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Deer TR, Hayek SM, Grider JS, Pope JE, Brogan SE, Gulati A, Hagedorn JM, Strand N, Hah J, Yaksh TL, Staats PS, Perruchoud C, Knezevic NN, Wallace MS, Pilitsis JG, Lamer TJ, Buchser E, Varshney V, Osborn J, Goel V, Simpson BA, Lopez JA, Dupoiron D, Saulino MF, McDowell GC, Piedimonte F, Levy RM. The Polyanalgesic Consensus Conference (PACC)®: Updates on Clinical Pharmacology and Comorbidity Management in Intrathecal Drug Delivery for Cancer Pain. Neuromodulation 2024:S1094-7159(24)00670-6. [PMID: 39297833 DOI: 10.1016/j.neurom.2024.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 07/23/2024] [Accepted: 08/13/2024] [Indexed: 09/29/2024]
Abstract
INTRODUCTION The International Neuromodulation Society convened a multispecialty group of physicians based on expertise with international representation to establish evidence-based guidance on using intrathecal drug delivery in chronic pain treatment. This Polyanalgesic Consensus Conference (PACC)® project's scope is to provide evidence-based guidance for clinical pharmacology and best practices for intrathecal drug delivery for cancer pain. MATERIALS AND METHODS Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Meeting Abstracts, and Scopus from 2017 (when the PACC last published guidelines) to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations were based on the strength of evidence, and when evidence was scant, recommendations were based on expert consensus. RESULTS The PACC evaluated the published literature and established evidence- and consensus-based expert opinion recommendations to guide best practices in treating cancer pain. Additional guidance will occur as new evidence is developed in future iterations of this process. CONCLUSIONS The PACC recommends best practices regarding the use of intrathecal drug delivery in cancer pain, with an emphasis on managing the unique disease and patient characteristics encountered in oncology. These evidence- and consensus-based expert opinion recommendations should be used as a guide to assist decision-making when clinically appropriate.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA.
| | - Salim M Hayek
- Case Western Reserve University, University Hospitals of Cleveland, Cleveland, OH, USA
| | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | | | - Shane E Brogan
- Department of Anesthesiology, Division of Pain Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Jennifer Hah
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, CA, USA
| | - Tony L Yaksh
- Anesthesiology and Pharmacology, University of California San Diego, San Diego, CA, USA
| | - Peter S Staats
- ElectroCore, Rockaway, NJ, USA; National Spine and Pain Centers, Rockville, MD, USA
| | | | - Nebojsa Nick Knezevic
- Department of Anesthesiology and Surgery at University of Illinois, Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Mark S Wallace
- Division of Pain Management, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Julie G Pilitsis
- Department of Neurosurgery, University of Arizona, Tucson, AZ, USA
| | - Tim J Lamer
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eric Buchser
- Department of Anaesthesia and Pain Management, Neuromodulation Centre, Morges, Switzerland
| | - Vishal Varshney
- Providence Health Care, University of British Columbia, British Columbia, Canada
| | - Jill Osborn
- Department of Anesthesiology, Providence Health Care, Vancouver, British Columbia, Canada
| | - Vasudha Goel
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
| | - Brian A Simpson
- Department of Neurosurgery, Cardiff and Vale University Health Board, Cardiff, UK
| | - Jose A Lopez
- Service of Neurosurgery and Pain Clinic, University Hospital "Puerta del Mar," Cadiz, Spain
| | - Denis Dupoiron
- Department of Anesthesiology and Pain Medicine, Institut de Cancerologie de L'Ouset, Angers, France
| | | | | | - Fabian Piedimonte
- Fundaciόn CENIT, University of Buenos Aires, Buenos Aires, Argentina
| | - Robert M Levy
- International Neuromodulation Society and Director of Neurosurgical Services, Director of Clinical Research, Anesthesia Pain Care Consultants, Tamarac, FL, USA
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Różańska A, Baranowska-Tateno K, Pac A, Gajda M, Wójkowska-Mach J. Post-discharge surveillance of urinary tract infections in patients following hip and knee arthroplasty: Identifying targets for infection prevention and control. Am J Infect Control 2024; 52:852-856. [PMID: 38583774 DOI: 10.1016/j.ajic.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/09/2024]
Abstract
This population-based study aimed to evaluate the incidence of urinary tract infections following hip and knee arthroplasty (HPRO and KPRO) and identify urinary tract infection risk factors among Polish patients. The analysis included data from 83,525 patients, with incidence rates of 0.7% and 0.49% after HPRO and KPRO, respectively. We identified women, individuals over 65 years old, residents of long-term care facilities, patients with chronic circulatory, endocrine, or digestive diseases, and those operated on due to trauma as targets for infection prevention and control.
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Affiliation(s)
- Anna Różańska
- Chair of Microbiology, Jagiellonian University Medical College, Kraków, Poland; Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Katarzyna Baranowska-Tateno
- Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland; Doctoral School of Medical and Health Sciences, Jagiellonian University Medical College, Kraków, Poland.
| | - Agnieszka Pac
- Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland; Chair in Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Mateusz Gajda
- Chair of Microbiology, Jagiellonian University Medical College, Kraków, Poland; Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Jadwiga Wójkowska-Mach
- Chair of Microbiology, Jagiellonian University Medical College, Kraków, Poland; Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
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Ansorge A, Betz M, Wetzel O, Burkhard MD, Dichovski I, Farshad M, Uçkay I. Perioperative Urinary Catheter Use and Association to (Gram-Negative) Surgical Site Infection after Spine Surgery. Infect Dis Rep 2023; 15:717-725. [PMID: 37987402 PMCID: PMC10660755 DOI: 10.3390/idr15060064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 11/22/2023] Open
Abstract
This study evaluates potential associations between the perioperative urinary catheter (UC) carriage and (Gram-negative) surgical site infections (SSIs) after spine surgery. It is a retrospective, single-center, case-control study stratifying group comparisons, case-mix adjustments using multivariate logistic regression analyses. Around half of the patients (2734/5485 surgeries) carried a UC for 1 day (median duration) (interquartile range, 1-1 days). Patients with perioperative UC carriage were compared to those without regarding SSI, in general, and Gram-negative, exclusively. The SSI rate was 1.2% (67/5485), yielding 67 revision surgeries. Gram-negative pathogens caused 16 SSIs. Seven Gram-negative episodes revealed the same pathogen concomitantly in the urine and the spine. In the multivariate analysis, the UC carriage duration was associated with SSI (OR 1.1, 95% confidence interval 1.1-1.1), albeit less than classical risk factors like diabetes (OR 2.2, 95%CI 1.1-4.2), smoking (OR 2.4, 95%CI 1.4-4.3), or higher ASA-Scores (OR 2.3, 95%CI 1.4-3.6). In the second multivariate analysis targeting Gram-negative SSIs, the female sex (OR 3.8, 95%CI 1.4-10.6) and a UC carriage > 1 day (OR 5.5, 95%CI 1.5-20.3) were associated with Gram-negative SSIs. Gram-negative SSIs after spine surgery seem associated with perioperative UC carriage, especially in women. Other SSI risk factors are diabetes, smoking, and higher ASA scores.
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Affiliation(s)
- Alexandre Ansorge
- University Spine Centre Zürich, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Michael Betz
- University Spine Centre Zürich, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Oliver Wetzel
- University Spine Centre Zürich, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Marco Dimitri Burkhard
- University Spine Centre Zürich, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Igor Dichovski
- University Spine Centre Zürich, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Mazda Farshad
- University Spine Centre Zürich, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Ilker Uçkay
- Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
- Infectiology and Infection Control, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
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Chen KJ, Huang YC, Yao YC, Yang TC, Lin HH, Wang ST, Chang MC, Chou PH. Investigation of preoperative asymptomatic bacteriuria as a risk factor for postvertebroplasty infection. J Chin Med Assoc 2023; 86:233-239. [PMID: 36652570 DOI: 10.1097/jcma.0000000000000852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Postvertebroplasty infection (PVI) is a catastrophic complication after vertebroplasty (VP). Although the urinary tract has been considered as a source of infectious pathogens, whether asymptomatic bacteriuria (ASB) is a risk factors for PVI remains unknown. METHODS This retrospective study included 716 patients (207 males; 509 females) treated with VP for osteoporotic vertebral fractures in a single medical center between May 2015 and December 2019. Clinical symptoms, urinalysis results, and culture data were collected preoperatively to identify patients with ASB. The primary outcome was PVI at the index level during follow-up. Demographic data and laboratory test results were compared between the PVI and non-PVI groups. RESULTS The mean age of the cohort was 78.6 ± 9.6 (range, 63-106). The prevalence of ASB was 14.1%, with female predominance (63.4%). The overall PVI rate was 1.26% (9/716). The PVI group had more patients with ASB (4/9, 44.4%) than did the non-PVI group (97/707, 13.7%) (p = 0.027). The rate of ASB treatment was similar between the PVI and non-PVI groups (25% vs. 23.7%, respectively). No case of PVI was caused by the urine culture pathogen. Multivariate analysis identified the following risk factors for PVI: ASB (odds ratio [OR], 5.61; 95% CI, 1.14-27.66; p = 0.034), smoking (OR, 16.26; 95% CI, 2.58-102.65; p = 0.003), and malignancy (OR 7.27; 95% CI, 1.31-40.31; p = 0.023). CONCLUSION ASB was not uncommon among patients admitted for VP and should be considered a marker of relatively poor host immunity. Preoperative ASB, a history of malignancy, and smoking were identified as significant risk factors for PVI.
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Affiliation(s)
- Kuan-Jung Chen
- Department of Orthopedics, China Medical University Hsinchu Hospital, Hsinchu, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yen-Chun Huang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yu-Cheng Yao
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Tzu-Cheng Yang
- Department of Orthopedics, China Medical University Hsinchu Hospital, Hsinchu, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Hsi-Hsien Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shih-Tien Wang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Ming-Chau Chang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Po-Hsin Chou
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Hollenbeck BL, Hoffman M, Fang CJ, Counterman K, Cohen S, Bell CA. Elimination of Routine Urinalysis before Elective Orthopaedic Surgery Reduces Antibiotic Utilization without Impacting Catheter-associated Urinary Tract Infection or Surgical Site Infection Rates. Hip Pelvis 2021; 33:225-230. [PMID: 34938692 PMCID: PMC8654593 DOI: 10.5371/hp.2021.33.4.225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/18/2021] [Accepted: 03/29/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose Routine preoperative urinalysis has been the standard of care for the orthopedic population for decades, regardless of symptoms. Studies have demonstrated antibiotic overuse and low concordance between bacteria cultured from the surgical wound and the urine. Testing and treatment of asymptomatic urinary tract colonization before total joint arthroplasty (TJA) is unnecessary and increases patient risk. We investigated reducing antibiotic use by (1) modifying testing algorithms to target patients at risk, (2) modifying reflex to culture criteria, and (3) providing treatment guidelines. Materials and Methods A pre-post study was conducted to determine identify the impact of eliminating universal urinalysis prior to TJA on surgical site infection (SSI) and catheter-associated urinary tract infection (CAUTI) rates and number of antibiotic prescriptions. Patients who underwent primary hip or knee TJA or spinal fusions from February 2016 to March 2018 were included. Patient data was collected for pre- and post-practice change period (February 2016-October 2016 and August 2017-March 2018). Patient demographics, urinalysis results, cultures, and prescriptions were analyzed retrospectively from every tenth chart in the pre-period and prospectively on all patients in the post-period. Results A total of 4,663 patients were studied. There was a 96% decrease in urinalyses performed (P<0.0001), and a 93% reduction rate in antibiotic utilization (P<0.001). No significant difference in SSI and CAUTI rates was observed (P>0.05). Conclusion The elimination of routine urinalysis before orthopedic surgery resulted in a reduction in antibiotic utilization with no significant change in the SSI or CAUTI rates. Cost savings resulted from reduced antibiotic usage.
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Affiliation(s)
- Brian L Hollenbeck
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, MA, USA
| | - Megan Hoffman
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, MA, USA
| | - Christopher J Fang
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, MA, USA
| | - Kevin Counterman
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, MA, USA
| | - Susan Cohen
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, MA, USA
| | - Christine A Bell
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, MA, USA
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Hernández-Hernández D, Padilla-Fernández B, Ortega-González MY, Castro-Díaz DM. Recurrent Urinary Tract Infections and Asymptomatic Bacteriuria in Adults. CURRENT BLADDER DYSFUNCTION REPORTS 2021; 17:1-12. [PMID: 34868442 PMCID: PMC8634747 DOI: 10.1007/s11884-021-00638-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 12/14/2022]
Abstract
Purpose of review Our goal was to summarize recent evidence regarding recurrent urinary tract infections and asymptomatic bacteriuria in different adult populations. Recent findings Several research groups are focused on the description of resident bacterial flora in the bladder and urinary dysbiosis in the microbiome era. Even the definitions might change in light of these discoveries. However, the role of urinary microbiome and bacterial interference has still to be determined. Summary Systematic treatment of asymptomatic bacteriuria is not recommended and even classic indications such as asymptomatic bacteriuria in pregnant women are controversial. In fact, its treatment is associated with a higher probability of symptomatic UTI and a higher prevalence of antibiotic-resistant bacteria. Improving the diagnosis of asymptomatic bacteriuria and optimizing the management of recurrent urinary tract infections, especially through non-antibiotics measures, are needed in order to minimise antimicrobial resistance.
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Affiliation(s)
| | - Bárbara Padilla-Fernández
- Department of Urology, Complejo Hospitalario Universitario de Canarias, La Laguna, Tenerife Spain.,Departamento de Cirugía, Facultad de Medicina, Universidad de La Laguna, Tenerife, Spain
| | | | - David Manuel Castro-Díaz
- Department of Urology, Complejo Hospitalario Universitario de Canarias, La Laguna, Tenerife Spain.,Departamento de Cirugía, Facultad de Medicina, Universidad de La Laguna, Tenerife, Spain
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Medico-Legal Issues Related to Hip and Knee Arthroplasty: A Literature Review Including the Indian Scenario. Indian J Orthop 2021; 55:1286-1294. [PMID: 33814596 PMCID: PMC8009269 DOI: 10.1007/s43465-021-00398-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/22/2021] [Indexed: 02/04/2023]
Abstract
Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are commonly performed surgeries worldwide. The number of joint replacement surgeries being performed has increased considerably over the past two decades, but it has also seen an increase in litigation associated with it. The purpose of our study was to review and consolidate literature regarding medico-legal issues pertaining to THA and TKA cases. We looked at the causes of litigation, medico legal aspects of pre-operative requirements, optimisation of medical condition, indications and contraindications for arthroplasty, informed consent, implants, mixing of components from different manufacturers and post-operative rehabilitation. We also wanted to analyse available literature and legal proceedings regarding these cases in India specifically.
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Weale R, El-Bakri F, Saeed K. Pre-operative asymptomatic bacteriuria: a risk factor for prosthetic joint infection? J Hosp Infect 2019; 101:210-213. [DOI: 10.1016/j.jhin.2018.04.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 04/06/2018] [Indexed: 01/03/2023]
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Punjani N, Lanting B, McClure JA, Winick-Ng J, Welk B. The Impact of Common Urologic Complications on the Risk of a Periprosthetic Joint Infection. J Bone Joint Surg Am 2018; 100:1517-1523. [PMID: 30180061 DOI: 10.2106/jbjs.17.01405] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Periprosthetic infections after total hip arthroplasty (THA) or total knee arthroplasty (TKA) are substantial complications, and there are conflicting reports of their association with urologic complications. Our objective was to determine whether urinary tract infection (UTI) and acute urinary retention (AUR) are significant risk factors for joint infections after THA or TKA. METHODS We performed a population-based, retrospective cohort study of patients who were ≥66 years old when they underwent an initial THA or TKA between April 2003 and March 2013. Investigated exposures included a UTI presenting for treatment within 2 years after joint replacement, as well as AUR within 30 days after THA or TKA. The primary outcome was joint infection requiring hospital admission following THA or TKA (which had to occur within 2.25 years after THA or TKA for the UTI exposure or 120 days for the AUR exposure). RESULTS A total of 113,061 patients met the inclusion criteria and had arthroplasties (44,495 THAs and 68,566 TKAs) during the study period. The median age was 74 years (interquartile range [IQR], 70 to 79 years). Of those patients, 28,256 (25.0%) had at least 1 UTI and they were more likely to be older and female; to have had previous antibiotic exposure, cystoscopy, or urinary retention; and to have atrial fibrillation. Most of those UTIs were coded as nonspecific UTI, and the patient was seen for outpatient treatment in a non-emergency department setting. A total of 2,516 patients (2.2%) had AUR within 30 days of the procedure. Those patients were more likely to be older and male, to have medical comorbidities, to have had previous transurethral procedures or cystoscopy and previous urology visits, and to have received a general anesthetic during their procedure. A total of 1,262 patients (1.1%) had joint infection requiring hospital admission. In multivariate Cox regression analysis, UTI was associated with an increased risk of joint infection (hazard ratio [HR], 1.21 [95% confidence interval (CI), 1.14 to 1.28]; p < 0.01). However multivariate analysis did not demonstrate an association between AUR and joint infection (HR, 0.99 [95% CI, 0.60 to 1.64]; p = 0.98). CONCLUSIONS UTI was associated with increased risk of hip or knee periprosthetic joint infection, whereas AUR was not a significant risk factor. Timely and appropriate treatment of symptomatic UTIs in this patient population may be important to prevent periprosthetic joint infection. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nahid Punjani
- Departments of Surgery (N.P., B.L., and B.W.) and Epidemiology and Biostatistics (B.W.), Western University, London, Ontario, Canada
| | - Brent Lanting
- Departments of Surgery (N.P., B.L., and B.W.) and Epidemiology and Biostatistics (B.W.), Western University, London, Ontario, Canada
| | - J Andrew McClure
- Institute for Clinical Evaluative Sciences, London, Ontario, Canada
| | | | - Blayne Welk
- Departments of Surgery (N.P., B.L., and B.W.) and Epidemiology and Biostatistics (B.W.), Western University, London, Ontario, Canada.,Institute for Clinical Evaluative Sciences, London, Ontario, Canada
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