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Kirkham AM, Candeliere J, Fergusson D, Stelfox HT, Brandys T, McIsaac DI, Ramsay T, Roberts DJ. Prediction Models for Forecasting Risk of Development of Surgical Site Infection after Lower Limb Revascularization Surgery: A Systematic Review. Ann Vasc Surg 2024; 102:140-151. [PMID: 38307235 DOI: 10.1016/j.avsg.2023.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/01/2023] [Accepted: 11/08/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Surgical site infections (SSIs) are a common and potentially preventable complication of lower limb revascularization surgery associated with increased healthcare resource utilization and patient morbidity. We conducted a systematic review to evaluate multivariable prediction models designed to forecast risk of SSI development after these procedures. METHODS After protocol registration (CRD42022331292), we searched MEDLINE, EMBASE, CENTRAL, and Evidence-Based Medicine Reviews (inception to April 4th, 2023) for studies describing multivariable prediction models designed to forecast risk of SSI in adults after lower limb revascularization surgery. Two investigators independently screened abstracts and full-text articles, extracted data, and assessed risk of bias. A narrative synthesis was performed to summarize predictors included in the models and their calibration and discrimination, validation status, and clinical applicability. RESULTS Among the 6,671 citations identified, we included 5 studies (n = 23,063 patients). The included studies described 5 unique multivariable prediction models generated through forward selection, backward selection, or Akaike Information Criterion-based methods. Two models were designed to predict any SSI and 3 Szyilagyi grade II (extending into subcutaneous tissue) SSI. Across the 5 models, 18 adjusted predictors (10 of which were preoperative, 3 intraoperative, and 5 postoperative) significantly predicted any SSI and 14 adjusted predictors significantly predict Szilagyi grade II SSI. Female sex, obesity, and chronic obstructive pulmonary disease significantly predicted SSI in more than one model. All models had a "good fit" according to the Hosmer-Lemeshow test (P > 0.05). Model discrimination was quantified using the area under the curve, which ranged from 0.66 to 0.75 across models. Two models were internally validated using non-exhaustive twofold cross-validation and bootstrap resampling. No model was externally validated. Three studies had a high overall risk of bias according to the Prediction model Risk Of Bias ASsessment Tool (PROBAST). CONCLUSIONS Five multivariable prediction models with moderate discrimination have been developed to forecast risk of SSI development after lower limb revascularization surgery. Given the frequency and consequences of SSI after these procedures, development and external validation of novel prediction models and comparison of these models to the existing models evaluated in this systematic review is warranted.
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Affiliation(s)
- Aidan M Kirkham
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jasmine Candeliere
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Henry T Stelfox
- The O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada; Departments of Critical Care Medicine, Medicine, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Departments of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Tim Ramsay
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Kirkham AM, Candeliere J, McIsaac DI, Stelfox HT, Dubois L, Gill HL, Brandys T, Nagpal SK, Roberts DJ. Efficacy of Strategies Intended to Prevent Surgical Site Infection After Lower Limb Revascularization Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Ann Surg 2023; 278:e447-e456. [PMID: 36994744 DOI: 10.1097/sla.0000000000005867] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVE The objective of this study is to evaluate the efficacy of strategies intended to prevent surgical site infection (SSI) after lower limb revascularization surgery. BACKGROUND SSIs are common, costly complications of lower limb revascularization surgery associated with significant morbidity and mortality. METHODS We searched MEDLINE, EMBASE, CENTRAL, and Evidence-Based Medicine Reviews (inception to April 28, 2022). Two investigators independently screened abstracts and full-text articles, extracted data, and assessed the risk of bias. We included randomized controlled trials (RCTs) that evaluated strategies intended to prevent SSI after lower limb revascularization surgery for peripheral artery disease. We used random-effects models to pool data and GRADE to assess certainty. RESULTS Among 6258 identified citations, we included 26 RCTs (n=4752 patients) that evaluated 12 strategies to prevent SSI. Preincision antibiotics [risk ratio (RR)=0.25; 95% CI, 0.11-0.57; n=4 studies; I2 statistic=7.1%; high certainty] and incisional negative-pressure wound therapy (iNPWT) (RR=0.54; 95% CI, 0.38-0.78; n=5 studies; I2 statistic=7.2%; high certainty) reduced pooled risk of early (≤30 days) SSI. iNPWT also reduced the risk of longer-term (>30 days) SSI (pooled-RR=0.44; 95% CI, 0.26-0.73; n=2 studies; I2 =0%; low certainty). Strategies with uncertain effects on risk of SSI included preincision ultrasound vein mapping (RR=0.58; 95% CI, 0.33-1.01; n=1 study); transverse groin incisions (RR=0.33; 95% CI, 0.097-1.15; n=1 study), antibiotic-bonded prosthetic bypass grafts (RR=0.74; 95% CI, 0.44-1.25; n=1 study; n=257 patients), and postoperative oxygen administration (RR=0.66; 95% CI, 0.42-1.03; n=1 study) (low certainty for all). CONCLUSIONS Preincision antibiotics and iNPWT reduce the risk of early SSI after lower limb revascularization surgery. Confirmatory trials are required to determine whether other promising strategies also reduce SSI risk.
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Affiliation(s)
- Aidan M Kirkham
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jasmine Candeliere
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Daniel I McIsaac
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
- Departments of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Luc Dubois
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Division of Vascular Surgery, Department of Surgery, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Faculty of Medicine, Western University, London, ON, Canada
| | - Heather L Gill
- Division of Vascular Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Derek J Roberts
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
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Li A, Dreksler H, Nagpal SK, Brandys T, Jetty P, Dubois L, Parsons Leigh J, Stelfox HT, McIsaac DI, Roberts DJ. Outcomes After Neuraxial or Regional Anaesthesia Instead of General Anaesthesia for Lower Limb Revascularisation Surgery: A Systematic Review and Meta-Analysis of Randomised and Non-Randomised Studies. Eur J Vasc Endovasc Surg 2023; 65:379-390. [PMID: 36336286 DOI: 10.1016/j.ejvs.2022.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 10/19/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine whether receipt of neuraxial or regional anaesthesia instead of general anaesthesia for lower limb revascularisation surgery affects patient outcomes. DATA SOURCES MEDLINE, EMBASE, Evidence Based Medicine Reviews, and Google Scholar. REVIEW METHODS After protocol registration, the data sources were searched for randomised and non-randomised studies comparing neuraxial or regional anaesthesia with general anaesthesia for lower limb revascularisation surgery in adults. Two investigators independently selected articles, extracted data, and assessed risks of bias. Data were pooled using random effects models. GRADE was used to assess certainty in cumulative evidence. RESULTS From 10 755 citations identified, five randomised (n = 970) and 13 non-randomised (n = 96 800) studies were included. Use of neuraxial instead of general anaesthesia for lower limb revascularisation surgery was associated with no statistically significant reduction in short term (in hospital or 30 day) mortality in randomised studies (pooled odds ratio [OR] 0.77; 95% confidence interval [CI] 0.33 - 1.81; low certainty) and a statistically significant reduction in adjusted short term mortality in non-randomised studies (pooled OR 0.67; 95% CI 0.56 - 0.81; low certainty). Adults allocated to neuraxial anaesthesia in randomised studies had fewer pulmonary complications (pooled OR 0.35; 95% CI 0.16 - 0.76; low certainty). In non-randomised studies, neuraxial instead of general anaesthesia was associated with a lower adjusted odds of any morbidity (pooled OR 0.66; 95% CI 0.52 - 0.84), cardiac complications (pooled OR 0.68; 95% CI 0.58 - 0.79), pneumonia (pooled OR 0.81; 95% CI 0.64 - 1.02), prolonged mechanical ventilation (OR 0.09; 95% CI 0.002 - 0.55), and bypass graft thrombosis (OR 0.70; 95% CI 0.59 - 0.85), as well as a shorter operative duration (low certainty for all). Use of a nerve block instead of general anaesthesia was associated with a lower adjusted odds of delirium (OR 0.16; 95% CI 0.06 - 0.42) and a shorter operative duration (low certainty for both). CONCLUSION Randomised and non-randomised data suggest that neuraxial anaesthesia for lower limb revascularisation surgery reduces morbidity and possibly mortality. Until randomised trials with a low risk of bias become available, this study supports use of neuraxial anaesthesia for these procedures where appropriate.
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Affiliation(s)
- Allen Li
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Hannah Dreksler
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Luc Dubois
- Division of Vascular Surgery, Department of Surgery, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Faculty of Medicine, Western University, London, Ontario, Canada; ICES, Ontario, Canada
| | - Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Alberta, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; ICES, Ontario, Canada; Department of Anaesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; O'Brien Institute for Public Health, University of Calgary, Alberta, Canada; School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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de Launay D, Shiga S, Laschuk M, Brandys T, Roberts DJ. Extra-Anatomic Temporary Intravascular Shunting to Assist with Replantation of An Amputated Hand with Prolonged Ischemic Time. J Vasc Surg Cases Innov Tech 2022; 8:598-601. [PMID: 36248399 PMCID: PMC9556574 DOI: 10.1016/j.jvscit.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/10/2022] [Indexed: 12/01/2022] Open
Abstract
Although temporary intravascular shunting has been reported to assist with hand revascularization and replantation after traumatic amputation, most reports have described using ipsilateral upper limb inflow. We present a case of a traumatic hand amputation in a patient who had presented with 4 to 5 hours of warm ischemic time. Because the replantation team believed that extra-anatomic revascularization would be necessary, we performed a novel type of temporary intravascular shunting by connecting two arterial sheaths placed in the ulnar and superficial femoral arteries. This permitted the hand to be successfully replanted away from the inflow source and resulted in a good long-term functional outcome.
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Affiliation(s)
- David de Launay
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Sarah Shiga
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Matthew Laschuk
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Derek J. Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Division of Vascular and Endovascular Surgery, The Ottawa Hospital, Ottawa, ON, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Correspondence: Derek J. Roberts, MD, PhD, FRCSC, Division of Vascular and Endovascular Surgery, Department of Surgery, School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Division of Vascular and Endovascular Surgery, The Ottawa Hospital, Civic Campus, Room A-280, 1053 Carling Ave, Ottawa, ON K1Y 4E9, Canada
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Roberts DJ, Dreksler H, Nagpal SK, Li A, Parsons Leigh J, Brandys T, Jetty P, Dubois L, Stelfox HT, McIsaac DI. Outcomes After Receipt of Neuraxial or Regional Anesthesia Instead of General Anesthesia for Lower Limb Revascularization Surgery: Protocol for a Systematic Review and Meta-analysis. JMIR Res Protoc 2021; 10:e32170. [PMID: 34507273 PMCID: PMC8665382 DOI: 10.2196/32170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients undergoing lower limb revascularization surgery for peripheral artery disease (PAD) have a high risk of perioperative morbidity and mortality and often have long hospital stays. Use of neuraxial or regional anesthesia instead of general anesthesia may represent one approach to improving outcomes and reducing resource use among these patients. OBJECTIVE The aim is to conduct a systematic review and meta-analysis to determine whether receipt of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD results in improved health outcomes and costs and a shorter length of hospitalization. METHODS We will search electronic bibliographic databases (MEDLINE, EMBASE, the seven databases in Evidence-Based Medicine Reviews, medRxiv, bioRxiv, and Google Scholar), review papers identified during the search, and included article bibliographies. We will include randomized and nonrandomized studies comparing the use of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD. Two investigators will independently evaluate the risk of bias. The primary outcome will be short-term (in-hospital or 30-day) mortality. Secondary outcomes will include longer-term mortality; major adverse cardiovascular, pulmonary, renal, and limb events; delirium; deep vein thrombosis or pulmonary embolism; neuraxial or regional anesthesia-related complications; graft-related outcomes; length of operation and hospital stay; costs; and patient-reported or functional outcomes. We will calculate summary odds ratios (ORs) and standardized mean differences (SMDs) using random-effects models. Heterogeneity will be explored using stratified meta-analyses and meta-regression. We will assess for publication bias using the Begg and Egger tests and use the trim-and-fill method to estimate the potential influence of this bias on summary estimates. Finally, we will use Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology to make an overall rating of the quality of evidence in our effect estimates. RESULTS The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO). We executed the peer-reviewed search strategy on March 2, 2021. We completed the review of titles and abstracts on July 30, 2021, and plan to complete the review of full-text papers by September 30, 2021. We will complete full-text study data extraction and the risk-of-bias assessment by November 15, 2021, and conduct qualitative and then quantitative data synthesis and GRADE assessment of results by January 1, 2022, before drafting the manuscript. We anticipate that we will be able to submit the manuscript for peer review by the end of February 2022. CONCLUSIONS This study will synthesize existing evidence regarding whether receipt of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD results in improved health outcomes, graft patency, and costs and a shorter length of hospital stay. Study results will be used to inform practice and future research, including creation of a pilot and then multicenter randomized controlled trial. TRIAL REGISTRATION Prospero CRD42021237060; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=237060. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/32170.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, ON, Canada
| | - Hannah Dreksler
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Allen Li
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Luc Dubois
- Division of Vascular Surgery, Department of Surgery, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Faculty of Medicine, Western University, London, ON, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
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Roberts DJ, Nagpal SK, Stelfox HT, Brandys T, Corrales-Medina V, Dubois L, McIsaac DI. Risk Factors for Surgical Site Infection After Lower Limb Revascularization Surgery in Adults with Peripheral Artery Disease: Protocol for a Systematic Review and Meta-Analysis. JMIR Res Protoc 2021; 10:e28759. [PMID: 34161251 PMCID: PMC8485188 DOI: 10.2196/28759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 11/29/2022] Open
Abstract
Background Surgical site infections (SSIs) are common, costly, and associated with increased morbidity and potential mortality after lower limb revascularization surgery (ie, arterial bypass, endarterectomy, and patch angioplasty). Identifying evidence-informed risk factors for SSI in patients undergoing these surgeries is therefore important. Objective The aim of this study is to conduct a systematic review and meta-analysis of prognostic studies to identify, synthesize, and determine the certainty in the cumulative evidence associated with reported risk factors for early and delayed SSI after lower limb revascularization surgery in adults with peripheral artery disease. Methods We will search MEDLINE, Embase, the seven databases in Evidence-Based Medicine Reviews, review articles identified during the search, and included article bibliographies. We will include studies of adults (aged ≥18 years) with peripheral artery disease that report odds ratios, risk ratios, or hazard ratios adjusted for the presence of other risk factors or confounding variables and relating the potential risk factor of interest to the development of SSI after lower limb revascularization surgery. We will exclude studies that did not adjust for confounding, exclusively examined certain high-risk patient cohorts, or included >20% of patients who underwent surgery for indications other than peripheral artery disease. The primary outcomes will be early (in-hospital or ≤30 days) SSI and Szilagyi grade I (cellulitis involving the wound), grade II (infection involving subcutaneous tissue), and grade III (infection involving the vascular graft) SSI. Two investigators will independently extract data and evaluate the study risk of bias using the Quality in Prognosis Studies tool. Adjusted risk factor estimates with similar definitions will be pooled using DerSimonian and Laird random-effects models. Heterogeneity will be explored using stratified meta-analyses and meta-regression. Finally, we will use the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to determine certainty in the estimates of association between reported risk factors and the development of SSI. Results The protocol was registered in PROSPERO (International Prospective Register of Systematic Reviews). We will execute the peer-reviewed search strategy on June 30, 2021, and then complete the review of titles and abstracts and full-text articles by July 30, 2021, and September 15, 2021, respectively. We will complete the full-text study data extraction and risk of bias assessment by November 15, 2021. We anticipate that we will be able to submit the manuscript for peer review by January 30, 2022. Conclusions This study will identify, synthesize, and determine the certainty in the cumulative evidence associated with risk factors for early and delayed SSI after lower limb revascularization surgery in patients with peripheral artery disease. The results will be used to inform practice, clinical practice statements and guidelines, and subsequent research. Trial Registration PROSPERO International Prospective Register of Systematic Reviews CRD42021242557; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=242557 International Registered Report Identifier (IRRID) PRR1-10.2196/28759
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Affiliation(s)
- Derek J Roberts
- University of Ottawa, The Ottawa Hospital, Civic Campus, Room A-280, 1053 Carling Avenue, Ottawa, CA
| | - Sudhir K Nagpal
- University of Ottawa, The Ottawa Hospital, Civic Campus, Room A-280, 1053 Carling Avenue, Ottawa, CA
| | - Henry T Stelfox
- The O'Brien Institute for Public Health, University of Calgary, Calgary, CA
| | - Timothy Brandys
- University of Ottawa, The Ottawa Hospital, Civic Campus, Room A-280, 1053 Carling Avenue, Ottawa, CA
| | - Vicente Corrales-Medina
- University of Ottawa, The Ottawa Hospital, Civic Campus, Room A-280, 1053 Carling Avenue, Ottawa, CA
| | | | - Daniel I McIsaac
- University of Ottawa, The Ottawa Hospital, Civic Campus, Room A-280, 1053 Carling Avenue, Ottawa, CA
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Roberts DJ, Nagpal SK, Forster AJ, Brandys T, Murphy C, Jennings A, Strauss SA, Vishnyakova E, Lawson J, McIsaac DI. Disability, pain, and wound-specific concerns self-reported by adults at risk of limb loss: A cross-sectional study using the World Health Organization Disability Assessment Schedule 2.0. PLoS One 2021; 16:e0253288. [PMID: 34129633 PMCID: PMC8205167 DOI: 10.1371/journal.pone.0253288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/01/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction There has been limited study of patient-reported outcomes (PROs) in patients at risk of limb loss. Our primary objective was to estimate the prevalence of disability in this patient population using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Materials and methods We recruited patients referred to a limb-preservation clinic. Patients self-reported their disability status using the 12-domain WHODAS 2.0. Severity of disability in each domain was scored from 1 = none to 5 = extreme and the total normalized to a 100-point scale (total score ≥25 = clinically significant disability). We also asked patients about wound-specific concerns and wound-related discomfort or distress. Results We included 162 patients. Reasons for clinic referral included arterial-insufficient (37.4%), postoperative (25.9%), and mixed etiology (10.8%) wounds. The mean WHODAS 2.0 disability score was 35.0 (standard deviation = 16.0). One-hundred-and-nineteen (73.5%) patients had clinically significant disability. Patients reported they had the greatest difficulty walking a long distance (mean score = 4.2), standing for long periods of time (mean score = 3.6), taking care of household responsibilities (mean score = 2.7), and dealing with the emotional impact of their health problems (mean score = 2.5). In the two-weeks prior to presentation, 87 (52.7%) patients expressed concern over their wound(s) and 90 (55.6%) suffered a moderate amount or great deal of wound-related discomfort or distress. In adjusted ordinary least squares regression models, although WHODAS 2.0 disability scores varied with changes in wound volume (p = 0.03) and total revised photographic wound assessment tool scores (p<0.001), the largest decrease in disability severity was seen in patients with less wound-specific concerns and wound-related discomfort and distress. Discussion The majority of people at risk of limb loss report suffering a substantial burden of disability, pain, and wound-specific concerns. Research is needed to further evaluate the WHODAS 2.0 in a multicenter fashion among these patients and determine whether care and interventions may improve their PROs.
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Affiliation(s)
- Derek J. Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- * E-mail:
| | - Sudhir K. Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Alan J. Forster
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada
- School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Christine Murphy
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Alison Jennings
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Shira A. Strauss
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Evgeniya Vishnyakova
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Julie Lawson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Daniel I. McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Departments of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada
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Roberts DJ, Murphy C, Strauss SA, Brandys T, Corrales-Medina V, Zhang J, Lalonde KA, Meulenkamp B, Jennings A, Forster AJ, McIsaac DI, Nagpal SK. Structure, processes, and initial outcomes of The Ottawa Hospital Multi-Specialist Limb-Preservation Clinic and Programme: A unique-in-Canada quality improvement initiative. Int Wound J 2021; 19:326-338. [PMID: 34085390 PMCID: PMC8762562 DOI: 10.1111/iwj.13633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/20/2021] [Accepted: 05/25/2021] [Indexed: 11/28/2022] Open
Abstract
In 2017, The Ottawa Hospital initiated a unique-in-Canada quality improvement initiative by opening a novel, multi-specialist limb-preservation clinic. We sought to describe the structure, processes, and initial outcomes of the clinic and evaluate whether it is achieving its mandate of providing high-quality wound clinical care, education, and research. We conducted a descriptive prospective cohort study alongside a nested study of 162 clinic patients requiring serial assessments. There have been 1623 visits, mostly (72.2%) from outpatients. During 17.8% of visits, patients were evaluated by >1 specialist. Therapies provided most often included negative-pressure wound therapy (32.7%), biological wound dressings (21.6%), and total contact casting (18.5%). Furthermore, 1.2% underwent toe/ray amputations or skin grafting in clinic and 22.8% were initiated on antimicrobials. Mixed-effects models suggested that mean wound volumes for those requiring serial assessments decreased by 1.6 (95% confidence interval = -0.86 to -2.27) cm3 between visits. The clinic provided seven rotations to vascular surgery, infectious diseases, dermatology, and palliative care physicians; three nursing preceptorships; and two educational workshops. It also initiated provincial and national vascular health and wound care research initiatives. This study may be used to guide development of other limb-preservation clinics and programmes. Findings support that our programme is achieving its mandate.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Christine Murphy
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Shira A Strauss
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Vicente Corrales-Medina
- Division of Infectious Diseases, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jing Zhang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Karl-André Lalonde
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Bradley Meulenkamp
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Alan J Forster
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,IC/ES, Toronto, Ontario, Canada.,Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada.,School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel I McIsaac
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,IC/ES, Toronto, Ontario, Canada.,School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Departments of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
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Roberts DJ, Nagpal SK, Kubelik D, Brandys T, Stelfox HT, Lalu MM, Forster AJ, McCartney CJ, McIsaac DI. Association between neuraxial anaesthesia or general anaesthesia for lower limb revascularisation surgery in adults and clinical outcomes: population based comparative effectiveness study. BMJ 2020; 371:m4104. [PMID: 33239330 PMCID: PMC7687020 DOI: 10.1136/bmj.m4104] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To examine the associations between neuraxial anaesthesia or general anaesthesia and clinical outcomes, length of hospital stay, and readmission in adults undergoing lower limb revascularisation surgery. DESIGN Comparative effectiveness study using linked, validated, population based databases. SETTING Ontario, Canada, 1 April 2002 to 31 March 2015. PARTICIPANTS 20 988 patients Ontario residents aged 18 years or older who underwent their first lower limb revascularisation surgery in hospitals performing 50 or more of these surgeries annually. MAIN OUTCOME MEASURES Primary outcome was 30 day all cause mortality. Secondary outcomes were in-hospital cardiopulmonary and renal complications, length of hospital stay, and 30 day readmissions. Multivariable, mixed effects regression models, adjusting for patient, procedural, and hospital characteristics, were used to estimate associations between anaesthetic technique and outcomes. Robustness of analyses were evaluated by conducting instrumental variable, propensity score matched, and survival sensitivity analyses. RESULTS Of 20 988 patients who underwent lower limb revascularisation surgery, 6453 (30.7%) received neuraxial anaesthesia and 14 535 (69.3%) received general anaesthesia. The percentage of neuraxial anaesthesia use ranged from 0.6% to 90.6% across included hospitals. Furthermore, use of neuraxial anaesthesia declined by 17% over the study period. Death within 30 days occurred in 204 (3.2%) patients who received neuraxial anaesthesia and 646 (4.4%) patients who received general anaesthesia. After multivariable, multilevel adjustment, use of neuraxial anaesthesia compared with use of general anaesthesia was associated with decreased 30 day mortality (absolute risk reduction 0.72%, 95% confidence interval 0.65% to 0.79%; odds ratio 0.68, 95% confidence interval 0.57 to 0.83; number needed to treat to prevent one death=139). A similar direction and magnitude of association was found in instrumental variable, propensity score matched, and survival analyses. Use of neuraxial anaesthesia compared with use of general anaesthesia was also associated with decreased in-hospital cardiopulmonary and renal complications (odds ratio 0.73, 0.63 to 0.85) and a reduced length of hospital stay (-0.5 days, -0.3 to-0.6 days). CONCLUSIONS Use of neuraxial anaesthesia compared with general anaesthesia for lower limb revascularisation surgery was associated with decreased 30 day mortality and hospital length of stay. These findings might have been related to reduced cardiopulmonary and renal complications after neuraxial anaesthesia and support the increased use of neuraxial anaesthesia in patients undergoing these surgeries until the results of a large, confirmatory randomised trial become available.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Dalibor Kubelik
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine and O'Brien Institute for Public Health University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Manoj M Lalu
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON, Canada, K1Y 4E9
| | - Alan J Forster
- Department of Medicine, Ottawa Hospital, Ottawa, ON, Canada
| | - Colin Jl McCartney
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON, Canada, K1Y 4E9
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON, Canada, K1Y 4E9
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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Roberts DJ, Nagpal S, Kubelik D, Brandys T, Stelfox H, Lalu M, Forster A, McIsaac D. Association Between Receipt of Neuraxial or General Anesthesia for Lower Extremity Revascularization Surgery and Clinical Outcomes and Resource Use. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Roberts DJ, Nagpal S, Kubelik D, Brandys T, Stelfox HT, Lalu MM, Forster AJ, McCartney CJ, McIsaac DI. Type of Anesthesia for Lower Extremity Arterial Revascularization Surgery: A Population-Based Comparative Effectiveness Study. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kubelik D, Morellato J, Jetty P, Brandys T, Hajjar G, Hill A, Nagpal S. Endovascular Repair of a Chronic AV Fistula Presenting as Post-Partum High Output Heart Failure. EJVES Short Rep 2016; 31:19-22. [PMID: 28856304 PMCID: PMC5573105 DOI: 10.1016/j.ejvssr.2016.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 03/30/2016] [Accepted: 03/30/2016] [Indexed: 12/01/2022] Open
Abstract
Introduction Acute injury to the large vessels is the most feared of diagnoses for a spinal surgeon, but far more common is the delayed presentation of arteriovenous fistula (AVF) formation. The mean time to diagnosis of an AV fistula in this scenario is just over 1 month. Treatment can include both open and endovascular repair. Report This study presents a case of an otherwise healthy 39-year-old woman who initially presented with orthopnea, leg edema, and a presumptive diagnosis of post-partum cardiomyopathy. Cardiac investigations revealed high output cardiac failure and an abdominal CT scan confirmed an arterial venous fistula from the left common iliac artery to left common iliac vein. The patient maintained a cardiac output three times normal prior to her definitive treatment. This high flow physiology caused unique challenges for the endovascular procedure as the stent graft collapsed and distorted toward the iliac side wall. The AV fistula was eventually covered successfully and post-operative studies show no further fistula and normal cardiac function. This case demonstrates an unanticipated effect of very high flows of stent graft deployment. Discussion Extreme high flow AV fistulas can present as unexpected challenges to endovascular repair. These issues may be ameliorated by techniques such as controlled hypotension, adenosine, ventricular pacing, or proximal balloon occlusion. This chronic AV fistula was diagnosed 12 years after lumbar discectomy. Only after the normal physiological state of pregnancy, and its elevated high cardiac output requirements did the patient decompensate with orthopnea and edema. This otherwise healthy 39-year-old woman had three times the cardiac output expected which was caused by her iliac artery to iliac vein fistula. Endovascular treatment is a viable option to cover the fistula, but the high flows can collapse and distort the stent graft during deployment. Controlled hypotension, adenosine, ventricular pacing or proximal balloon occlusion may be appropriate if extreme flows are anticipated.
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Affiliation(s)
- D Kubelik
- Division of Vascular Endovascular Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - J Morellato
- Division of Orthopedics, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - P Jetty
- Division of Vascular Endovascular Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - T Brandys
- Division of Vascular Endovascular Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - G Hajjar
- Division of Vascular Endovascular Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - A Hill
- Division of Vascular Endovascular Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - S Nagpal
- Division of Vascular Endovascular Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Price J, Naik V, Boodhwani M, Brandys T, Hendry P, Lam B. 376 The impact of after-hours simulator practice on performance of vascular anastomosis during surgical training: A randomized trial. Can J Cardiol 2011. [DOI: 10.1016/j.cjca.2011.07.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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