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Ramendra R, Duong A, Zhang CYK, Huszti E, Zhou X, Havlin J, Ghany R, Cypel M, Yeung JC, Keshavjee S, Sage AT, Martinu T. Airway pepsinogen A4 identifies lung transplant recipients with microaspiration and predicts chronic lung allograft dysfunction. J Heart Lung Transplant 2024; 43:973-982. [PMID: 38211836 DOI: 10.1016/j.healun.2024.01.002] [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: 08/13/2023] [Revised: 12/04/2023] [Accepted: 01/02/2024] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Aspiration is a known risk factor for adverse outcomes post-lung transplantation. Airway bile acids are the gold-standard biomarker of aspiration; however, they are released into the duodenum and likely reflect concurrent gastrointestinal dysmotility. Previous studies investigating total airway pepsin have found conflicting results on its relationship with adverse outcomes post-lung transplantation. These studies measured total pepsin and pepsinogen in the airways. Certain pepsinogens are constitutively expressed in the lungs, while others, such as pepsinogen A4 (PGA4), are not. We sought to evaluate the utility of measuring airway PGA4 as a biomarker of aspiration and predictor of adverse outcomes in lung transplant recipients (LTRs) early post-transplant. METHODS Expression of PGA4 was compared to other pepsinogens in lung tissue. Total pepsin and PGA4 were measured in large airway bronchial washings and compared to preexisting markers of aspiration. Two independent cohorts of LTRs were used to assess the relationship between airway PGA4 and chronic lung allograft dysfunction (CLAD). Changes to airway PGA4 after antireflux surgery were assessed in a third cohort of LTRs. RESULTS PGA4 was expressed in healthy human stomach but not lung. Airway PGA4, but not total pepsin, was associated with aspiration. Airway PGA4 was associated with an increased risk of CLAD in two independent cohorts of LTRs. Antireflux surgery was associated with reduced airway PGA4. CONCLUSIONS Airway PGA4 is a marker of aspiration that predicts CLAD in LTRs. Measuring PGA4 at surveillance bronchoscopies can help triage high-risk LTRs for anti-reflux surgery.
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Affiliation(s)
- Rayoun Ramendra
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Allen Duong
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Chen Yang Kevin Zhang
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Xuanzi Zhou
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Jan Havlin
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan C Yeung
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Andrew T Sage
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Ali A, Huszti E, Noordin S, Ali U, Sale JEM. Examining treatment targets and equity in bone-active medication use within secondary fracture prevention: a systematic review and meta-analysis. Osteoporos Int 2024:10.1007/s00198-024-07078-5. [PMID: 38740589 DOI: 10.1007/s00198-024-07078-5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/27/2024] [Indexed: 05/16/2024]
Abstract
PURPOSE This systematic review seeks to evaluate the proportion of fragility fracture patients screened in secondary fracture prevention programs who were indicated for pharmacological treatment, received prescriptions for bone-active medications, and initiated the prescribed medication. Additionally, the study aims to analyze equity in pharmacological treatment by examining equity-related variables including age, sex, gender, race, education, income, and geographic location. METHODS We conducted a systematic review to ascertain the proportion of fragility fracture patients indicated for treatment who received prescriptions and/or initiated bone-active medication through secondary fracture prevention programs. We also examined treatment indications reported in studies and eligibility criteria to confirm patients who were eligible for treatment. To compute the pooled proportions for medication prescription and initiation, we carried out a single group proportional meta-analysis. We also extracted the proportions of patients who received a prescription and/or began treatment based on age, sex, race, education, socioeconomic status, location, and chronic conditions. RESULTS This review included 122 studies covering 114 programs. The pooled prescription rate was 77%, and the estimated medication initiation rate was 71%. Subgroup analysis revealed no significant difference in treatment initiation between the Fracture Liaison Service and other programs. Across all studies, age, sex, and socioeconomic status were the only equity variables reported in relation to treatment outcomes. CONCLUSION Our systematic review emphasizes the need for standardized reporting guidelines in post-fracture interventions. Moreover, considering equity stratifiers in the analysis of health outcomes will help address inequities and improve the overall quality and reach of secondary fracture prevention programs.
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Affiliation(s)
- Anum Ali
- Institute of Health Policy, Management and Evaluation, University of Toronto, 4th Floor - 155 College Street, Toronto, ON, M5T 3M6, Canada.
| | - Ella Huszti
- Institute of Health Policy, Management and Evaluation, University of Toronto, 4th Floor - 155 College Street, Toronto, ON, M5T 3M6, Canada
| | - Shahryar Noordin
- Department of Surgery, Aga Khan University, National Stadium Rd, P.O. Box 3500, Karachi City, Sindh, Pakistan
| | - Usman Ali
- Department of Surgery, Aga Khan University, National Stadium Rd, P.O. Box 3500, Karachi City, Sindh, Pakistan
| | - Joanna E M Sale
- Institute of Health Policy, Management and Evaluation, University of Toronto, 4th Floor - 155 College Street, Toronto, ON, M5T 3M6, Canada
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, 5th Floor - 149 College Street, Toronto, ON, M5B 1W8, Canada
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Michaeli J, Ge N, Huszti E, Greenblatt EM. Is a day 7 blastocyst predictive of the reproductive potential of sibling day 5 and day 6 blastocysts? J Assist Reprod Genet 2024:10.1007/s10815-024-03129-2. [PMID: 38730126 DOI: 10.1007/s10815-024-03129-2] [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: 10/25/2023] [Accepted: 04/26/2024] [Indexed: 05/12/2024] Open
Abstract
PURPOSE To explore if a day 7 blastocyst is predictive of the reproductive potential of sibling day 5 or day 6 blastocysts? METHODS Retrospective cohort of autologous frozen embryo transfers (FET), February 2019 to April 2022. Cycles divided into groups 1 to 5, according to the day of embryo cryopreservation and the presence of a day 7 blastocyst sibling within the cohort: group 1/group 2-day 5 blastocyst without/with a day 7 sibling, group 3/group 4-day 6 blastocyst without/with a day 7 sibling, group 5-day 7 blastocyst. Clinical, ongoing pregnancy and miscarriage rates, cycle, and patient characteristics are reported. Multivariable generalized estimating equations (GEE) logistic regression analysis accounts for confounders and assesses the effect of a sibling day 7 blastocyst on ongoing pregnancy rates of day 5 or day 6 blastocyst FETs. RESULTS Ongoing pregnancy rates are 38.4%, 59.5%, 30.8%, 32.7%, and 4.4% in groups 1-5, respectively. When correcting for maternal age, number of oocytes retrieved and discarded per cohort, and ploidy, embryos cryopreserved on either day 6 or day 7 have reduced odds of ongoing pregnancy after FET compared to day 5 blastocysts (OR = 0.76, IQR [0.61-0.95], p-value = 0.01). However, the presence of a day 7 sibling does not significantly affect odds of ongoing pregnancy of day 5 or day 6 blastocysts compared to the same-day blastocyst without a day 7 sibling (p-value = 0.20 and 0.46, respectively). This finding is consistent within both the Preimplantation Genetic Testing for Aneuploidy (PGT-A) unscreened and screened (euploid) embryo subgroups. CONCLUSIONS Day of embryo cryopreservation significantly affects ongoing pregnancy rates. However, day 7 embryos within a cohort do not affect the reproductive potential of sibling day 5 and day 6 blastocysts, suggesting that slow embryo development is an embryo-specific trait.
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Affiliation(s)
- Jennia Michaeli
- Mount Sinai Fertility, Sinai Health System, 250 Dundas St. West, Suite 700, Toronto, ON, M5T 2Z5, Canada.
- Department of Obstetrics and Gynaecology, University of Toronto, 123 Edward St., Suite 1200, Toronto, ON, M5G 1E2, Canada.
| | - Natalie Ge
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Ellen M Greenblatt
- Mount Sinai Fertility, Sinai Health System, 250 Dundas St. West, Suite 700, Toronto, ON, M5T 2Z5, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, 123 Edward St., Suite 1200, Toronto, ON, M5G 1E2, Canada
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Nolan RP, Syed F, Stogios N, Maunder R, Sockalingam S, Tai ES, Cobain M, Peiris RG, Huszti E. The evaluation of goal-directed activities to promote well-being and health in heart failure: EUROIA scale. J Patient Rep Outcomes 2024; 8:47. [PMID: 38683439 PMCID: PMC11058156 DOI: 10.1186/s41687-024-00723-x] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 04/14/2024] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND The EvalUation of goal-diRected activities to prOmote well-beIng and heAlth (EUROIA) scale is a novel patient-reported measure that was administered to individuals with chronic heart failure (CHF). It assesses goal-directed activities that are self-reported as being personally meaningful and commonly utilized to optimize health-related quality of life (HRQL). Our aim was to evaluate psychometric properties of the EUROIA, and to determine if it accounted for novel variance in its association with clinical outcomes. METHODS This study was a secondary analysis of the CHF-CePPORT trial, which enrolled 231 CHF patients: median age = 59.5 years, 23% women. Baseline assessments included: EUROIA, Kansas City Cardiomyopathy Questionnaire-Overall Summary (KCCQ-OS), Patient Health Questionnaire-9 for depression (PHQ-9), and the Generalized Anxiety Disorder-7 (GAD-7). 12-month outcomes included health status (composite index of incident hospitalization or emergency department, ED, visit) and mental health (PHQ-9 and GAD-7). RESULTS Exploratory Principal Axis Factoring identified four EUROIA factors with satisfactory internal reliability: i.e., activities promoting eudaimonic well-being (McDondald's ω = 0.79), social affiliation (⍺=0.69), self-affirmation (⍺=0.73), and fulfillment of social roles/responsibilities (Spearman-Brown coefficient = 0.66). Multivariable logistic regression indicated that not only was the EUROIA inversely associated with incidence of 12-month hospitalization/ED visits independent of the KCCQ-OS (Odds Ratio, OR = 0.95, 95% Confidence Interval, CI, 0.91, 0.98), but it was also associated with 12-month PHQ-9 (OR = 0.91, 95% CI, 0.86, 0.97), and GAD-7 (OR = 0.94, 95% CI, 0.90, 0.99) whereas the KCCQ-OS was not. CONCLUSION The EUROIA provides a preliminary taxonomy of goal-directed activities that promote HRQL among CHF patients independently from a current gold standard state-based measure. CLINICAL TRIAL REGISTRATION NCT01864369; https://classic. CLINICALTRIALS gov/ct2/show/NCT01864369 .
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Affiliation(s)
- Robert P Nolan
- Behavioral Cardiology Research Unit, Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.
- Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, ON, Canada.
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
| | - Fatima Syed
- Behavioral Cardiology Research Unit, Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, ON, Canada
| | - Nicolette Stogios
- Behavioral Cardiology Research Unit, Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, ON, Canada
| | - Robert Maunder
- Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, Sinai Health System, Toronto, ON, Canada
| | - Sanjeev Sockalingam
- Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Education, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - E Shyong Tai
- Division of Endocrinology, National University Hospital, Singapore, Singapore
| | | | - Rachel G Peiris
- Behavioral Cardiology Research Unit, Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
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Tator CH, Moore C, Buso C, Huszti E, Li Q, Prentice EB, Khodadadi M, Scott O, Tartaglia CM. Cause of Concussion With Persisting Symptoms Is Associated With Long-Term Recovery and Symptom Type, Duration, and Number in a Longitudinal Cohort of 600 Patients. J Neurotrauma 2024. [PMID: 38468550 DOI: 10.1089/neu.2023.0263] [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] [Indexed: 03/13/2024] Open
Abstract
It is important for patients and clinicians to know the potential for recovery from concussion as soon as possible after injury, especially in patients who do not recover completely in the first month and have concussion with persisting concussion symptoms (C+PCS). We assessed the association between the causes of concussion and recovery from C+PCS in a consecutive retrospective and prospective cohort of 600 patients referred to the Canadian Concussion Center (CCC) at Toronto Western Hospital. Data were obtained from clinical records and follow-up questionnaires and not from a standardized database. A novel method was used to assess long-term recovery, and multi-variable Cox proportional hazards models were used to assess relationships between cause of concussion and time to recovery. We examined the subsequent recovery of patients who had not recovered after at least one month from the time of concussion. Patients were grouped into the following four causes: sports and recreation (S&R, n = 312, 52%); motor vehicle collisions (MVC, n = 103, 17%); falls (n = 100, 17%); and being struck by an object including violence (SBOV, n = 85, 14%). The MVC group had the highest percentage of females (75.7%), the oldest participants (median: 40.0 [interquartile range (IQR):30.5-49.0] years), the most symptoms (median:11.0 [IQR:8.5-15.0]), and the longest symptom duration (median: 28.0 [IQR:12.0-56.00] months). In contrast, the S&R group had the highest percentage of males (58.1%), the youngest participants (median:20.0 [IQR:17.0-30.0] years), the best recovery outcome, and shortest symptom duration (median:22.0 [IQR:8.0-49.5] months). Significant differences among the four causes included age (p < 0.001), sex (p < 0.001), number of previous concussions (p < 0.001), history of psychiatric disorders (p = 0.002), and migraine (p = 0.001). Recovery from concussion was categorized into three groups: (1) Complete Recovery occurred in only 60 (10%) patients with median time 8.0 (IQR:3.5-18.0) months and included 42 S&R, 7 MVC, 8 falls, and 3 SBOV; (2) Incomplete Recovery occurred in 408 (68.0%) patients with persisting median symptom time of 5.0 (IQR:2.0-12.0) months; and (3) Unknown Recovery occurred in 132 (22.0%) patients and was because of lack of follow-up. In summary, the cause of C+PCS was associated with the type, number, and duration of symptoms and time required for recovery, although all causes of C+PCS produced prolonged symptoms in a large percentage of patients, which emphasizes the importance of concussions as a public health concern necessitating improved prevention and treatment strategies.
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Affiliation(s)
- Charles H Tator
- Canadian Concussion Centre, Division of Neurosurgery, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Connor Moore
- Canadian Concussion Centre, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Chloé Buso
- Canadian Concussion Centre, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Qixuan Li
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Emma B Prentice
- Canadian Concussion Centre, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Mohzgan Khodadadi
- Canadian Concussion Centre, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Olivia Scott
- Canadian Concussion Centre, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Carmela M Tartaglia
- Canadian Concussion Centre, Division of Neurology, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
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Clarfield L, Shapiro J, Cherniak R, Szadkowski L, Huszti E, Whittle W, Czikk M, Menzies R. Short Cervix Following Initial Cerclage-Reinforcing Cerclage Versus Expectant Management. J Obstet Gynaecol Can 2024; 46:102286. [PMID: 37972692 DOI: 10.1016/j.jogc.2023.102286] [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: 06/13/2023] [Revised: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES To determine whether reinforcing cerclage following ultrasound evidence of cerclage failure before 24 weeks is an effective method to delay gestational age at delivery, and to decrease the rate of preterm and peri-viable delivery. METHODS A retrospective review was conducted for all patients who underwent any cervical cerclage procedure at a single tertiary care centre in Toronto, Canada between 1 December 2007 and 31 December 2017. RESULTS Of 1482 cerclage procedures completed during the study period, 40 pregnant persons who underwent reinforcing cerclage were compared with 40 pregnant persons who were found to have cerclage failure before 24 weeks but were managed expectantly. After adjusting for the shortest cervical length measured prior to 24 weeks, there was no significant difference between the reinforcing cerclage and control group for gestational age at delivery, preterm, or peri-viable birth (P = 0.52, P = 0.54, P = 0.74, respectively). In an unadjusted model, there was a statistically significant increase in placental infection identified on postpartum placenta pathology in the reinforcing cerclage group compared with the expectant management group, 92.9% compared with 66.7% (P = 0.028). CONCLUSION Reinforcing cerclage is unlikely to successfully delay the gestational age at delivery and reduce rates of preterm and pre-viable birth, especially if irreversible and progressive cervical change has begun. Future work should examine the role of preoperative amniocentesis to explore the impact of pre-existing intra-amniotic infection and reinforcing cerclage success.
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Affiliation(s)
- Lauren Clarfield
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON.
| | - Justin Shapiro
- Department of Otolaryngology - Head and Neck Surgery, Western University, London, ON
| | - Rebecca Cherniak
- Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON
| | - Leah Szadkowski
- Biostatistics Research Unit, University Health Network, Toronto, ON
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON
| | - Wendy Whittle
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON
| | - Marie Czikk
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON
| | - Rebecca Menzies
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON; Department of Obstetrics and Gynaecology, Trillium Health Partners, Mississauga, ON
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Saddoughi SA, Martinu T, Patriquin C, Barth D, Huszti E, Ghany R, Tinckam K, McRae K, Singer LG, Keshavjee S, Cypel M, Aversa M. Impact of intraoperative therapeutic plasma exchange on bleeding in lung transplantation. J Heart Lung Transplant 2024; 43:414-419. [PMID: 37813131 DOI: 10.1016/j.healun.2023.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 05/23/2023] [Revised: 09/21/2023] [Accepted: 10/02/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Our program uses a desensitization protocol that includes intraoperative therapeutic plasma exchange (iTPE) for crossmatch-positive lung transplants, which improves access to lung transplant for sensitized candidates while mitigating immunologic risk. Although we have reported excellent outcomes for sensitized patients with the use of this protocol, concern for perioperative bleeding appears to have hindered broader adoption of it at other programs. We conducted a retrospective cohort study to quantify the impact of iTPE on perioperative bleeding in lung transplantation. METHODS All first-time lung transplant recipients from 2014 to 2019 who received iTPE were compared to those who did not. Multivariable logistic regression was used to determine the association between iTPE and large-volume perioperative transfusion requirements (≥5 packed red blood cell units within 24 hours of transplant start), adjusted for disease type, transplant type, and extracorporeal membrane oxygenation or cardiopulmonary bypass use. The incidence of hemothorax (requiring reoperation within 7 days of lung transplant) and 30-day posttransplant mortality were compared between the 2 groups using chi-square test. RESULTS One hundred forty-two patients (16%) received iTPE, and 755 patients (84%) did not. The mean number of perioperative pRBC transfusions was 4.2 among patients who received iTPE and 2.9 among patients who did not. iTPE was associated with increased odds of requiring large-volume perioperative transfusion (odds ratio 1.9; 95% confidence interval: 1.2-2.9, p-value = 0.007) but was not associated with an increased incidence of hemothorax (5% in both groups, p = 0.99) or 30-day posttransplant mortality (3.5% among patients who received iTPE vs 2.1% among patients who did not, p = 0.31). CONCLUSIONS This study demonstrates that the use of iTPE in lung transplantation may increase perioperative bleeding but not to a degree that impacts important posttransplant outcomes.
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Affiliation(s)
- Sahar A Saddoughi
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Tereza Martinu
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Christopher Patriquin
- Division of Medical Oncology & Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - David Barth
- Division of Medical Oncology & Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Kathryn Tinckam
- Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Karen McRae
- Department of Anesthesia and Pain Management, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Meghan Aversa
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.
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Kawashima M, Ma J, Huszti E, Levy L, Berra G, Renaud-Picard B, Takahagi A, Ghany R, Sato M, Keshavjee S, Singer L, Husain S, Kumar D, Tikkanen J, Martinu T. Association between cytomegalovirus viremia and long-term outcomes in lung transplant recipients. Am J Transplant 2024:S1600-6135(24)00095-9. [PMID: 38307417 DOI: 10.1016/j.ajt.2024.01.027] [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: 06/04/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/04/2024]
Abstract
Although cytomegalovirus (CMV) viremia/DNAemia has been associated with reduced survival after lung transplantation, its association with chronic lung allograft dysfunction (CLAD) and its phenotypes is unclear. We hypothesized that, in a modern era of CMV prophylaxis, CMV DNAemia would still remain associated with death, but also represent a risk factor for CLAD and specifically restrictive allograft syndrome (RAS)/mixed phenotype. This was a single-center retrospective cohort study of all consecutive adult, first, bilateral-/single-lung transplants done between 2010-2016, consisting of 668 patients. Risks for death/retransplantation, CLAD, or RAS/mixed, were assessed by adjusted cause-specific Cox proportional-hazards models. CMV viral load (VL) was primarily modeled as a categorical variable: undetectable, detectable to 999, 1000 to 9999, and ≥10 000 IU/mL. In multivariable models, CMV VL was significantly associated with death/retransplantation (≥10 000 IU/mL: HR = 2.65 [1.78-3.94]; P < .01), but was not associated with CLAD, whereas CMV serostatus mismatch was (D+R-: HR = 2.04 [1.30-3.21]; P < .01). CMV VL was not associated with RAS/mixed in univariable analysis. Secondary analyses with a 7-level categorical or 4-level ordinal CMV VL confirmed similar results. In conclusion, CMV DNAemia is a significant risk factor for death/retransplantation, but not for CLAD or RAS/mixed. CMV serostatus mismatch may have an impact on CLAD through a pathway independent of DNAemia.
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Affiliation(s)
- Mitsuaki Kawashima
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Jin Ma
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Liran Levy
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Gregory Berra
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Benjamin Renaud-Picard
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Akihiro Takahagi
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Masaaki Sato
- Department of Thoracic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Lianne Singer
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shahid Husain
- Transplant Infectious Diseases & Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Deepali Kumar
- Transplant Infectious Diseases & Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Belousova N, Huszti E, Li Q, Vasileva A, Ghany R, Gabarin R, El Sanharawi M, Picard C, Hwang D, Levy L, Keshavjee S, Chow CW, Roux A, Martinu T. Center variability in the prognostic value of a cumulative acute cellular rejection "A-score" for long-term lung transplant outcomes. Am J Transplant 2024; 24:89-103. [PMID: 37625646 DOI: 10.1016/j.ajt.2023.08.014] [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: 04/27/2023] [Revised: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 08/27/2023]
Abstract
The acute rejection score (A-score) in lung transplant recipients, calculated as the average of acute cellular rejection A-grades across transbronchial biopsies, summarizes the cumulative burden of rejection over time. We assessed the association between A-score and transplant outcomes in 2 geographically distinct cohorts. The primary cohort included 772 double lung transplant recipients. The analysis was repeated in 300 patients from an independent comparison cohort. Time-dependent multivariable Cox models were constructed to evaluate the association between A-score and chronic lung allograft dysfunction or graft failure. Landmark analyses were performed with A-score calculated at 6 and 12 months posttransplant. In the primary cohort, no association was found between A-score and graft outcome. However, in the comparison cohort, time-dependent A-score was associated with chronic lung allograft dysfunction both as a time-dependent variable (hazard ratio, 1.51; P < .01) and when calculated at 6 months posttransplant (hazard ratio, 1.355; P = .031). The A-score can be a useful predictor of lung transplant outcomes in some settings but is not generalizable across all centers; its utility as a prognostication tool is therefore limited.
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Affiliation(s)
- Natalia Belousova
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Toronto, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Canada; Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France.
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Qixuan Li
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Anastasiia Vasileva
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Toronto, Canada
| | - Ramy Gabarin
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Canada
| | | | - Clement Picard
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - David Hwang
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Canada
| | - Liran Levy
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Toronto, Canada
| | - Chung-Wai Chow
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Toronto, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Canada
| | - Antoine Roux
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France; Paris Transplant Group, Paris, France
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Program and Division of Respirology, University Health Network, Toronto, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Canada
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10
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Deri O, Ovadia D, Huszti E, Peled M, Saute M, Hod T, Onn A, Seluk L, Furie N, Shafran I, Mass R, Chatterji S, Levy L. Referral rates and barriers to lung transplantation based on pulmonary function criteria in interstitial lung diseases: a retrospective cohort study. Ther Adv Respir Dis 2024; 18:17534666231221750. [PMID: 38179653 PMCID: PMC10771041 DOI: 10.1177/17534666231221750] [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: 03/25/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Interstitial lung diseases (ILD) unresponsive to medical therapy often require lung transplantation (LTx), which prolongs quality of life and survival. Ideal timing for referral for LTx remains challenging, with late referral associated with significant morbidity and mortality. Among other criteria, patients with ILD should be considered for LTx if forced vital capacity (FVC) is less than 80% or diffusion capacity for carbon monoxide (DLCO) is less than 40%. However, data on referral rates are lacking. OBJECTIVES To evaluate referral rates for LTx based on pulmonary function tests (PFTs) and identify barriers associated with non-referral. DESIGN A single-center retrospective cohort study. METHODS The study consisted of ILD patients who performed PFT between 2014 and 2020. Patients with FVC < 80% or a DLCO < 40% were included in the study. Patients with absolute contraindications to LTx were excluded. Referral rates were computed, and a comparison was made between referred and non-referred subjects. RESULTS Out of 114 ILD patients meeting criteria for referral to LTx, 35 were referred (30.7%), and 7 proceeded to undergo LTx. Median time from PFT to referral for assessment was 255 days [interquartile range (IQR) 35-1077]. Median time from referral to LTx was 89 days (IQR 59-143). Referred patients were younger (p = 0.003), had lower FVC (p < 0.001), DLCO (p < 0.001), and a higher rate of pulmonary hypertension (p = 0.04). Relatively better PFT, and older age, were significantly associated with non-referral of patients. CONCLUSION There is under-referral of ILD patients who are eligible for LTx, which is associated with severe disease and missed opportunities for LTx. Further research is required to validate these findings.
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Affiliation(s)
- Ofir Deri
- Institute of Pulmonary Medicine, Sheba Medical Center Hospital – Tel Hashomer, Office #32, Derech Sheba 2, Ramat Gan, Tel Hashomer 52621, Israel
| | - David Ovadia
- Department of Respiratory Care and Rehabilitation, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Michael Peled
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Milton Saute
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tammy Hod
- Renal Transplant Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Onn
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lior Seluk
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nadav Furie
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Inbal Shafran
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Mass
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sumit Chatterji
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liran Levy
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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11
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Da Conceicao D, Perlas A, Giron Arango L, Wild K, Li Q, Huszti E, Chowdhury J, Chan V. Validation of a novel point-of-care ultrasound method to assess diaphragmatic excursion. Reg Anesth Pain Med 2023:rapm-2023-104983. [PMID: 37940349 DOI: 10.1136/rapm-2023-104983] [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: 09/08/2023] [Accepted: 10/16/2023] [Indexed: 11/10/2023]
Abstract
INTRODUCTION Point-of-care ultrasound can assess diaphragmatic function and rule in or rule out paresis of the diaphragm. While this is a useful bedside tool, established methods have significant limitations. This study explores a new method to assess diaphragmatic motion by measuring the excursion of the uppermost point of the zone of apposition (ZOA) at the mid-axillary line using a high-frequency linear ultrasound probe and compares it with two previously established methods: the assessment of the excursion of the dome of the diaphragm (DOD) and the thickening ratio at the ZOA. METHODS This is a single-centre, prospective comparative study on elective surgical patients with normal diaphragmatic function. Following research ethics board approval and patient written consent, 75 elective surgical patients with normal diaphragmatic function were evaluated preoperatively. Three ultrasound methods were compared: (1) assessment of the excursion of the DOD using a curvilinear probe through an abdominal window; (2) assessment of the thickening fraction of the ZOA; and (3) assessment of the excursion of the ZOA. The last two methods performed with a linear probe on the lateral aspect of the chest. RESULTS Seventy-five patients were studied. We found that the evaluation of the excursion of the ZOA was more consistently successful (100% bilaterally) than the evaluation of the excursion of the DOD (98.7% and 34.7% on the right and left sides, respectively). The absolute values of the excursion of the ZOA were greater than and well correlated with the values of the DOD. CONCLUSION Our preliminary data from this exploratory study suggest that the evaluation of the excursion of the ZOA on the lateral aspect of the chest using a linear probe is consistently successful on both right and left sides. Future studies are needed to establish the distribution of normal values and suggest diagnostic criteria for diaphragmatic paresis or paralysis. TRIAL REGISTRATION NUMBER NCT03225508.
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Affiliation(s)
- Diogo Da Conceicao
- Anesthesia and Pain Management, Toronto Western Hospital - University Health Network, Toronto, Ontario, Canada
| | - Anahi Perlas
- Anesthesia and Pain Management, Toronto Western Hospital - University Health Network, Toronto, Ontario, Canada
| | - Laura Giron Arango
- Anesthesia and Pain Management, Toronto Western Hospital - University Health Network, Toronto, Ontario, Canada
| | - Kim Wild
- Anesthesia and Pain Management, Toronto Western Hospital - University Health Network, Toronto, Ontario, Canada
| | - Qixuan Li
- Biostatistical Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistical Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Jayanta Chowdhury
- Anesthesia and Pain Management, Toronto Western Hospital - University Health Network, Toronto, Ontario, Canada
| | - Vincent Chan
- Anesthesia and Pain Management, Toronto Western Hospital - University Health Network, Toronto, Ontario, Canada
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12
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Ninan K, Murphy KE, Asztalos EV, Jiang Y, Huszti E, Matthews SG, Santaguida P, Mukerji A, McDonald SD. The Impact of Infant Sex on Multiple Courses versus a Single Course of Antenatal Corticosteroids: A Secondary Analysis of a Randomized Controlled Trial. Am J Perinatol 2023. [PMID: 37935374 DOI: 10.1055/s-0043-1776348] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
OBJECTIVE Animal literature has suggested that the impact of antenatal corticosteroids (ACS) may vary by infant sex. Our objective was to assess the impact of infant sex on the use of multiple courses versus a single course of ACS and perinatal outcomes. STUDY DESIGN We conducted a secondary analysis of the Multiple Courses of Antenatal Corticosteroids for Preterm Birth trial, which randomly allocated pregnant people to multiple courses versus a single course of ACS. Our primary outcome was a composite of perinatal mortality or clinically significant neonatal morbidity (including neonatal death, stillbirth, severe respiratory distress syndrome, intraventricular hemorrhage [grade III or IV], cystic periventricular leukomalacia, and necrotizing enterocolitis [stage II or III]). Secondary outcomes included individual components of the primary outcome as well as anthropometric measures. Baseline characteristics were compared between participants who received multiple courses versus a single course of ACS. An interaction between exposure to ACS and infant sex was assessed for significance and multivariable regression analyses were conducted with adjustment for predefined covariates, when feasible. RESULTS Data on 2,300 infants were analyzed. The interaction term between treatment status (multiple courses vs. a single course of ACS) and infant sex was not significant for the primary outcome (p = 0.86), nor for any of the secondary outcomes (p > 0.05). CONCLUSION Infant sex did not modify the association between exposure to ACS and perinatal outcomes including perinatal mortality or neonatal morbidity or anthropometric outcomes. However, animal literature indicates that sex-specific differences after exposure to ACS may emerge over time and thus investigating long-term sex-specific outcomes warrants further attention. KEY POINTS · We explored the impact of infant sex on perinatal outcomes after multiple versus a single course of ACS.. · Infant sex was not a significant effect modifier of ACS exposure and perinatal outcomes.. · Animal literature indicates that sex-specific differences after ACS exposure may emerge over time.. · Further investigation of long-term sex-specific outcomes is warranted..
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Affiliation(s)
- Kiran Ninan
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Kellie E Murphy
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth V Asztalos
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Yidi Jiang
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Stephen G Matthews
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Pasqualina Santaguida
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Amit Mukerji
- Division of Neonatology, Department of Pediatrics, McMaster University, Ontario, Canada
| | - Sarah D McDonald
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Radiology, McMaster University, Hamilton, Ontario, Canada
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
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Hossain N, Prashad M, Huszti E, Li M, Alibhai S. Age-related differences in symptom distress among patients with cancer. J Geriatr Oncol 2023; 14:101601. [PMID: 37597295 DOI: 10.1016/j.jgo.2023.101601] [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: 11/27/2022] [Revised: 06/12/2023] [Accepted: 08/01/2023] [Indexed: 08/21/2023]
Abstract
INTRODUCTION Differences in symptom distress among older (age 65-74) and very old (age 75+) patients with cancer, compared to younger patients, remain to be well explored. These differences are important to understand given the heterogeneity of older populations and may have implications for age-appropriate symptom detection and management. MATERIALS AND METHODS We examined routinely collected Edmonton Symptom Assessment System Revised (ESAS-r) scores from 9,143 patients age 40+ initiating chemotherapy for solid malignancies at a single academic cancer centre, between September 2011 and May 2019. We used multivariable logistic regression models to determine associations between the most common symptoms and age group (ages 40-64, 65-74, 75-84, and 85+), cancer site, clinical stage, sex, and income levels. We focused our findings on patients with the five most common cancers, breast (n = 1,532), prostate (n = 923), lung (n = 889), pancreatic (n = 429), and colorectal (n = 368), prior to receiving treatment. RESULTS Within our sample, 58.0% were age 40-64, 27.3% age 65-74, 11.8% age 75-84, and 2.9% age 85+. Among the nine symptoms in the ESAS-r (anxiety, depression, tiredness, wellbeing, nausea, pain, drowsiness, appetite, and shortness of breath), the most common symptoms overall were anxiety (moderate-severe scores [ESAS-r 4 or higher] were reported by 33.8% of patients), lack of well-being (38.3%), and tiredness (38.3%). Older age was associated with lower odds of moderate/severe anxiety (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.73-0.90 for age 65-74; OR 0.81, 95%CI 0.70-0.93 for age 75-84; OR 0.62, 95%CI 0.47-0.82 for age 85+; referent is 40-64-year-olds for all analyses), and increased odds of tiredness (OR 1.00, 95%CI 0.90-1.11 for age 65-74; OR 1.19, 95%CI 1.04-1.37 for age 75-84; and OR 1.34, 95%CI 1.04-1.72 for age 85+). Advanced stage, female sex, and lower income levels were associated with higher odds of moderate/severe tiredness, anxiety, and lack of well-being in adjusted models. Patients with pancreatic and lung cancers reported worse scores for these three symptoms than patients with other cancers. DISCUSSION Older age was associated with differences in symptom experiences such as increased tiredness and reduced anxiety. Supportive care interventions and future research should focus on addressing these symptoms to improve patient quality of life.
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Affiliation(s)
- Nazia Hossain
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Michael Prashad
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Madeline Li
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Shabbir Alibhai
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University Health Network, Toronto, Ontario, Canada
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14
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Aversa M, Kiernan J, Martinu T, Patriquin C, Barth D, Li Q, Huszti E, Ghany R, Cypel M, Keshavjee S, Singer LG, Tinckam K. Outcomes after flow cytometry crossmatch-positive lung transplants managed with perioperative desensitization. Am J Transplant 2023; 23:1733-1739. [PMID: 37172694 DOI: 10.1016/j.ajt.2023.04.033] [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: 12/01/2022] [Revised: 03/06/2023] [Accepted: 04/03/2023] [Indexed: 05/15/2023]
Abstract
Our program previously reported successful outcomes following virtual crossmatch (VXM)-positive lung transplants managed with perioperative desensitization, but our ability to stratify their immunologic risk was limited without flow cytometry crossmatch (FCXM) data before 2014. The aim of this study was to determine allograft and chronic lung allograft dysfunction (CLAD)-free survival following VXM-positive/FCXM-positive lung transplants, which are performed at a minority of programs due to the high immunologic risk and lack of data on outcomes. All first-time lung transplant recipients between January 2014 and December 2019 were divided into 3 cohorts: VXM-negative (n = 764), VXM-positive/FCXM-negative (n = 64), and VXM-positive/FCXM-positive (n = 74). Allograft and CLAD-free survival were compared using Kaplan-Meier and multivariable Cox proportional hazards models. Five-year allograft survival was 53% in the VXM-negative cohort, 64% in the VXM-positive/FCXM-negative cohort, and 57% in the VXM-positive/FCXM-positive cohort (P = .7171). Five-year CLAD-free survival was 53% in the VXM-negative cohort, 60% in the VXM-positive/FCXM-negative cohort, and 63% in the VXM-positive/FCXM-positive cohort (P = .8509). This study confirms that allograft and CLAD-free survival of patients who undergo VXM-positive/FCXM-positive lung transplants with the use of our protocol does not differ from those of other lung transplant recipients. Our protocol for VXM-positive lung transplants improves access to transplant for sensitized candidates and mitigates even high immunologic risk.
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Affiliation(s)
- Meghan Aversa
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey Kiernan
- HLA Laboratory, Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Tereza Martinu
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Christopher Patriquin
- Division of Medical Oncology & Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - David Barth
- Division of Medical Oncology & Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Qixuan Li
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Kathryn Tinckam
- HLA Laboratory, Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada.
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15
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Caragata R, Emerson S, Santema ML, Selzner N, Sapisochin G, Wang S, Huszti E, Van Klei W, McCluskey SA. Intraoperative hypotension and the risk of acute kidney injury following liver transplantation. Clin Transplant 2023; 37:e15053. [PMID: 37350742 DOI: 10.1111/ctr.15053] [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: 01/31/2023] [Revised: 06/07/2023] [Accepted: 06/11/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a frequent adverse outcome following liver transplantation (LT) with a multifactorial etiology. It is critical to identify modifiable risk factors to mitigate the risk. One key area of interest is the role of intraoperative hypotension, which remains relatively unexplored in liver transplant cohorts. METHODS This was a retrospective observational cohort study of 1292 adult patients who underwent LT (between 2009 and 2019). Multivariable logistic regression analysis was used to explore the association between intraoperative hypotension, quantified by time duration (in min) under various mean arterial pressure (MAP) thresholds, and the primary outcome of early postoperative AKI according to the KDIGO criteria. RESULTS AKI occurred in 40% of patients and was independently associated with greater than 20 min spent below MAP thresholds of 55 mm Hg (adjusted OR = 1.866; 95% CI = 1.037-3.44; P = 0.041) and 50 mm Hg (adjusted OR = 1.801; 95% CI = 1.087-2.992; P = 0.023). Further sensitivity analyses demonstrated that the association between intraoperative hypotension and postoperative AKI was accentuated after restricting the analysis to patients with a normal preoperative renal function. CONCLUSIONS Prolonged (>20 min) intraoperative hypotension (below a MAP of 55 mm Hg) was independently associated with AKI following LT, after adjusting for several known confounders.
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Affiliation(s)
- Rebecca Caragata
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sophia Emerson
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael L Santema
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Nazia Selzner
- Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Stella Wang
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Wilton Van Klei
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Departement of Anesthesiology, University of Utrecht, Utrecht, The Netherlands
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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16
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Waters M, Huszti E, Ramirez ME, Lok CE. Infectious outcomes of fibrin sheath disruption in tunneled dialysis catheters. J Vasc Access 2023; 24:1091-1098. [PMID: 35001725 PMCID: PMC10631277 DOI: 10.1177/11297298211070690] [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: 01/18/2021] [Accepted: 11/28/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Fibrin sheath (FS) formation around tunneled central venous catheters (CVC) increases the risk of catheter-related bloodstream infections due to bacterial adherence to a biofilm. We sought to investigate whether FS disruption (FSD) at the time of CVC removal or exchange affects infectious outcomes in patients with CVC-related infections. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS Retrospective cohort study of 307 adult maintenance hemodialysis patients aged 18 years or older at a single center academic-based hemodialysis program (UHN, Toronto) who developed CVC-related infections requiring CVC removal or exchange between January 2000 and January 2019. Exposure was FSD at the time of CVC removal or exchange. Outcomes were infectious metastatic complications, recurrent infection with the same organism within 1 year, or death due to infection. We created a Markov Multi-State Model (MMSM) to assess patients' trajectories through time as they transitioned between states. A time-to-event analysis was performed, adjusted for clinically relevant factors. RESULTS There was no significant relationship between FSD status at the time of CVC removal, the development of infectious complications in the multivariable model (adjusted HR = 0.71, 95% CI 0.09-5.80, p = 0.76), or mortality from infection (HR = 0.84, 95% CI 0.34-2.11, p = 0.73). CONCLUSIONS FSD at the time of CVC removal was not associated with increased risk of infectious complications or death due to infection. Further prospective study is needed to determine whether FSD contributes to reducing CVC infectious related complications.
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Affiliation(s)
- Mara Waters
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Maria Erika Ramirez
- Division of Nephrology, Department of Medicine, St. Luke’s Medical Center, Quezon City, Philippines
| | - Charmaine E. Lok
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Nephrology, Department of Medicine, University Health Network – Toronto General Hospital, Toronto, ON, Canada
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Ramendra R, Fernández-Castillo JC, Huszti E, Ghany R, Aversa M, Havlin J, Riddell P, Chaparro CM, Singer LG, Liu L, Keshavjee S, Yeung JC, Martinu T. Oesophageal stasis is a risk factor for chronic lung allograft dysfunction and allograft failure in lung transplant recipients. ERJ Open Res 2023; 9:00222-2023. [PMID: 37817870 PMCID: PMC10561084 DOI: 10.1183/23120541.00222-2023] [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: 04/12/2023] [Accepted: 07/04/2023] [Indexed: 10/12/2023] Open
Abstract
Background Morbidity and mortality in lung transplant recipients are often triggered by recurrent aspiration events, potentiated by oesophageal and gastric disorders. Previous small studies have shown conflicting associations between oesophageal function and the development of chronic lung allograft dysfunction (CLAD). Herein, we sought to investigate the relationship between oesophageal motility disorders and long-term outcomes in a large retrospective cohort of lung transplant recipients. Methods All lung transplant recipients at the Toronto Lung Transplant Program from 2012 to 2018 with available oesophageal manometry testing within the first 7 months post-transplant were included in this study. Patients were categorised according to the Chicago Classification of oesophageal disorders (v3.0). Associations between oesophageal motility disorders with the development of CLAD and allograft failure (defined as death or re-transplantation) were assessed. Results Of 487 patients, 57 (12%) had oesophagogastric junction outflow obstruction (OGJOO) and 47 (10%) had a disorder of peristalsis (eight major, 39 minor). In a multivariable analysis, OGJOO was associated with an increased risk of CLAD (HR 1.71, 95% CI 1.15-2.55, p=0.008) and allograft failure (HR 1.69, 95% CI 1.13-2.53, p=0.01). Major disorders of peristalsis were associated with an increased risk of CLAD (HR 1.55, 95% CI 1.01-2.37, p=0.04) and allograft failure (HR 3.33, 95% CI 1.53-7.25, p=0.002). Minor disorders of peristalsis were not significantly associated with CLAD or allograft failure. Conclusion Lung transplant recipients with oesophageal stasis characterised by OGJOO or major disorders of peristalsis were at an increased risk of adverse long-term outcomes. These findings will help with risk stratification of lung transplant recipients and personalisation of treatment for aspiration prevention.
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Affiliation(s)
- Rayoun Ramendra
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Juan C. Fernández-Castillo
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Meghan Aversa
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jan Havlin
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Peter Riddell
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Cecilia M. Chaparro
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Lianne G. Singer
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Louis Liu
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jonathan C. Yeung
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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18
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Levy L, Moshkelgosha S, Huszti E, Hunter S, Renaud-Picard B, Berra G, Kawashima M, Fernandez-Castillo J, Fuchs E, Dianti M, Ghany R, Keshavjee S, Singer LG, Tikkanen J, Martinu T. Pulmonary epithelial markers in phenotypes of chronic lung allograft dysfunction. J Heart Lung Transplant 2023; 42:1152-1160. [PMID: 36963446 DOI: 10.1016/j.healun.2023.03.009] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 02/21/2023] [Accepted: 03/10/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND Airway epithelial injury is thought to be a key event in the pathogenesis of chronic lung allograft dysfunction (CLAD). We investigated whether markers of epithelial activity and injury in bronchoalveolar lavage fluid (BAL) correlate with CLAD diagnosis and major CLAD phenotypes: bronchiolitis obliterans syndrome (BOS) vs restrictive allograft syndrome (RAS)-related phenotypes (including RAS, mixed phenotype, and all other patients with RAS-like opacities). METHODS CLAD status and phenotypes were retrospectively determined in a cohort of all consecutive adult, first, bilateral lung transplants performed 2010-2015, with available BAL samples. All patients with RAS-related phenotypes were included and 1:1 matched with BOS patients based on the time from transplant to CLAD-onset. Subjects who were CLAD-free for a minimum of 3 years post-transplant were 1:1 matched to CLAD patients and included as controls. Proteins that maintain the barrier function of the airway epithelial mucosa (club cell secretory protein, surfactant protein-D and epithelial mucins: MUC1, MUC5AC, MUC5B, MUC16), as well as epithelial cell death markers (M30&M65 representing epithelial cell apoptosis and overall death, respectively), were measured in BAL obtained within 6-months post CLAD onset using a double-sandwich ELISA or a multiplex bead assay. Protein levels were compared using Mann-Whitney-U-test. Association between protein levels and graft survival was assessed using Cox proportional hazards models, adjusted for CMV serology mismatch status and CLAD phenotype. RESULTS Fifty-four CLAD (27 BOS, 11 RAS, 7 mixed, 9 others with RAS-like opacities) patients and 23 CLAD-free controls were included. Median BAL levels were significantly higher in patients with CLAD compared to CLAD-free controls for M30 (124.5 vs 88.7 U/L), MUC1 (6.8 vs 3.2 pg/mL), and MUC16 (121.0 vs 30.1 pg/mL). When comparing CLAD phenotypes, M30 was significantly higher in patients with RAS-related phenotypes than BOS (160.9 vs 114.6 U/L). In multivariable models, higher M30 and MUC5B levels were associated with decreased allograft survival after CLAD onset independent of phenotype (p < 0.05 for all). CONCLUSIONS Airway epithelial mucins and cell death markers are enhanced in the BAL of patients with CLAD and can assist in differentiating between CLAD phenotypes and post-CLAD outcomes. Abnormal airway mucin expression and epithelial cell death may be involved in the pathogenesis of CLAD, and therefore their detection may aid in future selection of targeted therapies.
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Affiliation(s)
- Liran Levy
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Institute of Pulmonary Medicine, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Sajad Moshkelgosha
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Sarah Hunter
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | | | - Gregory Berra
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Mitsuaki Kawashima
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | | | - Eyal Fuchs
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Milagros Dianti
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
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19
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Choi C, Shing P, Wang S, Huszti E. Measuring vibration and shock in power wheelchairs for clinical application. Assist Technol 2023:1-8. [PMID: 37463511 DOI: 10.1080/10400435.2023.2230485] [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] [Accepted: 06/23/2023] [Indexed: 07/20/2023] Open
Abstract
Research evidence demonstrates the negative effects of Whole-Body Vibration (WBV) and correlation between exposure to WBV and detriment to health. ISO Standard 2631-1 (1997) is the accepted standard for human exposure to WBV in vehicle vibration, and provides vibration guidelines for health and comfort. These standards have not been applied to power wheelchairs (PWC), and no clinical tool exists that measures vibration levels during live power wheelchair driving. This study measures WBV and shock levels during PWC driving, considering the impact of terrains, base configurations, and seat cushions. A sensor tag accelerometer was used to measure vibration and shock in three different PWC configurations driven over seven different terrains. Data was collected for two runs per wheelchair, per terrain type, per cushion type. Differences were significant (p < .001) for overall mean and median peak vibration compared across the seven terrains, and for overall mean vibration for basic and enhanced cushions. Differences were also noted in mean and peak vibration in the three different base configurations (p = .0052). Results were compared with ISO 2631-1 guidelines. Mechanical shock on certain terrains created peak vibration levels with likely health risk. Results from this study can inform PWC prescription process.
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Affiliation(s)
- Cathy Choi
- Seating Clinic, Hennick Bridgepoint Hospital - Sinai Health, Toronto, Canada
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada
| | - Paula Shing
- Professional Practice, Hennick Bridgepoint Hospital - Sinai Health, Toronto, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - Stella Wang
- Biostatistics Research Unit, University Health Network (UHN), Toronto, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network (UHN), Toronto, Canada
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20
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Rozenberg D, Shore J, Camacho Perez E, Nourouzpour S, Ibrahim Masthan M, Santa Mina D, Campos JL, Huszti E, Green R, Khan MH, Lau A, Gold D, Stanbrook MB, Reid WD. Feasibility of a Home-Based Cognitive-Physical Exercise Program in Patients With Chronic Obstructive Pulmonary Disease: Protocol for a Feasibility and Pilot Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e48666. [PMID: 37436794 PMCID: PMC10372770 DOI: 10.2196/48666] [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: 05/11/2023] [Accepted: 05/25/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a progressive condition associated with physical and cognitive impairments contributing to difficulty in performing activities of daily living (ADLs) that require dual tasking (eg, walking and talking). Despite evidence showing that cognitive decline occurs among patients with COPD and may contribute to functional limitations and decreased health-related quality of life (HRQL), pulmonary rehabilitation continues to focus mainly on physical training (ie, aerobic and strength exercises). An integrated cognitive and physical training program compared to physical training alone may be more effective in increasing dual-tasking ability among people living with COPD, leading to greater improvements in performance of ADLs and HRQL. OBJECTIVE The aims of this study are to evaluate the feasibility of an 8-week randomized controlled trial of home-based, cognitive-physical training versus physical training for patients with moderate to severe COPD and derive preliminary estimates of cognitive-physical training intervention efficacy on measures of physical and cognitive function, dual task performance, ADLs, and HRQL. METHODS A total of 24 participants with moderate to severe COPD will be recruited and randomized into cognitive-physical training or physical training. All participants will be prescribed an individualized home physical exercise program comprising 5 days of moderate-intensity aerobic exercise (30-50 minutes/session) and 2 days of whole-body strength training per week. The cognitive-physical training group will also perform cognitive training for approximately 60 minutes, 5 days per week via the BrainHQ platform (Posit Science Corporation). Participants will meet once weekly with an exercise professional (via videoconference) who will provide support by reviewing the progression of their training and addressing any queries. Feasibility will be assessed through the recruitment rate, program adherence, satisfaction, attrition, and safety. The intervention efficacy regarding dual task performance, physical function, ADLs, and HRQL will be evaluated at baseline and at 4 and 8 weeks. Descriptive statistics will be used to summarize intervention feasibility. Paired 2-tailed t tests and 2-tailed t tests will be used to compare the changes in the outcome measures over the 8-week study period within and between the 2 randomized groups, respectively. RESULTS Enrollment started in January 2022. It is estimated that the enrollment period will be 24 months long, with data collection to be completed by December 2023. CONCLUSIONS A supervised home-based cognitive-physical training program may be an accessible intervention to improve dual-tasking ability in people living with COPD. Evaluating the feasibility and effect estimates is a critical first step to inform future clinical trials evaluating this approach and its effects on physical and cognitive function, ADL performance, and HRQL. TRIAL REGISTRATION ClinicalTrials.gov NCT05140226; https://clinicaltrials.gov/ct2/show/NCT05140226. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/48666.
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Affiliation(s)
- Dmitry Rozenberg
- Respirology and Lung Transplantation, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Josh Shore
- Division of Respirology, University Health Network, Toronto, ON, Canada
| | | | - Sahar Nourouzpour
- Division of Respirology, University Health Network, Toronto, ON, Canada
| | | | - Daniel Santa Mina
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Jennifer L Campos
- Toronto Rehabilitation Institute (KITE), University Health Network, Toronto, ON, Canada
- Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Robin Green
- Toronto Rehabilitation Institute (KITE), University Health Network, Toronto, ON, Canada
| | | | - Ambrose Lau
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Respirology, University Health Network, Toronto, ON, Canada
| | - David Gold
- Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Matthew B Stanbrook
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Respirology, University Health Network, Toronto, ON, Canada
| | - W Darlene Reid
- Toronto Rehabilitation Institute (KITE), University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
- Interdivisional Department of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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21
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Baghlaf H, Snelgrove JW, Li Q, Huszti E, McDonald SD, Asztalos E, Palermo MSF, Murphy KE. One vs 2 courses of antenatal corticosteroids in pregnancies at risk of preterm birth: a secondary analysis of the MACS trial. Am J Obstet Gynecol MFM 2023; 5:101002. [PMID: 37149145 DOI: 10.1016/j.ajogmf.2023.101002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 02/19/2023] [Revised: 04/27/2023] [Accepted: 04/30/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Birth is unpredictable and many patients who receive antenatal corticosteroids for preterm birth remain pregnant. Some professional societies recommend rescue antenatal corticosteroids for those who remain pregnant ≥14 days following the initial course. OBJECTIVE This study aimed to explore a single vs a second course of antenatal corticosteroids in terms of severe neonatal morbidity and mortality. STUDY DESIGN This is a secondary analysis of the Multiple Courses of Antenatal Corticosteroids for Preterm Birth (MACS) trial. The MACS study was a randomized clinical trial conducted in 80 centers in 20 different countries from 2001 to 2006. Participants who received only 1 course of intervention (ie, either a second course of antenatal corticosteroids or placebo) were included in this study. The primary outcome was a composite of stillbirth, neonatal mortality in the first 28 days of life or before discharge, severe respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage stage III and IV, periventricular leukomalacia, and necrotizing enterocolitis. Two subgroup analyses were planned to address the effect of a second course of antenatal corticosteroids on infants born before 32 weeks or within 7 days from the intervention. Moreover, a sensitivity analysis was performed to assess the effect of intervention on singleton pregnancies. Baseline characteristics were compared between the groups using chi-square and Student t tests. Multivariable regression analysis was performed to adjust for confounding variables. RESULTS There were 385 and 365 participants included in the antenatal corticosteroid and placebo groups, respectively. The composite primary outcome occurred in 24% and 20% of participants in the antenatal corticosteroid and placebo groups, respectively (adjusted odds ratio, 1.09; 95% confidence interval, 0.76-1.57). Moreover, severe respiratory distress syndrome rate was similar between the 2 groups (adjusted odds ratio, 0.98; 95% confidence interval, 0.65-1.48). Newborns exposed to antenatal corticosteroids were more likely to be small for gestational age (14.9% vs 10.6%; adjusted odds ratio, 1.63; 95% confidence interval, 1.07-2.47). These findings remained true among singleton pregnancies for the primary composite outcome and birthweight <10th percentile (adjusted odds ratio, 1.29 [0.82-2.01]; and adjusted odds ratio, 1.74 [1.06-2.87]; respectively). Subgroup analyses of infants born before 32 weeks or within 7 days from the intervention did not show any benefits in terms of the composite primary outcome with antenatal corticosteroids vs placebo (50.5% vs 41.8% [adjusted odds ratio, 1.16; 95% confidence interval, 0.78-1.72]; and 42.3% vs 37.1% [adjusted odds ratio, 1.02; 95% confidence interval, 0.67-1.57]; respectively). CONCLUSION Neonatal mortality and severe morbidities, including severe respiratory distress syndrome, were not improved by a second course of antenatal corticosteroids. Policy makers need to be thoughtful when recommending a second course of antenatal corticosteroids and consider whether not only short-term but also long-term benefits can be gained from such administration.
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Affiliation(s)
- Haitham Baghlaf
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada (Drs Baghlaf, Snelgrove, and Murphy); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Canada (Dr Baghlaf)
| | - John W Snelgrove
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada (Drs Baghlaf, Snelgrove, and Murphy)
| | - Qixuan Li
- Biostatistics Research Unit, University Health Network, Toronto, Canada (Ms Li and Dr Huszti)
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Canada (Ms Li and Dr Huszti)
| | - Sarah D McDonald
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada (Dr McDonald); Departments of Radiology, and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada (Dr McDonald)
| | - Elizabeth Asztalos
- Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Canada (Dr Asztalos)
| | - Mario S F Palermo
- Faculty of Medical Sciences, Department of Obstetrics and Gynecology, University of Buenos Aires, Buenos Aires, Argentina (Dr Palermo)
| | - Kellie E Murphy
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada (Drs Baghlaf, Snelgrove, and Murphy).
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22
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Levy L, Deri O, Huszti E, Nachum E, Ledot S, Shimoni N, Saute M, Sternik L, Kremer R, Kassif Y, Zeitlin N, Frogel J, Lambrikov I, Matskovski I, Chatterji S, Seluk L, Furie N, Shafran I, Mass R, Onn A, Raanani E, Grinberg A, Levy Y, Afek A, Kreiss Y, Kogan A. Timing of Lung Transplant Referral in Patients with Severe COVID-19 Lung Injury Supported by ECMO. J Clin Med 2023; 12:4041. [PMID: 37373734 DOI: 10.3390/jcm12124041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 04/06/2023] [Revised: 05/24/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
Severe respiratory failure caused by COVID-19 often requires mechanical ventilation, including extracorporeal membrane oxygenation (ECMO). In rare cases, lung transplantation (LTx) may be considered as a last resort. However, uncertainties remain about patient selection and optimal timing for referral and listing. This retrospective study analyzed patients with severe COVID-19 who were supported by veno-venous ECMO and listed for LTx between July 2020 and June 2022. Out of the 20 patients in the study population, four who underwent LTx were excluded. The clinical characteristics of the remaining 16 patients were compared, including nine who recovered and seven who died while awaiting LTx. The median duration from hospitalization to listing was 85.5 days, and the median duration on the waitlist was 25.5 days. Younger age was significantly associated with a higher likelihood of recovery without LTx after a median of 59 days on ECMO, compared to those who died at a median of 99 days. In patients with severe COVID-19-induced lung damage supported by ECMO, referral to LTx should be delayed for 8-10 weeks after ECMO initiation, particularly for younger patients who have a higher probability of spontaneous recovery and may not require LTx.
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Affiliation(s)
- Liran Levy
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ofir Deri
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON M5G 1X6, Canada
| | - Eyal Nachum
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Stephane Ledot
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Nir Shimoni
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Milton Saute
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Thoracic Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Leonid Sternik
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ran Kremer
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Thoracic Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Yigal Kassif
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Nona Zeitlin
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Thoracic Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Jonathan Frogel
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ilya Lambrikov
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ilia Matskovski
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Sumit Chatterji
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Lior Seluk
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Nadav Furie
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Inbal Shafran
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ronen Mass
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Amir Onn
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ehud Raanani
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Amir Grinberg
- General Management, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Yuval Levy
- General Management, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Arnon Afek
- General Management, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Yitshak Kreiss
- General Management, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Alexander Kogan
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
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Vasileva A, Hanafi N, Huszti E, Matelski J, Belousova N, Wu JKY, Martinu T, Ghany R, Keshavjee S, Tikkanen J, Cypel M, Yeung JC, Ryan CM, Chow CW. Intra-subject variability in oscillometry correlates with acute rejection and CLAD post-lung transplant. Front Med (Lausanne) 2023; 10:1158870. [PMID: 37305133 PMCID: PMC10248398 DOI: 10.3389/fmed.2023.1158870] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/04/2023] [Indexed: 06/13/2023] Open
Abstract
Background Chronic lung allograft dysfunction (CLAD) is the major cause of death post-lung transplantation, with acute cellular rejection (ACR) being the biggest contributing risk factor. Although patients are routinely monitored with spirometry, FEV1 is stable or improving in most ACR episodes. In contrast, oscillometry is highly sensitive to respiratory mechanics and shown to track graft injury associated with ACR and its improvement following treatment. We hypothesize that intra-subject variability in oscillometry measurements correlates with ACR and risk of CLAD. Methods Of 289 bilateral lung recipients enrolled for oscillometry prior to laboratory-based spirometry between December 2017 and March 2020, 230 had ≥ 3 months and 175 had ≥ 6 months of follow-up. While 37 patients developed CLAD, only 29 had oscillometry at time of CLAD onset and were included for analysis. These 29 CLAD patients were time-matched with 129 CLAD-free recipients. We performed multivariable regression to investigate the associations between variance in spirometry/oscillometry and the A-score, a cumulative index of ACR, as our predictor of primary interest. Conditional logistic regression models were built to investigate associations with CLAD. Results Multivariable regression showed that the A-score was positively associated with the variance in oscillometry measurements. Conditional logistic regression models revealed that higher variance in the oscillometry metrics of ventilatory inhomogeneity, X5, AX, and R5-19, was independently associated with increased risk of CLAD (p < 0.05); no association was found for variance in %predicted FEV1. Conclusion Oscillometry tracks graft injury and recovery post-transplant. Monitoring with oscillometry could facilitate earlier identification of graft injury, prompting investigation to identify treatable causes and decrease the risk of CLAD.
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Affiliation(s)
- Anastasiia Vasileva
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nour Hanafi
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Natalia Belousova
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
| | - Joyce K. Y. Wu
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Pulmonary Function Laboratory, University Health Network, Toronto, ON, Canada
| | - Tereza Martinu
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
- Division of Thoracic Surgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jussi Tikkanen
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
- Division of Thoracic Surgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jonathan C. Yeung
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
- Division of Thoracic Surgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Clodagh M. Ryan
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Pulmonary Function Laboratory, University Health Network, Toronto, ON, Canada
| | - Chung-Wai Chow
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Multi-Organ Transplant Unit, University Health Network, Toronto, ON, Canada
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24
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Muñoz-Leyva F, Perlas A, Chin KJ, Soheili M, Li Q, Huszti E, Chan V. A hood shield reduces postdoffing contamination during simulated COVID-19 airway management: an exploratory, simulation-based randomized study. Can J Anaesth 2023; 70:869-877. [PMID: 37020172 PMCID: PMC10075501 DOI: 10.1007/s12630-023-02400-x] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 04/07/2023] Open
Abstract
PURPOSE SARS-CoV-2 poses a significant occupational health threat to health care workers performing aerosol-generating medical procedures, with a threefold increased risk of a positive test and predicted infection compared with the general population. Nevertheless, the personal protective equipment (PPE) configuration that provides better protection with lower contamination rates is still unknown. METHODS We enrolled 40 practitioners with airway management training (anesthesiologists, anesthesia assistants/nurses) in an exploratory, simulation-based randomized study. We evaluated the performance of a novel, locally designed hood (n = 20) in terms of protection from surrogate contamination using an ultraviolet (UV) marker during a standardized urgent intubation procedure and a simulated episode of coughing in a high-fidelity simulation setting compared with standard PPE (n = 20). The primary outcome was the presence of residual UV fluorescent contamination on any base clothing or exposed skin of the upper body after doffing PPE assessed by a blinded evaluator. RESULTS The proportion of participants with residual contamination on any base clothing or exposed skin of the upper body after doffing was less than half in the hood PPE group compared with the standard PPE group (8/20 [40%] vs 18/20 [90%], respectively; P = 0.002). CONCLUSIONS Compared with standard PPE, enhanced PPE with a locally designed prototype hood was associated with reduced contamination of the upper torso and fewer body areas being exposed to droplets after a simulated aerosol-generating scenario without designed airflow. STUDY REGISTRATION ClinicalTrials.gov (NCT04373096); registered 4 May 2020.
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Affiliation(s)
- Felipe Muñoz-Leyva
- Department of Anesthesiology and Pain Medicine, University Health Network, Toronto Western Hospital, University of Toronto, 399 Bathurst St., Mc Laughlin Pavilion, 2-405, Toronto, ON, M5T 2S8, Canada
- Hospital Universitario Mayor, Méderi, Bogotá, Colombia
- Faculty of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Anahi Perlas
- Department of Anesthesiology and Pain Medicine, University Health Network, Toronto Western Hospital, University of Toronto, 399 Bathurst St., Mc Laughlin Pavilion, 2-405, Toronto, ON, M5T 2S8, Canada.
| | - Ki Jinn Chin
- Department of Anesthesiology and Pain Medicine, University Health Network, Toronto Western Hospital, University of Toronto, 399 Bathurst St., Mc Laughlin Pavilion, 2-405, Toronto, ON, M5T 2S8, Canada
| | - Mehdi Soheili
- Department of Anesthesiology and Pain Medicine, University Health Network, Toronto Western Hospital, University of Toronto, 399 Bathurst St., Mc Laughlin Pavilion, 2-405, Toronto, ON, M5T 2S8, Canada
| | - Qixuan Li
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Vincent Chan
- Department of Anesthesiology and Pain Medicine, University Health Network, Toronto Western Hospital, University of Toronto, 399 Bathurst St., Mc Laughlin Pavilion, 2-405, Toronto, ON, M5T 2S8, Canada
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ISHIWATA T, Wang S, Huszti E, Aversa M, Singer L, Martinu T. Association of Peripheral Blood Absolute Lymphocyte Count with Chronic Lung Allograft Dysfunction and Survival after Lung Transplantation: A Retrospective Single-Center Cohort Study. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1596] [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: 04/05/2023] Open
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26
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Saddoughi S, Martinu T, Singer L, Ge X, Ghany R, Huszti E, Patriquin C, Barth D, McRae K, Keshavjee S, Cypel M, Aversa M. Impact of Intraoperative Therapeutic Plasma Exchange on Bleeding in Lung Transplantation. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.419] [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: 04/05/2023] Open
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27
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McInnis M, Wang S, Houbois C, Karur G, Berra G, Levy L, Chow C, Singer L, Huszti E, Martinu T. Quantitative CT Identifies Phenotypes of Chronic Lung Allograft Dysfunction (CLAD) in Single Lung Transplants (LTx) with Greater Allograft Injury Compared to Double LTx. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1440] [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: 04/05/2023] Open
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28
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Dianti M, Martinu T, Sidhu A, Huszti E, Ghany R, Singer L, Aversa M. Diagnostic Utility of Surveillance Transbronchial Biopsies after the First Post-Lung Transplant Year. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1402] [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: 04/05/2023] Open
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29
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Rozenberg D, Al Kaabi N, Camacho Perez E, Nourouzpour S, Lopez-Hernandez L, McGillis L, Goligher E, Reid WD, Chow CW, Ryan CM, Kumbhare D, Huszti E, Champagne K, Raj S, Mak S, Santa Mina D, Clarke H, Mittal N. Evaluation and Management of Dyspnea in Hypermobile Ehlers-Danlos Syndrome and Generalized Hypermobility Spectrum Disorder: Protocol for a Pilot and Feasibility Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e44832. [PMID: 36939815 PMCID: PMC10131980 DOI: 10.2196/44832] [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: 12/17/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Dyspnea is a prevalent symptom in individuals with hypermobile Ehlers-Danlos Syndrome (hEDS) and generalized hypermobility spectrum disorder (G-HSD), yet its contributors have not been identified. One known contributor to dyspnea is respiratory muscle weakness. The feasibility and effectiveness of inspiratory muscle training (IMT) in combination with standard-of-care rehabilitation (aerobic, resistance, neuromuscular stabilization, and balance and proprioception exercises) in improving respiratory muscle strength and patient-reported outcomes in patients with hEDS or G-HSD have not been evaluated. OBJECTIVE This study aims to evaluate dyspnea, respiratory muscle strength, and patient-reported outcome measures (PROMs) in hEDS or G-HSD compared with healthy controls and to assess the feasibility of a randomized controlled trial of IMT and standard-of-care rehabilitation for improving respiratory muscle strength, exercise capacity, and PROMs compared with standard-of-care rehabilitation in hEDS and G-HSD. METHODS The study will include 34 participants with hEDS or G-HSD and 17 healthy, age- and sex-matched controls to compare respiratory muscle structure and function and PROMs. After baseline assessments, participants with hEDS or G-HSD will be randomized into the intervention group and provided IMT combined with Ehlers-Danlos Syndrome standard-of-care rehabilitation or into the usual care group, and provided only standard-of-care rehabilitation for 8 weeks. The intervention group will be prescribed IMT in their home environment using the POWERbreathe K5 IMT device (POWERbreathe International Ltd). IMT will comprise 2 daily sessions of 30 breaths for 5 days per week, with IMT progressing from 20% to 60% of the baseline maximal inspiratory pressure (MIP) over an 8-week period. Feasibility will be assessed through rates of recruitment, attrition, adherence, adverse events, and participant satisfaction. The primary pilot outcome is MIP change over an 8-week period in hEDS or G-HSD. Secondary outcomes will include the evaluation of dyspnea using Medical Research Council Scale and 18-point qualitative dyspnea descriptors; diaphragmatic thickening fraction using ultrasound; respiratory muscle endurance; pulmonary function; prefrontal cortical activity using functional near-infrared spectroscopy; aerobic capacity during cardiopulmonary exercise testing; quality of life using Short Form-36; and scores from the Depression, Anxiety, and Stress scale-21. These measures will also be performed once in healthy controls to compare normative values. Multivariable regression will be used to assess the contributors to dyspnea. Paired 2-tailed t tests will be used to assess the changes in MIP and secondary measures after 8 weeks of IMT. RESULTS Study recruitment began in August 2021 and, with several disruptions owing to COVID-19, is expected to be completed by December 2023. CONCLUSIONS This study will provide a better understanding of the factors associated with dyspnea and the feasibility and effectiveness of IMT combined with standard-of-care rehabilitation. IMT may be a novel therapeutic strategy for improving respiratory muscle function and patient-reported outcomes in individuals with hEDS or G-HSD. TRIAL REGISTRATION ClinicalTrials.gov NCT04972565; https://clinicaltrials.gov/ct2/show/NCT04972565. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/44832.
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Affiliation(s)
- Dmitry Rozenberg
- Respirology and Lung Transplantation, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
| | - Noor Al Kaabi
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
- Respirology, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Encarna Camacho Perez
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
- Respirology, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Sahar Nourouzpour
- Respirology, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Laura Lopez-Hernandez
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
| | - Laura McGillis
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
| | - Ewan Goligher
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Respirology, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - W Darlene Reid
- KITE-Toronto Rehab, University Health Network, Toronto, ON, Canada
- Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Chung-Wai Chow
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Respirology, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Clodagh M Ryan
- KITE-Toronto Rehab, University Health Network, Toronto, ON, Canada
| | - Dinesh Kumbhare
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- KITE-Toronto Rehab, University Health Network, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | | | - Satish Raj
- Department of Cardiac Sciences, Cumming School of Medicine, Calgary, AB, Canada
| | - Susanna Mak
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Cardiology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Daniel Santa Mina
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Hance Clarke
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Nimish Mittal
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
- KITE-Toronto Rehab, University Health Network, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
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Khalil C, Zarabi S, Kirkham K, Soni V, Li Q, Huszti E, Yadollahi A, Taati B, Englesakis M, Singh M. Validity of non-contact methods for diagnosis of Obstructive Sleep Apnea: a systematic review and meta-analysis. J Clin Anesth 2023; 87:111087. [PMID: 36868010 DOI: 10.1016/j.jclinane.2023.111087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 10/08/2022] [Revised: 01/16/2023] [Accepted: 02/20/2023] [Indexed: 03/05/2023]
Abstract
STUDY OBJECTIVE Obstructive Sleep Apnea (OSA) is associated with increased perioperative cardiac, respiratory and neurological complications. Pre-operative OSA risk assessment is currently done through screening questionnaires with high sensitivity but poor specificity. The objective of this study was to evaluate the validity and diagnostic accuracy of portable, non-contact devices in the diagnosis of OSA as compared with polysomnography. DESIGN This study is a systematic review of English observational cohort studies with meta-analysis and risk of bias assessment. SETTING Pre-operative, including in the hospital and clinic setting. PATIENTS Adult patients undergoing sleep apnea assessment using polysomnography and an experimental non-contact tool. INTERVENTIONS A novel non-contact device, which does not utilize any monitor that makes direct contact with the patient's body, in conjunction with polysomnography. MEASUREMENTS Primary outcomes included pooled sensitivity and specificity of the experimental device in the diagnosis of obstructive sleep apnea, in comparison to gold-standard polysomnography. RESULTS Twenty-eight of 4929 screened studies were included in the meta-analysis. A total of 2653 patients were included with the majority being patients referred to a sleep clinic (88.8%). Average age was 49.7(SD±6.1) years, female sex (31%), average body mass index of 29.5(SD±3.2) kg/m2, average apnea-hypopnea index (AHI) of 24.7(SD±5.6) events/h, and pooled OSA prevalence of 72%. Non-contact technology used was mainly video, sound, or bio-motion analysis. Pooled sensitivity and specificity of non-contact methods in moderate to severe OSA diagnosis (AHI > 15) was 0.871 (95% CI 0.841,0.896, I2 0%) and 0.8 (95% CI 0.719,0.862), respectively (AUC 0.902). Risk of bias assessment showed an overall low risk of bias across all domains except for applicability concerns (none were conducted in the perioperative setting). CONCLUSION Available data indicate contactless methods have high pooled sensitivity and specificity for OSA diagnosis with moderate to high level of evidence. Future research is needed to evaluate these tools in the perioperative setting.
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Affiliation(s)
- Carlos Khalil
- University of Toronto, 27 King's College Cir, Toronto, ON M5S 1A1, Canada
| | - Sahar Zarabi
- University of Toronto, 27 King's College Cir, Toronto, ON M5S 1A1, Canada
| | - Kyle Kirkham
- University of Toronto, 27 King's College Cir, Toronto, ON M5S 1A1, Canada; Department of Anesthesiology and Pain Medicine, University Health Network, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - Vedish Soni
- McMaster University, 1280 Main Street West, Hamilton, ON, Canada, L8S 4L8
| | - Qixuan Li
- University of Toronto, 27 King's College Cir, Toronto, ON M5S 1A1, Canada; Biostatistics Research Unit, University Health Network; 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - Ella Huszti
- University of Toronto, 27 King's College Cir, Toronto, ON M5S 1A1, Canada; Biostatistics Research Unit, University Health Network; 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - Azadeh Yadollahi
- University of Toronto, 27 King's College Cir, Toronto, ON M5S 1A1, Canada; KITE-Toronto Rehabilitation Institute (TRI), University Health Network, 550 University Avenue, Toronto, ON M5G 2A2, Canada
| | - Babak Taati
- University of Toronto, 27 King's College Cir, Toronto, ON M5S 1A1, Canada; KITE-Toronto Rehabilitation Institute (TRI), University Health Network, 550 University Avenue, Toronto, ON M5G 2A2, Canada
| | - Marina Englesakis
- Library and Information Services, University Health Network, 200 Elizabeth St., Toronto, ON M5G 2C4, Canada
| | - Mandeep Singh
- University of Toronto, 27 King's College Cir, Toronto, ON M5S 1A1, Canada; Department of Anesthesiology and Pain Medicine, University Health Network, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada.
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31
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Dason ES, Maxim M, Hartman A, Li Q, Kanji S, Li T, Ng C, Huszti E, Sobel M, Chan C. Pregnancy outcomes with donor oocyte embryos in patients diagnosed with adenomyosis using the Morphological Uterus Sonographic Assessment criteria. Fertil Steril 2023; 119:484-489. [PMID: 36539054 DOI: 10.1016/j.fertnstert.2022.12.021] [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: 03/21/2022] [Revised: 12/08/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To use the Morphological Uterus Sonographic Assessment (MUSA) criteria to evaluate the impact of adenomyosis on the live birth rate after donor egg embryo transfer. DESIGN Retrospective cohort study. SETTING Tertiary fertility care center. PATIENT(S) A total of 100 patients who received 223 donor embryo transfers from January 2014-2020. All patients underwent ultrasound before their first transfer. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Our study was powered (80%) to assess the primary outcome of live birth rate; the secondary outcomes included the clinical pregnancy, biochemical pregnancy, and miscarriage rates. RESULT(S) Only 22 of 100 patients were diagnosed with adenomyosis on the original ultrasound report. When the MUSA criteria were applied, 76 patients had at least 1 possible ultrasonographic feature of adenomyosis; all 76 patients had an interrupted junctional zone. The second most common feature of adenomyosis was a globular and/or enlarged uterus (89.4%). Adjusted modeling demonstrated that a single ultrasound feature, 2 or more features, specific features, or the location of features did not affect the live birth outcome. A per-centimeter increase in the diameter of focal lesions was significantly associated with a decrease in the odds of live birth by the factor of 0.91. CONCLUSION(S) To our knowledge, our study is the first to characterize adenomyosis using the MUSA criteria in the donor oocyte population. Overall, our data were reassuring in that the ultrasonographic features of adenomyosis may not impact reproductive outcomes. However, we identified that the location and size of focal lesions may be important and should be studied further.
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Affiliation(s)
- Ebernella Shirin Dason
- Department of Obstetrics and Gynaecology, University of Toronto, Temerty Faculty of Medicine, Toronto, Ontario, Canada; Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Madalina Maxim
- University of Toronto, Temerty Faculty of Medicine, Toronto, Ontario, Canada.
| | | | - Qixuan Li
- Biostatistics Research Unit, University Health Network, Toronto General Hospital, Ontario, Canada
| | - Salina Kanji
- Department of Obstetrics and Gynaecology, University of Toronto, Temerty Faculty of Medicine, Toronto, Ontario, Canada; Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Tiantian Li
- The Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
| | - Charis Ng
- Department of Obstetrics and Gynaecology, University of Western Ontario, London Health Sciences Centre - Victoria Hospital, London, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto General Hospital, Ontario, Canada
| | - Mara Sobel
- Department of Obstetrics and Gynaecology, University of Toronto, Temerty Faculty of Medicine, Toronto, Ontario, Canada; Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Crystal Chan
- Department of Obstetrics and Gynaecology, University of Toronto, Temerty Faculty of Medicine, Toronto, Ontario, Canada; The Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
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Taran S, Coiffard B, Huszti E, Li Q, Chu L, Thomas C, Burns S, Robles P, Herridge MS, Goligher EC. Association of Days Alive and at Home at Day 90 After Intensive Care Unit Admission With Long-term Survival and Functional Status Among Mechanically Ventilated Patients. JAMA Netw Open 2023; 6:e233265. [PMID: 36929399 PMCID: PMC10020882 DOI: 10.1001/jamanetworkopen.2023.3265] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
IMPORTANCE Many conventional end points in randomized clinical trials of interventions for critically ill patients do not account for patient-centered concerns such as time at home, physical function, and quality of life after critical illness. OBJECTIVE To establish whether days alive and at home at day 90 (DAAH90) is associated with long-term survival and functional outcomes in mechanically ventilated patients. DESIGN, SETTING, AND PARTICIPANTS The RECOVER prospective cohort study was conducted from February 2007 to March 2014, using data from 10 intensive care units (ICUs) in Canada. Patients were included in the baseline cohort if they were aged 16 years or older and underwent invasive mechanical ventilation for 7 or more days. The follow-up cohort analyzed here comprised RECOVER patients who were alive and had functional outcomes ascertained at 3, 6, and 12 months. Secondary data analysis occurred from July 2021 to August 2022. EXPOSURES Composite of survival and days alive and at home at day 90 after ICU admission (DAAH90). MAIN OUTCOMES AND MEASURES Functional outcomes at 3, 6, and 12 months were evaluated with the Functional Independence Measure (FIM), the 6-Minute Walk Test (6MWT), the Medical Research Council (MRC) Scale for Muscle Strength, and the 36-Item Short Form Health Survey physical component summary (SF-36 PCS). Mortality was evaluated at 1 year from ICU admission. Ordinal logistic regression was used to describe the association between DAAH90 tertiles and outcomes. Cox proportional hazards regression models were used to examine the independent association of DAAH90 tertiles with mortality. RESULTS The baseline cohort comprised 463 patients. Their median age was 58 years (IQR, 47-68 years), and 278 patients (60.0%) were men. In these patients, Charlson Comorbidity Index score, Acute Physiology and Chronic Health Evaluation II score, ICU intervention (eg, kidney replacement therapy or tracheostomy), and ICU length of stay were independently associated with lower DAAH90. The follow-up cohort comprised 292 patients. Their median age was 57 years (IQR, 46-65 years), and 169 patients (57.9%) were men. Among patients who survived to day 90, lower DAAH90 was associated with higher mortality at 1 year after ICU admission (tertile 1 vs tertile 3: adjusted hazard ratio [HR], 0.18 [95% CI, 0.07-0.43]; P < .001). At 3 months of follow-up, lower DAAH90 was independently associated with lower median scores on the FIM (tertile 1 vs tertile 3, 76 [IQR, 46.2-101] vs 121 [IQR, 112-124.2]; P = .04), 6MWT (tertile 1 vs tertile 3, 98 [IQR, 0-239] vs 402 [IQR, 300-494]; P < .001), MRC (tertile 1 vs tertile 3, 48 [IQR, 32-54] vs 58 [IQR, 51-60]; P < .001), and SF-36 PCS (tertile 1 vs tertile 3, 30 [IQR, 22-38] vs 37 [IQR, 31-47]; P = .001) measures. Among patients who survived to 12 months, being in tertile 3 vs tertile 1 for DAAH90 was associated with higher FIM score at 12 months (estimate, 22.4 [95% CI, 14.8-30.0]; P < .001), but this association was not present for ventilator-free days (estimate, 6.0 [95% CI, -2.2 to 14.1]; P = .15) or ICU-free days (estimate, 5.9 [95% CI, -2.1 to 13.8]; P = .15) at day 28. CONCLUSIONS AND RELEVANCE In this study, lower DAAH90 was associated with greater long-term mortality risk and worse functional outcomes among patients who survived to day 90. These findings suggest that the DAAH90 end point reflects long-term functional status better than standard clinical end points in ICU studies and may serve as a patient-centered end point in future clinical trials.
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Affiliation(s)
- Shaurya Taran
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin Coiffard
- Department of Respiratory Medicine, Assistance Publique-Hopitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Ella Huszti
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Qixuan Li
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Leslie Chu
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Claire Thomas
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Stacey Burns
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Priscila Robles
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Margaret S. Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
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Bilek AJ, Cullen S, Tan CM, Li Q, Huszti E, Norman RE. Opioid use in older orthopedic rehabilitation inpatients: a retrospective study. Eur J Phys Rehabil Med 2023; 59:192-200. [PMID: 36745157 PMCID: PMC10170320 DOI: 10.23736/s1973-9087.23.07650-5] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND While there is much evidence about pain management for orthopedic patients in the immediate perioperative setting, little is known about how opioids are used during inpatient rehabilitation, particularly in older adults. A safe upper limit of 50 mg oral morphine equivalents (OME) is frequently cited in guidelines. AIM The aim of this study was to characterize the dosing of opioids in an older adult population undergoing inpatient orthopedic rehabilitation (IOR). DESIGN Retrospective observational study. SETTING Inpatient units at an academic rehabilitation hospital in Toronto, Canada. POPULATION All adults aged ≥50 years old admitted for orthopedic rehabilitation between November 2019 and June 2021 following acute care admissions for either a surgical or non-surgical orthopedic indication. METHODS Participants were divided into groups of prior opioids users, new opioids users, and opioid non-users during IOR. Demographic, clinical, and medication administration data were collected through the electronic health record and manual chart review. Average daily opioid dose for the first seven days of each stay was characterized using OME. Linear regression was used to assess for variables independently associated with opioid dose. RESULTS A total of 643 patients undergoing orthopedic rehabilitation were included: 125 (19.4%) were prior opioid users, 416 (64.7%) were new opioid users, and 102 (15.9%) were non-users, with median age respectively of 72, 79, and 83. Median daily OME over the first week for prior users was 30.3 and for new users was 6.9. Opioid dose was inversely associated with age and admission for a non-surgical indication; it was positively associated with reported pain (as defined by day 3 pain score) and admission for knee replacement. CONCLUSIONS Opioids are frequently but heterogeneously used in older adults undergoing IOR. Median OME use in this cohort of older adults was substantially lower than the 50 OME threshold suggested in guidelines, particularly for new opioid users. CLINICAL REHABILITATION IMPACT Older adults require much lower opioid doses than younger patients. Pain management in older orthopedic rehabilitation inpatients is distinct from the perioperative setting and deserves tailored guidance, with a focus on using the lowest effective dose.
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Affiliation(s)
- Aaron J Bilek
- Division of Geriatric Medicine, Sinai Health, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | - Stephanie Cullen
- Division of Geriatric Medicine, Sinai Health, Toronto, ON, Canada.,Queen's University, Kingston, ON, Canada
| | - Carolyn M Tan
- Division of Geriatric Medicine, Sinai Health, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Qixuan Li
- Unit of Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Ella Huszti
- Unit of Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Richard E Norman
- Division of Geriatric Medicine, Sinai Health, Toronto, ON, Canada - .,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Kciuk O, Li Q, Huszti E, McDermott CD. Pelvic floor symptoms in cisgender women with Ehlers-Danlos syndrome: an international survey study. Int Urogynecol J 2023; 34:473-483. [PMID: 35751670 DOI: 10.1007/s00192-022-05273-8] [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: 03/22/2022] [Accepted: 05/30/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Ehlers-Danlos Syndrome (EDS) is a group of inherited connective tissue disorders associated with abnormal collagen, and is more prevalent in women than in men. The aim of this cross-sectional study was to characterize pelvic floor symptoms in cisgender women with EDS and to describe their impact on quality of life. METHODS An online questionnaire on obstetric and gynecological experiences of cisgender women with EDS was disseminated through EDS patient societies and social media. This study was a sub-analysis of the broader questionnaire and focused on pelvic floor disorders, whereby self-reported symptoms and validated questionnaires were used to assess pelvic floor symptom severity (Pelvic Floor Distress Inventory, PFDI-20), impact on quality of life (Pelvic Floor Impact Questionnaire, PFIQ-7), and sexual function (Female Sexual Function Index, FSFI-6). Groups based on age and EDS type were compared using Kruskal-Wallis and Chi-squared tests. RESULTS A total of 1,303 participants were included in the analysis. Pelvic floor symptom prevalence included: stress urinary incontinence in 60%, urgency urinary incontinence in 54%, fecal incontinence in 24%, and pelvic organ prolapse in 21%. Bladder symptoms were reported to be the most bothersome. The impact of prolapse symptoms on quality of life was higher in women under age 40 than in older participants (p<0.001). Pelvic pain was reported in 71%. Pain ratings were highest for dysmenorrhea, muscle and joint pain, and backache (median 7 out of 10 for each). Almost half of participants screened positive for possible sexual dysfunction and 36% reported dyspareunia more than half the time. CONCLUSIONS This large, observational study demonstrated that cisgender women with EDS report a high prevalence of pelvic floor symptoms that appear to be more severe than in the general population.
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Affiliation(s)
- Olga Kciuk
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
| | - Qixuan Li
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Colleen D McDermott
- Division of Female Pelvic Medicine and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.
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Gong S, Qian D, Riazi S, Chung F, Englesakis M, Li Q, Huszti E, Wong J. Association Between the FRAIL Scale and Postoperative Complications in Older Surgical Patients: A Systematic Review and Meta-Analysis. Anesth Analg 2023; 136:251-261. [PMID: 36638509 PMCID: PMC9812423 DOI: 10.1213/ane.0000000000006272] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Several frailty screening tools have been shown to predict mortality and complications after surgery. However, these tools were developed for in-person evaluation and cannot be used during virtual assessments before surgery. The FRAIL (fatigue, resistance, ambulation, illness, and loss of weight) scale is a brief assessment that can potentially be conducted virtually or self-administered, but its association with postoperative outcomes in older surgical patients is unknown. The objective of this systematic review and meta-analysis (SRMA) was to determine whether the FRAIL scale is associated with mortality and postoperative outcomes in older surgical patients. METHODS Systematic searches were conducted of multiple literature databases from January 1, 2008, to December 17, 2022, to identify English language studies using the FRAIL scale in surgical patients and reporting mortality and postoperative outcomes, including postoperative complications, postoperative delirium, length of stay, and functional recovery. These databases included Medline, Medline ePubs/In-process citations, Embase, APA (American Psychological Association) PsycInfo, Ovid Emcare Nursing, (all via the Ovid platform), Cumulative Index to Nursing and Allied Health Literature (CINAHL) EbscoHost, the Web of Science (Clarivate Analytics), and Scopus (Elsevier). The risk of bias was assessed using the quality in prognosis studies tool. RESULTS A total of 18 studies with 4479 patients were included. Eleven studies reported mortality at varying time points. Eight studies were included in the meta-analysis of mortality. The pooled odds ratio (OR) of 30-day, 6-month, and 1-year mortality for frail patients was 6.62 (95% confidence interval [CI], 2.80-15.61; P < .01), 2.97 (95% CI, 1.54-5.72; P < .01), and 1.54 (95% CI, 0.91-2.58; P = .11), respectively. Frailty was associated with postoperative complications and postoperative delirium, with an OR of 3.11 (95% CI, 2.06-4.68; P < .01) and 2.65 (95% CI, 1.85-3.80; P < .01), respectively. The risk of bias was low in 16 of 18 studies. CONCLUSIONS As measured by the FRAIL scale, frailty was associated with 30-day mortality, 6-month mortality, postoperative complications, and postoperative delirium.
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Affiliation(s)
- Selena Gong
- From the Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada,Department of Anesthesiology and Pain Medicine, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Dorothy Qian
- From the Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada,Department of Anesthesiology and Pain Medicine, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sheila Riazi
- From the Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada,Department of Anesthesiology and Pain Medicine, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada,Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Frances Chung
- From the Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada,Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Marina Englesakis
- Library & Information Services, University Health Network, Toronto, Ontario, Canada
| | - Qixuan Li
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Jean Wong
- From the Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada,Department of Anesthesiology and Pain Medicine, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada,Library & Information Services, University Health Network, Toronto, Ontario, Canada
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Baghlaf H, Snelgrove J, Li Q, Huszti E, McDonald SD, Asztalos E, Palermo M, Murphy KE. One vs. two courses of antenatal corticosteroids: A secondary analysis of the MACS trial. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.832] [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: 01/09/2023]
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Zhao ZY, Lovatsis D, Gagnon L, Wang S, Huszti E, McDermott CD. Comparing vitamin B2 versus 5% dextrose in water for optimal ureteric jet visualisation at the time of pelvic reconstructive surgery: A randomised controlled trial. BJOG 2022; 130:610-618. [PMID: 36504349 DOI: 10.1111/1471-0528.17363] [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: 07/11/2022] [Revised: 11/27/2022] [Accepted: 12/30/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To compare preoperative vitamin B2 versus intraoperative cystoscopy distension using 5% dextrose in water (D5W) for ureteric jet visualisation during pelvic reconstructive surgery. DESIGN Double-blinded, randomised controlled trial. SETTING Three tertiary hospitals in Toronto, Canada. POPULATION Adult women undergoing pelvic reconstructive surgery. METHODS Patients were randomised to receive 100 mg of vitamin B2 preoperatively versus bladder distension with D5W intraoperatively. MAIN OUTCOMES The primary outcome was the rate of accurate detection of bilateral ureteric jets during cystoscopy. Secondary outcomes included the time elapsed until visualisation, use of intravenous furosemide or fluorescein to assist with visualisation, surgeon satisfaction, and positive urine culture 1 week after surgery. RESULTS The intervention was completed by 236 patients (vitamin B2 n = 117, D5W n = 119). Preoperative characteristics were similar across groups. Accurate detection of both ureteric jets was high in both groups (vitamin B2 97.4% vs. D5W 90.8%, p = 0.051). The vitamin B2 group had significantly lower use of fluorescein rescue compared with the D5W group (3.4% vs. 11.8%, respectively, p = 0.025). Surgeon satisfaction while using vitamin B2 was significantly higher (p < 0.001). There were no significant differences in the time elapsed until visualisation, the use of furosemide, or the incidence of positive urine culture at 1 week after surgery. CONCLUSIONS Both preoperative vitamin B2 and intraoperative cystoscopy distension with D5W are highly available and inexpensive methods to detect ureteric jets with high accuracy at the time of pelvic reconstructive surgery. Vitamin B2 was shown to have lower rates of fluorescein rescue for visualisation and higher rates of surgeon satisfaction.
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Affiliation(s)
- Zi Ying Zhao
- Division of Urogynecology, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Obstetrics and Gynaecology, Health Sciences Centre, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - Danny Lovatsis
- Division of Urogynecology, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Louise Gagnon
- Division of Urogynecology, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Stella Wang
- Biostatistics Research Unit, University Health Networkfig, University of Toronto, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Networkfig, University of Toronto, Toronto, Ontario, Canada
| | - Colleen D McDermott
- Division of Urogynecology, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Warshafsky C, Kirubarajan A, Chaikof M, Stere A, Chudawala U, Li Q, Huszti E, Mohamed D, Abdalla MH, Hartman A, Sanders A, Murji A, Sobel M. Preventing Isthmocele After Cesarean Section (PICS): A Pilot Randomized Controlled Trial. J Obstet Gynaecol Can 2022; 44:1134-1135. [PMID: 35970439 DOI: 10.1016/j.jogc.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/07/2022] [Accepted: 08/08/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Chelsie Warshafsky
- Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON.
| | | | - Michael Chaikof
- Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON
| | - Alison Stere
- Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON
| | - Umaimah Chudawala
- Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON
| | - Quixuan Li
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, ON
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, ON
| | - Dina Mohamed
- Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON
| | - Mohamed Hassan Abdalla
- Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON
| | | | - Ari Sanders
- Peter Lougheed Centre, University of Calgary, Calgary, AB
| | - Ally Murji
- Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON
| | - Mara Sobel
- Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON
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Syed F, Stogios N, Sockalingam S, Maunder R, Cobain M, Tai E, Nolan R, Peiris R, Huszti E. AN ASSESSMENT OF GOAL-DIRECTED BEHAVIOURS THAT PROMOTE HEALTH-RELATED QUALITY OF LIFE: A PROOF-OF-CONCEPT STUDY. Can J Cardiol 2022. [DOI: 10.1016/j.cjca.2022.08.103] [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: 11/25/2022] Open
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Peiris RG, Ross H, Chan CT, Poon S, Auguste BL, Rac VE, Farkouh M, McDonald M, Kaczorowski J, Code J, Duero Posada J, Ong S, Kobulnik J, Tomlinson G, Huszti E, Arcand J, Thomas SG, Akbari A, Maunder R, Grover S, Seto E, Simard A, Pope B, Bains M, McIntyre C, Torbay C, Syed F, Nolan RP. Automated digital counselling with social network support as a novel intervention for patients with heart failure: protocol for randomised controlled trial. BMJ Open 2022; 12:e059635. [PMID: 36691152 PMCID: PMC9445232 DOI: 10.1136/bmjopen-2021-059635] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/25/2022] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Heart failure (HF) symptoms improve through self-care, for which adherence remains low among patients despite the provision of education for these behaviours by clinical teams. Open Access Digital Community Promoting Self-Care, Peer Support and Health Literacy (ODYSSEE-vCHAT) combines automated digital counselling with social network support to improve mortality and morbidity, engagement with self-care materials, and health-related quality of life. METHODS AND ANALYSIS Use of ODYSSEE-vCHAT via Internet-connected personal computer by 162 HF patients will be compared with a control condition over 22 months. The primary outcome is a composite index score of all-cause mortality, all-cause emergency department visits, and HF-related hospitalisation at trial completion. Secondary outcomes include individual components of the composite index, engagement with self-care materials, and patient-reported measures of physical and psychosocial well-being, disease management, health literacy, and substance use. Patients are recruited from tertiary care hospitals in Toronto, Canada and randomised on a 1:1 ratio to both arms of the trial. Online assessments occur at baseline (t=0), months 4, 8 and 12, and trial completion. Ordinal logistic regression analyses and generalised linear models will evaluate primary and secondary outcomes. ETHICS AND DISSEMINATION The trial has been approved by the research ethics boards at the University Health Network (20-5960), Sunnybrook Hospital (5117), and Mount Sinai Hospital (21-022-E). Informed consent of eligible patients occurs in person or online. Findings will be shared with key stakeholders and the public. Results will allow for the preparation of a Canada-wide phase III trial to evaluate the efficacy of ODYSSEE-vCHAT in improving clinical outcomes and raising the standard of outpatient care. TRIAL REGISTRATION NUMBER NCT04966104.
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Affiliation(s)
- Rachel Grace Peiris
- Cardiac eHealth and Behavioural Cardiology Research Unit, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Heather Ross
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
- Division of Cardiology, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Christopher T Chan
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
- Division of Nephrology, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Stephanie Poon
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
- Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Bourne Lewis Auguste
- Division of Nephrology, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Valeria E Rac
- Institute of Health Policy, Management, and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
- Program for Health System and Technology Evaluation, Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Michael Farkouh
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
- Peter Munk Centre of Excellence in Multinational Clinical Trials, University Health Network, Toronto, Ontario, Canada
| | - Michael McDonald
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Janusz Kaczorowski
- Department of Family and Emergency Medicine, University of Montreal Faculty of Medicine, Montreal, Quebec, Canada
| | - Jillianne Code
- Department of Curriculum and Pedagogy, University of British Columbia, Vancouver, British Columbia, Canada
- HeartLife Foundation, Vancouver, British Columbia, Canada
| | - Juan Duero Posada
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Stephanie Ong
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Jeremy Kobulnik
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
- Division of Cardiology, Sinai Health System, Toronto, Ontario, Canada
| | - George Tomlinson
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
- Division of Biostatistics, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Ella Huszti
- Institute of Health Policy, Management, and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - JoAnne Arcand
- Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada
- Department of Nutritional Sciences, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Scott G Thomas
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
| | - Ayub Akbari
- Division of Nephrology, Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Robert Maunder
- Department of Psychiatry, Sinai Health System, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Steven Grover
- Department of Medicine, McGill University, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Emily Seto
- Institute of Health Policy, Management, and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
- Centre for Global eHealth Innovation, University Health Network, Toronto, Ontario, Canada
| | - Anne Simard
- Program for Health System and Technology Evaluation, Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Brad Pope
- Cardiac eHealth and Behavioural Cardiology Research Unit, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Marc Bains
- HeartLife Foundation, Vancouver, British Columbia, Canada
| | - Carmen McIntyre
- Cardiac eHealth and Behavioural Cardiology Research Unit, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Chris Torbay
- Cardiac eHealth and Behavioural Cardiology Research Unit, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Fatima Syed
- Cardiac eHealth and Behavioural Cardiology Research Unit, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Robert P Nolan
- Cardiac eHealth and Behavioural Cardiology Research Unit, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Zhang CYK, Ahmed M, Huszti E, Levy L, Hunter SE, Boonstra KM, Moshkelgosha S, Sage AT, Azad S, Ghany R, Yeung JC, Crespin OM, Singer LG, Keshavjee S, Martinu T. Utility of bile acids in large airway bronchial wash versus bronchoalveolar lavage as biomarkers of microaspiration in lung transplant recipients: a retrospective cohort study. Respir Res 2022; 23:219. [PMID: 36028826 PMCID: PMC9419323 DOI: 10.1186/s12931-022-02131-5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 08/04/2022] [Indexed: 11/20/2022] Open
Abstract
Background Bronchoalveolar lavage (BAL) is a key tool in respiratory medicine for sampling the distal airways. BAL bile acids are putative biomarkers of pulmonary microaspiration, which is associated with poor outcomes after lung transplantation. Compared to BAL, large airway bronchial wash (LABW) samples the tracheobronchial space where bile acids may be measurable at more clinically relevant levels. We assessed whether LABW bile acids, compared to BAL bile acids, are more strongly associated with poor clinical outcomes in lung transplant recipients. Methods Concurrently obtained BAL and LABW at 3 months post-transplant from a retrospective cohort of 61 lung transplant recipients were analyzed for taurocholic acid (TCA), glycocholic acid (GCA), and cholic acid by mass spectrometry and 10 inflammatory proteins by multiplex immunoassay. Associations between bile acids with inflammatory proteins and acute lung allograft dysfunction were assessed using Spearman correlation and logistic regression, respectively. Time to chronic lung allograft dysfunction and death were evaluated using multivariable Cox proportional hazards and Kaplan–Meier methods. Results Most bile acids and inflammatory proteins were higher in LABW than in BAL. LABW bile acids correlated with inflammatory proteins within and between sample type. LABW TCA and GCA were associated with acute lung allograft dysfunction (OR = 1.368; 95%CI = 1.036–1.806; P = 0.027, OR = 1.064; 95%CI = 1.009–1.122; P = 0.022, respectively). No bile acids were associated with chronic lung allograft dysfunction. Adjusted for risk factors, LABW TCA and GCA predicted death (HR = 1.513; 95%CI = 1.014–2.256; P = 0.042, HR = 1.597; 95%CI = 1.078–2.366; P = 0.020, respectively). Patients with LABW TCA in the highest tertile had worse survival compared to all others. Conclusions LABW bile acids are more strongly associated than BAL bile acids with inflammation, acute lung allograft dysfunction, and death in lung transplant recipients. Collection of LABW may be useful in the evaluation of microaspiration in lung transplantation and other respiratory diseases. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-022-02131-5.
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Affiliation(s)
| | - Musawir Ahmed
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Liran Levy
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Sarah E Hunter
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Kristen M Boonstra
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Sajad Moshkelgosha
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Andrew T Sage
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Sassan Azad
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Jonathan C Yeung
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Oscar M Crespin
- Division of General Surgery, University Health Network, Toronto, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada.,Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada.,Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada. .,Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
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Lane S, Gross M, Arzola C, Malavade A, Szadkowski L, Huszti E, Friedman Z. What are we missing? The quality of intraoperative handover before and after introduction of a checklist. Can J Anaesth 2022; 69:832-840. [PMID: 35314994 DOI: 10.1007/s12630-022-02238-9] [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: 07/28/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Intraoperative handovers are common in anesthesia practice and are associated with increased patient morbidity and mortality. Checklists may improve transfer of information during handovers. This before-and-after study sought to examine the effect of a checklist on intraoperative handover. We hypothesized that introducing a handover checklist would improve our primary outcome of completeness of data transfer. METHODS From February to August 2016, anesthesia providers (residents, fellows, and consultants) at a single tertiary academic center participated in a handover study. Baseline handovers between anesthesia care providers were videotaped, analyzed, and compared with anesthetic records. An intraoperative handover checklist was then introduced, and handovers completed with it were videotaped. The completeness of handovers was compared between the baseline routine and checklist groups. The primary outcome was completeness of information transfer. RESULTS Sixty-seven anesthesia providers participated in the study. Use of the intraoperative handover checklist improved completeness of handover by 6% (95% confidence interval [CI], 2 to 10; P < 0.01). There was no relationship observed between the provider (consultants/fellows vs resident) of the handovers and the degree of completeness (95% CI, 3 to 8; P = 0.33). Complexity had a significant impact on the handover completeness with low or high complexity cases more completely handed over than those of medium complexity both before and after the intervention-a 6% increase for low complexity (95% CI, 1 to 11; P = 0.02) and a 9% increase for high complexity (95% CI, 3 to 14; P < 0.01). CONCLUSION Use of a checklist during intraoperative handovers improved completeness of data transfer. Handover checklists should be considered to improve handover completeness.
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Affiliation(s)
- Sophia Lane
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Marketa Gross
- Perioperative Services, Sinai Health System, Toronto, ON, Canada
- Department of Nursing, Ryerson University, Toronto, ON, Canada
| | - Cristian Arzola
- Department of Anaesthesia and Pain Management, Sinai Health System, University of Toronto, 600 University Avenue Toronto, Toronto, ON, M5G1X5, Canada
| | - Archana Malavade
- Department of Anaesthesia and Pain Management, Sinai Health System, University of Toronto, 600 University Avenue Toronto, Toronto, ON, M5G1X5, Canada
| | - Leah Szadkowski
- Biostatistics Research Unit (BRU), University Health Network, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit (BRU), University Health Network, Toronto, ON, Canada
| | - Zeev Friedman
- Department of Anaesthesia and Pain Management, Sinai Health System, University of Toronto, 600 University Avenue Toronto, Toronto, ON, M5G1X5, Canada.
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Rajeswaran V, Devine L, Lorens E, Robertson S, Huszti E, Panisko DM. Types of clinical reasoning in a summative clerkship oral examination. Med Teach 2022; 44:657-663. [PMID: 35000527 DOI: 10.1080/0142159x.2021.2020230] [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] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Dual-process theory characterizes clinical reasoning (CR) as Type 1 (intuitive) and Type 2 (analytical) thinking. This study examined CR on a summative clinical clerkship structured clinical oral examination (SCOE). METHODS AND SUBJECTS 511 clinical clerks at the University of Toronto underwent SCOEs. Type 1, Type 2, and Global CR performance were compared to other internal medicine clerkship assessments using descriptive statistics and Spearman correlations. RESULTS Clinical clerks achieved mean marks >75% on the three clinical reasoning stations, on Type 1 and 2 CR tasks, and the overall SCOE. Performance on the SCOE CR stations correlated with each of the other clerkship assessments: written examination, inpatient, and ambulatory clinic assessments. The correlation of performance between Type 1 and Type 2 clinical reasoning tasks was statistically significant but weak (rs = 0.28). This suggests that defined measures of Type 1 and Type 2 reasoning were indeed assessing distinct constructs. CONCLUSION Clinical clerks used both Type 1 and Type 2 reasoning with success. This study's characterization of Type 1 and Type 2 CR as separate domains, distinct from existing measures on the SCOE as well as the other clerkship assessments, can suggest a further addition to multimodal clerkship assessment.
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Affiliation(s)
- Vamana Rajeswaran
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Endocrinology, William Osler Health System, Brampton, Canada
| | - Luke Devine
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
- The HoPingKong Centre, University Health Network, Toronto, Canada
| | - Edmund Lorens
- Statistics & Evaluation, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sumitra Robertson
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Daniel M Panisko
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
- The HoPingKong Centre, University Health Network, Toronto, Canada
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44
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Van Mieghem T, Lewi L, Slaghekke F, Lopriore E, Yinon Y, Raio L, Baud D, Dekoninck P, Melamed N, Huszti E, Sun L, Shinar S. Prediction of fetal death in monochorionic twin pregnancies complicated by Type-III selective fetal growth restriction. Ultrasound Obstet Gynecol 2022; 59:756-762. [PMID: 35258125 DOI: 10.1002/uog.24896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/02/2022] [Accepted: 02/15/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Monochorionic diamniotic twin pregnancies complicated by Type-III selective fetal growth restriction (sFGR) are at high risk of fetal death. The aim of this study was to identify predictors of fetal death in these pregnancies. METHODS This was an international multicenter retrospective cohort study. Type-III sFGR was defined as fetal estimated fetal weight (EFW) of one twin below the 10th percentile and intertwin EFW discordance of ≥ 25% in combination with intermittent absent or reversed end-diastolic flow in the umbilical artery of the smaller fetus. Predictors of fetal death were recorded longitudinally throughout gestation and assessed in univariable and multivariable logistic regression models. The classification and regression trees (CART) method was used to construct a prediction model of fetal death using significant predictors derived from the univariable analysis. RESULTS A total of 308 twin pregnancies (616 fetuses) were included in the analysis. In 273 (88.6%) pregnancies, both twins were liveborn, whereas 35 pregnancies had single (n = 19 (6.2%)) or double (n = 16 (5.2%)) fetal death. On univariable analysis, earlier gestational age at diagnosis of Type-III sFGR, oligohydramnios in the smaller twin and deterioration in umbilical artery Doppler flow were associated with an increased risk of fetal death, as was larger fetal EFW discordance, particularly between 24 and 32 weeks' gestation. None of the parameters identified on univariable analysis maintained statistical significance on multivariable analysis. The CART model allowed us to identify three risk groups: a low-risk group (6.8% risk of fetal death), in which umbilical artery Doppler did not deteriorate; an intermediate-risk group (16.3% risk of fetal death), in which umbilical artery Doppler deteriorated but the diagnosis of sFGR was made at or after 16 + 5 weeks' gestation; and a high-risk group (58.3% risk of fetal death), in which umbilical artery Doppler deteriorated and gestational age at diagnosis was < 16 + 5 weeks' gestation. CONCLUSIONS Type-III sFGR is associated with a high risk of fetal death. A prediction algorithm can help to identify the highest-risk group, which is characterized by Doppler deterioration and early referral. Further studies should investigate the potential benefit of fetal surveillance and intervention in this cohort. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- T Van Mieghem
- Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - F Slaghekke
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Y Yinon
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - L Raio
- Department of Obstetrics and Gynecology, Inselspital, University of Bern, Bern, Switzerland
| | - D Baud
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - P Dekoninck
- Department of Obstetrics and Gynecology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - N Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - E Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - L Sun
- Fetal Medicine Unit & Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital of Tongji University, Shanghai, China
| | - S Shinar
- Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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Shechtman L, Ben-Haim G, Ben-Zvi I, Steel L, Ironi A, Huszti E, Chatterji S, Levy L. Physiological Effects of Wearing N95 Respirator on Medical Staff During Prolong Work Hours in Covid-19 Departments. J Occup Environ Med 2022; 64:e378-e380. [PMID: 35543650 PMCID: PMC9275795 DOI: 10.1097/jom.0000000000002542] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of the current study was to determine gas exchange abnormalities and physiological changes among healthcare workers during a 4-hour emergency department (ED) shift while wearing the N95 respirator. METHODS Single-center prospective observational study. Comparisons of paired measurements were performed using a non-parametric Wilcoxon matched-pairs signed-rank test. Results: Forty-one subjects were included. Prolonged N95 respirator use was associated with a significant decline in plasma pH (7.35 mmHg vs 7.34 mmHg, P = 0.02), PvO 2 (23.2 mmHg vs 18.6 mmHg, P < 0.001) and a concurrent increase in EtCO 2 (32.5 mmHg vs 38.5 mmHg, P < 0.0001). PvCO 2 and bicarbonate levels did not differ. No significant change was observed for heart rate or oxygen saturation. CONCLUSION Using an N95 respirator for prolonged periods by healthcare professionals may provoke changes in gas exchange. The clinical significance of these changes remains to be determined.
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Affiliation(s)
- Liran Shechtman
- From the Internal Medicine Department, Sheba Medical Center, Tel Hashomer, Israel (Dr Shechtman and Dr Ben-Zvi); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Dr Shechtman, Dr ben-Haim, Dr Ben-Zvi, Dr Steel, Dr Ironi, Dr Chatterji, and Dr Levy); Department of Emergency Medicine, Sheba Medical Center, Tel Hashomer, Israel (Dr Ben-Haim, Dr Steel, and Dr Ironi); Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, ON, Canada (Dr Huszti); Institute of Pulmonary Medicine, Sheba Medical Center, Tel-Hashomer, Israel (Dr Chatterji and Dr Levy)
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Kirubarajan A, Li X, Yau M, Yu C, Got T, Li Q, Huszti E, Leung S, Thangavelu N, Sobel M. Awareness, knowledge, and misconceptions of adolescents and young people regarding long-acting reversible contraceptives: a systematic review and meta-analysis. Fertil Steril 2022; 118:168-179. [DOI: 10.1016/j.fertnstert.2022.03.013] [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] [Received: 11/25/2021] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 11/04/2022]
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47
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Maxim M, Dason ES, Chan C, Luketic L, Li Q, Huszti E, P. Sanders A, Sobel M. Current diagnosis and management of adenomyosis in Canada: A survey of Canadian gynaecologists. Journal of Endometriosis and Pelvic Pain Disorders 2022. [DOI: 10.1177/22840265221093263] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: The purpose of this study was to understand how Canadian Obstetricians/Gynaecologists (OBGYNs) diagnose and manage adenomyosis. Methods: This cross-sectional study was performed via an online survey distributed to 262 OBGYNs at three Canadian universities (University of Toronto, University of Calgary, and McMaster University). Results: A total of 137 responses were obtained out of 262 OBGYNs (52.3%) with a completion rate of 98%. Adenomyosis was a diagnosis in 6%–10% of patients seen by OBGYNs. The most common clinical symptoms included heavy menstrual bleeding (HMB) (82.8%) and dysmenorrhea (91.0%). Most participants (83%) used transvaginal ultrasound (TVUS) as first-line imaging for diagnosis of adenomyosis. Many respondents (35.8%) indicated that adenomyosis was not associated with infertility or recurrent miscarriage. Treatment considerations for all patients with adenomyosis included levonorgestrel intra-uterine system (LNG-IUS) (91.8%), hysterectomy (88.8%), expectant management (85.1%), combined hormonal contraceptives (CHC) (83.6%), tranexamic acid (81.3%), gonadotropin releasing hormone (GnRH) agonists (64.2%), depo-provera (64.2%), dienogest (57.5%), and norethisterone acetate (NETA) (40.3%). Treatments for adenomyosis in patients wishing to conceive included expectant management (85.1%), tranexamic acid (79.1%), CHC (44.8%), LNG-IUS (32.8%), and GnRH agonists (35.8%). Excision of adenomyosis would only be offered by 24% of respondents. Uterine artery embolization (UAE) would not be used in the treatment of adenomyosis by 44% of respondents. Finally, 82.8% of respondents would use improvement of clinical symptoms to follow treatment success. Conclusion: Practice varies across Canada despite recent emerging evidence in the diagnosis and management of adenomyosis, highlighting the need for a clinical practice guideline on adenomyosis.
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Affiliation(s)
- Madalina Maxim
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ebernella Shirin Dason
- Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Crystal Chan
- Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lea Luketic
- St. Joseph’s Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
| | - Qixuan Li
- Biostatistics Research Unit, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Ari P. Sanders
- Peter Lougheed Centre, University of Calgary, Calgary, AB, Canada
| | - Mara Sobel
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
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Oliva L, Horlick E, Wang B, Huszti E, Hall R, Abrahamyan L. Developing a random forest algorithm to identify patent foramen ovale and atrial septal defects in Ontario administrative databases. BMC Med Inform Decis Mak 2022; 22:93. [PMID: 35387650 PMCID: PMC8988372 DOI: 10.1186/s12911-022-01837-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 05/24/2021] [Accepted: 03/17/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose Routinely collected administrative data is widely used for population-based research. However, although clinically very different, atrial septal defects (ASD) and patent foramen ovale (PFO) share a single diagnostic code (ICD-9: 745.5, ICD-10: Q21.1). Using machine-learning based approaches, we developed and validated an algorithm to differentiate between PFO and ASD patient populations within healthcare administrative data. Methods Using data housed at ICES, we identified patients who underwent transcatheter closure in Ontario between October 2002 and December 2017 using a Canadian Classification of Interventions code (1HN80GPFL, N = 4680). A novel random forest model was developed using demographic and clinical information to differentiate those who underwent transcatheter closure for PFO or ASD. Those patients who had undergone transcatheter closure and had records in the CorHealth Ontario cardiac procedure registry (N = 1482) were used as the reference standard. Several algorithms were tested and evaluated for accuracy, sensitivity, and specificity. Variable importance was examined via mean decrease in Gini index. Results We tested 7 models in total. The final model included 24 variables, including demographic, comorbidity, and procedural information. After hyperparameter tuning, the final model achieved 0.76 accuracy, 0.76 sensitivity, and 0.75 specificity. Patient age group had the greatest influence on node impurity, and thus ranked highest in variable importance. Conclusions Our random forest classification method achieved reasonable accuracy in identifying PFO and ASD closure in administrative data. The algorithm can now be applied to evaluate long term PFO and ASD closure outcomes in Ontario, pending future external validation studies to further test the algorithm. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-022-01837-2.
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Affiliation(s)
- Laura Oliva
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada
| | - Eric Horlick
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network (UHN), Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Bo Wang
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network (UHN), Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Techna Institute, UHN, Toronto, ON, Canada.,CIFAR, Toronto, ON, Canada
| | - Ella Huszti
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada.,Biostatistics Research Unit (BRU) Toronto General Hospital Research Institute, UHN, Toronto, ON, Canada
| | - Ruth Hall
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| | - Lusine Abrahamyan
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada. .,Toronto General Hospital Research Institute, UHN, 10th Floor Eaton North, Room 237, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada. .,Toronto Health Economics and Technology Assessment (THETA) Collaborative, UHN, Toronto, ON, Canada.
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Zhang C, Ramendra R, Fernandez-Castillo J, Berra G, Ghany R, Tikkanen J, Singer L, Aversa M, Huszti E, Keshavjee S, Yeung J, Martinu T. Association of Chronic Proton Pump Inhibitor Use in Lung Transplant Recipients with Long-Term Outcomes: A Retrospective Cohort Study. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1068] [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: 11/15/2022] Open
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50
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Fernandez-Castillo J, Ramendra R, Huszti E, Zhang K, Ghany R, Chaparro C, Singer L, Keshavjee S, Aversa M, Yeung J, Martinu T. Lower-than-Standard Cutoff Number of Reflux Episodes is Associated with Worse Lung Transplant Outcomes. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.345] [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: 11/16/2022] Open
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