Search

Background: General surgeons play an important role in the provision of trauma care in Canada and the current extent of their trauma experience during training is unknown. We sought to quantify the operative and nonoperative educational experiences among Canadian general surgery trainees. Methods: We conducted a multicentre retrospective study of major operative exposures experienced by general surgery residents, as identified using institutional trauma registries and subsequent chart-level review, for 2008-2018. We also conducted a site survey on trauma education and structure. Results: We collected data on operative exposure for general surgery residents from 7 programs and survey data from 10 programs. Operations predominantly occurred after hours (73% after 1700 or on weekends) and general surgery residents were absent from a substantial proportion (25%) of relevant trauma operations. The structure of trauma education was heterogeneous among programs, with considerable site-specific variability in the involvement of surgical specialties in trauma care. During their training, graduating general surgery residents each experienced around 4 index trauma laparotomies, 1 splenectomy, 1 thoracotomy, and 0 neck explorations for trauma. Conclusion: General surgery residents who train in Canada receive variable and limited exposure to operative and nonoperative trauma care. These data can be used as a baseline to inform the application of competency-based medical education in trauma care for general surgery training in Canada. Contexte : Les chirurgiennes et chirurgiens g n ralistes jouent un r le important dans la prestation de soins de traumatologie au Canada, et l' tendue actuelle de leur exp rience en traumatologie durant la formation est inconnue. Nous avons voulu quantifier les exp riences p dagogiques op ratoires et non op ratoires chez les stagiaires en chirurgie g n rale du Canada. M thodes : Nous avons men une tude r trospective multicentrique sur les expositions op ratoires majeures que vivent les r sidentes et r sidents en chirurgie g n rale, rep r es dans les registres de traumatologie des tablissements et dans le cadre d'un examen subs quent des dossiers, pour la p riode de 2008-2018. Nous avons aussi men une enqu te sur la formation en traumatologie et la structure de celle-ci. R sultats : Nous avons recueilli des donn es sur l'exposition op ratoire des r sidentes et r sidents en chirurgie g n rale de 7 programmes ainsi que des donn es d'enqu te de 10 programmes. Les interventions chirurgicales avaient principalement lieu en dehors des heures normales (73% apr s 17h ou la fin de semaine), et les r sidentes et r sidents taient absents d'une proportion consid rable (25%) des interventions de traumatologie pertinentes. La structure de la formation sur le sujet tait h t rog ne entre les programmes, avec une importante variation d'un tablissement l'autre dans la participation des sp cialit s chirurgicales dans les soins de traumatologie. Durant leur formation, les r sidentes et r sidents en chirurgie g n rale qui terminaient leurs tudes avaient chacun particip environ 4 laparotomies initiales de traumatologie, 1 spl nectomie, 1 thoracotomie et 0 exploration du cou pour un trauma. Conclusion : Les r sidentes et r sidents en chirurgie g n rale form s au Canada sont expos s de fa on variable et limit e aux soins de traumatologie op ratoires et non op ratoires. Ces donn es peuvent servir de valeur de r f rence pour orienter l'application d'une formation m dicale fond e sur les comp tences en traumatologie dans la formation en chirurgie g n rale au Canada., Traumatic injury is the leading cause of death and disability for Canadians aged 1-44 years. (1) Care for the trauma patient is provided by a multitude of providers, most notably [...]

Background: Access to the operating room (OR) is variable among emergency general surgery (EGS) services, with some having dedicated EGS ORs, and others only a shared queue. Currently in Canada, only a limited number of acute care surgery services have dedicated daytime operating room (OR) access; hence, we aimed to describe the burden of after-hours EGS operating in Canada and differences associated with OR access. Methods: In this multicentre retrospective cohort study, we used data from a previously conducted study designed to evaluate nonappendiceal, nonbiliary disease across 8 Canadian hospitals. We performed a secondary analysis to describe booking priorities and timing of operative interventions, compare sites with and without access to a dedicated EGS daytime OR, and identify differences in morbidity and mortality based on timing of operative intervention. Results: Among 1244 patients, operations were performed during weekday daytime in 521 cases (41.9%), in the evening in 279 (22.4%), on the weekend in 293 (23.6%) and overnight in 151 (12.1%). Operating room booking priority was more than 2 hours to 8 hours in 657 cases (52.8%), more than 8 hours to 24 hours in 334 (26.9%) and more than 24 hours to 48 hours in 253 (20.3%). Substantial variation in booking priority was observed for the same preoperative diagnoses. Sites with dedicated EGS ORs performed a greater proportion of cases during daytime versus overnight compared to sites without dedicated EGS ORs (198/237 [83.5%] v. 323/435 [74.2%], p = 0.006). No significant differences in outcome were found between cases performed during the daytime, evening and overnight. Conclusion: We found considerable variation in OR booking priority within the same preoperative diagnoses among EGS patients in Canada. Sites with dedicated EGS ORs performed more cases during weekday daytime compared to sites without dedicated EGS ORs; however, this study showed no evidence of compromised outcomes based on OR timing. Contexte : Tous les services de chirurgie générale d'urgence (CGU) n'ont pas le même accès aux blocs opératoires (BO). Certains ont des BO dédiés, d'autres doivent se placer dans une file d'attente partagée. ?€ l'heure actuelle, au Canada, seul un nombre limité de services de chirurgie d'urgence disposent de BO dédiés accessibles durant le jour. Nous avons donc voulu décrire le fardeau imposé aux services de CGU qui doivent opérer en dehors des heures régulières au Canada et les différences d'accès aux BO. Méthodes : Dans cette étude de cohorte multicentrique rétrospective, nous avons utilisé les données d'une étude précédente qui a porté sur des cas non liés à l'appendicite ou à la cholécystite dans 8 hôpitaux canadiens. Nous avons procédé à une analyse secondaire afin de décrire les priorités d'inscription et le moment des chirurgies, comparer les établissements pourvus ou non d'un accès à des BO dédiés pour les CGU durant le jour, et établir les différences de morbidité et de mortalité selon le moment des interventions. Résultats : Sur un total de 1244 cas, les opérations ont été effectuées un jour de semaine et durant le jour dans 521 cas (41,9 %), le soir dans 279 cas (22,4 %), un jour de fin de semaine dans 293 cas (23,6 %) et la nuit dans 151 cas (12,1 %). La priorité d'inscription aux BO était de plus de 2 heures à 8 heures dans 657 cas (52,8 %), de plus de 8 heures à 24 heures dans 334 cas (26,9 %) et de plus de 24 heures à 48 heures dans 253 cas (20,3 %). On a observé une variation substantielle des priorités d'inscription pour de mêmes diagnostics préopératoires. Les hôpitaux pourvus de BO dédiés pour les CGU ont pris en charge un plus grand nombre de cas durant le jour plutôt que la nuit, comparativement aux établissements dépourvus de BO dédiés aux CGU (198/237 [83,5 %] c. 323/435 [74,2 %], p = 0,006). On n'a observé aucune différence en ce qui concerne l'issue des interventions selon qu'elles avaient eu lieu le jour, le soir ou la nuit. Conclusion : Nous avons constaté une variation substantielle des priorités d'inscription aux BO pour les mêmes diagnostics préopératoires dans les cas de CGU au Canada. Les établissements pourvus de BO dédiés pour les CGU ont opéré un plus grand nombre de cas les jours de semaine durant le jour que les établissements dépourvus de BO dédiés aux CGU; par contre, cette étude n'a mis au jour aucune complication associée au moment d'utilisation des BO., Despite widespread implementation of the acute care surgery (ACS) model, after-hours emergency general surgery (EGS) care accounts for a sizeable proportion of the ACS workload in Canada. Although the ACS [...]

IntroductionOver the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs).MethodsThis multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability.Results1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well.ConclusionThis validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes.Level of evidencePrognostic/Epidemiologic retrospective multicenter trial, level III.

Background: The risk of death after a postoperative complication--known as failure to rescue (FTR)--has been proposed to be superior to traditional benchmarking outcomes, such as complication and mortality rates, as a measure of system quality. The purpose of this study was to identify the current FTR rate in emergency general surgery (EGS) centres across Canada. We hypothesized that substantial variability exists in FTR rates across centres. Methods: In this multicentre retrospective cohort study, we performed a secondary analysis of data from a previous study designed to evaluate operative intervention for nonappendiceal, nonbiliary disease by 6 EGS services across Canada (1 in British Columbia, 1 in Alberta, 3 in Ontario and 1 in Nova Scotia). Patients underwent surgery between Jan. 1 and Dec. 31, 2014. We conducted univariate analyses to compare patients with and without complications. We performed a sensitivity analysis examining the mortality rate after serious complications (Clavien-Dindo score 3 or 4) that required a surgical intervention or specialized care (e.g., admission to intensive care unit). Results: A total of 2595 patients were included in the study cohort. Of the 206 patients who died within 30 days, 145 (70.4%) experienced a complication before their death. Overall, the mortality rate after any surgical complication (i.e., FTR) was 16.0%. Ranking of sites by the traditional outcomes of complication and mortality rates differed from the ranking when FTR rate was included in the assessment. Conclusion: There was variability in FTR rates across EGS services in Canada, which suggests that there is opportunity for ongoing quality-improvement efforts. This study provides FTR benchmarking data for Canadian EGS services. Contexte : On a propose que le risque de deces apres une complication postoperatoire--appele << echec de sauvetage >>--pourrait s'averer une mesure plus pertinente de la qualite du systeme de sante que les indicateurs comparatifs traditionnels, comme les taux de complications et de mortalite. Cette etude visait a determiner le taux reel d'echec de sauvetage dans les centres de chirurgies generales d'urgence (CGU) au Canada. Notre hypothese etait que ce taux varie grandement d'un centre a l'autre. Methodes : Dans le cadre de cette etude de cohorte retrospective multicentrique, nous avons realise une analyse secondaire des donnees issues d'une etude anterieure, dont l'objectif etait d'evaluer les interventions chirurgicales relatives a des atteintes ne touchant ni l'appendice ni la vesicule biliaire effectuees par 6 centres de CGU au Canada (1 en Colombie-Britannique, 1 en Alberta, 3 en Ontario et 1 en Nouvelle-Ecosse). Ces interventions ont eu lieu du 1er janvier au 31 decembre 2014. Nous avons compare les 2 categories de patients--avec complications et sans complications--au moyen d'analyses univariees. Nous avons aussi mene une analyse de sensibilite con-cernant le taux de mortalite apres des complications graves (3 ou 4 selon la classification de Clavien-Dindo) qui ont necessite une intervention chirurgicale ou des soins specialises (par exemple, une admission en soins intensifs). Resultats : L'etude a porte sur un total de 2595 patients. Sur les 206 patients decedes dans les 30 jours, 145 (70,4 %) ont eu une complication avant leur deces. Globalement, le taux de mortalite apres une complication postoperatoire (soit le taux d'echec de sauvetage) etait de 16,0 %. Le classement des centres avec les indicateurs traditionnels (taux de complications et de mortalite) n'etait pas le meme une fois pris en compte le taux d'echec de sauvetage. Conclusion : Le taux d'echec de sauvetage varie d'un centre de CGU a l'autre au pays, ce qui laisse croire qu'une amelioration continue de la qualite reste possible. Cette etude fournit des donnees de reference sur les taux d'echec de sauvetage aux centres de CGU au Canada., Emergency general surgery (EGS) conditions present a substantial health care burden, accounting for 7% of all hospital admissions in the United States. (1) About 25% of patients admitted with an [...]

Background: The federal Cannabis Act came into force on Oct. 17, 2018, in Canada, making Canada only the second country in the world to legalize the cultivation, acquisition, possession and consumption of cannabis and its by-products. This provided a unique opportunity to evaluate the impact of this legislation on drug-related trauma. Methods: We performed a prospective observational study on the use of cannabis and other illicit drugs in the trauma population at a lead Canadian trauma centre in London, Ontario, in the 3 months before (July 1 to Sept. 30, 2018) and 3 months after (Nov. 1, 2018, to Jan. 31, 2019) the legalization of cannabis in Canada. We defined cannabis use as a positive cannabinoid screen result at the time of assessment by the trauma team. We also screened for opioids, amphetamines and cocaine. Results: A total of 210 patients were assessed by our trauma service between July 1 and Sept. 30, 2018, and 141 patients were assessed between Nov. 1, 2018, and Jan. 31, 2019. Motor vehicle collisions were the most common cause of trauma both before (101 [48.1%]) and after (67 [47.5%]) legalization. The mean Injury Severity Score was 17.6 (standard deviation [SD] 13.0) and 19.7 (SD 14.8), respectively. Drug screens were done in 88 patients (41.9%) assessed before legalization and 99 patients (70.2%) assessed after legalization. There was no difference in the rate of positive cannabinoid screen results before and after legalization (22 [25%] v. 22 [22%]). There was a trend toward higher rates of positive cannabinoid screen results (2/10 [20%] v. 5/8 [62%]) and positive toxicology screen results (5/10 [50%] v. 6/8 [75%]) after legalization among patients with penetrating trauma, but our sample was too small to achieve statistical significance. Conclusion: We found no difference in the rates of positive cannabinoid screen results among patients assessed at our trauma centre in the 3 months before and the 3 months after legalization of cannabis; however, there was a trend toward an increase in the rates of positive results of toxicology screens and cannabinoid screens among those with penetrating trauma. These preliminary single-centre data showing no increased rates of cannabis use in patients with trauma after legalization are reassuring. Contexte: La Loi federate sur le cannabis est entree en vigueur ici le 17 octobre 2018, faisant du Canada le second pays a legaliser la culture, l'acquisition, la possession et la consommation du cannabis et de ses produits derives. Cette situation fournit une occasion unique d'evaluer l'impact de cette loi sur les traumatismes lies aux drogues. Methodes: Nous avons procede a une etude d'observation prospective sur la con-sommation du cannabis et d'autres drogues illicites chez une population de victimes de traumatismes dans un grand centre canadien de traumatologie de London, en Ontario, au cours des 3 mois precedant (1er juillet au 30 septembre 2018) et des 3 mois suivant (1er novembre 2018 au 31 janvier 2019) la legalisation du cannabis au Canada. La consommation de cannabis etait confirmee par l'obtention de resultats positifs aux tests de depistage des cannabino'ides demandes par l'equipe de traumatologie. Nous avons aussi effectue un depistage des opio'ides, des amphetamines et de la cocaine. Resultats: En tout, notre service de traumatologie a vu 210 patients entre le 1er juillet et le 30 septembre 2018, et 141 entre le 1er novembre 2018 et le 31 janvier 2019. Les accidents de la route ont ete la plus frequente cause de traumatisme avant (101 [48,1 %]) et apres (67 [47,5 %]) la legalisation. L'indice moyen de gravite des blessures a ete de 17,6 (ecart-type [E.-T.] 13,0) et 19,7 (E.-T. 14,8), respectivement. Un depistage de drogues a ete effectue chez 88 patients (41,9 %) vus avant la legalisation et chez 99 patients (70,2 %) vus apres la legalisation. On n'a observe aucune difference quant aux taux de resultats positifs aux tests de depistage des cannabino'ides enregistres avant et apres la legalisation (22 [25 %] c. 22 [22 %]). Les taux de resultats positifs aux tests de depistage des cannabino'ides (2/10 [20 %] c. 5/8 [62 %]) et aux tests toxicologiques (5/10 [50 %] c. 6/8 [75 %]) ont eu tendance a etre plus eleves apres la legalisation chez les patients victimes de traumatismes penetrants, mais notre echantillon etait trop petit pour atteindre une portee statistique. Conclusion: Nous n'avons observe aucune difference quant aux taux de resultats positifs au depistage des cannabino'des au cours des 3 mois precedant et suivant la legalisation du cannabis; par contre, les taux de resultats positifs aux tests de depistage des drogues et du cannabis ont eu tendance a etre plus eleves chez les victimes de trau-matismes penetrants. Ces donnees preliminaires provenant d'un seul centre qui ne montrent pas d'augmentation des taux de consommation de cannabis chez les poly-traumatises sont rassurantes., On Oct. 17, 2018, the federal Cannabis Act came into force in Canada, making this country only the second country in the world to legalize the cultivation, acquisition, possession and [...]

Background: Most of the literature on emergency general surgery (EGS) has investigated appendiceal and biliary disease; however, EGS surgeons manage many other complex conditions. This study aimed to describe the operative burden of these conditions throughout Canada. Methods: This multicentre retrospective cohort study evaluated EGS patients at 7 centres across Canada in 2014. Adult patients (aged > 18 yr) undergoing nonelective operative interventions for nonbiliary, nonappendiceal diseases were included. Data collected included information on patients' demographic characteristics, diagnosis, procedure details, complications and hospital length of stay. Logistic regression was used to identify predictors of morbidity and mortality. Results: A total of 2595 patients were included, with a median age of 60 years (interquartile range 46-73 yr). The most common principal diagnoses were small bowel obstruction (16%), hernia (15%), malignancy (11 %) and perianal disease (9%). The most commonly performed procedures were bowel resection (30%), hernia repair (15%), adhesiolysis (11%) and debridement of skin and soft tissue infections (10%). A total of 47% of cases were completed overnight (between 5 pm and 8 am). The overall in-hospital mortality rate was 8%. Thirty-three percent of patients had a complication, with independent predictors including increasing age (p = 0.001), increasing American Society of Anesthesiologists score (p = 0.02) and transfer from another centre (p = 0.001). Conclusion: This study characterizes the epidemiology of nonbiliary, nonappendiceal EGS operative interventions across Canada. Canadian surgeons are performing a large volume of EGS, and conditions treated by EGS services are associated with a substantial risk of morbidity and mortality. Results of this study will be used to guide future research efforts and set benchmarks for quality improvement. Contexte : La plupart des etudes sur les services de chirurgie generate d'urgence (CGU) s'interessent seulement aux atteintes de l'appendice et de la vesicule biliaire. Pourtant, les chirurgiens du domaine traitent beaucoup d'autres problemes complexes. L'objectif de Petude etait de decrire le travail chirurgical associe a ces problemes dans l'ensemble du Canada. Methodes : Notre etude de cohorte retrospective multicentrique inclut les patients adultes ([greater than or equal to] 18 ans) qui ont subi en 2014 une operation non planifiee pour une atteinte qui ne touchait ni l'appendice ni la vesicule biliaire dans 1 des 7 centres selectionnes, repartis un peu part out au pays. Nous avons recueilli les donnees suivantes : renseignements de base des patients, diagnostic, details de l'intervention, nature des complications et duree d'hospitalisation. Puis nous avons degage les facteurs predictifs de morbidite et de mortalite en appliquant un modele de regression logistique. Resultats : L'echantillon totalisait 2595 patients, pour un age median de 60 ans (ecart interquartile 46-73 ans). Les diagnostics principaux les plus courants etaient l'occlusion de l'intestin grele (16%), la hernie (15 %), la tumeur maligne (11 %) et les lesions perianales (9%). Les interventions les plus frequentes etaient la resection de l'intestin (30%), la reparation d'une hernie (15%), le debridement (11 %) et le debridement de tissus mous ou cutanes infectes (10 %). L'operation a eu lieu le soir ou la nuit (entre 17 h et 8 h) dans 47 % des cas. Le taux global de mortalite a l'hopital etait de 8 %. Des complications sont survenues chez 33% des patients, dont les facteurs predictifs independants etaient Page avance (p = 0,001), un score ASA (de l'American Society of Anesthesiologists) eleve (p = 0,02) et le transfert a partir d'un autre centre (p = 0,001). Conclusion : Cette etude dresse le profil epidemiologique des interventions effectuees par les services de CGU du Canada en presence d'atteintes autres que celles de l'appendice et de la vesicule biliaire. Les chirurgiens du pays font beaucoup d'interventions generates urgent es, pour traiter des affections associees a un risque eleve de morbidite et de mortalite. Les resultats de Petude guideront les prochaines recherches et serviront de points de reference en matiere d'amelioration de la qualite., Emergency general surgery (EGS) is associated with a tremendous burden of disease. In the United States, EGS admissions represent 7% of all hospital admissions, and in 2010 they cost the [...]

Background: Most studies evaluating acute care surgery (ACS) models of care for patients with emergency general surgery (EGS) conditions have focused on patients who undergo surgery while admitted under the care of the ACS service. The purpose of this study was to prospectively examine the case mix of admissions and consultations to an ACS service at a tertiary centre to identify the frequency and distribution of both operatively and nonoperatively managed EGS conditions. Methods: In this prospective cohort study, we evaluated consecutive patients assessed by the ACS team between July 1 and Aug. 31, 2015, at a large Canadian tertiary care centre. This included all consultations and outside hospital transfers. Diagnoses, demographic characteristics, comorbidities, intervention(s), complications, readmission and in-hospital death were captured. Results: The ACS team was involved in the care of 359 patients, 176 (49.0%) of whom were admitted under the direct care of the ACS team. Nonoperative care was indicated in 82 patients (46.6%) admitted to the ACS service and 151 (82.5%) of those admitted to a non-ACS service (p < 0.001). Bowel obstruction (37 patients [21.0%]) was the most common reason for admission, followed by wound/abscess (24 [13.6%), biliary disease (24 [13.6%]) and appendiceal disease (23 [13.1%]). Rates of 30-day return to the emergency department and readmission were 17.0% and 9.1%, respectively, and the in-hospital mortality rate was 1.7%. Conclusion: Acute care surgery teams care for a wide breadth of disease, a considerable amount of which is managed nonoperatively. Contexte : La plupart des etudes qui ont evalue les modeles de soins chirurgicaux aigus (SCA) chez des patients souffrant de problemes de sante necessitant un traitement de chirurgie generale (TCG) d'urgence ont porte sur des patients ayant subi une intervention lors de leur admission dans un service de SCA. Le but de cette etude etait d'analyser de maniere prospective la clientele admise ou vue en consultation dans le service de SCA d'un centre de soins tertiaires pour connaitre la frequence et la distribution des problemes de sante necessitant un TCG d'urgence effectivement traites chirurgicalement ou autrement. Methodes : Dans cette etude de cohorte prospective, nous avons evalue des patients consecutifs vus par l'equipe de SCA entre le 1 (er) juillet et le 31 aout 2015 dans un grand centre canadien de soins tertiaires. Cela incluait toutes les consultations et les transferts en provenance d'autres hopitaux. Nous avons note les diagnostics, les caracteristiques demographiques, les comorbidites, les interventions, les complications, readmissions et les deces en cours d'hospitalisation. Resultats : L'equipe de SCA a assure les soins de 359 patients, dont 176 (49,0 %) avaient ete admis directement au service de SCA. Des soins non chirurgicaux etaient indiques chez 82 patients (46,6 %) admis au service de SCA et chez 151 (82,5 %) patients admis dans d'autres services (p < 0,001). L'obstruction intestinale (37 patients [21,0 %]) a ete la raison la plus frequente des admissions, suivie de blessure ou d'abces (24 patients [13,6 %), maladie biliaire (24 patients [13,6 %]) et maladie appendiculaire (23 patients [13,1 %]). Les taux de retour aux urgences et de readmission dans les 30 jours ont ete de 17,0 % et de 9,1 %, respectivement, et le taux de mortalite en cours d'hospitalisation a ete de 1,7 %. Conclusion : Les equipes de soins chirurgicaux aigus prennent en charge un vaste eventail de pathologies, dont une part importante est geree de maniere non chirurgicale., A cute care surgery (ACS) services provide a framework of care for the management of emergency general surgery (EGS) patients, and many institutions around the world are now implementing such [...]

Background: The optimal timing of initiating low--molecular weight heparin (LMWH) in patients who have undergone nonoperative management (NOM) of blunt solid organ injuries (SOIs) remains controversial. We describe the safety [...]

Whether to temporarily place retrievable inferior vena cava filters for prophylaxis against pulmonary embolism in high-risk trauma patients has been a difficult question to answer. Guidelines regarding the management of these patients are mixed in their recommendations. The question merits further attention., The question of whether there is a role for the temporary placement of retrievable inferior vena cava (IVC) filters for prophylaxis against pulmonary embolism (PE) in high-risk trauma patients has [...]

Purpose: Surgery is a major risk factor for chronic opioid use among patients who had not recently been prescribed opioids. This study identifies the rate of, and risk factors for, persistent opioid use following laparoscopic cholecystectomy and open inguinal hernia repair in patients not recently prescribed opioids. Methods: This retrospective population-based cohort study included all patients who had not been prescribed opioids in the 6 months prior to undergoing open inguinal hernia repair or laparoscopic cholecystectomy from January 2013 to July 2016 in Ontario. Opioid prescription was identified from the provincial Narcotics Monitoring System and data were obtained from the Institute for Clinical Evaluative Sciences. The primary outcome was persistent opioid use after surgery (3, 6, 9 and 12 months). Associated risk factors and prescribing patterns were also examined. Results: Among the 90,326 patients in the study cohort, 80% filled an opioid prescription after surgery, with 11%, 9%, 5% and 1% filling a prescription at 3, 6, 9 and 12 months, respectively. Significant variability was identified in the type of opioid prescribed (41% codeine, 31% oxycodone, 18% tramadol) and in regional prescribing patterns (mean prescription/region range, 135–225 oral morphine equivalents). Predictors of continued opioid use included age, female gender, lower income quintile and being operated on by less experienced surgeons. Conclusion: Most patients who undergo elective cholecystectomy and hernia repair will fill a prescription for an opioid after surgery, and many will continue to fill opioid prescriptions for considerably longer than clinically anticipated. There is important variability in opioid type, regional prescribing patterns and risk factors that identify strategic targets to reduce the opioid burden in this patient population. [ABSTRACT FROM AUTHOR]

Purpose: Whether current standards of care management for malignant hyperthermia (MH)-susceptible patients result in acceptable postoperative clinical outcomes at a population level is not known. Our objective was to determine if patients with susceptibility to MH experienced similar outcomes as patients without MH susceptibility after surgery under general anesthesia.Methods: This was a retrospective, population-based cohort study from 1 April 2009 until 31 March 2016 in the Canadian province of Ontario. Participants were adults who underwent common in- or outpatient surgeries under general anesthesia. The exposure studied was either known or strongly suspected MH susceptibility as determined by usage of a specific physician billing code. The primary outcome was a composite of all-cause death, hospital readmission, or major postoperative complications, all within 30 postoperative days. Separate analyses were employed, based on whether a patient had in- or outpatient surgery. Inverse probability of exposure weighting based on the propensity score was used to estimate adjusted exposure effects.Results: The cohort included 957,876 patients (583,254 in- and 374,622 outpatients). There were 2,900 (0.3%) patients with a known or strong suspicion of MH susceptibility. For inpatients, the primary outcome occurred in 146,192 (25.1%) of the non-MH-susceptible group and in 337 (20.1%) of the MH-susceptible group (unadjusted risk difference [RD], -5.0%; 95% confidence interval [CI], -6.9 to -3.1%; P < 0.001). In outpatients, the primary outcome occurred in 9,146 (2.4%) of the non-MH-susceptible group and in 32 (2.6%) of the MH-susceptible group (RD, 0.2%; 95% CI, -0.7 to 1.1%; P = 0.72). After adjustment, MH susceptibility was not associated with the primary outcome in either the inpatients (adjusted risk difference [aRD], 1.2%; 95% CI, -1.3 to 3.6%; P = 0.35) or outpatients (aRD, -0.1%; 95% CI -1.0 to 0.9%; P = 0.90).Conclusions: Among adults in Ontario who underwent common surgeries under general anesthesia from 2009 to 2016, known or strongly suspected MH was not associated with a higher risk of adverse postoperative outcomes. These findings support the current standard of care management for MH-susceptible patients. [ABSTRACT FROM AUTHOR]