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Malik PRA, Fahim C, Vernon J, Thomas P, Schieman C, Finley CJ, Agzarian J, Shargall Y, Farrokhyar F, Hanna WC. Incentive Spirometry After Lung Resection: A Randomized Controlled Trial. Ann Thorac Surg 2018; 106:340-345. [PMID: 29702071 DOI: 10.1016/j.athoracsur.2018.03.051] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 02/26/2018] [Accepted: 03/22/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Incentive spirometry (IS) is thought to reduce the incidence of postoperative pulmonary complications (PPC) after lung resection. We sought to determine whether the addition of IS to routine physiotherapy following lung resection results in a lower rate of PPC, as compared with physiotherapy alone. METHODS A single-blind prospective randomized controlled trial was conducted in adults undergoing lung resection. Individuals with previous lung surgery or home oxygen were excluded. Participants randomized to the control arm (PHY) received routine physiotherapy alone (deep breathing, ambulation and shoulder exercises). Those randomized to the intervention arm (PHY/IS) received IS in addition to routine physiotherapy. The trial was powered to detect a 10% difference in the rate of PPC (β = 80%). Student's t test and chi-square were utilized for continuous and categorical variables, respectively, with a significance level of p = 0.05. RESULTS A total of 387 participants (n = 195 PHY/IS; n = 192 PHY) were randomized between 2014 and 2017. Baseline characteristics were comparable for both arms. The majority of patients underwent a pulmonary lobectomy (PHY/IS = 59.5%, PHY = 61.0%; p = 0.84), with no difference in the rates of minimally invasive and open procedures. There were no differences in the incidence of PPC at 30 days postoperatively (PHY/IS = 12.3%, PHY = 13.0%; p = 0.88). There were no differences in rates of pneumonia (PHY/IS = 4.6%, PHY = 7.8%; p = 0.21), mechanical ventilation (PHY/IS = 2.1%, PHY = 1.0%; p = 0.41), home oxygen (PHY/IS = 13.8%, PHY = 14.6%; p = 0.89), hospital length of stay (PHY/IS = 4 days, PHY = 4 days; p = 0.34), or rate of readmission to hospital (PHY/IS = 10.3%, PHY = 9.9%; p = 1.00). CONCLUSIONS The addition of IS to routine postoperative physiotherapy does not reduce the incidence of PPC after lung resection.
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McGrath M, Farrokhyar F, Ramesh S, Lorenzo A, Braga L. MP69-12 DOES BREASTFEEDING REDUCE THE RISK OF UTI IN INFANTS WITH PRENATAL HYDRONEPRHOSIS? J Urol 2018. [DOI: 10.1016/j.juro.2018.02.2236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Nath S, Koziarz A, Badhiwala JH, Alhazzani W, Jaeschke R, Sharma S, Banfield L, Shoamanesh A, Singh S, Nassiri F, Oczkowski W, Belley-Côté E, Truant R, Reddy K, Meade MO, Farrokhyar F, Bala MM, Alshamsi F, Krag M, Etxeandia-Ikobaltzeta I, Kunz R, Nishida O, Matouk C, Selim M, Rhodes A, Hawryluk G, Almenawer SA. Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis. Lancet 2018; 391:1197-1204. [PMID: 29223694 DOI: 10.1016/s0140-6736(17)32451-0] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 08/25/2017] [Accepted: 08/29/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Atraumatic needles have been proposed to lower complication rates after lumbar puncture. However, several surveys indicate that clinical adoption of these needles remains poor. We did a systematic review and meta-analysis to compare patient outcomes after lumbar puncture with atraumatic needles and conventional needles. METHODS In this systematic review and meta-analysis, we independently searched 13 databases with no language restrictions from inception to Aug 15, 2017, for randomised controlled trials comparing the use of atraumatic needles and conventional needles for any lumbar puncture indication. Randomised trials comparing atraumatic and conventional needles in which no dural puncture was done (epidural injections) or without a conventional needle control group were excluded. We screened studies and extracted data from published reports independently. The primary outcome of postdural-puncture headache incidence and additional safety and efficacy outcomes were assessed by random-effects and fixed-effects meta-analysis. This study is registered with the International Prospective Register of Systematic Reviews, number CRD42016047546. FINDINGS We identified 20 241 reports; after exclusions, 110 trials done between 1989 and 2017 from 29 countries, including a total of 31 412 participants, were eligible for analysis. The incidence of postdural-puncture headache was significantly reduced from 11·0% (95% CI 9·1-13·3) in the conventional needle group to 4·2% (3·3-5·2) in the atraumatic group (relative risk 0·40, 95% CI 0·34-0·47, p<0·0001; I2=45·4%). Atraumatic needles were also associated with significant reductions in the need for intravenous fluid or controlled analgesia (0·44, 95% CI 0·29-0·64; p<0·0001), need for epidural blood patch (0·50, 0·33-0·75; p=0·001), any headache (0·50, 0·43-0·57; p<0·0001), mild headache (0·52, 0·38-0·70; p<0·0001), severe headache (0·41, 0·28-0·59; p<0·0001), nerve root irritation (0·71, 0·54-0·92; p=0·011), and hearing disturbance (0·25, 0·11-0·60; p=0·002). Success of lumbar puncture on first attempt, failure rate, mean number of attempts, and the incidence of traumatic tap and backache did not differ significantly between the two needle groups. Prespecified subgroup analyses of postdural-puncture headache revealed no interactions between needle type and patient age, sex, use of prophylactic intravenous fluid, needle gauge, patient position, indication for lumbar puncture, bed rest after puncture, or clinician specialty. These results were rated high-quality evidence as examined using the grading of recommendations assessment, development, and evaluation. INTERPRETATION Among patients who had lumbar puncture, atraumatic needles were associated with a decrease in the incidence of postdural-puncture headache and in the need for patients to return to hospital for additional therapy, and had similar efficacy to conventional needles. These findings offer clinicians and stakeholders a comprehensive assessment and high-quality evidence for the safety and efficacy of atraumatic needles as a superior option for patients who require lumbar puncture. FUNDING None.
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Ekhtiari S, Haldane CE, de SA D, Simunovic N, Wong IH, Farrokhyar F, Ayeni OR. The use of antibiotic prophylaxis in hip arthroscopy is under-reported and lacks evidence-based guidelines: a systematic review and survey. J ISAKOS 2018. [DOI: 10.1136/jisakos-2017-000157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Sommer DD, Arbab-Tafti S, Farrokhyar F, Tewfik M, Vescan A, Witterick IJ, Rotenberg B, Chandra R, Weitzel EK, Wright E, Ramakrishna J. A challenge-response endoscopic sinus surgery specific checklist as an add-on to standard surgical checklist: an evaluation of potential safety and quality improvement issues. Int Forum Allergy Rhinol 2018; 8:831-836. [PMID: 29485750 DOI: 10.1002/alr.22106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 01/29/2018] [Accepted: 02/01/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND The goal of this study was to develop and evaluate the impact of an aviation-style challenge and response sinus surgery-specific checklist on potential safety and equipment issues during sinus surgery at a tertiary academic health center. The secondary goal was to assess the potential impact of use of the checklist on surgical times during, before, and after surgery. This initiative is designed to be utilized in conjunction with the "standard" World Health Organization (WHO) surgical checklist. Although endoscopic sinus surgery is generally considered a safe procedure, avoidable complications and potential safety concerns continue to occur. The WHO surgical checklist does not directly address certain surgery-specific issues, which may be of particular relevance for endoscopic sinus surgery. METHODS This prospective observational pilot study monitored compliance with and compared the occurrence of safety and equipment issues before and after implementation of the checklist. Forty-seven consecutive endoscopic surgeries were audited; the first 8 without the checklist and the following 39 with the checklist. The checklist was compiled by evaluating the patient journey, utilizing the available literature, expert consensus, and finally reevaluation with audit type cases. The final checklist was developed with all relevant stakeholders involved in a Delphi method. RESULTS Implementing this specific surgical checklist in 39 cases at our institution, allowed us to identify and rectify 35 separate instances of potentially unsafe, improper or inefficient preoperative setup. These incidents included issues with labeling of topical vasoconstrictor or injectable anesthetics (3, 7.7%) and availability, function and/or position of video monitors (2, 5.1%), endoscope (6, 15.4%), microdebrider (6, 15.4%), bipolar cautery (6, 15.4%), and suctions (12, 30.8%). CONCLUSION The design and integration of this checklist for endoscopic sinus surgery, has helped improve efficiency and patient safety in the operating room setting.
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Haldane CE, Ekhtiari S, de Sa D, Simunovic N, Safran M, Randelli F, Duong A, Farrokhyar F, Ayeni OR. Venous Thromboembolism Events After Hip Arthroscopy: A Systematic Review. Arthroscopy 2018; 34:321-330.e1. [PMID: 28969946 DOI: 10.1016/j.arthro.2017.07.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 07/05/2017] [Accepted: 07/05/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this systematic literature review focused on hip arthroscopy was to (1) report the venous thromboembolism (VTE) event incidence in patients who receive VTE prophylaxis and those who do not, (2) report how VTE prophylaxis is currently being administered, and (3) report operative and patient-related risk factors for VTE identified in the literature. METHODS The electronic databases MEDLINE, Embase, and PubMed were searched from database inception to October 10, 2016, and screened in duplicate for relevant studies. Data were collected regarding VTE prophylaxis, traction use, surgical time, VTE incidence, patient and operative factors, and postoperative weight bearing and rehabilitation. Study quality was assessed in duplicate with the Methodological Index for Non-Randomized Studies criteria. RESULTS Outcome analyses included 14 studies that involved 2,850 patients (2,985 hips). The weighted mean follow-up period was 19 ± 8 months, ranging from 7 days to 103 months. The weighted mean age was 40.7 ± 7 years, ranging from 6 to 82 years, and 39.6% of patients were male patients. The overall weighted proportion of VTE events after hip arthroscopy found in 14 included studies was 2.0% (95% confidence interval, 0.01%-4.1%), with 25 VTE events. Several studies reported patient risk factors, which included increased age, increased body mass index, prolonged traction time, and use of oral contraceptives. CONCLUSIONS The use and efficacy of VTE prophylaxis are highly under-reported within hip arthroscopy. The low incidence of VTE events found in this review (2.0%) suggests that prophylaxis may not be necessary in low-risk patients undergoing hip arthroscopy; however, the true rate may be under-reported. Current literature suggests that prophylaxis is typically not prescribed. Early mobility and postoperative rehabilitation may also help to further mitigate the risk of VTE events, but use of these strategies needs further prospective evaluation. LEVEL OF EVIDENCE Level IV, systematic review of Level II through IV studies.
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Chaudhary V, Brent M, Lam WC, Devenyi R, Teichman J, Mak MYK, Kaur H, Barbosa J, Carter R, Farrokhyar F. Genetic Risk Factors Are Not Associated with Wet Age-Related Macular Degeneration Treatment Response to Ranibizumab. Ophthalmologica 2018; 239:240. [DOI: 10.1159/000481178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 08/31/2017] [Indexed: 11/19/2022]
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Fong N, Easterbrook B, Farrokhyar F, Sabri K. Parental knowledge of pediatric eye health in an ophthalmology clinic setting: validation and delivery of the EYEE questionnaire. Can J Ophthalmol 2017; 53:210-214. [PMID: 29784155 DOI: 10.1016/j.jcjo.2017.10.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 10/02/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We aimed to develop and assess the reliability of a questionnaire assessing parental knowledge on core topics in pediatric eye health. METHODS In Phase I, the Evaluate Your Eye Education Questionnaire (EYEE-Q) was developed and distributed to ascertain face validity (n = 20). In Phase II, participants completed EYEE-Q twice to determine test-retest reliability (n = 40). In Phase III, EYEE-Q was administered to parents in a tertiary level pediatric ophthalmology clinic to assess knowledge (n = 193). RESULTS EYEE-Q had good test-retest reliability (Kripendorff's alpha = 0.77). Mean knowledge was 71% on eye physiology, 59% on pediatric vision care, 58% on refractive error, 53% on common childhood eye conditions, and 48% on eye care professional (ECP) roles. Low income, non-Caucasian race, and English as a second language status were associated with poorer scores. CONCLUSION EYEE-Q is a reliable means of assessing parental knowledge on select pediatric eye health-related topics. Knowledge appears to be suboptimal among parents of children attending tertiary level ophthalmology clinics. ECPs should actively provide educational materials in various languages and formats to promote understanding of medical jargon and patient compliance. The influence of educational interventions on knowledge can be assessed using the EYEE-Q.
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Braga LH, McGrath M, Farrokhyar F, Jegatheeswaran K, Lorenzo AJ. Society for Fetal Urology Classification vs Urinary Tract Dilation Grading System for Prognostication in Prenatal Hydronephrosis: A Time to Resolution Analysis. J Urol 2017; 199:1615-1621. [PMID: 29198999 DOI: 10.1016/j.juro.2017.11.077] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE The Urinary Tract Dilation grading system for prenatal hydronephrosis was introduced to address potential shortcomings of the Society for Fetal Urology classification. Hydronephrosis resolution is an important patient outcome and is frequently discussed during family counseling. We compared these 2 grading systems and their ability to predict time to hydronephrosis resolution. MATERIALS AND METHODS We prospectively screened 855 patients with prenatal hydronephrosis due to ureteropelvic junction obstruction-like hydronephrosis, nonrefluxing primary megaureter or vesicoureteral reflux between 2009 and 2015. Of the patients 454 were excluded due to surgery, late referral, absence of postnatal dilatation or presence of other anomalies, resulting in 401 eligible patients (of whom 81% were male) to be included for analyses. Hydronephrosis grades collected at baseline and last followup were compared to identify resolution trends through time. Hydronephrosis resolution was defined as renal pelvis anteroposterior diameter 10 mm or less at last followup. Time to resolution was analyzed using Cox proportion regression. RESULTS Of 401 patients 328 (82%) had resolution during a mean ± SD followup of 24 ± 18 months (maximum 107). Cumulative resolution rate at 3 years was 98% for Society for Fetal Urology grade I hydronephrosis, 87% for grade II, 76% for grade III and 57% for grade IV. The 3-year hydronephrosis resolution rate was 90% for Urinary Tract Dilation postnatal grade 1 (low risk), 81% for grade 2 (intermediate risk) and 71% for grade 3 (high risk). CONCLUSIONS Patients with distinctive baseline hydronephrosis grades (classified by Society for Fetal Urology or Urinary Tract Dilation system) had significantly different resolution times for hydronephrosis (p <0.001). Counseling families regarding time to resolution of prenatal hydronephrosis should remain the same whether using Society for Fetal Urology or Urinary Tract Dilation grading system.
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Thoma A, Farrokhyar F, Waltho D, Braga LH, Sprague S, Goldsmith CH. Users' guide to the surgical literature: how to assess a noninferiority trial. Can J Surg 2017; 60:426-432. [PMID: 29173262 DOI: 10.1503/cjs.000317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
SUMMARY A well-planned randomized controlled trial (RCT) is the most optimal study design to determine if a novel surgical intervention is any different than a prevailing one. Traditionally, when we want to show that a new surgical intervention is superior to a standard one, we analyze data from an RCT to see if the null hypothesis of "no difference" can be rejected (i.e., the 2 surgical interventions have the same effect). A noninferiority RCT design seeks to determine whether a new intervention is not worse than a prevailing (standard) one within an acceptable margin of risk or benefit, referred to as the "noninferiority margin." In the last decade, we have observed an increase in the publication of noninferiority RCTs. This article explores this type of study design and discusses the tools that can be used to appraise such a study.
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Stacey MC, Phillips SA, Farrokhyar F, Swaine JM. Reliability and measurement error of digital planimetry for the measurement of chronic venous leg ulcers. Wound Repair Regen 2017; 25:901-905. [DOI: 10.1111/wrr.12587] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 09/07/2017] [Indexed: 01/13/2023]
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Chin B, Ramji M, Farrokhyar F, Bain JR. Efficient Imaging: Examining the Value of Ultrasound in the Diagnosis of Traumatic Adult Brachial Plexus Injuries, A Systematic Review. Neurosurgery 2017; 83:323-332. [DOI: 10.1093/neuros/nyx483] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 08/28/2017] [Indexed: 11/14/2022] Open
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Stacey M, Phillips S, Farrokhyar F, Swaine JM. Evaluation of Biomarkers for Predicting Wound Healing in Venous Leg Ulcer. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Brownrigg N, Braga LH, Rickard M, Farrokhyar F, Easterbrook B, Dekirmendjian A, Jegatheeswaran K, DeMaria J, Lorenzo AJ. The impact of a bladder training video versus standard urotherapy on quality of life of children with bladder and bowel dysfunction: A randomized controlled trial. J Pediatr Urol 2017; 13:374.e1-374.e8. [PMID: 28733159 DOI: 10.1016/j.jpurol.2017.06.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 06/22/2017] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Bladder and bowel dysfunction (BBD) can negatively impact the quality of life (QoL) of children. Urotherapy is an accepted treatment option for BBD; however, literature that examines the impact of management options on QoL in this population is scarce. OBJECTIVE To determine whether a bladder training video (BTV) is non-inferior to standard urotherapy (SU) in improving QoL in children with BBD. METHODS Children aged 5-10 years and who scored ≥11 on the Vancouver Non-Neurogenic Lower Urinary Tract Dysfunction/Dysfunctional Elimination Syndrome Questionnaire (NLUTD/DES) were recruited from a pediatric tertiary care center. Children were excluded with known vesicoureteral reflux; spinal dysraphism; learning disabilities; recent urotherapy; and primary nocturnal enuresis. Quality of life was evaluated using the Pediatric Incontinence Quality-of-Life questionnaire (PinQ). Questionnaires were administered at the baseline and 3-month follow-up clinic visits. Following centralized electronic blocked randomization schemes to guarantee allocation concealment, patients were assigned to receive SU or BTV during their regular clinic visits. An intention-to-treat protocol was followed. Between-group baseline and follow-up QoL scores were compared using paired and unpaired t-tests, and linear regression analysis. RESULTS Of the 539 BBD patients who were screened, 173 (32%) were eligible, and 150 (87%) were randomized. Of these, 143 (96%) completed the study, five (3%) were lost to follow-up, and two (1%) withdrew. In total, 140/143 (97%) completed the QoL questionnaire at baseline and follow-up. Mean follow-up time was 3.5 ± 1.1 months for BTV patients and 3.7 ± 1.6 months for SU. At baseline, BTV and SU patients had a mean QoL score of 26.6 ± 13 and 23.8 ± 12, respectively (P = 0.17). Between-group mean change in PinQ scores from baseline was not statistically significant (BTV: 6.25 ± 12.5 vs SU: 3.75 ± 12.2; P = 0.23; Summary Fig.). Significant predictors of positive change in QoL were: higher symptomatology score, with a correlation coefficient of 0.5 (95% CI: 0.2-0.9; P = 0.003), and worse baseline QoL score, with a correlation coefficient of 0.5 (95% CI: 0.4-0.7; P < 0.001). Overall, most patients had improved symptomatology and QoL scores. CONCLUSION Significant and similar QoL changes from baseline to follow-up were observed in both the BTV and SU groups, suggesting that BTV was non-inferior to SU in improving QoL in children with BBD. Quality of life assessment should be considered when evaluating interventions for BBD, as it appears to be an important clinical outcome with which to determine urotherapy success.
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Gallo L, Eskicioglu C, Braga LH, Farrokhyar F, Thoma A. Users' guide to the surgical literature: how to assess an article using surrogate end points. Can J Surg 2017; 60:280-287. [PMID: 28730989 DOI: 10.1503/cjs.002217] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
SUMMARY Phase 3 randomized controlled trials are the widely accepted gold standard through which treatment decisions are made, as they assess the efficacy of a novel treatment against the control on the relevant patient population. The effectiveness of the novel treatment should be derived by measuring patient-important outcomes; however, to accurately assess these outcomes, clinical trials often require extensive patient follow-up and large sample sizes that can incur substantial expense. For this reason, investigators substitute surrogate end points to reduce the sample size and duration of a trial, ultimately reducing cost. The purpose of this article is to help surgeons appraise the surgical literature that use surrogate end points for patient-important outcomes.
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Kameda-Smith MM, Klurfan P, van Adel BA, Larrazabal R, Farrokhyar F, Bennardo M, Gunnarsson T. Timing of complications during and after elective endovascular intracranial aneurysm coiling. J Neurointerv Surg 2017; 10:374-379. [PMID: 28652299 DOI: 10.1136/neurintsurg-2017-013110] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/27/2017] [Accepted: 05/31/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the time to complications during and after elective endovascular intracranial aneurysm coiling. METHODS A retrospective chart review of patients undergoing elective endovascular aneurysm coiling between March 2006 and October 2013 in one large Eastern Canadian Neurointerventional Service was performed. Data regarding the incidence, time and type of complication related to the endovascular coiling procedure and clinical outcome at last follow-up were collected. Patient, aneurysm and operation factors were analyzed to determine any factors associated with complication occurrence. RESULTS Of the 150 patient procedures analyzed, 16% experienced a coiling-related complication, although none resulted in death. 6.7% of patients experienced an intraoperative complication, of which thromboembolism was the most common type. The majority of the complications were detected in the first 6 hours after reversal of anesthesia, and a small proportion the next morning prior to discharge. Only 3.3% of patients had persistent neurological deficit after the procedure on last follow-up. Duration of the operation demonstrated a strong association with the occurrence of procedure-related complications. CONCLUSION This study demonstrates that coiling-related complications of elective endovascular coiling tend to occur either intraoperatively or are detected shortly after reversal of anesthesia. Further investigation with a larger cohort may help to guide important preoperative communication with patients and identify a select group of patients who may not necessarily require prolonged admission to hospital for observation.
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De Waele M, Agzarian J, Hanna WC, Schieman C, Finley CJ, Macri J, Schneider L, Schnurr T, Farrokhyar F, Radford K, Nair P, Shargall Y. Does the usage of digital chest drainage systems reduce pleural inflammation and volume of pleural effusion following oncologic pulmonary resection?-A prospective randomized trial. J Thorac Dis 2017; 9:1598-1606. [PMID: 28740674 DOI: 10.21037/jtd.2017.05.78] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Prolonged air leak and high-volume pleural drainage are the most common causes for delays in chest tube removal following lung resection. While digital pleural drainage systems have been successfully used in the management of post-operative air leak, their effect on pleural drainage and inflammation has not been studied before. We hypothesized that digital drainage systems (as compared to traditional analog continuous suction), using intermittent balanced suction, are associated with decreased pleural inflammation and postoperative drainage volumes, thus leading to earlier chest tube removal. METHODS One hundred and three [103] patients were enrolled and randomized to either analog (n=50) or digital (n=53) drainage systems following oncologic lung resection. Chest tubes were removed according to standardized, pre-defined protocol. Inflammatory mediators [interleukin-1B (IL-1B), 6, 8, tumour necrosis factor-alpha (TNF-α)] in pleural fluid and serum were measured and analysed. The primary outcome of interest was the difference in total volume of postoperative fluid drainage. Secondary outcome measures included duration of chest tube in-situ, prolonged air-leak incidence, length of hospital stay and the correlation between pleural effusion formation, degree of inflammation and type of drainage system used. RESULTS There was no significant difference in total amount of fluid drained or length of hospital stay between the two groups. A trend for shorter chest tube duration was found with the digital system when compared to the analog (P=0.055). Comparison of inflammatory mediator levels revealed no significant differences between digital and analog drainage systems. The incidence of prolonged post-operative air leak was significantly higher when using the analog system (9 versus 2 patients; P=0.025). Lobectomy was associated with longer chest tube duration (P=0.001) and increased fluid drainage when compared to sub-lobar resection (P<0.001), regardless of drainage system. CONCLUSIONS Use of post-lung resection digital drainage does not appear to decrease pleural fluid formation, but is associated with decreased prolonged air leaks. Total pleural effusion volumes did not differ with the type of drainage system used. These findings support previously established benefits of the digital system in decreasing prolonged air leaks, but the advantages do not appear to extend to decreased pleural fluid formation.
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Aref M, Martyniuk A, Nath S, Koziarz A, Badhiwala J, Algird A, Farrokhyar F, Almenawer SA, Reddy K. Endoscopic Third Ventriculostomy: Outcome Analysis of an Anterior Entry Point. World Neurosurg 2017; 104:554-559. [PMID: 28532915 DOI: 10.1016/j.wneu.2017.05.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 05/09/2017] [Accepted: 05/11/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Endoscopic third ventriculostomy (ETV) is a safe and effective treatment for hydrocephalus. An entry point located 4 cm anterior to the coronal suture, 3 cm anterior to Kocher point, and approximately 9 cm from the pupil at the midpupillary line has been used successfully for the last 20 years in our center. We aimed to evaluate this alternative anterior entry point routinely used for ETV, with or without concurrent endoscopic biopsy. METHODS Patients undergoing this proposed entry point were examined to evaluate its safety and efficacy. Factors such as patients' age, sex, hydrocephalus etiology, tumor location and pathology, and complication rate were examined through regression analyses to evaluate their impact on tumor biopsy and ETV success rates, and the need for subsequent ventricular shunting. RESULTS A total of 131 patients were included in the study. ETV was successful in 125 (95.4%) patients. Of these, 26 (19.8%) patients required a biopsy, which was successful in 21 (80.8%) cases. A complication was observed in 10 (7.6%) patients, with a trend toward complications occurring after ETV failure. There was no association between ETV success rate and patients' age (P = 0.5) or sex (P = 0.99). CONCLUSIONS The anterior entry point is a safe and effective method for ETV, especially when considering concurrent ventricular tumor biopsy. This entry point may be considered as a more minimally invasive procedure when using rigid endoscopy and may also eliminate the need for a flexible scope.
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Sergeant A, Kameda-Smith MM, Manoranjan B, Karmur B, Duckworth J, Petrelli T, Savage K, Ajani O, Yarascavitch B, Samaan MC, Scheinemann K, Alyman C, Almenawer S, Farrokhyar F, Fleming AJ, Singh SK, Stein N. Analysis of surgical and MRI factors associated with cerebellar mutism. J Neurooncol 2017; 133:539-552. [DOI: 10.1007/s11060-017-2462-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 05/06/2017] [Indexed: 11/28/2022]
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Hartman J, Khanna V, Habib A, Farrokhyar F, Memon M, Adili A. Perioperative systemic glucocorticoids in total hip and knee arthroplasty: A systematic review of outcomes. J Orthop 2017; 14:294-301. [PMID: 28442852 DOI: 10.1016/j.jor.2017.03.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/26/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Perioperative systemic glucocorticoids are frequently included in multimodal analgesia and antiemetic regimens administered to patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). The objective of this systematic review was to evaluate the available randomized controlled trials (RCTs) to determine the effect of perioperative systemic glucocorticoids on postoperative nausea and vomiting (PONV), pain, narcotic consumption, antiemetic consumption, length of stay in hospital, and major complications in patients undergoing elective THA or TKA. METHODS A predefined protocol of eligibility and methodology was used for conduct of systematic reviews. Two reviewers screened citations for inclusion, assessed methodological quality, and verified the extracted data. RESULTS Six RCTs were included for analysis. Across all outcomes analyzed, patients who received glucocorticoids experienced either a benefit or no difference compared to those patients who did not receive glucocorticoids. There were no instances in which perioperative glucocorticoids had a negative impact on any of the outcomes that were analyzed. Furthermore, perioperative glucocorticoids had no effect on the rates of superficial infection, deep infection, wound complications or deep vein thrombosis (DVT). CONCLUSION The results of this systematic review support the use of perioperative systemic glucocorticoids in patients undergoing elective total hip and knee arthroplasty. Perioperative glucocorticoids have overall positive outcomes with the benefits being more robust in those patients undergoing TKA compared to THA. Glucocorticoids did not increase the occurrence of major complications. There is limited data to support the conclusion that they can reduce length of stay in hospital.
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Nath S, Badhiwala JH, Alhazzani W, Nassiri F, Belley-Cote E, Koziarz A, Shoamanesh A, Banfield L, Oczkowski W, Sharma M, Sahlas D, Reddy K, Farrokhyar F, Singh S, Sharma S, Zytaruk N, Selim M, Almenawer SA. Atraumatic versus traumatic lumbar puncture needles: a systematic review and meta-analysis protocol. BMJ Open 2017; 7:e014478. [PMID: 28363928 PMCID: PMC5387934 DOI: 10.1136/bmjopen-2016-014478] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Lumbar puncture is one of the oldest and most commonly performed procedures in medicine, used to diagnose and treat disease. Headache following lumbar puncture remains a frequent complication, causing significant patient discomfort and often requiring narcotic analgesia or invasive therapy. Needle tip design has been proposed to affect the incidence of headache postlumbar puncture, with pencil-point 'atraumatic' needles thought to reduce its incidence in comparison to bevelled 'traumatic' needles. Despite this, the use of atraumatic needles and knowledge of their existence remains significantly limited among clinicians. This study will systematically review the evidence on atraumatic lumbar puncture needles and compare them with traumatic needles across a variety of clinical outcomes. METHODS AND ANALYSES We will include published randomised controlled trials (RCTs), observational studies and abstracts, with no publication type or language restrictions. Search strategies will be designed to peruse the MEDLINE, EMBASE, Web of Science, ClinicalTrials.gov, CINAHL, WHO Clinical Trials Database and Cochrane Library databases. We will also implement strategies to search the grey literature. 3 reviewers will thoroughly and independently examine the search results, complete data abstraction and conduct quality assessment. Included RCTs will be assessed using the Cochrane risk of bias assessment tool and eligible observational studies will be examined using the Newcastle-Ottawa Scale. We will examine the outcomes of: headache and its type, intensity, duration and treatment; backache; success rate; hearing disturbance and nerve root irritation. The primary outcome will be the incidence of postdural puncture headache. We will calculate pooled estimates, relative risks for dichotomous outcomes and weighted mean differences for continuous outcomes, with corresponding 95% CIs. Statistical heterogeneity will be measured using Cochran's Q test and quantified using the I2 statistic. We will also conduct prespecified subgroup and sensitivity analyses to examine if covariates exist and to explore potential heterogeneity. ETHICS AND DISSEMINATION Research ethics board approval is not required for this study as it draws from published data and raises no concerns related to patient privacy. This review will provide a comprehensive assessment of the evidence on atraumatic needles for lumbar puncture and is directed to a wide audience. Results from the review will be disseminated extensively through conferences and submitted to a peer-reviewed journal for publication. TRIAL REGISTRATION NUMBER CRD42016047546.
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Petrelli T, Farrokhyar F, McGrath P, Sulowski C, Sobhi G, DeMatteo C, Giglia L, Singh SK. The use of ibuprofen and acetaminophen for acute headache in the postconcussive youth: A pilot study. Paediatr Child Health 2017; 22:2-6. [PMID: 29483787 DOI: 10.1093/pch/pxw011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objective Acute postconcussive headaches are problematic for children after mild traumatic brain injury. There are no evidence-based guidelines for their management. This pilot study aims to assess the feasibility and efficacy of routine analgesia administration. Methods A four-arm open-label randomized controlled trial pilot/feasibility study was conducted: (i) acetaminophen, (ii) ibuprofen, (iii) alternating acetaminophen and ibuprofen and (iv) a control group. Children and youth 8 to 18 years of age presenting to emergency department with headache within 48 hours of their first concussion were recruited consecutively and sequentially randomized. Children with abnormal neuroimaging, history of previous concussions and bleeding disorder were excluded. A headache survey was administered at recruitment. All participants were provided with standard concussion management education and were also instructed on how to use the headache diary for the 1-week study follow-up period. The diary captures (i) headache days, (ii) number of headaches, (iii) headache intensity and (iv) return-to-school information. Feasibility was assessed based on study recruitment and compliance. Results There were no feasibility concerns with the recruitment and no major compliance issues. Patients on acetaminophen, ibuprofen or both had significantly less headache days, episodes of headache and lower headache intensity than did the standard care group. Patients on both ibuprofen and acetaminophen (79.0%) and on ibuprofen alone (61.0%) were more likely to be back at school 1 week postinjury as compared with the acetaminophen group (33.3%) and the standard care group (21.1%). Conclusion Results showed routine analgesia administration was feasible and effective for postconcussive headache management. A larger full-scale randomized controlled trial is required to further assess the efficacy with longer follow-up, a wider variety of patients and more concussion related outcomes.
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Rickard M, Easterbrook B, Kim S, Farrokhyar F, Stein N, Arora S, Belostotsky V, DeMaria J, Lorenzo AJ, Braga LH. Six of one, half a dozen of the other: A measure of multidisciplinary inter/intra-rater reliability of the society for fetal urology and urinary tract dilation grading systems for hydronephrosis. J Pediatr Urol 2017; 13:80.e1-80.e5. [PMID: 27916387 DOI: 10.1016/j.jpurol.2016.09.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/22/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The urinary tract dilation (UTD) classification system was introduced to standardize terminology in the reporting of hydronephrosis (HN), and bridge a gap between pre- and postnatal classification such as the Society for Fetal Urology (SFU) grading system. Herein we compare the intra/inter-rater reliability of both grading systems. MATERIALS AND METHODS SFU (I-IV) and UTD (I-III) grades were independently assigned by 13 raters (9 pediatric urology staff, 2 nephrologists, 2 radiologists), twice, 3 weeks apart, to 50 sagittal postnatal ultrasonographic views of hydronephrotic kidneys. Data regarding ureteral measurements and bladder abnormalities were included to allow proper UTD categorization. Ten images were repeated to assess intra-rater reliability. Krippendorff's alpha coefficient was used to measure overall and by grade intra/inter-rater reliability. Reliability between specialties and training levels were also analyzed. RESULTS Overall inter-rater reliability was slightly higher for SFU (α = 0.842, 95% CI 0.812-0.879, in session 1; and α = 0.808, 95% CI 0.775-0.839, in session 2) than for UTD (α = 0.774, 95% CI 0.715-0.827, in session 1; and α = 0.679, 95% CI 0.605-0.750, in session 2). Reliability for intermediate grades (SFU II/III and UTD 2) of HN was poor regardless of the system. Reliabilities for SFU and UTD classifications among Urology, Nephrology, and Radiology, as well as between training levels were not significantly different. DISCUSSION Despite the introduction of HN grading systems to standardize the interpretation and reporting of renal ultrasound in infants with HN, none have been proven superior in allowing clinicians to distinguish between "moderate" grades. While this study demonstrated high reliability in distinguishing between "mild" (SFU I/II and UTD 1) and "severe" (SFU IV and UTD 3) grades of HN, the overall reliability between specialties was poor. This is in keeping with a previous report of modest inter-rater reliability of the SFU system. This drawback is likely explained by the subjective interpretation required to assign grades, which can be impacted by experience, image quality, and scanning technique. As shown in the figure, which demonstrates SFU II (a) and SFU III (b), as assigned by a radiologist, it is possible to make an argument that either of these images can be classified into both categories that were observed during the grading sessions of this study. CONCLUSION Although both systems have acceptable reliability, the SFU grading system showed higher overall intra/inter-rater reliability regardless of rater specialty than the UTD classification. Inter-rater reliability for SFU grades II/III and UTD 2 was low, highlighting the limitations of both classifications in regards to properly segregating moderate HN grades.
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Nassar A, Coates A, Tuma F, Farrokhyar F, Reid S. The MacTRAUMA TTL Assessment Tool: Developing a Novel Tool for Assessing Performance of Trauma Trainees: Initial Reliability Testing. JOURNAL OF SURGICAL EDUCATION 2016; 73:1046-1051. [PMID: 27687539 DOI: 10.1016/j.jsurg.2016.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/02/2016] [Accepted: 05/16/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To develop a novel assessment tool for trainees-led trauma resuscitation. Assess psychometric properties of the proposed tool. Evaluate feasibility and utility of the tool. INTRODUCTION Trauma resuscitation is a structured and complex process involving unique sets of skills. There is currently no published structured formative evaluation tool for trauma trainees. Therefore, many trauma trainees rely upon limited, unstructured feedback on their performance. We developed a tool to assess trainee performance while leading a trauma resuscitation and to assist faculty in providing trainee feedback after the encounter. METHODS This study was conducted in a level I trauma centre in Ontario, Canada. Principles of learning theories, literature review, and clinical expert opinions were used to design a tool to assess clinical competence required to lead the resuscitation. In total, 5 critical domains were identified. High-fidelity simulation-based environment was used to test interrater reliability using intraclass correlation coefficients. To gauge feasibility, practicality, and utility of the tool, an online survey was sent to raters and trainees at the end of the study. RESULTS We found "excellent" agreement for "initial critical assessment" domain (0.80) and "moderate to good" agreement for the "communication and leadership" (0.67) and "clinical performance" domains (0.53). "Poor" agreement was identified for the "decision-making" domain (0.33). The coefficients for individual items reached "good" agreement for 5 items, and "moderate" agreement for 8 items. Intraclass correlation coefficients for the remaining 7 items were "fair" or "poor." Most raters agreed that items in the medical training domain were not applicable. Feedback from raters and trainees confirmed the feasibility and acceptability of the tool for formative feedback, in addition to some suggestions to enhance the tool. CONCLUSION MacTrauma TTL assessment tool is a novel tool for formative feedback for trainees' performance during trauma resuscitation. Initial psychometric property testing is promising. Further reliability and validity testing of the modified tool is needed. The tool has been shown to be feasible and acceptable by both trainees and faculty as a formative assessment tool.
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Vernon J, Andruszkiewicz N, Schneider L, Schieman C, Finley CJ, Shargall Y, Fahim C, Farrokhyar F, Hanna WC. Comprehensive Clinical Staging for Resectable Lung Cancer: Clinicopathological Correlations and the Role of Brain MRI. J Thorac Oncol 2016; 11:1970-1975. [DOI: 10.1016/j.jtho.2016.06.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/10/2016] [Accepted: 06/12/2016] [Indexed: 12/25/2022]
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