Evaluating Best Methods for Crisis Resource Management Education: Didactic Teaching or Noncontextual Active Learning.

INTRODUCTION: Health care training traditionally focuses on medical knowledge; however, this is not the only component of successful patient management. Nontechnical skills, such as crisis resource management (CRM), have significant impact on patient care. This study examines whether there is a difference in CRM skills taught by traditional lecture in comparison with low-fidelity simulation consisting of noncontextual learning through team problem-solving activities. METHODS: Two groups of multidisciplinary preclinical students were taught CRM through lecture or noncontextual active learning. Both groups were given a cardiopulmonary resuscitation simulation and clinical performance assessed by basic life support (BLS) checklist and CRM skills by Ottawa Global Rating Scale. The groups were reassessed at 4 months. A third group, who received no CRM education, served as a control group. RESULTS: The mean BLS scores after CRM education were 18.9 and 24.9 with mean Ottawa Global Rating Scale (GRS) scores of 22.4 and 29.1 in the didactic teaching and noncontextual groups, respectively. The difference between intervention groups was significant for BLS (P = 0.02) and Ottawa GRS (P = 0.03) score. At 4-month follow-up, there was no statistically significant difference in BLS (P = 1.0) or Ottawa GRS score (P = 0.55) between intervention groups. In comparison with the control group, there was a marginally significant difference in Ottawa GRS score (P = 0.06) at 4-month follow-up. CONCLUSIONS: Noncontextual active learning of CRM using low-fidelity simulation results in improved CRM performance in comparison with didactic teaching. The benefits of CRM education do not seem to be sustained after one education session, suggesting the need for continued education and practice of skills to improve retention.

Patient-reported symptoms following mastectomy alone or lumpectomy plus radiation for early stage breast cancer: a cohort study.

PURPOSE: Studies examining symptom differences between surgeries for breast cancer patients rarely incorporate the effects of adjuvant treatment choice. We sought to understand differences in patient-reported symptoms between lumpectomy plus radiation and mastectomy in the year following surgery. METHODS: This cohort study used linked administrative datasets. The exposure was defined as lumpectomy plus radiation or mastectomy. The outcomes of moderate-to-severe (score ≥ 4) patient-reported symptoms were obtained using the Edmonton symptom assessment system (ESAS). Line plots were created to determine symptom trajectories in the 12 months following surgery, and the relationships between surgery and each of the nine symptoms were assessed using multivariable analyses. Clinical significance was determined as a difference of 10%. RESULTS: Of 13,865 Stage I-II breast cancer patients diagnosed 2007-2015, 11,497 underwent lumpectomy plus radiation and 2368 underwent mastectomy. Symptom trajectories were similar for all nine symptoms until approximately 5 months postoperatively when they diverged and mastectomy symptoms started becoming more severe. On multivariable analyses, patients undergoing mastectomy were at an increased risk of reporting moderate-to-severe depression (RR 1.19, 95% CI 1.09-1.30), lack of appetite (RR 1.11, 95% CI 1.03-1.20), and shortness of breath (RR 1.16, 95% CI 1.04-1.15) compared to those undergoing lumpectomy plus radiation. CONCLUSIONS: Even with the addition of adjuvant radiation, patients who are treated with lumpectomy fare better in three of nine patient-reported symptoms. Further examination of these differences will assist in better shared decision-making regarding surgical treatments.

A comparison of revisional and primary bariatric surgery.

BACKGROUND: Revisional surgery is an important component of addressing weight regain and complications following primary bariatric surgery. Owing to provincial need and the complexity of this patient population, a specialized multidisciplinary revision clinic was developed. We sought to characterize patients who undergo revision surgery and compare their outcomes with primary bariatric surgery clinic data. METHODS: We completed a retrospective chart review of bariatric revision clinic patients compared with primary bariatric surgery patients from December 2009 to June 2014. RESULTS: We reviewed the charts of 2769 primary bariatric clinic patients, 886 of whom had bariatric surgery, and 534 revision bariatric clinic patients, 83 of whom had revision surgery. Fewer revision clinic patients underwent surgery than primary clinic patients (22% v. 32%). The mean preoperative body mass index (BMI) was 44.7 ± 9.5 in revision patients compared with 45.7 ± 7.6 in primary bariatric surgery patients. Most revision patients had a prior vertical banded gastroplasty (VBG; 48%) or a laparoscopic adjustable gastric band (LAGB; 24%). Bands were removed in 36% of all LAGB patients presenting to clinic. Of the 134 procedures performed in the revision clinic, 83 were bariatric weight loss surgeries, and 51 were band removals. Revision clinic patients experienced a significant decrease in BMI (from 44.7 ± 9.5 to 33.8 ± 7.5, p < 0.001); their BMI at 12-month follow-up was similar to that of primary clinic patients (34.5 ± 7.0, p = 0.7). Complications were significantly more frequent in revision patients than primary patients (41% v. 15%, p < 0.001). CONCLUSION: A bariatric revision clinic manages a wide variety of complex patients distinct from those seen in a primary clinic. Operative candidates at the revision clinic are chosen based on favourable medical, anatomic and psychosocial factors, keeping in mind the resource constraints of a public health care system.

CONTEXTE: La chirurgie de révision est une intervention importante lors d'une reprise de poids ou lors de complications à la suite d'une chirurgie bariatrique primaire. Compte tenu des besoins provinciaux et de la complexité de cette population de patients, une clinique de révision multidisciplinaire spécialisée a été créée. Nous avons voulu caractériser les patients qui subissent une chirurgie de révision et comparer leurs résultats aux données de la clinique de chirurgie bariatrique primaire. MÉTHODES: Nous avons procédé à un examen rétrospectif des dossiers des patients de la clinique de révision bariatrique par rapport aux patients ayant subi une chirurgie bariatrique primaire entre décembre 2009 et juin 2014. RÉSULTATS: Nous avons examiné les dossiers de 2769 patients de la clinique bariatrique primaire, dont 886 avaient subi une chirurgie bariatrique, et 534 patients de la clinique de révision, dont 83 avaient subi une chirurgie de révision. Un moins grand nombre de patients de la clinique de révision ont subi une chirurgie comparativement aux patients de la clinique primaire (22 % c. 32 %). L'indice de masse corporelle (IMC) préopératoire moyen était de 44,7 ± 9,5 chez les patients de la clinique de révision, contre 45,7 ± 7,6 chez les patients ayant subi la chirurgie bariatrique primaire. La plupart des patients de la clinique de révision avaient déjà subi une gastroplastie verticale (48 %) ou une pose d'anneau gastrique ajustable par voie laparoscopique (24 %). Les anneaux gastriques ont été retirés chez 36 % de tous les patients de ce dernier groupe s'étant présentés à la clinique. Parmi les 134 interventions effectuées à la clinique de révision, 83 étaient des chirurgies bariatriques (pour perte de poids) et 51 concernaient des retraits d'anneaux. Les patients de la clinique de révision ont obtenu une diminution significative de leur IMC (de 44,7 ± 9,5 à 33,8 ± 7,5, p < 0,001), qui, au moment du suivi après 12 mois, était semblable à celui des patients de la clinique primaire (34,5 ± 7,0, p = 0,7). Les complications ont été considérablement plus fréquentes chez les patients soumis à une chirurgie de révision que chez les patients soumis à une chirurgie primaire (41 % c. 15 %, p < 0,001). CONCLUSION: Une clinique de révision bariatrique gère une grande diversité de patients complexes, qui sont différents de la population suivie dans une clinique d'intervention primaire. À la clinique de révision, les candidats à l'opération sont choisis en fonction de facteurs médicaux, anatomiques et psychosociaux favorables, en gardant à l'esprit les ressources limitées du système de santé public.

Occult pneumothoraces in ventilated pediatric trauma patients: a review.

BACKGROUND: Currently there is no clinical consensus on how to treat occult pneumothoraces in adults, and even less research has been done in children. We sought to understand the outcomes of severely injured, ventilated children with occult pneumothoraces. METHODS: Using the Alberta Trauma Registry, we retrospectively reviewed the charts of all ventilated pediatric patients at a children's hospital from 2001 to 2011 who had an injury severity score greater than 12 and a diagnosis of occult pneumothorax (seen on computed tomography scan but not on supine chest radiograph). RESULTS: There were 1689 severely injured children, with 496 admitted to the pediatric intensive care unit (PICU) and ventilated. A total of 130 children were found to have pneumothoraces, and of those, 96 were admitted to the PICU. Of those, 15 children had a total of 19 occult pneumothoraces, and all were successfully treated without chest tubes. The average age was 13.4 (range 2.0-17.0) years, and 54% of these children were male. The average time spent on the ventilator was 2.3 (range 0-13) days, and 7 children had at least 1 operation. CONCLUSION: In our institution, occult pneumothoraces occur in very few severely injured, ventilated pediatric trauma patients. Our study adds to the increasing evidence in the adult and pediatric literature suggesting that occult pneumothoraces may be safely observed even while under positive-pressure ventilation.

CONTEXTE: À l'heure actuelle, il n'existe pas de consensus clinique sur la façon de traiter le pneumothorax occulte chez les adultes et encore moins de recherches ont porté sur les enfants. Nous avons voulu comprendre comment évoluent les enfants grièvement blessés porteurs d'un pneumothorax occulte placés sous respirateur. MÉTHODES: À partir du registre de traumatologie de l'Alberta, nous avons analysé de manière rétrospective les dossiers de tous les patients pédiatriques sous respirateur dans un hôpital pour enfants entre 2001 et 2011; ces enfants présentaient un score de gravité des blessures supérieur à 12 et un diagnostic de pneumothorax occulte (révélé par la tomodensitométrie mais non par la radiographie pulmonaire en décubitus dorsal). RÉSULTANTS: Nous avons dénombré 1689 enfants grièvement blessés, dont 496 ont été admis dans une unité de soins intensifs pédiatriques (USIP) et placés sous respirateur. En tout, 130 enfants présentaient un pneumothorax et 96 d'entre eux ont été admis à l'USIP. Parmi ceux-ci, 15 présentaient en tout 19 pneumothorax occultes, et tous ont été traités avec succès sans drains thoraciques. L'âge moyen était de 13,4 (entre 2,0 et 17,0) ans et 54 % de ces enfants étaient de sexe masculin. La durée moyenne de la ventilation assistée a été de 2,3 (entre 0 et 13) jours et 7 enfants ont dû subir au moins une intervention chirurgicale. CONCLUSION: Dans notre établissement, le pneumothorax occulte s'observe chez très peu de grands blessés pédiatriques placés sous respirateur. Notre étude vient étayer les preuves présentées dans la littérature sur les adultes et sur les enfants selon lesquelles les patients atteints de pneumothorax occulte peuvent être placés en observation en toute sécurité, même sous ventilation en pression positive.

Outcome analysis of ulnar shortening osteotomy for ulnar impaction syndrome.

BACKGROUND: Ulnar-sided wrist pain is a common problem in the upper extremity. It affects a broad patient population and can be difficult to treat. Ulnar impaction syndrome (UIS) is major cause of ulnar-sided wrist pain and a number of different operations have been used to correct it, including ulnar shortening osteotomy (USO). OBJECTIVE: To retrospectively review functional outcomes and complication rates of USO for UIS at the Hand and Upper Limb Centre (London, Ontario) over a two-year period. METHODS: Twenty-eight patients who underwent USO between 2007 and 2009 participated in the present study. Ulnar variance pre- and post-surgery was assessed using standard radiographic examination. Patient-rated outcomes were measured using a visual analogue scale (VAS) for pain and the Disabilities of the Arm, Shoulder and Hand (DASH) survey for functional outcomes. Objective grip strength and range of motion were compared with the contralateral extremity. RESULTS: On average, USO achieved a 3.11 mm reduction in ulnar variance. Nonunion occurred in five patients and required a secondary bone grafting procedure. All USO eventually healed. Overall, pain improved by 47.2% and the mean DASH score after surgery was 37.21. Flexion, extension and supination range of motion decreased by 10° compared with the unaffected side. Eleven patients (39%) elected to undergo a second surgery for hardware removal. Patients receiving compensation from the Workplace Safety and Insurance Board experienced significantly higher residual pain (VSA 5.24 versus 1.97) and disability levels (DASH 60.23 versus 25.70). Smokers also experienced worse outcomes in terms of pain (VSA 4.43 versus 2.36) and disability (DASH 51.06 versus 29.67). In this cohort, smoking was not associated with a higher rate of nonunion. CONCLUSION: USO is effective in reducing pain in UIS and improves disability, at the price of a small decrease in range of motion. Smokers and people receiving compensation from the Workplace Safety and Insurance Board, however, have significantly worse subjective outcomes (VAS and DASH), but similar objective outcomes (range of motion).

HISTORIQUE: La douleur au cubitus du poignet est un problème courant des membres supérieurs. Elle touche une grande population de patients et peut être difficile à traiter. Le syndrome d'impaction ulnaire (SIU) est une cause importante de douleur au cubitus du poignet. Diverses opérations ont été utilisées pour la corriger, y compris l'ostéotomie de raccourcissement ulnaire (ORU). OBJECTIF: Procéder à l'analyse rétrospective des issues fonctionnelles et des taux de complication d'ORU du SIU au Hand and Upper Limb Centre de London, en Ontario, sur une période de deux ans. MÉTHODOLOGIE: Vingt-huit patients qui ont subi une ORU entre 2007 et 2009 ont participé à la présente étude. Les chercheurs ont évalué la variance ulnaire avant et après l'opération au moyen d'un examen radiographique classique. Ils ont mesuré les issues classées par les patients au moyen d'une échelle analogique visuelle (ÉAV) de la douleur et du sondage DASH sur les incapacités du bras, de l'épaule et de la main évaluant les issues fonctionnelles. Ils ont comparé la force de préhension et l'amplitude de mouvement objectives à celles du membre controlatéral. RÉSULTATS: En moyenne, l'ORU a permis d'obtenir une réduction de 3,1 mm de la variance ulnaire. Chez cinq patients, une non-fusion a exigé une greffe osseuse secondaire. Toutes les ORU ont fini par guérir. Dans l'ensemble, la douleur a diminué de 47,2 %, et l'indice DASH moyen après l'opération s'élevait à 37,21. L'amplitude de flexion, d'extension et de supination a diminué de 10° par rapport au côté non touché. Onze patients (39 %) ont choisi de subir une deuxième opération afin d'extraire les tiges de métal. Les patients indemnisés par la Commission de la sécurité professionnelle et de l'assurance contre les accidents du travail ressentaient une douleur résiduelle (ÉAV de 5,24 par rapport à 1,97) et des taux d'invalidité (DASH de 60,23 par rapport à 25,70) considérablement plus élevés. Les fumeurs présentaient également une issue moins favorable sur le plan de la douleur (ÉAV de 4,43 par rapport à 2,36) et de l'invalidité (DASH de 51,06 par rapport à 29,67). Au sein de cette cohorte, le tabagisme ne s'associait pas à un taux plus élevé de non-fusion. CONCLUSION: L'ORU est efficace pour réduire la douleur en cas de SIU et amenuise l'incapacité au prix d'une légère diminution de l'amplitude de mouvement. Les fumeurs et les personnes indemnisées par la Commission de la sécurité professionnelle et de l'assurance contre les accidents du travail, cependant, ont une issue subjective bien pire (ÉAV et DASH), mais une issue objective similaire (amplitude de mouvement).

Catheter-directed thrombolysis with tPA to restore renal function after iliac venous thrombosis post-renal transplantation.

BACKGROUND: Successful salvage of a failing renal allograft secondary to compromised venous outflow from acute deep venous thrombus (DVT) has not been reported in the post-operative setting. CASE REPORT: We present a case of acute DVT extending from the popliteal vein to the bifurcation of the inferior vena cava leading to renal allograft dysfunction in the post-operative period. The allograft was successfully salvaged with catheter directed thrombolysis of the DVT with tPA through the ipsilateral popliteal vein over a 48 hr period. CONCLUSIONS: Post-operative renal transplant dysfunction secondary to iliac vein thrombosis can be successfully treated with catheter-directed thrombolysis using tPA.

A novel approach to development of monoclonal antibodies using native antigen for immunization and recombinant antigen for screening.

The production of monoclonal antibodies (MAb) specific to microbes is rapidly growing. Finding an appropriate antigen to screen hybridoma clones has become increasingly important. However, the conventional method, in which the purified antigen from the microbe is routinely used for screening, cannot avoid selection of false positive hybridoma clones, since even highly purified antigen is found to be contaminated with some other proteins from the microbe. In this study, MAbs against anthrax protective antigen (PA), the central component of the three-part toxin secreted by Bacillus anthracis were developed using a pair of the roughly purified native PA as an immunogen and the recombinant PA as a screening antigen without any possibility of false selection, since the recombinant PA was produced by a gene engineering approach and impossible to be contaminated with any other proteins from B. anthracis. In total, nine stable hybridoma clones secreting anti-PA MAbs were developed. All of them had the same type of heavy and light chains, IgG1/kappa. The binding profiles for these anti-PA MAbs were investigated by ELISA. This novel approach to the development of MAbs should be applicable to the production of MAbs to other microbes, especially to those from which antigens can hardly be purified to a high degree.