ABSTRACT
Background: The COVID-19 pandemic has compounded limitations in access to the operating room, highlighting the need for improved surgical prioritization rules for common pathologies, including acute cholecystitis. The objective of this study was to compare the performance of our institution's surgical prioritization rules to the Tokyo diagnostic criteria and to develop a novel decision rule to predict acute cholecystitis on surgical pathology. Methods: All consecutive adult patients undergoing emergency cholecystectomy at a single academic institution between April 2017 and April 2021 were reviewed. The primary outcome was diagnosis of acute inflammation on final pathologic analysis. Multiple logistic regression was performed with a training subset using relevant clinical variables that were selected a priori. A simple weighted decision rule was created and compared with the Tokyo diagnostic criteria and the institution's existing prioritization rules via an analysis of receiver operating characteristic curves on a second subset of the population. Results: Among 756 patients undergoing emergency cholecystectomy, 97.6% met criteria for acute cholecystitis as per Tokyo diagnostic criteria. Tokyo criteria (area under the curve [AUC] 0.51, sensitivity 99%, specificity 3%) poorly discriminated for acute inflammation on final pathology. Discrimination of the hospital's case prioritization rules was moderate (AUC 0.63, sensitivity 48%, specificity 78%), and a new simple decision rule incorporating fever, Murphy sign, leukocytosis and inflammation on imaging was significantly higher (AUC 0.69, sensitivity 72%, specificity 64%, p < 0.003). Conclusion: In this large cohort of emergency cholecystectomies, the Tokyo diagnostic criteria were highly sensitive but nonspecific for acute cholecystitis on final pathology. An existing institutional case prioritization rule showed moderate discrimination for these outcomes but was outperformed by a novel parsimonious score incorporating readily available preoperative variables. These findings may be useful in the prioritization of emergency cholecystectomies at busy centres but remain to be validated in outside cohorts.
ABSTRACT
OBJECTIVES: With increased bicycle use during the COVID-19 pandemic and growing availability of bicycle-sharing programs in Montreal, we hypothesize helmet use has decreased. The aim of this study was to evaluate helmet use and proper fit among Montreal cyclists during the pandemic relative to historical data. METHODS: Nine observers collected data on bike type, gender, helmet use, and ethnicity using the iHelmet© app at 18 locations across the island of Montreal from June to September 2021. Proper helmet wear was assessed at one busy location. Multiple logistic regression was used to identify factors associated with helmet wear and results were compared to a historical study. RESULTS: Of the 2200 cyclists observed, 1109 (50.4%) wore a helmet. Males (OR = 0.78, 95%CI = 0.65-0.95), young adults (OR = 0.65, 95%CI = 0.51-0.84), visible minorities (OR = 0.38, 95%CI = 0.28-0.53), and bike-share users (OR = 0.21, 95%CI = 0.15-0.28) were less likely to be wearing a helmet, whereas children (OR = 3.92, 95%CI = 2.17-7.08) and cyclists using racing bicycles (OR = 3.84, 95%CI = 2.62-5.62) were more likely to be wearing a helmet. The majority (139/213; 65.3%) of assessed cyclists wore properly fitting helmets. Children had the lowest odds of having a properly fitted helmet (OR = 0.13, 95%CI = 0.04-0.41). Compared to 2011, helmet use during the pandemic increased significantly (1109/2200 (50.4%) vs. 2192/4789 (45.8%); p = 0.032). CONCLUSION: Helmet use among Montreal cyclists was associated with age, gender, ethnicity, and type of bicycle. Children were least likely to have a properly fitted helmet. The recent increase in popularity of cycling and expansion of bicycle-sharing programs reinforce the need for bicycle helmet awareness initiatives, legislation, and funding prioritization.
RéSUMé: OBJECTIF: Avec la popularité grandissante du vélo durant la pandémie COVID-19 et l'expansion du vélopartage à Montréal, nous croyons que le port du casque a diminué. L'objectif de cette étude était d'évaluer l'utilisation du casque et le port adéquat parmi les cyclistes montréalais et de comparer nos résultats avec des données historiques. MéTHODE: Neuf observateurs, stationnés à 18 emplacements, ont recueilli les informations suivantes en utilisant l'application mobile iHelmet© : type de vélo, sexe, origine ethnique et port du casque. Le port adéquat du casque a été observé à un endroit. L'association de chaque variable avec le port et le port adéquat a été fait par régression multivariable et comparé à des données historiques. RéSULTATS: Des 2 200 cyclistes observés, 1 109 (50,4 %) portaient un casque. Les enfants (OR = 3,92, IC95% = 2,177,08) et les cyclistes de performance (OR = 3,84, IC95% = 2,625,62) portaient le casque plus fréquemment tandis que les hommes (OR = 0,78, IC95% = 0,650,95), les jeunes adultes (OR = 0,65, IC95% = 0,510,84), les minorités visibles (OR = 0,38, IC95% = 0,280,53), et les utilisateurs de vélopartage (OR = 0,21, IC95% = 0,150,28) le portaient moins. La majorité (139/213; 65,3 %) des casques étaient portés adéquatement. Les enfants étaient plus à risque de porter un casque mal ajusté (OR = 0,13, IC95% = 0,040,41). L'utilisation d'un casque chez les cyclistes montréalais a augmenté significativement depuis 2011 (1 109/2 200 (50,4 %) c. 2 192/4 789 (45,8 %); p = 0,032). CONCLUSION: Le port du casque à vélo à Montréal est associé à l'âge, le sexe, l'origine ethnique et le type de vélo. Les enfants sont plus à risque de mal porter un casque. Des stratégies de promotion ainsi que la législation peuvent favoriser des comportements sécuritaires à vélo.
Subject(s)
COVID-19 , Craniocerebral Trauma , Male , Child , Young Adult , Humans , Head Protective Devices , Bicycling , Cross-Sectional Studies , Pandemics , COVID-19/epidemiology , COVID-19/prevention & controlABSTRACT
PURPOSE: The optimal noninvasive modality for oxygenation support in COVID-19-associated hypoxemic respiratory failure and its association with healthcare worker infection remain uncertain. We report here our experience using high-flow nasal oxygen (HFNO) as the primary support mode for patients with COVID-19 in our institution. METHODS: We conducted a single-centre historical cohort study of all COVID-19 patients treated with HFNO for at least two hours in our university-affiliated and intensivist-staffed intensive care unit (Jewish General Hospital, Montreal, QC, Canada) between 27 August 2020 and 30 April 2021. We report their clinical characteristics and outcomes. Healthcare workers in our unit cared for these patients in single negative pressure rooms wearing KN95 or fit-tested N95 masks; they underwent mandatory symptomatic screening for COVID-19 infection, as well as a period of asymptomatic screening. RESULTS: One hundred and forty-two patients were analysed, with a median [interquartile range (IQR)] age of 66 [59-73] yr; 71% were male. Patients had a median [IQR] Sequential Organ Failure Assessment Score of 3 [2-3], median [IQR] oxygen saturation by pulse oximetry/fraction of inspired oxygen ratio of 120 [94-164], and a median [IQR] 4C score (a COVID-19-specific mortality score) of 12 [10-14]. Endotracheal intubation occurred in 48/142 (34%) patients, and overall hospital mortality was 16%. Barotrauma occurred in 21/142 (15%) patients. Among 27 symptomatic and 139 asymptomatic screening tests, there were no cases of HFNO-related COVID-19 transmission to healthcare workers. CONCLUSION: Our experience indicates that HFNO is an effective first-line therapy for hypoxemic respiratory failure in COVID-19 patients, and can be safely used without significant discernable infection risk to healthcare workers.
RéSUMé: OBJECTIF: La modalité non invasive optimale pour le soutien en oxygène lors d'insuffisance respiratoire hypoxémique liée à la COVID-19 et son association avec l'infection des travailleurs de la santé restent incertaines. Nous rapportons ici notre expérience avec l'utilisation de canules nasales à haut débit (CNHD) comme principale modalité de soutien pour les patients atteints de COVID-19 dans notre établissement. MéTHODE: Nous avons mené une étude de cohorte historique monocentrique de tous les patients atteints de COVID-19 traités par CNHD pendant au moins deux heures dans notre unité de soins intensifs affiliée à l'université et dotée d'intensivistes (Hôpital général juif, Montréal, QC, Canada) entre le 27 août 2020 et le 30 avril 2021. Nous rapportons leurs caractéristiques cliniques et leurs résultats. Les travailleurs de la santé de notre unité ont soigné ces patients dans des chambres individuelles à pression négative en portant des masques KN95 ou N95 ajustés; ils ont subi un dépistage symptomatique obligatoire de l'infection à la COVID-19, ainsi qu'un dépistage en période asymptomatique. RéSULTATS: Cent quarante-deux patients ont été analysés, avec un âge médian [écart interquartile (ÉIQ)] de 66 [59-73] ans; 71 % étaient des hommes. Les patients avaient un score SOFA (Sequential Organ Failure Assessment) médian [ÉIQ] de 3 [2, 3], un ratio médian [ÉIQ] de saturation en oxygène par oxymétrie de pouls/fraction d'oxygène inspiré de 120 [94-164], et un score 4C (un score de mortalité spécifique à la COVID-19) médian [ÉIQ] de 12 [1014]. Dans l'ensemble, 48/142 patients (34 %) ont reçu une intubation endotrachéale, et la mortalité hospitalière globale était de 16 %. Un barotraumatisme est survenu chez 21/142 (15 %) patients. Parmi les 27 tests de dépistage symptomatiques et 139 tests asymptomatiques, aucun cas de transmission de COVID-19 liée aux CNHD aux travailleurs de la santé n'a été observé. CONCLUSION: Notre expérience indique que les CNHD constituent un traitement de première intention efficace pour l'insuffisance respiratoire hypoxémique chez les patients atteints de COVID-19 qui peut être utilisé en toute sécurité, sans risque d'infection significatif discernable pour les travailleurs de la santé.