel preparation remains uncertain., Methods: This study aims to determine the feasibility of conducting a randomized controlled trial assessing the efficacy of oral antibiotics, with or without mechanical bowel preparation, in reducing the rates of post-operative infection in pediatric colorectal surgery. Participants aged 3 months to 18 years undergoing elective colorectal surgery will be randomized pre-operatively to one of three trial arms: (1) oral antibiotics; (2) oral antibiotics and mechanical bowel preparation; or (3) standard care. Twelve patients will be included in each trial arm. Feasibility outcomes of interest include the rate of participant recruitment, post-randomization exclusions, protocol deviations, adverse events, and missed follow-up appointments. Secondary outcomes include the rate of post-operative surgical site infections, length of hospital stay, time to full enteral feeds, reoperation, readmission, and complications., Discussion: If the results of this trial prove feasible, a multi-center trial will be completed with sufficient power to evaluate the optimal pre-operative bowel preperation for pediatric patients undergoing elective colorectal surgery., Trial Registration: ClinicalTrials.gov: NCT03593252., (© 2024. The Author(s).)

Background: Trigeminal neuralgia (TN) is a debilitating disease with an annual incidence of approximately 4-27/100,000. In Ontario, over 2000 patients receive interventions for profound pain, including medical and surgical therapies. The global expected cost of these approaches is unknown. This study aims to analyze the cost-effectiveness of one surgical therapy, microvascular decompression (MVD), compared with the best medical therapy (carbamazepine) as first-line therapy., Methods: Costs were gathered from the Canadian Institute for Health Information, Ontario Drug Benefit Formulary, and Ontario Ministry of Health Schedule of Benefits for Physician Services. Academic literature was used to estimate unavailable items. A cost-benefit Markov model was created for each strategy with literature-based rates for annual cycles from years 1 to 5, followed by a linear recurrent cycle from years 6 to 10. Incremental cost-effectiveness ratios (ICERs) were calculated based on the incremental cost in 2022 Canadian Dollars (CAD) per pain-free year., Results: Base case cost per patient was $10,866 at 10 years in the "MVD first" group and $10,710 in the "carbamazepine first" group. Ten-year ICER was $1,104 for "MVD first," with strict superiority beyond this time point. One-way deterministic sensitivity analysis for multiple factors suggested the highest cost variability and ICER variability were due to surgery cost, medication failure rate, and medication cost., Conclusion: Economic benefit is established for a "MVD first" strategy in the Ontario context with strict superiority beyond the 10-year horizon. If a cost-effectiveness threshold of $50,000 per pain-controlled year is used, the benefit is established at 4 years., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Surgical Neurology International.)

Background: Cerebellar mutism (CM) is characterized by a significant loss of speech in children following posterior fossa (PF) surgery. The biological origin of CM remains unclear and is the subject of ongoing debate. Significant recovery from CM is less likely than previously described despite rigorous multidisciplinary neuro-rehabilitational efforts., Methods: A national multi-centered retrospective review of all children undergoing PF resection in four midsized Canadian academic pediatric institutions was undertaken. Patient, tumor and surgical factors associated with the post-operative development of CM were reviewed. Retrospective identification of PF surgery patients including those developing and those that did not (internal control)., Results: The study identified 258 patients across the 4 centers between 2010 and 2020 (mean age 6.73 years; 42.2% female). Overall, CM was experienced in 19.5% of patients (N = 50). Amongst children who developed CM histopathology included medulloblastoma (35.7%), pilocytic astrocytoma (32.6%) and ependymoma (17.1%). Intraoperative impression of adherence to the floor of the 4th ventricle was positive in 36.8%. Intraoperative abrupt changes in blood pressure and/or heart rate were identified in 19.4% and 17.8% of cases. The clinical resolution of CM was rated to be complete, significant resolution, slight improvement, no improvement and deterioration in 56.0%, 8.0%, 20.0%, 14.0% and 2.0%, respectively. In the cohort of children who experienced post-operative CM as compared to their no-CM counterpart, proportionally more tumors were felt to be adherent to the floor of the 4th ventricle (56.0% vs 49.5%), intraoperative extent of resection was a GTR (74% vs 68.8%) and changes in heart rate were noted (≥ 20% from baseline) (26.0% vs 15.9%). However, a multiple regression analysis identified only abrupt changes in HR (OR 5.97, CI (1.53, 23.1), p = 0.01) to be significantly associated with the development of post-operative CM., Conclusion: As a devastating surgical complication after posterior fossa tumor surgery with variable clinical course, identifying and understanding the operative cues and revising intraoperative plans that optimizes the child's neurooncological and clinical outcome are essential., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Limited research exists regarding the impact of neuroimaging on endovascular thrombectomy (EVT) decisions for late-window cases of large vessel occlusion (LVO) stroke., Objective: T0 assess whether perfusion CT imaging: (1) alters the proportion of recommendations for EVT, and (2) enhances the reliability of EVT decision-making compared with non-contrast CT and CT angiography., Methods: We conducted a survey using 30 patients drawn from an institutional database of 3144 acute stroke cases. These were presented to 29 Canadian physicians with and without perfusion imaging. We used non-overlapping 95% confidence intervals and difference in agreement classification as criteria to suggest a difference between the Gwet AC1 statistics (κ G )., Results: The percentage of EVT recommendations differed by 1.1% with or without perfusion imaging. Individual decisions changed in 21.4% of cases (11.3% against EVT and 10.1% in favor). Inter-rater agreement (κ G ) among the 29 raters was similar between non-perfusion and perfusion CT neuroimaging (κ G =0.487; 95% CI 0.327 to 0.647 and κ G =0.552; 95% CI 0.430 to 0.675). The 95% CIs overlapped with moderate agreement in both. Intra-rater agreement exhibited overlapping 95% CIs for all 28 raters. κ G was either substantial or excellent (0.81-1) for 71.4% (20/28) of raters in both groups., Conclusions: Despite the minimal difference in overall EVT recommendations with either neuroimaging protocol one in five decisions changed with perfusion imaging. Regarding agreement we found that the use of automated CT perfusion images does not significantly impact the reliability of EVT decisions for patients with late-window LVO., Competing Interests: Competing interests: JWBD: Honoraria from Medtronic. Travel grant fromMicrovention; MAA: Member of the scientific advisory board of Palmera Medical;TRM: Principal of eVasc Neurovascular., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To collect information on the current equity, diversity, and inclusion (EDI) landscape at Canadian ophthalmology academic centres., Design: Cross-sectional survey., Participants: Faculty representatives from 15 accredited Canadian ophthalmology postgraduate training programs and 57 ophthalmology resident survey respondents., Method: A three-phase virtual EDI initiative was conducted by the Association of Canadian University Professors of Ophthalmology in 2021. A qualitative survey of Canadian academic ophthalmology programs and an anonymous survey of Canadian ophthalmology residents were completed., Results: All Canadian ophthalmology programs provided information on their current EDI strategies, yielding a response rate of 100%. The majority (73%) of Canadian academic ophthalmology centres identified as being in the beginning stages of building an EDI framework. Of the 57 responding resident physicians, 44% identified as a woman and 51% as a visible minority. There were no respondents who identified as Indigenous. Three respondents identified as having a disability per the Accessible Canada Act. Most respondents either agreed or strongly agreed that their programs are equal opportunity providers (80%), trustworthy (72%), respectful (74%), and of diverse opinions and ideas (71%). There were no statistically significant associations between responses to EDI questions and gender across population groups., Conclusions: Most Canadian ophthalmology academic centres are in the beginning stages of implementing EDI initiatives. Multiple priorities have been identified as areas for improvement, such as increasing EDI education for patients, learners, and physicians, and implementing EDI policies in selection and recruitment., (Crown Copyright © 2022. Published by Elsevier Inc. All rights reserved.)

Introduction: Tarlov cysts (TC) are sacral perineural cysts that are often found incidentally during spinal imaging. In a small fraction, symptomatic TC can cause pain, bowel, bladder and/or sexual dysfunction, as well as motor and sensory deficits. While many surgeons regard TCs as a non-operative entity, there have been suggestions that operative intervention in carefully selected symptomatic patients may be beneficial. The aim of this meta-analysis is to identify whether surgical treatment for symptomatic TCs is beneficial with an acceptable complication profile. Materials and methods: The authors conducted a systematic outcome analysis of symptomatic TCs treated either with surgery or conservatively managed. Results: Sixteen studies (N = 238) met the inclusion criteria for final meta-analysis. The literature search was performed using PubMed, Ovid MEDLINE, CINAHL, and EMBASE databases up to September 2017 and with an updated search in April 2019. The post-operative complication rate in patients undergoing surgical intervention was 16.9 (11.8 to 22.7) and cyst recurrence was 8.5 (3.5 to 15.4). When a complication occurred, the most frequent complication of surgical intervention was the development of a surgical site infection and/or CSF leak. Of the 15 studies reporting long-term follow-up, 81.0 (74.0-88.0) of patients remained symptom-free for more than 1 year (Mean: 27.5 months, SD = 11.5). Conclusion: We rigorously analyse the efficacy of open surgical decompression and repair of symptomatic TCs and corroborate the findings of sustained long-term resolution of symptoms.

Background: Guidelines recommend the use of perfusion computed tomography (CT) to identify emergent large vessel ischemic stroke (ELVIS) patients who are likely to benefit from endovascular thrombectomy (EVT) if they present within 6-24 hour (late window) of stroke onset. We aim to determine if the interrater and intrarater reliability among physicians when recommending EVT is significantly different when perfusion CT or non-perfusion CT is reviewed., Methods: A total of 30 non-consecutive patients will be selected from our institutional database comprising 3144 cranial CT scans performed for acute stroke symptoms January 2018 to August 2022. The clinical and radiologic data of the 30 patients will be presented in random order to a group of 29 physicians in two separate sessions at least three weeks apart. In each session, the physicians will evaluate each patient once with automated perfusion images and once without. We will use non-overlapping 95% confidence intervals and difference in agreement classification as criteria to suggest a difference between the Gwet AC1 statistics (κG)., Discussion: The results obtained from this study, combined with the clinical outcomes data of patients categorized through the two imaging techniques and a cost-effectiveness analysis, will offer a comprehensive evaluation of the clinical utility of perfusion CT neuroimaging. Should there be no significant disparity in the reliability of decisions made by clinicians using the two neuroimaging protocols, it may be necessary to revise existing recommendations regarding neuroimaging in the later time window to align with these findings., Competing Interests: JBD: Honoraria from Medtronic. Travel grant from Microvention RF: Conflict of Interest: None. Disclosure of Funding: None. AB: Conflict of Interest: None. Disclosure of Funding: None. ATO: Conflict of Interest: None. Disclosure of Funding: None. VMP: Conflict of Interest: None. Disclosure of Funding: None. JS: Conflict of Interest: None. Disclosure of Funding: None. TRM: Principal of eVasc Neurovascular PD: Conflict of Interest: None. Disclosure of Funding: None. SS: Conflict of Interest: None. Disclosure of Funding: None. FF: Conflict of Interest: None. Disclosure of Funding: None. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Diestro et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Traumatic brain injury (TBI) is a complex condition where heterogeneity impedes the advancement of care. Understanding the diverse presentations of TBI is crucial for personalized medicine. Our study aimed to identify clinically relevant patient endotypes in TBI using latent class analysis based on comorbidity data. We used the Medical Information Mart for Intensive Care III database, which includes 2,629 adult TBI patients. We identified five stable endotypes characterized by specific comorbidity profiles: Heart Failure and Arrhythmia, Healthy, Renal Failure with Hypertension, Alcohol Abuse, and Hypertension. Each endotype had distinct clinical characteristics and outcomes: The Heart Failure and Arrhythmia endotype had lower survival rates than the Renal Failure with Hypertension despite featuring fewer comorbidities overall. Patients in the Hypertension endotype had higher rates of neurosurgical intervention but shorter stays in contrast to the Alcohol Abuse endotype which had lower rates of neurosurgical intervention but significantly longer hospital stays. Both endotypes had high overall survival rates comparable to the Healthy endotype. Logistic regression models showed that endotypes improved the predictability of survival compared to individual comorbidities alone. This study validates clinical endotypes as an approach to addressing heterogeneity in TBI and demonstrates the potential of this methodology in other complex conditions., (© 2024. The Author(s).)

Background: Guidelines recommend the treatment of emergent large vessel ischemic stroke (ELVIS) patients presenting beyond 6 hours of last known well time with endovascular thrombectomy (EVT) based on perfusion computed tomography (CT) neuroimaging. We compared the outcomes (long-term good clinical outcomes, symptomatic intracranial hemorrhage (sICH), and mortality) of ELVIS patients according to the type of CT neuroimaging they underwent., Methods: We searched the following databases: Medline, Embase, CENTRAL, and Scopus from January 1, 2015, to June 14, 2023. We included studies of late-presenting ELVIS patients undergoing EVT that had with data for non-perfusion and perfusion CT neuroimaging. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data were pooled using a random effects model., Results: We found 7 observational cohorts. Non-perfusion versus perfusion CT was not statistically significantly different for both long-term clinical (n = 3,224; RR: 0.96; 95% CI 0.86 to 1.06; I2 = 18%) and sICH (n = 3,724; RR: 1.08 95% CI 0.60 to 1.94; I2 = 76%). Perfusion CT had less mortality (n = 3874; RR: 1.22; 95% CI 1.07 to 1.40; I2 = 0%). The certainty of these findings is very low because of limitations in the risk of bias, indirectness, and imprecision domains of the Grading of Recommendations, Assessment, Development and Evaluations., Conclusion: The use of either non-perfusion or perfusion CT neuroimaging may have little to no effect on long-term clinical outcomes and sICH for late-presenting EVT patients. Perfusion CT neuroimaging may be associated with a reduced the risk of mortality. Evidence uncertainty warrants randomized trial data., Competing Interests: The authors have declared that no competing interests exist in relation to this particular work., (Copyright: © 2024 Diestro et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)